Legal Opinion

To whom it may concern:

The following legal opinion, about the use of psychotropic medication, especially antipsychotic drugs, for people with learning difficulties (given APANA Pro Bono Publico by barrister Paul Bowen of the Doughty Street Chambers and solicitor Karen Ashton of Tyndallwoods in Birmingham) will be of interest to a number of bodies within your Authority. The advice should be seen by the Director(s) of Social Care & Health, the Chair of the Primary Care Trust and/or Health Authority, Executive Councillor/Committee Chair for Social Care & Health, and the Chair of the Learning Disability Partnership Boards with a request that the information be directed at staff under their management.

Note that the Opinion can be seen as underlining and clarifying the government's advice in Valuing People: "Studies of the management of people with challenging behaviour have shown an over-dependence on the use of psychotropic drugs with poor outcomes as a consequence."

Very serious harm can be caused by these medications especially but not solely with longterm use. Except in clear cases of psychosis it is very unlikely to be in the best interests of any patient to initiate a regime of antipsychotic prescribing.

Where such a regime is already in place steps should be taken towards gradual reduction, aiming at eventual complete withdrawal from neuroleptics where possible, or maintenance at the lowest feasible level. Some people will find after decades of brain adaptation to these drugs that complete withdrawal is too distressing. Discontinuation syndromes should not be allowed to provoke prescribing cascades. Abrupt withdrawal from any psychotropic medication will only be in the best interest of any patient when life-threatening toxic effects such as Neuroleptic Malignant Syndrome are occurring. Otherwise there is every reason not to hasten this process which should always be over a period of months rather than weeks.

Service providers of every sort should ensure that all staff are trained to recognise and report both adverse effects and withdrawal effects. Community pharmacists should play an active role in developing and disseminating adequate training.

PSYCHOTROPIC PRESCRIBING AND PEOPLE WITH LEARNING DIFFICULTIES:

Summary of Counsel's Discussion Paper

Prepared for APANA

1. Medical treatment amounts to an assault on the individual treated unless:-

(a) the individual being treated consents.
(b) if the individual is "mentally incapacitated", the treatment is in that individual's best interests.
(c) the treatment is permitted without consent under the Mental Health Act 1983.

What follows does not consider (c), and only deals with the circumstances where the individual has not been detained under the Mental Health Act.

Mental Capacity

2. "Mental capacity" is therefore key to the individual retaining their right of self-determination. An individual is presumed to have capacity to make decisions about their own medical treatment unless he or she is unable to:-

(a) take in and retain the information which is relevant to the decision, particularly the likely consequences of having or not having the treatment; or
(b) believe the information; or
(c) weigh the information in the balance as a part of the process of arriving at the decision.

Capacity is not "all or nothing". An individual may have sufficient capacity to make some decisions, but not others. Any assessment as to a person's capacity therefore has to be made in relation to a particular course of treatment. Just because an individual has a "mental disorder" it does not mean that they do not have the capacity to make a treatment decisions.

Best Interests

3. The Courts have developed principles in an attempt to protect the interests people who are incapacitated. Medical treatment should only be provided where it is necessary, and it is in the best interests of the individual concerned. It is not enough for the doctors simply to be able to say that his/her treatment is not negligent.

4. What should be taken into account in deciding what is in any particular individual's best interests? In a fairly recent case the Court said that ethical, moral, social and welfare considerations should be taken into account. It has also been suggested that the following factors are important:-

(a) the views of those whom it is appropriate to consult and take into account e.g.
partners and near relatives;
(b) whether the same result be achieved by some less restrictive/intrusive means. (When psychotropic medication is being prescribed, consideration should be given to whether the problem can be resolved through removal of environmental triggers.); and
(c) the individual themselves should participate as fully as possible in the decision.

The Role of the Court

5. If there is a dispute about capacity and/or whether proposed treatment is in an individual's best interests, that dispute can only be resolved by the Court.

6. The Family Division of the High Court can make a declaration in advance of treatment as to whether or not it is in the individual's best interests. It has tended to limit the use of this power to what it sees as the most serious forms of treatment. "Invasive surgery" falls within that category, which is why many of the cases have concerned, for example, forced steralisation of people with learning difficulties. However, the Court may well be willing to exercise its power in relation to the prescribing of psychotropic drugs, particularly where serious side-effects are well-established.

The Human Rights Act 1998

7. The rights protected by the Human Rights Act 1998 do not add much to what has been said above.

8. However, where they may be helpful is in relation to "procedural safeguards". One of the problems with the rights set out above is that they can only protect the individual against future treatment (or continuing treatment) if the case is taken to the High Court which has the power to declare it to be unlawful. If the individual does not have mental capacity to make his or her own decisions, he or she will be dependent on someone else doing this for them. There may be an argument that two of the rights under the Human Rights Act require more than this, in some circumstances. These are the rights to respect for private life, and the right to a fair trial (Articles 8 and 6). These rights may, in effect, require doctors to seek the approval of the Court before treating someone without mental capacity where that treatment, potentially, has serious side-effects.

9. Breaches of human rights give rise to the right to sue for compensation, although the breach, generally speaking, will have to have taken place after 2 October 2000, when the Human Rights Act came into effect.

KA/Tyndallwoods/20.6.02



Chair : David N Andrews : http://www.angelfire.com/in/AspergerArtforms/ Patron : Wendy Lawson : http://www.mugsy.org/wendy c/o 1 Oak Tree House Redington Gardens London NW3 7RY UK