Autonomy,liberty,and risk: The ethical and legal challenges of suspending leave of absence for patients detained under the Mental Health Act 1983 during the COVID-19 (coronavirus) pandemic

Abstract

During the COVID-19 pandemic, many governments around the world have imposed significant restrictions on freedom of movement to tackle the virus. Mental health units have mirrored this approach, implementing restrictive measures to safeguard the health of patients, staff, and the wider community. This paper explores the relevant legal provisions and ethical principles that guide medical decisions regarding restriction of liberty, before considering the suspension of leave from hospital that occurred in several mental health services in response to the pandemic. It reviews how existing ethical principles within the field of public health may support a better-informed decision-making process, should similar widespread restrictions be imposed again.

Keywords

COVID-19 coronavirus mental health law

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References

Rosenthal

Sundram

. International human rights in mental health legislation. N Y Law School J Int Comp Law 2001; 21: 469.

Wilson

. The abolition or reform of mental health law: how should the law recognise and respond to the vulnerability of persons with mental impairment? Med Law Rev 2020; 1: 30–64.

Care Quality Commission. Monitoring the Mental Health Act in 2019/2020 , https://www.cqc.org.uk/sites/default/files/20201127_mhareport1920_report.pdf (accessed 20 January 2022).

Donnelly

. Healthcare decision-making and the law: autonomy, capacity and the limits of liberalism. Cambridge University Press, 2010.

Gillon

. Ethics needs principles – four can encompass the rest – and respect for autonomy should be “first among equals.” J Med Ethics 2003; 29:307.

UK Government. Modernising the Mental Health Act: Increasing Choice, Reducing Compulsion - Final Report of the Independent Review of the Mental Health Act 1983. 2018 , https://www.gov.uk/government/publications/modernising-the-mental-health-act-final-report-from-the-independent-review (accessed 22 January 2022).

UN General Assembly. Convention on the Rights of Persons with Disabilities . 2007, https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html (accessed 20 February 2021).

Gosney

Bartlett

. The UK government should withdraw from the convention on the rights of persons with disabilities. Br J Psychiatry 2020; 216: 296–300.

Waddington

Lawson

. The UN convention on the rights of persons with disabilities in practice: a comparative analysis of the role of courts. Oxford University Press, 2018.

10.

Meyer

, editor. Legitimacy, justice and public international law. Cambridge University Press, 2009.

11.

Council of Europe. 2021. European Convention for the Protection of Human Rights and Fundamental Freedoms, as amended by Protocols Nos. 11 and 14. https://www.echr.coe.int/documents/convention_eng.pdf (accessed 20 February 2021).

12.

Brown

Keene

Hooper

, et al. Isolation of patients in psychiatric hospitals in the context of the COVID-19 pandemic: an ethical, legal, and practical challenge. Int J Law Psychiatry 2020; 71: 101572.

13.

Dixon

Oyebode

. Uncertainty and risk assessment. Adv Psychiatr Treat. 2007;13:70–78.

14.

Sandman

. Responding to community outrage: strategies for effective risk communication. The American Industrial Hygiene Association, 1993.

15.

Rose

. In search of certainty: risk management in a biological age. J Public Ment Health 2005; 4:14–22.

16.

Eastman

Adshead

Fox

, et al. Forensic psychiatry. Oxford University Press; 2012.

17.

Freudenburg

. Perceived risk, real risk: social science and the art of probabilistic risk assessment. Science 1988; 242: 44–49.

18.

The National Archives. Mental health act 1983, https://www.legislation.gov.uk/ukpga/1983/20/contents (accessed 21 February 2021).

19.

Department of Health. Mental health act 1983: code of practice. TSO Publishing, 2015.

20.

Morin

Franck

. Rehabilitation interventions to promote recovery from schizophrenia: a systematic review. Front Psychiatry. 2017; 8: 00.

21.

UK Parliament, House of Commons Library. Coronavirus: the Lockdown Laws , https://commonslibrary.parliament.uk/research-briefings/cbp-8875/ (accessed 20 February 2022).

22.

Public Health England. Communicable disease outbreak management; operational guidance. 2014, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/343723/12_8_2014_CD_Outbreak_Guidance_REandCT_2__2_.pdf (accessed 20 January 2022).

23.

The National Archives. The coronavirus act, https://www.legislation.gov.uk/ukpga/2020/7/contents/enacted (accessed 15 January 2022).

24.

Royal College of Psychiatrists. Legal matters – COVID-19 guidance for clinicians , https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/responding-to-covid-19-guidance-for-clinicians/legal-covid-19-guidance-for-clinicians (accessed 20 January 2022).

25.

Williamson

Walker

Bhaskaran

, et al. OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients. MedRxiv . 2020.

26.

Sanyaolu

Okorie

Marinkovic

, et al. Comorbidity and its impact on patients with COVID-19. SN Comprehen Clin Med 2020; 2: 1069–1076.

27.

Haddad

Llewellyn-Jones

Yarnold

, et al. Improving the physical health of people with severe mental illness in a low secure forensic unit: an uncontrolled evaluation study of staff training and physical health care plans. Int J Ment Health Nurs 2016; 25: 554–565.

28.

Nyashanu

Pfende

Ekpenyong

. Exploring the challenges faced by frontline workers in health and social care amid the COVID-19 pandemic: experiences of frontline workers in the English midlands region, UK. J Interprof Care 2020; 18: 1–7.

29.

Prem

Liu

Russell

, et al. The effect of control strategies to reduce social mixing on outcomes of the COVID-19 epidemic in Wuhan, China: a modelling study. Lancet Public Health 2020; 5: e261–e270.

30.

NHS England. Legal guidance for services supporting people of all ages during the coronavirus pandemic . 2021, https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C1075-legal-guidance-for-mh-ld-autism-specialised-commissioning-services-v4-25-jan-21.pdf (accessed 18 February 2022).

31.

Care Quality Commission. 2020. Brief guide: the use of ‘blanket restrictions’ in mental health wards , https://www.cqc.org.uk/sites/default/files/20191125_900767_briefguide-blanket_restrictions_mental_health_wards_v3.pdf (accessed 18 February 2022).

32.

Royal College of Psychiatrists. COVID-19: ethical considerations , https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/responding-to-covid-19-guidance-for-clinicians/covid-19-ethical-considerations (accessed 18 February 2022).

33.

Repucci

Slipowitz

. Democracy under lockdown: the impact of COVID-19 on the global struggle for freedom. Freedom House; 2020, https://apo.org.au/node/308628 (accessed 20 February 2022).

34.

Bartlett

. The United Nations convention on the rights of persons with disabilities and the future of mental health law. Psychiatry 2009; 8: 496–498.

35.

Rabone v Pennine Care NHS Foundation Trust 2012. UKSC.

36.

Hiller v Austria . 2016. ECHR.

37.

Fernandes de Oliveira v Portugal . 2019. ECHR.

38.

39 Essex Chambers. Fernandes de Olivera v Portugal . 2019, https://www.39essex.com/cop_cases/fernandes-de-olivera-v-portugal/ (accessed 20 January 2021).

39.

World Health Organisation. Ethical considerations in developing a public health response to pandemic influenza 2007. Geneva WHO, 2007

40.

Flaxman

Mishra

Gandy

, et al. Estimating the effects of non-pharmaceutical interventions on COVID-19 in Europe. Nature 2020; 584: 257−561.

41.

United Nations Nations Sub-Commission on Prevention of Discrimination and Protection of Minorities. The Siracusa principles on the limitation and derogation provisions in the international covenant on civil and political rights 1984. Siracusa: UN, 1984.

42.

R v Broadmoor Special Hospital Authority, Ex Parte S, H and D . 1998. EWCA.

43.

Pountney v Griffiths. 1975. QBD.

44.

39 Essex Chambers. Munjaz v United Kingdom , https://www.39essex.com/cop_cases/munjaz-v-united-kingdom/ (accessed 30 July 2020).

45.

Munjaz v United Kingdom. 2012. ECHR.

46.

Reid

. A practitioner’s guide to the European convention on human rights. Sweet & Maxwell, 2011.

47.

Curtice

Bashir

Khurmi

, et al. The proportionality principle and what it means in practice. Psychiatrist 2011; 35: 111–116.

48.

Wadham

Edmundson

. Blackstones guide to the human rights act 1998. Oxford University Press, 2009.

49.

Wynia

. Ethics and public health emergencies: restrictions on liberty. Am J Bioeth 2007; 7: 1–5.

50.

McLeod

Sherwin

. Relational autonomy, self-trust, and health care for patients who are oppressed. Philosophy Publications, Western Universirty; 2000.

51.

Whitelaw

Mamas

Topol

, et al. Applications of digital technology in COVID-19 pandemic planning and response. Lancet Digit Health 2020; 2: e435–e440.

52.

Antonello

Panzenhagen

Balanzá-Martínez

, et al. Virtual meetings and social isolation in COVID-19 times: transposable barriers. Trends Psychiatry Psychother. 2020; 42: 221–222.

53.

Care Quality Commission. 2019. Assessment of mental health services in acute trusts programme. How are people's mental health needs met in acute hospitals, and how can this be improved? https://www.cqc.org.uk/sites/default/files/20201016b_AMSAT_report.pdf (accessed 06 March 2022).

54.

UN Human Rights Committee. 1989 CCPR General Comment No. 18: non-discrimination, https://www.refworld.org/docid/453883fa8.html (accessed 06 March 2022).