3. The Psychiatrists Debate
Of course, like any therapeutic approach, CTOs do not work for every patient. Patients who respond poorly to medication do not to do well on CTOs and a few patients who have entrenched oppositional personality traits may actively resist the CTO. Often these poor candidates are recognizable a priori, but in some cases a trial of treatment under a CTO is required to determine if it will help.
Distributive justice demands that all citizens have an equal right to treatment and should not be deprived thereof because they lack the capacity to recognize a need for treatment. We do not deprive demented or intellectually impaired individuals of the treatment they need when they lack capacity and equally we should not deprive people with mental illness. This parens patriae duty has long been accepted as a basic responsibility of a society to take care of vulnerable citizens.(p. 297)
3.1. The Evidence Debate
Patients will find their liberty restricted without any clinical benefit in return. Care providers will have their hopes falsely raised. Clinicians have probably the most to lose. CTOs bring with them bureaucratic and time-consuming obligations that distract us from other more effective and evidence-based activity. Perhaps most important, it will perpetuate an image of our profession as one that follows fads and fashions and ignores the evidence when it is inconvenient.
Justification for using coercion is generally based on “medical necessity” and “dangerousness”. These subjective principles are not supported by research and their application is open to broad interpretation, raising questions of arbitrariness that has come under increasing legal scrutiny. “Dangerousness” is often based on inappropriate prejudice, rather than evidence. There also exists compelling arguments that forced treatment, including with psychotropic medications, is not effective, despite its widespread use.
3.2. Missing Evidence in the Debate
4. Clinician and Cultural Bias
5. Consent and Insight
6. Legal Considerations
Conflicts of Interest
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