Involuntary Care: Legal and Effective is not Enough

“The end justifies the means. But what if there never is an end? All we have is means.” ― Ursula K. Le Guin

Debates on involuntary treatment are back in the spotlight again in BC. These debates often fall along two lines: (a) is involuntary treatment defensible in a human rights challenge? (b) is involuntary treatment effective or harmful? While we debate laws and evidence, we miss a third vitally important area: ethics.

I bring two main experiences to this topic. I work in the area of public health. I am also a person with lived experience advocating for and supporting my loved ones who have been certified under The Mental Health Act, and have been certified under the Act myself. 

I want to begin by bringing my lived experiences to the forefront.  We focus on the technicalities, the legalities, and the outcomes of involuntary treatment. But involuntary treatment itself is often a black box - a vast range of actions all under the guise of treatment.

Involuntary treatment is a woman one curtain away in the ER being strapped down and left alone while she cries that she’s thirsty. It’s armed police charging into the home, handcuffing, and pushing my medically fragile friend onto the hard bench of a police car. It’s sitting with all the other loved ones at the ER only to be told I’m the only support person who cannot stay with my friend as he must go with a security guard to a separate psychiatric ER alone. It’s my friend who has been sexually assaulted having male security guards tackle them to the ground, strip off their clothes, and leave them in a room alone. It’s being woken up at 4 AM in the pediatric ward by security guards three times my size holding my wrists down hard enough that they leave bruises so I can be injected with a sedative, restrained to a stretcher, and moved to a different city.

This is the involuntary treatment we are currently debating. We are considering whether we believe we can reliably and effectively adjudicate someone’s capabilities, incapabilities, needs, and wants in these situations. We are deciding if we support an approach that often relies on drugging, restraints, non-consensual touch, physical force, isolation, punishment, humiliation, deprivation of human needs, and the denial of human dignity. We are considering how - or if - we account for pain, shame, terror, loneliness, and alienation. My first argument is that when we debate involuntary treatment, we must acknowledge the full realities of how involuntary treatment is enacted and experienced.  

Of course there are also elements of legality and effectiveness here. How care is conducted often determines its legality and effectiveness. If done carefully, treatment may be justifiable from a legal perspective, and effective as an immediate interim intervention. However, if done in the coercive and harmful ways often done in BC, it is likely to contravene the human right of humane treatment and ultimately result in higher treatment resistance. 

Still, even if we had reliably legal and effective involuntary treatment, deeming involuntary treatment therefore justifiable is debatable. For instance, a utilitarian perspective could support treatment that is forced, causes harm, but ultimately achieves a remission. But utilitarianism is only one approach. Do we, as a society and healthcare system, subscribe to this utilitarian perspective?

This is my second argument: We must be clear what our ethics are. Whether something is right is not binary and absolute. Rather, it is multifaceted and contextual. What is right is inclusive of evidence and laws, but also values. And there are many values we may deem important, such as dignity, solidarity, equity, sustainability, and so on. As individuals and communities, it is integral we explicate our ethics and integrate them meaningfully into decisions.

My final argument is that we cannot debate legality, effectiveness, or even ethics without considering the current context of mental health in our society. Mental health is strongly influenced by the social determinants of health. Few mental health challenges have medical cures. Our most effective approaches are ones that address people’s social determinants of health, work collaboratively, and support their holistic wellbeing. What is ethical when it comes to mental health treatment is often much more complex and context-dependent than the decisions we may make for chemotherapy, mechanical ventilation, or organ transplant.

In conclusion, involuntary treatment cannot continue to be considered only objectively,  judged by one singular ethical orientation, and devoid of broader context. Instead, what is right must attend to the practices and experiences of involuntary treatment, the values we wish to prioritize, and the relevant contextual aspects. I will close by returning to the quote at the beginning of this essay, rephrasing to say: the cure justifies the care. But what if there never is a cure? Then all we have is care. All we have is care, which therefore must be justifiable in and of itself. Care being legal and effective is not enough, it must also be ethical. 

- C.M. (VIVED member & organizer)