SOCW 6443 WK 11 Discussion 2: Cultural and Contextual Considerations

COMMENTARY

The Social Worker, Psychotropic Medication, and Right to Refuse

Mark L. Ruffalo

“No right is held more sacred, or is more care- fully guarded by the common law, than the right of every individual to the possession and control of his own person, free from all re- straint or interference of others.” — Union Pacific Railway Co. v. Botsford (1891)

Social workers employed in psychiatric and mental health settings face a multitude of po-tential ethical dilemmas in daily practice. One such dilemma is coercive treatment with psychotro- pic medications. What is the role of the social worker in such situations wherein a patient is refus- ing prescribed psychotropic drugs? Does the social worker have an ethical responsibility to act in such circumstances? The answer to these questions lies in an understanding of the social work ethical prin- ciple of self- determination and, more broadly, the political and philosophical basis of our democracy.

In a society such as ours, which places such a high premium on the freedom and autonomy of the indi- vidual, the legitimacy of medical and psychiatric treatment does not depend on its efficacy; instead, it depends on its being administered with the informed consent of the patient. Whether or not a medication will help a patient, treat or cure his or her symptoms, or prevent death, is irrelevant in consideration of the patient’s right to refuse treatment. The U.S. court system has repeatedly upheld the right of even invol- untarily committed psychiatric patients to refuse psychotropic medications, with few exceptions, such as if the patient poses imminent and substantial danger to himself or herself or others in the immediate en- vironment. The legendary psychiatrist and psycho- analyst Thomas S. Szasz (1977) noted that “with the exception of certain life-saving measures on uncon- scious patients, a medical intervention imposed on a person without his consent is not treatment but as- sault and battery” (p. 48). Reamer (2003) noted that psychiatric patients have a right to refuse treatment, particularly when coerced treatment violates their

First Amendment rights to freedom of speech and religion or their Eighth Amendment rights to protec- tion from cruel and unusual punishment. Readers are directed to Schaler (2012) and Szasz (2009) for de- tailed discussions of the legal and ethical aspects of coercion in psychiatry.

Social workers employed in psychiatric and men- tal health settings must be ready to support and de- fend a psychiatric patient’s constitutional right to refuse medication, even if such a patient is deemed to be “seriously and persistently mentally ill.” Cer- tain patients who have been deemed incompetent can be legally medicated forcibly with psychotropics under certain circumstances, but the social worker must also consider these practices an infringement of the patient’s civil liberty and a gross violation of the central social work principle of client self- determination. In a society that values freedom, there is no morally legitimate justification for coer- cive medication treatment.

Social workers who find themselves in such situa- tions must also be prepared for potential backlash from physicians, nurses, and other professionals involved in the care of the patient who may adopt a paternalistic and authoritarian stance on forced treatment. Social workers are reminded that such professionals may be misguided by a belief that a patient has an ethical “right to treatment,” an idea that is in direct contradiction to the principles of self-ownership and self- determination. A careful philosophical investigation of such a “right” reveals that it is baseless and equates to a nonexistent “right to treat” ( Szasz, 1977). No professional has a “right to treat” another person unless the person provides consent, with the obvious exception of the unconscious person who is assumed to consent to treatment.

Frequently, health care providers working with patients who are refusing medication will attempt to persuade or convince them to accept medication under threat of consequence or by withholding im- portant information from them. Such a provider

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might educate patients about the potential benefits of treatment without informing them of risks of such treatment, or similarly prompt them to accept medication or risk deprivation of other rights, such as freedom of movement. The social worker must stand firmly in opposition to such attempts to un- dermine a patient’s right to refuse treatment and must view such actions as unethical, immoral, and illegal. A social worker should educate clients in- volved in such cases about their legal right to refuse treatment, and must be prepared to support them in any decision they choose, even in situations wherein there is disagreement among professional colleagues.

The National Association of Social Workers’ (2015) Code of Ethics recognizes client self-determination as a central ethical responsibility of social workers and notes that social workers may limit self-determination only when “client’s actions or potential actions pose a serious, foreseeable, and imminent risk to them- selves or others” (p. 7). Because many victims of co- ercive medication treatment are neither dangerous nor pose any imminent risk, and because the concept of “dangerousness” can be broadened to include vir- tually any person said to be mentally ill, the social worker must consider all attempts at forced medica- tion to be in violation of the client’s civil liberties. The actual right of a person to own his or her own body and mind supersedes the nonexistent right of the provider to treat a person without consent.

Defending the psychiatric patient’s right to refuse treatment falls squarely in the domain of the social worker who is uniquely qualified to address issues pertaining to ethicality as they relate to a client’s posi- tion as a member of the broader society. Protecting a client’s right to refuse medication requires no spe- cial training in psychopharmacology but, rather, knowledge and understanding of the rule of law and the application of professional ethics. The right of the individual to own his or her body and self, and thus refuse medication treatment with psychotro- pics, is a sacred right in our society, and the social worker must serve first and foremost as a defender of freedom and human dignity.

REFERENCES National Association of Social Workers. (2015). Code of

ethics of the National Association of Social Workers. Washington, DC: Author.

Reamer, F. G. (2003). Social work malpractice and liability: Strategies for prevention (2nd ed.). New York: Columbia University Press.

Schaler, J. S. (2012). Strategies of psychiatric coercion. Cato Unbound. Retrieved from http://www.cato-

unbound.org/2012/08/06/jeffrey-schaler/strategies- psychiatric-coercion

Szasz, T. S. (1977). Psychiatric slavery: When confinement and coercion masquerade as cure. New York: Free Press.

Szasz, T. S. (2009, July/August). The shame of medicine: The depravity of psychiatry. Freeman, 59, 21–22.

Union Pacific Railway Company v. Botsford, 141 U.S. 250 (1891).

Mark L. Ruffalo, LCSW, is a psychotherapist in private practice, 10335 Cross Creek Boulevard, Suite 15, Tampa, FL 33647; e-mail: [email protected].

Original manuscript received June 3, 2015 Final revision received September 28, 2015 Accepted November 2, 2015 Advance Access Publication April 27, 2016

Social Work Volume 61, Number 3 July 2016272

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