rose nikolas - unreasonable rights mental illness and the limits of the law

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Unreasonable Rights: Mental Illness and the Limits of the LawAuthor(s): Nikolas RoseReviewed work(s):Source: Journal of Law and Society, Vol. 12, No. 2 (Summer, 1985), pp. 199-218Published by: Blackwell Publishing on behalf of Cardiff UniversityStable URL: http://www.jstor.org/stable/1409967 .

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JOURNALFLAWANDSOCIETY

VOLUME2, NUMBER, SUMMER9850263-323X$3.00

UnreasonableRights:MentalIllnessand the Limitsof theLaw

NIKOLAS OSE*

Over the last twenty years, many progressivecampaigns or reformsof the

position of socially disadvantagedgroupshave articulated hemselvesintermsof rights.The languageof rightshas been adoptedboth to formulatedefensive claims - rights not to be intruded upon - and to advance

positive demands - rights to various kinds of social provisions and

resources.The passageof the Mental Health (Amendment)Act 1982-later consolidated nto the Mental HealthAct 1983 was the culminationof a vigorousreforming ampaignwhichwas couched n these terms.In theforefront of this campaignwas MIND - the National Association forMentalHealth- led by its LegalDirectorLarryGostin. In a plethoraof

publications, n evidence to official committeesand in the courts, it was

arguedthatmany aspectsof the treatmentof those diagnosedas mentallyill were an abuse or denial of theirrights,and that legal means should beused to

rightsuch

wrongs.1Theobjectof this comment s not to make a detailedcriticalappraisalofthe provisionsof the Act; undoubtedly pragmatic argumentscould bemade in favour of many of the changes introduced. Rather, throughconsideringhe strategywhichculminated n the Act, I wish to disrupt woof the underpinnings f rightbased strategiesfor social reform.FirstlyIwillcastdoubtupontheoppositionto professionaldiscretionand the beliefthat legalisation of decision making processes and their subjection to

quasi-judicialreview is an effective means of constrainingprofessional

powerand ensuring ts properaccountability.Second, I will questionthepoliticsof posingdemands n terms of rightsandentitlementsas meansof

directingsocial resourcesto particularpolicy objectives. The weaknessesidentified n thisparticular trategyof reformof provision or the mentallyill illustrateclearlysome fundamental imitationsof rightsdiscourse n theformulationand advancementof progressivestrategiesof social reform.

THE IDEOLOGY OF ENTITLEMENT

LarryGostinhastermedthe basisof thisstrategy or mentalhealth reform'the ideology of entitlement'.2 t has three axes. Firstly,to establishthat

* Departmentf SociologyandSocialAnthropology,BrunelUniversity,Uxbridge,MiddlesexUB83PH, GreatBritain

A shorter version of this paper was given at the Conference of the Socio-Legal Group in

Oxford in March 1985. I would like to thank Phil Jones and Hilary Lim for discussing theissues with me, and Hilary Allen, Rob Baldwin, David Freedman, Barry Hindess, Carol

Stephens and Clive Unsworth for critical comments on a longer draft.199



health and social services for the mentally ll are not dependent upon thediscretion of politicians, administrators r professionalsbut are entitle-ments, enablingthe courtsto be used to ensure that these rightsare notdenied. It is arguedthat this would allow the developmentof effectiveremedies - judicial, administrativeor financial- where entitlementscreated by statutes were not met by the appropriateauthorities, andprovide a mechanismfor enforcing the allocation of resources to the

mentally ll, for improving onditions n institutions,andforpromoting he

developmentof services n 'the community'and the transferof patientstothem.3

The second axis of this strategy has the objective of limiting thediscretion of psychiatristsand regulatingpsychiatricactivity. It seeks toinvolvenon-medicalexpertise- principally ocial workers in decisions

as to whether a personshould be compulsorily ommittedto hospital, tosubmit decisions as to compulsorydetention to automatic and regularquasi-judicialreview, to limit to a minimum the administration oftreatment without the patient's consent, and to constrain the non-consensualuse of treatment,thusprotecting ndividualsagainstabusesoftheirrights.4

These two axes areto be supportedby a third the maintenanceof thecivil status of the mentallyill, in particular he rightto vote and to have

access to the courts. Not only would such reformschallengeentrenchedpaternalisticattitudes to the mentally ill, it is argued, but they wouldenable them to exerciselegal andpoliticalpressure o enforce theirrights.Enfranchisementwould ensure access to the politicalprocess;access to thecourts would enable the detained patient to obtain legal redress fordetention or treatmentwhichinfringed egal or humanrights.5

The ideologyof entitlementthus seeks to providea coherent basisfor a

strategywhichutilisesthe languageof rightsand the powersof the law tominimisethe use of

psychiatriccompulsion,curtail

arbitraryprofessionaland administrativepower, improvethe qualityand efficiencyof servicesandpreserve he status anddignityof the mentallydistressed.Manyof the

provisionsof the Mental Health Act 1983 and certain of the judgmentsmadeby the EuropeanCourt of HumanRights certainlyprovidenew anddistinctforumsin whichcompulsorilydetained mentalpatientsmay havethe groundsfor such detention reviewed, and this may indeed preventunwarranteddetention to the benefit of the individualsconcerned.6The

newlyestablishedMental HealthAct Commissionmay prove an effective

instrument or monitoringpracticein psychiatrichospitals.There can belittle justificationfor the continued civil and juridicaldisqualificationssufferedbythose in mentalhospitalsor with a recordof mental llness. Butthe ideology of entitlement is fundamentallyflawed as the basis of a

progressive trategyof mentalhealth reform,in respectof its analysisof

the powers and social vocation of psychiatry, ts capacityto formulateobjectivesor to constructeffectivepolicies for their implementation.7

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THE POWERSOFPSYCHIATRY

The apparent opposition between 'legalism' and 'discretion'in publicpolicy for the mentallydistressedhas been so often repeatedthat it has

acquired he statusof truth.8 Legalism'has been associated n particular

with procedural formalisation and judicial determinationin the civilcommitmentprocess,a concernwithsafeguardinganepersonsagainst he

dangerof unwarranted etention.Proponentsof anenlightenedpsychiatryhave criticised such a concern with legal safeguardsas unnecessarilyobstructinga humanitarianherapeuticenterprise.9Othershave criticisedsuch civil libertarianismon the grounds that it can only react to theactivitiesof psychiatry,and this responsecan only be to seek limitations

upon psychiatricactivity.10However Gostin arguesthat this strategy s a'new

legalism'which does not seek to re-erecta cumbersome tructureof

proceduralregualtionor to substitutelegal for psychiatricdiscretion.11Whilst a centralfocus is still the wish to controlpsychiatricauthority, heconcernnow is not so much the liberties of the sane as the rightsof theinsane themself. This is grounded in a profound scepticism as to thescientific credentials and therapeutic efficacy of modern psychiatricmedicine,locatedwithina generaloppositionto the vestingof professionalagentswith discretionary owers.12

It is argued hatpsychiatrys unwilling o putits diagnostic udgments o

objective test and when it does so they are frequentlyfound wanting.Psychiatryhas adopted hazardousand intrusive methods of treatmentwithoutproperevaluation and where there is little evidenceof beneficialeffectsyet considerableevidenceof harmful side effects'.Psychiatrists re

incapableof making judgmentsas to the 'dangerousness' f patientsand

demonstrably ver-predict he likelihood thatindividuals re dangerous othemselvesor others. Yet, despite these deficiencies,psychiatristshavebeen given, or have assumed, unique powers in determining the

deprivation f the libertyof individualsand,oncehavingso determined, nimposing somatic treatmentsupon them without their consent. These

arguments trengthena muchmore generalopposition n rightsstrategiesto professionaland administrativediscretion. Discretion, it is argued,allowsstate empoweredagentsto make decisionsaccording o ad hoc, ad

hominem, variableand unjustifiedcriteria,within the very broad limitsestablishedby most legislationon welfare matters. But justice demandsthat decisions be made accordingto formalised,publiclyavailable rules

applying o largecategoriesof personsandspecifying n preciseterms thedecisionsappropriateo particular ircumstances. t also demands,where

necessary,rightsof appealagainstdecisions,togetherwithprocedures orthe presentation of evidence, argument and proof regulated by due

process.Hence the argumenthas led to demands or the establishmentofrules to legalise decisions, and for forums of adjudicationin whichdecisionscan be judicialised.13

It is claimed that legal mechanisms have a role which is not merelyreactive and defensive. In refusing to accept psychiatric judgments

201



concerning he need for compulsorydetentionunlessthey can be backed

by objectiveevidence and justifiedto lay personsand lawyersin MentalHealth Review Tribunals,good practicecan be promoted.In limitingtheuse of irreversibleand hazardousmethods of treatment,and those whose

efficacy has not been fully established,by requiringthe consent of the

patientand/orsecondmedicalopinionsand consultationwithotherparties(nursesand non-medicalprofessionals) t can promote open discussionoftreatmentoptionswith patientsandthe developmentof multi-disciplinaryteam work.14

We maysingleout four elements of thisargumentor criticism.Firstly ts

dependenceupon a flawedsociological critiqueof the professionalisationand medicalisationof social control. Second, the concept of individualfreedomwhichit uses to oppose or seek to limitthe use of compulsion n

psychiatry. Thirdly,the status of its

critiqueof the

scientificityof

psychiatry.And, fourthly, the efficacy of the tribunalreview which itadvocates as a means of constraining and monitoring professionaldiscretion.

1. SocialcontrolThepowersallocated o psychiatryunderthe 1959MentalHealthAct haveoften been understood n terms of the medicalisation f social control.15 tis arguedthat modernsocieties tend to allocateproceduresof controlof

deviantandtroublesomegroupsandindividualso 'experts'.Theseexpertsrationaliseand legitimisesuch controlby appealto a specialisedbody ofesotericscientificknowledge medicalorpsychological whichprovidesthe basis andjustification or their socialrole andpower. This legitimisesthe moralenterpriseof controlby definingdeviantbehaviouras sickness,controlas therapy,andthe activitiesof the socialcontrollersas scientific,rational and based upon objective judgements. It justifies control as

enlightenedat best, paternalisticat worst- motivatedby humanitarian

concernfor the good of the sick individualratherthan socialandpoliticalconcernfor the maintenanceof a docilepopulation.It disablesthose who

are the subjectof these measures,leadingthem to accepta definitionof

themselves as sick and to enter a passive 'sick role', dependent upon

professionalexpertise ratherthan havingtheir fate in their own hands.

Lastly,it provides ucrativeemployment,socialstatusandgreat powerfor

the agentson the bordersof medicineand psychologywho specialisein

providing this enterprise of moral judgment and regulation with its

theoreticalcodificationsand technologiesof control.I have arguedelsewherethatthe criticalpretensionsof these exposesof

social control are illusory.16 Given that any social and institutional

arrangementsorm,shapeandconstrainhumancapacitiesandactions,the

discoveryof 'control' is hardly surprising.The hidden agenda of such

strategies s usuallya switch n controlfrom one agencyto another fromdoctorsto psychotherapists,ocialworkersor lawyers or the advocacyof a new alignment of professional sectors and powers. Analyses of

psychiatryn these termsprovideno basis for a politicsof reform,for they

202



lackthe means to conceptualise he nature,objectivesandconsequencesofdifferentmechanismsof control- who seeks to regulatewhat, by whatmeans, in relation to what problems, in pursuit of what objectives,according o what distributionof powers.

Further,analyses n terms of socialcontrolpossessonlythe crudest oolswith which to evaluate the moral and political implicationsof different

techniquesof regulationand to formulate the objectivesof reform. It is

clearlyinadequateto appealto some fundamentaloppositionof coercionto liberty, freedom and privacy. For even the demarcationof space of

personalautonomywhich is 'notthe law's business'does not constituteanabsenceof regulationso much as a changein its modality.Here one can

point, on the one hand, to the proliferationof the psychotherapeutictechnologiesof marriageguidance,childrearing,sexual difficultiesandthe

problemsof everyday ife, and, on the other hand, to the ever increasinguse of pharmacologicaldevices to assuage personal unhappiness.The

contemporarypsychiatric ystemoperates predominantlynot by coercionbut by contractuality:personal life is adjusted through images 'freely'chosen and aspiredto, and by means of assistancesought by choice andreceivedwith gratitude.17 Indeed, oppositionto the 'coercive'aspectsofmodernpsychiatryhasbeen centralto the modernisation ndextensionofthe psychiatric ystemto new sites, problemsandpopulations;hence it is

not surprisingthat it cannot provide the means for an analysis ofpsychiatry's ocial functioningor politicalimplications.

2. Freedom ochooseA familiartheme in civil liberationcritiquesof social regulationis the

argument that danger to others is the only justification for stateintervention,and the role of the law is to defend the freedom, liberty,privacyand autonomyof the individual,and to limit treatmentto that

occurring throughfree contractual

relationships between consentingparties. Thus many advocate the 'right to be different' and to claim acontinuitybetween the involuntaryconfinement of the disturbingeccen-tric, the quarrelsomealcoholic or the sociallydisruptivederelict and theGulag.18

But the modelsof choice, intentionalityandrationalitywhichunderpinthe libertarian ejectionof compulsionare partial.The individual ree tochoose - beloved of both 'radical' ibertariansand 'reactionary'marketconservatives is no natural,universalor self-evidentground or analysisandcritique.Indeed,ashasbeen pointedoutbyauthors romKarlMarx oMichel Foucault, this individualwas invented by Western social andpoliticaldiscourse. It providedthe basisfor a historically pecificmode ofsocialorganisationbasedon the disciplinedsubject,the isolatedlabourer,the contractandthe market.It was invested with a soul and a conscienceby Christianity,and it was liberal democracywhich constitutedit as acitizenwith rightsand duties.19

Whilst rights-basedmoral discourse is fundamentallydogmatic, there

203



maybe pragmatic easons for optingfor an ethics framed n terms of thefreedomof the individualandthe Rightsof Man. But it is justasconsistentto use such a choice as a justification or compulsory ocialinterventionasit is to use it to proscribe uchintervention.For far fromthose designatedmentally ll in our culturebeingfree individuals quippedwith rights,the

reverse is the case. In our culture it is preciselythe inabilityof personstoconformto or support hisconceptionof free, rational,consistent, unified,choosingindividual hat is frequently he groundfor makingan ascriptionof insanity.And the objectiveof muchmodern nstitutionalpsychiatrys totake those who have lost theirsense of freedom,who feel at the mercyof

circumstances,of outside forces, of thought insertions or inexplicablemoodswingsbeyondtheircontrol,and to workuponthemso as to rebuild

individuality.Thus many modern psychiatricpracticesseek to promote

autonomy, to encourage the acceptance of responsibility, the re-establishmentof control over previouslyuncontrollableaspects of exist-ence. Libertarianargumentsare ill-equipped to weigh up the choicebetween a short period of 'coercion' leading to a long period of

'autonomy',and radicalnon-interventioneadingto a life permanentlyatthe mercyof the fates. Contemporarypsychiatry includingmuchof itsuse of compulsory reatment is based upon the modernconceptionofthe individualand seeks, not to destroyit, but to construct t.20

3. ScientificityThe rights trategybasesitselfupona further et of criticisms f psychiatry.These concern the validityof its claimto scientificity.21 It is arguedthat

diagnoses n psychiatryhave a status whichis, in principle,differentfromthose in other fieldsof medicine,giventhat'objective'correlatesof mentaldisorder demonstrableorganic esions, abnormalities f cells or tissues,

physiologicalor biochemicalmalfunction are rarelypresent.Hence the

particularneed to

subjectsuch 'clinical'

judgmentsto

scrutinyand to

requirepsychiatry o justifyitself to those who have no vested interestin

preserving he dubiouspowersand mystiqueof the profession.But there is no differencein principlebetween diagnosisin psychiatry

and diagnosisin the rest of medicine. Firstly, many conditionscurrentlydiagnosed in non-psychiatricmedicine have no established organiccorrelates forexample migraine.Manydiseasesnow considered o have

biological foundationwere characterised ong before their mechanismswere worked out - for example epilepsy and tuberculosis.If clinical

medicine was to limit its treatmentsto those where there was a clearknowledgeof organicmode of action,mostavailabledrugsandtechniquewould have to be rejected- we do not even know how aspirinworks.

And, of course, it is paradoxical hat the criticsof psychiatry requentlyadvocatealternative orms of therapywhichhave not even attemptedto

justify their efficacy according to the canons of science.22

Further, the process of diagnosis in non-psychiatric medicine involves farmore than the demonstration of identifiable organic malfunction. Clinical

204



judgment nvolvesthe constitutionof phenomenaas symptoms,a processnecessarilydependenton culturallyvariablenorms. It entailsthe organiz-ation of symptomsinto meaningful patterns, the eliminationof certain

interpretations nd the selection of others, the constructionof prognosesand the choice of treatment. Accounts of this process demonstratehow

little it is amenable to rationalreconstruction,either at the level of itsformalcodes or at the level of the forms of medicalreasoningat workinclinicalpractice.Clincialmedicine entails an explicitrejectionof medical

philosophyand metaphysicalsystematisation, n favour of a method of

training,practiceandjudgmentbaseduponexperienceat the bedside.The

inabilityof clinicians o formulatecommonlyagreedprotocolsof diagnosiswhichwould be intelligibleandconvincing o non-doctorss not, therefore,grounds or denyingmedicineits professional tatusbut the reverse- for

it is this which underpinsthe claim for the special competence of thetrainedclinician.23

Thus psychiatric diagnosis is not differentiablefrom other clinical

diagnoses on grounds of 'lack of objectivity'. But perhaps it can be

distinguishedbecause of its particular nabilityto make diagnosesin a

clinicallyuseful manner. For a diagnosisto be clinicallyuseful it must bemade according o formaland agreedupon categorieswhich both classifyandcommunicate he problemand have a bearingupon the remedy.It is

frequently suggested that psychiatricdiagnoses are suspect on thesegroundsbecause of their low reliability- the low level of agreementbetween trained clinicians upon how a particular case should beclassified.24But diagnostic reliabilityis similarly ow in non-psychiatricmedicine. Further, there is evidence that high levels of diagnosticconcordance in psychiatry can be produced by improved training,defintionsof symptomsand diagnoses,and better interview echniques.25Henceproblemsof diagnosticreliabilityare notpeculiar o psychiatry,and

theycast no

specificdoubts

uponits

scientificity.Ratherthangroundinga strategyof psychiatric eformupon allegationsof spuriousscientificity,attentionand resourceswould be better directedto analysing he specificproblemsof diagnosticprocessesandclassificatorysystems.Issues of diagnosis,of the strengthsand weaknessesof different

classificatory ystems, and of the validityof certaindiagnosticcategorieshave been matters of discussion within psychiatrysince its inception.26There is no reasonthat suchdiscussion hould be confinedto those trainedas psychiatrists indeedit has not been so confined. But it is unlikelythat

these issues will be effectively opened up for scrutiny by constrainingpsychiatricdecisionmakingwithprocedural afeguards,or subjecting t totribunal review. In the debates leading to the new Act, psychiatristsobjected vociferouslyto proposals to subject their clinical decisions toreview by lay persons, and demands for tribunal review of treatmentdecisions were ultimately rejected in favour of certain proceduralformalisationsnvolvingintra-and inter-professional onsultationbeforethe administration f certain classes of treatment.27But it is important o

205



recognise,firstly,thatthis defence of clinicalprivilege s morethanmerelyprofessionalhauteur. The correlation of the diagnostic powers of theclinicianwithprofessionalexclusivityarefundamental lementsof modernclinicalmedicine;a strategyto transform hese powersneeds to think its

objectivesandmechanismswith morecare thanis evidentin rights-basedoppositionto professionaldiscretion.Further,at a practical evel, thereisno evidence to suggest that hedging the diagnosticprocess about with

procedural afeguards, egally encodingsubstantivecriteriaor subjectingpsychiatric udgmentsto judicial review will improve the reliabilityof

diagnoses,their validityor therapeuticutilityor transform he relationsbetween expertise and those subject to it. Nothing in this strategywill

improve psychiatric raining,make the discussion of classificationmore

sophisticated, or affect the organisational and economic factors -

availabilityof time, staffinglevels, case loads, treatmentand so forth-which frequently have as much influence upon decision making in

psychiatric ettingsas its formal codes.

4. Quasi-judicialeviewOf course there is a very significant difference between psychiatricdecisionsand most of those in generalmedicine. The consequenceof a

psychiatricdecision may be that an individual is detained in hospital

againsthis or her will. Hence given the contentious and non-consensualnature of these decisions, and their consequences for the liberty of

individuals, here are strong groundsfor ensuringthat such commitmentdecisions are subjectto review. The MIND strategysoughtto extend the

scope and powers of Mental Health Review Tribunals. Whilst suchtribunals had been introducedin the 1959 Act, upon the abolition of

judicial commitment, they were explicitly conceived as predominantlynon-judicialn theirfunction,actingas a therapeuticback-upprovidinga

'secondopinion'. Hence rights strategistsarguedthat they functionedtolegitimatethe therapeuticenterprise,not contest it; they sought to turnsuch tribunals nto quasi-judicialreview bodies, subjecting professionaldiscretionto an independentreview which would protect the rights of

patients.They saw them as forumswithinwhichthe legalityof psychiatricjudgmentsas to the need for detention could be scrutinised,and their

objectivityand justificationevaluated.But suchtribunalsdo not, in fact,operateeffectivelyto regulate professionaldecisionmaking.Nor do theymake their decisions on the basisof a review of whetherthe legal criteria

for detention are satisfied. And even if tribunalswere more effectivelylegalised,thiswould neitherresolvetheproblemof discretionaryudgmentnor act effectivelyto improve psychiatricpractice.These considerations

suggest that a more effective strategyof reform might seek to further

de-legalisetribunals,and increasetheir efficacyas forumsfor inter- and

intra-professionaleviewof diagnoses,treatmentsandprognoses.28Firstly,it is by no means clear that the involvementof lawyersand lay

persons n tribunalsmakes them more competent,objectiveor rational n

206



making udgments oncerning ommitmenthanarepsychatrists.Research

suggeststhat non-medical ribunalmembers are more likely thandoctorsto conceive of bizarrebehaviouras resulting rom mental llness,andmore

likelyto associatemental llnesswithpotentialdangerousness. t is thusnot

surprisinghatmedical membersof tribunalsare relativelymoredisposed

to discharge han others. Secondly,the belief thatsuchbodies maketheir

judgmentsaccording o legally specifiedrules is also ill founded.As hasbeen shown in relation to other tribunals, Mental Health Tribunals

frequentlydo not operate accordingto legal criteria, and indeed theirmembersare often ignorantor wrongaboutthe natureof the law. Theirdecisions are more often guided by 'commonsense' understandingsof

madness,dangerousness nd beliefsconcerning he need for containment.

Theyare influencedmoreby therapeuticgoals- whattheyconsider o be

in the best interests of the patient - than by legalistic applicationofrules.29Hence tribunalsneither remove discretion rom decisionmaking,nor subjectit to an 'objective'review. They shift discretion o a different

place, involve different agencies and establish new powers. There mayindeedbe advantagesn the involvementof differenttypesof professionalexpertise n such decisionmaking,but these clearlycannotbe analysed ntermsof anoppositionbetweenprofessionaldiscretionand the rightsof thedetainedpatient.

Rights strategists,in England and the United States, have often laidmuchblame for the growthof discretionarypower upon loosely framed

legislation.The new Mental Health Act, like its predecessorand manysimilarmeasures,is indeed framed in loose terms. Mental illness is not

defined,otherconditions(severementalimpairment,mentalimpairment,psychopathicdisorder)are defined ambiguously,and the termson whichdetentionmust be justified- the interests of the personsown health or

safety or for the protection of others - allow enormous scope for

discretionary udgment.Given these medicalandtherapeuticcriteria, t isnot surprisinghattribunals ely upon, anddefer to medicalexpertise.Buthowevercodifiedandprecisethe criteria,discretionandjudgmentwouldstill be involved in theirapplication o cases. We can see this clearly f weconsiderthe issue of 'dangerousness'.

MIND's originalproposal, which was not adopted in the legislation,soughtto resolveproblemsof the subjectivityof diagnosisby substitutingclear, objective and demonstrablecriterionof judgment.They proposedthat 'formaladmissionto hospitalbe based upon behaviouralcriteria of

dangerousnessalone. Only graveand genuinelyprobablefutureharmtoothers should form the basis of compulsory admission . . .'.30 Thedangerousness tandardwas one which was compatiblewith the liberata-rian principle that harm to others is the only justificationfor statecurtailment f individualiberty.But sucha standardwouldnotresolvethe

problemof decisionmaking.Dangerousnesss not a clinicalcategorynor atype of personality,but an uncertainprediction;not surprisingly,neitherlay persons, nor clinicalor legal expertisehave proved adept at making

207



such a prediction.31Whether or not a particular ndvidualwill performdangerousactsin the futurecannot be extrapolated roman analysisof the

personconcernedor even theirpasthistory,for it depends upona host of

presentandfuture nter-personal, ocial and environmental ircumstances.

Judgmentsabout commitmentand dischargewill alwayshave to be made

by fallible individuals ubjectto non-rationalanxietiesand on the basis ofincompleteknowledge. Such decisions will always involve weighing upcomplexethical issues as to whether it is preferable o err on the side ofover-caution or risk harm to others for the possible benefit of theindividual.Trained and experiencedcliniciansand other involvedprofes-sionalsare morelikelyto be able to makesuchjudgments ensitivelyand in

responseto changingpublicmoresthan arelawyersdisguising heirvaluesandethics under the cover of rights.

Thus these complex problemsof judgmentwould not be assisted bymakingtribunalsmore 'legalistic',codifying he rules, increasing he levelof legalrepresentation ndoperatingaccordingo legalformsof reasoning.Legal reasoning s only one possiblemechanism or decisionmakingandcan claimno specialprivileges.Firstly,while belief that legal reasoning srule governed may be the spontaneousphilosophyof the lawyer, it doesnot adequately describe such reasoning. All legal judgments involve

discretion,and the appealto the rulesby anadvocateor a judgeis no less achoice within a set of availableand

justifiablelegaltactics than is the

attempt o claimthe existenceof discretion.Secondly, egalreasoning romthe lowest courts to the highest is far from the ideal of logic which it

purports.Thirdly, egalreasoningutilisesspecifictechniquesof argument-ation to supporttruthclaims, techniqueswhichare neitherself-evidently

superior to others nor unproblematic. Legal reasoning appeals to

'objectiveevidence'whilstchoosingto forgetthatwhat countsas evidence

is itselfa matterof judgment,andthat, in the case of mentaldistress,whatis at stake is, constitutively,a subjective phenomenon. Legal reasoning

seeks simple chainsof argumentwhere causationsmay be complex andoverdeterminedand cleaves to proceduralformulationswhere no con-

sistencymay,in fact, existin cases,contextsandconsequences nowhere

less so thanin instancesof mental distress.32Recent trials have demonstrated clearly the differences between,

psychiatricconceptionsof evidence, modes of argument,techniquesof

judgmentand notionsof proofandthose employedin the law. Psychiatricreasoning depends upon the interpretationof fundamentallyambiguous

aspects of language, behaviour, belief, emotion and understanding.Itdepends upon the applicationof a clinicalgaze trainednot throughthe

study of scholarly texts or logical procedures, but through clinical

experience.It is not surprising, hen, that psychiatricdecisionmakingis

anathemato lawyers,for the two modes of thoughtstart from different

problemsand seek differentsolutions, find them by differentmeansandevaluate them by different criteria.33Of course psychiatricjudgmentdepends upon historicallycontingentbodies of knowledge, is subject to

vagariesof fashion and the

availabilityof techniques,and is dependent

208



upon the skill, conscientiousnessand commitmentof individualprac-titioners.And, of course,we can ask how psychiatry stablishes ts claimsto truth,bywhatmeans andwith whatconsequences.But we mustnot fallvictim to the jurists'blindness to the social conditionsand interpretivecharacteristicsf theirowndiscourse.Thereis no epistemologicalprivilege

of legal thought which justifies it seeking to extend its hegemony bydenyingthe 'objectivity'of other modes of judgment.

THELIMITSOFENTITLEMENTS

The notion of entitlement in rightsbased strategiesfor reform of socialwelfarederives from the wish to transform onditionsof individualaccessto socialresources.It is

arguedhat wheresuchaccess is not

by rightbutis

in the gift of powerfulauthorities,in the form of charity,privilegesor

gratuities,recipientsaredeterred,demeanedandstigmatised.Establishingentitlementswill ensure that access is by right,with dignityand without

stigma,and enable the provisionof resources to be enforcedupon state

agencies throughthe mechanismsof the law.34 Hence the ideology ofentitlement in mental health reform claimed to provide the basis of a

strategycapableof achievingsubstantivegains in public provisionfor a

disadvantagedgroup through the combination of a campaignfor the

enactmentof statutoryprovisionsand the combativeuse of the courts toenforcethe recognitionof entitlementsand the allocationof resourcestomeet them.

As far as such a transformationof provisionis concerned, the most

significantconsequencesare thoughtto flow from the claimthata personhas a rightto treatment n the leastrestrictive ettings.This is derived romthe principlethat the use of compulsorypowersmustalwaysbe the leastinvasiveof personal libertynecessaryfor the achievementof validpublic

objectives. Gostin argues that such a principle 'would require theGovernment o create a fullrangeof community ervices .. [and]requirethe social worker to explore communityalternativesbefore making an

applicationto hospital and to refuse to make an applicationwhere the

personcouldbe supportedat home or in a non-institutionaletting'.35 Letus considerthis claimand its implications.

In the United States, litigation has persuaded the courts that theconstitutional ightsof the mentally ll aremanifold.As far as treatment s

concerned, they include the right to treatmentand the right to refusetreatment,the right to protectionfrom harmand from forced administ-rationof hazardousor intrusiveprocedures.In relationto confinement,theserights ncludethat to treatment n the 'leastrestrictive' ettingsandtoprocedural and substantive protections during the civil commitment

process.36But the consequences of these developments have beenequivocal.Legalmechanismshaveprovedcompetentat the limitingof civilcommitment, the closure of wards, the dischargingof patients fromhospitaland upholdingthe 'right'to refuse treatment.In the American

209



context, where some eighty per cent of hospital admissionswere under

compulsion,the consequencesof the rights movement have thus been

considerable,especially n conjunctionwith a moregeneralmovementforde-institutionalisationsupported from a range of different politicalpositions.

Butwhenit comesto the positive changesuponwhichthe strategybasesits claims for progressive mental health policy reform - improvingbuildings,staffing evels andproficiency,conditions,standardsof conductor treatmentregimes,or providing he 'alternativeso institutionalisation'the resultshave not been promising.In the United States the courts andthe legalapparatus avenot, in general,provedto be effective mechanismsfor specifying,enforcingor monitoringchangesin substantiveprovisions.Inmanycasestheproposedcommunity acilitieswerenot planned,funded

or implemented.37Those patientsde-institutionalisedwere merelytrans-ferredto other institutions, requently n the privatesector, often runforconsiderableprofits, usuallyprovidinganenvironmentmore'institutional'andless stimulating, ongenial,secureandprivate han the much criticised

asylum. Hence the numerous articlesarguingthat the effects of such a

strategywere that mentallyill people were 'dyingwith their rightson',decarceratedhrough he self-righteous ctionsof the civillibertarians nlyto wanderthe streetsand accumulate n the ghettos, exploitedby private

landlords,withoutcareor assistance,enjoyingformal but not substantiveliberty.38 The civil libertarianstrategy can constrain and delimit theactivitiesof professionalsand, at its extreme, reduce social interventioninto the lives of mentallydistressedpeople to that minimumprovidedbythe criminal aw- emptyingthe mentalhospitalsanddenyingpsychiatryits socialmandate.But it is impotentwhen it comesto debatingor securingpositivepolicyalternatives.

In England,the strategyof utilisingthe courts to enforce substantive

changes n patternsof spendingbyhealthandsocialservice authoritieswillbe even less successful.Whilstsome rulingsof the EuropeanCommissionof Human Rights have led to the allocation of resources to improvehospitalconditions,no indigenousbody of constitutionalrightsexists to

appeal to.39 Whilst the English courts have occasionally overturneddecisions of authorities to refuse benefits, in general the courts arereluctant to usurp the power of the legislature and the executive in

determining he natureand patternof state provision.4? In anyevent, the

Englishsituationdiffersmarkedly rom that whichprevailed n the UnitedState priorto the movement for the rightsof the mentallyill. Since theMental TreatmentAct 1930, the proportionof compulsoryadmissions o

hospitalhas been decreasing.Priorto the introductionof the 1983Act,compulsionwas involved n onlyaround enpercentof admissions.Forthevast majorityof those in hospitalas informalpatients,not to mentionthe

many thousands more who are in receipt of psychiatric attention as

out-patients, day-patients, in clinics, in local authority and voluntaryestablishments, obtaining psychoactive drugs from their general prac-

210



titioneror psychotherapyon a privatebasis, these provisionsof the newMentalHealth Act, are irrelevant,and the campaignswhich led up to itwere diversionary.41

Indeed, this strategy should itself be seen as in line with, and

contributingo, the directionof modernisation f psychiatry. t contributes

to the modernisation f psychiatryby seekingto free it from those aspectsof its social role which de-legitimise t. The use of mentalhospitalsas a

repository or those whoseonly 'illness' s thattheyare unableto copewiththe demandsof a life outside casts doubtuponthe therapeuticpotentialof

psychiatry;heir use as custodial nstitutions or those whose only 'illness'is that they are a 'danger to society' casts doubt upon the medical

legitimacyof psychiatry.Hence the strategyforms one element in theannexationof psychiatryo generalmedicine,the limitationof the role of

hospitalisation, he reduction n numbersof in-patientbeds and lengthofstay, the minimisationof compulsorydetention and the utilisation ofnon-medical nstitutions fromthe prisonto the socialservicegrouphome)for the containment of those populations not amenable to therapy.Yesterday's candalsof the institutionare replacedby today'sscandalsof'the community'.42

THEPOLITICSOFRIGHTS

But we should not confineourselvesto a criticismof the inabilityof rightsbased strategiesto deliver the social resourceswhich they promise;weshouldalso considerthe politics underlying he discourseof rights.

The ideologyof entitlementarguedthat the minimisationof the use ofthe psychiatricnstitutionand the promotionof mental healthservices'inthe community'was a consequenceof the recognitionof the 'right' totreatment n the least restrictive

ettings.This

appearso be based

uponan

evident fact: that detention in a psychiatric institution is the mostrestrictiveof all the forms of provision for the mentally distressed.However this assertionclearly depends upon the criteriaaccordingtowhich'restriction's evaluated.Manydifferentcriteriamaybe offered ascandidates:physicalconfinement,intellectualconfusion,emotional rela-

tionships,personalhappiness,productiveactivityandso forth. It is by nomeansclear thatexistencein hospital,in physicalcomfortandinstitutional

stability,is any more 'restrictive' hat the 'liberty'to remain n ones own

home unableto reachthe shopsbecauseof anxietyor depression,visitedonce weeklyby the 'communitypsychiatricnurse'.Nor arelocalauthoritygrouphomes, or privateestablishments,necessarily less restrictive' han

hospitals even whentheyare 'in the community'n the senseof beinginthe same administrativearea as that where the inmate once lived. Butwhilst this shows the impossibility of resolving questions about the natureof provision - let alone its efficacy or preferability - in terms of an appealto rights, it also illuminates the politics of rights strategies. For the

211



psychiatric eformsurged n the nameof the least restrictivealternativedidnot flow from the discoveryof a right. On the contrary,the 'right'wasinventedas the groundfor the desiredoutcome. The languageof rightsdisguises a social judgment and a political strategy - to curb the

professionalpowers of psychiatryand hence reduce the role of the

institutionscontrolledby the psychiatricprofession. To forwardsuch a

strategyby appealingto a right, appearsto removethe necessityfor thebasis and implicationsof this judgmentto be arguedout.

This is significant,for the advocatesof the move awayfrom medicineseemto haveno similarreservationsabout the discretionary owersof the

professionsof the social, and the apparatuswhich they control - 'the

community'.Yet at the verytime whena welcomeis beingextendedto theincreasedrole andpowersof social workers n thefieldof mentalhealth,in

child care policy and the juvenile courts the knowledge claims andprofessionalmotives of the welfare apparatusare being scrutinisedand

challenged.On the one side, this socialsectoris castigatedby legalistsforits normativityandbias and its involvementwith a paternalistic ystemof

surveillanceand social control. Yet, simultaneously, he new legalistsof

mental healthseek to allocatethis sector new powersin judgmentsas to

confinement,anda new role in mentalhealthservices.The socialrealityof

rights based strategies is not to transformthe relations of dominance

between professionals and those subject to them, but to effect aredistributionof status, competence and resources amongst the manysectorsinvolvedin the professionalistion f unhappiness.43

These issues lead on to some more fundamentalproblemswith rightsbasedstrategies.To argue or a right s to makea claimthatthesatisfactionof a perceivedneed be regardedas a legitimateobligationby a governmentor its agencies.But differentclaimsmaybe formulated n termsof rights,and these may be contradictoryor compete for attention or resources.

There is, of course, a venerable literaturein moral

philosophyand

jurisprudenceconcerning the existence and nature of rights and the

appropriate orms of their recognition, constructionand/or protection.There are unresolved debates concerning the relationship between

ontologicalrights,grounded n the nature of humansas individuals,or of

society, and legal rights, enacted in positive law or constitutedthrough

proceduralformalities. Moral philosophershave devoted considerableattentionto how rightsmaybe ranked n orderof priority,whetherrightscan conflictand,if so, howsuch conflictsmightbe resolved.Suchquestionsareunresolvedand the debateoverthemis, in a literalsense, interminable;rightsdiscourseis incapableof providingauthoritativesolutions to the

problems of our contemporaryfragmentedmoral order.44 Hence the

appealto rightscanprovideno effectivemeansof substantiating emands

thatparticular laimsare valid and shouldhave priorityover others.For example, the 'right'of a patient to refuse to enter hospital may

impose'duties'upontheirrelativeswhohaveto toleratebizarrebehaviourandprovidenurturance t the expenseof theirown 'rights' o liberty.Such

212



relativesmight,with some justification,claima 'right'to measureswhichwould promotethe rapidrecoveryof their loved one and their returntosocial and interpersonalcompetence. And, of course, persons in the

communitycan, anddo, claim their 'right' o be left in peacefrombizarreand frighteningbehaviour. And governments,or individual

taxpayers,mightclaima 'right' o take measureswhichwouldpromotethe maximum

efficiency of a system of psychiatriccare and the rapid restorationofdisabled ndividuals o a conditionwheretheycanexist withoutadditionalsocialsupport.The doctrinesof rightsandentitlementscannot resolvetheissue of whose 'rights'shall prevail; it merely dissimulatesthe groundsuponwhichchoicesare made.

Whetherthe languageof rights s deployedin respectof individualsor,asmorerecently, n anattempt o formulate heoriesof collectiverights, ts

realityis to disguisethe moral and political groundsuponwhichinterestsare construedto exist and their satisfactiondemanded.For example, byutilising he courts to establisha rightandto demandthat it be met, rightsstrategistsare seeking to directresourcesto those sectors whichthey are

currently upporting,at the expenseof other who haveno suchadvocates.For a court to order improved conditions or set specified standards

according o whichaninstitutionoughtto be run,or for a courtto demandthat a state authorityestablishcertainprovisions n order not to infringe

the constitutionalrightsof its citizens for treatment in 'least restrictive'settings,effectivelyconstitutesa legalarrogation f discretion n choices asto allocationof funds amongstcompetingpriorities.The appealto rightsthus substitutes legal rhetoric for political argument, and grounds an

attempt o shiftpowersfromthe politicalapparatuso the legal apparatus;paradoxicallyt de-politicises he debate overpriorities n the allocationofresourcesandover differencemechanismsof socialregulation.In specificcircumstanceshere may be pragmatic acticalreasonsto adopt such an

approach.But this is verydifferent romseekingto base a politicalstrategyupon the moralityof rights.

RIGHTSMINDEDNESS N SOCIALREFORM

Thenewlegalism n mentalhealthreform s a strategywhich s both limitedandlimiting.It is unlikelyto further he interestsof the majorityof thosesuffering mental distress. For the bulk of those who are desperatelyunhappy,bleaklydepressed,disabledbyanxiety,anguishedor crippledbymadness,the problemsthey face are not those of an abuseof rights.Thefocus on compulsionis misleading.The virtues of a transfer of expertpowerfrommedicineto lawandsocialworkaredisputable.Thebenefitsoftransferringndividuals rominstitutions o 'the community'are question-able. The solutions proposed are unlikely to achieve the desired effects.And the very terms in which the strategy is conceived are problematic.

To formulate political arguments and demands in terms of rights is to

213



attributesof humansandthe rules of just conduct.It evades the politicalissuesby its inability o confrontthe questionof the distribution f scarceresources amongst priorities and by disguisingthe politics of its ownutilisationof legal mechanisms or the exerciseof politicalpower.

Themechanismsandforumsprovided

bythe lawmayallowsymbolicallysignificant guerilla'assaultson particularpracticesand institutions.Thereare undoubtedly tactical reasons for using legal means to challengeparticularnstancesof institutionalpower, and for seeking changesin the

legal specificationsof the powers and competencesof professionalandother authoritativeagents. Changes n the law may be one element in aneffectiveprogrammeof socialreform.But rightsstrategiesdo not providea useful basisfor those who would wishto transform he socialpositionofthe mentally ll- oranyothergroupforthatmatter.Onthe contrary, hey

illustrate he limitedconceptionsheld bymanylegalactivistsof the natureof law and legal mechanismsvis-a-visother mechanismsof organising,monitoringand transformingocialprovisions.The weaknesses dentifiedin the 'newlegalism' n mentalhealthreformserve also to illustratesomeof the unfortunate consequences of the current tendency to re-cast

socio-politicaldiscourse n legal terms.

NOTESAND REFERENCES

1 See especiallyL. Gostin,A HumanCondition 2 vols., 1975,1977);MIND, Evidence otheRoyalCommmission n theNHS withRegard o Servicesor Mentallyll People(1977).For official discussions ee D.H.S.S., A Reviewof the MentalHealthAct 1959 (1976);D.H.S.S., Reviewof theMentalHealthAct 1959(1978,Cmnd.7320);D.H.S.S., ReformofMentalHealthLegislation 1981,Cmnd.8405).

2 L. Gostin,"The deologyof entitlement:heapplication f contemporaryegalapproachesto psychiatry"nMental llness:Changes nd Trends1983a; d. P. Bean)p.27. See alsoL.

Gostin,"Contemporaryocialhistoricalperspectives n mentalhealthreform" 1983b)10

J. LawandSociety47.

3 L. Gostin,op.cit.n.2, 1983a,pp.30-34andop.cit.,n.2, 1983b,pp.49-53. For adiscussionof the concept of 'community' n debates aroundpsychiatry,see N. Rose "British

psychiatry ocietyandcommunityn the twentiethcentury"n ThePowersof Psychiatry(1986);ed. P. Millerand N. Rose).

4 L. Gostin, op.cit., n.2, 1983a,pp.37-46 andop.cit., n.2, 1983b,pp.55-61; L. Gostin,"Themergerof incompetencyand certification: he illustration f unauthorisedmedicalcontact in the psychiatric ontext"(1979) 2 Int. J. Law and Psychiatry126; L. Gostin,"Psychosurgery:hazardousandunestablished reatment?A case for the importation f

American egalsafeguardso GreatBritain" 1982)J. SocialWelfareLaw83.

5 L. Gostin, op.cit., n.2, 1983a,pp.46-50 and op.cit., n.2, 1983b,pp.61-66; L. Gostin,op.cit., n. 1, 1975,chap.8; L. Gostin, "Unimpededaccess to the courts" 1979)129NewLawJ. 213;L. Gostin,"A mentalpatient'srightto vote"(1976)2 Poly. LawRev. 17.

6 B. Hoggett,MentalHealthLaw(2nd.ed.; 1984) s thebestgeneralaccountof thecurrentstate of the law. See also D. Carson,"Mentalprocesses:the Mental Health Act 1983"

(1983)J. Social WelfareLaw 195.

7 In this paper I do not discussissues concerningmentallydisorderedoffenders.For a

215



criticalanalysisof the role of psychiatryn thecriminalusticesystem,see thepapersbyP.Carlenand S. Ramon n Millerand Rose ed., op.cit., n.3.

8 See especiallyK. Jones,A Historyof theMentalHealthServices 1972).

9 Eg. K. Jones,"The imitations f the legal approacho mentalhealth" 1980)3Int.J. LawandPsychiatry ;A. Clare,"Can he lawreformpsychiatricare?" 1981)48MindOut17;D. Carson,op.cit.For a carefulgeneraldiscussion f the issuessee A. Clare,PsychiatrynDissent(2n.ed.; 1980)chap.8.

'o P. Sedgwick,Psychopolitics 1982)pp.212-221.

1 Op.cit., n.2, 1983a,pp.28-29.

12Id., p.37.

13 Id., pp.38-39. Amongstthe generaltexts Gostincites in supportare R.D. Laing, TheDividedSelf (1968);T. S. Szasz, TheMyth of MentalIllness(1972);G. Baruchand A.

Treacher,Psychiatry

Observed(1978);

P.Bean, Compulsory

Admissions to Mental

Hospitals 1980);D. Ingleby ed.) CriticalPsychiatry1981).Onrights trategies enerally,see the discussion n J. Jowell, "Thelegal controlof administrative iscretion" 1973)PublicLaw 178.

14 L. Gostin,op.cit., n.2, 1983b,pp.59-61. See also L. Gostin,op.cit., n.2, 1979.

15 Eg. N. Kittrie,TheRight o be Different 1971);I.K. Zola, "Medicine s aninstitution fsocialcontrol" 1972)20SociologicalRev.487;A. Scull,"Frommadness o mental llness:medicalmenas moralentrepreneurs"1975)16ArchivesEuropeenes eSociologie218;P.ConradandJ. W. Schneider,Deviance:FromBadness o Sickness 1980);A. TreacherandG.

Baruch,"Towards critical

historyof the

psychiatric rofession"n D.

Ingleby(ed.)op.cit.,n.13. See alsoT. S. Szasz,LawLiberty ndPsychiatry1974)andI. Illich,Limits oMedicine 1977).

16 D. Adlamand N. Rose, "Thepoliticsof psychiatry"n PoliticsandPower4: LawPoliticsand Justice(1981;ed. D. Adlam et al.) Some recentreassessments f the utilityof the

conceptof socialcontrolarein S. Cohen and A. Scull(eds.) SocialControland the State

(1983). My criticism s developedand substantiatedn the papers by Peter Millerand

myself in P. Miller and N. Rose (eds.) op.cit.,n.3. In The PsychologicalComplex:PsychologyPolitics andSociety n England1869-1939(1985)I show that the emergenceandfunctioning f psychological xpertisecannot be understoodn these terms.

17 I discussthis point further n the texts cited in n.16. See also, in differentcontexts,J.

Donzelot, ThePolicing of Families 1979)chap5; C. Lasch,Haven in a HeartlessWorld

(1977)chap.8.

18 Especially,of course, Szasz,op.it., n. 15.

19 Fora carefuldiscussion f these issues,see P. Hirstand P. Woolley,SocialRelationsandHumanAttributes1982),chap.7. See alsoA. MacIntyre,AfterVirtue 1982).

2o0On'insanityascriptions',ee J. Coulter,ApproachesoInsanity 1973).Fordiscussions fthe links between models of rationality ndthe rightsof the mentally ll, see L. H. Roth,

"Involuntaryivilcommitment: he rightto treatmentand the rightto refuse treatment"(1977) 7 PsychiatricAnnals 244; J. Monahan,"JohnStuartMill on the libertyof the

mentally ll" (1977) 134Am. J. Psychiatry1428;N. Milner,"Modelsof rationalityandmental health rights"(1981) 4 Int. J. Law and Psychiatry35. On the promotionof

responsibilityn modernpsychiatry, ee Rose, op. cit. n. 3.

21 L. Gostin.op.cit.,n.2, 1983a pp.37-38 and 1983b, p.55. See also S. Morse "Crazybehaviour,moralsandscience:ananalysisof mentalhealth aw"(1978)51 CaliforniaLawRev. 527.

216



22 See Adlam and Rose, op. cit., n.16; A. Clare, Psychiatryn Dissent(1980); Sedgwick,op.cit., n. 10 Chap1 and P. Hirst and P. Woolley, op.cit., n.19.

23 See supra, n.22. See also H. T. EngelardtJr. et al. (eds.) ClinicalJudgment:A Critical

Appraisal 1979)and M. Foucault,The Birthof the Clinic(1973).

24 For two examplesfrom the extensive literatureon reliabilitysee N. Kreitman,"The

reliabilityof psychiatric iagnosis" 1961) 107 Journalof MentalScience8766and R. L.

Spitzerand J. L. Fleiss,"Areanalysis f the reliability f psychiatric iagnosis"1974)125BritishJournalof Psychiatry 41.

25 A numberof these studiesare discussed n Clare, 1980,op.cit. n.9, pp.138-9.

26 For a good overviewof issues see R. E. Kendell, TheRole of Diagnosisin Psychiatry(1975). Diana Adlam and I have shown elsewhere (op.cit., n.16) that the view that

pathologiesof the mind arein principlenot amenable o diagnosiscannot be sustained.

27 See the discussion n Clare,op.cit., pp.371-377.

28 Foranaccountof the newpowersof MentalHealthReviewTribunals,ee Hoggett,op.cit.29 P. W. H. Fennell,"TheMentalHealth ReviewTribunal: questionof imbalance"1977)

British ournalof LawandSociety186;J. Peay,"MentalHealthReviewTribunals"1981)5 Law and HumanBehaviour161;J. Peay, "MentalHealth Review Tribunalsand theMentalHealth(Amendment)Act" (1982)CriminalLawRev. 794.

3o L. Gostin,op.cit.,n.1, 1975,pp.33-34. Thisdrewuponreformsncommitmentaws ntheUnitedStates.

31 See J. CocozzaandH. Steadman,"The ailureof psychiatric redictions f dangerousness:

clearandconvincing vidence" 1976)29 RutgersLawRev. 1084 andthe otherstudiesbythe sameresearchers ummarisedn H. Steadman,"Attemptingo protectpatientsrightsunder a medicalmodel"(1979)2 Int. J. Law and Psychiatry185. See also N. Walker,"Dangerouspeople" (1978)1 Int. J. Law andPsychiatry 7.

32 The complexitiesof legal reasoninghave of course been extensivelydiscussed.See for

exampleN. MacCormick,LegalReasoningandLegalTheory 1978).See also T. Murphyand P. Rawlings,"Afterthe Ancien Regime:the writingof judgments n the House ofLords" 1971)44 ModernLaw Review617 and(1982)45 ModernLaw Review34.

33 Theobviousexample s the trialof PeterSutcliffe TheYorkshireRipper'which ookplacein May1981.Butnotethat whileH. Fingaretten TheMeaning f Criminalnsanity 1972)sees the accountsgivenby law andpsychiatry s incompatibleM. S. Moorein Law and

Psychiatry 1984)seeks to showfundamentalommonalities etweenthem. Howeversuch

analysesat the level of theoreticalcodes are not adequateto characterise he practicalrelationshipsbetweenlegal and psychiatricdiscourses.For an incisivediscussionof thequestion of criminalresponsibilitysee H. Allen, "At the mercy of her hormones:pre-menstrualensionandthe law"(1983)9 m/f 19.

34 See especiallyC. Reich,"Thenewproperty"1964)73 YaleLawJ. 733"Individualsightsandsocialwelfare" 1964)74 Yale LawJ.1245;K. C. Davis, Discretionaryustice 1969).

See also M. Adler andS. Asquith (eds.) Discretionand Welfare 1982).35 L. Gostin,op.cit., n.2, 1983a,p.50.36

P. M. WaldandP. R. Friedman,"Thepoliticsof mentalhealthadvocacy n the UnitedStates" 1978)1 Int.J. Lawand Psychiatry 37.

37 As Gostin now seems to recognise:Gostin, 1983a, op.cit., n.2, p.36. See also M. S.Lottman,"Enforcement f judicialdecrees:now come the hardpart"(1976) 1 MentalDisablilityLawReporter 9.

217



38 Forsomeanalysesof de-institutionalisationn the USA see A. Scull,Decarceration2nd.ed., 1985) and the papersgatheredtogetherin 57 MilbankMemorialFund Quarterly(1979).See also Wald andFriedman,op. cit., p. 145.

39 Gostincites a numberof successfulcases in op. cit., n.2 1983app.31-34.

40

For exampleR v

Secretary fState

orSocial ServicesWestMidlands

RegionalHealth

Authority nd BirminghamAHA (Teaching) xparteHincksand Othersreported n TheLancet(1984)No. 8413,p. 1224.

41 S. 57 of the Act requiring onsentand asecondopinionbeforethe adminstrationf certain

veryserioustreatments uchas psychosurgeryppliesalso to informalpatients.

42 Eg "Bedsitdespairof the mentalhospitaloutcasts"TheSundayTimes20 November1983;"Tauntedman's death fall" The Times 9 January1984;"Mental health"The London

ProgrammeLondonWeekendTelevision, 15June 1984.

43 Forcriticisms f professional iscretionnsocialworksee forexample hecontributionso

H. Geachand E. Szwed,ProvidingCivilJusticeor Children1983).A usefuldiscussion fproblemswith the notionof the 'communityare' s P. Abrams,"Communityare" 1977)6 PolicyandPolitics 125.S. Cohen, in "Thepunitivecity:noteson the dispersalof socialcontrol" 3 ContemporaryCrises 339 analyses analagoustrends towards 'communityalternatives o imprisonment'n termsof a wideningof the net of socialcontrol,thinningthe mesh andblurringhe boundariesbetweenthe normalandthe abnormal, ndbetweenthe institutionandsociety.These issuesare discussed urther n Rose, op.cit., n.3.

44 The best discussionof these issues is in MacIntyre,op.cit.

45 T. Campbell,TheLeftandRights 1983)providesa usefuloverviewof the criticismswhilst

himselfseekingto rebutthem.46 On themobilising apacityof rights ee S. Scheingold,ThePoliticsof Rights 1974).On the

defenceof political ibertiessee E. P. Thompson,Whigsand Hunters 1975)Conclusionand "Theruleof lawinEnglishhistory" 1980)Bull. HaldaneSociety.For a re-assessmentof the utilityof rights n formulating ndcampaigningorsocialistobjectivessee A. Hunt,"Thepoliticsof law andjustice" nPoliticsandPower4: LawPoliticsandJustice 1981;ed.D. Adlamet al.). See also Campbell,op.cit.

rose nikolas - unreasonable rights mental illness and the limits of the law

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