Suzanne Crowe: People with severe mental illness will be failed by proposed new law

Psychosis robs people of their ability to understand how ill they are. If enacted, the Mental Health Bill will mean people stripped of insight by their illness will be able to refuse treatment

Dr Crowe writes that a good intention — to protect patients' rights — has led to a Mental Health Bill which would deny people with psychosis treatments they need if they choose to decline them: It's the illness and not the treatment that robs them of their autonomy. Picture: iStock

My mother reminded me recently of a warm summer’s evening when I was a child, when the neighbour’s son Mark jumped over our garden wall and ran straight through our house, with two gardaí chasing him.

Mark was in his early 20s and had schizophrenia. Every year or so he became acutely mentally ill. That night he howled and tore at his hair as the guards restrained him. 

He didn’t go easy, and we were frightened of the man we knew as a gentle character. 

He needed involuntary admission to hospital and treatment. A few months later, he was back in our housing estate, peaceably mowing lawns for a few quid. Life was difficult for Mark’s parents when he was sick, the worry etched deep on their faces.

The Mental Health Bill 2024 is beginning Oireachtas committee stage, for debate and amendments. It offers lots of innovation, with a clear clinical and legal framework for mental healthcare, including the management of children in approved centres. 

Inexplicably, however, it drops the ball for seriously sick people like Mark.

Significant mental illness is a world away from the ebb and flow of mood and distress experienced by most of the population. 

Services for the mental health of most people do not require such tight regulation or legislation, as the person feeling unwell mostly understands their poor health and is actively asking for help. 

They can advocate for their human rights, including their right to be treated when they are sick.

People with psychosis don't know they are ill 

A relatively small number of people, like Mark, suffer from terrifying delusions, hallucinations where they see things that are not real, and voices telling them horrible things. Or have episodes of mania where they run through the streets in the dead of night, handing away their possessions and scribbling furious letters to hundreds of people known and unknown. 

The ripple effects on a person affected, their family, their community, and emergency services are terrible. A subtle but critically important difference between a distressed man with crippling depression and a man with delusions of torturing demons often amounts to one key detail: Insight.

Irish Medical Council president and consultant paediatric intensivist and anaesthesiologist Suzanne Crowe. Picture: Moya Nolan

Psychosis robs the sick person of any insight into their illness. They cannot ask for treatment because although they are suffering beyond all pain that we can comprehend, they do not know that they are sick. And that their demons are treatable.

In medicine, there are only a small number of people who are unable to ask for treatment, including those experiencing psychosis. Knowing how they would wish to be treated is helpful, which is why Mark’s parents could support his involuntary treatment, as they knew he was happiest when he was well.

The Mental Health Bill, if enacted in its current form, will mean that Mark can still be detained without his consent — but in his active psychotic state he cannot be treated if he says that he does not want treatment.

A young man who believes he is being monitored by special agents or evil scientists intent on draining his blood, is unlikely to accept treatment from the doctors who have assessed him. 

The psychiatrist who wants to treat Mark will have to make an application to a circuit court judge for permission to treat Mark against his will — but not for the detention itself.

Unlike those suffering from most mental illnesses or physical ailments, people with psychosis are unaware they are sick, let alone how ill they are. Stock picture

Mental Health Bill creates a bizarre anomaly

Bizarrely, a situation is created by this proposed new legislation where the doctors are detaining, and the judges are treating. 

Going to court for permission to treat will add to the legal complexity for patients, families, and staff, and increase legal costs. If the judge allows the treatment to go ahead, the care plan must then be agreed with the minister for health — an Orwellian development that sees medical care directed by politicians. 

Even if the health minister were a doctor — as has happened — it is still an unprecedented degree of control over the medical care of any person. Why are the mentally sick and vulnerable being singled out for this political influence?

Psychosis robs patients of their autonomy

It appears that the care of severely sick people is being bound up in these legislative chains because of a positive intention to better protect their human rights, particularly the right to choose to decline medical treatment. 

Autonomy over our lives is a core human right. 

One of the key things to understand about people experiencing psychosis is that their capacity to comprehend their illness is robbed by the illness itself. Picture: iStock 

When the capacity to comprehend your illness is robbed by the illness itself, autonomy is eroded by the illness as choices, risks, and benefits may not be understood either. 

Early treatment assists the sick person to regain their autonomy, in addition to protecting their right to dignity, respect, access to healthcare, and the avoidance of cruel or degrading treatment.

Leaving a person psychotic and untreated is degrading and avoidable and I don’t believe any of us would want that for ourselves or our loved ones.

Current act respects patients' rights 

There is no doubt that in the past there were plenty of situations where autonomy and other human rights have not been respected in the context of psychiatric illness. 

However, the current Mental Health Act 2001 — with mental health tribunals and the oversight of the Mental Health Commission — has been effective in ensuring that patients who are admitted and treated without their consent, have their care reviewed by an independent psychiatrist within days of their admission, and have access to an appeals process.

Other countries, such as the US, which have adopted laws which prohibit involuntary treatment, have seen seriously mentally ill people drift on to the streets, unable to engage with social services or benefits. A shopping trolley filled with cardboard boxes and belongings, or a prison cell, become their only home. It is timely treatment that restores people like Mark to better health, sending him home rather than risking arrest and imprisonment.

Acute mental illness intervention and care undoubtably requires a complete overhaul, with significant investment in community mental health teams, crisis intervention services, and holistic assessment separate from A&E — it doesn’t need this bill as it is currently drafted. 

Mental health remains a chronically underfunded part of healthcare, receiving 5.6% of our health budget in 2024 despite a Sláintecare commitment to increase it to 10%. 

To compound this ambivalent funding approach to such vulnerable people with a piece of legislation which holds the prospect of limiting care further is illogical and cruel.

Listen to parents who beg for intervention

Too often in intensive care, I have admitted young people who have tried to take their own lives. 

Often their admission, and sometimes their death, is accompanied by harrowing parental accounts of how they begged for their sick loved one to be involuntarily treated for their mental illness. The loss of human potential is heartbreaking.

To admit and not promptly treat denies the person their right to return to health. This incomprehensible flaw in the proposed bill needs urgent amendment.

• Suzanne Crowe is a consultant in paediatric intensive care and president of the Medical Council