Nigel Turner's HyperGUIDE to the Mental Health Act

Specific Guidance on Certain Medical Treatment

The Mental Health Act Commission has issued specific guidance over certain forms of medication. Section 58 allows some people who are detained in hospital to be treated, for their mental disorder, against their will. However, there are some types of medication which can only be given safely if the patient undergoes regular blood tests. If a patient refuses to have blood tests, does the Act authorise a doctor to take blood samples against the patient's will? Are the blood tests part of the medical treatment for mental disorder?

The medication in question is:

Clozapine

Clozapine was developed in the 1960s as an effective treatment for psychosis. However, for a small number of people, it was found to damage the body's ability to fight infection. It was withdrawn during its clinical trials in the UK in the 1970s. The lower resistance to infection takes the form of a reduction in the number of white blood cells.

Further information is now available about clozapine through further carefully controlled clinical trials, and because it was not withdrawn in all countries. It has been found that:

• clozapine is especially effective for patients for whom other mainstream anti-psychotic medication has proved ineffective
• clozapine has fewer side effects (of the type resembling Parkinson's Disease) than many other mainstream treatments
• while a reduction in the white blood cell count could prove extremely dangerous if substantial/prolonged, if the fall is noticed early and clozapine treatment is stopped, the white cell count will recover.

Given the considerable benefits of clozapine for some patients, in the 1990s it is now licensed for use, with the following safeguards:

• the white blood cell count must be monitored every week for the first 18 weeks of treatment and then every two weeks for as long as clozapine is taken
• doctors who wish to prescribe the drug have to register themselves, their patients and the dispensing pharmacist, with a special monitoring service.

These safeguards apply whether or not someone is detained under the Mental Health Act.

Lithium and Carbamazepine

These drugs are used as mood stabilisers in bi-polar affective disorder / manic depression. It is good / recommended practice to monitor the level of the drug in the bloodstream, to ensure it is high enough to have the desired therapeutic effect, but no so high as to be potentially toxic.

An Uncertain Legal Position

In the absence of definitive legal ruling, a number of possible views could be taken:

1. That there is no specific legal power to force someone to have a blood test. Therefore medication requiring blood tests cannot be given if the patient will not consent to blood tests.

2. The Mental Health Act, at Section 63, states that the patient's consent is not needed for medical treatment for mental disorder (when this is under the direction of the Responsible Medical Officer), other than for treatment which is covered by Section 57 and Section 58. Blood tests could be regarded as a Section 63 treatment. However, a blood test does not in itself treat a mental disorder. If the "treatment" is regarded as clozapine and the blood tests taken together, then this does not help because one "treatment" cannot fall under Section 63 and Section 58 at the same time.

3. The blood tests can be seen as an inseparable part of the medical treatment and therefore falling within the Section 58 consent to treatment provisions. In the case of clozapine it is especially pertinent that the taking of blood is an express requirement of the drug's licence.

The Mental Health Act Commission has indicated that the last of these approaches appears to be the most sensible, especially given the efficacy of the medication for many people. Patients often respond quite quickly to clozapine and have fewer side effects. They may well, therefore, be relatively quickly in a position to give informed consent once treatment is underway.

However, if a patient actively refuses to have a blood sample taken, the Responsible Medical Officer will have to use her/his judgement, in conjunction with the multi-disciplinary team, to decide whether to proceed. In considering whether to approve the use of clozapine against a patient's wishes, the Responsible Medical Officer and Second Opinion Appointed Doctor must give special consideration to the degree of the objection to blood tests, and to any reasons the patient gives, e.g. religious reasons.

The position may become clearer in future if a court has to make a ruling on the topic.