Back in July, the Conservatives mooted a plan to strip the mentally ill of their ESA benefits if they refuse to undergo treatment. More recently, they’ve talked about doing the same to those who are addicted to drugs or alcohol, and the clinically obese. I’m going to talk mainly about why the former proposal is a terrible idea, but much of the same applies to the latter.
I should start by pointing out that these aren’t yet official policies, and so details on how they might be implemented are sketchy, assuming they even do get implemented. That means I’ll have to second-guess the government, and to a certain extent I’ll be railing against a possible worst-case-scenario which might or might not bear any relation to reality. However, I believe that even by the most favorable interpretation, these proposals are just another attack on David Cameron’s arch-enemies, the poorest and most vulnerable members of society.
The right of a patient to refuse treatment is a fundamental feature of medical ethics. Any doctor or nurse knows that it is wrong for them to attempt to treat a patient without their informed consent (except in certain emergency situations) and it is definitely wrong to treat them after they have made an informed decision not to consent. It should clearly follow that it is unethical for the government to coerce someone into treatment they would not otherwise choose to undergo. The proposals as stated, that claimants could lose their entitlement to benefits if they do not consent to treatment, are prima facie unethical.
But why would someone not want to be treated, unless they were a malingerer? Surely these people must want to get better? Well, that rather depends on the nature of the patient, their illness, and the proposed treatment. Lots of patients have serious objections to particular treatments: sometimes because of well-founded doubts about safety or efficacy (for instance, recent meta-analysis of SSRIs have shown they may well be ineffective treatment for depression), sometimes because of a general distrust of certain medical practices, and sometimes from sheer clinical paranoia or medical phobia. Are these patients to be denied their right to refuse certain medical interventions? Will they be allowed second opinions or alternative treatment options?
There are a great many possible treatments for disorders like depression, anxiety, and substance abuse. Some involve medication, some therapy, some lifestyle changes – usually a combination of all of these. What works for one patient may not work for another. Usually, there is a long and difficult process of trial-and-error before there is any improvement, and this can be frustrating for the patient: many find it too difficult and cease to engage with treatment. This isn’t helped by the fact that therapy is expensive and mental health provision on the NHS is woefully lacking, with long waiting lists to see a therapist, and relatively little patient choice. I’ve heard it said (by a therapist) that there are as many types of therapy as there are therapists. While some of them are frankly bunk, a lot of this profusion is down to the fact that different approaches work better for different patients and different illnesses. Furthermore, successful therapy often depends on building a rapport between therapist and patient, and sometimes this just isn’t possible – the patient needs to see several different people before finding someone they can have a productive therapeutic relationship with.
Bearing all this in mind, what happens if a patient doesn’t like the first treatment option they are given? What if an atheist alcoholic objects to the religiously based and scientifically unsound (but free to the taxpayer) approach of Alcoholics Anonymous? What if an anxiety sufferer turns down a prescription for Xanax? What if someone with depression doesn’t get along with their therapist, or thinks Freudian psychoanalytic psychotherapy isn’t doing them any good? What if they miss a couple of appointments because they are too depressed to attend, and thus lose their place to the next person on the waiting list? What if someone sincerely believes that, despite all the evidence to the contrary, homeopathy is a better treatment for their bipolar disorder than lithium carbonate, or a paranoid schizophrenic believes that they are the victim of a medical conspiracy? As I stated earlier, I can only speculate on what will happen in these circumstances. However, given what I already know about the DWPs tendency to use any possible excuse to deny or cut-off benefits payments, I’d bet heavily on the answer to all of the above being “they lose their ESA benefit.” Because at the root, these proposals are not about helping people in need, they are about saving money, and shifting the blame for our economic woes from the haves to the have-nots, just like all of this government’s welfare policies.