- by Simon Wessely and Greg Smith
Few would dispute the gains arising for the individual, family and
wider society of helping long-term unemployed people back to work.
The links between unemployment and poor mental health including
suicide are just about the strongest links known to psychiatry.
Details emerged on Wednesday of the
review to be carried out by Dame Carol Black into how best to
support those with long-term health conditions who are unemployed,
yet could be helped to rejoin the world of work.
So far so good, but there is a sting in the tail, and it is a
pretty big one. All this started in February when David Cameron
announced that he had asked Black “to consider whether people
should face the threat of a reduction in benefits if they refuse to
engage with a recommended treatment plan”.
This is where things get tricky. Threatening to remove benefits
if people do not agree to treatment puts doctors (and indeed all
health professionals) in conflict with core principles of the law
and medical ethics. Furthermore, it could have serious unintended
Linking benefits to treatment sounds suspiciously like a
coercive measure to “incentivise” people who would not otherwise
have had treatment to accept it. And if so, it is legally
problematic. The people affected by this policy may turn up to
receive the treatment in question and therefore seem to be
consenting to it. But consent to treatment must be free from undue
influence, otherwise it is legally meaningless.
of Re T is the clear legal authority for this.
A woman was injured in a car accident. Although she had not
brought the subject up before, after spending time with her mother
(a Jehovah’s Witness) she unexpectedly said that she did not want
to receive a blood transfusion. The court held that the mother had
put pressure on her daughter to refuse it, to the extent that the
daughter had departed from her own wishes. As Lord Donaldson
observed: “In some cases, doctors will not only have to consider
the capacity of the patient to refuse treatment but also whether
the refusal has been vitiated because it resulted not from the
patient’s will, but from the will of others.”
The case also made clear that this principle of undue influence
vitiating consent would equally apply to the acceptance of
Treating an unemployed patient for obesity or drug/alcohol
addiction on the basis of them only undertaking treatment to avoid
a review of their benefits could put any health professional at
serious risk of litigation; if a person has the mental capacity to
make a decision not to consent to treatment, as nearly all will,
which is then not respected, this is likely to be an unlawful
trespass to the person involved.
And if that were not enough, it is likely that the same health
professional would also be in trouble with their regulatory body.
For example, a doctor would be in breach of the General Medical
Council (GMC) guidance on good medical practice and consent.
Doctors are told clearly they must have consent or other valid
authority before carrying out any examination, investigation or
The GMC also tells doctors that they have a duty to ensure
decisions are voluntary and warns that “patients may be put under
pressure by employers, insurers, relatives or others, to accept a
particular investigation or treatment. You should be aware of this
and of other situations in which patients may be vulnerable.” There
cannot be much doubt that this applies to anyone with a mental
disorder or addiction problem facing the threat of losing their
But even if this was completely legal and ethical, this policy
could have perverse practical consequences. The vital trust that
exists between the patient and the health professional will surely
diminish if the public starts to perceive the latter as the agents
of state employment/welfare policy. This could be particularly
damaging in relation to mental health, where already three-quarters
of people with common mental disorders such as anxiety and
depression do not receive treatment for their illness.
And will it work? Probably not. The evidence suggests that, in
general, positive incentives encourage positive behaviours and
negative ones don’t. Far from reducing costs and freeing up
resources (a perfectly legitimate goal) this is much more likely to
waste resources by forcing people into treatments that they don’t
Overall, we fully support the goal of getting people with mental
health or addictions problems back to work, and we wish Black’s
review well. But coercing people in this fashion is probably
illegal, unethical, impractical and won’t save money. As Talleyrand
said, “it is worse than a crime, it’s a blunder”.
Read the article on The Guardian Website.
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