www.crossingdialogues.com/journal.htm NEW IDEAS Crossing Dialogues Association Involuntary antipsychotic medication and freedom of thought MARI STENLUND Centre for Social Ethics, Department of Systematic Theology, University of Helsinki (Finland) In this article I clarify the relationship between the use of involuntary antipsychotic medication and a delusional person's freedom of thought in the light of three different views of freedom, namely, freedom as negative freedom, freedom as having an autonomous mind and freedom as capability. It is not clear how freedom of thought as a psychotic person's human right should be understood and protected in practice. Therefore, further discussion is needed. These different ways of understanding a patient's freedom of thought also encourages to consider individual situations, hear the patient's voice and work both multiprofessionally and across disciplines. Keywords: freedom of thought, freedom, psychosis, delusions, involuntary treatment, antipsychotic medication. DIAL PHIL MENT NEURO SCI 2011; 4(2): 31-33 31 INTRODUCTION The use of involuntary antipsychotic medication in the treatment of delusional patients is a problematic issue from a viewpoint of freedom of thought. In the human rights discussion, freedom of thought concerns with the individual's private and internal sphere. Unlike the right to express and manifest one's thoughts, which concerns the public and external sphere, a right to hold thoughts "in one's mind" is defi ned as an absolute human right which should be not restricted in any situation for any reason (e.g., Nowak 1993, p.314-315; Partch 1981, p.217). Moreover, the defi nition of what constitutes thought is very inclusive. According to Tazhib (1996, p.313), "freedom of thought applies to every conceivable kind of thought on any subject an individual might have". Thus, it seems that most delusions could also be defi ned as thoughts, at least if we take the previous defi nition literally. If a person has a right to hold delusions, the use of involuntary antipsychotic medication would be a questionable matter since the purpose of the use of medication is to infl uence the patient's thoughts, namely, his or her delusions. This kind of accusation has been presented in discussions critical of psychiatry (e.g., Szasz 1990; Gosden 1997). However, the mental health legislation of many countries, ethical principles and psychiatric practice show that the use of involuntary antipsychotic medication has not been considered as a violation of some absolute human right but is, in fact, permitted in certain situations. However, it is unclear why this is so. DISCUSSION In my ongoing doctoral research into social ethics, I have noticed that the view of the relationship between the use of involuntary antipsychotic medication and freedom of thought depends on how the concept of freedom is understood. Classically freedom of thought has been understood as negative freedom (see Berlin 1958), that is as a right which operates when other people or the state do not prevent the individual from ascribing and holding his or her thoughts. This way of understanding freedom of thought is visible for example in ethical guidelines of psychiatry which state that mental health treatment should be the least restrictive or intrusive as possible (e.g., Principles for the protection of persons with mental illness and the improvement of mental health care 1991, principle 9:1). It is this kind of approach that is usually present when it Dialogues in Philosophy, Mental and Neuro Sciences DIAL PHIL MENT NEURO SCI 2011; 4(2): 31-33 Stenlund is argued that involuntary treatment restricts a psychotic person's freedom (e.g., Kaltiala-Heino et al 2000, p.213). It is this view of freedom in particular which most challenges the use of involuntary antipsychotic medication: it can be asked whether the nursing staff violates the absolute rights of a patient by manipulating his or her brain with the use of medication. When freedom is understood in this way, further discussion raises, among others, the problematic question concerning the relationship between competence or capacity and absolute rights. Secondly, freedom of thought can be understood in terms of an "autonomous mind". From this viewpoint, a person may have thoughts which are alien to him or her and, thus, the question is whether the person's thoughts are really his or her own authentic thoughts (Pietarinen 1998, p.22-23). Inauthentic, or alien, thoughts may be the result of so-called brainwashing. Delusions might also be understood as thoughts which are alien to the person who holds them. Therefore, a psychotic disorder is seen as restricting the person's freedom of thought by distorting his or her authentic thoughts. Often this view is presented implicitly by noting that delusional people are not autonomous because of their mental disorder (e.g., Gutheil 1980, p.327; Beauchamp and Childress 1989, p.224). From this point of view, one of the goals of involuntary antipsychotic medication is to "return" the individual's freedom of thought. The goal of the use of medication is to liberate the person from the power of psychosis and allow him or her to regain the authenticity of their thinking. The problem is whether thoughts can be classifi ed as inauthentic when people themselves claim that the thoughts are really their own. The third view of freedom of thought is rooted in the capabilities approach (e.g., Sen 2000; Nussbaum 2000). This view asks what kinds of intellectual resources and abilities the individual has and how capable he or she is in reaching his or her ideological and creative goals. If freedom of thought is understood from this point of view, both psychotic disorder and psychiatric treatment increase and reduce a person's freedom of thought. On the one hand, people with psychosis sometimes feel that their creativity and ability to develop new ideas have increased (see Jamison 1993). According to Kapur (2003, p.15), before experiencing a psychosis people have experiences about "greater awareness". Antipsychotic medication may damp down not only this psychotic experience but also the (so-called) healthy abilities connected to thinking and experiencing. On the other hand, a psychosis and its consequences very often impair a person's capabilities in several areas of life which may in turn infl uence his or her intellectual resources and capabilities in reaching his or her ideological and creative goals. Psychiatric treatment may increase and return these capabilities. The problem with this view of freedom is that the concept of freedom becomes so wide that the border (if there is one) between freedom and other important values turns out to be unclear. CONCLUSIONS It seems that these different understandings of freedom of thought and their applicability to delusional individuals lead to a lack of clear common ethical rules in psychiatry. Since different kinds of approaches are somewhat controversial, emphasizing one view may also lead to decisions that seriously restrict other important aspects of a delusional person's freedom of thought. Even though legislation and ethical guidelines demand the protection of the patient's freedom of thought it is not self evident how this right is actually understood and how it should be protected in practice. There seems to be a need for further interdisciplinary discussion. Human rights theory in particular should be developed so that the tension between the use of involuntary antipsychotic medication and freedom of thought will be more carefully considered. However, these diverse understandings of a delusional individual's freedom of thought should not just be regarded as a problem but also as a challenge with potentially positive consequences. If diversity is acknowledged it may lead to consider the individual situations, hear the patient's voice and work both multiprofessionally and across disciplines in order to understand which aspects of freedom of thought are central in each individual case and why. Thus the 32 www.crossingdialogues.com/journal.htm challenge posed by these different understandings may even have benefi cial consequences in terms of protecting the psychotic patient's human rights as a whole. 33 Corresponding Author: Mari Stenlund Centre for Social Ethics, Department of Systematic Theology, Faculty of Theology, P.O. Box 33, 00014 University of Helsinki, Finland Phone: +358 44 2841309 email: mari.stenlund@helsinki.fi Copyright © 2011 by Ass. Crossing Dialogues, Italy REFERENCES Beauchamp T, Childress JF. Principles of biomedical ethics. Third edition. Oxford University Press, New York and Oxford, 1989. Berlin I. Two concepts of liberty, 1958. In: Berlin I. Liberty. Oxford University Press, Oxford, 2005:166-217. Gosden R. Shrinking the freedom of thought: how involuntary psychiatric treatment violates basic human rights, 1997. www.freewebs.com/administrationdelajustice/documents/ gosden.pdf. Accessed 22 September 2011. Gutheil T. 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