they are not satisfiedwith their treatment or should referrals be at the discretion of .... acceptance that she must remain for the rest of her life in a state of confused ...
An Ethical Debate Second opinions: a right or a concession? Should patients have a right to a second medical opinion if they are not satisfied with their treatment or should referrals be at the discretion of doctors to prevent waste of scarce resources? The father of a psychiatric patient describes his experiences of trying to obtain a second opinion, and we asked a range of interestedprofessionalsfortheircomments.
Patient's perspective
TAnarkshire Healthcare NHS Trust, Hairmyres Hospital, East Kilbride G75 gRJ AnthonyJ Pelosi, consultant
psyhiatrist Mencap National Centre, London ECIYORT
E B McGinnis, special adviser
McGill University Centre forMedicine, Ethics and Law, Montreal, Quebec, Canada H3A 1W9 Carl Elliott, assistant professor The Surgery, Woodbury, Exeter EX5 lNZ Angela Douglas, general
proautner 670
My daughter, M, now aged 42, has been treated by a long succession of psychiatrists since she was 16 and has been called schizophrenic for at least 10 years. Three and a half years ago, while she was detained for six months under the Mental Health Act 1983 and in a depressing local hospital, a consultant at Maudsley Hospital said that she could take her immediately for assessment provided that her present consultant or her general practitioner would refer her. The consultant refused on the ground that he had a plan for her treatment and that it was "not clinically necessary." Her general practitioner talked with the consultant and supported him. So M could not go to Maudsley. The consultant's "plan" broke down later, because M would not stay in the sheltered accommodation in which he had placed her. We sought advice through the National Schizophrenia Fellowship on a patient's right to a second opinion. The Mental Health Act Commission and a senior member of the Royal College of Psychiatrists both concluded that there is no established right to a second opinion; a referral is at the discretion of the doctors concerned. The patient's charter confirms this situation: "Every citizen has the following established National Health Service rights ... (4) to be referred to a consultant acceptable to you, when your general practitioner thinks it necessary, and to be referred for a second opinion if you and your general practitioner agree this is desirable." Two years later M, even iller than before, came under the care of a different psychiatric consultant, Dr A, because she had changed her address. Dr A's training is psychoanalytic, and four years earlier he had treated M privately for 11 months, without any success. As she was deluded, confused, and sunk in apathy, it seemed to me and my wife, judging by what we have read about the drug clozapine, that it might help to bring her out of this state. We wrote to Dr A and asked him to consider clozapine. He replied brusquely that it is highly toxic and that he had no intention ofusing it. Subsequently, in a lecture given to the National Schizophrenia Fellowship, a Dr B from the Institute of Psychiatry (associated with Bethlem Royal and Maudsley Hospitals) said that the institute could now take patients without a referral. On the telephone Dr B said that he would be pleased to arrange for M to be interviewed with a view to admission. He was going abroad, but a colleague would deal with this. We wrote to Dr A, with a letter signed by our daughter supporting the request, asking him to refer her to the institute for a second opinion. He refused. When I telephoned another doctor at the institute and asked if they could see M without a referral the answer was no. Dr B had been mistaken. By now, because of various moves, our daughter was not on any general practitioner's list.
Further correspondence followed, ending with a
letter from our daughter's consultant (Dr A) to the psychiatrist at the institute (Dr B) suggesting that it was quite improper for Dr B to have made the offer of a consultation without having first spoken to him. He continued that he disagreed with Maudsley Hospital's "pharmacological" attitude towards psychiatric illness and with testing "new and potentially dangerous chemicals on cohorts of individuals." The letter ended with a veiled threat that he could make M a ward of court-no mention of applying to do so. There remains one possible way out for our daughter: to apply to the hospital trust that employs Dr A for a change of consultant. But is it not likely that a new consultant would stand by his or her colleague?* Author's comment It seems to me that psychiatrists, although their specialty is more divided and less founded on objectivity than other branches of medicine, may be more prone to such absolute resistance to second opinionsperhaps because they are not used to having patients with a mind of their own. When we sent Dr A the letter signed by our daughter asking to be referred to the Institute of Psychiatry he questioned whether she had signed with full understanding. A fair question, of course (though she is a voluntary patient). But, by the same token, is she capable of understanding the implications of his treatment, which seems to require acceptance that she must remain for the rest of her life in a state of confused apathy, lightly medicated, kindly treated, and "with a lot of input from professionals"? *Eight months after M came under his care (when we had written to his hospital trust, the local health authority, our member of parliament, and the mental health association MIND), Dr A conceded a second opinion. By then M was in a hostel, given chlorpromazine and temazepam and kindly treated. She spent most of the time in bed, often incontinent, doing nothing except obsessively repeating certain phrases. Her new general practitioner agreed to refer her to Maudsley Hospital's second opinion clinic. She was interviewed there in a month, admitted to Bethlem Royal Hospital within another three weeks, and almost immediately given clozapine. In two weeks the repetitions stopped, and she began to improve. Six months later, M is back in her own flat with occasional visits from a support worker.
I'imitations of psychiatry AnthonyJ Pelosi The author is correct to state that psychiatry is more divided and less founded on objectivity than other branches of medicine. Despite this there are principles of good practice' which seem not to have been followed in his daughter's case. This family has suffered because some informal medical advisers have failed to grasp that schizophrenia is idiopathic and is almost certainly not a single disease entity. Therefore, treatment must be unsatisfactory and there is no knowledge base and no technical skills which could justify superspecialist clinical opinions. Misguided enthusiasm is the best BMJ VOLUME 311
9SEPTEMBER1995
