In Norway, the Ombudsman concluded in December 2018, with reference to the Psychiatry Act, that it violated the law to use forced treatment with an antipsychotic in a concrete case.
According to Norwegian law, forced drugging can only be used when, with “high probability, it can lead to recovery or significant improvement in the patient’s condition, or if the patient avoids a significant worsening of the disease.” Many other countries have similar laws, but sometimes the probability criterion is related to forced admission rather than forced treatment — it is then understood that forced admission allows forced treatment.
“High probability” for a significant improvement of forced drugging means a good deal more than 50%. Referring to science, the Ombudsman noted that the probability of achieving the intended improvement is only 10-20%, which means that for decades, unlawful decisions about forced drugging have been made.
The Ombudsman criticized many other issues, commonly seen also in other countries. It is a prerequisite for forced drugging that the beneficial effect must clearly outweigh the harms (called “disadvantages”) but, in violation of the law, the authority had not assessed this balance.
The authority referred to “what arose” in a conversation with the patient; what was in the patient’s files; and a conversation with the staff that mainly was about how the patient appeared and behaved. It was a breach of good administrative practice that no notes were taken from the conversation with the staff, or from conversations between the hospital and the authority.
The authority also pointed out that the staff expressed they had come to the “end of the road” concerning achieving an improvement without antipsychotics; that the responsible professional believed it would be “irresponsible and unethical” not to initiate medical treatment to prevent significant deterioration; that the general knowledge of the effect of the medicines had to be relied upon; that the patient was ill and needed help; that the person responsible for the treatment had chosen to use the relevant medicines; and that they had broad professional expertise and experience with a focus on the patient’s best interest. None of these explanations were accepted by the Ombudsman, as they have nothing to do with the law’s requirements to the probability of a significant improvement.
The authority also referred to the Drug Compendium, but the Medicines Agency replied that one cannot say anything about the probability of a positive effect for an individual patient.
The authority asked why the Ombudsman wanted to go into an academic issue of whether the responsible therapist had used relevant drugs in the specific case. Similar arguments are heard elsewhere when outsiders try to objectively assess the issues, and their aim is to keep people away so that the psychiatrists are not accountable to anyone. The Ombudsman was surprised about this question because his legitimate task was to find out whether the law had been violated.
I have collaborated with Norwegian former Supreme Court Attorney Ketil Lund on these issues, and already in 2016, we explained in a law journal why forced medication cannot be justified.1 The efficacy of the medicine is poor, and the risk of serious harms so great that forced medication seems to do far more harm than good.2 We also explained why it is misleading to assert that antipsychotics can prevent relapses in a quarter of the patients, which the Ombudsman mentioned. What is called recurrence when the patients no longer receive the drug is very often withdrawal symptoms that appear because the brain has been accustomed to the drug. What is seen in a randomized withdrawal trial in the drug-free group is therefore usually the damaging effects of the drug and not the relapse of the disease.
In all countries, we need to work for ensuring that forced medication for psychiatric patients becomes forbidden by law. Virtually all countries, apart from the United States, have ratified the United Nations Convention on the Rights of Persons with Disabilities,3 which prohibits forced drugging, but as far as I know not a single country has done anything.
In 2003, using scientific arguments, lawyer Jim Gottstein convinced the Supreme Court in Alaska to decide that the government cannot drug someone against their will without first proving by clear and convincing evidence that it is in their best interests and there is no less intrusive alternative available. Unfortunately, this victory for human rights has not created a precedence in Alaska where the authorities continue to force people into being treated with antipsychotics. Just like anywhere else, including Norway. This must stop.
