The Least Worst Option

There was a point as a young officer, when I got really frustrated by my inability to always do the right thing at work. In mental health terms, this could include working in a city where no place of safety (PoS) service existed at all and as a consequence I spent countless hours and days of my life that I will never get back, sitting in cell blocks and A&E departments, responsible for patients who should long since have become the responsibility of mental health services. It used to drive me up the wall, to be honest: why have a legal Code of Practice that states how s136 or a PoS should work, if we just ignore it? Who polices the implementation of these legal frameworks?! Whoever it was, it did not seem to be very effective.

Meanwhile in the real world, we were busy detaining people under the Mental Health Act, recovering AWOL patients and supporting NHS and MHA procedures. To be doing so in a context of imperfect options, meant I learned a very important in lesson police-work and life: decision-making is, sometimes, about selecting the least-worst option from a whole range of things you’d prefer not do.

Some real examples from policing and mental health:

  • Would you rather release a murder suspect in a gravely psychotic condition into the street without any supporting care / structures OR wilfully detain them in your cells without any obvious legal authority to do so, risking all the civil, human rights and potential criminal liabilities this entails?
  • Would you prefer to remove a patient under s136 MHA who is intoxicated, resistant and / or aggressive to an A&E department who have been known on occasion to patronise, complain or refuse to deal because they are “simply NOT a place of safetyOR would you prefer to take them to custody where the sergeant bemoans your decision because resistance or aggression might be, but probably isn’t, a risk factor for clinically significant issues which place the person at grave risk in the cells?
  • Would you rather see a self-harming, non-responsive service user who has a history of hurting paramedics and police officers and is crisis whilst in possession of razor blades or knives struck to the arms with a metal pole knowing it could break their arm OR would you prefer to see them struck with 50,000 volts from a police taser – all in the decision-making of keeping people safe?

THROWING YOUR TEDDY FROM THE PRAM

It is fruitless to stamp your foot in frustration or throw your toys from the pram – even where the situation arises because of a short-coming somewhere else or a lack of insight by someone else. It really doesn’t matter whether an AMHP could do this or that; whether A&E are right or wrong; whether the custody sergeant is being too risk-averse – you are where you are. You have to take this decision and grab the nettle; not insist upon the hypothetical one you’d prefer to take because it’s not available to you.

Doesn’t take long to work it out, does it? – you take the least worst option. The most defendable thing in the circumstances, perhaps the morally correct thing. Or do you? To do so, philosophically speaking, is to act in the utilitarian tradition of moral philosophy, or to act consequentially. Consequentialism interests me greatly, but I’ll let you find out more about that for yourself.

Sometimes, you may take these decisions in the real world whilst fighting other battles – let me explain:

The first dilemma – this was a situation in my police force area some years ago and I’ve come across it several times. There was an inter-area dispute about a patient. He was resident in Area A, but had allegedly offended and been arrested in Area B. After the MHA assessment, the poor AMHP was left in one hell of a position which had a knock-on consequence for the police: the first recommending Doctor waved goodbye at 5pm intending to play no further part in searching for a high-demand bed within a Medium Secure Unit (MSU). The search would resume at 9am, apparently. The problem for the custody officer was the detention clock on the murder suspect ran out at 2am and there was, for various legal reasons, insufficient evidence to charge him with murder. What was he then expected to do?! The first bullet point, above, was his very real dilemma.

“Well, if there’s no bed, there’s no bed. That’s all we can say.” It actually isn’t! – the state has various legal duties here so we’ll have to talk to a court about people breaching them, if you really insist? Oddly enough, a bed was found whilst we were planning for ‘the least worst thing’.

The second dilemma – this one plays itself out again and again in the UK and has featured in various inquests into high-profile deaths in custody. It’s all very well there being a legal framework and various Royal College guidelines, Codes of Practice and this and that, but the officers deciding whether to take a detainee presenting in a challenging way will have to take their decision in the environment in which they work, not the one in which they would prefer to work. It’s all very well saying, “Violent or aggressive patients cannot be safely detained in a psychiatric place of safety” or an Accident & Emergency Department, but if they are presenting in that way because of underlying clinical conditions or if there are ongoing risks from any restraint being applied to prevent harm to self or others: what do you want the officers to do?

We know from the MS v UK case, that the courts have shown an interest in the police related conditions where psychiatric patients are detained. We need to absorb the learning from cases like this and weave it into our psyche about what ‘good’ looks like. And we need to do it together because if this situation presented itself again, I think I’d resort to the first solution and speak to the force solicitor.

The third dilemma – this gets to the heart of the police use of force on vulnerable people. It is beyond doubt we would rather not use force at all and would happily spend hours talking people into the safe resolution we would all prefer. But if time is not on your side as the attending officer and the alternative is to watch someone self-harm until they can self-harm no more or put police officers at risk of death or life-altering, career ending injury, we may have to take the decision to use force. If we had to take it against a background of knowing some potential short-coming in previous health or social care responses, it can only add to frustrations.

Would we rather ‘risk’ the use of police equipment which may well cause physical injury by breaking bones or causing bruising, or the use of a controversial weapon which some will say is linked to the death of people who may be suffering from underlying health conditions that are literally invisible and potentially unknowable to the officer whose job it may have become to use force?

THE HUMAN RIGHTS ACT

Many people don’t like the Human Rights Act. I actually do. I haven’t come across a so-called ‘stupid judgement’, which when read doesn’t make sense. << This doesn’t mean I agree with every judgement! I just don’t think it is anything like the caricature present by our media. I had to study it, extremely superficially, for my inspector’s exam and couldn’t find anything to dislike.  I would also recommend you follow the UK Human Rights Blog, which is invaluable.

Two quite incidental pet facts of mine to point out, frequently misunderstood:

1. The European Convention on Human Rights was law in the UK before the Human Rights Act 1998. The HRA simply made challenges under the European Convention possible in the British Courts, although current appeals against the finding of British Courts can ultimately still go to Strasbourg.
2. The European Convention and the European Court of Human Rights is not the same thing as the European Union. Quite different. Leaving the EU, doesn’t get you out of the ECHR or vice versa, even if you think one or both of those things is a good idea.

Human Rights considerations are relevant to all three situations above. The right to life is covered by article 2 ECHR; the right not to suffer inhumane or degrading treatment is covered by article 3; the right to liberty, except in situations prescribed by law, is covered by article 5.

By virtue of these provisions, the above three situations represent a conflict. All three bullet points are a challenge to police officers as to which provision they would rather breach. So how do you decide?

CONSEQUENTIALISM

If you want to read more about consequentialism and decision-making in ambiguous circumstances, I suggest you read the work of Dr Toby ORD and those towards whom his work points.  He is a research fellow at the University of Oxford and apart from the fact that he is known for being the academic who intends to give over £1m of his salary to charity in the course of his career, Toby’s work on consequentialism and moral philosophy, as well as on decision-making in uncertain conditions, is nothing short of absolutely fascinating.

It is against this philosophical background and practical reality, that I argue we must learn how to reach for the least worst option, measured in terms of potential and actual consequences for the well-being of other human beings. The opposing philosophical position – deontology – just doesn’t cut it for me and can’t be easily applied to operational policing which is, by necessity, pragmatic.  Notwithstanding that “we don’t know what we don’t know” in various mental health related situations, this doesn’t mean there isn’t a rationale, intuitive framework for assessing how to act in ambiguous circumstances.

But form your own view – this is simply mine.

_________________________________________________________________________________________________________________________

BadgeThe Mental Health Cop blog won

– the Mind 2012 Digital Media Award, in memory and in honour of Mark Hanson.
The Awards celebrate the “best portrayals of and reporting on mental health in the media.”
– a World of Mentalists 2012 #TWIMAward for the best in mental health blogs.
It was described as “a unique mix of professional resource, help for people using services and polemic.”

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7 thoughts on “The Least Worst Option

  1. if say six officers crowd a patient who is psychotic this can make someone worse. I agree though that it can be a difficult situation in certain circumstances where life is at risk but any restraint must be done very carefully bearing in mind the condition of that patient could lead to sudden death. The training I did with the police was very very good but also as a mother I have been in quite a few situations myself and the worst thing is to react in such a way that is not calm but agitated yourself or try and rush someone. This can make matters worse.

    I know very well that you cannot always reason with someone but that person is likely to calm down if left alone or if officers give some time and do not rush that person- the wards are not safe places to be on yet many people think that is the best place rather than a police cell. I would disagree as the first thing is that drugs are given – the hospital were keen to get rid of my daughter and dump her back time and time again in a scheme she was not happy. Social services and the NHS are failing and a new approach is needed such as Soteria, Chy Sawel and Root and Branch Project and then the police would not be having the problem of dealing with the same people being brought back time and time again to the wards. You mention the Human Rights ACt well I am afraid that all too often human rights go out of the window within the current mental health care system. I have seen what goes on in the wards and community.

    There is much that the police could do rather than just arrest – such people are often are isolated in society but for instance, the police once organised a wonderful week visit to Pineapple Dance Studios and to a show in the West End during a half term holiday for school childen locally. The police could also liaise with groups like Speak Out Against Psychiatry – they need to reach out to the these people more in order to understand and improve their image which is not good amongst so that are affected.

    The best approach is sympathetic and to remember that many of the patients are very highly intelligent under the mental health therefore a condescending patronising approach is not a good thing or to shout and reprimand as that person could be in a dream-like state as I have seen my daughter with no control over behaviour at times.

  2. Thank you for an interesting post about moral decision making which I think is essentially about being professional in our jobs? It is in these dilemmas that we realise how our learning should help us not hinder us and our knowledge of what it is to be human is demonstrated for all to see. Simply treating the job as a job does not help anyone but many professionals who also belong to royal colleges (;-)) feel that they lack support and/or understanding and have already given up on developing their skills in morally aware, compassionate care. It is good to hear a a different view that is honest about the dilemmas faced but while we are all under the scrutiny of the powerful media our decision making could very well be slightly flawed.

    1. I think I agree. I would argue that a slightly less pragmatic moral position, deontological or otherwise, would attract far greater criticism in the wake of untoward events. This may not matter to some, but as public service and policing in particular rests so precariously upon public consent for our near-monopoly on the use of legitimate force, it is important that imperfect decision-making can secure public support in the circumstances. Other comments, for example, on the Taser debate (see my previouvs blog post) that say “Taser is never acceptable” are too rigid, in my view. To say “we’d all prefer taser not to be used” or “we’d all prefer that people were not forced to accept medication” etc., is to miss a very obvious point about consequences.

      Thanks for the comment – I enjoy the debate! 🙂

      1. Thinking back to when I was a PC in North London in 1982 there were standard phrases that would come out on the radio from Scotland Yard when there was uncertainty about what was actually happening perhaps due to a panicking caller. The call would be to a “male or female beserk”. As a young PC I attended one of these calls alone to the Royal Free Hospital which concerned a mental health patient running amok around the hospital. My radio did not work within the hospital and as I walked along the corridors the wards were locked with anxious faces peering through the glass pointing which way the patient had gone. The place was eerily quiet. The trail was fairly easy to follow with smashed lights and other damage along the way. As I rounded a corner I saw a very large man who was threatening a medical student with something in his hand and was lunging towards him with the object. Instinctively I attempted to restrain the gentleman with a bear hug from behind which was totally ineffective and I was thrown around the corrider. The medical student assisted me and we were eventually able to restrain him but not very effectively, what he had in his hand turned out to be broken bic pen and he proceeded to gouge chunks out of his forearm with it. The medical student somehow managed to calm him down by talking to him for which I was very grateful. I have to be honest and think that if tasers had been around at that time; I would have been tempted to use it although I don’t know how effective this would have been on this particular patient.

  3. Another top blog, thanks.

    You make a really interesting point around how we justify our decisions to a public that we rely on for legitimacy. I agree that consequentialism is easy to understand, and appears intuitively correct, compared to, for example, the categorical imperative. Could we then say that an additional benefit of a consequentialist approach (in a very begging-the-question way), is the better ability to explain actions to the public, and thus maintain public support and confidence? We don’t make decisions in isolation, and when you look at ethics in a more academic setting, it’s easy to forget the practical significance of what we are doing.

    Can we use another ethical framework though? Consequentialism has some big problems, which I’m sure you’re familiar with (and there are some rebuttals), and I’m not a fan of Kant, but what of virtue ethics, the third of the ‘big-three’ ethical paradigms? What I really find interesting is the differences in decision making when you have 1 second, 1 minute, an hour or a week to make the decision. The less time you have, the more you have to fall back on our more intuitive/emotional means of deciding things (the so called ‘system 1’ in the psychology literature), rather than the more rational though-through approach. This is, of course, dominated by character, experience and values – concepts that are hard to inculcate through a computer based training package – but concepts that lead us in the direction of virtue ethics. Of course, explaining virtue ethics to a general, skeptical, audience is not going to be easy…

    In the issues around Taser in the previous post, we clearly had a conflict between certain principles and certain consequences. Regardless of the actual differences, what we need, in my humble opinion, is the ability to be able to articulate our arguments and engage in a constructive manner with those who have differing ideas, with the aim of either i) influencing them into agreeing with us, ii) allowing their valid points to shape our arguments, perhaps even to change our position or iii) politely agreeing where the division is, and managing the fall-out. This needs thoughtful leadership at many levels, from the PC practitioner upwards. So even if we aren’t relying on innate virtue to shape the 1-second decision, some of those same skills, abilities and ideas are needed to help explain the more reasoned decisions. (Dare I mention professionalism?)

    I would say more, but this is a MH blog, not an ethics one!

    PS. I really agree with your stance on ECHR, and the seeming failure of anyone to successfully champion it in the face of (apparent) populist angst.

  4. I agree Alex that this is a professional issue not simply an ethical issue which is always going to be shaped by the values and beliefs of each individual profession and individual person. Here the word culture enters into the dilemma as what is readily acceptable in one culture may not be in another. Decision making therefore is not simply the weighing up of evidence or outcomes but the very substance of our moral beings although we may not see it that way in our everyday lives or practice. The ethics debate does help us to question this though and whether we do this more safely in academia or practice is perhaps where the debate should lie? Michael Sandel’s presentations at the BBC Reith Lectures are worth listening to – http://www.bbc.co.uk/programmes/b00kt7rg

  5. Still not convinced.
    Police somehow managed without Tasers before they existed – so to somehow present Taser as the ‘least worst’ (sic) option is pretty disingenuous.
    Communication is key (as Susan Bevis points out above, not patronising them and speaking to them like a naughty six-year-old! Mental health problems do not equal learning disabilities. *Some* police officers need to learn this – commentary not aimed at anyone specific).
    If force is needed, I would have thought police are trained in how to restrain someone without causing permanent damage (and this blog is pretty clear that they are). I know of 2 female service users who have had arms broken when detained. I find that concerning. I would be more concerned however if they had been Tasered. It’s the lack of control resulting from total incapacitation, for someone who is already terrified (hence resisting) that can be traumatic. Also yes Taser has been linked to deaths in people with underlying medical conditions.
    People have the right to harm themselves/ make unwise decisions, and you’ve said so in other posts with which the part about using Taser to prevent self-harm seems inconsistent.
    Taser seems open to abuse. Tempting to use ‘because it’s there’. Easier to press a button and shut the person up than bother with communication and proper restraint…just say they were violent, after all, who is going to believe a mental over a police officer?

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