Supervised Self Harm Plan
An innovative scheme allowing patients who self harm to do so under supervision in hospital, has attracted considerable comment in the healthcare and general press. Those reports indicate that patients will be allowed to carry on cutting themselves, but would be offered substitutes such as holding ice cubes or wearing tight elastic bands. The scheme is regarded as being of therapeutic benefit as many patients who self harm do so as a way of coping and/or as a relief from their problems. The traditional approach has been to seek to prevent people from self harming by, for example, confiscating the means of self harm. Under the new scheme healthcare professionals will talk to each patient about where, when and how they injure themselves, in addition to offering them psychotherapy. Patients will not be provided with the means to self harm, but they will not be prevented from so doing if they are already using such methods.
This scheme touches on a number of legal issues which, should this approach eventually be adopted by other mental health hospitals, will need thorough consideration. The main issues relate to:
- The duty of care owed to the patient
- Risk management
- A patient’s human rights
- Issues relating to capacity of the patient
If the standard practice for dealing with patients who self harm continues to involve preventing such people from self harming it will be important to consider whether patients should be allowed to self harm under supervision and, if so, a careful record will have to be made as to the criteria for making such a decision. If it can be established that supervised self harm is likely to be of considerable therapeutic benefit to a patient this will probably be sufficient to discharge the relevant duty of care, provided other factors are met (see below).
If such a scheme is widely introduced it will be essential to have careful risk assessments of participating patients on a regular basis. Consideration will have to be given to the therapeutic benefit of self harm for the patient, the patient’s intention in self harming and whether the means of self harm used is likely to cause serious damage to the patient’s health and/or pose risk to the patient’s life.
Having regard to the particular circumstances of a self-harming patient, it will be necessary to assess what implications there might be for the patient’s human rights. The European Court of Human Rights jurisprudence has established that organisations such as hospitals are under a duty to protect life where they “know or ought to know of a real and immediate risk to the life of a particular person”. The duties to protect the life of a vulnerable patient having regard to Article 2, which provides a right to life and imposes on the state the duty to protect an individual’s life, will involve the need for a detailed risk assessment. In particular, consideration will have to be given to whether a patient is likely to be a suicide risk and whether any previous attempts at suicide have involved the methods that the patient uses in self harming.
The right to life will have to be balanced against the right to a family life, which has been interpreted to include the right of a person to respect for their personal autonomy (Article 8). Consideration will thus have to be given to the patient’s capacity, namely their level of understanding of the consequences of self harming. Patients with fluctuating capacity are less likely to be appropriate candidates for a supervised self harm programme. Even where patients are fully competent, hospitals may be able to rely on Article 8(2) if the patient needs protection from the consequences of self-harm.
We would suggest that any patient who has diminished capacity so as to be unable to understand the reasons for the supervised self harm approach and the safeguards, such as infection advice, that are put into such a programme, would not be patients for whom supervised self harm plans would be appropriate. In exceptional cases, it will be critical for a detailed risk assessment to be undertaken and the reasons for entering the patient into the programme, with reference to his/her best interests, to be recorded. It will also be necessary to undertake a cautious approach to involving children in such a programme.
Any healthcare organisation that is considering introducing a supervised self harm plan in the future is strongly advised to introduce a policy relating to such a programme so that proper procedures are laid out as guidance for staff.
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