8 March 2002
by Nicolas S. Martin
Executive Director
American Iatrogenic Association
In the face of intense pressure being applied to reduce errors and improve care quality, the American Hospital Association has come up with a novel response. AHA proposes to modify the “one-hour rule” for keeping patients in “seclusion or restraints” because this federal rule “compromises operations and safe patient care” by forcing hospitals to have a prisoner, er patient, observed by a physician within the hour. The AHA also wants to reduce the undue burden the rule places on its member hospitals by allowing nurses to replace doctors in deciding the course of the imprisonment, or to allow physicians to make the call over the phone instead of in-person.
Why are hospitals, nurses, and physicians in the business of secluding (locking up) and restraining people? Obviously it because those people are found to be “mentally ill.” But we are constantly told that “mentally illness is just like any other illness,” so does the AHA also propose putting diabetics, asthmatics, and stroke victims in seclusion or restraints? Not just yet.
The Constitution does not accord special police powers to medical staff. Nor does it provide that people labeled “mentally ill” have fewer rights than the rest of us. If a person is unruly he should be evicted from the hospital. If he causes damage to person or property, before or after arriving at the facility, he should be taken to jail. We have ample laws, such as against disturbing the peace, that can be applied to people who misbehave, and their enforcement is no job for medical staff. It may not be true that “mental illness is just like any other illness,” but it is true that the “mentally ill” are Americans just like any other Americans under the Constitution. They should be accorded the same rights and responsibilities under law. A person who disturbs the peace in a restaurant, shoe store, or supermarket would be arrested and jailed for trial. If he disturbs the peace in a hospital he should face the same fate. (It must be said that force is frequently used against patients who are not exhibiting unruly behavior on the grounds that they might be suicidal.)
Mental illness is a model of circular reasoning. A person misbehaves because he is mentally ill, and he is mentally ill because he misbehaves. If he had a genuine brain disease, such as Alzheimer’s or epilepsy, “seclusion or restraint” would be considered nothing less than torture. But because there is no physical evidence of “mental illness” the person “diagnosed” as having it can be treated as harshly as the medical staff deems necessary. (Most people are unaware that epileptics were labeled “pathological criminals” and imprisoned in “colonies” in the century just past. Physicians were just as confident then about the medical necessity of imprisoning epileptics as they are now about “secluding or restraining” and forcibly drugging the “mentally ill,” and some of the "colonies" were eventually converted into "mental hospitals.")
Americans seem willing to cede unlimited powers to physicians. For an indefinite period doctors can restrain, imprison, and drug people who are not charged with crimes or found not guilty. (Now the AHA wants nurses to have the same power.) They can force people to drug their children or risk losing custody of them. They control when, how, and with what we are allowed to be medicated. Now they agitate both for greater roles in “suicide prevention” and killing people (“physician assisted suicide”). Then there are the many “prevention” campaigns in which physicians play a lead role, lobbying against smoking, eating “junk” foods, gun ownership. Most people seem quite prepared to become utterly dependent on medical specialists with dictatorial powers. “Health” was a major theme of the Nazi holocaust, and physicians were primary architects of that horror. The Soviet Union justified mass drugging, imprisonment, and torture on medical-psychiatric grounds. From those experiences we have learned nothing.
Take note of this remarkable admission from the AHA comment:
“ . . . being an (sic) physician does not automatically convey special insight into patient behavior.”
In that simple statement the AHA has demolished the entire justification for psychiatry, which depends on the pretense that physicians do have special insights.
If physicians have no special insight into patient (human) behavior, why do they and we pretend as if they do? Why have we given them the power to use force against their (Often unwilling) clients? Why don't we give car mechanics and waitresses, people who occupations also do not "automatically convey special insight," the same power?
The AHA has inadvertently admitted something we should all recognize. And it should lead us to reduce the authority physicians possess to control us. Then perhaps we can begin to reduce the huge death toll associated with medicine and the malignant growth of the “therapeutic state.”
Nicolas S. Martin
Executive Director
American Iatrogenic Association
The following is a comment by the American Society for Healthcare Risk Management of the American Hospital Association.
http://www.ashrm.org/asp/highlights/patientsrights.asp
Hot Topics - ASHRM Position
ASHRM
Comments on
HHS Regulatory Reform Initiative
Submitted on March 5, 2002
Hospital Conditions of Participation for Patients' Rights
Seclusion and Restraint for Behavior Management § 482.13(f)(3)(ii)(C) Tag A 786
A physician or other licensed independent practitioner must see and evaluate the need for restraint or seclusion within one (1) hour after the initiation of this intervention.
Statement of Problem/Concern
The one-hour rule compromises operations and safe patient care by forcing the Medical Staff or "licensed independent practitioners" to physically come to the hospital to evaluate patients placed in behavioral restraints. This requirement places an arbitrary and unnecessary burden on hospitals to comply. Should hospital regulations or state law preclude the use of "licensed independent practitioners", the burden for evaluation falls entirely upon the Medical Staff. If the Medical Staff objects, because of the inconvenience involved or simply the recognition that being an (sic) physician does not automatically convey special insight into patient behavior, the hospital is faced with either not restraining the patient in order to comply with the standard (thereby placing the patient, other patients, and staff at risk), or acting in the patient's best interests by restraining them and then hope the hospital is not subjected to civil monetary penalties or other discipline by the Center for Medicare and Medicaid Services (CMS) if an investigation ensues.
In a comment letter addressed to Ms. Joan Simmons, Deputy Director, Health Care Financing Administration (now CMS), on January 11, 2000, ASHRM stated that the one-hour rule may be an impossible standard for some hospitals to meet (e.g., rural hospitals).
ASHRM Recommendation:
Set aside the "in person" requirement altogether and allow for a telephone consultation or, as is the case in other situations, permit the nursing staff to simply implement and/or suspend some emergency interventions with subsequent sign-off by the patients' treating physician or hospital.
In ASHRM's comment letter of January 11, 2000, ASHRM recommended that, while a telephone call may be inadequate, the interpretive guidelines do not speak to the use of two-way audiovisual observations, real-time telemetry transmission of vital signs, and two-way communication with personnel attending the patient. Such a model provides considerable observation and interaction to enable the physician or licensed independent practitioner to evaluate the patient. Thus, it is recommended that this option be included as an alternative to an on-site face-to-face evaluation.
How Solution maintains original intent
The proposed solutions facilitate prompt assessment of the incident/situation that led to the intervention, as well as the physiological and psychological condition of the patient at the time of the assessment.
American Iatrogenic Association
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