Is the Refusal of Care "Symptomatic of a Mental Pathology"?

Is the Refusal of Care “Symptomatic of a Mental Pathology”?

By the CICNS (March 2011)

The actors of the anti-cult fight all share the “belief” that the human behaviours observed or supposed in unrecognised spiritual groups are specific to those groups and that it would therefore be fitting to treat this “problem” in an equally specific way.

Apart from this common characteristic, the various publications of the organisations fighting “the cults” allow two distinct currents to be glimpsed.

The first is that of the associations, such as the ADFI and the CCMM, of which Anne-Lise Diet, a psychoanalyst and author of a few articles on “the cults”, declares:

“These associations are however themselves very vulnerable, for reasons they have not always given themselves the means to think through, because they have hesitated to professionalise themselves. Dealing with perverse hold and with delirium, they are marked by the suffering of the volunteers, who have for the most part lost a child, a parent, a spouse in an organisation, and are constantly in the dramatisation effected by the testimonies they receive. As far as we have known them, they have refused the necessary theorisation that only psychoanalysis was capable of providing them, denied the work of supervising the teams, repudiated the fact that the subject who sinks into an organisation has, initially, consented to it, and that it is this consent that must be analysed. These last assertions are felt by the associations as a diminution of the grave perverse attacks of which the followers are the object by the organisations, and would weaken the responsibility of those organisations. The temptation to reify evil is the major danger of the fight against cultic organisations, whose most perverse effect is thereby to give them a considerable power and importance. (…) The introduction of professionals into the field of voluntary work would have the advantage (…) of moving straight away out of the unified discourse — virtuous, certainly, but which runs the risk of opposing itself frontally and as a mirror to that of the cultic organisation — and would make it possible to work more deeply on the response to the demand of former followers.” (Source)

The second current is therefore that of the “professionals”, and a declaration, again by Anne-Lise Diet, reveals to us in what way the members of these unrecognised spiritual groups would come under their authority:

“We dispose rapidly of the desire for spirituality often invoked to explain adherence to a cultic organisation. The ‘desire for spirituality’ can find in our societies solid institutions that have proved themselves. If these patients do not choose to make this demanding approach, it is because it is not spirituality that is in question, but a demand to find outside themselves solutions to their malaise. Which is the royal road for the leader and his organisation.” (Source)

Thus, in this “reasoning by the absurd”, there appears a bipolar world where, on one side, people in quest of God join a “solid institution” and, on the other, the victims of a malaise (the “patients”) join an unrecognised spiritual organisation. All these organisations are to be grouped under the appellation of “cults” and they must be fought, because their only objective can be to exploit that condition of unease in their “followers” which, not being recognised by medicine either, they are not qualified to treat.

The anti-cult fight flows from this primary manichaeism, and logic dictates treating this malaise of the “victims of cults”, “without their knowing full well”, by official medicine, alone qualified to answer the unease of our society.

Edzard Ernst, Professor, holder of the chair of Complementary Medicine at the Peninsula Medical School, Universities of Exeter & Plymouth, United Kingdom, declared during a colloquium “Health and cultic hold” organised by the GEMPPI1 in 2004:

“If complementary medicine (CM) has become so unavoidable, it is indeed thanks to the popularity it enjoys. In the developed countries, 25 to 75% of the total population have recourse to one form or another of CM. It can be defined as ‘A diagnosis, a treatment and/or a prevention that comes as a complement to conventional medicine, by contributing to a common whole, by answering a demand not satisfied by orthodox medicine, or again by diversifying the conceptual frameworks of medicine.’” (Source)

This “diversification” is not to everyone’s taste, and France in particular distinguishes itself from neighbouring countries by its approach in favour of the “conventional”.

Nicolas About, co-author, with Catherine Picard, of the Law of 12 January 2001 on the cults, shows himself moreover enthusiastic: “The neurosciences are making dazzling progress; they are going to demonstrate the limits of discernment and of freedom of decision; they are bringing psychiatry and neurology, too long separated, closer together. The next fifty years will be fabulous in this domain. One need only place an electrode at such and such a place in the brain to provoke a brutal depression, and move it slightly for life to become beautiful again… The human brain is so fragile…” (Source).

In a national colloquium organised in October 2005 by the GEMPPI in Marseille on the theme “Refusals of care for ideological causes”, these differences of approach appear quite clearly between the discourses of the members of anti-cult associations and the professionals (psychotherapy, psychiatry, philosophy) who were invited to present their point of view. Their declarations seem more nuanced and sometimes offer elements for universalising the reflection, thus moving out of the “cult or not cult” framework to enter the vaster field of what may or may not seem “reasonable” and apply to any person, within the framework of the law.

We reproduce a few extracts from the proceedings of this colloquium.

According to Mr Didier Pachoud, president of the GEMPPI: “Our aim today is not to fight against parallel, non-conventional or alternative medicines and therapies, nor against religious beliefs in miracles. Our aim today is to sensitise health professionals and consumers of care to the numerous problems, sometimes grave, with which the GEMPPI association and the ‘Health, ethics, ideologies’ commission are very frequently seized. (…) These problems bear in particular on the irrational and risky abstention from classic medical care, or are generated by deviant psychotherapies that alienate and destroy couples and families.”

“Given the ‘holistic’ nature of these new therapies or of these ancient medicines brought back into fashion by those nostalgic for a bygone golden age, reputed more natural and more authentic because ancient or exotic, we would be hard put to rely on scientific bases to establish constants, laws, and facts reproducible thanks to the implementation of those laws. These medicines assert, most of the time, that they have a singular and distinct effect on each patient, which makes the subjective aspect preponderant and verifications impossible.”

Thus millennia of traditional medicine, from China to India by way of Tibet, from South America to Australia via Africa, are thrown mercilessly on the scrapheap. Assuming, of course, that we may still with impunity mention nettles… (source)

The objective is clear:

”(…) we have chosen to end this colloquium by treating the effects of the eccentric and absurd doctrine of the Jehovah’s Witnesses consisting in sacrificing one’s life or the life of one’s children (it is possible in certain countries with lax legislation on this point) by abstaining from blood transfusions that are vital in certain cases, in order to respect the symbol of life that blood is in the Bible. If one counted up the people thus sacrificed on the altar of the doctrinal cultic fanaticism of the Jehovah’s Witnesses, we would doubtless exceed the number of victims, suicides or murdered, of the Order of the Solar Temple. But rest assured, the Jehovah’s Witnesses do not disturb public order, they let themselves die in silence (…)”

After having concentrated on the spiritual minorities, the anti-cult fight extended its action towards the alternative therapies, some of which had developed within spiritual minorities but others not. The means of trying to curb all these people were then developed: the locking of access to the status of religious association, the About-Picard law, the identification of people not wishing to be treated conventionally or who refuse vaccination, etc.

The anti-cult fight thus finds itself facing two questions: how to constrain people refusing to let themselves be treated and, subsidiarily, how to twist the notion of “disturbance of public order” so that it automatically encompasses “doings of a cultic character”, in order to be able thus to eliminate the “cults” without finding itself confronted with European justice?

“The only conditions in France for benefiting from these fiscal advantages are to have as one’s activity exclusively public worship and not to disturb public order. (…) It is a legal and administrative arrangement, from which any cult could benefit in the future provided it respects its forms… A refusal of recognition, in that case, could be brought before the European Court of Human Rights.”

“Faced with certain incoherences and imprecisions, we really think that the French notion of ‘public order’ must be closely reviewed and made more precise, especially when one considers that a Jehovah’s Witness abstaining from a vital blood transfusion today has almost a 50% chance of no longer being a follower of the cult within the following 10 years (according to the Jehovah’s Witness society’s own statistics), if only he is left a possibility of surviving when he needs a vital blood transfusion.”

In an interview given to Riposte Laïque, Mr Pachoud specified:

“An example of a first task to be undertaken would be: the notion of ‘disturbance of public order’, which is so vague and so little restrictive that it is hardly exploitable by the French authorities to refuse the fiscal advantages attaching to religious associations to a group considered as involving dérives sectaires. (…) It would be fitting to make more precise, without becoming trapped in detail, the notion of ‘disturbance of public order’ and to rigidify it in order to guard against groups known to be at the origin of dérives sectaires. (…) All this in order to tend ideally towards there being only a single type of association (with a religious object or not); this would avoid a great many ambiguities.” (Source)

Among the examples cited to justify the GEMPPI’s positions is the case of Doctor Gérard Guéniot:

“I should also like to introduce you to the spirit that motivated the holding of this national day for the benefit of victims of cultic therapeutic conceptions, by relating to you one last case, typical and quite illustrative of the nature of the problems and questions that present themselves to us, with a phenomenon of massive increase of late.

Doctor Guéniot treats cancer with… carrot juice. He is in prison

La Dernière Heure, 10-11-2005 (Belgian press). BRUSSELS. Dr Gérard Guéniot, a Frenchman forbidden to practise in France, was arrested last month at Nivelles for fraud and illegal practice of the art of healing. On another level, Guéniot has never hidden being a Bearer of the Cross, a branch of the Grail, which offers followers a greater well-being through spiritual purification. (…)”

Charline Delporte, president of the ADFI Nord, declares on this subject:

“As an example of a so-called natural technique, of the kind found in abundance in new age groups and in the cults, that of Dr Guéniot, who was a member of the Grail Movement, is emblematic. In my view, he will have trouble with the courts, notably following the death of a patient… Dr Guéniot proved very dangerous by treating cancers with holly… One person died of it although she could have been saved and was curable, if she had followed a classic medical treatment.

Here is one of the grave consequences of mental manipulation of the cultic type, which has nothing to do, from the point of view of the consequences, with the little manipulations of which we are the object daily through advertising notably. In one case, one may lose one’s life, as is the case of Jehovah’s Witnesses refusing vital blood transfusions, and in the other, one will have let oneself be convinced to buy yoghurts.”

Now, following 10 years of investigation, Doctor Guéniot was acquitted on 17 February 2009 by the Court of Appeal of Douai, which explained “that Dr Guéniot had examined the patient on only one occasion. And that consequently, he could not be convicted of ‘failure to assist a person in danger’.” (Source)

In the fourth part of this colloquium, professionals explore the possible answers to the questions of the anti-cult associations.

Is the refusal of care symptomatic of a mental pathology? Can the medico-legal framework of the obligation to undergo care apply?

Point of view of Dr Eric Kania, psychiatrist at the Baumettes remand prison in Marseille, member of the GEMPPI and of the “Health, ethics, ideologies” commission:

“I propose to approach today’s theme from a psychiatric angle. I specify that it will be only the point of view of one psychiatrist, because I do not claim to enunciate a point of view that could generalise the opinion of the psychiatric community. Moreover, there is no univocal point of view of the psychiatrist on these questions. The psychiatric community is very heterogeneous, as is psychiatry moreover, which is a science comprising many hypotheses and few certainties.”

“From what point is a person who refuses care, even at the peril of his health or his life, stricken with madness or unreason?”

“As regards the refusal of medical care, the general principle is that of consent. The doctor must obtain the patient’s consent for any medical act (…).

Let us recall (…) an old general principle, taken up recently in the ‘Kouchner law’ of 4 March 2002, which stipulates that ‘no medical act, nor any treatment, may be carried out without the free and informed consent of the person, and this consent may be withdrawn at any moment’.”

“This text contains important words. For example, what is ‘free and informed consent’? The refusal of care is legally authorised, but it must emanate from a certain and informed will of an individual having the government of his person and of his thoughts.”

“For example, it is considered that minors, children, cannot validly refuse care that is vital for themselves. In those cases, it is the parents’ opinion that is taken into account, and if the parents oppose care deemed vital, the doctor may appeal to the judicial authority for the care to be administered.

“It is the same for adults lacking legal capacity, persons placed under guardianship, who likewise could not validly refuse vital treatments. The problem would arise all the same if the guardian were caught up in a cultic ideology and refused vital care for the person for whom he assures guardianship. I do not know whether there exists case law on this point. In any case and in a general manner, the doctor must ensure that the patient has sufficient lucidity, which can be a delicate question. It is known that lucidity must not be confused with freedom of thought. Classically the doctor must not take into consideration the motives for which the patient refuses the therapy, and religious convictions do not automatically signify the loss of all lucidity.

“This general principle of consent has exceptions. During a meeting preparatory to this colloquium, we had during a ‘brainstorming’ brought out the idea of the obligation to undergo care, since one of the exceptions to the principle of consent — but it is not really an exception, rather a particular case — is that legal arrangement called ‘the obligation to undergo care’.

In our reflection group, some of us, including in particular a lawyer, proposed using this legal framework of the obligation to undergo care to constrain patients who refuse care for cultic causes to be treated.”

The “legal principle” of the obligation to undergo care “cannot apply to what interests us today. (…) The obligation to undergo care is a measure pronounced by a criminal judge, that is to say at a moment when a person commits an offence. The judge may pronounce this obligation to undergo care if he considers that there is a link between the offence and a possible pathology to be treated. (…) All that is quite remote from the theme of refusals of care for ideological causes. People who refuse medical care because they have extremist or cultic religious convictions are not a priori delinquents in the general case. So this legal principle of the obligation to undergo care cannot apply in those cases.”

“There are 2 modes of hospitalisation: compulsory hospitalisation and hospitalisation at the request of a third party. But in the great majority of cases, as regards people who refuse medical care for cultic religious reasons, there is no real psychiatric pathology requiring medical care in a hospital setting. I do not say that these sick people refusing medical care are always completely free in their choice; there may exist a certain number of cases, difficult to delimit, where delirious patients integrate a cultic ideology.”

“But in most cases, people refusing care for cultic causes do not really present psychotic decompensation, in the psychiatric sense of the term, even if there are fairly often underlying personality disorders. In these people adhering to extremist cults to the point of refusing vital care, there are quite often ‘borderline’ personality disorders, or grave neuroses. Even if one cannot completely assimilate adherence to a cult to a psychiatric pathology, it is evident to everyone that certain gurus present quite proven paranoid traits, and the people who follow them can sometimes be seized by a sort of collective hysteria that verges all the same on pathology, but that does not justify constrained hospitalisations.

“Thus doctors or psychiatrists find themselves in a delicate position when they are called to the rescue in this kind of situation where people refuse care at the peril of their life. They have no symptom of pathology, as is the case, for example, of the Jehovah’s Witnesses who generally present a certain lucidity in reasoning, with a form of logic proper to them, but which cannot be qualified as delirious pathology in the psychiatric sense. There remains the question: How can these people, apparently sound in mind, whose faculties of reasoning seem more or less preserved, arrive at this extremism and refuse care at the peril of their life in order to respect the rules laid down by a guru or the central college (world leadership of the Jehovah’s Witnesses)?”

“I confess that I have no single answer to the question, which seems to me of an extreme complexity. Perhaps certain theologians could evoke the mysteries of faith, even if differences must be recognised between faith and fanaticism, but on the purely scientific or psychiatric level it is sometimes difficult to make the distinction between what belongs to faith, of which the theologians speak, and what is fanaticism, including in its extreme forms. Moreover, one could say that in every era, in every religion, there have been martyrs. For example, the first Christians accepted being devoured by lions for their faith… Today it is certain Islamists who blow themselves up in order to obey their ideology… Where is the limit between faith, fanaticism and mental pathology? For some, faith belongs to psychopathological phenomena.” Freud said quite clearly that religion is the obsessional neurosis of humanity in “The Future of an Illusion”. One could turn the argument back on him concerning psychoanalysis, which could also be designated as a form of illusion whose future is uncertain. Without wanting to make too abusive an amalgam, one might wonder whether in the great instituted religions there are not sometimes discourses a little difficult to accept medically — notably the Vatican’s position against condoms, which can also have disastrous effects at the level of public health, perhaps not so much in France because Catholics do not necessarily follow the Vatican’s positions as if they were divine words. In certain countries (African notably), on the other hand, this can pose a problem. So, is it more dangerous to hold a discourse against transfusions or to forbid the condom? As a doctor, both seem to me condemnable.”

“For the legal questions, the legislator wanted to put in place an arrangement to limit the damage of the cults in the domain of health, notably by creating the so-called ‘About-Picard’ law, named after the deputies who reported it. This law at the outset wanted to institute an offence of mental manipulation. These terms have an evident interest for the psychiatrist, even if the legislator renounced this appellation, in part because of the reservations expressed by the representatives of the religious communities (and of course of the cults) as well as the national human rights committee, because these terms seemed too vague to be juridically applicable. So, in the course of the debates and the various shuttles between the assemblies, these terms were replaced by ‘offence of fraudulent abuse of the ignorance or weakness of a person in a state of physical or psychological suggestion’… (…) It is, according to [our parliamentarians], the act of a person within a grouping that pursues activities having as their aim or effect the creation or exploitation of the psychological or physical dependence of the persons who participate in those activities, of exercising on one of them grave and repeated pressures or of using techniques apt to alter their judgement in order to lead them, against their will or not, to an act or an abstention that is gravely prejudicial to them. This text seems clear for jurists, but what is psychological dependence? How does one define techniques apt to alter judgement?”

It emerges from this intervention that the legal arrangement of the obligation to undergo care does not apply in cases of refusal of care for ideological causes; that the About-Picard law, by reason of its imprecision, is as ill adapted to the medical milieu as it is in the legal domain; and that the refusal of medical care for “cultic” religious reasons is not considered a psychiatric pathology.

Dr Victor Hugo Espinosa, President of ECOFORUM, remarks:

“Therapeutic excesses of a cultic nature are doubtless favoured by deficiencies emanating from the classic health system. Perhaps it would now be necessary to act more upstream, more in prevention, and to find solutions for injecting more humanity into the hyper-technological universe of classic medicine; otherwise people will always tend to look elsewhere.”

Pierre Le Coz, president of the Centre for Study and Research in Medical Ethics (CEREM), presents opinion 87 of the National Consultative Ethics Committee on the refusal of treatment and the autonomy of the person…

“Today, because of the increased complexity of therapeutic proposals, often invasive if not aggressive, a greater autonomy of decision is recognised for sick persons (law of 4 March 2002) in the domain of medical care. He who consents must have the possibility of refusing. (…) This refusal of treatment always appears — envisaged from the side of medicine — as a sort of transgression of the principle of beneficence.”

“However, the Committee considers that the dilemma is not resolved by force. It is not by obliging a Jehovah’s Witness to undergo a transfusion that one arrives at a satisfactory solution to the problem of his refusal of transfusion. (…) If the subject is an adult, his refusal of transfusion poses an insoluble case of conscience to the doctor: on the one hand the regulations in force scarcely accommodate a therapeutic intervention without the consent of the person concerned; on the other, his professional vocation obliges him to transfuse.”

“The subject finds himself constrained to sacrifice one of the two values to which he is most strongly attached (his life or his belonging to the ‘elect’). But though constrained, it nonetheless remains an effective choice, as is attested by the case of followers who decide to accept the transfusion, thereby assuming their exclusion from the group. That is why the doctor cannot decide on the basis of belonging (sometimes temporary) to this or that community.”

”(…) Respect for the refusal of treatment is required as a general rule, even if it is founded on the religious convictions of the person concerned. Freedom of religion is guaranteed by our constitution and by the European Convention on Human Rights.”

“The Committee proposes to distinguish three acceptations of the term ‘autonomy’:

“An autonomy of action, which refers to the possibilities of bodily motility. (…) From this point of view, neither the very young child nor the mentally handicapped person can be said to be ‘autonomous’.

2nd) An autonomy of will, which broadens the subject’s independence to his capacity to suspend the impulsive spontaneity that mechanically determines his action, in order to decide according to a conscious and personalised resolution. (…)

”- as self-limitation, (…) the free decision consists in the respect of universal duties towards others and towards oneself. An autonomous being cannot take a decision that is not universalisable. To be autonomous is to be moral, and morality commands that one decide out of pure respect for duty. Following this perspective, a man could not be said to be free in the full sense of the term if his behaviour is the effect of the fear of a god or of mechanical obedience to an irrational dogma. Heteronomy (obedience to a ‘law’ imposed by another) is an alienation of reason that mutilates the human being of the most essential dimension of his being.

”(…) This rationalist interpretation of autonomy implies that certain people are not autonomous, despite what they say: the woman who refuses the help of a blood transfusion during a haemorrhage in childbirth (Jehovah’s Witness), the suicidal person, the hunger striker, the drug addict adopt conducts whose maxims are not universalisable.”

”- as self-determination (or ‘sovereignty’): In more equivocal cases where the patient refuses a treatment of which one cannot be sure that it will save his life, the reference to the universalisation of the maxim of our actions becomes problematic: must one oblige a patient to subscribe to a therapeutic strategy on the grounds that his principle of action (‘to let oneself die rather than undergo the throes of a heavy and uncertain treatment’) could not be universalised?”

“To obey reason could authorise every abuse. The Committee has retained the sense of the autonomy of the will as individual sovereignty. (…) One has the right to be mad, as long as that madness does not harm others.”

“No universal reason can settle the dilemmas. That is why the patient who refuses care does not have to be protected against himself (against his unreason) but solely against the destabilising and threatening environment in which he finds himself plunged from the outset on arriving at the hospital. From this point of view, in the case of a refusal of treatment, it falls to the doctor only to ensure that the patient is not deciding under the hold of psychological constraint exercised by a third party. The logic of this model of liberty ends in affirming that, from the moment the doctor has observed no external pressure on the patient, he may consider that his refusal expresses his autonomy and that consequently he must respect it. He does not have to ask himself whether this refusal is determined by various causalities, nor to seek to exercise a ‘benevolent’ pressure on the patient to inflect his conduct (paternalism).

“This has as a consequence, where appropriate, that the doctor knows how to renounce any attempt at persuasion, including when there exists an available curative means that the patient refuses. Doubtless, on the diagnosis for example of a lymphoma with a very good prognosis for the success of chemotherapy, the doctor will in general decide to take the time necessary to change the mind of the patient who declines the proposal in the name of the side effects linked to that treatment. For all that, can we qualify as respectful this quest for the patient’s consent? If the latter has perfectly understood the situation, is insistence not an incitement? Incited, does consent remain as ‘free’ as the law demands?”

“Article 7 of the code of deontology stipulates that the doctor ‘must never depart from a correct and attentive attitude towards the person examined’. (…) If by chance he managed to carry his consent by a rhetorical coup de force, would he not place the patient in the situation of having to face the heaviness of a treatment in a state of moral suffering aggravated by nostalgia for his initial refusal? One may even wonder whether the effectiveness of a treatment is not diminished by the fact that it is accepted only reluctantly (what is the impact of an antidepressant for a patient who resigns himself to it only with regret, for example?).”

“The position of the National Consultative Ethics Committee on the subject of the refusal of care can give matter for reflection. Personally, it seems to me that the legitimation of the refusal of care in the name of respect for individual sovereignty rests on the postulate of a subject free in his choices, conscious and independent of any external pressure, which may appear as a scarcely credible hypothesis in several occurrences of clinical life. What of, for example, the refusal by a patient to follow a treatment nevertheless adapted to his cancerous pathology, because he knows that it is liable to hamper the course of his professional career durably? Does such a refusal not express a form of subjection to economic and social constraints? When the patient seems to him caught in a network of contexts (personal, social, cultural) that determine his reactions, can the doctor make it his duty to act as if he were dealing with a free subject, on the grounds that he has observed no manifest pressures on the part of those around him? Can one say that he ‘respects’, properly speaking, the patient who finds himself before him?”

The numerous questions posed envisage the deprivation of liberty of individuals whose life choices differ from the norm and, in a genuinely democratic society, they would have no reason to be posed. The CICNS is nevertheless glad that the answers brought are not definitive and seem to leave a door open through which avenues of reflection not yet glimpsed may emerge. Our association presents itself as a partner for broadening the debate by presenting the spiritual minorities of our country no longer as a scourge worthy of an Inquisition but as full members of the social fabric, capable of proposing solutions to the “malaise” of our time.

1 The GEMPPI is a movement associated with the CCMM for the Bouches-du-Rhône and a member of FECRIS. It steers the “Health, ethics, ideologies” commission, which studies more especially the cases of cultic hold in the health sector. (Source)