More on psychiatrists and the prevention of terrorism

I am not, generally speaking, greatly drawn to Tory MPs. When Kenneth Clarke was on Desert Island Discs twenty odd years ago, I was dismayed to find that we had overlapping musical tastes. It did not shift my opinion about his politics. Yesterday morning, I heard Dr Sarah Wollaston on the BBC’s Today programme, explaining why she had changed sides in the EU referendum campaign. She particularly emphasised her unwillingness to campaign on lies about a financial benefit to the NHS from Brexit, and her concern over the impact that the Leave campaign is having on her constituents who are migrants. I was impressed. It took courage and integrity. It was uplifting to see a British politician acting on first principles rather than out of expediency.

This weekend, Dr Jonathan Hurlow posted a response to my blog about radicalisation and mental health, countering my criticisms of comments by Simon Cole, Chief Constable of Leicestershire. I have had a chance to think about what he wrote. I know Dr Hurlow, who is a consultant forensic psychiatrist with strong views about Prevent. I like him. We do not agree on a number of points. I am highly sceptical about Prevent, but I have yet to make up my mind about all of the issues. I do not doubt his integrity. I accept that he believes that the position that he takes is the best thing for people with mental health problems who are at risk of radicalisation, and I have no doubt that the same is true of Simon Cole.

In the course of my career, I have seen a huge shift in attitudes to the fundamental principles of medical practice. What once were inviolable boundaries with clear edges have become items of general guidance with indistinct borders. I have expressed my concern over religion and clinical practice at great length, and I will not repeat that here. Confidentiality is another example. There are now so many accepted justifications to the breach of medical confidentiality that there is a risk that the principle could eventually disappear altogether.

If someone discloses to a doctor that they were sexually abused as a child, and that the abuser is still alive, or might be alive, and in contact with children, then there is an obligation to institute child protection procedures, whether the patient wants this or not. Obviously, no one wants to passively collude with the sexual abuse children. I do not know how often a forced breach of confidentiality leads to the conviction of a paedophile, but I have been involved in quite a few of these situations, and not one has led to a conviction. No matter how carefully you handle the process, it is traumatic for the patient. They often withdraw from treatment as a consequence.

I am not saying that this is wrong in principle or in practice. What I am pointing out is that tangible harm flows from a policy intended to protect children. I am in no position to judge the overall balance of harm and benefit. There is a strong consensus, which I agree with, that we should prioritise the welfare of children. This means that quite a lot of harm to adults can be justified in pursuit of measures of relatively limited effectiveness in protecting children. The concept of proportionality involves the application of values as well as a quantitative weighing of relative probabilities.

At the other end of the spectrum, there is no ambiguity over the rights and wrongs of some aspects of the law in Northern Ireland, where termination of pregnancy remains almost completely illegal. The number of legal medical terminations there is about twenty a year. There are draconian penalties for breaking the law and for doctors who fail to report breaches of the law to the authorities (as opposed to procuring an abortion themselves). We are talking very long prison terms in both cases. Mifepristone is a drug that is used to induce miscarriage in early pregnancy. Its use is prohibited in Northern Ireland by the Offences Against the Person Act 1861. A doctor who knows that a woman has used this medication is meant to report her to the authorities, or face a hefty penalty himself. No matter what his or her personal opinion about termination of pregnancy, a doctor should not abide by this law. It is wrong. No patient could conceivably benefit in any way as a result of being reported to the police by their doctor under these circumstances.

Prevent is, in my opinion, currently halfway between these extremes. I am not convinced that it is possible for a doctor or anyone else to reliably identify people who will go on to commit terrorist atrocities. I am especially sceptical that this is possible before they form an intention to do anything, in other words when they at risk of radicalisation rather than after they are committed to the use of violence. I am equally unconvinced that there are effective and benign interventions that will divert them away from terrorism once they have been so identified. I am seriously concerned that Prevent is alienating two sections of the community: Muslims (especially young men) and people diagnosed with mental illness. There is real harm here and I would like proper evidence of benefit. There is a substantial possibility that Prevent is having the opposite effect to that intended. I am in favour of preventing atrocities, but I do not think we should feel obliged to accept radical changes to the principles of clinical practice just because someone says it will achieve this. As an absolute minimum we need a prima facie case.

Psychiatrists need to debate Prevent without being accused of being Islamophobes or apologists for terrorism. Ultimately, we may have to emulate Sarah Wollaston and take a position because it is right, even if that makes life more difficult for us. Our default position should be fidelity to first principles, because the alternative is to lose our integrity.