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Deprecated: Return type of WP_Theme::offsetExists($offset) should either be compatible with ArrayAccess::offsetExists(mixed $offset): bool, or the #[\ReturnTypeWillChange] attribute should be used to temporarily suppress the notice in /home/1/s/speilvendt/www/wp-includes/class-wp-theme.php on line 554

Deprecated: Return type of WP_Theme::offsetGet($offset) should either be compatible with ArrayAccess::offsetGet(mixed $offset): mixed, or the #[\ReturnTypeWillChange] attribute should be used to temporarily suppress the notice in /home/1/s/speilvendt/www/wp-includes/class-wp-theme.php on line 595

Deprecated: Return type of WP_Theme::offsetSet($offset, $value) should either be compatible with ArrayAccess::offsetSet(mixed $offset, mixed $value): void, or the #[\ReturnTypeWillChange] attribute should be used to temporarily suppress the notice in /home/1/s/speilvendt/www/wp-includes/class-wp-theme.php on line 535

Deprecated: Return type of WP_Theme::offsetUnset($offset) should either be compatible with ArrayAccess::offsetUnset(mixed $offset): void, or the #[\ReturnTypeWillChange] attribute should be used to temporarily suppress the notice in /home/1/s/speilvendt/www/wp-includes/class-wp-theme.php on line 544

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Deprecated: Return type of WP_REST_Request::offsetUnset($offset) should either be compatible with ArrayAccess::offsetUnset(mixed $offset): void, or the #[\ReturnTypeWillChange] attribute should be used to temporarily suppress the notice in /home/1/s/speilvendt/www/wp-includes/rest-api/class-wp-rest-request.php on line 995

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Deprecated: Return type of WP_Block_List::offsetUnset($index) should either be compatible with ArrayAccess::offsetUnset(mixed $offset): void, or the #[\ReturnTypeWillChange] attribute should be used to temporarily suppress the notice in /home/1/s/speilvendt/www/wp-includes/class-wp-block-list.php on line 127

Deprecated: Return type of WP_Block_List::count() should either be compatible with Countable::count(): int, or the #[\ReturnTypeWillChange] attribute should be used to temporarily suppress the notice in /home/1/s/speilvendt/www/wp-includes/class-wp-block-list.php on line 199

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Om økonomiske valg og tvangsmedisinering – Speilvendt
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Om økonomiske valg og tvangsmedisinering


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Ifølge Tidsskriftet for den Norske Legeforeningen sto tvangsmedisinering i 2014 for omtrent 94% av alle tvangsbehandlingsvedtak, og siden det har omfanget av bruken holdt seg stabilt høyt (Lund, 2017). Kan det være at vi ser et overforbruk av tvangsmedisinering fordi denne formen for behandling er mer kostnadseffektiv på kort sikt enn annen behandling?

Tekst: Jenny Birkeland Nordland

Å benytte seg av tvungen medikamentering er en alvorlig beslutning som bare skal tas dersom det er helt nødvendig for å ivareta pasientens sikkerhet (Fylkesmannen, 2017). På Helsedirektoratets hjemmeside står det at «Hovedregelen i psykisk helsevern er at behandling skal skje med pasientens samtykke.» (Helsedirektoratet, 2017). Allikevel har bruken av tvangsmedisinering gått opp, selv om både myndighetene og fagpersoner mener at bruken må reduseres (Helse- og omsorgsdepartementet, 2016, s.1). Hva er grunnen til at det ikke skjer noen reduksjon i bruk av tvangsmedisinering? Kan det være at økonomiske hensyn fører til mer tvang enn en rent faglig tilnærming ville ført til?

Som med helsevesenet generelt, er de enkelte psykiatriske sykehusenes handlingsrom i stor grad betinget av økonomien. Dette blir utslagsgivende for hva slags behandling pasientene får tilbud om. De enkelte psykiatriske sykehusene er underlagt fem store regionale helseforetak styrt av staten, og det er disse som har ansvaret for å fordele penger mellom henholdsvis somatikken og psykiatrien. Hvor stor økonomisk frihet sykehusene har, bestemmes altså av det regionale helseforetaket og har betydning for handlingsrommet for det enkelte sykehuset.

Helseforetaksreformen ble innført 1. januar 2002. Før det var sykehusene underlagt fylkene, nå skulle de ligge under regionale helseforetak. Den nye konstruksjonen innebar å avvikle regional folkevalgt styring og erstatte den med styring etter mønster fra næringslivet (Stortinget, 2015). Reformen var inspirert av New Public Management, som vil si at måten man driver offentlig virksomhet på har markedet som forbilde (Wyller et al, 2013). Sykehusene skulle i prinsippet drives som private bedrifter, med den forskjell at de i stedet for å sørge for så god inntjening som mulig, skulle få mest mulig helse ut av hver krone. Dette blir dermed et insentiv for å effektivisere behandlingstilbudene.

Også Psykisk helsevern bærer preg av denne markedstenkningen: Man skal oppnå best behandling med bruk av færrest mulig kroner. Ettersom bruken av tvangsmedisinering er så høy, er det dermed grunn til å anta at denne formen for behandling er et kostnadseffektivt redskap på kort sikt, fordi det krever mindre personell og tid enn frivillige behandlingsformer gjør. Men spørsmålet er om dette går utover det som hadde vært best både for pasienten og samfunnet på lang sikt.

Det er naturligvis viktig å tilføye at tvangsmedisinering kan være livreddende i situasjoner hvor pasienten er til fare for seg selv eller andre. Men dersom bruk av tvangsmedisinering blir besluttet på bakgrunn av økonomiske hensyn og ikke av faglige begrunnelser, er det grunn til å frykte at bruken øker og går på bekostning av pasientens autonomi. Ønsket om å innfri økonomiske mål blir dermed ikke bare et økonomisk spørsmål, men også et moralsk og politisk anliggende fordi det rokker ved de rettigheter og krav på frihet et menneske har, i kraft av det å være et medlem av samfunnet.

I somatikken har pasientene så og si alltid frihet til å takke ja eller nei til behandling. Slik er det ofte ikke i psykiatrien. I mange tilfeller handler dette om at pasienten ikke er samtykkekompetent, det vil si at fagfolk mener de ikke innser rekkevidden av egne valg eller handlinger. Men det er viktig å huske på at de som sitter med definisjonsmakten også har et budsjett å forholde seg til. Det er alvorlig dersom selvbestemmelsesretten begrenses som følge av ressursmangel og ikke av en rent faglig begrunnelse.

I følge psykiatrisk overlege ved Drammen sykehus, Marianne Mjaaland, er det et paradoks at man reduserer sengeplasser i rekordfart, samtidig som helseministeren har bestemt at tvangsmedisineringen skal ned. Dersom en skal kunne tilby tvangsfri medikamentering vil pasientene trenge andre, mer psykologisk innrettede behandlingstilbud, som kan ta lengre tid og sannsynligvis også vil kreve mer personell. Det er vanskelig å innfri når sengeplasser legges ned og den økonomiske støtten står stille. Hun forteller at det år etter år blir gitt prosentvis mer penger til somatikk enn psykiatri, selv om myndighetene vedtar tiltak innenfor psykisk helsevern som vil koste mer. Årsaken til at somatikken får mer, kan være at psykisk helsevern har en yrkesgruppe med en tradisjon for å ikke uttale seg i offentligheten, samt at de har pasientgrupper som er tause og ofte ressurssvake. Andre grupper, gjerne innenfor somatikken, roper høyere, og blir oftere hørt.

1. september i år ble det vedtatt en ny lov som i større grad skal sikre pasientens selvbestemmelsesrett gjennom å skjerpe vilkårene for hva det vil si å være samtykkekompetent. Denne innebærer en dreining fra fokus på diagnose til fokus på funksjonsnivå. Det vil si at personer som er samtykkekompetente til tross for alvorlige sinnslidelser ikke skal kunne tvinges til medisinering om de ikke ønsker det (Helsedirektoratet, 2017). Det blir interessant å se om dette vil få ned tallene for bruk av tvangsmedisinering. Men dette vil kreve mer ressurser, og da er det avgjørende at helseforetakene gir økonomisk støtte til dette.

Jenny Birkeland Nordland går 2. semester på profesjonsprogrammet i psykologi.

Les også «Regler for tvang»

Referanser

Fylkesmannen. (2017). Tvang. Hentet fra https://www.fylkesmannen.no/Helse-omsorg-og-sosialtjenester/Tvang/

Helsedirektoratet. (2017). Endring av helsevernloven. Hentet fra https://helsedirektoratet.no/Documents/Lovfortolkninger/Psykisk%20helsevernloven/Informasjon%20og%20invitasjon-Endringer%20i%20psykisk%20helsevernloven-2017.pdf

Stortinget. (2015). Representantforslag fra stortingsrepresentantene Kjersti Toppe, Per Olaf Lundteigen og Janne Sjelmo Nordås om å avvikle foretaksmodellen og innføre folkevalgt styring av sykehusene. Hentet fra https://www.stortinget.no/no/Saker-og-publikasjoner/Publikasjoner/Representantforslag/2014-2015/dok8-201415-096/1/

Helse- og omsorgsdepartementet. (2016) Innstilling fra helse- og omsorgskomiteen om Endringer i psykisk helsevernloven mv. (økt selvbestemmelse og rettssikkerhet). (Prop 147 L 2015-2016). Hentet fra https://www.stortinget.no/no/Saker-og-publikasjoner/Publikasjoner/Innstillinger/Stortinget/2016-2017/inns-201617-147l/?all=true

Wyller, V B., Gisvold, S E., Hagen, E., Heggedal, R., Heimdal, A., Karlsen, K., … Wyller, T B. (2013, 19. mars). Ta faget tilbake! Tidsskriftet for den Norske Legeforening. Hentet fra http://tidsskriftet.no/2013/03/kronikk/ta-faget-tilbake

Lund, Ketil. (2017, 20. februar). Tvangsmedisinering må forbys. Tidsskriftet for den Norske Legeforeningen. Hentet fra http://tidsskriftet.no/2017/02/kommentar-og-debatt/tvangsmedisinering-ma-forbys-0


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