Tuesday, April 12, 2016

Update II

Is it sometimes rational to refuse psychiatric treatment? If yes, how do we justify mandating it for some people? Well, see above conflict between different parts of the system regarding what you should and should not be allowed to do. Dangerousness is the usual dividing line in statute. If you are dangerous to self or others, or have an inability to care for yourself – leaving food out for days, not paying the heating bill, not attending to a wound – we can put you in a hospital. In NH, we still can’t make you accept treatment except under very specific circumstances, usually involving additional hearings. Merely being inconvenient or annoying to society isn’t enough. Having recently been dangerous is not enough. Our wanting to treat you and send you on your way so we can use the bed for someone else isn’t enough. Preventing you from losing your job, your family, your housing, and all your money isn’t enough. From a hospital perspective, you can refuse a lot of treatment for very bad reasons.

 So I bristle a bit at the very question of the rationality of refusing treatment. Then I remember the added requirements that some people in my field would like to require you to do, and I realise my view comes from one place in the system. I also remember individual cases where we shrugged and said “Fine then, that’s your choice” even when we disagreed. In fact, we do it a lot. Those don’t stick in the mind because we have had those philosophical discussions years ago and we don’t revisit them. It is in our bones to know what we are going to insist on and what we won’t. We also know we are far more permissive than families, neighbors, landlords, and local police would have us be, so we tend to disregard accusations from the opposite flank. What does stick in the mind are the daily discussions with psychotic people who have very bad reasons for refusing medications that they very much need, so I tend to think of that as the primary issue.

I blind myself. I actually know dozens of cases, maybe hundreds, that lie on the borders of the rules and rights, cases where it is not clear what should be done. I tend to see each of those as an exception, so I have never thought of categories of them, or what lessons might be learned. I’m not sure how I would go about recalling them all, or even some significant percentage of them at this point. But those are likely to be the more interesting questions for the general reader.  I'll try.


Outpatient commitments to treatment do indeed imply that law enforcement might have to become involved if there is noncompliance (the PC term is nonadherence now for reasons which were never clear to me). That is how it plays out in NH. It is a sheriff’s dept which transports you to the state hospital from an emergency room or a courthouse. There has been an exception over the years. There are a few hospitals which are designated receiving facilities and have some involuntary psychiatric beds, so it is possible to go directly to a psych unit from their ER. As this involves armed hospital security officers, however, it’s not much different. Being brought to the ER may have also involved law enforcement, though of course one might walk in, be brought by family, or come by ambulance. Yet this is not specific to outpatient commitments, but to all secure transport, including those with mental illness. Sheriff’s departments often have required procedures which include handcuffing, even of small children or frail grannies. Neither of those are typically under conditional discharge. I have never seen it used with children, and chronically mentally ill elders have usually long since been assigned guardians who can consent to transport on their behalf.


Sam L. said...

I get the impression that the burden of such cases builds over time, and likely leads to burn-out or an immense desire to change professions.

Texan99 said...

A friend of a friend recently went to pick up his young kids for the weekend from his estranged wife, only to find she'd murdered them both the night before. It appears she may have been bi-polar and maybe recently received medication for her disorder, which she took in excess, or in any case for some reason she went completely off her head. It had been obvious she was troubled, but no one around her believed there was a dangerous crisis looming. All they had to go on was a sense of unease and a need to find a long-term solution. Wouldn't it be great if we could always know who was about to blow? But we don't.

I'm not sure whether or when we're entitled to force treatment on people, but I'm satisfied we sometimes are justified in restraining them while they present an imminent danger. Deciding who presents an imminent danger, however, is incredibly difficult. It's hard enough to build a just system to address past concrete crimes.

jaed said...

The imminent-danger situation strikes me as sort of like the lifeboat situation - times when the usual moral rules are suspended because the situation is so unusual. Normally you can't shoot someone, but if they're about to stab you or someone else, it's a different story. Normally knocking down a friend and sitting on him would be considered a hostile act, but not if he's trying to jump off a rooftop. And normally, incarcerating someone who hasn't committed a crime would be unacceptable.

The problem arises when we want to retain those powers in situations that aren't exceptional - maybe for good reasons and maybe for evil ones, but either way, powers that aren't legitimately ours. And the idea of extending or expanding the "lifeboat" rules becomes very compelling. ("But I could do so much good for society if I had the life-and-death powers of the captain of a lifeboat! And really, isn't Planet Earth sort of a lifeboat for all of us...?")

That's when the horrors come out, when we're tempted to justify using moral powers over others that aren't rightly ours.


Also, I just wanted to say that this:
I tend to see each of those as an exception, so I have never thought of categories of them, or what lessons might be learned.
is probably the best thing I've read all week or longer, about the tendency to see events that don't fit as exceptions. I know I've seen it in politics - during the Clinton administration, even very pro-freedom Democrats seemed to see civil liberties violations as some sort of horrible abberation that didn't really count; and I know that when I see insulting and/or deranged comments aimed at lefties by righties, I don't like it but I think of it as an exception, but I don't react that way when it's the other way around.

An excellent thing to keep in mind, and elegantly expressed. Thank you.