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.