The “involuntary treatment” of very ill psychiatric patients who say they don’t want to be treated is widely accepted as necessary in certain cases for the sake of patients and society, but it can raise serious ethical concerns as well as legal issues.
In an opinion essay published in the journal JAMA, Dominic Sisti, Ph.D., an assistant professor of Medical Ethics & Health Policy at the Perelman School of Medicine at the University of Pennsylvania, argues that some of the concerns about treating mental health patients without their consent would be alleviated if health clinicians recognized an important distinction among these cases.
“The current strict limitations on involuntary treatment risk allowing people with psychiatric illness to go untreated and experience worsening symptoms despite compelling evidence that they would want to be well,” said Sisti, who is also the director of the director of Penn’s Scattergood Program for Applied Ethics in Behavioral Health Care, and an assistant professor of Psychiatry at Penn.
“A patient may have previously expressed a wish to be treated while in crisis — in which case, a treatment framed as involuntary is actually something else. The proposed concept of nonvoluntary treatment provides a more precise categorization of such cases.”
Sisti suggests using the term, and treating accordingly, when there is compelling evidence that patients would agree to receiving treatment if their judgment were not impaired by their illness.
Patients covered under this term would include those who have specifically expressed a desire to be treated when needed, those who have been living successfully in recovery from mental illness and clearly wish to continue doing so, and those who have difficulty escaping severe drug addiction despite an evident wish to become addiction-free.
The “nonvoluntary” category could also cover patients experiencing their first psychotic episode — due to undiagnosed schizophrenia or bipolar disorder, for example — who essentially have no idea what is happening to them.
“With no prior experience of psychosis, these patients have not been able to develop informed preferences about treatment,” Sisti said.
The burden of mental illness, including disorders that may require hospitalization, remains very high in the United States. Psychosis-causing disorders alone affect more than ten million people. According to the National Institute of Mental Health, about 100,000 people every year in the U.S. experience their first episode of psychosis.
The evidence to justify nonvoluntary treatment could include advance directives already provided by the patient to caregivers, as well as testimony from family members, case managers, and primary caregivers — and even the patient’s own social media posts.
This concept of nonvoluntary treatment would still involve a degree of ethical risk, as the evidence of a patient’s true desires might be ambiguous. However, Sisti notes that this challenge is similar to those found in other areas of health in which a patient is impaired and caregivers and family members must use their best judgment regarding treatment.
In addition, he asserts that not treating these very sick patients carries the potential of much greater harm than giving nonvoluntary treatment.