Involuntary treatment

Involuntary treatment (also referred to by proponents as assisted treatment and by critics as forced drugging) refers to medical treatment undertaken without the consent of the person being treated.

"Right to refuse medical treatment" redirects here. You may be looking for right to die.
For treatment in hospital wards, see involuntary commitment.

Protest graffiti against Involuntary treatment, Turin; TSO = MORTE means Involuntary treatment = Death

The most common cases of involuntary treatment are psychiatric treatment administered despite an individual's objections. These are typically individuals who have been diagnosed with a mental disorder and are deemed by some form of clinical practitioner, or in some cases law enforcement or others, to be a danger to themselves or to others. Some jurisdictions have more recently allowed for forced treatment for persons deemed to be "gravely disabled" or asserted to be at risk of psychological deterioration.

Involuntary treatment is normally governed by a formal legal process, in some countries this is controlled by the judiciary through court orders, in others by medical doctors.

Involuntary treatment normally happens in a hospital setting after some form of commitment, though individuals may be compelled to undergo treatment outside of hospitals via outpatient commitment.

Effects

A 2014 Cochrane systematic review of the literature found that compulsory outpatient treatment "results in no significant difference in service use, social functioning or quality of life compared with standard voluntary care."[1]

A 2006 review found that as many as 48% of respondents did not agree with their treatment,[2] though a majority of people retrospectively agreed that involuntary medication had been in their best interest.

A review in 2011 looked at people's experience of coercion. It found common themes of feelings violated, disrespected, and not being heard, commonly conceptualized as being dehumanized through isolation. A minority of narratives from people who had been treated involuntarily talked about the necessity of treatment in retrospect.[lower-alpha 1]

Coercion of people in voluntary treatment

Individuals may be forced to undergo treatment voluntarily under the threat of involuntary treatment. Many individuals who legally would be viewed as receiving treatment voluntarily believe that they have no choice in the matter.[lower-alpha 2]

Once voluntarily within a hospital setting rules, process and information-asymmetry, can be used to achieve compliance from a person in voluntary treatment. To prevent someone from leaving voluntarily, staff may use stalling tactics made possible by the fact that all doors are locked. For example, the person may be referred to a member of staff who is rarely on the ward, or made to wait until after lunch or a meeting, behaving as if a person in voluntary treatment does not have the right to leave without permission. When the person is able to talk about leaving, the staff may use vague language to imply that the person is required to stay, relying on the fact that people in voluntary treatment do not understand their legal status.[lower-alpha 3]

Szmukler and Appelbaum constructed a hierarchy of types of coercion in mental health care, ranging from persuasion to interpersonal leverage, inducements, threats and compulsory treatment. Here persuasion refers to argument through reason. Interpersonal may arise from the desire to please health workers with whom a relationship has formed. Threats may revolve around a health worker helping or hindering the receipt of government benefits. [6]

Law

United States

All states in the U.S. allow for some form of involuntary treatment for mental illness or erratic behavior for short periods of time under emergency conditions, although criteria vary. Further involuntary treatment outside clear and pressing emergencies where there is asserted to be a threat to public safety usually requires a court order, and all states currently have some process in place to allow this. Since the late 1990s, a growing number of states have adopted Assisted Outpatient Commitment (AOC) laws.

Under assisted outpatient commitment, people committed involuntarily can live outside the psychiatric hospital, sometimes under strict conditions including reporting to mandatory psychiatric appointments, taking psychiatric drugs in the presence of a nursing team, and testing medication blood levels. Forty-five states presently allow for outpatient commitment.[7]

In 1975, the U.S. Supreme Court ruled in O'Connor v. Donaldson that involuntary hospitalization and/or treatment violates an individual's civil rights. The individual must be exhibiting behavior that is a danger to themselves or others and a court order must be received for more than a short (e.g. 72-hour) detention. The treatment must take place in the least restrictive setting possible. This ruling has since been watered down through jurisprudence in some respects and strengthened in other respects. Long term "warehousing", through de-institutionalization, declined in the following years, though the number of people receiving involuntary treatment has increased more recently. The statutes vary somewhat from state to state.

In 1979, the United States Court of Appeals for the First Circuit established in Rogers v. Okin that a competent person committed to a psychiatric hospital has the right to refuse treatment in non-emergency situations. The case of Rennie v. Klein established that an involuntarily committed individual has a constitutional right to refuse psychotropic medication without a court order. Rogers v. Okin established the person's right to make treatment decisions so long as they are still presumed competent.

Additional U.S. Supreme Court decisions have added more restraints, and some expansions or effective sanctioning, to involuntary commitment and treatment. Foucha v. Louisiana established the unconstitutionality of the continued commitment of an insanity acquittee who was not suffering from a mental illness. In Jackson v. Indiana the court ruled that a person adjudicated incompetent could not be indefinitely committed. In Perry v. Louisiana the court struck down the forcible medication of a prisoner for the purposes of rendering him competent to be executed. In Riggins v. Nevada the court ruled that a defendant had the right to refuse psychiatric medication while he was on trial, given to mitigate his psychiatric symptoms. Sell v. United States imposed stringent limits on the right of a lower court to order the forcible administration of antipsychotic medication to a criminal defendant who had been determined to be incompetent to stand trial for the sole purpose of making them competent and able to be tried. In Washington v. Harper the Supreme Court upheld the involuntary medication of correctional facility inmates only under certain conditions as determined by established policy and procedures.[8]

However, the involuntary treatment of minors remains legally permitted in most states, usually with the consent of a parent or guardian. The use or purported overuse of psychotropic drugs on minors has exploded in recent years, and this fact has received some increased attention from the public, legal experts, people who have received treatment, as well as medical researchers concerned over long-term effects on development.

Proponents and detractors

Supporters of involuntary treatment include organizations such as the National Alliance on Mental Illness (NAMI), the American Psychiatric Association, and the Treatment Advocacy Center.

A number of civil and human rights activists, Anti-psychiatry groups, medical and academic organizations, researchers, and members of the psychiatric survivors movement vigorously oppose involuntary treatment on human rights grounds or on grounds of effectiveness and medical appropriateness, particularly with respect to involuntary administration of mind altering substances, ECT, and psycho-surgery. Some criticism has been made regarding cost, as well as of conflicts of interest with the pharmaceutical industry. Critics, such as the New York Civil Liberties Union, have denounced the strong racial and socioeconomic biases in forced treatment orders.[9][10]

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See also
  • United States of America:
  • California: 5150 (involuntary psychiatric hold) and Laura's Law (providing for court-ordered outpatient treatment)

Notable activists

Advocacy organizations

Notes
  1. See table 1 of [3]: "The aspects of care leading to the experience of coercion were broad, but all involved the forcing of “treatment” onto patients against their will. The themes from these articles highlight feelings of violation, disrespect, and not being heard by their clinicians. The most common conceptualization was that of being dehumanized through a loss of normal human interaction and isolation. Using a wide range of thematic analyses, we found that these themes emerged in each article for a range of treatment interventions; this finding was robust. Positive themes were mentioned in three of the five articles from a minority of patients. These tended to emerge in retrospect, well after a patient's hospitalization, and focused on the need or rationale for treatment. These positive themes tended to reflect the social norms and explanations for compulsory care's leading to coercion, rather than the emotive or subjective responses elicited by such care."
  2. "A significant proportion of voluntarily admitted service userscan experience the same level of perceived coercion as that experienced by involuntarily admitted service users. It needs to be ensured that if any service user, whether voluntary or involuntary, experiences treatment pressures or coercion, that there is sufficient oversight of the practice to ensure that individual's rights are respected."[4]
  3. See section 6.1 entitled "stalling" in [5]. From this section: "[T]he patient’s mistaken belief that she cannot leave the hospital facilitates the staff’s efforts to stall her. Most importantly, uncertainties regarding formal status make it possible for clinicians to phrase persuasive statements in strategic ways. At times, they might use words that connote coercion where coercion is not formally used. At other times, they might use words of cooperation when formal coercion is in fact applied. Similarly, particular symptoms of the patient, such as a temporary inability to concentrate, might serve as a resource for the staff in managing information in order to accomplish compliance."

References
  1. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Kisely SR, Campbell LA. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD004408. DOI: 10.1002/14651858.CD004408.pub4
  2. Katsakou C, Priebe S (October 2006). "Outcomes of involuntary hospital admission—a review". Acta Psychiatr Scand. 114 (4): 232–41. doi:10.1111/j.1600-0447.2006.00823.x. PMID 16968360.
  3. Newton-Howes, Giles; Mullen, Richard (2011). "Coercion in Psychiatric Care: Systematic Review of Correlates and Themes". Psychiatric Services. American Psychiatric Association Publishing. 62 (5): 465–470. doi:10.1176/ps.62.5.pss6205_0465. ISSN 1075-2730.
  4. O'Donoghue, Brian; Roche, Eric; Shannon, Stephen; Lyne, John; Madigan, Kevin; Feeney, Larkin (2014). "Perceived coercion in voluntary hospital admission". Psychiatry Research. Elsevier BV. 215 (1): 120–126. doi:10.1016/j.psychres.2013.10.016. ISSN 0165-1781.
  5. Sjöström, Stefan (2006). "Invocation of coercion context in compliance communication — power dynamics in psychiatric care". International Journal of Law and Psychiatry. Elsevier BV. 29 (1): 36–47. doi:10.1016/j.ijlp.2005.06.001. ISSN 0160-2527.
  6. Szmukler, George; Appelbaum, Paul S. (2008). "Treatment pressures, leverage, coercion, and compulsion in mental health care". Journal of Mental Health. Informa UK Limited. 17 (3): 233–244. doi:10.1080/09638230802052203. ISSN 0963-8237.
  7. "Browse by State".
  8. "Washington et al., Petitioners v. Walter Harper". Retrieved 10 October 2007.
  9. New York Lawyers for the Public Interest, Inc., "Implementation of Kendra's Law is Severely Biased" (April 7, 2005) http://nylpi.org/pub/Kendras_Law_04-07-05.pdf Archived 28 June 2007 at the Wayback Machine (PDF)
  10. [ NYCLU Testimony On Extending Kendra's La NYCLU Testimony On Extending Kendra's Law]
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