Jones v. Gerhardstein: the involuntarily committed mental patient's right to refuse treatment with psychotropic drugs

The question of whether an involuntary committed mental patient has a fundamental right to refuse treatment with psychotropic drugs continues to be a subject of much debate. Over the past twenty-five years, psychotropic drugs have become the most common form of treatment for the mentally ill. For many patients, these drugs provide substantial benefits; for others, however, they produce severe, sometimes debilitating, side effects. Because of the possibility of serious harm to the patient and because of the potential for abuse of drug treatment by psychiatric staffs, the mental health bar generally has argued for increased procedural protection for mental patients. In Jones v. Gerhardstein, the Wisconsin Supreme Court responded to these concerns by requiring that a judicial hearing be held on the issue of a patient's competency to refuse treatment before the attending physician may administer medication without the patient's consent. This Note discusses the controversy between the legal and medical communities over treatment refusal by mentally ill patients in light of the impact of the Jones decision on institutional practice and on refusing patients. The author argues that the strictly rights-based analysis used by the Jones court has done little to benefit involuntarily committed mental patients. The author suggests alternative ways of approaching treatment refusal that might be more responsive to the distinctive needs of the mentally ill.     

Treatment refusal among forensic inpatients

Although the United States Supreme Court has not offered a definite opinion, some states have established the qualified right of involuntarily committed patients to refuse treatment. Controversy continues between psychiatry and law over what procedural protections should be provided to patients when therapists seek to override nonemergency refusal of treatment. The authors review Oregon's administrative approach and its application to the treatment refusal of 33 state hospital forensic patients. Patient characteristics, refusal patterns, and implications of treatment refusal are also described.     

Supreme Court of Canada's “Beautiful Mind” case

The Supreme Court of Canada's (SCC) first case involving capacity and the refusal of involuntary psychiatric treatment involved a self described “professor” who had been referred to as “Canada's Beautiful Mind”. He had been found not criminally responsible on account of mental disorder for uttering death threats. While considered incapable of making a treatment decision by psychiatrists and a review board, three levels of court, including the SCC, found him to be capable. “Professor” Starson therefore continued to refuse treatment for his psychosis and spent over seven years detained because he refused the treatment required to become well enough to be released. This refusal of treatment is permitted under Ontario law, although it is not permitted in some other Canadian provinces, and in many other countries.This article describes Starson's situation, Ontario's law with respect to consent to treatment and relevant Canadian constitutional and criminal law. It provides an analysis of the Consent and Capacity Board decision and the court appeals. Implications from Starson's case are analyzed in relation to what happened to Starson, human rights and comparative law pertaining to involuntary patients' refusal of treatment, especially their relevance to the Canadian Charter of Rights and Freedoms, and laws in some other countries. Many Canadian and foreign jurisdictions where laws apparently accord with human rights codes do not allow a person to refuse the treatment required to restore their liberty. We conclude that a law that allows a person with a mental illness to be incarcerated indefinitely in a “hospital” because needed psychiatric treatment cannot, by law, be provided is not justifiable in a caring democratic jurisdiction.     

Operation of guardianship laws in the emergency ward

Enduring and workable legislative schemes typically include (a) a balanced approach to the rights and duties of all parties under their purview; and (b) consideration of all major consequences that may flow from the codification of underpinning doctrines. This column examines the 1999 amendments to the Guardianship and Administration Act 1986 (Vic) regulating patients' consent to medical treatment focusing on their application in modern emergency departments. The legislation needs to reconcile the human rights principle that humane and appropriate treatment is a fundamental right of all those who suffer from ill health and disease, with the principle that all patients (including those with impaired, but not totally absent, decisional capacity) have an absolute right to refuse life-saving treatment. Consent and refusal of treatment provisions should be based on the notion of reasonableness, including recognition that the mental and emotional states experienced by physically ill people may, in the short-term, adversely affect their decision-making capacity. Unless the consent legislation factors in the realities of modern emergency practice and resources, statutory thresholds for decisional competence, instead of affording protection, may result in much worse outcomes for vulnerable patients.     

The right to refuse treatment and the movement for mental health reform

The right to refuse treatment is the most controversial of the rights of mental patients, and usually polarizes the movement for mental health reform between providers of care and external activist reformers. A broad alliance supported earlier struggles for recognition of patients' rights, but most professionals oppose recognizing this most extreme right of treatment refusal. Professional opposition to treatment refusal is not based on a wide extent of actual refusal; rather it derives from a defense against challenges to professional and institutional autonomy, an opposition to legal interference, and a belief that the community as well as the patient must be protected. These three reasons for opposition are examined by reviewing studies of attitudes toward patients' rights, knowledge about patients' rights, and implementation of patients' rights. Finally, the implications of these studies for future directions in the movement for patients' rights are examined.     

The impact of the right to refuse treatment in a forensic patient population: six-month review

In December of 1987, the Wisconsin supreme court held that all involuntarily committed mental patients in the state had the right to refuse psychotropic medication unless a court held that they were incompetent to make treatment decisions. The authors studied the effects of this decision in a 165-bed forensic hospital over the first six months after implementation of the decision. They found that 29 percent of patients already on psychotropic medication initially refused further treatment as opposed to 75 percent of newly admitted patients. Of refusers, 32 percent eventually resumed taking medication voluntarily; courts overturned the refusals of all the 51 percent who maintained their refusals, after an average delay of over a month. The length of procedural delays actually increased over the six months of the study as the courts learned of the decision. The authors compare their findings with other reported studies of implementation of right to refuse treatment decisions and discuss differences between the right to refuse treatment for civilly and criminally committed patients.     

The right to refuse treatment under Rogers v. Commissioner: preliminary empirical findings and comparisons

Preliminary findings on the effects of the Massachusetts ruling in Rogers v. Commissioner, an important right to refuse treatment case, are compared with models in other jurisdictions. In sum, few cases are reviewed; in almost all reviewed, the court overrides the patients' refusal. The case raises troubling implications about due process and quality of care.     

Autonomy and the competent patient's right to refuse life-prolonging medical treatment--again

This article discusses the recent decision of the Court of Appeal of the United Kingdom in Re B (Adult: Refusal of Medical Treatment) [2002] 2 All ER 449, which confirmed the common law right of a competent patient to refuse medical treatment, even though exercise of the right would (and later did) result in the patient's own death. Re B indicates that if a competent refusal is not respected, health professionals and hospitals face the prospect of awards of damages being made against them for unlawful trespass.     

部分履行的法律问题研究——《合同法》第72条的法解释论

部分履行构成对全面履行原则的违反。判断某一履行是否为部分履行,要考察有待进行的履行本身是否具有整体性。债权人拒绝受领债务人部分履行的拒绝权属于一种法定的对债权人的保障措施,其功能在于使债权人可以拒绝受领而不构成债权人迟延。但是,债权人的拒绝权也受到一定的限制,当部分履行不损害债权人的利益时,后者不得拒绝。如果债权人受领部分履行,将导致债的部分消灭,但是不影响债权人采用其他措施来维护自己的利益。     

Medicaid program; use of restraint and seclusion in psychiatric residential treatment facilities providing psychiatric services to individuals under age 21. Health Care Financing Administration (HCFA), HHS. Interim final rule with comment period

This interim final rule with comment period establishes a definition of a "psychiatric residential treatment facility" that is not a hospital and that may furnish covered Medicaid inpatient psychiatric services for individuals under age 21. This rule also sets forth a Condition of Participation (CoP) that psychiatric residential treatment facilities that are not hospitals must meet to provide, or to continue to provide, the Medicaid inpatient psychiatric services benefit to individuals under age 21. Specifically, this rule establishes standards for the use of restraint or seclusion that psychiatric residential treatment facilities must have in place to protect the health and safety of residents. This CoP acknowledges a resident's right to be free from restraint or seclusion except in emergency safety situations. We are requiring psychiatric residential treatment facilities to notify a resident (and, in the case of a minor, his or her parent(s) or legal guardian(s)) of the facility's policy regarding the use of restraint or seclusion during an emergency safety situation that occurs while the resident is in the program. We believe these added requirements will protect residents against the inappropriate use of restraint or seclusion.     

Refusing medical treatment after attempted suicide: rethinking capacity and coercive treatment in light of the Kerrie Wooltorton case

The inquest into the death of Kerrie Wooltorton in Norfolk, England, ignited extensive public debate on the scope of the common law right to refuse medical treatment where a patient is distressed, depressed or actively suicidal. In Australia, a patient's wishes need not be honoured if the patient is not legally competent, if he or she falls within the ambit of the compulsory treatment provisions in the mental health legislation, and possibly also if there is a recognised public interest in preventing suicide which is sufficient to override the patient's choice. This article argues that decisions about whether to give medical treatment despite an apparent refusal should be based solely on a determination of the patient's competence to make their own choice. However, the test for legal competence must take into account the person's agency in making the decision, and decisions which will effectively end the person's life must be shown to be thought through.     

Invocation of coercion context in compliance communication -- power dynamics in psychiatric care

This article draws on observations from ethnographic fieldwork to develop a theoretical understanding of the power dynamics in psychiatric care. The aim is to analyze how psychiatric clinicians solve compliance problems by invoking "coercion context". It is suggested that clinicians take a rather instrumental approach to laws regulating coercive intervention. Clinicians may invoke a coercion context even with voluntary patients. For example, they may use wordings that connote coercion, or they may make use of how treatment wards are set up to accommodate involuntary patients, thus stalling voluntary patients who cannot exit through locked doors. A coercion context can also be invoked to solve mundane practical problems, e.g. when clinicians talk about "coerced showers". The management of information and maintaining a suitable "awareness context" with regards to coercion is an essential feature in clinical attempts to achieve compliance from patients. In conclusion, the notion of coercion context helps explain the confusing findings from previous research about patients' apparent misconceptions of their formal legal status. Furthermore, it is argued that research that rely on decontextualised, objectifications of "coercion" risk to miss the meaning coercion is assigned in everyday clinical practice.     

Civil commitment to outpatient psychotherapy: a case study

Commitment to outpatient psychiatric treatment evolved in the courts to protect patients' right to freedom from compulsory hospitalization. This ruling has been criticized by the psychiatric profession, who prioritize treatment rather than liberty. The following case demonstrates the use of commitment as a therapeutic tool in the psychotherapy of a woman with severe borderline pathology. Although the use of coercion in psychotherapy is controversial, its potential use and its ramifications on transference and countertransference issues are discussed.     

“法官不得拒绝裁判”原则的逻辑再造:从绝对性到相对性

作为一项现代司法原则,"法官不得拒绝裁判"已然广泛运用于我国司法实践中。在回应实践发展的理论研究中,"法官不得拒绝裁判"原则的本质界定居于中心位置。实践中,当事人视角下的"唯满意论"解读和裁判者视角下的"唯制定法论"解读,使其陷入了绝对化的陷阱,尤其在司法责任之归责模式上陷入"全有"或"全无"的窘境。"法官不得拒绝裁判"原则应当提倡作相对性解读:就整体层面而言,表现为司法解决纠纷范围的有限性;就具体层面而言,表现为司法裁判的过程性与"拒绝裁判"的多元性、"拒绝裁判"评价标准的客观性与合理性以及"拒绝裁判"受司法责任调整的有限性。唯有如此,"法官不得拒绝裁判"原则的规范意涵才能得以彰显。     

Law, autonomy and advance directives

The principle of autonomy underpins legal regulation of advance directives that refuse life-sustaining medical treatment. The primacy of autonomy in this domain is recognised expressly in the case law, through judicial pronouncement, and implicitly in most Australian jurisdictions, through enactment into statute of the right to make an advance directive. This article seeks to justify autonomy as an appropriate principle for regulating advance directives and relies on three arguments: the necessity of autonomy in a liberal democracy; the primacy of autonomy in medical ethics discourse; and the uncontested importance of autonomy in the law on contemporaneous refusal of medical treatment. This article also responds to key criticisms that autonomy is not an appropriate organising principle to underpin legal regulation of advance directives.     

Gardner; Re BWV: resolved and unresolved issues at end of life

The Medical Treatment Act 1988 (Vic) gives statutory recognition to a patient's (or their agent or guardian if incompetent) right to refuse medical treatment. The case of Gardner; Re BWV confirmed that medical treatment as defined under the Act included artificial nutrition and hydration and as such could be withdrawn, notwithstanding that this would result in the patient's death. This article analyses Gardner; Re BWV and argues that, by deliberately dealing narrowly with the issues at hand, both the Victorian Civil and Administrative Tribunal at first instance and the Victorian Supreme Court knowingly left BWV to die from dehydration over a period of weeks. By not addressing these issues, the tribunal, and more particularly the Supreme Court, lost an opportunity for a reform of the law, so urgently needed at end of life, which would have allowed for "mercy killing", thus sparing BWV and her family the lingering death she was given.     

Adolescents and mental disorder: who consents to treatment?

Although English law recognises that developing adolescents may acquire the capacity to make decisions about medical treatment themselves it does not address the problem of mentally disturbed or disordered adolescents. This article examines the nature of adolescent refusal of treatment and suggests that a line be drawn between three categories of adolescent disturbance--the competent young person who refuses treatment that an adult too may refuse, the rebellious teenager whose refusal is triggered by simple teenage angst, and the mentally ill teenager whose refusal is triggered by mental illness. It suggests that adolescent autonomy needs to be more fully understood and the Mental Health Act more readily used in treating young people.     

Psychiatric patients and AIDS: the forensic clinician perspective

A survey was completed by American Academy of Forensic Sciences (AAFS) Psychiatry and Behavioral Science members regarding their opinions on acquired immunodeficiency syndrome, (AIDS)-related issues. A considerable range of opinions was found, probably reflecting such differences in society. There was general agreement that psychiatric hospitals should not be allowed to refuse AIDS patients and that education about AIDS is useful for psychiatric patients. There was also support for notifying the public health department, known sexual contacts, and hospital staff about human-immunodeficiency virus (HIV)-seropositive patients.     

The influence of the right to refuse treatment on precommitment patients

The unplanned extension of the right to refuse treatment to the precommitment period is described in this paper. This extension of the right to refuse treatment has important public policy implications for the civil commitment process. These implications, as well as the pros and cons of the extension of the right to refuse treatment, are discussed.