Providers face these ethical challenges with commitment

They must make clinical, legal determinations

The need to protect others from a potentially harmful patient is a pressing ethical issue not just for health care providers, but for society to contemplate at this juncture, according to Gary E. Jones, PhD, JD, professor in the Philosophy Department at University of San Diego (CA).

“If there is an ethical dilemma surrounding involuntary commitment, it is society’s heretofore unwillingness to address mental illness as a whole,” says Jones. “Involuntary commitment is only one aspect of mental illness, albeit a significant aspect when lives are lost as a result of a mentally ill person who is dangerous.”

The legal and clinical worlds have mechanisms in place to involuntarily commit a person when they are a danger to themselves, to others, or when they are gravely disabled, says Jones, but “the whole process of involuntary commitment is only as effective as the laws which regulate it.”

Thus, if society as a whole believes the laws governing involuntary commitment are ineffective, the onus is on society to change the laws, he argues. “There is virtually no opportunity during the process of involuntary commitment to make an arbitrary decision as to committing a person if the clinician, law enforcement personnel, and legal representative are following the law and their particular training,” says Jones. “Simply put, if the person in question meets certain clinical and legal criteria, he or she may be involuntarily committed.”

Awareness of laws

There are two determinations to make — a clinical and legal determination — before a person is involuntarily committed, says Jones. Clinically, a psychosocial history is taken, the person is questioned as to the imminence of the danger to self, to others, or grave disability, and a provisional diagnosis of a mental illness is made or a person’s previous psychiatric diagnosis is reviewed.

“Much information must be gathered and put into context in order to determine whether a person is a danger to themselves, to others, or is gravely disabled,” says Jones. Legally, the threshold, or burden of proof, to determine or persuade authorities that there is an imminent danger to self, to others, or grave disability is very low — that of probable cause, which is a relatively low standard of evidence, he notes.

When a person is put on a 72-hour involuntary hold, he or she is continually observed and assessed with the goal of stabilizing that person, says Jones, and the psychiatric facility must make the determination to petition the court to extend the involuntary hold or release the person. “Many factors are taken into consideration as to whether the facility will release the person or extend the hold,” says Jones. For example, if the person has little or no psychiatric history and has been stabilized, he or she is usually released and given referrals for outpatient treatment, but if the person has not been stabilized, and there is a previous psychiatric history, the hold is usually extended.

“The Sandy Hook school shooting will not change the way a clinician or a legal representative determines whether a person should be involuntarily committed,” says Jones. “This horrific massacre should change society’s awareness of the laws governing involuntary commitment, and more broadly, treatment for the mentally ill. Through this awareness, the laws must change.”

Sources

  • Marianne L. Burda, MD, PhD, Pittsburgh, PA. Phone: (724) 933-0265. E-mail: burdam@duq.edu.
  • Gary E. Jones, PhD, JD, Professor, Philosophy Department, University of San Diego (CA). Phone: (619) 260-4089. E-mail: garyj@sandiego.edu.
  • John Z. Sadler, MD, The Daniel W. Foster, MD, Professor of Medical Ethics, UT Southwestern, Dallas, TX. Phone: (214) 648-4960. E-mail: John.sadler@UTsouthwestern.edu.