Providers’ obligation: Protect both patients and society

Excessive use of involuntary commitment is concern

Unfounded and ineffective excesses in the use of involuntary commitment proceedings could result from the public’s horror over recent mass shootings, according to John Z. Sadler, MD, Daniel W. Foster, MD, professor of medical ethics and professor of psychiatry and clinical sciences at University of Texas (UT) Southwestern in Dallas, TX, pointing to the sociological concept of the “outrage dynamic,” which emerges in the face of rare but horrific tragedies.

“The media coverage is excessive, the public becomes outraged, and political opportunism and legislative haste can generate quick and bad policy,” he says. “Providers should understand the context and limitations of using involuntary treatment as a social control mechanism for the very infrequent events of mass shootings.”

Sadler says what is needed is widely accessible and good quality mental health care, including prevention. Encounters with mental health professionals are avoided by potential offenders, he says, and mental health and nonspecialist health care providers are very poor at predicting violence and tend to over-predict rather than under-predict. The best mental health experts can do is identify long-term risk factors, which are relatively useless for predicting behavior over the next few hours or days, says Sadler.

“This means that the prevention rate of an actual violent event is going to be very low, even with an aggressive, low-threshold commitment policy,” he says. “To increase the capture rate, we would have to involuntarily seclude many more people than could be ethically tolerable in terms of tradeoffs between safety and the preservation of civil liberties.”

Difficult risk/benefit decisions

The decision to commit someone should be based upon a thorough examination, and alternatives to hospitalization should be vigorously sought, says Sadler. “A consideration of the long-term consequences of involuntary treatment should be made for the patient,” he says. “These often provoke difficult risk-benefit decisions.” For instance, providers might have to decide whether to commit a depressed patient who is likely to lose her job as a result of the hospitalization.

“Finally, the clinician needs to ask him- or herself whose interest the commitment is serving. In my professional travels and consulting, I’ve seen too many doctors tempted to treat their own anxiety by committing patients who could be better served by less restrictive alternatives,” says Sadler.

Recent mass shootings may have providers assessing a patient’s risk to him- or herself, providers, or third parties more in-depth, and possibly considering these risks with patients that they may not have done so in the past, says Marianne L. Burda, MD, PhD, a Pittsburgh, PA-based ethics consultant and educator. “Each patient’s medical care and treatment should be based on that particular patient’s history, physical exam, and evaluation,” she emphasizes. “Hopefully, recent events will result in an increase in resources and access to mental health services for those in need of these services.”

Providers should weigh preventing harm to the patient, health care providers, and/or third parties, with respect for a patient’s autonomy, especially if the patient is refusing recommended medical care and treatment, when deciding whether to involuntarily commit a patient, says Burda. She says providers should do the following:

  • Ensure patients have access to needed medical care and services, including mental health services.
  • Respect the patient’s autonomy by providing a full informed consent and shared decision-making with the patient, along with assessing the patient’s decision-making capacity in that particular situation.
  • Maintain patients’ trust in their providers and the health care system.

Burda says, “Confidentiality is one important aspect of this trust and the provider-patient relationship.”

  • Determine if there is a clear and identifiable threat from the patient to him- or herself, providers, and/or third parties.

If there is a threat, preventing harm by breaching confidentiality or involuntary commitment is the right thing to do ethically. “If no threat exists, providers must balance breaching the patient’s confidentiality or involuntarily committing the patient with the possible result of loss of the patient’s trust and damaging the provider-patient relationship, which may result in the patient avoiding obtaining needed medical care and treatment,” says Burda.

Unintended consequences

A policy of overuse of involuntary commitment proceedings will have unfortunate unintended consequences, such as potential patients becoming even more wary of seeking psychiatric help for fear of being “locked up,” says Sadler. “A policy intended to protect the public at the expense of patients’ civil liberties will drive away patients whom we would most want to obtain treatment,” he says. “The answer is to provide full and easy access to mental health care in the United States. We are distinctive among our industrialized neighbors and European countries in both having a mass shooting problem and the poorest access to mental health care.”

As access to good quality mental health care increases, the need for involuntary treatment decreases, adds Sadler. “This suggests that our poor record in providing adequate mental health services for Americans substitutes the value of autonomy for the coercion of sick, neglected people through involuntary treatment,” he says. “This is an ethical failure of our society.”