New York State Mental Hygiene Law - the Need for Involuntary Medication - Research Paper Example

?New York mental hygiene law- The need for involuntary medication Introduction In recent years, mental illness has taken on a more notable position in the health care system. Such position has also allowed for the improved management of mental illnesses, including more diverse forms of treatment and the elimination of obsolete and unproven methods of treatment. The involuntary medication of patients has also become an important option for health professionals in managing patients who pose a danger to themselves and to others. Its application however has remained controversial, with opposing opinions made on the practice. On one hand, those who oppose involuntary medication argue that it goes against the patient’s right to autonomy and self-determination; those who support the practice also argue that its use is for the best interest of the patient and the bigger population. This essay shall discuss this issue, arguing both sides of the issue, and taking a stand or position on the debate, while also discussing the counterarguments to the position taken. Body Involuntary treatment is defined as medical treatment administered to the patient without his consent. In most cases, this treatment is seen in mentally ill patients especially those who are deemed by the court or by mental health professionals as dangerous (Kallert, et.al., 2011). Individuals with mental health illnesses are generally attributed the same right as other patients to self-determination. However, this has not always been the case. For many years, individuals with mental health issues have been struggling against a negative stigma about their competence and their safety in society (Kallert, et.al., 2011). At present, the negative stigma has been questioned by health professionals who argue that mental illness does not necessarily imply an inability to make sound decisions. Involuntary mental health treatment can be applied in numerous contexts. The most common is the court-ordered commitment to inpatient mental facilities. It also includes the involuntary medication as imposed by mental health professionals and treatment imposed for specific prisoners who may indeed pose a danger to themselves and others (MHA, 2013). Mental illness is hardly a crime; however, there are times when individuals suffering from mental illness manifest unfavorable and illegal behavior (Freckelton and Petersen, 2006). Violations carried out by individuals with mental illnesses can come about in various ways. The mental condition of an accused at the time the act was committed is an essential element in proving intent (Freckelton and Petersen, 2006). Whether or not the accused offender during the commission of the offense was able to distinguish between right from wrong can be considered in the determination of his case. Kendra’s Law has been implemented in New York since 1999. This law ensured the involuntary commitment and treatment of individuals following court determination of the mental illness, even without the consent of the individuals deemed mentally ill (Carpinello, 2005). In general, this law has been able to secure significant benefits for the patients and for the general public’s safety. In fact in a long-term study published in the Psychiatric Services journal (Phelan, et.al., 2010), significant benefits in assisted outpatient treatment has been seen. The study also found that the group not receiving AOT was twice likely to be arrested as compared to the group who received it. For those receiving AOT, the possibility of any arrest was at 2.66 times greater before their participation than after (Phelan, et.al., 2010). Finally, for those undergoing AOT, the possibility of arrest for violent offenses was 8.61 times higher before their participation in AOT than after. It is important to apply involuntary treatment for patients who present a danger to self and others. In the case of Washington v. Harper, a mentally ill inmate filed a case questioning the practice of correctional systems administering antipsychotic drugs to inmates without the latter’s consent. The defendant in this case was incarcerated for robbery and agreed to the administration of psychotropic medications (Elm and Passon, 2007). The inmate was later paroled on the condition that he would continue his treatment. His parole was later revoked when he assaulted two individuals. He was later diagnosed with schizophrenia but did not want to seek treatment for that. The court declared in the case that an inmate’s right based on the due process clause relating to the need to avoid the unwanted administration of antipsychotic drugs must be founded on the context of the inmate’s imprisonment (Elm and Passon, 2007). The court determined that the due process clause allows the state to manage an inmate having serious mental illness with antipsychotic drugs even if it would be against his will, especially if he poses a danger to himself or to others. The key element in the determination of the case is the danger posed by the patient and others (Elm and Passon, 2007). The problem of involuntary medications on a defendant before conviction was also evaluated in the case of Riggins v. Nevada (504 U.S. at 130-31). The defendant in this case was convicted for murder and later sentenced to death. He was administered the antipsychotic Mellaril because he said he was hearing voices and had trouble sleeping. He was deemed competent enough for trial and he wanted to suspend his medication intake for him to show the jury what his mental state was, thereby supporting his insanity defense. The court ruled that there was no reason for the antipsychotics to be administered because the inmate did not pose a danger to others and to himself (Riggins v. Nevada, 504 US 130-131). One of the most notable cases on involuntary treatment is the Sell v. United States case (539 U.S. at 179). In this case, the Supreme Court evaluated the forced administration of medications for the purpose of restoring mental competence during trial. The defendant had a lengthy history of mental illness. He was a dentist who often went through psychotic episodes. Initial mental health assessment established that Dr. Sell was able to stand trial and he was later indicted for mail fraud and money laundering. The government sought to revoke the bail set due to allegations that the defendant was intimidating witnesses. During his bail hearing, he was erratic and was displaying aggressive behavior, even spitting on the judge. His bail was later revoked. He was deemed competent to stand trial and was ordered to take antipsychotics. He refused. The magistrate was able to demonstrate how Dr. Sell represented a danger to himself and others. The involuntary administration of the drugs was therefore ordered. The court however warned that the involuntary administration of drugs can only be allowed in specific cases. The court must first note government interests to be at stake; the court must also discover that involuntary medications would support state interests; the court must also conclude that the treatment would be needed to support said interests without better ways to reach trial competency; and the court must also establish that the administration of drugs is medically recommended and in the best interest of the defendant-patient (Elm and Passon, 2007). Paternalism mostly focuses on the health interests of patients. It is an accepted practice in medicine, except in psychiatry where its application is still considered controversial. In instances of paternalism, family members and health care professionals may make decisions and act in the best interest of the patient (Szmukler, 2000). This would therefore include treatment without the patient’s consent in cases where the patient lacks the capacity to make his own decision, even if such decision be against his wishes (Munro and Rumgay, 200). The ultimate goal in this case is to restore the patient’s health and in the end, also to restore their capacity to make decisions. The protection of others is an important consideration in the involuntary treatment of patients. There is sufficient justification in intervening in the medical treatment of patients in order to protect others from harm or the possible risk of harm (Munro and Rumgay, 2000). Such risk may not necessarily pertain to illness or a patient’s ability to make decisions on treatment. The figure below drawn by Szmukler (2000) establishes a clear link between capacity and best interests, including dangerous behavior. The lack of capacity is clear, however, indications are needed in relation to treatment for the best interests of the patient (Mental Health America, 2013). What is considered ‘best interests’ does not refer to patient having the capacity, especially as these individuals can freely make decisions on their treatment. Even if said decisions may not be in their ‘best interests,’ the patient would still make the choice on his treatment (MHA, 2013). Where the capacity to make the decision is lost, then the decision would be made for the best interest of the patient. In any case, where a patient does not have the capacity to make decisions, and treatment would work for his or her best interests, then involuntary treatment would be appropriate, even if the patient may or may not present dangerous tendencies (Szmukler, 2000). The danger which the patient poses may be important in determining whether the treatment would be in his best interests and whether or not it would likely urge specific immediate decisions to promote safety. In instances when the patient lacks the capacity and there is no treatment which can be administered for the patient’s best interests, (especially where the patient is not responsive to available medication options), a decision for the patient would be based on the danger he would pose to others (Goss, 2010). The danger itself would actually be a significant determinant for involuntary treatment, even if the treatment is mostly for containment, especially as serious harm caused to others would impact negatively on the patient and may sometimes worsen the overall treatment conditions (Goss, 2010). In cases where dangerousness is directly related to an individual’s mental disorder with treatment possibly reducing the risk, the use of involuntary treatment would have better application (Kisely, et.al., 2005). In some cases, the frequency or possibility of violence would require special measures for patients. However, the possibility of violence is usually increased only in some patients, most often those who have substance abuse issues (Steadman, et.al., 1998). The majority of incidents with violence involve the presence of mental illness. There is also limited evidence indicating that violence is a greater risk among those with mental illness. The indication of violence in general is poor, and would not likely be more predictable among those with mental disorders, as compared to those without mental disorders, such as the heavy drinkers or wife beaters (Szmukler, 2000). There are various reasons, ranging from the scientific to the practical, why involuntary treatment for the severely mentally ill patients is deemed necessary. In the scientific sense, various studies have established that about 40% to 50% of patients with schizophrenia and with bipolar disorder have an impaired understanding of their disease (Torrey, 2013). Their disease has affected the prefrontal cortex, the part which usually controls self-reflection in their needs and decisions. In effect, most individuals suffering from severe mental illness are very much like patients who have had strokes which may have affected their self-awareness processes as well as those individuals in the initial stages of Alzheimer’s disease (Torrey, 2013). Based on humane reasons, not treating these individuals usually leads to incarceration on criminal charges or in some cases, wandering the streets homeless (Katsakou, et.al., 2010). The streets and prisons are filled with these mentally ill individuals. For humane reasons, it would not be fair to abandon these individuals to the mercy of the streets and jails, especially as they may not be aware of their severe mental illness (Katsakou, et.al., 2010). The problem of public protection emerges due to some individuals with severe mental illness, not being treated and oftentimes becoming dangerous. There are numerous studies which have indicated that unmanaged individuals with severe mental illness are more dangerous than the normal population. In a study by the Dawson and Langan (1998), 4.3% of all homicides have been carried out by individuals suffering from mental illness and most of these crimes would not have been committed if these criminals were treated for their mental illness (in Torrey, 2013). In relation to public safety, patients suffering from schizophrenia or bipolar disorder who are not being managed can be likened to individuals with untreated epilepsy who are driving their cars. In such case, as these individuals also use the streets and pose a danger to the rest of society, they must then be subjected to treatment (in Torrey, 2013). Involuntary treatment must also be used when needed, especially because it works. In a study in New Hampshire, the application of conditional release was seen to improve compliance with medications and was seen to decrease symptoms of violence (O’Keefe, et.al., 1997). Outpatient commitment has also been seen to significantly decrease readmission rates in various studies in different states. Arguments against involuntary treatment are unfounded. For one, some individuals argue that where the mental health services are attractive enough, the patients would likely seek out these services themselves (Swartz, et.al., 2010). However, patients who are not aware of their disease would not actually seek out services, especially as they do not actually believe they need any help. Others also argue that involuntary treatment would just drive patients away, and eventually make them even more difficult to treat (Swartz, et.al., 2010). Studies however indicate that most patients who have been medicated without their consent later agreed with the manner by which they were managed (Torrey, 2013). In yet another study, 60% of the patients eventually believed that being forcefully medicated was the best choice which could have been made in their behalf (Torrey, 2013). Others however, disagree with involuntary treatment because it indicates possible abuse dangers, often triggering memories from the past, as in Nazi Germany or Stalin-ruled Russia where patients were made subject to medical treatments and experiments without their consent (Pollack, 2004). Abuse in treatment is often an unspoken risk; however, where the appropriate and adequate medical management systems are in place, such potential for abuse would be dispelled (Pollack, 2004). For those who are vigilant in their rights and the care of their relatives, such abuse can be prevented, especially if the conditions for involuntary treatment are not present. Arguments based on civil liberties are also based on the declaration that involuntary treatment violates an individual’s basic rights. It is important however to ask if the individual with schizophrenia or bipolar disorder living in the streets and untreated is actually free and living a meaningful life with the disease (Priebe, at.al., 2009). Herschel Hardin expressed it well in declaring that the argument against involuntary treatment does not exhibit a clear understanding of the elements of civil liberties (McLeod and Wright, 2009). Medication can liberate patients from their diseases, allowing them to live their lives with dignity and allowing for a more meaningful application of their civil liberties within the realms of more logical and healthy conditions. It is also important to point out that mental illnesses, such as schizophrenia are clearly established and are proven to be brain dysfunctions. Hundreds of studies have clearly established that these patients have differences in their brain structure when compared with the normal brain structures (Torrey, 1997). It is therefore incorrect to discount its possible implications. It is also incorrect to indicate that antipsychotic medications would likely lead to brain changes. In fact studies show that issues like ventricular enlargement or the decrease of gray matter would be seen in patients with schizophrenia who have never undergone treatment with antipsychotics (Gilbert, et.al., 2010). A New York Bellevue Hospital study which claims to have found no difference between the group receiving outpatient services without forced treatment and the group which underwent forced treatment is only one study against the multiple studies which support the benefits of outpatient commitment (Zipurksy, et.al., 1998). The New York study actually even indicated that the group under forced treatment was in the hospital fewer days as compared to those who were not under forced treatment. Claims about violence perpetuated by the seriously mentally ill being rare occurrences are very naive and inaccurate claims (Torrey, 2013). In instances where the patient is being treated, the violence may indeed be rare. However, for those who are not receiving any medication, various studies indicate that violence is all too common. Families of the mentally ill indicate that they have experienced various incidents of violence from their seriously ill relative. Conclusion The use of involuntary treatment for the patients with serious mental illness is an important option which must therefore be made available in the delivery of mental health services. Although the primary rule in ethics indicate the importance of self-determination and autonomy, including consent, such right would have to be set aside where the welfare of the larger public is put at risk. In these instances, involuntary treatment would have to be authorized because the risk of harm is ever present and the patient may also be liable for the commission of acts which under logical and lucid conditions he may not do. The passage of Kendra’s Law alone was based on unfortunate circumstances, with the death of Kendra Webdale after schizophrenic Anthony Goldstein pushed her to her death in front of a train. Other incidents involving violence stemming from mental illness support the need to impose legal actions against those who pose a risk to themselves and to general society. 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