Trading Autonomy for Therapy

by Dallas M. Ducar 

The City Board of Supervisors of San Francisco County is considering implementing a law which would mandate “Assisted Outpatient Therapy,” known to many as involuntary treatment of mental health patients on an outpatient basis.[1] This law would specifically target those who have refused aid from San Francisco County.

The law was originally passed by the California State Legislature in 2002, however, for it to be authorized the city’sCounty Board of Supervisors must first authorize it locally and pass a resolution.

While 44 U.S States have authorized similar laws, only two counties within California have passed a resolution on Laura’s Law. San Francisco County had already denied passage of the law once after public health officials claimed that compelled medication was necessary for Laura’s Law to have its intended effect.

The law specifically attempts to break the cycle of patients wandering from the streets and then to the hospital or jail, and back again. Advocates for the law claim that it will save the city money in the long-run, and ensure more mental health patients are receiving the aid they require.

However, in 2001 the Rand Corporation reviewed the effectiveness of involuntary outpatient treatment and concluded that they could not assertively declare whether the treatment is effective or not.[2]

Doctor and Patient TeamStill, advocates of the law claim that it has the possibility to preclude further calamities, such as the killing of Laura Wilcox, for whom the law is named after, or additional mass shootings.  But how effective will a treatment be when the patient is opposed to the clinician? Mental health treatment depends on a fiduciary relationship between clinician and patient, one that is unlikely to form when the patient is forced into treatment.

Leaving efficacy off the table, deeper ethical issues are at stake here. While many groups throughout the county have been included in the discussion regarding Laura’s Law, one group omitted has been the mental health patients themselves. Perhaps the county should be going to the potential patients directly and encourage discussion regarding Laura’s Law.

Moreover, all of us should consider one question, “Is it morally reprehensible to compel people to be treated against their will?”

Mental health patients have commonly been treated as second-class citizens, with little say in the workings of their own community. Moreover, patients with severe conditions have often been equated with violent offenders.

The MacArthur Community Violence Study, an in-depth analysis of the prevalence of the risk of violence among newly released mental health patients, concluded: “The prevalence of violence among people who have been discharged from a hospital and who do not have symptoms of substance abuse is about the same as the prevalence of violence among other people living in their communities who do not have symptoms of substance abuse.”[3] Why then are mental health patients equated so closely by society to violent offenders? Contemporary research that has drawn other conclusions and proposals such as Laura’s Law may possibly increase stigma surrounding mental health diagnoses and treatment.

Before continuing with the possibility of involuntary treatment, governments should consider the ethical ramifications of treating a patient without consent. In 2011 the county launched Community Independence Placement Project (CIPP), which started as a program wherein patients could be referred for treatment and would have to voluntarily agree to participate. CIPP administrators have noted that many who have voluntarily signed up for CIPP have gone on to lead healthy, independent lives.

Perhaps treating patients cannot and should not be resolved by violating autonomy. At the very least, this law highlights the government’s utilitarian position, that violating autonomy is permissible when in the best interest of the whole.

More preventative measures should be taken to ensure patients are never in need of such severe treatment. Furthermore, it is highly likely that better outcomes will follow suit when working compassionately with patients and ensuring a trusting relationship is developed, rather than involuntary treatment.

Instead of resorting to brute force tactics, societies, such as San Francisco County, should include current and prospective patients, in dialogue, instead of omitting them entirely from the decision-making process.

[1]http://www.sfbos.org/index.aspx?page=16358

[2] Ridgely, M. S., Borum, R., & Petrila, J. (2001). The effectiveness of involuntary outpatient treatment: Empirical evidence and the experience of eight states. RAND.

[3] Steadman, H., Mulvey, E., Monahan, J., Robbins, P., Appelbaum, P., Grisso, T., Roth, L., & Silver, E. (1998). Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Archives of General Psychiatry, 55, 393-401.

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