Moral Side of Medicine
When Is Involuntary Commitment the“ Right” Choice? by Johnathan Bilbro, MD
After the murder trial of Lindsay Clancy captured the nation’ s attention earlier this year, a family member asked me a question I’ m sure crossed the minds of many Americans who followed the case: why didn’ t her psychiatrist do more to help her? While it wasn’ t explicitly stated, the implication was that Clancy should’ ve been involuntarily hospitalized to prevent the tragic deaths of her children. In contemplating my answer, I found myself returning to a foundational question most psychiatrists face early on during their training: when is it morally acceptable to involuntarily hospitalize a patient?
Involuntary commitment of psychiatric patients has been practiced in America for nearly the entirety of its existence. 1 During the 18th and 19th centuries, the very presence of mental illness was thought to be associated with a lack of medical decision-making capacity. There was no distinction between voluntary and involuntary hospitalization, and physicians were able to order the hospitalization and treatment of a psychiatric patient with essentially no procedural barriers. As one might expect, this system was frequently abused, and many patients were hospitalized unnecessarily. A desire to protect patient rights, along with the development of medications – specifically, antipsychotics – capable of effectively treating severe mental illness, led to a period of“ deinstitutionalization” in the second half of the 20th century. The legal standard for involuntary hospitalization changed from a need-for-treatment model to a dangerousness model, which continues to guide every U. S. state’ s civil commitment requirements to this day. In Kentucky, for example, four criteria must be met for involuntary hospitalization: 2
( 1) The individual has a mental illness.
( 2) The individual presents a danger or threat of danger to self, family or others because of the mental illness.
( 3) The individual can reasonably benefit from treatment.
( 4) Hospitalization is the least restrictive alternative mode of treatment presently available.
I think most people would agree legality does not always equal morality. How, then, does one determine when an action is good or bad? Knowing right from wrong is something we expect of children by the time they reach school age, yet most hospitals employee entire committees of highly trained professionals focused on making such distinc-
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