A June ruling by the Supreme Court is the latest example of our institutions wrestling with the mentally ill’s place in society. Different perceptions about what is right are sometimes based along political and philosophical lines but on the street it’s a different story.
Both the Supreme Court and psychiatric community are struggling with the competence of the severely mentally ill to make their own choices.
The issues at the center of the conflict are the:
- individual rights of the severely mentally ill to make their own choices
- government’s right to protect its citizens
- obligations of health care to serve their patients.
In a split decision, the Supreme ruled that a severely mentally ill person may be competent enough to stand trial with the aid of a lawyer but not competent enough to defend himself.
Majority votes were cast by liberal and moderate judges while dissenting votes were cased by conservative jurists.
This issue is discussed by Dr Peter Kramer on his blog “In Practice”; the title of the post is Degrees of Competence: Do Liberals and Conservative Understand Mental Illness Differently?
The liberal majority indicated that they felt a judge could finely grade the competence of a severely mental ill person; and their ability to participate in their own defense. The underlying assumption is that participating in the trial with the aid of a lawyer is less demanding than defending one’s self.
On the other hand, the dissenting votes of conservative Court members seemed to give the absolute concepts of autonomy, liberty and individual rights greater standing. In the case before him, Judge Scalia also cited the coherence presented by the man who was on trial.
Some people who are psychotic can be artful about how they communicate but yet be suffering from severe delusion. Perhaps Judge Scalia was more worried about the protection of the public at large or the courts being co-opted to send people to the gulag than the nuances of justice for the mentally ill.
The psychiatric community also struggles with the patient’s ability to act in his own self interest.
Does it take less competence on the part of a psychotic patient to accept a doctor’s recommendation than to refuse it. Some ethicists says “yes”. Refusing a doctor’s recommendation is a more complex decision because it would require evaluating other options.
A more specific example of this dilemma is whether or not the government can force a person to take their medications
In some states if the People determine that the person is a danger to himself or others, they entitled to force them to take their meds. As a practical matter states don’t have the resources to monitor compliance.
IMO, judges should exercise the ability to understand the level of competence of a person with severe mental illness so they can participate in their own trial to the maximum extent possible; and states should be able to force a patient to take medication for the protection of the public and patient.
As for the competence of a severely ill person to make his own health decisions, the person has every right to make choices as long as he is not dangerous.
In these extreme circumstances, society’s burden to respect the rights of the mentally ill falls upon the psychiatrist and the judge. As for the every life, affirmation and respect for people with mental illness severe or not, can lift the rest of us whether at work, a sporting event, or the neighborhood coffee shop.
