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Abolition of Involuntary Commitment?

From the above no other conclusion can be drawn than that usually no good, operational, and ascertainable criteria exist on which to base a decision of involuntary commitment. In the current situation, when both in the Netherlands and outside it, particularly in the United States, there is an inclination to anchor the whole procedure more in law, the prediction of danger is the cornerstone on which this procedure rests. Treatment of so committed patients becomes uncertain as it is unlikely that it would encompass more than intervention during emergencies. Furthermore, it will become impossible to commit patients who are in serious trouble but not dangerous. Involuntary commitment seems to be becoming a speculative as well as ineffective intervention.

In criminal law it would be unthinkable that people would be sentenced to detention on grounds of “evidence” as flimsy as the arguments usually presented for involuntary commitment. If that would happen it would mean fairly the end of the rights on which our state prides itself. Furthermore, except for a very few instances, preventive detention of potentially dangerous people violates what in democratic countries is felt to be human rights.

When involuntary commitment is a social intervention that is morally justified by claiming benefit either for the patient or for society; when feedback on this measure is hardly possible; when we realize that involuntary commitment means drastic intervention in people’s lives; when there are no tangible and ascertainable operational criteria for it; and when, finally, the feared dangers cannot be accurately predicted, and in addition the efficacy of commitment in preventing these dangers remains unclear, then the inescapable conclusion is that involuntary commitment should indeed be abolished.

So regarding involuntary commitment I reach the same conclusion as does Szasz, albeit partly through a different line of reasoning, namely a teleological one. To Szasz, freedom is a core value that takes precedence to health and depriving people of freedom to benefit their health is never admissible. In addition, it is a prime medical-ethical rule (see Chapter III, 2.5) that examination and treatment of illness can transpire only upon patients’ consent (barring conditions such as coma). In fact the conceptualization of “madness” as mental illness should have already made an end to involuntary commitment. Here the principle consideration leads to a conclusion comparable to the argumentation, deontology to a conclusion comparable to teleology.

It could be that abolition of involuntary commitment would totally change the climate of psychiatry, as voluntary hospitalization and treatment also transpire on a background of the option for involuntary commitment. This happens not infrequently. Of all the people involuntarily hospitalized in 1974, 321, which was about one-ninth, were originally hospitalized voluntarily. It is difficult to interpret such a figure. It could mean a praiseworthy attempt to first try voluntary admission as well as a blameworthy inclination to hold people, once they are hospitalized, longer than they themselves wish. The number is large enough to assume that in clinical therapy there is preoccupation with the idea of converting voluntary hospitalization into involuntary hospitalization as soon as the going gets rough. In any case it means a turnabout in the relationship between the psychiatrist and the patient. The way of seeking solutions together seems blocked and the way of exercising coercion over the patient is chosen. Cooperation is replaced by the conflict so tirelessly emphasized by Szasz and also mentioned by De Smit. Presumably, when the option of coercion is no longer within reach, therapists’ attitudes will change. Their dual loyalty, serving the patient as well as possible but also resolving the conflict with force when necessary, will be replaced by the obligation to treat the patient to the best of their knowledge and ability as is customary in medicine.

The attitudes of family and environment who by exerting immense pressure sometimes make involuntary commitment unavoidable, will also have to change, which will not always be to patients’ detriment. There may come a place for alternatives to hospitalization.

In cases when someone wishes to terminate hospitalization, for instance because of a disagreement with the therapists, power will shift towards that person, possibly expanding his options for hospitalization somewhere else.

Abolition of involuntary commitment leaves us with the group of “non-opposing” patients in addition to voluntary admission. Many of these people such as the elderly are already considered voluntary patients, which necessitates protection of rights. A desirable procedure regarding the hospitalization of people over age 65 in psychiatric hospitals or nursing homes could be requiring the additional consent of an impartial patient advocate who has discussed this with the person in advance.

This would not be the introduction of a new form of involuntary commitment through the back door. The measure would serve only to provide extra assurance of rights for a very vulnerable group of “non-opposing” patients, and would not be applicable to patients who refuse hospitalization. There could, however, be an overlapping area of people who are so confused, and formulate their refusal so absurdly, that one can hardly take that refusal seriously anymore than their consent. My point is to design procedures for this category of patients. I wish to suggest some lines of thinking. I wish for better protection of the rights of people who are hospitalized “without due process” because they do not resist, sometimes to their detriment.

Abolition of involuntary commitment would not only stimulate the creativity of helping professionals.

In the first place it would victimize some people. This cannot be an argument to continue current practices as there is no way to measure how many people are victimized by involuntary commitment. It does mean, however, that it would be an unwise and irresponsible strategy to abolish it before there has been an opportunity to design alternatives. After all it is an institution deeply rooted in our history and tradition.

Secondly, the Patients’ Movement in the Netherlands does not reach the conclusion that involuntary commitment should be abolished entirely. A publication by this movement posits that involuntary commitment is admissible for people who are demonstrably in crisis due to which they are dangerous for themselves or others when no acceptable alternative is available. Therapists’ impartiality is stressed as well as protection of people’s rights and termination of the involuntary commitment as soon as the acute danger has waned or the person indicates that he is willing to remain voluntarily.

In the third place, Toews et al approached a number of involuntarily committed patients after their release. It appeared that in retrospect there was less resistance to the involuntary commitment than they had expected. The average assessment of the 61 responders was neutral (however, 18 refused to cooperate, and an estimated 11 responders had difficulties understanding the questions). Most of the ex-patients were of the opinion that their physicians should be able to arrange an involuntary commitment if those physicians considered it necessary. Toews et al further noted, as did Gordon et al, that the opinions of ex-patients about their hospitalization and treatment are rarely investigated. The problem with this type of research, as well as Weinstein’s (see Chapter VI, 4) is the same as discussed in 2.2, namely that identification with the aggressor leading to adoption of the therapists’ point of view by the patients cannot be ruled out. Besides, afterwards the suffering has become a fait accompli with which one is challenged to learn to live, and “make the best of it.” This too may have influenced research results.

The Patients’ Movement does not endorse unconditional abolition of involuntary commitment. In very rare cases it would be risky to not involuntarily commit someone. Only for those rare cases should the law continue to provide the means for involuntary commitment. One must consider, however, that in recent history many countries vacillated back and forth between rules with psychiatric design and those with legal design regarding involuntary commitment. Neither design was able to satisfy the need. Therefore it would not seem prudent to expect any serious improvement from new commitment laws. In my opinion we can expect the best results from an interim provision which would serve as a transitional period leading toward total abolition of involuntary commitment. During this transitional period alternatives can be sought and experience with those alternatives can be accrued. These experiences can then be a guide for designing further policy. In the next section I will discuss some proposals for this interim period.
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