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Involuntary Commitment to a Psychiatric Hospital

Involuntary commitment to a psychiatric hospital is a legal and psychiatric measure intended to prevent a person with a psychiatric disorder from endangering himself or others or disturbing public order and safety. It is a consistently occurring theme in Szasz’s work. Not only does he condemn the event in itself, but to him it is the paradigmatic example of coercion and deprivation of liberty in psychiatry. Szasz categorically objects to every involuntary commitment. To him there is only one valid reason to deprive a person of liberty, namely, having committed a crime for which the person was sentenced to a prison term.

So Szasz opposes the virtually world-wide custom of committing psychiatrically disordered people against their wishes. Curran and Harding relate that formalized legal proceedings do not exist everywhere and that there are many different criteria for involuntary commitment. Accordingly the percentage of voluntary admittances ranges between the extremes of 0 and 100%. However, such statistics should be interpreted with great caution as the ways the facts are collected and the ways voluntariness is defined vary enormously. A few premises regarding involuntary commitment are fairly generally endorsed according to Curran and Harding. Firstly, there is a desire for as much parity as possible with other psychiatric patients in order to avoid stigmatization. Secondly, the involuntary commitment is viewed as a last resort or emergency which is considered only when all other solutions have proven impossible.

In medicine the presence of illness on its own is hardly ever a reason for taking legal measures. This is possibly the most suitable fact on which to base a discussion on involuntary commitment. The legal measures that are taken regarding some illnesses are linked to the fact that those illnesses present risks to the health of the community. These risks justify isolating the sufferers of such diseases that are dangerous for others as well.

In the Netherlands there is an obligation to immediately report some infectious diseases, the so-called A diseases, to the authorities as soon as they are suspected. The most well-known of these is typhoid fever of which an average of 36 cases per year were reported in the period 1970 - 1979. Immediate action such as quarantine for the purpose of guarding the health of the community can be taken only regarding A diseases.

Psychiatric disorders are comparable in the sense that involuntary commitment is a last-ditch measure when the psychiatric disorder manifests itself as behaviors that are risky to the patient and others. Current law in the Netherlands has two procedures for that called court power of attorney and guard order. A court power of attorney can be issued when “definite placing of an insane person in a psychiatric institution whether in the interest of public order or the sufferer himself is required.” A guard order is applied “when there is serious suspicion that a person presents such an immediate threat to himself, to others, or to the public order due to insanity, that placing the person in a psychiatric institution cannot be postponed until there is court ruling.”

In 1980 there were 21,254 patients in psychiatric hospitals in the Netherlands. Of those, 11,434 were women and 9,820 were men. Of these 88% were voluntary patients. The other 12%, that is 2,550 people, were in the hospitals involuntarily. The number of admittances in 1980 were 20,163; 10,581 women and 9,582 men. Of these, 15.5%, that is 3,125 people, were committed involuntarily. The number of guard orders (emergency hospitalizations) was about double the number of court powers of attorney in 1980. The numbers were similar in 1977 and 1978.

In 1970 the number of involuntary commitments involved 2,781 people which was 25% of the total. The number of involuntary commitments remained fairly stable between 1970 and 1980, around 2,800 to 3,000 per year. The percentage of involuntary commitments dropped to circa 15% in that period. This decline is to be ascribed to the rise in voluntary admittances. It is noteworthy that in 1974 nearly 75% of the people committed with a guard order continued to remain in the psychiatric hospital voluntarily for some time after the guard order had expired. The percentage of involuntary commitments in the United States was consistently somewhat higher. For instance in 1974 it was 42% of all admittances to Mental Hospitals. In England and Wales it was lower, for instance in 1979 it was 10% of all admittances.

There are clear differences between laws regarding involuntary commitment of people with physical and psychiatric disorders. The first is that the risk of infectious disease has to be very high and must pose a danger to large numbers of people before involuntary commitment can be considered. In psychiatric disorders posing a danger to one person suffices, and even that is not essential because the danger to public order and safety is not necessarily a danger for one or more persons. A second difference is that in infectious diseases the danger is posed by the germ. In psychiatric disorders it is the patient himself. The terminology is sometimes confusing however. After all, disordered behavior that is dangerous is a manifestation, a symptom of a disorder which can often be described only as a disorder of behavior. Often the dangerous behavior is considered the result, or even the product, of a psychiatric disorder, as in the Durham Rule in the United States. (See Chapter 1, 6.1.) That is not logical. Something cannot be its own cause.

In accordance with these differences involuntary commitment of sufferers of A diseases is extremely rare. Another reason is that the sufferer will usually be happy to cooperate. In contrast the involuntary commitment of people with psychiatric disorders is a commonplace event in our society.

Involuntary commitment is an invasive social event for the person involved that must be ethically justified. Szasz adopts a deontological viewpoint regarding this justification: there is no ethical justification whatsoever for depriving of liberty a person who has not violated the law. Furthermore, in general, the risk that a crime may be committed is not a justification for removing a person from society. If this last postulation is correct then it is also not justified when risky behavior can be conceptualized as a psychiatric disorder. This concept is so vague that the only result of such a procedure can be unsurveyable arbitrariness and legal inequality, according to Szasz. With this Szasz has posed a serious dilemma. When one does not follow Szasz in his views that psychiatric disorders are not diseases the dilemma becomes even greater. It can be formulated like this: How, in a society that considers preventive detention categorically inadmissible, can detention of people who display ominous behaviors that can be interpreted as psychiatric disorders be ethically justified? This question is the point of departure in the argumentation below.
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