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Incompetence and Disease Insight as Basic Elements

Some of the elements that play a key role in the problematic issue of involuntary commitment and treatment have been thoroughly discussed already in Chapter VII. Two such elements have become more prominent than twenty years ago:
  • Incompetence, or the question of to what extent a person can be held responsible for his behavior and decisions regarding his treatment; and
  • Insight into illness.
Therefore I will discuss these two elements below.

(In)competence refers to a person’s ability to freely determine his own volition and defend his own interests regarding treatment in case of illness or a psychiatric disorder. As such, it has a key role in every kind of coercion. When a person is competent and has the ability to make choices the same as “normal” people do, involuntary commitment and treatment are never an option. When such a person displays dangerous behavior or commits a crime, he is responsible, and should be channeled into the criminal justice system. This is clearly expressed in the phrase “danger due to mental illness.” When the illness is what generates the danger, this is beyond the patient’s control. He then becomes a powerless victim of his illness.

The concept of incompetence was launched into the center of the controversy from the moment that medical paternalism was buried. Now that the doctor is not in a better position to judge, because he is wiser, it has become the patients’ turn to decide whether or not he wishes to be treated. When disagreement arises between the physician and the patient, the patient’s ability to make such a decision is called into question, and with that the issue of competence comes into center stage.

Objections to using the concept of incompetence were discussed in Chapter V. To this the following can be added.

Sometimes incompetence is obvious, in which case legal measures such as guardianship may be taken. This happens, for instance, in severe oligophrenia or the last stages of Alzheimer’s disease. Usually such a self-evident state is not involved when involuntary commitment is being considered. The competence in question is in a large gray area. People’s choices lie on a continuum somewhere between making the conscious choices that most people would, and being powerlessly driven. In any case it seems that sometimes there is more free choice than other times.

Science endeavors to make the area in which man can be free, and can make free choices at his own responsibility, continuously smaller. This is not the aim, but it happens indirectly when more and more facts and physical laws are mapped. When human behavior is based on immutable laws, human freedom disappears. It is difficult to determine which differences exist among people in this respect, because the concept of “mental health” and the related free volition are so difficult to describe. (See Chapter V)

From a social point of view, a totally different image emerges. Our society is founded on the axiom that every person is free, and therefore responsible for his actions, so can also be held responsible. A society not founded on this axiom is unimaginable. All of the conditions in our society are based on the assumption that people can and should be responsible. This social viewpoint is evident in legal judgments about force majeure and intention. The point of departure is individual responsibility for one’s actions. Yet in addition to this principle, is the experience that in exceptional circumstances a person may be less, even very much less, capable of being responsible. In order to do justice, not absolute definitions are sought, but comparisons.

So we find ourselves in a field of contradictions. Science seeks determinations, and therefore can persuade us to believe that freedom is an illusion that can only exist because of the enormous complexity of human life. Society and law dictate to us that we must acknowledge social reality, and that we can only judge people by comparing them to a kind of average person. It is a legal consideration rather than a psychiatric one. Yet, in recent discussions on the concept of incompetence, this concept is regarded as a key element in dealing with the problems pertaining to involuntary commitment and treatment. The concept is often used in a reified form and applied to people as a group: the incompetents. Glass draws the following conclusion from her research, “…there is still no agreement on either the exact criteria or the methods of assessing mental competency.”

Here, too, the formulation of theories has received a great deal more attention than empirical research. One example of research into this area is by Grisso and Appelbaum. Comparing psychiatric patients, heart patients, and healthy people, they concluded, “Most patients hospitalized with serious mental illness have abilities similar to persons without mental illness for making treatment decisions.” Tan et al concluded that in the case of anorexia nervosa, the frequent dilemmas regarding involuntary commitment and treatment cannot be solved by declaring these patients incompetent, because they simply are not incompetent. So empirical support for the key position regarding the concept of incompetence can scarcely be found, if at all. Wishing nevertheless to apply this concept is pseudoscientific and unjust.

Disease insight is another key concept used to justify involuntary interventions. In essence the idea is that “those agreeing with their treating psychiatrist have insight, those who disagree have not.” . This author, Høyer, expresses surprise that the concept of disease insight is accepted at face value in the literature. The degree to which disease insight is absent is seldom considered, nor to which extent a lack in disease insight effects the ability to make decisions or influences the relevant competency. One might add that in psychiatry’s turn toward neopositivism, the lack of disease insight is sometimes short-circuited as a manifestation of a dysfunction in the brain’s pre-frontal lobe. This unproven and therefore unscientific explanation suggests that the patient’s choice is limited by a brain disorder. Needless to say that this assumption is a clear example of the ‘scientific’ tendency to explain away human capacity for choice. As psychiatrists’ criteria for an intact disease insight tend to vary considerably, Saravanan et al propose to assume the presence of insight, “if a person could acknowledge some kind of non-visible change in his or her body or mind that affects the ability to function socially, and if he or she feels the need for restitution.” The problem with this is that although patients with schizophrenia can have very different ideas about what is wrong with them, they cannot be expected to adopt the evolving views that psychiatry develops in the course of time about themselves and their disorders. In addition, there does not seem to be a consistent relationship between that which people express in words and their decision to cooperate or not with treatment. Finally, the involuntarily committed patient remains in a state of conflict with the psychiatrist. Precisely this can influence what he can or wants to reveal about of the thoughts he has about himself.
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