M09.03.008 Committed Patients

Understanding the legal rights of committed patients with mental illnesses is crucial for ensuring ethical treatment and safeguarding their autonomy. This guide outlines these rights and the decision-making processes involved.

Rights of Committed Patients

A committed mentally ill adult possesses several legal rights:

1. Right to Treatment
   • Patients must be informed about available treatment options regularly.
2. Right to Refuse Treatment
   • Patients, including those with severe schizophrenia, retain the right to refuse antipsychotic medication unless they pose a danger to themselves or others.
3. Right to Request a Legal Hearing
   • Patients can demand a trial to determine their sanity, as competence is a legal issue that only a court can decide.
4. Civil Liberty Limitations
   • While patients lose the civil liberty to “come and go” freely, they can still choose to take their medication but cannot leave the facility without permission.

Decision-Making Standards

Key Points:

• Assume a patient is competent unless clear behavioral evidence suggests otherwise.
• Competence is a legal issue determined only by a court.
• Physicians can assess a patient’s capacity to understand medical issues but cannot legally declare competence or incompetence.

Indicators of Incompetence

Clear behavioral evidence of incompetence may include:

• Attempted suicide.
• Severe impairment in reality perception (psychosis) preventing basic communication.

Important Note:

If there is uncertainty, physicians should assume the patient is competent until clear evidence indicates otherwise.

Surrogate Decision-Making

When patients cannot make medical decisions for themselves, a surrogate must do so under the following conditions:

1. The patient must be incapacitated.
2. The patient must not have an advance directive.
3. The surrogate must know the patient’s wishes if they are competent.

Decision-Making Hierarchy for Surrogates:

1. Spouse
2. Adult children
3. Parents
4. Adult siblings
5. Other relatives

Criteria for Surrogate Decision-Making

1. Subjective Standard

• Decisions are based on the actual wishes of the patient.
• Questions to consider:
  • Is there a verified advance directive?
  • What has the patient said in the past?

2. Substituted Judgment

• Decisions are made as if the patient were competent.
• Questions to consider:
  • Who best represents the patient?
  • What would the patient likely choose if competent?

3. Best Interests Standard

• Decisions are made based on what a reasonable person would choose, considering benefits and burdens.
• Questions to consider:
  • Is the decision in the best interest of the patient rather than the decision-maker?

Conclusion

Physicians must navigate the complexities of legal rights, decision-making standards, and surrogate processes carefully, ensuring respect for patient autonomy and legal obligations.

Points to Remember

• Always assume competence unless proven otherwise.
• Familiarize yourself with decision-making hierarchies for surrogate representation.
• Prioritize the patient’s wishes and best interests in surrogate decision-making.

Bibliography

• Beauchamp, T. L., & Childress, J. F. (2019). Principles of Biomedical Ethics. Oxford University Press.
• Gostin, L. O., & Hodge, J. G. (2016). The Law and the Public’s Health: A Handbook for Medical Professionals. The American Public Health Association.
• McCarthy, M. (2021). Ethics and Law in the Health Care Setting. Wiley-Blackwell.