Where Do We Draw the Line?: Psychiatric Patient Autonomy

    My sophomore year I took two classes called “Philosophy of Mental Health” and “Drugs and Society”, in which we discussed an important ethical issue of patient autonomy and their right to refuse treatment. An interesting story in one of the required readings was about a college boy who experienced a psychotic break and broke into a family’s home to take a bath. After the police detained him and he was eventually brought to the hospital, the boy refused all treatment and demanded to leave despite the doctor and his parents pleading for him to get the help he obviously needed. Ultimately, he was allowed to leave unmedicated and untreated (although the boy was sued later on for trespassing). As college students we rarely experience or hear of stories like this, but it made me question what lines and regulations should allow doctors to virtuously overrule patients that refuse treatment they need? What would I have done if I was the doctor?

    While the majority of psychiatrists hold their patient’s wellbeing at the highest of their priorities, an ethics dilemma that has been at the forefront of psychiatric care for years is the need of boundaries and framework to override patient autonomy if intervention is deemed necessary. Primarily, a patient’s diagnosis or mental incapacity is usually relied on as justification for these decisions, but this is an obvious violation of rights for people with mental disabilities if the foundation of these claims is not supported. So, what ultimately decides these two criteria for overriding patient autonomy? For the diagnostic lens, many people have considered physiologic biomarkers and epistemic irrationality as indicators. However, these measures are not always reliable as epistemic irrationality is commonly used hastily to diagnose untreated patients despite the possibility of mental disorder and epistemic irrationality being exclusively mutual from each other. Biomarkers similarly are not always constant across every mental disorder. Therefore, biomarkers and epistemic irrationality cannot be means of reason for intervention in the health of psychiatric patients. 

    Currently, the mental incapacity criteria for intervention is the favored approach as it focuses on decision-making capabilities of the individual and incorporates the patients’ autonomy into the equation. The only challenge with this is where to draw the line and how to baseline mental incapacity, as neurodiversity creates an uneven playing field for defining “normal” and “rational” thought/behavior. A better model that has been proposed (and I believe to be fairer) is defining mental incapacity by statistical normality, although there are holes that are left uncovered as well. Ultimately, this issue remains open-ended, which I fear a ”silver bullet” model will never be found as there are only advantages and disadvantages for every proposed solution to get people the treatment they need while keeping their autonomy intact. 

 

Craigie, J., & Bortolotti, L. (2015). Rationality, diagnosis, and patient autonomy in psychiatry. In 

J. Z. Sadler, W. (C. W. . van Staden, & K. W. M. Fulford (Eds.), The Oxford handbook of psychiatric ethics., Vol. 1. (pp. 387–404). Oxford University Press.