Rethinking mental health laws
The mass shooting at Marjory Stoneman Douglas High School in Parkland, Fla., has drawn attention to the nation’s mentalhealth system. In a televised speech, President Donald Trump said his administration wants to “tackle the difficult issue of mental health.” At a town hall hosted by CNN, Dana Loesch, a spokeswoman for the National Rifle Association, announced, “None of us support people who are crazy, who are a danger to themselves, who are a danger to others getting their hands on a firearm.”
Many such conversations about mental health and guns tend not only to stigmatize mental illness but also to ignore the realities of mental health care. Psychiatric care is filled with uncertainty. Predicting whether individuals will hurt themselves or others can be a difficult and inexact science, even for the most skilled mental health providers.
While making these kinds of predictions is guided by clinical judgment, deciding what to do next often is governed by laws. And the legal frameworks around mental health care in the United States give primacy to personal liberty.
In reaction to the historical abuses of psychiatry, such as widespread neglect of patients in dilapidated asylums, and to preserve patients’ freedoms, laws across the country have introduced checks and balances at nearly every step in psychiatric treatment.
Elyn Saks, a mental-health expert and law professor at the University of Southern California, once wrote, “Law is based on a theory of personhood; that is, the concept of someone who can make choices and suffer consequences, and who understands the threat of sanction. The doctrine of informed consent (indeed, most of American political theory) presumes that we are not just subjects to be directed, but rather autonomous beings capable of making independent decisions.”
The problem is that mental illness raises challenging questions about that very autonomy, along with uncertainties about the kinds of decisions that unwell people should be able to make. Does a patient with fixed delusions about her medications have a right to refuse them? Is it ethical to allow a patient with an eating disorder to starve to death?
Should someone suffering from mental illness own a gun?
From the start of residency training, psychiatrists must learn to navigate this interface between deciding what is the best care for patients and following mentalhealth laws that are based on principles of patient autonomy.
For example, if a patient threatening to hurt himself or others comes into the hospital, psychiatrists often have to decide if the patient appears to be truly dangerous and needs to be placed on a temporary legal hold. When patients cannot take care of themselves because of debilitating hallucinations, paranoia or other symptoms of severe mental illness, we are supposed to stabilize them and determine whether legal action such as conservatorship is necessary to get them back on their feet.