Abnormal Psychology

Ethical and Legal Issues 739

in a less restrictive environment (such as in a residential setting and with outpatient

treatment).

One year after this ruling, the Supreme Court ruled that civil commitment

must entail more than warehousing or confi ning people; the Court ruled that ap-

propriate treatment must also be provided, while recognizing that treatment might

not necessarily be successful (Rouse v. Cameron, 1967). In subsequent cases dur-

ing the 1970s, courts in various jurisdictions outlined specifi c minimal criteria for

such treatment—including the minimum staffi ng ratio (number of patients per care

provider) and number of hours per week of treatment, as well as the need for each

patient to have an individualized treatment plan (Wyatt v. Stickney, 1971). The spe-

cifi cs of these requirements differ from jurisdiction to jurisdiction.

The Supreme Court also ruled that civil commitment may not be used simply to

confi ne people against their will indefi nitely (except as previously noted with some

sexual predators). When patients no longer meet the criteria for commitment (that

is, they are no longer dangerous) and can survive independently or with help from

willing family members, then they must be discharged (O’Connor v. Donaldson,

1975). The reasoning behind this ruling is that the purpose of the confi nement is

treatment, and so when inpatient treatment is no longer required, the person should

be released.

Right to Refuse Treatment

A federal district court in New Jersey set another standard when it ruled that a

civilly committed patient has the right to refuse treatment (Rennie v. Klein, 1978).

Generally, this ruling has been applied to a patient’s right to refuse to take medica-

tions, most frequently traditional antipsychotics that carry the risk of a serious side

effect called tardive dyskinesia (see Chapter 12) (Perlin, 2000b). However, the court

did not establish the right to refuse treatment in all situations. As long as there has

been a fair and adequate hearing of the issues involved for a given patient, his or her

refusal can be overridden after weighing certain factors (Meyer & Weaver, 2006):

• the patient is physically threatening to others (which may include patients and

staff members),

• the proposed treatment carries only a small risk of irreversible side effects,


• there are no less restrictive treatment alternatives available, and


• the patient’s capacity to decide rationally about particular treatments is signifi -

cantly diminished.

Competence to Refuse Treatment

One of the acceptable circumstances for overriding a committed patient’s refusal of

a treatment is that he or she does not have the capacity to decide rationally about

treatment. How can mental health clinicians and the courts determine whether

someone is competent to refuse treatment? (Being competent to refuse treatment is

different from being competent to stand trial, although both competencies involve

some of the same mental processes and abilities.) One study that investigated the

general question of competence to refuse treatment (Appelbaum & Grisso, 1995;

Grisso & Appelbaum, 1995) found that about half of patients with schizophre-

nia performed reasonably well on several tasks assessing decision-making ability.

Not surprisingly, those with more severe symptoms of schizophrenia did less well.

After 2 weeks of treatment, those whose symptoms had improved also improved in

their decision-making abilities related to competence. An even greater proportion

of patients hospitalized for depression—about 75%—performed adequately on the

tasks that assess decision making. Unlike the patients with more severe symptoms

of schizophrenia, those with more severe depression were not necessarily less com-

petent to make decisions. Thus, having a severe mental illness did not routinely

make these patients “not competent to refuse treatment.”