The Right to Refuse Medications

July 6 juillet 13:45 – 17:45
(extended session)

Room NCDH–201

Chair: Jagannathan Srinivasaraghavan , Southern Illinois University

Social activist or double agent? The perils of Prozac and Ritalin

Jeffrey Spike  

University of Rochester

There has been much discussion of the many ways doctors are asked to be agents for social causes, such as testing pregnant women for drug abuse to protect the fetus, or drivers in accidents to help those injured in the crash (or their insurance companies). These are sometimes called being a dual or double agent. This is often criticized, saying the traditional role of the physician as an advocate for the patient is compromised. Social activists, in contrast, are usually seen as working to correct the inequities in society, and carry a positive connotation. But there is also a political agenda to which each group is considered in a positive light. For people concerned about law and order, or the rights of innocent victims, the first group, double agents, are refusing to let their patients harm others, and so it is akin to the second group. In psychiatry, there are controversies about two drugs, Prozac and Ritalin, which might be beneficially analyzed in these categories. The controversies around Prozac are well known. I will review them briefly, focusing especially on the role of social change. Over the past century, the expectations of work have increased dramatically, with productivity measures becoming almost an obsession in business and management circles. School teachers commonly work a 50-hour week, and doctors 60-90 hours, depending upon their specialty. Could it be these external pressures are making otherwise normal people feel inadequate? Further, the pressure to be productive may mean less tolerance for people with an existential or poetic nature. Aptly named, many have decided that it is better to be prosaic. Similarly, the rise of ADHD has occurred over the century of urbanization. One hundred years ago most ADHD children would have had a future working on the family farm, while only the most academically talented child from a family of five or ten children would go to college. In contrast, now 1 or 2% of the population in economically developed nations work on farms, over 50% go to college, and are considered a failure if you don’t at least graduate from high school. The ability to sit in class and memorize (whether in a textbook or on the board) are essential, rather than optional skills. Indeed, it is often the school’s that ask for the child to be evaluated (and medicated), not the parents. Whether these psychopharmacological interventions are seen as helpful and patient friendly, or overused and done primarily for the good of others, will be the topic of my presentation, and of the discussion afterwards. Together we can decide whether psychiatrists are being used as double agents, and whether it is a justifiable role for them to assume.

Right to refuse medications: Evolution and models

Jagannathan Srinivasaraghavan  

Southern Illinois University

Paul Appelbaum  

University of Massachusetts

In the 1960’s, the criteria for civil commitment shifted from need for treatment to need for confinement based on dangerousness. With increasing acceptance of the doctrine of informed consent, the decision making power shifted from physicians to patients. Along with these changes, a civilly committed person’s right to decision making, including the right to refuse medications, came to be recognized. The right of refusal is adjudicated either judicially or administratively. Giving patients’ autonomy and rights greater significance than treatment considerations are models fashioned like Rogers v. Commissioner of Mental Health (Mass 1983), using judicial review mechanisms. Models that emphasize treatment, not just confinement, and that rely on the principles of Rennie v. Klein (Third Circuit Court 1983), are models that utilize administrative review panels. This lecture will highlight these two models and variants of these models currently in operation in the United States.

Non-judicial “forced medication panel” in the State of Maryland

Geetha Jayaram  

Johns Hopkins University

Psychiatric care in Maryland is provided both voluntarily and involuntarily in general medical and psychiatric hospitals. Severely mentally ill patients often refuse treatment. Such patients may present a danger to themselves or others if released without appropriate care. The law in the State of Maryland–HG 10-708–provides for a “forced medication panel” to prescribe treatment under these circumstances. This lecture will outline the procedures involved in administration of medication over patients’ objection by a clinical review panel. There will be case examples to demonstrate the working of this panel emphasizing how it is possible to safely and successfully treat involuntary patients with forced medications in a responsible and humane manner.

A performance improvement project to improve utilization of court-ordered treatment in a state hospital

Malini Patel  

Finch University of Health Sciences

Daniel Hardy  

Loyola University of Chicago

The overturning of Right to Refuse Psychotropic Medications is a function of the judicial system in the State of Illinois. There is wide discrepancy among hospitals and psychiatrists how this statute is utilized for the benefit of the patients. This presentation focuses on methods that encourage the use of court-ordered treatment in a 500-bed State hospital. Literature and clinical practice confirm that denial or delay in treatment can result in an increase in morbidity and adverse events for patients. A performance improvement project aimed at encouraging staff psychiatrists to actively pursue the option of court-ordered treatment for appropriate patients was designed. The major theme of the project was education and feedback to address the court avoidance attitude of psychiatrists. Results: In four years the number of petitions seeking court-ordered medications doubled. This project also led to a hospital wide effort to foster the theme of assertive treatment extending to other disciplines. The heightened awareness of the benefits of assertive treatment contributed to a decrease in average length of stay as well as reduced restraint usage and patient-to-patient injuries during the same period. Conclusion: Severely mentally ill patients derive benefit by early medication intervention, even if it is court-ordered. Education, support, and feedback can positively influence clinician attitudes and behaviors.

Correlation between peer review of professional performance and outcome in judicially enforced medication trials

Jagannathan Srinivasaraghavan , Alan Felthous , Wenona Whitfield  

Southern Illinois University

Sarah Andrew , Nancy Watkins  

Choate Mental Health Center, Anna, Illinois

Objective: To test whether the combined ratings of the quality of testimony of the psychiatrist, the performance of the State Attorney and Public Defender can differentiate between two groups of cases where the petition for medication of psychotropic medications was granted or denied. Subjects: From 1991 to 1999, in Southern Illinois, there were 17 denials and 109 grants of petition for administration of psychotropic medications in Union County Court. Preliminary study involves transcripts of randomly selected six denials and eight granted petitions. Method: From the court transcripts, any reference to the court decisions is deleted. An academic forensic psychiatrist and an academic lawyer rate the content and process of psychiatric testimony, and the performance of legal professionals on a scale of one to four (poor, fair, good, and excellent). Results: Mean rating of the performance of the Psychiatrist, State’s Attorney and Defense Attorney for granted and denied petitions are noted. There were six psychiatrists, four State Attorneys, two Defense Attorneys, and one judge involved. Conclusion: Co-efficient of the Linear Discriminant Function suggests that the most important variable for discrimination between the two groups is the rating of overall performance of the psychiatrist. The study provides opportunity to improve psychiatric testimony by education and regular feedback.

Administrative review model in a maximum security hospital in Louisiana

Alan W. Newman  

Tulane University

The East Louisiana Mental Health System, Forensic Division, is the maximum security inpatient forensic hospital for Louisiana. The population comprises of patients who are unfit to stand trial, not guilty by reason of insanity, permanently incompetent defendants and patients too dangerous to be in state civil hospitals. Although judicial review is not required to force medications, the facility has adopted procedures to ensure that the patient receives appropriate due process when refusing medications. When a patient refuses medications, the treating physician requests an Administrative Review to assess the appropriateness of enforced medications. The Medical Director reviews the patient’s hospital record, including staff reports of the patient’s behavior and the treating physician’s recommendations. The Director interviews the patient with a patient advocate to determine if the patient is competent to make an informed decision regarding medications. In order to force medication, the Director must determine that the patient is mentally ill or suffering from substance abuse and is dangerous to self or others, or gravely disabled without the medication, and that the recommended medication is the most appropriate treatment. The presenter will discuss the data collected over the past three years concerning outcomes of this process and factors which contribute to the decision whether to force medications involuntarily.

Implications of the right to refuse treatment in defendants found unfit to stand trial

Angeline Stanislaus  

Southern Illinois University

In the criminal setting, psychiatrists are frequently confronted with the issue of the right to refuse treatment. In Illinois, after a defendant is found Unfit to Stand Trial, he is committed to a Department of Human Services forensic inpatient facility for treatment and restoration to Fitness. But the defendant has the right to refuse treatment. The statutes outlining the criteria for court-ordered enforced medication also apply to the mentally ill criminal defendants. But the issues arising from treatment refusal by these inpatients are different to those committed for civil reasons. In Riggins v. Nevada, the issue of enforcing treatment with psychotropic medications in order to restore Fitness to Stand Trial was raised. Even if the defendant is medicated for restoration of Fitness to Stand Trial, whether the medications would affect the ability of the individual to effectively take part in the trial has been questioned. There is a tug-of-war between the liberty interest of the defendant and the State’s interest to expedite the trial. The case laws addressing these issues will be reviewed. The clinical, legal and ethical dilemmas faced by psychiatrists who work in the forensic inpatient facilities will also be addressed.

Legal v. ethical issues related to enforcing medications for restoration of competency to be executed

Stephen Robinson  

Southern Illinois University

The Supreme Court determined in the case of Ford v. Wainwright that an incompetent defendant cannot be executed. This led to competency-to-be-executed evaluations on death row inmates. One of the most controversial issues in psychiatry is the participation of psychiatrist in capital punishment. Once found incompetent to be executed, the question of the prisoner’s right to refuse treatment comes into play. In Perry v. Louisiana, the Supreme Court was faced with the issue of determining whether forcibly medicating a death row inmate in order to restore competency-to-be-executed is unconstitutional. Often the prison psychiatrist is called upon to treat the death row inmate for restoration of competency. Our ethical values are greatly questioned under these circumstances, when our goals depart from treatment to relieve suffering to treatment to allow execution. What are the clinical and ethical problems, when the prisoner refuses treatment? The case laws addressing this issue will be reviewed, along with a discussion of the ethical dilemmas.  

Discussant: Maggie Tweddle, University of Alberta

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