Wednesday, January 2, 2008

Outpatient Psychiatric Commitment

President Harry Truman only wanted advice from one-armed economists, to avoid being told “one the one hand…but on the other hand…”

I have tried to follow Truman’s guidance in giving talks about ethics. An “on the one hand/on the other hand” talk tends to sedate the audience. If listeners think the speaker is all wrong, at least they are awake and thinking.

But a happy article in a recent Washington Post brings up an issue for which two-armed policy advisors and ethicists are desirable. Susan Wezel, a 50 year old New York woman who suffers from a severe psychotic illness, was required to undergo outpatient treatment under a New York law (“Kendra’s law”) that allows court-mandated treatment. Despite having been hospitalized more than a dozen times in the previous ten years, she has been stable and functioning well for the past 18 months. She now takes medication regularly and credits the law with saving her life. Her husband Chris says "there was nothing I could do to get her into any help before this."

The primary political impetus for laws that allow forced outpatient treatment is fear of the rare but highly publicized acts of violence by persons with psychiatric illness. The New York State law was passed after 32 year old Kendra Webdale was killed by being pushed in front of a subway train by Andrew Goldstein, who suffered from schizophrenia. California passed “Laura’s Law” after 19 year old Laura Wilcox, who was working in a public mental health clinic during a school break, was shot to death by Scott Thorpe, who believed that the FBI was trying to poison him and force him to see an incompetent psychiatrist, and who rejected his family’s pleas that he go back onto antipsychotic medication.

Most psychiatrists have seen happy situations like Susan Wezel’s, in which a gravely impaired person regains access to their innate capacities when the psychosis that has intruded on their function is controlled. Two decades ago a patient of mine voluntarily accepted, albeit reluctantly, injections of an antipsychotic medication. These have continued every four weeks, in very low dose, to the present, and the person has been able to turn life around in a way that brings substantial fulfillment.

Lawmakers ask -- if people can be helped in this way but cannot be persuaded to participate in treatment – why not set the ball of recovery rolling by requiring treatment? Especially if the specter of preventing violence is added to the equation! The argument for outpatient commitment is powerful. But so is the critique, which is based on principle (opposition to coercion) and practice (questions about the efficacy of outpatient commitment).

I come out in favor of cautious and careful outpatient commitment programs, modeled on New York, which has not simply passed a law but has also provided funding to allow treatment of the sort that Susan Wezel has benefited from. But people of good will and good knowledge of the issues will continue to disagree.

The reason for this posting, however, is not the substantive issue, but the policy lesson that comes from the policy debate itself. Many state legislatures – like New York and California, and now Virginia, which has been activated by the Virginia Tech killings – have conducted remarkably thoughtful deliberation – involving gathering data, benchmarking other states, hearing the range of viewpoints, and educative debate.

This has been the kind of educative policy debate we need for sound governance of our health care system. The two key ingredients that allow it to happen are the (a) presence of well-informed advocates and advocacy groups for a range of perspectives and (b) absence of political posturning and virulent self-righteousness that has impeded deliberation in so many areas.

To some extent, our having such well informed advocates has helped to keep demagogues at bay. That may be the key policy lesson.

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