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The Limits of Autonomy: Should the Mentally Ill Be Forced into Treatment?

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The best advice I ever received from a psychoanalyst concerned the son of a friend of mine (let's call him Joe). Joe kind of adopted me, and often came over seeking advice. The young man was unrealistically optimistic. If his boss complimented him on some job he carried out, Joe was sure he soon would receive a promotion. When none of this was forthcoming, far from being crushed, Joe would spin a new tale: he expected to be soon moved to a choice location. And when this move did not materialize, Joe assumed it was just being delayed.

The same with dating: a smile was interpreted as a sure sign of deep interest, and a long deep look meant a potential keeper. And there always was another tomorrow. Joe was never down -- except when I tried to call his attention to his poor reality testing. The therapist warned me not to take away Joe's defenses -- before I provided him with some other foundations on which to base his self-esteem. Sadly, I never found a way to help him find more realistic sources of contentment. Accordingly, I just listened sympathetically but tried not to reinforce his illusions.

I was reminded of this episode when I read in The New Yorker about a delusional woman named Linda, who believed that she was fighting off government spies and that God would provide whatever she needed. When she was hospitalized, she refused to accept that she was mentally ill. Therapists, The New Yorker reports, tend to see in such refusals -- exhibited by about half of mentally ill patients -- a sign of illness and insist that patients accept their conditions as a first step toward a cure. Such acceptance is also needed to encourage the patients to take their medication. However, for Linda -- and many others, it seems -- this meant great humiliation. In her case, she would have to give up on the heroic role she had spun for herself and accept that she was, in her words, "crazy" -- that is, give up on the narrative that kept her going before any new ones were formed. She left the hospital, moved into an abandoned house, lived on apples she collected at night, and eventually died from malnutrition.

The New Yorker -- writing about her and many other such patients -- implies that this is the life she wanted. It was her choice; to keep her hospitalized against her will, and make her recognize her illness, would have violated her autonomy. Many other physicians and therapists and even medical ethicists would agree. They tend to see the will of the patient as free will, which should take precedent over all other considerations unless the person poses even merely potential albeit plausible threats to others or to herself. (The fact that Linda might harm herself was not clearly evident when she was released.) Thus, it seems that a considerable number of therapists hold that one should not make or even unduly pressure mentally ill patients who refuse to take their medication, even if once they are on the meds they realize their benefits. The medical community wonders which is their "true" self -- the medicated or the un-medicated one? -- and whose preferences to follow.

As I see it, mental patients are like children who are not fully competent to make decisions. Adults, who are charged with their care, owe it to the community -- and above all to the children -- to second-guess and amend their decisions, if need be by use of force. As a parent I did not let my 2-year-old run into the street out of respect for his free will, nor drive when he was 16 and high -- even when I had to wrestle away the car keys. True, as children grow older, the range of decisions they can make on their own ought to be increased -- as and if their capacity grows. But even for, say, a 17-year-old, I would veto his decision to invest his savings, say, in a hedge fund, not to mention pork bellies.

The same goes for mental patients. True, they vary in their capacities, which hopefully can be made to grow, which in turn will require allowing them to make more decisions on their own and learn from their failures. However, at the end of the day, they should be medicated and, if need be, held if there are reasons to believe that may harm themselves or others. Protecting life takes precedent over respecting a will that is not free but distorted by mental and often genetic, chemical or other malfunctions.

Amitai Etizoni is a University Professor at The George Washington University and the author of New Common Ground (Potomac Books, 2009).

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