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The Ethics of Involuntary Treatment |
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The Ethics of Involuntary Treatment Prepared by CH Cahn, MD This paper was prepared for the Professional Standards and Practice Council, chaired by Dr N el-Guebaly, and approved by the Board of Directors of the Canadian Psychiatric Association in May 1981. This paper deals primarily with the medical treatment of the mentally ill in the absence of a valid consent given by the patient. Consideration is given to certain central issues, such as the semantics of "involuntary" and of "treatment", the attitude of concerned persons, the notion of "dangerousness", and the setting where the treatment takes place. It also deals with certain paired concepts that are frequently discussed as one opposed to the other: detention versus treatment, least intrusive versus most effective treatment, effective treatment in exchange for loss of freedom, the right to treatment versus the right to refuse treatment, emergency versus definitive treatment, the psychiatrist's obligations to the patient as against his duties to the rest of society, and "judicialization" versus "psychiatrization". Some other issues that are related to the subject are considered beyond the scope of this paper, such as the involuntary treatment of children and of moribund patients, behaviour control, the sterilization of the mentally retarded, involvement of patients in psychiatric research without their personal consent, and the involuntary treatment of political dissidents in certain other places. Brief Historical Note The issue of the involuntary treatment of the mentally ill has come into much sharper focus as a result of several historical trends: the patients' rights movement; the much greater availability of potent treatment methods; the changing role of psychiatric hospitals; the greater interest in the subject by the legal profession; and the increased emphasis on the quality of life in general and of handicapped persons in particular. Some would add the "anti-psychiatry" movement to this list. During the past 200 years one may say that not a decade has gone by without major publicity having been given to alleged abuses of the mentally ill: patients being put in strait-jackets, secluded for long periods of time, "put away" in "lunatic asylums," patients treated against their will for insufficient reasons, patients forgotten and rejected by their families and society in general, and patients being discriminated against because of their mental illness. Fortunately in Canada such adverse publicity occurs less often; when it does occur it is sometimes quite distorted or excessively dramatized. However, in the minds of ethicists, legislators, health professionals, lawyers, and others, there is still a rather large area of concern. That is why this paper is being presented now. Let us return for a moment to one of the most important developments in psychiatry during the last 50 years: the introduction of active psychiatric treatments. Some of these such as coma insulin, lobotomy and continuous narcosis at first appeared to be most promising, but because of side-effects and sometimes serious complications are now seldom used. Others, such as ECT and pharmacotherapy, are still held to be controversial by some, but are very effective, have undergone many refinements and continue to be evaluated carefully. Definitions ETHICS: The Oxford Dictionary defines ethics as "the science of morals and rules of conduct," and the word "moral" is defined as "concerned with character or disposition, or with the distinction between right and wrong." The Canadian Medical Association's Code of Ethics is a guide to the ethical behaviour of physicians and contains 49 clauses. Two of these are particularly relevant to our subject: "An ethical physician will recognize that the patient has the right to accept or reject any physician and any medical care recommended to him" and "an ethical physician will, when the patient is unable, and an agent unavailable, to give consent, render such therapy as he believes to be in the patient's interest." These two clauses when considered together imply that the attending physician fully respects the right of the patient to accept or refuse the treatment offered, but intervenes therapeutically when the patient is unable to give or refuse consent, for whatever reason. Another position paper on "Consent in Psychiatry" (1) deals with the various aspects of the consent process, including the psychiatrist's role in determining whether or not the patient is capable of giving a valid consent. Whenever a physician overrules the objections of a mentally ill person to receiving a certain treatment, the physician is faced with an ethical dilemma. This theme will be elaborated below. INVOLUNTARY: Other words used to describe restrictions placed on mentally ill patients are"commitment", "formal admission," "cure fermée" (in Quebec), all of which are covered by the various provincial mental health acts (2). In addition, there are lieutenant-governors' warrants and other court orders according to which restrictions are imposed on patients under the Criminal Code of Canada. These laws are concerned primarily with involuntary admission to designated facilities, and do not usually distinguish clearly between "involuntary admission" and "involuntary treatment." In the Province of Quebec, the term "cure fermée" is particularly interesting from the etymological and semantic points of view. One interpretation of this expression that psychiatrists in Quebec have given is that it confers on psychiatrists the right to order treatment which in their opinion such patients need. Another interpretation is that the expression "cure fermée" merely means the detention in the hospital of a patient who may receive their ordinary care such as food, shelter, clothing, basic nursing care, and so forth, but not psychiatric treatment such as anti-psychotic medication. Further clarification from the legal point of view is required. In other provinces, such as Ontario, the law makes a distinction between control of dangerous behaviour due to mental illness by drugs in an emergency situation (which is permitted without the patient's consent), and definitive psychiatric treatment, for which the patient's consent is required. This is so even if the chemical substance remains the same as the patient passes from the emergency to the non-emergency situation. Further provisions are made for situations in which the patient is not able to give his valid consent (as this position paper deals with the ethics rather than the legalities of involuntary treatment, the reader is referred to the relevant texts for further information). TREATMENT: We are here primarily concerned with the psychiatric treatment of patients by physical or chemical means. Psychotherapy is not included in this discussion, as it is hard to conceive of "involuntary" psychotherapy (the subject "Ethics of Psychotherapy" is thoroughly covered in an article by T.B. Karasu in the American Journal of Psychiatry, Volume 137, pages 1502-12, December 1980, with 79 references), in the usually accepted meaning of these words. Behaviour therapy and its varieties are not considered here, and as already stated above the involuntary application of behaviour modification techniques are beyond the scope of this paper; it will be the subject of another paper. INVOLUNTARY TREATMENT: It should be pointed out that the notions of voluntary and involuntary are not like white and black, but that there are many shades of grey. In fact there is a continuum of voluntary to involuntary, which could be described as follows: active cooperation, passive cooperation, ambivalence, silent objection, irrational opposition, rational refusal. A patient may move along this continuum in either direction during the course of his illness. Furthermore, the patient may accept some treatments but not others, or may change his mind. Another fact to be considered is the non-psychiatric medical or surgical treatment of the mentally ill; general practitioners, surgeons and other medical specialists to whom patients with physical problems are referred are involved in the decision-making process, and, depending on the urgency of the situation, may have to intervene without the patient having given or being able to give a valid consent. Attitudes of Concerned Persons THE PUBLIC: There are still many misunderstandings and misperceptions as to the power of psychiatrists to take away the freedom of persons because of mental illness. The public still grossly overestimates the number and percentage of involuntary patients in psychiatric hospitals. Civil libertarians, certain lawyers, and the "anti-psychiatry movement" contribute to this negative image. Stone (3) has stated: "The rich admixture of science and humanism that diffuses the discipline and the idiom of psychiatry all too often arouse the antipathy of the sceptical, tough-minded lawyer who is trained to demand and expect precision." PSYCHIATRISTS: Some psychiatrists are more permissive, others more authoritarian in their approach to involuntary treatment. Psychiatrists at either end of the scale are more likely to be criticized than the ones in the middle. The literature in recent times focuses more on the interventions by "over-zealous psychiatrist" (4,5) while, as discussed below, in the minds of the relatives of patients, psychiatrists often do not go far enough. Psychiatrists as members of the medical profession have a long tradition of being committed to placing the patient's well being and longevity above all else and in using their own judgment in decision-making rather than that of others. Physicians have often felt that patients were too ignorant to make decisions on their own behalf and that it was better to treat the patient promptly, without inducing new fears and reinforcing unwise decisions on the part of the patient. Nowadays increasing demands are put on the physician to enter into a meaningful dialogue with the patient and to obtain from the patient a valid consent insofar as this is possible. PATIENTS: Relatively few patients are skillful in articulating well their stand with regard to involuntary treatment. Many who express negative opinions have delusions or impaired judgment. The majority of patients do not express any opinion at all; very few raise valid objections, but when this happens, psychiatrists and other mental health authorities are sometimes strongly criticized. "Let one paranoid patient bleat but once about his mistreatment, and 15 members of the Civil Liberties Association make headlines with it for a year" (6). RELATIVES: Relatives of mentally ill patients far more often wish involuntary treatment than any other group of interested persons. In the present atmosphere, where the rights of the individual have encroached so heavily on the rights of others, relatives frequently suffer the most from threatening, frightening, and/or annoying behaviour of the mentally ill. In the past, when paternalism was more acceptable it was easier to take the problems caused by patients out of the hands of relatives by having the patient hospitalized, sometimes for long periods of time. Nowadays, with paternalism often being equated with excessive authoritarianism, and with the shorter duration of stay in hospital, patients are more likely to be repeatedly troublesome to their relatives. The latter can sometimes obtain comfort and support from organizations such as the Association of Relatives and Friends of the Mentally Ill. Dangerousness This subject has been debated extensively and a great number of papers have been written on it. Where there is actual or obvious danger to self or to others due to a patient's mental illness, few would argue that involuntary treatment is required; the arguments start when one considers what kind of treatment is indicated, and also when the danger is less obvious. This is one of the most complex issues psychiatrists are facing today. As long as it is proved statistically that psychiatrists are no better than others in predicting dangerousness it is likely that the law will not or will no longer permit psychiatrists to restrict the liberty of patients to refuse treatment on the basis of potential danger alone. It would seem that only in cases of patients who repeat the same pattern of dangerous behaviour which responds favourably to psychiatric treatment but recurs when the patient discontinues such treatment may there be justification in treating a patient against his will on a preventive basis. However, we must not forget that criminal recidivists are not placed in preventive detention in countries where human freedoms are as highly prized as in Canada. Therefore, whenever possible, a psychiatrist should have a frank and full discussion with a patient who has recovered from an episode of mental illness with dangerous behaviour, hoping that the patient will cooperate with continued psychiatric treatment on a voluntary basis. In the case where a patient never does achieve this sort of insight and repeatedly breaks off therapy, it may be better to utilize Section 16 of the Criminal Code of Canada, that is, the patient, having been charged with an offense is acquitted by reason of insanity and is then placed under "Lieutenant-Governor's Warrant"; if such a patient refuses treatment, the Provincial Review Board may authorize psychiatric treatment. A patient under "L.G.W.", having been hospitalized may be discharged and followed as an outpatient in a way similar to a convicted criminal discharged from a detention centre being helped by a probation officer to keep the peace. Detention Versus Treatment Psychiatric hospitals, whatever the previous title (lunatic asylum or mental institution) have a long history of functioning as quasi- jails for persons who have had to be admitted involuntarily ("committed") or who had been charged as criminals but found to be too mentally ill to be cared for in prisons or other detention centres. Only in recent times have other psychiatric treatment facilities been included in accepting involuntary patients. This seems eminently fair, as it tends to diminish the stigma attached to psychiatric hospitals, and fits better with modern concepts of community psychiatry. But there is still the problem of the use or perhaps abuse of psychiatric facilities for the detention of persons considered mentally ill by the public, the police, or judges as an alternative to imprisonment, even for people with personality disorders for whom psychiatrists have no adequate treatment. For such individuals the hospital serves primarily as a detention centre. Psychiatrists are reluctant to allow hospital beds to be occupied for long periods of time by such individuals, especially when there are waiting lists for psychiatric patients for whom treatment is more successful. However, the public tends to regard hospitalization as a treatment in itself; in fact, before the days of active psychiatric treatment, and even today, psychiatrists may themselves regard admission to hospital as the most important treatment for the patient. In the hospital, the patient is taken care of, that is, he receives food, clothing, shelter, nursing care, and a program of structured activities, which for many patients improves the quality of their life as compared with the life they led in the community. Whether a patient benefiting from being in the hospital under these circumstances should in addition have to undergo involuntary psychiatric treatment, because the psychiatrist has a treatment that he thinks should be given in the belief that it will further improve the patient's mental condition, remains a controversial issue. This issue is causing a good deal of friction between psychiatrists of the more traditional type and patients' rights advocates of the more activist type. One of the most important functions of physicians is to relieve suffering; therefore, although psychiatrists may ardently wish to treat all the mentally ill who are treatable, there are certain patients such as simple or hebephrenic schizophrenics who do not appear to be suffering very much from their symptoms (judging from their facial expressions they may actually seem to be enjoying some of their symptoms). Certainly it is ethical to treat involuntarily patients who are in patent or overt distress because of the illness (such as patients with depressive or paranoid delusions). This does imply that some patients, especially certain chronic schizophrenics, will continue to have symptoms and may have to remain hospitalized or otherwise be looked after if they refuse active psychiatric treatment, even though the psychiatrist is convinced that with such treatment the patient would be greatly improved. The psychiatrist may feel perfectly justified in pursuing an objective of active treatment, in the belief that it will reduce chronicity, save money, or improve the hospital's discharge statistics. But the more ethical approach is for the psychiatrist to allow the patient to make some decisions for himself, or at least to have a continuing dialogue with the patient to try to persuade him to accept treatment on a voluntary basis. Setting Involuntary treatment may be given in hospitals, in detention centres, and also in some jurisdictions on an outpatient basis or even at home. The most frequent setting for involuntary psychiatric treatment is of course the hospital. It is in the hospital where the therapeutic team is working in familiar surroundings. Expert staff and up-to-date equipment are readily available, especially in emergencies. Patients can be treated involuntarily in other settings, but the desirable supportive services are less readily available there. For relatively uncomplicated treatment, such as bi-weekly fluphenazine injections, an outpatient setting or treatment in the patient's home is quite feasible. DISCHARGING THE UNCOOPERATIVE PATIENT: Physicians are generally the only group of professionals entitled to order the admission and discharge of patients (patients under Lieutenant-Governor's or Judge's orders are considered separately). When a patient refuses the treatment offered, the attending physician often responds by discharging the patient from the hospital. The physician may wish to make the bed available to a more cooperative patient. The hospital may have a utilization review committee whose objective is to ensure that the duration of stay in hospital is not too long. Hopefully the patient will not be discharged prematurely by reason primarily of hostile reaction of the attending staff. Some patients wish to stay in hospital without necessarily accepting the treatment offered. More frequently, patients leave the hospital, but soon return because their mental condition becomes worse, or there may be more subtle reasons. Some patients have learned how to take advantage of their "mentally ill" status as a means to evade the law or other social responsibilities. For financial or political reasons there may be an overall policy to discharge chronic patients back into the community. If the patient is not properly prepared, there is the risk of "replacing back wards with back alleys." All these factors have to be considered carefully by the attending physician when deciding how a given patient is best managed. None of them singly seems to be sufficient to justify intrusive psychiatric treatment against the patient's will. Least Intrusive Versus Most Effective Treatment In psychiatry, as in much of medicine and surgery, the most effective treatment is often the most intrusive. One could compare psychosurgery with the surgical removal of a brain tumour, or neuroleptic therapy for schizophrenia with insulin therapy for diabetes, or physically restraining a violent patient with the reduction of a dislocated shoulder. There are many similar examples, but the most important difference is that where there is no mental illness, a valid consent given by the patient to the intervention, no matter how drastic, can usually be readily obtained before the intervention is undertaken. Hence the vigorous search for effective psychiatric treatments with less intrusiveness and fewer side-effects. Psychosurgery has all but disappeared from the therapeutic armamentarium. ECT has been very much refined and more carefully controlled. Psychopharmacology researchers are constantly searching for new drugs with fewer side-effects. Greater effort is being made to evaluate the quality of treatment by means of medical audits and peer review. Furthermore, the setting where the treatment takes place is constantly being improved: psychiatric hospitals have more and better staff than formerly, fewer patients are admitted involuntarily and for shorter periods of time, alternative settings for treatment such as departments of psychiatry in general hospitals, various outpatient clinics, day care, home care, and supervised community living are all being utilized much more than heretofore. The advantages of treating the patient in the least restrictive setting must be weighed against the disadvantages of not always being able to offer the most effective treatment; for example, it is more difficult to prevent the suicide of a severely depressed patient at home than in hospital. Effective Treatment in Exchange for Loss of Freedom The medical profession has always held that the patient has the right to receive the best available treatment. In the case of the mentally ill, physicians have above all wished to give their patients the maximum benefit of available treatments even if this meant that the patient, because of his mental illness, was not entirely free to decide for himself what should be done. This has given rise to the notion of "quid pro quo," which implies that the patient will receive effective and beneficial treatment in exchange for the loss of his freedom. What certainly is no longer acceptable is that patients be detained in hospitals "without more." The more the patient's freedom to move around as he pleases and to make his own decisions is restricted, the greater is the obligation on the physician and the hospital staff to provide effective, and harmless treatment. It is very difficult to apply the equation with perfect fairness, but psychiatrists and other health professionals should always strive towards this ideal. There are four possibilities which are illustrated in Table I (simplified for theoretical purposes; in reality the lines of demarcation are by no means clear cut).
COMMENTS: "Effective Treatment" ideally is treatment that has been proven to be effective by scientific research methodology; but treatment may be effective in a given case without having been validated scientifically. "No Treatment" here means that the patient does not receive effective treatment. There may be four possible reasons for this: Value judgments will continue to have to be made and priorities assigned before budgets are approved to spend the public's tax dollars for this category of patients. Although ideally the cost of treatment should not be a factor, in reality it will continue to be especially difficult to apply the above equation fairly to all mentally ill offenders inside maximum security facilities. The Right to Treatment Versus the Right to Refuse Treatment This is one of the most contentious issues in modern psychiatry. A paper by Redlich and Mollica in the American Journal of Psychiatry (7) entitled "Overview: Ethical Issues in Contemporary Psychiatry" describes the historical, ethical, legal, as well as medical points of view in the United States. One of the statements these authors make is as follows: "With some shame we state that most of the changes in establishing patients' rights were not brought about primarily by psychiatrists but civil libertarians led by lawyers, and that the most important decisions were by enlightened judges." The authors of this paper discussed changing moral values at length and seemed to be rather critical of the American medical profession in general and psychiatry in particular. In Canada so far there is not as much concern in this area; certainly far fewer legal actions have been taken against psychiatrists and psychiatric treatment facilities than south of the border. But this should not lead us to a false sense of security; on the contrary, we should keep ourselves well informed as to the involvement of our American colleagues. Even in Great Britain where medical ethics reach further back in history than on the North American continent this matter has received increased attention - following a six-hour debate in the British House of Commons in February 1979 on the review of the Mental Health Act, the reporter for the British Medical Journal (8) stated: "On the question of consent to treatment there were two safeguards for the patient in circumstances where staff had to override his wishes. Firstly, treatment should be imposed against the patient's wishes only if it is necessary to save life, to prevent violence, or to prevent deterioration in the patient's condition. Secondly, the Government had proposed that except in an emergency the patient's wishes should be overridden only when a concurring second opinion had been obtained." From the above it is evident that psychiatrists have a growing obligation to evaluate, as objectively as possible, the patient's prognosis for behaviour dangerous to self or to others before subjecting the patient to involuntary treatment. In Britain it appears that the psychiatrist may still order involuntary treatment "to prevent deterioration in the patient's condition"; in the United States, the patients' rights movement seems to make this increasingly difficult, and only behaviour imminently dangerous may justify involuntary treatment. In Canada, as is so often the case, we seem to be somewhere in between the British and the American situation. In true emergencies, that is, where a patient's behaviour due to mental illness is obviously dangerous to himself or to others, the medical profession has great leeway to intervene energetically with therapeutic and preventive motivation. In fact, society confers on the physician the obligation to treat the patient until the emergency is over. This may be a matter of minutes, hours, or days, but rarely longer than that. Of course the emergency may recur, especially if definitive treatment is not instituted. There are also two related questions which are not always easy to answer: When is the emergency over? Who defines what is an "emergency"? The psychiatrist has to observe the patient closely for at least the period of time when he believes that the emergency still exists, and for some time afterwards, and he also has to take into account other people's opinions as to what constitutes an emergency even if he himself does not think there is one, or vice versa. In any case, the psychiatrist has to get to know the patient as quickly as possible, and dispel the uncertainties in his mind and that of those closely associated with the patient (family, friends, employers, police, hospital staff, and so on). Once the psychiatrist has decided that emergency treatment is indicated, he has available a choice of measures including a forceful verbal approach to the patient, seclusion, manual or mechanical restraints, or various drugs administered orally or parenterally ("chemical restraint"). Fortunately, these measures are in most cases effective and relatively harmless. The difficult ethical problem does not exist so much at the beginning of the emergency, but later on: at what point in time is the psychiatrist no longer justified in treating the patient without a valid consent? It is here that the psychiatrist's knowledge and skill have to be optimally applied; it is hoped that this paper will help the psychiatrist to weigh the various factors before proceeding with the treatment. A comment concerning the emergency treatment given by non-psychiatric physicians to patients who have made suicidal attempts: it would appear to be more ethical for such physicians, especially those working in general hospitals with psychiatrists on the staff, to request a psychiatric consultation before sending the patient home than to omit this. This statement is not intended to question the ability of the non-psychiatric physician to handle emergencies occasioned by patients with mental disorders, but merely to point out an ethical aspect of the situation. It is suggested here that the medical staff by-laws of general hospitals with departments of psychiatry or psychiatrists on their staff include a consideration of this matter. Psychiatrist's Duties to Patient Versus Duties to Society The psychiatrist is often called upon to "wear two hats," one as the patient's therapist, when his allegiance is with the patient, and the other, when he has to communicate with third parties such as giving explanations to the patient's family or other interested persons, when he has to make reports to the courts, or declare the patient incompetent for one reason or another. In acting thus as a "double agent," the psychiatrist must always establish his own priorities in terms of his ethics, the reality of the situation, his relationship with the patient, and his responsibility to both the patient and the public. Since so many psychiatric patients are uncooperative or lack insight, the psychiatrist in making decisions may disregard the patient's present attitude to treatment for the sake of obtaining a good result later on. Does the end justify the means? In any case, the psychiatrist should inform the various parties concerned what action he or she is going to take. Related to this issue is the question of the choice of therapist: does the patient have the right to choose his psychiatrist? There are many problems in the organization of psychiatric services in hospitals, and with the widespread shortage of psychiatrists, patients often do not have much choice, if any. Thus one patient may find himself with an attending psychiatrist who is rather authoritative, whereas another patient has one who is much more permissive. The first type of psychiatrist is more likely to prescribe involuntary treatment than the second. This is an ethical problem insofar as in the first case the patient is more likely to complain, while in the second case the relatives are more likely to complain about the psychiatrist's attitude, with the result that society accuses psychiatrists as a group of being inconsistent. "Judicialization" Versus "Psychiatrization" By "judicialization" is meant the excessive involvement of the legal profession in decision-making concerning the mentally ill just as the word "psychiatrization" implies the excessive involvement by psychiatrists in matters (sometimes remotely) related to mental health or mental illness. Redlich and Mollica (7) have stated that: "Psychiatrists in general opt for medical informality rather than for legal formality and for flexible medical therapeutic action rather than bureaucratic and legal surveillance . . . The control of deviance - largely forced upon psychiatry by society - is more of a curse than a boon to our profession . . . we should be happy to leave it in the hands of the law for enforcement." The history of the relationship between the legal and medical professions is lengthy and full of controversy, with the pendulum swinging from side to side insofar as ultimate authority is concerned. We now appear to be in a phase where the legal profession has the ascendancy, and psychiatrists, particularly in the United States, seem to be more affected by the phenomenon of "judicialization" than the legal profession is by the phenomenon of "psychiatrization". In Canada a similar tendency is discernible but to a lesser extent. One may assume that the excesses of the one side are a reaction to the excesses of the other; our primary goal should be to avoid such excesses. Sharing of Decision-Making If we are to conceptualize the doctor-patient relationship as a form of partnership, we must recognize that the degree of cooperation attainable between the two depends to a large measure on the patients mental condition: to the extent that the latter precludes cooperation, third parties may be called upon to enter this relationship. A partial list of such "third parties" would include another physician; another health professional; relatives and friends; a guardian, trustee, or curator; an ombudsman; a citizen advocate; the clergy; and members of the legal profession. With such a variety of persons who may be involved in patient management, the subjective factor is bound to enter in, mistakes may occur and the art of public relations is very important. Psychiatrists are usually well trained in the dynamics of interpersonal relationships and are in a good position to control the degree of involvement of third parties. The psychiatrist can usually decide who should be involved, when, and to what extent, but there are many uncontrollable and unforeseeable situations where this is not possible. When decisions are made to treat a patient against his will, it becomes that much more important to have the other appropriate parties well briefed, and to make frequent reviews with them of the effectiveness of the treatment plan. Returning to the issue of who should have the ultimate authority for instituting involuntary treatment, ideally this is a decision which should be shared by the attending physician and a judge according to "due process of law." For strictly practical reasons, medical decision-making saves a lot of time, and may save lives. (For instance, it was reported that a depressed patient jumped out of a window of a court house while the psychiatrists had to wait for the judge's decision.) In that sense, it is more ethical not to rely on the conventional legal system, because it tends to be unwieldy and slow. If a judge were readily available at the treatment centre, the problem might be solved; but this is an expensive arrangement, and has not been instituted anywhere as far as we know. In the meantime it will be necessary in most instances for the attending psychiatrist or other physician, as the case may be, to decide when a patient's objection should be overruled and when not. In any doubtful case, it is advisable to obtain the opinion of a colleague. In extreme cases, judicial opinion should be sought. Recommendations Psychiatrists must consider carefully the semantics of "involuntary treatment" and help to explain to the public the difference between involuntary hospitalization ("commitment") and involuntary treatment. They are to evaluate carefully the equations "least intrusive versus most effective treatment" and "effective treatment in exchange for loss of freedom." The attending psychiatrist is to attempt to have a continuing dialogue with an objecting patient to try to persuade him to accept treatment on a voluntary basis. In emergencies, the attending psychiatrist is to carry out promptly all the necessary treatments, but when the emergency is over, he should carefully review with the patient what was done and what still remains to be done. It is therefore recommended:
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