In a recent article in the Sunday Review of The New York Times, Dr. Irene Hurford of the University of Pennsylvania discussed forcing psychotic patients to take medication against their will. [¹] She described a patient from 13 years ago. This patient had AIDS, but he believed his suffering was the will of God, as explained to him by the Archangel Michael, who had come to him in a vision three decades earlier and called him to prophecy. “The Prophet” refused medical treatment for either his AIDS or his psychosis. He came to the emergency room to preach. Dr. Hurford wondered if she should use laws that allowed her to force him to be medicated: Was it was better for him to continue to believe he was a Prophet or to be medicated and learn that he was a homeless man with AIDS? Dr. Hurford decided to force the man to accept treatment, but has questioned the decision ever since.

The article questions whether we have a moral right to force people with psychosis to leave the reality that they live in and force them to live in our alternate reality. Dr. Hurford provides other examples of people whose lives have seemingly been devastated by their psychosis, and wonders if it is helpful to force treatment on these people. She cites one meta-analysis of three randomized-controlled studies of more than 700 people, which found no statistically significant benefit of enforced outpatient care in reducing hospitalizations, arrests, homelessness or improving quality of life, [²] and other studies that demonstrate that positive experiences of psychosis, such as missing either the voices or the feeling of power, are one reason people stop taking medication, in addition to side effects like weight gain, mental dulling and painful muscle spasms. [³]

Two letters from practicing psychiatrists published in a later issue of The New York Times stressed that positive experiences of psychosis are rare, that schizophrenia is usually a horribly destructive disease, and that in the vast majority of cases patients are better off when they are forced to take medication if they will not take it voluntarily. [⁴]  This agrees with most of my experiences with Social Security disability clients who hear voices. In most cases, the voices are disturbing, and often tell my clients to steal things, or to hurt themselves or others.

However, I also have anecdotes of clients with positive experiences of psychosis. One client of mine told me that the voices would tell him to pay his bills, or to look both ways when he crossed the street, or to be careful when he did something dangerous. I had to refrain from telling him that he should listen to the voice in his head.

My wife, a psychotherapist, once told me about a client of hers who heard the voice of a little girl. The little girl would sing to the woman, giggle, and tell the woman jokes. Anti-psychotic medication made the voice go away, but the woman stopped taking the medication because she missed the little girl.

While the opinions from these psychiatrists may be worthy, their approach is insufficient. When a doctor is treating a patient, the doctor’s first concern should be what is in the best interests of the patient. But another concern should also be the personal autonomy of the patients. We should make sure that the patients can, to the best of their ability, make their own informed and lucid decisions as to how much and what kind of treatment. The goal should be for patients themselves to decide what is in their own best interests.

This does not mean that we should never force medication on an unwilling patient. Clearly, doctors should be able to force medication on the very few patients whose conditions cause them to be a danger to others.

Many people with mental disabilities have an impaired ability to make their own decisions. The inability to make one’s own decisions can result from a many causes, including from being overwhelmed by emotions to a direct incapacitation of the executive area of the brain that makes decisions. A mentally disabled person may not be able to realize that they need assistance, and may need psychiatrists to substitute their expert judgment for the patient’s. When determining whether to force treatment on an unwilling patient, the question that the doctor should be asking is not, “Has my patient made a bad decision about refusing treatment?” but rather, “Has my patient been able to make a lucid and informed decision?”

“Autonomy” is much closer to current American constitutional law than the simple standard of whether one doctor believes forced medication is in the immediate best interest of the patient.  While the U.S. Supreme Court has not articulated minimum constitutional standards for forced psychiatric medication in all cases, [⁵] the most recent case on the topic states that individuals have a significant constitutionally protected liberty interest in avoiding the unwanted administration of antipsychotic drugs. That liberty interest can be overcome. The Supreme Court requires that administration of the drugs be in the patient’s best medical interest in light of the patient’s medical condition. But that is not enough. In order to force psychiatric medication, the state must also show that doing so is necessary to significantly further important government interests. And the state must show this through the constitutional due process of a judicial hearing with an opportunity for appeal. [⁶]

When a doctor orders a patient to be medicated against the patient’s will, if done legally, the doctor is by definition acting as an agent of the state. Ultimately, the determination of what qualifies as the best interest of the patient should be determined by the patient, when (and if) they are in a position to make that determination.