Last Saturday’s tragic events in Tucson have called attention to the behavior of Jared Loughner, the perpetrator, as well as the political climate in which this horrific event occurred. While it is likely too early to determine to what degree, if any, Loughner’s political views may have motivated this unspeakable act, information has come to light regarding his unusual behavior and unorthodox opinions, raising questions regarding his mental state.
Without direct observation of Loughner and his behavior, it would be risky to posit a diagnosis at this time. Even though details are emerging, I do not yet know whether Loughner had been diagnosed with an illness, or whether he was taking medications. But if it is determined by forensic experts that Loughner did indeed suffer from a psychiatric illness, one question that is certain to arise is: Can a person with an illness that gives rise to unconventional views and a potential for violence be forcibly treated, so that events like this can be prevented?
[Before answering this question, two things should be emphasized: First, mental illness very rarely causes violent behavior; and as a consequence, the function of psychiatric medication is not to prevent violence (indeed, see my earlier post). Antipsychotic drugs can, however, minimize delusional and paranoid thoughts, and improve a person’s ability to negotiate the difference between reality and fantasy, and some mood stabilizers and antidepressants may lessen impulsivity and aggression, but we cannot assume that medications could have prevented Loughner’s act.]
Several landmark cases addressing this very issue have said no; patients retain the right to refuse treatment. Patients can, however, be involuntarily committed to a hospital, but only when immediate intervention is required to prevent death or serious harm to themselves or to another person, or to prevent deterioration of the patient’s clinical state. In California, the relevant section of the law is section 5150 of the Welfare and Institutions Code. This allows a law enforcement officer or a clinician to involuntarily confine a person to treatment for a 72-hour period. The criteria for a 5150 hold require the presence of “symptoms of a mental disorder” prior to the hold. (Thus, self-injurious behavior as a result of alcohol intoxication does not qualify a person for a legal hold.) All states provide some comparable form of brief involuntary commitment for those suspected of danger to self or others, or grave disability, as a result of a mental illness.
Even after hospital admission, though, patients have the right to refuse medications. Medications can only be given involuntarily if a court determines, based on evidence presented by doctors, that a patient lacks the capacity to give informed consent (in California, this process is called a Riese hearing).
But what about cases that are less acute? If Loughner’s behavior arose from a psychotic disorder such as paranoid schizophrenia (and his behavior does indeed have hallmarks of such a diagnosis) but not significant enough to require hospitalization, one might argue that adherence to an antipsychotic regimen may have prevented the extreme behavior we saw on Saturday.
He still could have refused. A number of court decisions (discussed here) have established and affirmed this right. Recent exceptions include Kendra’s Law in New York and Laura’s Law in California. Kendra’s Law, enacted in 1999, allows courts to order seriously mentally ill individuals to accept treatment as a condition for living in the community. It was originally designed to target those with a history of repeat hospitalizations that resulted from nonadherence to medications. Patients can be ordered into assisted outpatient treatment if they are “unlikely to survive safely in the community without supervision” and have demonstrated either (a) acts of serious violent behavior toward self or others, or (b) at least two hospitalizations within the last 3 years, resulting from nonadherence to a treatment regimen. Laura’s Law was signed into law in 2002 in California, although as of 2010 only two California counties have implemented it. Studies reviewing the effects of these laws have found that patients in assisted outpatient treatment had fewer hospitalizations, fewer arrests and incarcerations, and had were less likely to be homeless or to abuse alcohol or drugs.
If Loughner had made threats of violence while engaged in treatment, another related decision, the Tarasoff duty, could have been invoked. In the 1976 case of Tarasoff vs Regents of University of California (and a second ruling in 1982), it was determined that a physician or therapist who has reason to believe that a patient may injure or kill someone must warn the potential victim (the 1982 ruling broadened the decision to include the duty to protect, as well). Thus, if a patient makes a threat against another person—and the clinician perceives it to be credible—he or she must warn the targeted individual, law enforcement, or take any other steps that are “reasonably necessary.”
Clearly, there is a great deal of uncertainty and latitude in the above cases. While the Tarasoff duty is clearly designed to prevent danger to others, it may potentially destroy the trust between doctor and patient and therefore hinder treatment; similarly, it is often difficult to determine whether a patient’s threats are credible. In the case of a patient like Loughner, would antigovernment rhetoric prompt a warning? What about threats to “politicians” in general? The clinician’s responsibility is not always clear.
With regard to Kendra’s and Laura’s Laws, the meaning of “survival in the community” can be debated, and it is often arguable whether compliance with medications would prevent hospitalization. Opponents argue that the best solution is more widespread (and more effective) voluntary outpatient treatment, rather than forced treatment.
As more information on this case comes to light, these issues are certain to be discussed and debated. We must not rush to judgment, however, regarding motives and explanations for Loughner’s behavior and the
steps we could take (or could have taken) to prevent it.