Among the numerous challenges facing psychiatric care providers today, few experiences are as ubiquitous as treatment refusal. Tragically, it is often the case that the very patients who are most inclined to refuse treatment are the ones who are in most need of it. Further complicating this matter, the dilemma pits 2 of the highest ethical principles in direct confrontation: respect for patient autonomy and beneficence. Being caught in a Scylla and Charybdis situation often forces clinicians to navigate a treacherous path between the need to protect the patient and those around him or her while steering clear of any failure to respect the person. Mishaps behind the wheel of this vessel can result in poor outcomes—medically and legally—with potentially high costs for patients, society, and mental health providers. As such, it is essential that all clinicians understand the right to refuse treatment, along with its ethical and legal implications.
Historically, the ability to force treatment on unwilling patients derived from a need-for-treatment justification. This approach started to change in the 1960s when there was a gradual move toward the "dangerous patient" justification—unwanted treatment could be imposed only if or when the patient presented a significant risk of harming himself or others. Under this new system, patient advocates began to press for the patient's right to determine what was done to his own body, creating instances in which the committed patient could decline treatment with medication. As these matters began to make legal appearances around the country, virtually every involved court recognized some substantial patient interest in a right to refuse treatment.1
Several cases are considered landmarks in the evolution and gradual codification of this patient right and are described below.
Superintendent of Belchertown State School v Saikewicz
Although it did not directly address treatment refusal by the mentally ill, the 1977 Massachusetts case of Superintendent of Belchertown State School v Saikewicz2 is essential for its recognition of the right of both competent and incompetent patients to refuse treatment and the elaboration of the "substituted judgment" doctrine. Joseph Saikewicz was a 67-year-old with profound mental retardation and acute myeloblastic leukemia. His guardian ad litem sought to protect him from the pain and discomfort inherent in a treatment that could only delay his inevitable demise.
The Supreme Judicial Court of Massachusetts recognized that there "exists a general right in all persons, competent and incompetent, to refuse medical treatment in appropriate circumstances."2 Having recognized this right in incompetent patients, the court went on to elaborate a process whereby decisions are made in accordance with what the incompetent person would want if he were competent. The court ultimately concluded that Mr Saikewicz, if competent, would have refused treatment and could still do so despite his incompetence. This case laid down some crucial stepping-stones for future decisions delineating mentally ill patients' rights to refuse treatment.
Guardianship of Roe
In the 1981 case of Guardianship of Roe,3 the Supreme Judicial Court of Massachusetts directly addressed the patients' right to refuse treatment in mental illness and it squarely placed the task of determining substituted judgment with the courts. In this matter, Richard Roe III's guardian (his father) consented to the administration of antipsychotic medications over the patient's objection, and in the absence of either institutionalization or an emergency. The court opined, "It cannot be assumed that a mentally ill ward lacks the capacity to make decisions whether to undergo treatment involving antipsychotic medication [and even if he does lack this capacity] his stated preference is entitled to serious consideration."3 Echoing Saikewicz,2 the court called for a determination of substituted judgment, and it placed this responsibility with the courts and mandated a consideration of the patient's stated preferences, religious beliefs, impact on his family, probability of adverse side effects, likely results of refusing treatment, and prognosis with treatment.
Rennie v Klein
The 1983 case of Rennie v Klein4 addressed the issue of an involuntarily committed patient's right to refuse treatment with antipsychotic medication. John Rennie, on his 12th involuntary hospitalization, initiated a class-action suit claiming a right to refuse antipsychotic medication. The US Court of Appeals for the Third Circuit categorically recognized that "involuntarily committed mentally ill patients have a constitutional right to refuse administration of antipsychotic drugs."4 The court examined the requirements of due process necessary to abridge this right. The standard applied to override Rennie's refusal was a determination of dangerousness to himself or others, made by medical providers exercising "professional judgment." The court elaborated that "such a judgment and the resulting decision to administer medication will be presumed valid unless it is shown to be a 'substantial departure from accepted professional judgment, practice, or standards.'"4