"In regard to psychiatric hospitalizations, the principles of ethics are imperative in determining how to proceed in each case."
TALES FROM THE CLINIC
In this installment of Tales of the Clinic: the Art of Psychiatry, we visit the issue of involuntary hospitalizations. Many (if not most) emergency centers and urgent care facilities across the United States lack access to full psychiatric care for their patients.
Emergency physicians are faced with the decisions to hospitalize or not in an ever-evolving landscape of legal changes and emphasis on individual decision-making and least restrictive means of treatment. When a decision to hospitalize is made, boarding—waiting for a hospital bed to become available—is also a significant issue.
“Rebecca” is a 16-year-old girl with a history of depression/anxiety, a prior suicide attempt, and inpatient psychiatric hospitalization who presents to a Florida emergency room with suicidal ideation with a plan to hang herself. She looked on Google how to make a noose and what type of material to tie it to, learning that tree branches break easily but ceiling fans are more reliable. She ordered a rope online, set to arrive at her home in discreet packaging.
Rebecca has no somatic complaints and the physical exam is unremarkable. Labs including toxicology panel, alcohol levels, pregnancy test, and COVID-19 are all negative. Rebecca disclosed how she felt to her parents, and they brought her for care. Her parents are requesting admission to inpatient psychiatric hospital, but Rebecca is ambivalent. She says staying ºalive is not “a bad idea, after all I did talk to my parents, so part of me wants to live,” but does not feel that hospitalization is necessarily the best option.
Your emergency center does not have psychiatry access, so emergency medicine has to decide on the logistics of the hospitalization. Your case manager informs you that the admitting facility is requiring that you execute an involuntary psychiatric placement because the patient is a minor. The charge nurse balks and says both the patient and the parents are requesting voluntary admission: “This isn’t their first rodeo. Why do we need to do a Baker Act [emergency detention order] on her?”
You are confused because the patient is ambivalent, but the parents are fully agreeable to sign her in. You are not sure why the potential accepting facility is asking for involuntary status paperwork. Additionally, you are somewhat concerned about what could happen if the parents change their minds.
The 4 Principles in Medicine
Medicine has changed considerably over the years with advancing treatments and technology; however, the 4 core ethical principles governing the art of practice have remained stable and consist of beneficence, nonmaleficence, justice, and autonomy.1
Beneficence ensures that a physician acts to benefit the patient, while nonmaleficence protects patients by assuring a physician does no harm. The principle of justice functions in assuring all persons are treated in an appropriate and equitable manner; while autonomy refers to an individual’s intrinsic worth, which protects their right to make a rational and moral choice regarding themselves.1
Autonomy, in most developed countries, is the primary ethical principle of medicine. Preserving an individual’s autonomy overrules a physician’s responsibility to beneficence, nonmaleficence, and justice.2 The right to autonomy is based on both competence and capacity (Figure 1).
Those deemed incompetent by court judgment lose this right, while capacity is an ever-changing notion decided by a physician in particular circumstances.
In society, incompetence may be referred to when someone is developmentally delayed, mentally ill, or physically ill to the point they have lost the ability to form a rational decision, but the legal notion needs to be determined by the courts, not by layperson use of the term.1 Decisions about the care of individuals deemed incompetent rely on an appointed individual such as a health care proxy or a legal guardian.
In addition, a minor under the age of 18 is considered “incompetent” in regard to health care decisions, no matter their physical or mental health status.1 Therefore, in these cases, decisions are made by a legal guardian unless there is an emergency situation. In this case, the parents are willing to sign the patient in for hospitalization, but an involuntary hold would have to be instituted if they declined, given how well formed the patient’s suicidal plan was. In this case, the patient’s autonomy is also superseded by concern for her safety and she would meet criteria for involuntary hospitalization.
Ethics in Psychiatry
The principle of autonomy is of value in all fields of medicine, but it is particularly prevalent in the field of psychiatry. In psychiatry, physicians are faced with patients who are acutely ill. Many times these patients present in crisis, but they may not agree with needing help, or may not want help. Acute care patients are typically admitted for crisis stabilization because of the potential of harm being imposed on oneself or others.3
In these cases, it is imperative that a risk assessment be completed to determine whether the patient has the capacity to deny treatment and hospitalization. Admitting professionals must take into consideration the patient’s other treatment options, the dangers of the patient becoming reliant on the hospitalized setting, and the consequences of the patient being managed exclusively as an outpatient.3 This evaluation determines whether a patient can be admitted to the hospital involuntarily or whether they can be admitted on a voluntary basis, thereby adhering to the least restrictive means of treatment.
A patient who is considered voluntary is actively seeking treatment; they have the capacity to make the decisions necessary to receive treatment, with the understanding that taking medications or participating in a psychiatric therapeutic milieu and other therapeutic elements can improve their condition.4
\Involuntary patients are those who are deemed to lack the capacity to a make rational decision about their treatments and illnesses. An involuntary patient is severely sick, they have rapidly decompensated, and/or they are a threat to themselves or others.4 Involuntarily hospitalized patients are found incapacitated and the physician then has the duty to decide whether they must be put before a judge for evaluation of competence.
In US states and Washington, DC, there are laws allowing a person to be held involuntarily in an emergency hold for observation, treatment, and/or stabilization.5 The rules behind these holds differ from state to state by the cause and amount of time a person can be held (Figure 2).
The most common reason for involuntary psychiatric holds in the United States is danger to oneself or others.
A patient who has been admitted under an involuntary hold does not have the ability to leave the facility but can request to leave; that does not mean they are without rights. The United States requires all those involuntarily hospitalized for a psychiatric condition to have access to judicial hearings and representation within a timely manner from time of hospitalization.2
Psychiatric Hospitalizations in Minors
While the determination of competence is imperative for psychiatric patients, it becomes difficult in the case of a minor presenting with psychiatric illness. By definition, a minor is considered incompetent and therefore does not have the autonomy to make decisions regarding their health care. However, not all minors with psychiatric illness are presenting in acute crisis, they are not all an immediate threat to themselves or others, and some of them are actively seeking the necessary treatment for their mental illness.
In fact, one of the strongest predictors of and most common presenting conditions in pediatric psychiatric hospitalizations are depressive symptoms, and often these patients have the capacity to understand they are sick and need help.6 That said, voluntary admission to a psychiatric hospital as a pediatric patient is not as simple as walking in and asking for help.
In the pediatric population, parents can admit their children to the hospital, but a child older than 16 years can be admitted on a voluntary basis without their parents’ consent in some states.7 For a child younger than 16 years, a voluntary admission requires an application by the parent or guardian that is supported by a medical professional.7 While this is considered voluntary, it is very reflective of the involuntary process and therefore does not appear voluntary to many patients.
Furthermore, even though substance abuse disorders fall under a psychiatric illness as per the DSM-5, there are different laws regarding hospitalization and treatment for substance abuse in the pediatric population. The criteria for voluntary hospitalization for substance abuse are different from than for psychiatric disorders. In fact, in most states the process of voluntary admission for substance abuse has fewer rules and such admission is easier for a minor to obtain.5
In some instances, minors can voluntarily ask for detoxification treatment from substances without consent from their parents but cannot voluntarily ask for inpatient depression treatment without parental consent. The process by which mental health treatment can be sought in the pediatric population imposes a barrier to getting help.
Example State: Florida Law
The laws for psychiatric holds differ among states, including those surrounding pediatric patients. We are using Florida as a hypothetical example for this case vignette. In Florida, a minor is not considered legally competent regarding decisions about their health care, therefore, any mental health treatment must be through consent of the legal guardian.8
In addition, to be considered a voluntary patient in Florida, the minor needs not only an application from a legal guardian, but also a judicial hearing that will confirm the minor is agreeable with voluntary admission. Without the consent of the court, the minor cannot be considered voluntarily regardless of parental consent.8 In this case, “voluntary” is really court ordered.
Florida implemented the Baker Act criteria, which serve as the basis for involuntary hospitalization of an individual for psychiatric purposes. To qualify for a Baker Act, a person must meet all 3 criteria as outlined by the law (Table).9
In terms of outpatient psychiatric treatment, a minor older than 13 years has the legal right to request outpatient crisis intervention and treatment without the consent of their guardian in Florida. Therefore, the child has some autonomy when it comes to their mental health; however, this treatment cannot surpass 2 visits in 1 week, so there are regulations surrounding the help they can receive.9
In comparison, an individual older than 18 years could seek outpatient treatment daily for 2 weeks without consequence or check themself into a psychiatric hospital for treatment without ever alerting the courts or family.
In addition, treatment of substance abuse in Florida is not subject to as many regulations even though substance abuse is considered a mental illness. A minor in Florida can request voluntary admission to inpatient substance abuse services including detox and treatment programs without consulting the courts or a guardian.9
In regard to psychiatric hospitalizations, the principles of ethics are imperative in determining how to proceed in each case. Involuntary hospitalization differs from state to state but applies to all persons who reside in the United States regardless of age. Voluntary hospitalization regulations differ among states, preventing easy access to these services for individuals younger than 18 years. Mental health resources should be available to anyone regardless of the age of the patient without requiring multiple steps along the way.
In this case, if Rebecca were just 2 years older, there would be no further discussion regarding her voluntary status. While a child may not have the capacity to make many decisions regarding their health, a 16-year-old with an extensive history of mental illness who is requesting voluntary mental health treatment deserves to have that option. In these cases, holding a child involuntarily is not looking out for their best interests, but rather is preventing them from being at the forefront of their treatment and recovery.
Dr Hobday is a resident in psychiatry at East Carolina University. Dr Altman is an emergency medicine attending at Aiken Regional Medical Center in South Carolina. Dr Tucci is the director of research and scholarly activity for the Oak Hill Hospital Emergency Medicine Residency Program in Brooksville, Florida; a professor of emergency medicine and research for William Carey University College of Osteopathic Medicine in Hattiesburg, Mississippi; and copresident and founder of the Interdisciplinary Collaborative on Psychiatric Emergencies.
1. Varkey B. Principles of clinical ethics and their application to practice. Med Princ Pract. 2021;30(1):17-28.
2. Fariba KA, Gupta V. Involuntary commitment. StatPearls Publishing; 2023.
3. Nathan R, Gabbay M, Boyle S, et al. Use of acute psychiatric hospitalisation: a study of the factors influencing decisions to arrange acute admission to inpatient mental health facilities. Front Psychiatry. 2021;12:696478.
4. Yuan Yang, Li W, An RF, et al. Voluntary and involuntary admissions for severe mental illness in China: a systematic review and meta-analysis. Psychiatr Serv. 2020;71(1):83-86.
5. Hedman LC, Petrila J, Fisher WH, et al. State laws on emergency holds for mental health stabilization. Psychiatr Serv. 2016;67(5):529-535.
6. Geng F, Jiang F, Conrad R, et al. Factors associated with involuntary psychiatric hospitalization of youths in China based on a nationally representative sample. Front Psychiatry. 2020;11:607464.
7. Kennedy A. The psychiatric case and the law. II. Admission to hospital. Br Med J. 1952; 1(4762):810-812.
8. Report on involuntary examinations of minors. Florida Department of Children and Families. 2019. Accessed July 17, 2023. https://www.usf.edu/cbcs/baker-act/documents/dcfoddyearreport2019.pdf
9. Lenderman MSW, Cadigan S. Baker Act Benchguide. Florida Court Education Council’s Publications Committee. 2016. Accessed July 17, 2023. https://www.flcourts.gov/content/download/215973/file/Baker-Act-Benchguide.pdf