Legal and Ethical Issues in Psychiatry I: Informed Consent, Competency, Treatment Refusal, and Civil Commitment

Overview

This chapter covers four related medicolegal concepts, each of which is central to the practice of psychiatry and other mental health professions. The unifying concept for all of these topics is the ethical principle of individual autonomy, which has been made operational through various legal protections. The word autonomy is from the Greek “auto” = self and “nomos” = law; literally “self-rule.” Autonomy is often summarized as our right to be left alone. In health care, this concept of self-rule or self-determinism gives rise to the fundamental premise that all adults have the right to make their own decisions regarding, among other things, their treatment for medical conditions, including mental illness.

In this chapter, we will examine how autonomy interests are protected, who exercises them when individuals lack the ability to do so, and under what circumstances treatment and confinement can be imposed. In this and subsequent chapters, we will describe interactions with the legal system and will use terms that may not be familiar to some readers. We will also provide an overview of the legal system as psychiatrists may encounter it.

An Introduction to Interactions with the Legal System

The American legal system is composed of parallel systems of state and federal constitutions, statutes, and courts. The United States Constitution is the controlling body of law, and any law, state or federal, that conflicts with the Constitution will be struck down if challenged. The rulings of the United States Supreme Court, which interprets the Constitution, are therefore controlling on Constitutional and federal law matters. States are free to provide greater protections of Constitutional rights than the Supreme Court interprets the Constitution as requiring, but may not provide less. On purely state law matters, including most civil matters, the decisions of state courts and state statutes are controlling.

Litigation is divided into two general categories: civil and criminal. Civil matters are those involving a dispute between parties in which one party claims to have been injured by another, or some other transgression has occurred, that can be remedied by the payment of money (damages) or performance or cessation of certain activities (injunctive relief). The purpose of civil litigation is to right the wrong that one party has inflicted on the other or otherwise correct the offensive behavior of the wrongdoer. Criminal matters are those in which a party has committed an act that has been declared illegal by a government authority, and for which the penalty may be a monetary fine, incarceration, or both. Both civil and criminal trials can be before a judge alone (bench trials) or before a judge and jury (jury trials). In a jury trial, the jury decides the issues of fact—for example, guilty or not guilty, liable or not—and the judge rules on the principles of law, such as, the admissibility of specific evidence. In a bench trial, the judge both rules on the law and is the fact-finder.

In all litigation, the party bringing the action can only prevail by supplying evidence that meets the standard of proof. That standard varies with the type of legal action involved ( Box 85-1 ). In personal injury cases, such as malpractice claims, the plaintiff (the party claiming to have been injured) must prove his or her case by a preponderance of the evidence: that is, the plaintiff must convince the fact-finder that his or her claims are more likely true than not. This is the lowest standard of proof. At the other end is the standard used in criminal prosecutions: the prosecution must prove the defendant's guilt beyond a reasonable doubt. In other types of cases, such as civil commitment, a standard of proof between these extremes is required: clear and convincing evidence, per the United States Constitution.