Mappes & DeGrazia, Chapter 5: Lecture Notes/Outline by Larry Hauser
Mental Illness, Retardation, & Dementia

Mental Illness and Involuntary Civil Commitment

• Personal and social problems posed by mental illness
• incapacitation of individuals
• mentally ill may be disoriented and deluded
• incapable of holding a job or pursuing an education
• incapable of caring for their own basic needs
• even depressed to the point of being suicidall
• disruption of family realationships
• burdens of care
• disruption of ordinary day to day activities
• threats of harm
• disruptive influences in society
• may be public nuissances
• may engage in offensive and antisocial behavior
• may pose threats to the lives and safety of others
• These problems motivate medical, psychological, and legal intervention in the lives of those deemed mentally ill.
• At issue: under what circumstances is unauthorized intervention (without consent) morally justified or even required?
• Involuntary commitment to mental hospitals.
• Treatment without their informed consent.
• Involuntary sterilization of the mentally retarded.

The Concept of Mental Illness

• The issue of unauthorized intervention complicated by the difficulty of defining mental illness.
• Least of our difficulties -- offhand use of psychiatric labels in common parlance
• "he's sick", "you must be insane", "what a retard", etc.
• Worst of it: disagreements among psychologists
• "Mental health professionals subscribe to widely varying theories of mental health"
• even practioners "in the same school of thought often disagree about whether or not a particular diagnosis applies"
• Of course other medical practioners can disagree in their dianoses too . . . but compare expert tesitmoy
• a neurologist testifies that the defendant had a brain tumor
• a psychiatrist testifies that the defendant has post traumatic stress disorder
• Szasz's radical view: mental illness is a myth
• a normative judgment
• disguised as a medical diagnosis
• a person is diagnosed mentally ill for deviation from ethical, social, or political norms
• Further support:
• Soviet Russian use of psychiatric diagnoses to remand political dissidents for forced treatment
• U.S.A.: illegal drug use: a sickness or a crime?
• some we lock up: the poor & nonwhite
• others we allow a "treatment" option & notice the involuntary component even here
• it's get treatment: a huge industry
• or go to jail

Involuntary Civil Commitment

• What it is
• forced confinement of an individual to a mental hospital
• as a result of a legal declaration of mental illness
• Szasz's view: Involutary civil commitment is a crime against humanity and should be abolished.
• At Issue: is it permissible that those classified as mentally be committed on any of the following grounds
• to keep them from harming others (harm principle)
• to prevent them from offending others (offense principle)
• to keep them from harming themselves (benevolence principle)
• to benefit them (extreme benevolence principle)
• not mentioned in the text (beyond the pale?)
• to keep them from acting immorally (the legal moralism principle)
• the benefit society (the social benefit principle)
• Two issues to keep in mind in analyzing any would be justified case of involuntary commitment
1. which of these principles are morally acceptable liberty limiting principles
2. which principle is actually being used (explicitly or implicitly) to justify commitment
• explicit appeal to a more solid principle -- usually harm -- is frequent
• when the actual unstated (implicit) grounds are perhaps something more dubious, like offense.
• "Much of the behavior that earns the mentally ill the label dangerous is a most offensive to others" (254), e.g.,
• shouting harrangues on street corners
• public nudity

Dangerousness and the Harm Principle

• Given the generally acknowledged warrantedness of the harm principle, involuntary commitment would seem most warranted when the individual commited poses a real danger to others.
• And there would seem to be clear cases of such individuals, e.g.,
• schizophrenics who are trying to carry out commands of disembodied voices ordering them to kill: Son of Sam
• paranoid individuals with histories of violent acts who are currently issuing threats.
• However, not everyone mentally ill is dangerous
• Studies suggest either
• "that psychiatric patients as a group are no more dangersous to others" than others
• or at worst "the differences are so small that they allow very little success in prediction" of potential dangerousness (254)
• Considerable controvery surrounds pronouncements of psychologists that individual patients are "dangerous"

Paternalism and Autonomy

• When an individual is incapable of making decisions affecting their own well-being
• if we decide for them there's infringment of their autonomy
• they don't have any autonomy to be being infringed
• Problem cases arise when an individuals decision-making capacity is diminished, but not entirely absent
• diminishing factors commonly associated with mental illnesses include
• delusions
• compulsions
• nevertheless such an individual commonly understands enough about commitment
• to know what it is
• and to know they don't want it
• The pro-commitment line: it's warranted in such problem cases because
• if they weren't mentally ill they'd realize the commitment would be benefit them in the long run
• if they weren't deranged they'd want to be so benefitted
• if they thinking clearly they would want whatever treatment promised to restore their full decision making capacity
• involuntary commitment is warranted both
• to keep them from harming themselves
• and to resore their diminished autonomy

Managing Mental Illness and Dementia

• Chronic (ongoing) nature of many mental illnesses and dementia
• many schizophrenics can't be curee but can be stabilized
• similarly for those with bi-polar disorder (manic-derpression)
• likewise dementia
• dementia is "a general mental deterioration typically due to organic factors and characterized by memory loss"
• senile dementia perhaps the most familiar variety
• dementia is generally irreversable
• but the demented can sometimes be helped to learn to cope with their impairments
• Issues
• to what extent should society assist them in managing their conditions
• to what extent -- how agressively -- should society impose management (whether they want it or not)
• Deinstitutionalization movement proposed, according to E. Fuller Torey, director of the National Institute of Mental Health, was the following (p. 255):
1. The prevention of inappropriate mental hospital admissions through the provision of community alternative to treatment,
2. the release to the community of all institutionalized patients who have been given adequate preparation for such a change, and
3. the establishment and maintenance of community support systems for noninstitutionalized people receiving mental health services in the community.
• A controversial practice: actual results:
• massive release of chronically mentally ill into communities
• with very facilities and very little aftercare provided
• between 1955 and 1984 433,407 psychiatric hospital beds were taken out of use
• Effects according to Torrey
1. There are at least twice as many seriously mentally ill individuals living on streets and in shelters as there are in public mental hospitals.
2. There are increasing numbers of seriously mentally ill individuals in the nations jails and prisons.
3. Seriously mentally ill individuals are regularly released from hospitals with little or no provision for aftercare or followup treatment.
4. Laws designed to protect the rights of the mentally ill primarily protect their right to remain mentally ill.
5. The majority of mentally ill persons discharged from hospitals have been officially lost.  Nobody knows where they are.
• A few ethical questions
• Should the deinstitutionalized receive more support in the ongoing management of their conditions?
• Should potentially suicidal patients
• be released out of regard for their autonomy (perhaps) and the supposed social benefits of deinstutionalization
• or should they be kept institutionalized for their own protection?
• Should dementia sufferers who resist liberty limiting safety measures
• be forces to accept them
• by institutionalization if necessary

The Mentally Retarded -- Sterilization and Rights

• Sorry history of misunderstanding and abuse.
• unneccessary institutionalization . . . no more the warehousing
• denial of educational and other opportunities . . . special education is a recent innovation
• forced sterilization out of
• belief that retardation was hereditary
• fear that retarded will be promiscuous and/or easy prey for sexual predators
• Currently
• In many states even the mildly retarded may be deemed "legally incompetent"
• the legally incompetent may not
• marry
• have children
• live alone
• enter into a contractual agreement without a guardian's consent
• Standard justification of these restrictions
• the retarded pose a danger to others (harm)
• and themselves (paternalism)
• Are such warranted in the case of the mildly retarded (IQ range of 52-68)?
• "Individuals may lack the cognitive skills to solve a geometric problem yet have sufficient cognitive abilitiy to make everyday decisions about housing, meals, and other practical affairs." (257)
• The retarded's "ability function on a day-to-day level differs widely, depending on their education, training, and experience." (257)
• Involuntary Sterilization: is it warranted?
• Robert Neville: It's warranted when "in the best interests of mildly retarded persons who lack the capacity to give or withhold informed consent because they do not understand the issues involved" (257).
• Alternative: implantable contraceptives
• Juengst & Siegal worry that involuntary implantation raises most of the of the same issues as involuntary sterilization (257)
• Community vs. Custodial Care Movement
• apparent dillema:
• the retarded require special attention
• yet advocates of the retarded argue for equal treatment -- allowing them "the same basic rights as all other citizents" (257)
• various codes or manifestos
• a code actually written by "intellectually disadvantaged representatives"
• asserts the rights of the retarded to make their own choices "about employment, housing, and so forth" (257)
• "We are humans first and disadvantaged second" it says.
• code proposed by the International League of Societies for the Mentally Handicapped (in this chapter) asserts
1. the same basic rights for the retarded as those had by other citizens
2. a set of special rights, e.g. (least controversially) to protection from exploitation and abuse