Case Studies: Should Competence Be Coerced?

Abstract

DL was arrested and charged with rape. He is accused of assaulting a neighborhood woman with whom he is only casually acquainted. According to police records, DL manifested psychotic symptoms--including auditory hallucinations and paranoid delusions-at the time of his arrest. He was quickly transferred to the forensic unit of the state psychiatric hospital and examined by a psychiatrist, who concluded after a thorough examination that he was not competent to stand trial. Following a brief court hearing, DL was returned to the forensic unit to receive treatment, including neuroleptic medication, designed to return him to a state of competency. Competency-which includes such factors as being able to understand the criminal charges, understand the elements of a criminal trial, and participate in one's defense-is required for a defendant to be able to stand trial. Shortly after being placed on medication, DL's psychotic symptoms remitted. According to the state-appointed forensic psychiatrist who examined him, DL is now oriented to time and place, is not hallucinating or delusional, and is able to participate in his own defense in court. The psychiatrist thus has informed DL's court-appointed attorney, the prosecutor, and the court that he is competent to stand trial. DL's attorney originally planned to enter a plea of "not guilty by reason of insanity" on his behalf. The attorney is convinced that at the time of the rape, which DL admits having committed, he was psychotic and unable to distinguish between right and wrong. However, now that DL has been medicated, is competent, and appears quite "normal," the attorney is concerned that a jury will have a difficult time believing that DL was insane at the time of the rape. On the advice of his attorney, DL refuses continued neuroleptic medication. He believes that it is in his best interests to risk the likely return of psychotic symptoms to avoid having to face a jury as a competent defendant. DL understands that this decision may mean that he will remain for years on the forensic unit of the psychiatric hospital, technically awaiting competency. The prosecutor is outraged that the defense attorney has advised his client to refuse therapeutic medication in order to avoid trial. She argues that the defense attorney is seeking to deprive his client of needed medication, contrary to his client's best interests, and also is undermining the state's legitimate interest in resolving a pending criminal matter. Does DL have the right to refuse treatment of his psychotic symptoms to avoid trial in criminal court? Is it proper for DL's attorney to advise his client to do so? By now it is well accepted that voluntary psychiatric patients have a broad-based right to refuse treatment, as long as standard informed consent procedures are followed. Paternalism has its limits. However, there is no consensus with respect to involuntary patients. Case law is evolving and there are a number of conflicting court decisions. It is not clear to what extent involuntary patients, particularly those who are hospitalized following arrest on a criminal charge, forfeit the "right to refuse" held by voluntary patients. Ordinarily, debate about the right to refuse centers on risks to the patient or to third parties who may be affected by the patient's decision to forgo treatment. In this case there is also an additional concern: whether the public's interest in resolving a pending criminal matter should take precedence over the patient's right to self-determination. Only the most orthodox libertarians would argue that a psychiatric patient has an inviolable light to determine his or her own fate. There are ample precedents where compelling public interest trumps individual rights. For instance, the well-known Tarasoff case, and others like it, demonstrates that prima facie rights ordinarily held by recipients of mental health services sometimes give way when they clash with public interest. …