Round pegs, square holes.

Abstract

Letters Health AffairsVol. 22, No. 6 Round Pegs, Square HolesMichael Allen AffiliationsBazelon Center for Mental Health Law Washington, D.C.PUBLISHED:November/December 2003No Accesshttps://doi.org/10.1377/hlthaff.22.6.280-aAboutSectionsView articleView Full TextView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions View articleTOPICSMental healthMental disordershealthaffHealth Aff (Millwood)Health AffairsHealth Aff0278-27151544-5208Project HOPE - The People-to-People Health Foundation, Inc.Monahan John, Bonnie Richard J., and University of Virginia Charlottesville, VirginiaSwartz MarvinDuke University Durham, North Carolina112003The authors respond:Unlike E. Fuller Torrey, we do not believe that the concept of anosognosia is sufficiently nuanced or familiar enough to key decision-makers to be used uncritically in this context. Failure to acknowledge oneself as mentally ill and in need of treatment is multidetermined and not purely a biological phenomenon. An important challenge, as he correctly states, is to better understand the relationship between cognitive deficits in severe mental illness and nonadherence with treatment. Ethically and legally, neither cognitive impairment nor poor adherence is a sufficient basis for coercion. A key question is where mandated treatment of various kinds fits within a system of care appropriately configured to meet the needs of all patients. We do not deny that the issue of violence is pertinent to the discussion of mandated treatment; the question we raised, however, is how risk management fits into the IOM quality framework.Contrary to Michael Allen, we believe that mandated treatment is inescapable and therefore needs to be brought within the prevailing health care quality paradigm. We would never, as he writes, dream of mandating care for (competent) people with cancer, heart disease, or diabetes, but our point would be self-evident if tuberculosis or severe acute respiratory syndrome (SARS) were inserted into the previous sentence. We agree that many public mental health systems are woefully inadequate and that engaging patients in treatment is always preferable to coercing them, but it hardly follows that trying to understand the role of mandated treatment across different systems of care is unnecessary or unimportant. Mandated community treatment is inevitably and perhaps properly a highly politicized topic. We are not surprised to find ourselves somewhere in the vast policy space bounded on the one side by Torrey and on the other by Allen. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 1 History Published online 1 November 2003 InformationCopyright 2003 by Project HOPE - The People-to-People Health Foundation, Inc.PDF downloadCited byThe Case for Mandatory Outpatient TreatmentJournal of Psychosocial Nursing and Mental Health Services, Vol. 46, No. 2