The rights of involuntary patients to refuse pharmacotherapy: what is reasonable?

A number of prominent and often well-reasoned cases have increasingly defined a limited right, on the part of involuntarily detained psychiatric patients, to refuse treatment.3-12 Historically, most of these cases dealt with prisoners,6 or with patients who had religious objections to the treatments being imposed.3 However, as the mental health bar expanded and as scholarly critiques proliferated,13-20 the courts have been called upon to extend this right. That is, to extend it to nonprisoners on constitutional grounds other than religion. Over the last year, three federal district courts have reached different conclusionj as to how this right should be extended. First, in Rennie v. Klein 11 the court developed the least-restrictive-alternative reasoning of earlier cases21 -23 and commentaries24 ,25 in finding that the plaintiffpatient had a qualified right to refuse treatment. That case, initially decided after detailed scrutiny of that one patient's treatment needs, was subsequently broadened into a class-action suit. 26 The second opinion in the case, besides continuing to hold that a right to refuse treatment exists, created an elaborate review process. That process is extra-judicial, an independent psychiatrist is established to review treatment decisions; and quasi-judicial, the patient must be provided with an advocate, often a lawyer, to protect this new right. The second court found, in Rogers v. Okin, a constitutionally-rationalized absolute right-to-refuse treatment.27 Treatment could proceed over the patient's objections in only two circumstances: either in a narrowly defined emergency; or, where the patient had previously been adjudicated incompetent and a guardian had consented to the treatment. This second class-action suit significantly widened the right-to-refuse doctrine in comparison with Rennie. The third court, inA. E. and R. R. v. Mitchell,