The right to refuse psychiatric treatment: a clinical perspective.

Within recent years, psychiatrists and lawyers have increasingly debated the right of psychiatric patients to refuse treatment. Predictably, the right has advocates as well as opponents who, although often uninformed, are still adamant. Just last year the Academy was admonished that a right to refuse psychiatric treatment was "one right too many,". since it would be "antithetical" to the right to receive treatment. It was further alleged that patients had a "right to be free from psychosis."2 Yet Friedman and Halpern find no basic inconsistency between a right to refuse and a right to receive psychiatric treatment. 3 Carnahan declares these rights to be complementary.4 We are indebted to the American Psychiatric Association's Task Force on Right to Treatment for resolving this debate, for they explicitly recognize both rights, noting that the patient, if legally competent, can refuse treatment "except in emergencies."S Unfortunately, they forgot to define what constitutes an emergency. Perhaps there is some comfort in believing that an emergency, whatever its own characteristics, does not continue interminably. My own opinion, incidentally, is that the patient's right to refuse treatment is ,a necessary complement to his right to receive treatment, assuming that both rights seek a common goal of adequate treatment. The patient should be as able to refuse inadequate or unnecessary care as to request appropriate treatment. Conceivably, the patient's right to refuse further treatment in essence, his right to terminate treatment may signal the success of treatment insofar as the patient thereby indicates a willingness to assume responsibility for his actions: a goal which is not unknown among existing therapeutic orientations. In a different vein, the psychiatric literature evidences some confusion as to the context within which the right to refuse treatment is exercised. For some, the right finds its most eloquent expression in the patient's refusal of hospitalization; for other authors, however, the right to refuse treatment has meaning only within the context of ongoing therapy. Yet the parties and even the controversies differ in the two situations. In refusing hospitalization, for example, the patient contests the state's finding that institutional care is required; once within the hospital, however, the patient who refuses treatment is essentially negotiating with his therapist about the parameters of treatment. Still, the psychiatric literature often confuses these critical differences; some authors protest that patients denied treatment via civil commitment are thereby allowed to "die with their rights on,"6 while other authors decry institutional care rendered in the absence of a patient'S informed consent and even in the face of his vehement protest. Although I shall attempt to address both situations in these remarks, I do so mindful that their differences may well outweigh their similarities. Finally, it is obvious that law, as well as psychiatry, offers no magical insight regarding the patient's right to refuse psychiatric treatment. There is virtually no case law directly