What is a Place of Safety?

Introduction

The term “place of safety” is used in the Mental Health Act 1983, an Act of the Parliament of the United Kingdom.

Section 136 of the Act gives police officers the power to remove an apparently mentally disordered person who is in a public place and is apparently a danger to themselves or to other people, to a “place of safety” where they may be assessed by a doctor.

Section 135 of the Act gives police powers to remove a person who is not in a public place to a place of safety after the issue of a warrant by a Justice of the Peace.

According to a unilateral statement by the Home Office, places of safety should typically be hospitals, other medical facilities, residential care homes or the home of a relative or friend of the person; police stations should only be used as a “place of safety” as a last resort.

In practice, local agreements between local authorities, NHS Trusts and police constabularies are in place, designating certain establishments as places of safety. The owners or managers of an establishment acting as a place of safety have a legal obligation to ensure that a detained person cannot leave the premises until he or she has been fully assessed, which may take up to 24 hours. Invariably, therefore, to ensure safeguarding of both the detained person and the public, places of safety are typically restricted to psychiatric hospitals and police custody suites, and tend to exclude open general hospital wards and accident and emergency departments. For the same reason, it is most unusual for friends’ or relatives’ homes to be designated places of safety.

The decision whether to detain a particular person in a psychiatric hospital or in police custody is also subject to local agreements. It is a common arrangement for people to be taken to a psychiatric hospital unless they have a history of violence or are thought to be under the influence of alcohol or recreational drugs, in which cases they would be taken into police custody.

What is Informed Refusal?

Introduction

Informed refusal is where a person has refused a recommended medical treatment based upon an understanding of the facts and implications of not following the treatment. Informed refusal is linked to the informed consent process, as a patient has a right to consent, but also may choose to refuse.

Refer to Informed Consent, Mature Minor Doctrine, and Gillick Competence.

Background

The individual needs to be in possession of the relevant facts as well as of their reasoning faculties, such as not being intellectually disabled or mentally ill and without an impairment of judgement at the time of refusing. Such impairments might include illness, intoxication, drunkenness, using drugs, insufficient sleep, and other health problems. In cases where an individual is considered unable to give informed refusal, another person (guardian) may be authorised to give consent on their behalf. The concept grew out of and is similar to that of informed consent, but much less commonly used and applied. In the United States, it is recognised in certain state laws (in 2006: California, Nevada, Vermont, and Michigan) as well as in various court decisions.

As applied in the medical field, a physician has made an assessment of a patient and finds a specific test, intervention, or treatment is medically necessary. The patient refuses to consent to this recommendation. The physician then needs to explain the risks of not following through with the recommendations to allow the patient to make an informed decision against the recommendation. While in the past documentation of refusal of treatment has not been important, the widespread use of managed care, cost containment processes, as well as increased patient autonomy have created a situation where documented “informed refusal” is viewed as becoming more important. When refusal of treatment may result in significant damage or death, the interaction needs to be documented to protect the care giver in a potential later litigation against the allegation that the recommendation was either not made or not understood. On occasion, a patient will also refuse to sign the “informed refusal” document, in which case a witness would have to sign that the informed process and the refusal took place.

The pregnant patient represents a specific dilemma in the field of informed refusal as her action may result in harm or death to the foetus. Ethicists disagree on how to handle this situation.

What is Marion’s Case (1982)?

Introduction

Secretary of the Department of Health and Community Services v JWB and SMB, commonly known as Marion’s Case, is a leading decision of the High Court of Australia, concerning whether a child has the capacity to make decisions for themselves, and when this is not possible, who may make decisions for them regarding major medical procedures.

It largely adopts the views in Gillick v West Norfolk Area Health Authority, a decision of the House of Lords in England and Wales.

Refer to Mature Minor Doctrine, Informed Consent, and Informed Refusal.

Background

“Marion”, a pseudonym for the 14-year-old girl at the centre of this case, suffered from intellectual disabilities, severe deafness, epilepsy and other disorders. Her parents, a married couple from the Northern Territory sought an order from the Family Court of Australia authorising them to have Marion undergo a hysterectomy and an oophrectomy (removal of ovaries). The practical effect would be sterilisation and preventing Marion from being able to have children and many of the hormonal effects of adulthood.

Under the Family Law Act the primary concern for matters involving children is that the court must act in the child’s best interests. The majority of the High Court made it clear that it was merely deciding a point of law and that the decision about what was in the child’s “best interests” would be left to the Family Court of Australia after the case.

The main legal debate that arose was who has the legal authority to authorise the operation. Three options existed: the parents (as legal guardians of their daughter), Marion or an order of a competent court, such as the Family Court of Australia. The Full Court of the Family Court was asked to decide:

  1. Could the parents, as joint guardians authorise the sterilisation procedure;
  2. If not, does the Family Court have jurisdiction to:
    (a) authorise the carrying out of such a procedure;
    (b) enlarge the powers, rights or duties of the parents to enable them to authorise such a procedure; or
    (c) approve the consent of the Applicants, as to the proposed procedure.

The majority of the Family Court, Strauss and McCall JJ held that the parents, as joint guardians could authorise the sterilisation procedure. Nicholson CJ held that the Family Court had jurisdiction to authorise the procedure.

The department, together with the Attorney-General for Australia, argued that only a court could authorise such a major operation and that the Family Court jurisdiction included any matter relating to the welfare of a child even if it was not a dispute about custody, guardianship or access.

The parents, however, “argued that the decision to sterilise a child is not significantly different from other major decisions that parents and guardians have to make for children and that the involvement of the Family Court is optional and only of a ‘supervisory nature’. Their argument was that, provided such a procedure is in the best interests of the child, parents as guardians can give lawful consent to a sterilisation on behalf of a mentally incompetent child.”

Judgement

The High Court recognised the right of everyone to bodily integrity under national and international law, and made a distinction between therapeutic and non-therapeutic surgical procedures as well as the duty of surrogates to act in the best interests of the incompetent patient.

In the case, the High Court ruled that while parents may consent to medical treatment for their children, the authority does not extend to treatment not in the child’s best interests. Also, the Court held that if medical treatment has sterilisation as its principal objective, parents do not have the authority to consent on behalf of their child.

Obiter Dictum

The statement by Deane J that parents may grant surrogate consent for the non-therapeutic circumcision of male children is obiter dictum and not part of the judgment. Male circumcision was not at issue in the case and no evidence or testimony was offered regarding male circumcision.

What is the Age of Legal Capacity (Scotland) Act 1991?

Introduction

The Age of Legal Capacity (Scotland) Act 1991 (c.50) is an Act of the Parliament of the United Kingdom applicable only in Scotland which replaced the pre-existing rule of pupillage and minority with a simpler rule that a person has full legal capacity at the age of 16.

Refer to Gillick Competence.

Background

Under the previous Scots law (derived from Roman law), a child to the age of 12 if female, or 14 if male, had legal status of “pupil” and was under legal control of an adult (usually parent or parents) deemed “tutor”. From that age until the age of majority the child had legal status of a “minor”, and might have a responsible adult deemed “curator” or have no responsible adult (being referred to as “fors familiated”). The Scottish age of majority was originally 21 until reduced to 18 by the Age of Majority (Scotland) Act 1969. Pupils lacked any capacity to enter into legal contracts. Minors had capacity to enter into contracts, which included the capacity to make a will, but subject to rights to have these reduced by a court in certain circumstances, and sometimes requiring their curators consent. The rules as to when contracts did or did not require consent, and which were potentially reducible by court were complex. The age to enter into marriage was originally the age of minority, but this was raised to 16 years by the Age of Marriage Act 1929, and confirmed in the Marriage (Scotland) Act 1977.

Under the Age Legal Capacity Scotland Act 1991 the old rules and terms were replaced. The basic rule under the replacement regime is that under 16s have no legal capacity. This is qualified by section 2 which provides that under 16s can:

  1. Enter into a contract of a kind commonly entered into by persons of their age group, and on terms which are not unreasonable; and
  2. From age 12, make a Will, and are deemed to have capacity to instruct a lawyer to act on their behalf.
  3. The right to consent to an adoption was also subsequently inserted into this section by the Children (Scotland) Act 1995.

In all other cases the legal Guardian of the under 16 has legal right to deal with all contractual and consent matters on the child’s behalf.

From age 16 a person has full legal capacity to enter into any form of agreement. This subject to protection for younger persons by means of a right (under section 3) while under the age of 21, to have a contract made between the ages of 16 and 18 set aside as a “prejudicial transaction”. The test is whether a reasonably prudent adult would not have entered into such a contract, and the person has been prejudiced by entering into that contract. Under section 4 a contract may be approved in advance by a court, in which case it cannot later be reduced. Contracts entered into in the course of the young person’s business, or where they misrepresented their age also cannot be reduced.

There is also specific provision for persons having their birthday on 29 February; under section 6 they are treated as having their birthday on 01 March in every non-leap year for purposes of calculating their age.

What is Gillick Competence?

Introduction

Gillick competence is a term originating in England and Wales and is used in medical law to decide whether a child (under 16 years of age) is able to consent to their own medical treatment, without the need for parental permission or knowledge.

The standard is based on the 1985 judicial decision of the House of Lords with respect to a case of the contraception advice given by an NHS doctor in Gillick v West Norfolk and Wisbech Area Health Authority. The case is binding in England and Wales, and has been adopted to varying extents in Australia, Canada, and New Zealand. Similar provision is made in Scotland by the Age of Legal Capacity (Scotland) Act 1991. In Northern Ireland, although separate legislation applies, the then Department of Health and Social Services stated that there was no reason to suppose that the House of Lords’ decision would not be followed by the Northern Ireland courts.

The Gillick Decision

Gillick’s case involved a health departmental circular advising doctors on the contraception of minors (for this purpose, under 16s). The circular stated that the prescription of contraception was a matter for the doctor’s discretion and that they could be prescribed to under-16s without parental consent. This matter was litigated because an activist, Victoria Gillick, ran an active campaign against the policy. Gillick sought a declaration that prescribing contraception was illegal because the doctor would commit an offence of encouraging sex with a minor and that it would be treatment without consent as consent vested in the parent; she was unsuccessful before the High Court of Justice, but succeeded in the Court of Appeal.

The issue before the House of Lords was only whether the minor involved could give consent. “Consent” here was considered in the broad sense of consent to battery or assault: in the absence of patient consent to treatment, a doctor, even if well-intentioned, might be sued/charged.

The House of Lords focused on the issue of consent rather than a notion of ‘parental rights’ or parental power. In fact, the court held that ‘parental rights’ did not exist, other than to safeguard the best interests of a minor. The majority held that in some circumstances a minor could consent to treatment, and that in these circumstances a parent had no power to veto treatment.

Lord Scarman and Lord Fraser proposed slightly different tests (Lord Bridge agreed with both). Lord Scarman’s test is generally considered to be the test of ‘Gillick competency’. He required that a child could consent if he or she fully understood the medical treatment that is proposed:

As a matter of law the parental right to determine whether or not their minor child below the age of sixteen will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to understand fully what is proposed. Lord Scarman.

The ruling holds particularly significant implications for the legal rights of minor children in England in that it is broader in scope than merely medical consent. It lays down that the authority of parents to make decisions for their minor children is not absolute, but diminishes with the child’s evolving maturity. The result of Gillick is that in England today, except in situations that are regulated otherwise by law, the legal right to make a decision on any particular matter concerning the child shifts from the parent to the child when the child reaches sufficient maturity to be capable of making up his or her own mind on the matter requiring decision.

Subsequent Developments

A child who is deemed “Gillick competent” is able to prevent their parents viewing their medical records. As such, medical staff will not make a disclosure of medical records of a child who is deemed “Gillick competent” unless consent is manifest.

In most jurisdictions the parent of an emancipated minor does not have the ability to consent to therapy, regardless of the Gillick test. Typical positions of emancipation arise when the minor is married (R v D [1984] AC 778, 791) or in the military.

The nature of the standard remains uncertain. The courts have so far declined invitations to define rigidly “Gillick competence” and the individual doctor is free to make a decision, consulting peers if this may be helpful, as to whether that child is “Gillick competent”.

As of May 2016, it appeared to Funston and Howard that some recent legislation worked explicitly to restrict the ability of Gillick competent children to consent to medical treatment outside of clinical settings. For example, parental consent is required for the treatment of children with asthma using standby salbutamol inhalers in schools. These restrictions have yet to be tested in court.

R and W

The decisions In re R (1991) and Re W (1992) (especially Lord Donaldson) contradict the Gillick decision somewhat. From these, and subsequent cases, it is suggested that although the parental right to veto treatment ends, parental powers do not “terminate” as suggested by Lord Scarman in Gillick. However, these are only obiter statements and were made by a lower court; therefore, they are not legally binding. However, the parens patriae jurisdiction of the court remains available allowing a court order to force treatment against a child’s (and parent’s) wishes.

Axon

In a 2006 judicial review, R (on the application of Axon) v Secretary of State for Health, the High Court affirmed Gillick in allowing for medical confidentiality for teenagers seeking an abortion. The court rejected a claim that not granting parents a “right to know” whether their child had sought an abortion, birth control or contraception breached Article 8 of the European Convention on Human Rights. The Axon case set out a list of criteria that a doctor must meet when deciding whether to provide treatment to an under-16 child without informing their parents: they must be convinced that they can understand all aspects of the advice, that the patient’s physical or mental health is likely to suffer without medical advice, that it is in the best interests of the patient to provide medical advice, that (in provision of contraception) they are likely to have sex whether contraception is provided or not, and that they have made an effort to convince the young person to disclose the information to their parents.

2020s

In late 2020, Bell v Tavistock considered whether under-16s with gender dysphoria could be Gillick competent to consent to receiving puberty blockers. Due to the unique specifics of that treatment, the High Court concluded that in such cases the answer will almost always be ‘no’, a priori. In late 2021, the Court of Appeal overturned Bell v Tavistock, as the clinic’s policies and practices had not been found to be unlawful.

In early September 2021, guidance circulated to NHS trusts stated that most 12- to 15-year-olds should be deemed “Gillick competent to provide [their] own consent” to be vaccinated against COVID-19, despite the JCVI “fail[ing] to recommend Covid-19 vaccines for healthy 12- to 15-year-olds”. Campaigner Molly Kingsley, who had co-founded the campaign group UsForThem over the issue, warned that “Were vaccination of children to happen on school premises without fully respecting the need for parental consent it would really prejudice parents’ trust in schools.” Epidemiologist and SAGE member John Edmunds said that “if we allow infection just to run through the population, that’s a lot of children who will be infected and that will be a lot of disruption to schools in the coming months.

Australian Law

The Australian High Court gave specific and strong approval for the Gillick decision in “Marion’s Case”, Secretary of the Department of Health and Community Services v JWB and SMB (1992) 175 CLR 189. The Gillick competence doctrine is part of Australian case law (see, e.g., DoCS v Y [1999] NSWSC 644).

There is no express authority in Australia on In re R and Re W, so whether a parent’s right terminates is unclear. This lack of authority reflects that the reported cases have all involved minors who have been found to be incompetent, and that Australian courts will make decisions in the parens patriae jurisdiction regardless of Gillick competence.

In South Australia and New South Wales legislation clarifies the common law, establishing a Gillick-esque standard of competence but preserving concurrent consent between parent and child for the ages 14-16.

Confusion regarding Gillick Competence

On 21 May 2009, confusion arose between Gillick competence, which identifies under-16s with the capacity to consent to their own treatment, and the Fraser guidelines, which are concerned only with contraception and focus on the desirability of parental involvement and the risks of unprotected sex in that area.

A persistent rumour arose that Victoria Gillick disliked having her name associated with the assessment of children’s capacity, but an editorial in the BMJ from 2006 claimed that Gillick said that she “has never suggested to anyone, publicly or privately, that [she] disliked being associated with the term ‘Gillick competent'”.

Fraser Guidelines

It is lawful for doctors to provide contraceptive advice and treatment without parental consent providing certain criteria are met. These criteria, known as the Fraser guidelines, were laid down by Lord Fraser in the Gillick decision and require the professional to be satisfied that:

  • The young person will understand the professional’s advice;
  • The young person cannot be persuaded to inform their parents;
  • The young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment;
  • Unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer; and
  • The young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent.

Although these criteria specifically refer to contraception, the principles are deemed to apply to other treatments, including abortion. Although the judgment in the House of Lords referred specifically to doctors, it is considered by the Royal College of Obstetricians and Gynaecologists (RCOG) to apply to other health professionals, “including general practitioners, gynaecologists, nurses, and practitioners in community contraceptive clinics, sexual health clinics and hospital services”. It may also be interpreted as covering youth workers and health promotion workers who may be giving contraceptive advice and condoms to young people under 16, but this has not been tested in court.

If a person under the age of 18 refuses to consent to treatment, it is possible in some cases for their parents or the courts to overrule their decision. However, this right can be exercised only on the basis that the welfare of the young person is paramount. In this context, welfare does not simply mean their physical health. The psychological effect of having the decision overruled would have to be taken into account and would normally be an option only when the young person was thought likely to suffer “grave and irreversible mental or physical harm”. Usually, when a parent wants to overrule a young person’s decision to refuse treatment, health professionals will apply to the courts for a final decision.

An interesting aside to the Fraser guidelines is that many[weasel words] regard Lord Scarman’s judgment as the leading judgement in the case, but because Lord Fraser’s judgement was shorter and set out in more specific terms – and in that sense more accessible to health and welfare professionals – it is his judgement that has been reproduced as containing the core principles, as for example cited in the RCOG circular.

What is Mental Health Law?

Introduction

Mental health law includes a wide variety of legal topics and pertain to people with a diagnosis or possible diagnosis of a mental health condition, and to those involved in managing or treating such people. Laws that relate to mental health include:

  • Employment laws, including laws that prohibit employment discrimination on the basis of a mental health condition, require reasonable accommodations in the workplace, and provide mental health-related leave;
  • Insurance laws, including laws governing mental health coverage by medical insurance plans, disability insurance, workers compensation, and Social Security Disability Insurance;
  • Housing laws, including housing discrimination and zoning;
  • Education laws, including laws that prohibit discrimination, and laws that require reasonable accommodations, equal access to programmes and services, and free appropriate public education;
  • Laws that provide a right to treatment;
  • Involuntary commitment and guardianship laws;
  • Laws governing treatment professionals, including licensing laws, confidentiality, informed consent, and medical malpractice;
  • Laws governing admission of expert testimony or other psychiatric evidence in court; and
  • Criminal laws, including laws governing fitness for trial or execution, and the insanity defence.

Mental health law has received relatively little attention in scholarly legal forums. The University of Memphis Cecil C. Humphreys School of Law in 2011 announced the formation of a student-edited law journal entitled “Mental Health Law & Policy Journal.”

United States

Employment

Title I of the Americans with Disabilities Act of 1990 (“ADA”) is a civil rights law that protects individuals with depression, posttraumatic stress disorder (“PTSD”), and other mental health conditions in the workplace. It prohibits employers with 15 or more employees from firing, refusing to hire, or taking other adverse actions against a job applicant or employee based on real or perceived mental health conditions. It also strictly limits the circumstances under which an employer can ask for information about medical conditions, including mental health conditions, and imposes confidentiality requirements on any medical information that the employer does have.

The ADA also requires employers to provide reasonable accommodations to job applicants or employees with mental health conditions under some circumstances. A reasonable accommodation is a special arrangement or piece of equipment that a person needs because of a medical condition to apply for a job, do a job, or enjoy the benefits and privileges of employment. Examples include a flexible schedule, changes in the method of supervision, and permission to work from home. To have the right to a reasonable accommodation, the worker’s mental health condition must meet the ADA’s definition of a “current disability.” Conditions that should easily qualify include major depression, PTSD, bipolar disorder, obsessive-compulsive disorder (“OCD”), and schizophrenia. Other conditions may also qualify, depending on what the symptoms would be if the condition were left untreated, during an active episode (if the condition involves active episodes). The symptoms do not need to be severe or permanent for the condition to be a disability under the ADA.

Under the Family and Medical Leave Act of 1993 (FMLA), certain employees are entitled to up to twelve weeks of job-protected and unpaid leave to recover from a serious illness or to care for a family member with a serious illness, among other reasons. To be eligible, the employer must have had 50 or more employees in 20 or more workweeks in the current or preceding calendar year, or else must be a public agency, elementary school, or secondary school, and the employee must have worked for the employer for at least 12 months, must have at least 1,250 hours of service for the employer during the 12-month period immediately preceding the leave, and must work at a location where the employer has at least 50 employees within 75 miles.

United Kingdom

Various pieces of legislation including Mental Health Act 1983 and the Mental Capacity Act 2005 govern mental health law giving mental health professionals the ability to commit individuals, treat them without consent and place restrictions on them while in public through outpatient commitment, according to the rules of this legislation. These decisions can be challenged through the mental health tribunals which contain members of the judiciary, though the initial decisions are made by mental health professionals alone.

Around the World

Civil Commitment

Mental health legislation is largely used in the management of psychiatric disorders, such as dementia or psychosis, and developmental disabilities where a person does not possess the ability to act in a legally competent manner and requires treatment and/or another person to act in his or her best interests. The laws generally cover the requirements and procedures for involuntary commitment and compulsory treatment in a psychiatric hospital or other facility.

In some jurisdictions, court orders are required for compulsory treatment; in others, psychiatrists may treat compulsorily by following set procedures, usually with means of appeal or regular scrutiny to ensure compliance with the law.

Sources of Law

Mental health law includes areas of both civil and criminal common and statutory law.

Common law is based on long-standing English legal principles, as interpreted through case law. Mental health-related legal concepts include mens rea, insanity defences; legal definitions of “sane,” “insane,” and “incompetent;” informed consent; and automatism, amongst many others.

Statutory law usually takes the form of a mental health statute. An example is the Mental Health Act 1983 in England and Wales. These acts codify aspects of the treatment of mental illness and provides rules and procedures to be followed and penalties for breaches.

Not all countries have mental health acts. The World Health Report (2001) lists the following percentages, by region, for countries with and without mental health legislation.

What is the Community Mental Health Act of 1963?

Introduction

The Community Mental Health Act of 1963 (CMHA) (also known as the Community Mental Health Centres Construction Act, Mental Retardation Facilities and Construction Act, Public Law 88-164, or the Mental Retardation and Community Mental Health Centres Construction Act of 1963) was an act to provide federal funding for community mental health centres and research facilities in the United States.

Background

This legislation was passed as part of John F. Kennedy’s New Frontier. It led to considerable deinstitutionalisation.

In 1955, Congress passed the Mental Health Study Act, leading to the establishment of the Joint Commission on Mental Illness and Mental Health. That Commission issued a report in 1961, which would become the basis of the 1963 Act.

The CMHA provided grants to states for the establishment of local mental health centres, under the overview of the National Institute of Mental Health. The NIH also conducted a study involving adequacy in mental health issues. The purpose of the CMHA was to build mental health centres to provide for community-based care, as an alternative to institutionalisation. At the centres, patients could be treated while working and living at home.

Only half of the proposed centres were ever built; none were fully funded, and the act did not provide money to operate them long-term. Some states saw an opportunity to close expensive state hospitals without spending some of the money on community-based care. Deinstitutionalisation accelerated after the adoption of Medicaid in 1965. During the Reagan administration, the remaining funding for the act was converted into a mental-health block grant for states. Since the CMHA was enacted, 90% of beds have been cut at state hospitals.

The CMHA proved to be a mixed success. Many patients, formerly warehoused in institutions, were released into the community. However, not all communities had the facilities or expertise to deal with them. In many cases, patients wound up in adult homes or with their families, or homeless in large cities, but without the mental health care they needed.

What was Addington vs Texas (1979)?

Introduction

Addington v. Texas, 441 U.S. 418 (1979), was a landmark decision of the US Supreme Court that set the standard for involuntary commitment for treatment by raising the burden of proof required to commit persons for psychiatric treatment from the usual civil burden of proof of “preponderance of the evidence” to “clear and convincing evidence”.

Background

Before Frank Addington was arrested on the misdemeanour charge of “assault threat” against his mother, Addington’s mother filed a petition with the court, in accordance with Texas law, requesting that Addington be indefinitely involuntarily committed to a state psychiatric hospital. Addington had a long history of mental and emotional problems and past psychiatric hospitalisations. The state trial court issued jury instructions that the decision be based on “clear, unequivocal and convincing evidence” that Addington was mentally ill and that hospitalisation was required for his own welfare and the welfare of others. The jury found that Addington was mentally ill and required hospitalisation. Thereupon the trial court ordered his indefinite commitment. He was indefinitely committed to Austin State Hospital.

However, Addington appealed to the Texas Court of Appeals, based on the argument the court should have used the “beyond a reasonable doubt” standard of proof. The appeals court reversed, agreeing with Addington. The Texas Supreme Court then reversed the Court of Appeals’ decision, reinstating the trial court’s orders. It concluded that the standard of proof of the preponderance of the evidence satisfied due process in a civil commitment proceeding.

Addington then appealed to the US Supreme Court on a writ of certiorari (in law, certiorari is a court process to seek judicial review of a lower court of government agency).

Opinion of the Court

The appeal was dismissed and certiorari granted; the lower court’s decision was vacated and remanded. The court said the issue of an individual’s interest in liberty is of such weight and gravity that a higher standard of proof is required than is normal in civil cases brought under state law. Because of the uncertainties of psychiatric diagnosis, the burden of proof does not need to be as high as “beyond a reasonable doubt” in criminal cases, but should be a “clear and convincing” standard of proof as required by the Fourteenth Amendment in such a civil proceeding to commit an individual involuntarily for an indefinite period to a state psychiatric hospital.

Further, the opinion touched on the issue of an involuntary commitment as primarily medical in nature and needing the expertise of mental health experts.

Whether the individual is mentally ill and dangerous to either himself or others and is in need of confined therapy turns on the meaning of the facts which must be interpreted by expert psychiatrists and psychologists.

Subsequent Developments

The court raised the bar for committing someone against their will in a civil commitment proceeding. When the stakes are exceptionally high in civil matters, the burden of proof must be “clear and convincing evidence”. The case raised important issues regarding civil commitment by placing the burden of proof on the petitioner, that is the party seeking the involuntary commitment of a person.

The opinion also suggested that it was not necessarily for the trier of facts to draw the necessary conclusions without the expertise of psychiatrists and psychologists.

The Supreme Court also cited the Addington case in Santosky v. Kramer, which set a clear and convincing evidence standard in termination of parental rights cases.

What is Involuntary Commitment?

Introduction

Involuntary commitment, civil commitment, or involuntary hospitalisation (also known informally as sectioning or being sectioned in some jurisdictions, such as the UK) is a legal process through which an individual who is deemed by a qualified agent to have symptoms of severe mental disorder is detained in a psychiatric hospital (inpatient) where they can be treated involuntarily. This treatment may involve the administration of psychoactive drugs, including involuntary administration. In many jurisdictions, people diagnosed with mental health disorders can also be forced to undergo treatment while in the community; this is sometimes referred to as outpatient commitment and shares legal processes with commitment.

Refer to Voluntary Commitment.

Criteria for civil commitment are established by laws which vary between nations. Commitment proceedings often follow a period of emergency hospitalisation, during which an individual with acute psychiatric symptoms is confined for a relatively short duration (e.g. 72 hours) in a treatment facility for evaluation and stabilisation by mental health professionals who may then determine whether further civil commitment is appropriate or necessary. Civil commitment procedures may take place in a court or only involve physicians. If commitment does not involve a court there is normally an appeal process that does involve the judiciary in some capacity, though potentially through a specialist court.

Historically, until the mid-1960s in most jurisdictions in the US, all committals to public psychiatric facilities and most committals to private ones were involuntary. Since then, there have been alternating trends towards the abolition or substantial reduction of involuntary commitment, a trend known as “deinstitutionalisation”. In many currents, individuals can voluntarily admit themselves to a mental health hospital and may have more rights than those who are involuntarily committed. This practice is referred to as voluntary commitment.

In the United States, an indefinite form of commitment is applied to people convicted of some sexual offences.

Purpose

For most jurisdictions, involuntary commitment is applied to individuals believed to be experiencing a mental illness that impairs their ability to reason to such an extent that the agents of the law, state, or courts determine that decisions will be made for the individual under a legal framework. In some jurisdictions, this is a proceeding distinct from being found incompetent. Involuntary commitment is used in some degree for each of the following although different jurisdictions have different criteria. Some jurisdictions limit involuntary treatment to individuals who meet statutory criteria for presenting a danger to self or others. Other jurisdictions have broader criteria. The legal process by which commitment takes place varies between jurisdictions. Some jurisdictions have a formal court hearing where testimony and other evidence may also be submitted where subject of the hearing is typically entitled to legal counsel and may challenge a commitment order through habeas corpus. Other jurisdictions have delegated these power to physicians, though may provide an appeal process that involves the judiciary but may also involve physicians. For example in the UK a mental health tribunal consists of a judge, a medical member, and a lay representative.

First Aid

Training is gradually becoming available in mental health first aid to equip community members such as teachers, school administrators, police officers, and medical workers with training in recognising, and authority in managing, situations where involuntary evaluations of behaviour are applicable under law. The extension of first aid training to cover mental health problems and crises is a quite recent development. A mental health first aid training course was developed in Australia in 2001 and has been found to improve assistance provided to persons with an alleged mental illness or mental health crisis. This form of training has now spread to a number of other countries (Canada, Finland, Hong Kong, Ireland, Singapore, Scotland, England, Wales, and the United States). Mental health triage may be used in an emergency room to make a determination about potential risk and apply treatment protocols.

Observation

Observation is sometimes used to determine whether a person warrants involuntary commitment. It is not always clear on a relatively brief examination whether a person should be committed.

Containment of Danger

Refer to Obligatory Dangerousness Criterion.

Austria, Belgium, Germany, Israel, the Netherlands, Northern Ireland, Russia, Taiwan, Ontario (Canada), and the United States have adopted commitment criteria based on the presumed danger of the defendant to self or to others.

People with suicidal thoughts may act on these impulses and harm or kill themselves.

People with psychosis are occasionally driven by their delusions or hallucinations to harm themselves or others. Research has found that those who suffer from schizophrenia are between 3.4 and 7.4 times more likely to engage in violent behaviour than members of the general public. However, because other confounding factors such as childhood adversity and poverty are correlated with both schizophrenia and violence it can be difficult to determine whether this effect is due to schizophrenia or other factors. In an attempt to avoid these confounding factors, researchers have tried comparing the rates of violence amongst people diagnosed with schizophrenia to their siblings in a similar manner to twin studies. In these studies people with schizophrenia are found to be between 1.3 and 1.8 times more likely to engage in violent behaviour.

People with certain types of personality disorders can occasionally present a danger to themselves or others.

This concern has found expression in the standards for involuntary commitment in every US state and in other countries as the danger to self or others standard, sometimes supplemented by the requirement that the danger be imminent. In some jurisdictions, the danger to self or others standard has been broadened in recent years to include need-for-treatment criteria such as “gravely disabled”.

Deinstitutionalisation

Refer to Deinstitutionalisation.

Starting in the 1960s, there has been a worldwide trend toward moving psychiatric patients from hospital settings to less restricting settings in the community, a shift known as deinstitutionalisation. Because the shift was typically not accompanied by a commensurate development of community-based services, critics say that deinstitutionalisation has led to large numbers of people who would once have been inpatients as instead being incarcerated or becoming homeless. In some jurisdictions, laws authorising court-ordered outpatient treatment have been passed in an effort to compel individuals with chronic, untreated severe mental illness to take psychiatric medication while living outside the hospital (e.g. Laura’s Law and Kendra’s Law).

Before the 1960s deinstitutionalisation there were earlier efforts to free psychiatric patients. Philippe Pinel (1745-1826) ordered the removal of chains from patients.

In a study of 269 patients from Vermont State Hospital done by Courtenay M. Harding and associates, about two-thirds of the ex-patients did well after deinstitutionalisation.

Around the World

France

In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. Édouard Séguin developed a systematic approach for training individuals with mental deficiencies, and, in 1839, he opened the first school for the intellectually disabled. His method of treatment was based on the idea that the intellectually disabled did not suffer from disease.

United Kingdom

In the United Kingdom, provision for the care of the mentally ill began in the early 19th century with a large state-led effort. Public mental asylums were established in Britain after the passing of the 1808 County Asylums Act. This empowered magistrates to build rate-supported asylums in every county to house the many ‘pauper lunatics’. Nine counties first applied, and the first public asylum opened in 1812 in Nottinghamshire. Parliamentary Committees were established to investigate abuses at private madhouses like Bethlem Hospital – its officers were eventually dismissed and national attention was focused on the routine use of bars, chains and handcuffs and the filthy conditions the inmates lived in. However, it was not until 1828 that the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums.

The Lunacy Act 1845 was an important landmark in the treatment of the mentally ill, as it explicitly changed the status of mentally ill people to patients who required treatment. The Act created the Lunacy Commission, headed by Lord Shaftesbury, to focus on lunacy legislation reform. The commission was made up of eleven Metropolitan Commissioners who were required to carry out the provisions of the Act; the compulsory construction of asylums in every county, with regular inspections on behalf of the Home Secretary. All asylums were required to have written regulations and to have a resident qualified physician. A national body for asylum superintendents – the Medico-Psychological Association – was established in 1866 under the Presidency of William A. F. Browne, although the body appeared in an earlier form in 1841.

At the turn of the century, England and France combined had only a few hundred individuals in asylums. By the late 1890s and early 1900s, this number had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalisation was soon disappointed. Psychiatrists were pressured by an ever-increasing patient population. The average number of patients in asylums kept on growing. Asylums were quickly becoming almost indistinguishable from custodial institutions, and the reputation of psychiatry in the medical world had hit an extreme low.

United States

In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The Utica State Hospital was opened approximately in 1850. The creation of this hospital, as of many others, was largely the work of Dorothea Lynde Dix, whose philanthropic efforts extended over many states, and in Europe as far as Constantinople. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect.

In the United States and most other developed societies, severe restrictions have been placed on the circumstances under which a person may be committed or treated against their will as such actions have been ruled by the United States Supreme Court and other national legislative bodies as a violation of civil rights and/or human rights (e.g. O’Connor v. Donaldson). Thus a person is rarely committed against their will and it is illegal for a person to be committed for an indefinite period of time.

United Nations

United Nations General Assembly Resolution 46/119, “Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care“, is a non-binding resolution advocating certain broadly drawn procedures for the carrying out of involuntary commitment. These principles have been used in many countries where local laws have been revised or new ones implemented. The UN runs programmes in some countries to assist in this process.

Criticism

The dangers of institutions were chronicled and criticized by reformers almost since their foundation. Charles Dickens was an outspoken and high-profile early critic, and several of his novels, in particular Oliver Twist and Hard Times demonstrate his insight into the damage that institutions can do to human beings.

Enoch Powell, when Minister for Health in the early 1960s, was a later opponent who was appalled by what he witnessed on his visits to the asylums, and his famous “water tower” speech in 1961 called for the closure of all NHS asylums and their replacement by wards in general hospitals:

“There they stand, isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined, rising unmistakable and daunting out of the countryside – the asylums which our forefathers built with such immense solidity to express the notions of their day. Do not for a moment underestimate their powers of resistance to our assault. Let me describe some of the defenses which we have to storm.”

Scandal after scandal followed, with many high-profile public inquiries. These involved the exposure of abuses such as unscientific surgical techniques such as lobotomy and the widespread neglect and abuse of vulnerable patients in the US and Europe. The growing anti-psychiatry movement in the 1960s and 1970s led in Italy to the first successful legislative challenge to the authority of the mental institutions, culminating in their closure.

During the 1970s and 1990s the hospital population started to fall rapidly, mainly because of the deaths of long-term inmates. Significant efforts were made to re-house large numbers of former residents in a variety of suitable or otherwise alternative accommodation. The first 1,000+ bed hospital to close was Darenth Park Hospital in Kent, swiftly followed by many more across the UK. The haste of these closures, driven by the Conservative governments led by Margaret Thatcher and John Major, led to considerable criticism in the press, as some individuals slipped through the net into homelessness or were discharged to poor quality private sector mini-institutions.

Wrongful Involuntary Commitment

Mental health professionals have, on occasion, wrongfully deemed individuals to have symptoms of a mental disorder, and thereby commit the individual for treatment in a psychiatric hospital. Claims of wrongful commitment are a common theme in the anti-psychiatry movement.

In 1860, the case of Elizabeth Packard, who was wrongfully committed that year and filed a lawsuit and won thereafter, highlighted the issue of wrongful involuntary commitment. In 1887, investigative journalist Nellie Bly went undercover at an asylum in New York City to expose the terrible conditions that mental patients at the time had to deal with. She published her findings and experiences as articles in New York World, and later made the articles into one book called Ten Days in a Mad-House.

In the first half of the twentieth century there were a few high-profile cases of wrongful commitment based on racism or punishment for political dissenters. In the former Soviet Union, psychiatric hospitals were used as prisons to isolate political prisoners from the rest of society. British playwright Tom Stoppard wrote Every Good Boy Deserves Favour about the relationship between a patient and his doctor in one of these hospitals. Stoppard was inspired by a meeting with a Russian exile. In 1927, after the execution of Sacco and Vanzetti in the United States, demonstrator Aurora D’Angelo was sent to a mental health facility for psychiatric evaluation after she participated in a rally in support of the anarchists. Throughout the 1940s and 1950s in Canada, 20,000 Canadian children, called the Duplessis orphans, were wrongfully certified as being mentally ill and as a result were wrongfully committed to psychiatric institutions where they were forced to take psychiatric medication that they did not need, and were abused. They were named after Maurice Duplessis, the premier of Quebec at the time, who deliberately committed these children to in order to misappropriate additional subsidies from the federal government. Decades later in the 1990s, several of the orphans sued Quebec and the Catholic Church for the abuse and wrongdoing. In 1958, black pastor and activist Clennon Washington King Jr. tried enrolling at the University of Mississippi, which at the time was white, for summer classes; the local police secretly arrested and involuntarily committed him to a mental hospital for 12 days.

Patients are able to sue if they believe that they have been wrongfully committed. In one instance, Junius Wilson, an African American man, was committed to Cherry Hospital in Goldsboro, North Carolina in 1925 for an alleged crime without a trial or conviction. He was castrated. He continued to be held at Cherry Hospital for the next 67 years of his life. It turned out he was deaf rather than mentally ill.

In many American states sex offenders who have completed a period of incarceration can be civilly committed to a mental institution based on a finding of dangerousness due to a mental disorder. Although the United States Supreme Court determined that this practice does not constitute double jeopardy, organisations such as the American Psychiatric Association (APA) strongly oppose the practice. The Task Force on Sexually Dangerous Offenders, a component of APA’s Council on Psychiatry and Law, reported that “in the opinion of the task force, sexual predator commitment laws represent a serious assault on the integrity of psychiatry, particularly with regard to defining mental illness and the clinical conditions for compulsory treatment. Moreover, by bending civil commitment to serve essentially non-medical purposes, statutes threaten to undermine the legitimacy of the medical model of commitment.”

What is O’Connor vs. Donaldson (1975)?

Introduction

O’Connor v. Donaldson, 422 U.S. 563 (1975), was a landmark decision of the US Supreme Court in mental health law ruling that a state cannot constitutionally confine a non-dangerous individual who is capable of surviving safely in freedom by themselves or with the help of willing and responsible family members or friends.

Since the trial court jury found, upon ample evidence, that petitioner did so confine respondent, the Supreme Court upheld the trial court’s conclusion that petitioner had violated respondent’s right to liberty.

Refer to Involuntary Commitment.

Overview

Kenneth Donaldson (confined patient) had been held for 15 years in Florida State Hospital at Chattahoochee, due to needs of “care, maintenance, and treatment.” He filed a lawsuit against the hospital and staff members claiming they had robbed him of his constitutional rights, by confining him against his will. Donaldson won his case (including monetary damages) in United States District Court, which was affirmed by the United States Court of Appeals for the Fifth Circuit. In 1975, the United States Supreme Court agreed that Donaldson had been improperly confined but vacated the award of damages. On remand, the Fifth Circuit ordered that a new trial on damages be held.

A finding of “mental illness” alone cannot justify a State’s locking a person up against his will and keeping him indefinitely in simple custodial confinement. Assuming that that term can be given a reasonably precise content and that the “mentally ill” can be identified with reasonable accuracy, there is still no constitutional basis for confining such persons involuntarily if they are dangerous to no one and can live safely in freedom.

May the State confine the mentally ill merely to ensure them a living standard superior to that they enjoy in the private community? That the State has a proper interest in providing care and assistance to the unfortunate goes without saying. But the mere presence of mental illness does not disqualify a person from preferring his home to the comforts of an institution. Moreover, while the State may arguably confine a person to save him from harm, incarceration is rarely if ever a necessary condition for raising the living standards of those capable of surviving safely in freedom, on their own or with the help of family or friends. May the State fence in the harmless mentally ill solely to save its citizens from exposure to those whose ways are different? One might as well ask if the State, to avoid public unease, could incarcerate all who are physically unattractive or socially eccentric. Mere public intolerance or animosity cannot constitutionally justify the deprivation of a person’s physical liberty. In short, a State cannot constitutionally confine without more a non-dangerous individual who is capable of surviving safely in freedom by himself or with the help of willing and responsible family members or friends.

Kenneth Donaldson

The origins of Donaldson’s institutionalisation began in 1943, at age 34, when he suffered a traumatic episode. He was hospitalized and received treatment, before resuming life with his family.

In 1956 Donaldson travelled to Florida to visit his elderly parents. While there, Donaldson reported that he believed one of his neighbours in Philadelphia might be poisoning his food. His father, worried that his son suffered from paranoid delusions, petitioned the court for a sanity hearing. Donaldson was evaluated, diagnosed with “paranoid schizophrenia,” and civilly committed to the Florida State mental health system. At his commitment trial, Donaldson did not have legal counsel present to represent his case. Once he entered the Florida hospital, Donaldson was placed with dangerous criminals, even though he had never been proved to be dangerous to himself or others. His ward was understaffed, with only one doctor (who happened to be an obstetrician) for over 1,000 male patients. There were no psychiatrists or counsellors, and the only nurse on site worked in the infirmary.

He spent 15 years as a patient; he did not receive any treatment, actively refusing it, and attempting to secure his release. Throughout his stay he denied he was ever mentally ill, and refused to be put into a halfway house.

Donaldson later wrote a book about his experience as a mental patient titled Insanity Inside Out.