INFORMED CONSENT

by Gina Sestak

My first full-time job after law school was as a senior research associate with the University of Pittsburgh School of Medicine Law & Psychiatry Program. I was part of an interdisciplinary team -- one psychiatrist, two lawyers, and three sociologists. We wrote a book about informed consent to psychiatric treatment, based upon a study of the implementation of the newly enacted Pennsylvania Mental Health Procedures Act. Two of the sociologists were embedded in hospital settings, one with the staff and the other with patients. They made copious notes of what they saw and heard in an admissions unit, in an outpatient treatment clinic, and on an in-patient research ward.

For the purposes of our study, informed consent to treatment was broken down into five components: voluntariness, competence, information, understanding, and decision. It was my job to review the sociologist's notes and code them according to this model.

It is noteworthy that the first component listed was voluntariness -- consensual treatment presumes that the afflicted person will seek help. But not all people with mental health issues do so.

A question that has come up repeatedly since the shootings at Virginia Tech is this: why wasn't the obviously mentally ill shooter forced to undergo treatment, or at least locked up where he couldn't hurt anyone? A century ago, he could have been institutionalized for years upon the say-so of a doctor or two, but nowadays laws designed to protect the mentally ill from that kind of warehousing made that difficult. Laws designed to protect patient privacy made it illegal to even tell his parents how far gone he was.

In trying to understand what happened at Virginia Tech, it is important to remember that "mentally ill" and "dangerous" are not synonyms. Most people who have psychiatric diagnoses never commit murders; most murderers are nominally sane.

Generally speaking, no one in the United States can be involuntarily hospitalized for mental illness unless, in the opinion of an examining psychiatrist, that person is a present danger to self or others. That is, unless someone is suicidal or homicidal, or so seriously impaired as to be unable to manage day-to-day life functions (such as eating), that person cannot be involuntarily committed or, if committed, cannot be held beyond an initial short commitment period during which an evaluation is performed.

It is not always easy to predict dangerousness. The best predictor of dangerousness has been shown to be past acts -- people who have done dangerous things before are more likely to do dangerous things in the future than are people who have never done anything dangerous. It is interesting to me as a writer that the person who spotted Cho's dangerous tendencies was not the examining psychiatrist during his one short commitment but his writing teacher.