Chapter 7 - The mentally ill

Summary

In this chapter we explore how the general accounts of competence and of the ethical decision-making framework for those judged incompetent apply to the mentally ill. We consider it a virtue of our analysis that it applies equally to the mentally ill and to the treatment of mental illness as to the more common cases of medical treatment of physical illness. Nevertheless, there are several differences in the treatment of mental illness that necessitate a separate discussion. Perhaps most important is the fact that the mental illness itself often, although by no means always, impairs the person's ability to make a competent decision about his or her need for treatment. This occurs, of course, with physical illness as well, but the difference in frequency and directness of impairment of a person's decision-making capacities is important. A second important difference is the common separation of decisions to hospitalize the patient from decisions about treatment of the patient. Some psychiatric patients are involuntarily hospitalized who at the same time are deemed competent to refuse treatment for their illness. This is one of the most controversial features of our system of care for the mentally ill. Physicians responsible for the care of these patients then understandably protest that they are being put in the punitive role of jailers, instead of their proper role as healers.