Decision-Making Capacity Will Have a Limited Effect on Civil Commitment Practices

In “Reweighing the Ethical Tradeoffs in the Involuntary Hospitalization of Suicidal Patients,” Borecky, Thomsen, and Dubov (2019) argue that current civil commitment criteria—mentally ill and dangerous—have enabled a practice that imposes significant burdens and harms on detainees, despite scant empirical literature showing that it effectively curtails completed suicide. They suggest an additional criterion, lack of decision-making capacity, which they claim would restrict civil commitment to only those patients whose autonomy is demonstrably impaired. Although such a proposal would bring psychiatry in line with other medical disciplines that require a finding of incapacity prior to involuntary treatment, the expectation that assessments of decision-making capacity would significantly change practice is misplaced. “Rational suicide” seekers seldom show up to the psychiatric emergency room. Suicide is often a deeply ambivalent decision that is affected by multiple personal and interpersonal factors (O’Connor and Nock 2014). In emergency settings where suicide assessments for involuntary commitment are conducted, this ambivalence, in conjunction with the high stakes and the open question about whether mental illness is distorting decision making, will tend to lead evaluators to disqualify patients due to lack of appreciation or reasoning. Ultimately, whether or not decision-making capacity is added to civil commitment criteria, the population of involuntarily committed patients is not likely to change.