Many Ethics Concerns with Involuntary Psychiatric Holds

By Stacey Kusterbeck

Hospitals continue to see a surge of psychiatric patients. Some end up being held involuntarily, raising multiple ethical concerns.^1,2

“In my experience, the greatest ethical concern has to do with autonomy,” says Kimberly Nordstrom, MD, JD, an emergency psychiatrist at University of Colorado Anschutz. Nordstrom is being asked to review increasing numbers of cases where people were held for reasons such as “ease of transport” or “handoff concerns” between sending and accepting facilities.

The holds had nothing to do with actual emergency need based on a psychiatric condition. Sometimes the holds were used just for convenience. One issue was that local ambulance services were refusing to transport those with mental health conditions if there was not a hold in place.

“There were several misconceptions at play. It took many meetings and review of the law — that demands a default to voluntariness outside of certain conditions — to right this injustice,” says Nordstrom.

In Colorado, “transport holds” largely are used for police, who believe that mental illness is a factor with an individual but are not in a position to evaluate this. These holds last only until the person gets to a place (such as a clinic or hospital) where the need for a mental health hold can be evaluated.

“As a psychiatrist in Colorado, I can dismiss a mental health hold and commonly do, basing my decision-making on ethical principles,” says Nordstrom. States have different policies and procedures around involuntary holds, but generally require these factors for patients to be held involuntarily:

• having a mental illness;

• having a safety concern (actively suicidal or homicidal, or grave disability leading to decompensation of mental health or medical conditions);

• some immediacy around the safety concern;

• lack of voluntariness.

“When a person is placed on a hold, it takes away autonomy of the person regarding being held for treatment. Many times, the voluntariness has not been evaluated,” says Nordstrom.

Healthcare providers have to evaluate patients for both “capacity” and “voluntariness.” An individual might have decision-making capacity, but the person’s mental state could cause them to quickly alter decisions back and forth.

“This will commonly occur when someone is experiencing mania,” says Nordstrom. In those cases, the person might state, “I need help and agree that some time in the hospital will be good.” Yet, a short while later the person starts screaming, “How dare you imprison me!”

“You could make a case that this equals a lack of capacity. It is somewhat nuanced. For mental health holds, capacity is assumed because we are required to determine if the person wants to be voluntary,” Nordstrom explains.

For ethicists, simply raising the concern by asking whether clinicians evaluated voluntariness is helpful. “Placing holds tends to be a knee-jerk reaction,” says Nordstrom. Ideally, holds only are placed after an evaluation to determine voluntariness, immediacy of dangerousness, and whether there is a mental health condition.

Clinicians may be legally justified in holding a patient involuntarily to prevent public harm. The ethical justification centers largely on the concept of beneficence.

“In involuntary hold situations, the idea is that the hold is used to protect the person from dangerous acts that are directly related to the person’s acute exacerbation of mental illness,” explains Nordstrom.

Ethicists can assist by training clinicians who are able to place involuntary holds in thinking through all of these ethical concerns. When Nordstrom gives a presentation to psychiatric residents about involuntary holds, the first slide covers autonomy vs. paternalism.

“Beneficence ‘gone wrong’ is paternalism and used to be the way of medicine. Each person should be assumed to have decision-making capacity,” says Nordstrom. “Having psychosis or mania does not negate this, though sometimes mental state leads to unstable decisions.”

This needs to be investigated through an interview, after which clinicians may determine that the patient has limited capacity. To make things even more complex, decision-making capacity can fluctuate based on the patient’s symptoms. For example, when a depressed person is planning suicide, the person may appear ambivalent and give a lukewarm response, such as “treatment might be OK.”

Nordstrom uses this example to explain to residents how depression can affect decision-making. An involuntary hold might be useful to ensure a patient receives appropriate treatment in the interim, until depression has less of a grasp on the patient.

“This push-pull of ethics in determining appropriateness of holds is not largely discussed,” says Nordstrom. Physicians do not tend to regard involuntary hospitalization as “jailing” a person, but that might be exactly how the person feels. “Helping physicians and others find a way to honor autonomy in these situations would be a key way for ethicists to make their mark,” says Nordstrom. Ideally, ethicists provide training to physicians and other healthcare providers who may be involved in involuntary holds.

“It would be beneficial to take themes from these consultations involving involuntary treatment and create a grand rounds-type offering,” suggests Nordstrom.

REFERENCES

1. Quan A. The ethics of overriding patient refusals during 5150s and other involuntary psychiatric holds. Bioethics 2024;38:667-673.
2. Laureano CD, Laranjeira C, Querido A, et al. Ethical issues in clinical decision-making about involuntary psychiatric treatment: A scoping review. Healthcare (Basel) 2024;12:445.