Debate Persists on Ethics of Involuntary Outpatient Commitment Laws


Are involuntary outpatient commitment laws a good thing? Depends on who you ask and how that person is looking at the question, said a panel of experts in a symposium yesterday at APA’s 2016 Annual Meeting.

The presenters were Marvin Swartz, M.D. (above), a professor of psychiatry at Duke University School of Medicine; Ezra Griffith, M.D., professor emeritus of psychiatry at Yale University School of Medicine and chair of the APA Committee on Ethics; Robert Weinstock, M.D., past president of the American Association of Psychiatry and the Law; William Darby, M.D., a psychiatry resident at UCLA; and Kenneth Hoge, M.D., chair of APA’s Council on Psychiatry and Law.

Swartz, who chaired an APA work group that helped to develop a position statement and accompanying resource document approved by the APA Board of Trustees last December, emphasized that the question should be reposed as “Can IOC be effective, under what conditions, and for which patients?”

Before presenting essential points of the APA position statement and resource document, Swartz summarized the research that exists on IOC, noting that methodological problems plague most of the studies. But he said that research appears to indicate that involuntary outpatient commitment is effective when it is accompanied by adequate resources, adequate duration, and intensive services.

“IOC is a complex community intervention, not easily evaluated in a randomized trial design,” Swartz said. “A fair-minded reading of the literature on outpatient commitment’s effectiveness would be that it can be effective assuming effective implementation, provision of intensive community-based services, and adequate duration of the court order.”

APA’s statement and resource document include 15 “key statements” addressing the complexity of IOC, including such issues as patient and family engagement, due-process protections for individuals subject to IOC, use of psychotropic medications in IOC programs, and the critical question of whether IOC is disproportionately imposed on racial and ethnic minorities.

Ezra Griffith, M.D., chair of the APA Ethics Committee, said he believes the APA position did not sufficiently take into consideration the effect of IOC on racial and ethnic minority communities, especially African American communities. “IOC is not a simple solution for a complex problem—which is how our society is to deal with individuals who refuse psychiatric treatment,” Griffith said. “I favor a more balanced approach to its advantages and problems.”

Weinstock and Darby presented an approach to ethical analysis known as “dialectical principalism” that allows for a dispassionate consideration of conflicting ethical principles. “While APA has a position statement and resource document on IOC, a consensus on whether it is ethical or unethical will likely never be achieved,” Darby said. “We assert that a middle ground solution exists for IOC in that it is ethical for certain patients under certain circumstances and unethical in others. Further, safeguards can be incorporated to mitigate ethical problems related to IOC.”