The tricky question of involuntary commitment

Deciding to get a person with a serious mental illness into treatment is one of the most important steps families can take to protect a loved one's health and well-being. Unfortunately, it also can be one of the most difficult. Many mentally ill people don't realize they are sick and resist visiting a doctor, participating in therapy or taking medications, even to the point of becoming a danger to themselves or others. When that happens, families may have no choice but to try to commit them to an institution against their will. Yet doing so can be a frustrating and painful experience.

That's because the rules for involuntary commitments in Maryland are among the strictest in the country, even for people who obviously are in need of immediate help. Advocates for the families of mentally ill people say that too often individuals in crisis are turned away from hospital emergency rooms because the standard for judging whether they pose a danger to themselves or others is interpreted too narrowly. As a result, people don't get the help they need, their symptoms become worse, and eventually they end up at even greater risk of harming themselves or others.

A bill passed by the Maryland Senate this year is designed to make involuntary commitment of a close relative easier for families by expanding the definition of danger to self or others. Advocates of the measure say that under current law, hospital and other officials often define dangerousness solely on the basis of whether a patient might commit suicide or hurt someone else if not admitted to an institution. They are proposing changes that would broaden the definition of dangerousness to cases in which health care officials have a reasonable expectation that a person might become dangerous even if he doesn't exhibit serious symptoms at the time he is evaluated.

The measure has not yet been voted on in the House, where state Department of Health and Mental Hygiene officials testified against the measure last month. The department criticized the bill as overly broad and vague because it could be applied to many people who don't need to be hospitalized. Department officials said it would also leave hospitals without clear guidelines for admitting patients. Health professionals and administrative court judges who make commitment decisions already consider a range of factors in assessing dangerousness, the department noted, and in any case the proposed task force called for in the bill would duplicate a similar body included in the governor's gun legislation this year.

Current Maryland law requires health care professionals, police, clinical social workers and others to carefully weigh a person's need for treatment against the unavoidable infringement on personal liberties that confinement in a hospital entails. In virtually every case, making such judgments involves a difficult balancing act. To be committed involuntarily to an institution, a patient must be evaluated by a physician and a psychologist, or by two physicians, both of whom must agree that the person poses a danger to himself or others, shows symptoms of a mental disorder, is unwilling or unable to come into the hospital voluntarily and that a hospital is the least restrictive setting in which the illness can be treated.

State health officials argue these criteria are sufficient to confine people who need immediate help and keep them there until they can be safely released into a less restrictive environment. At the same time, the civil liberties protections they offer are robust enough to protect people who don't need to be in a hospital from being committed against their will.

These are thorny issues that need to be resolved before any solution is set in stone, and the best place to do that is probably in the working group established under the governor's gun legislation, which is far more likely than the Senate bill to become law this year.

While it might seem that expanding eligibility for involuntary commitments should be a relatively straightforward affair, in fact the issue is exceedingly complex and deserves sustained, careful scrutiny — something it is unlikely to get in the waning days of the legislative season. Given the realities of the calendar, it probably makes more sense to charge the governor's working group with studying the matter further rather than to rush through a last-minute compromise that risks creating more problems than it solves.

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