The paradox of autonomy : mandatory outpatient treatment of those with mental illness

This thesis explores the ethical territory charted by a relatively recent development in the treatment of the severely and persistently mentally ill, mandatory outpatient treatment (MOT). MOT is designed to treat patients who make a fair recovery from illness when they take their prescribed medications consistently, but who repeatedly quit taking their medication, only to suffer a series of relapses which result in involuntary commitment in psychiatric hospitals. For these individuals, MOT is believed to be a less restrictive alternative to inpatient commitment, and better method of preventing relapse than current patterns of repeated hospitalization. The thesis explores four areas of significant debate within the context of mandatory outpatient commitment. First, I address the definition of meaningful rational autonomy and its relationship to coercive treatment of mental illness. I examine how these issues are integrated into the movement for mandatory outpatient treatment of the mentally ill within their communities, and I conclude that MOT is a less restrictive and therefore more desirable treatment method than the forced hospitalization permitted under most commitment standards. Second, I address the inadequacy of many community resources and the debate over the efficacy of involuntary commitment statutes. I analyze recent research into the effectiveness of mandatory outpatient treatment, and I conclude that, while more research is needed, present findings suggest MOT commitments do improve patient compliance and can help patients lead more stable and productive lives. Third, I identify limitations of current MOT statutes by presenting a case study of a woman on mandatory outpatient treatment orders. I argue that outpatient commitment statutes are nothing more than empty rhetoric if they do not have adequate enforcement mechanisms in place, and I conclude that MOT orders need to be strengthened by such enforcement. Fourth, I look at different definitions of disability and their relevance and impact on the experience of those who have been diagnosed with mental illness. I conclude that certain forms of mandatory outpatient commitment do not constitute a double standard in the treatment of mental disability, and that, far fi"om committing harms against them, conscientious use of coerced community treatment for some individuals with severe and persistent mental illness offers the best hope of restoring their autonomy such that they may live relatively safe and purposeful lives. The conclusion of this thesis is that mandatory outpatient treatment involves a paradox. That is, for some individuals with severe and persistent mental illness, expanding their autonomy may require temporarily restricting it. This paradox can be best resolved through treatment methods such as mandatory outpatient commitment, since this involves less restriction on autonomy than traditional inpatient hospitalization and offers a better chance for the individual to regain stability within his or her own community.