INVOLUNTARY OUTPATIENT COMMITMENT: THE LIMITS OF PREVENTION Candice T. Player* Preventive outpatient commitment laws require people with mental illnesses to participate in mental health treatment before they meet the criteria for inpatient civil commitment—clear and convincing evidence of mental illness and dangerousness to self or others. These laws apply to people who are chronically ill but not imminently dangerous. Most outpatient commitment laws do not require a judicial determination of incompetence, nor do they require a criminal charge or a criminal conviction. As such, outpatient commitment statutes unearth an old question on law, ethics, and the limits of prevention: under what circumstances can we impose substantial restraints on individual liberty because we believe a person is likely to harm himself or others before he actually has done so? Although most authors rest the moral justification for outpatient commitment on a mental impairment—be it impaired insight, decisional-incapacity or incompetence to refuse treatment, this Article claims that government interventions into self-regarding harm and other-regarding harm require distinct moral justifications. When our primary concern is one of self-regarding harm, a court order to participate in outpatient treatment may be appropriate, but only for people with mental illnesses who are incompetent to make treatment decisions on their own. If, however, we are concerned about harm to others, a court order to participate in outpatient treatment may be appropriate, but only for people with mental illnesses who lack the moral capacities for criminal responsibility— either because they are unlikely to appreciate the wrongfulness of their conduct or because they are unable to conform their conduct to the requirements of the law. INTRODUCTION....................................................................................................... 160 I. THE RISE OF OUTPATIENT COMMITMENT ......................................................... 166 A. Deinstitutionalization ................................................................................. 166 1. The (Broken) Promise of Community Mental Health ......................... 166 * Assistant Professor of Law, Northwestern University School of Law; Ph.D. Ethics and Health Policy, Harvard University 2013; J.D. Harvard Law School, 2009; M.Phil, Institute of Criminology, Cambridge University, 2003 A.B. Harvard College, 2002. I am grateful to Anita L. Allen, Anne Barnhill, Eric Beerbohm, Stephanos Bibas, Dan Brock, Glenn Cohen, Steve Joffe, Michelle Mello, Stephen Morse, Ted Ruger, and Tobias Wolff for their comments on this Article. All errors are my own. 159 160 STANFORD LAW & POLICY REVIEW [Vol. 26:159 2. A Changing Legal Landscape ............................................................. 169 3. “Rotting with Their Rights On” .......................................................... 172 B. Preventive Outpatient Commitment ........................................................... 175 1. New York ............................................................................................ 176 a. Mechanics ...................................................................................... 176 b. Program Implementation ............................................................... 178 2. California ............................................................................................ 179 3. North Carolina ..................................................................................... 181 C. Empirical Research on Effectiveness ......................................................... 182 1. Randomized Controlled Trials ............................................................ 182 2. Observational and Quasi-Experimental Designs ................................. 185 D. Constitutional Challenges .......................................................................... 187 II. MORAL JUSTIFICATIONS AND PUBLIC POLICY RATIONALES ............................. 191 A. Harm to Others........................................................................................... 191 1. Violence and Mental Illness ................................................................ 192 a. Community Surveys ...................................................................... 192 b. Psychosis and Violence ................................................................. 194 2. Risk Assessment and Violence ........................................................... 196 3. The Criminal-Civil Distinction ........................................................... 199 B. Harm to Self ............................................................................................... 201 1. Autonomy Defined .............................................................................. 204 2. Conceptual Hurdles and Replies ......................................................... 205 3. Autonomy and Mental Illness ............................................................. 208 4. When—If Ever—Is Paternalism Justified? ......................................... 210 a. Retrospective Endorsement Theories ............................................ 210 b. The Soft Paternalist Strategy ......................................................... 211 C. Impaired Insight ......................................................................................... 212 1. Impaired Insight Defined .................................................................... 212 2. The Neuroscience of Insight ............................................................... 213 3. Impaired Insight in The Courtroom..................................................... 216 4. An Objection from Autonomy ............................................................ 217 III. THE LIMITS OF PREVENTION ............................................................................. 218 A. Harm to Self ............................................................................................... 220 1. Competence to Refuse Treatment ....................................................... 220 a. Understanding and Appreciation ................................................... 221 b. Reasoning and Communication ..................................................... 225 2. Competence without Insight ................................................................ 228 B. Harm to Others........................................................................................... 229 1. Cognitive Impairment ......................................................................... 231 2. Volitional Impairment ......................................................................... 232 IV. OBJECTIONS AND CONCLUSIONS ...................................................................... 235 INTRODUCTION In the years since deinstitutionalization, one of the most important questions in mental health policy is this: how can we care for psychiatric patients in the community who need treatment but resist treatment nonetheless? 2015] INVOLUNTARY OUTPATIENT COMMITMENT 161 The problem is particularly apparent for people with chronic mental illnesses who are high utilizers of inpatient care—so called “revolving door patients.” These patients improve when they are hospitalized and treated with psychotropic medications but frequently stop taking their medications shortly after they are released, creating a cycle of relapse and rehospitalization.1 Eventually, revolving door patients will deteriorate and meet the criteria for inpatient civil commitment—clear and convincing evidence of mental illness and dangerousness to self or others. However, involuntary outpatient commitment laws permit courts to intervene and order people with mental illnesses to comply with treatment in the community. A subtype of involuntary outpatient commitment—known as preventive outpatient commitment— permits court-ordered treatment for people with mental illnesses who do not satisfy the criteria for inpatient commitment. Proponents of these laws tout them as a solution to the revolving door problem.2 Forty-two states and the District of Columbia have involuntary outpatient commitment laws.3 At least nine jurisdictions permit preventive outpatient 1. Joan B. Gerbasi et al., Resource Document on Mandatory Outpatient Treatment, 28 J. AM. ACAD. PSYCHIATRY & L. 127, 128 (2000). Many revolving door patients have been diagnosed with schizophrenia or schizoaffective disorder. These patients impose an enormous economic burden on the healthcare system due to the high cost of hospitalization. See Thomas W. Haywood et al., Predicting the “Revolving Door” Phenomenon Among Patients with Schizophrenic, Schizoaffective, and Affective Disorders, 152 AM. J. PSYCHIATRY 856 (1995); Patricia Thieda et al., An Economic Review of Compliance with Medication Therapy in the Treatment of Schizophrenia, 54 PSYCHIATRIC SERVICES 508 (2003); Peter J. Welden & Mark Olfson, Cost of Relapse in Schizophrenia, 21 SCHIZOPHRENIA BULLETIN 419 (1995). 2. See, e.g., Gerbasi et al., supra note 1; Ken Kress, An Argument for Assisted Outpatient Treatment for Persons with Serious Mental Illness Illustrated with Reference to a Proposed Statute for Iowa, 85 IOWA L. REV. 1269 (2000). 3. ALA. CODE § 22-52-10.2 (Westlaw through 2014 Sess.); ALASKA STAT. ANN. § 47.30.795 (West, Westlaw through 2014 Sess.); ARIZ. REV. STAT. ANN. § 36-540 (Westlaw through 2014 Sess.); ARK. CODE. ANN. § 20-47-214(b)(1) (West, Westlaw through 2014 Sess.); CAL. WELF. & INST. CODE §