The Right to Treatment and the Right to Refuse Treatment

Lloyd I. Sederer, M.D.
Adjunct Professor, Columbia/Mailman School of Public Health
Medical Editor for Mental Health, Huffington Post/AOL

All patients have both a right to treatment and a right to refuse treatment. These rights sometimes become the centerpiece of debate and dispute for people who are hospitalized with an acute psychiatric illness.

The Right to Treatmentsederer

There is a long legal history on the right to treatment. Much of the law derives from court cases in the previous century involving people who were admitted to state psychiatric hospitals where they languished without proper treatment, sometimes for many years. Laws compelling a right-to-treatment law developed and became instrumental to the quality-controlled public psychiatric hospitals that exist today. In fact, in order for public psychiatric hospitals to receive Medicare and Medicaid (and other third-party) payment, they must obtain the same national certification as academic medical centers and local community hospitals. For patients and families, this means that a person admitted to a public psychiatric hospital has a right to receive—and should receive—the standard of care delivered in any accredited psychiatric setting.

The Right to Refuse Treatment

It may seem odd that a person can be involuntarily admitted, or “committed,” to a hospital and then refuse treatment. But the right to refuse treatment is also fundamental to the legal requirements for psychiatric treatment.

Someone who enters a hospital voluntarily and shows no imminent risk of danger to self or others may express the right to refuse treatment by stating he or she wants to leave the hospital. But a person admitted involuntarily, due to danger to self or others, cannot leave, at least not right away. However, despite having the authority to keep the patient in the hospital, the professional staff cannot treat the person against his or her will, except by court order.

The concept of a right to refuse treatment was built on basic rights to privacy, equal protection under the law, and due process. In other words, involuntarily hospitalized patients still have a right to decide what happens to their bodies.

Unfortunately, the right to refuse treatment can, and does, result in some patients being locked up in a hospital where doctors then cannot proceed with treatment. What’s worse, and deeply ironic, is that insurance companies may refuse to pay, stating there is “no active treatment.” This state of financial affairs, by and large, does not happen in state psychiatric hospitals, which represent the true safety net of services for people with serious and persistent mental illnesses, because these hospitals are not wholly dependent on insurance payment and cannot refuse to treat someone who cannot pay.

Exceptions to the Rule

There are exceptions to a patient’s right to refuse treatment. In an emergency, all bets are off. A doctor may provide involuntary treatment, usually a medication given by injection or by mouth, but only to control the emergency—which, again, is defined as “an imminent danger to self or others.” Whatever treatment is provided in an emergency cannot be continued after the immediate danger has passed, unless the patient agrees and gives informed consent. Clinicians cannot continue the medication, even if it could prevent another emergency situation; the patient has the right to decide whether to continue or not.

For involuntary treatment (treatment without consent) to be delivered outside of an acute emergency, the doctor and hospital must petition a court to order it. Laws vary from state to state and, of course, no two judges are alike.

Generally, judges rule in favor of well-prepared doctors and hospitals that show that

  1. the treatment is necessary for safety and recovery;
  2. all efforts at voluntary treatment were exhausted;
  3. family and others were engaged to help persuade the patient to accept care (and were not successful); and
  4. the benefits of treatment are likely to outweigh its risks.

Inpatient stays often last several weeks (or months) longer if court-ordered treatment is required. Notably, as clinicians have seen, once a court order is obtained, almost all patients comply with treatment within a day or so, and then, hopefully, proceed to respond to treatment.


We need better solutions than coercion—whether it is involuntary commitment by doctors (or courts) or involuntary treatment (ordered by courts). As I wrote in the Wall Street Journal earlier this year, “[g]ood intentions spawned [laws that protect patient privacy], but in practice they can interfere with or delay the delivery of necessary care and crucial communication between caregivers and families [. . .] [L]aws are made to serve the people. Let’s ask the families of people with serious mental illnesses what changes in law and clinical practices could better help their family members.”

What changes, if any, do you think will facilitate effective emergency care for people with mental health conditions that impair their decision-making abilities? 

What do you think is the appropriate role of families and physicians in treatment decisions?

Have you or a loved one created an advance directive, a plan that designates someone to make decisions in emergency situations when decision-making is impaired? How can we encourage people with mood disorders and their mental health providers to make advance planning a part of the treatment and recovery process? 

Facebook Comments

Husband of 30 years
Husband of 30 years

My wife and I have been married for almost 30 years.  (We were married 10 days before I went into the military).  Just prior to our getting married, I found out that a family member had abused her and she was NEVER offered treatment. Worse yet, it likely happened to other family members and they eventually sent my wife away like SHE had did something wrong.  Other the next few years, whenever we would have a conflict, I saw how angry she really was. I have often tried to get her into a treatment program.  A few years ago, I also noticed, as she approached her mid-40's, every "month" became worse.  We soon found out that she has a tumor inside of her uterus. From her other symptoms, she also is in the middle of either peri-menopause or beginning full blown menopause.  Last Saturday we had the most romantic day and evening that we have had in months. (We renewed our wedding vows in April and we were both so happy).  After a early night of passion, she went to take her sleeping pills she has been on for 3-5 years, and for some reason, she took more that she should have.  After watching her for about 20 minutes, I tried to get her to vomit up and then I noticed her pupils were not reacting with the light.  I was really afraid that her breathing may stop, so I had no choice but to call 911.  When we got to the hospital, the gave her a shot of Narcan, and she immediately became VERY agitated  They had already cathed her but she was yellow that she had to use the bathroom.  She knew I was there and she was asking me to get them off of her.  I just tried to reassure her.  Eventually, they took her up to ICU as they do not have a psych ward.  I did not see her for the first day, but sat up waited for 36 hours in the waiting room.  When she finally was alert enough she called for me. She told me that "They said she tried to kill herself" although she swears she does not remember it.  Secondly, they had her sign papers that were going to send her over 100 miles away.  Now we both have Sweeping Medical Power Of Attorneys. As I stated, I have known her for over 30 years and she has NEVER, E-V-E-R attempted to hurt herself or me, or our children in any way, shape, or form.  During the 3rd day at our local hospital, she told me that she had asked for a shower, or a sponge bath, and the day shift would not respond to her.  I did not try to talk to them because they all stayed behind the nurses station on the computer and did not seem to want to be bothered.  My wife then told me that the day before, a case worker from MHMR asked if she was ready to go home with me, or did she want to go to her mom's.  At this point, she was still completely out of from the medications, so I do not think ANY form she would have signed would be legal or any decision she made would be legal either.  When I found out that she had not been allowed to wash her face or sponge bath, I went to speak to the Administrator's Office.  The Assistant Administrator when in to see what was going on.  During this time our 14 year old daughter was with my wife visiting.  The next thing I knew, an off duty sheriff's officer told me that I had to leave the hospital!  I asked him why, and he stated that "I was making the nursing staff nervous!"  I tried explaining to him that I had not even spoken with one of the nurses or aids and was just trying to ensure my wife was being taking care of.  The next thing I know, my wife calls me and says they are taking her to a town 70 miles away by police car to a different facility!

I had worked for this hospital system and knew Executive Officers.  I beat them down there and the were COMPLETELY different.  My problem now is that people that were involuntary admitted after her have already been released.  The doctor she sees once a day at 7:00 a.m. for 4 minutes is concerned about her blood pressure being too high.  I asked her if she had mentioned that the generic version does this to her (as it did it to my Dad), and ALL she wants is to come home.  I have removed ALL prescription medication from our home, and also asked if she had told the doctor about her monthly cycle problems and her peri-menopause, however, I believe he is scared ANYTHNG she says will add days to her being there.  We have already decided to keep going to outpatient treatment, and to deal with the issues from her childhood.  She home schools our 14 year old and We need her at home.  I love her with ALL my heart and if I thought she was dangerous to herself or others, I would be the first to admit her back.  I just cannot see other people that were worse that he already have been discharged home and I cannot get my oving wife who has went to EVERY activity and EVERY session and participated fully.  Can someone PLEASE HELP ME????! 

no one
no one

I could not walk for a month, random shaking like epilepsy but was not that, weakness, dizziness, was sent for an mri for tumor in spine, refused to go, i have no insurance, been told i can not be a burden on the goverment in any way, will not get the that'll do service and left in a Coronado so waiting to see what happens next, the usa systme for insurance is a joke, since when has lives been worth money, if i die, hat ever, dont care any more, usa is nothing but dictators bullying people for money and they DO NOT care about life, as for me, hope what ever happens, happens soon, lost the will


if money is paid to take care of a patient and the patient died without being treated will your money be given back?

entry mats
entry mats

Where is the state intervention?
If a shopping-center arrests you for shoplifting, and lock you in their security-room, the police will just come out and free you, if there's no probable cause.

logo mats
logo mats

To consent to or refuse treatment, you must have the capacity to make that decision. Capacity means the ability to use and understand information to make a decision.

Under the terms of the Mental Capacity Act 2005, all adults are presumed to have sufficient capacity to decide on their own medical treatment, unless there is significant evidence to suggest otherwise.

Rosemarie Boyd
Rosemarie Boyd

I was involuntarily committed to a psych ward because I ticked off a policeman.He told me I was going to learn not to give him a rough time. The blood drawn in the ER proved I had no illegal drugs in my system or overdose of any kind. So he then told them he saw a gun in my lap. Poof, I was committed. I do have PTSD from spousal abuse etc. I am fearful of men. I did emotionally blackout during some of the policemans roughing me up. The psych ward was scarey. They not only had psych patients but also a rapist who was thrown out of his nursing home and couldn't find any where to live. He would actually get interviews on the ward with other homes. Since the suicide theory was shot down they tried to prove I was paranoid as I had told them about my ex stalking me. They called the daughter I had lived with and she confirmed every story I had told them. Then they tried to prove I was delusional as I had told them I was a national recognized psychic. Once again my daughter was called to confirm. I found that ridiculous as all they had to do was search the Internet and they would have pulled up the tv and radio shows I have done and the book I was written about in. At the hearing I had after 3 days they decided to keep me up to another 5 days. This was because I was told not to say any thing but my name. But when they started to list what the police said about me etc I stood up for myself. Even when it was my time to speak. The "judge" kept saying "you're not helping yourself". This was held in the staff lunchroom of the psych ward. I was released early as having a psycosis. I think the fact that I finally told the nurses that if the rapist made one more pass at me I was going to start kicking "nuts" might be what did it.

Because of this incident I have been treated as a mental patient since. I was then diagnosed with malabsorbtion syndrome which includes pernicious anemia and vitamin B12 deficiency. They called my daughter to try and get me back into the psych ward stating that since I was married 3 times I must have a mental problem.

I've now been diagnosed with osteoporosis, stenosis, arthritis in the spine, pinched nerves, 1 disk is herniating, one disk has slipped and is overlapping another, 2 synovial cysts in my spine, arthritis and joint degeneration in both my knees. I have been refused any painkillers because of "mental conditions" and arthritis meds because of my blood problems. My hematologist upon my discharge wrote I was to be continued on hydrocodone. They refuse. But she was the one who wanted me off the arthritis medicine which they did comply with.

My point is that you do not really need to be mentally ill. You just need to be different. My level of pain has become unbearable. You see before I moved here I had been in the care of a pain management clinic for 6 years. I had provided all records for the last 3 years along with drug screens and pharmaceutical records. I have decided to stop all medical supplementation that keeps me alive by helping me to produce blood. I do not want to die, make no mistake. But I can not live with this pain. I can not take care of myself or my home.

I am a 62 year old woman. I bet you never guessed that.


When your chart carries a mental health diagnosis, good luck getting a second opinion or having physical complaints addressed first. A patient shouldn't have to undergo an involuntary commitment of arbitrary length for mistaking anxiety for heart and/or circulatory trouble and seeking medical help. Getting an ulcer diagnosed shouldn't depend on the time of day a patient seeks treatment or the luck of the draw in emergency room physicians. Psych evaluations should also be done by professionals with the presence of mind to comb their hair when on call, if not actual physicians.

If psychiatrists are no longer willing or "able" to spend more than 15 minutes per session with a patient, then they should be required to work in conjunction with the patient's psychologist, or at least be checked by another psychiatrist, especially in inpatient settings. The responsibility for establishing trust shouldn't be solely the patient's burden, nor should psychiatrists hide behind the fine print on pharmacy printouts.

Psychiatric facilities, however, do have astonishing speed in treating meth addictions and suicide attempts in patients with little or no insurance; their ability to induce depression with low staffing that restricts recreational activities and specialized visitation for patients with adequate insurance is also excellent. When seconds count, psychiatric hospital staff are just minutes away . . .


the issue is completely controversial even today. that story about the 17 year old taken into custody and given chemotherapy for Hodgkin Lymphoma  against her will? it is wrong and a complete violation. so basically they said she had a good chance of survival, 8/10. still a 20% chance she would die. So she wanted alternatives, why in the world would they do that? it was her body and her rights! chemo can cause more cancer! Anyone care to explain? to argue? Please tell me what is real.


I requested a med to be DC'd in assisted living and they gave it anyway. They said I did not ask for them to hold it. Since I asked for it to be DC'd they gave it until they got the order. As a POA and family member I think they should not of given the medication. Saying I wanted it DC''d would also mean I wanted it held until they got the order.


I looked into an advance directive but learned they are pretty worthless when it comes to psychiatric treatment.  First, in my state they can be overridden in an emergency.  That renders then worthless.  Second, they are only in effect for an involuntary hospitalization.  So, all these so called "voluntary" hospitalizations where patients were threatened into signing consent, well the advance directive doesn't kick in here, even though many of these are really involuntary hospitalizations as well.  Third, in my state they are only good for one year.  Who is going to fill a new one out every single year?  That's not even logical.  Fourth, you cannot opt out of hospitalization.

What we need are enforceable advance directives that enforce what psychiatric patients want and/or do not want in an emergency.  Currently, they don't do that.

Larry Drain
Larry Drain

My view is expressed in the following quote from john grohol: “As a society, we’ve shown time and time again that we cannot devise a system that won’t be abused or used in ways that it was never intended. Judges simply don’t work as check for forced treatment, because they don’t have any reasonable basis on which to actually rest their judgment in the short time they’re given to make a determination.

The power to force treatment — whether through the old-style commitment laws or the new-style “assisted outpatient treatment” laws — cannot be trusted to others to wield compassionately or as an option of last resort.

What should be good enough for the rest of medicine should be good enough for mental health concerns. If an oncologist can’t force a cancer patient to undergo life-saving chemotherapy, there’s little that can justify our use of this type of power in psychiatry and mental health.”

larry drain


This is such a complicated issue. If a person isn't in their right mind it would seem that he wouldn't be able to make a rational decision even after the imminent danger to himself and others has passed. I am not a doctor but I would think someone admitted against their will would go through a process of coming to terms with hospitalization. It would almost than make sense to determine a time period for treatment to continue to not only remove any imminent danger but to stabilize the patient. This stabilization period would have to be monitored by not only a doctor but an intermediary such as a peer support specialist. It also seems that even if a patient refuses treatment there should be manditory counseling required. Another matter that can confuse this issue is that patients who most need care are those who cannot think rationally. About ten years ago my mother was hospitalized. Her health was severely compromised by the long term effects of uncared for diabetes. She stopped eating after having a heart attack and losing kidney function. There is a strong history of mental illness in her family but she had never been treated. At that time, a psychiatrist was called in to talk to her. She said she didn't want to talk to him and he left. He was paid by the insurance company for a visit lasting three minutes. My mother passed about eight months after that at the age of 62. There has to be some parameters created to get treatment to those who cannot make decisions rationally and there has to be some persistence on the doctors side to provide treatment.


  1. […] not everyone’s convinced that the ability to track pills will be good news for patients. The right to refuse treatment is an important, fragile principle in health care. Many are worried that tracking whether a pill is […]

  2. […] not everyone’s convinced that the ability to track pills will be good news for patients. The right to refuse treatment is an important, fragile principle in health care. Many are worried that tracking whether a pill […]

  3. […] An involuntary commitment, also known as a civil commitment, is a legal process by which a person is deemed to have a mental illness and is court ordered into recommended treatment. Historically, the mentally ill were “institutionalized” with little consideration for their civil rights. But these days, progress in the psychiatric field, especially since the 1960s, has improved psychiatric practices and given patients more autonomy. In this regard, respecting an essential civil rights protection in healthcare allows individuals who believe they are not mentally ill to legally refuse treatment. […]