Later On

A blog written for those whose interests more or less match mine.

Views of mental illness, conservative vs. liberal

with 4 comments

Interesting note by Peter Kramer in the Psychology Today blogs:

Last Thursday, the Supreme Court ruled that a mentally ill person may be competent to stand trial and yet not competent enough to represent him- or herself without the assistance of an attorney.

The decision rests on trial judges’ ability to distinguish fine differences in levels of competence. In the past (Godinez v. Moran, 1993), the Court had rejected the notion that to agree to a plea bargain requires more competence than to participate in a trial, where a lawyer can guide the proceedings. But here, in a majority opinion written by Justice Stephen G. Breyer, the Court ruled that collaborating with one’s lawyer is less demanding than acting on one’s own and that trial judges can determine when a defendant has one competence and not the other.

In dissent, Justice Antonin Scalia seems to attempt personally to gauge the competence of the criminal defendant, Ahmed Edwards, noting that although some of his written communications were unintelligible, others were coherent, as was his verbal presentation in court.

Both Justice Breyer and Justice Scalia consider issues of “autonomy” and “dignity” to be in play; both agree that self-representation is more likely to lead to an unfavorable outcome for a defendant than representation by an attorney.

The earlier (Godinez) case echoes a debate within health care. Some ethicists argue that consenting to care that doctors deem necessary requires a lower level of competence than refusing that care and risking a danger that is evident to qualified experts. Other ethicists argue that such a distinction puts too much power in the hands of authorities and institutions — favoring the choices doctors recommend.

When a demented patient signals, yes, he agrees to an intervention that may restore his thinking, we may believe that he should get that treatment even if we know he has limited reasoning power and is merely placing himself in his doctors’ hands. We might be more concerned over the same patient’s half-coherent refusal of the same intervention, on the grounds that assessing an alternative course of action, one that professionals consider riskier, requires additional capacity. All the same, it is easy to see what makes theorists uncomfortable about the argument that the same man is competent in one instance and not the other.

Justice Breyer argues that we can hold on to Godinez and still recognize differing levels of competence in the current case, Indiana v. Edwards. But the result does seem to imply a shift in viewpoint. The split decision suggests that the Court’s liberal and moderate members now believe that thoughtful experts (here, judges) can make difficult distinctions in the service of a humane outcome; the conservatives put more weight on a libertarian ideal of individual rights even in the face of impairment and likely self-harm.

Is there a further implication that the liberals more fully embrace the concept of mental illness, as substantially injuring judgment and diminishing self, while conservatives have their doubts? I hear hints of this latter viewpoint in Justice Scalia’s emphasis on coherence of expression. Many psychotic patients speak intelligibly, even when their argument is guided by a fixed delusion. Whether a given person is competent to make decisions that are likely to go against his or her own interests would seem a matter calling for a more complex standard, one that takes into account the differing mental functions that psychosis can impair.

Written by LeisureGuy

26 June 2008 at 10:04 am

4 Responses

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  1. I’ve worked with people with mental health challenges for several years. It is certainly my impression the competence is a selective and dynamic gauge. One can be competent in one area at given time and at the same time not be competent in another domain. Moreover, making bad decisions has nothing to do with it. Many people with no mental health challenges whatsoever make all kinds of mad decisions. We all have a right to make poor choices and, hopefully, learn from our errors.

    William Woolrich

    27 June 2008 at 6:13 am

  2. I’m not sure about the right to make poor choices—it’s certainly not a constitutional right. And, notoriously, one doesn’t have the right to make the poor choice of shouting “Fire!” in a crowded theater—or, perhaps more clearly, the right to murder some annoying person, however poor that choice may be. I think the “right to make poor choices” is, like many other asserted rights, not a right at all. It happens, of course, but it’s not a right.


    27 June 2008 at 7:54 am

  3. Hmm…I don’t think the examples you’ve provided are constitutional ones. I personally think bearing arms is a poor choice but it is a constitutional right. Having said that the examples you provide are certainly illegal; however I can provide just as many examples that are perfectly legal. People can legally smoke, eat fatty sugary food, and have unprotected sex with a stranger and nobody can lock them up for any legal violation. But the point is that people who have been labeled with a mental illness DO get locked up for violations of this sort because people attribute the cause of the poor choice to the “illness” as opposed to chalking it up to the human tendency to do things that please us in the moment despite the long term consequences.

    Going back to your original post, the Justices DO seem to appreciate this distinction because their decision was based on her competency not based on her choice to represent herself (however foolish that may be).

    William Woolrich

    27 June 2008 at 5:30 pm

  4. Ah, I see. Yes, some poor choices are a right. Other poor choices are not. I was misled by your comment “We all have a right to make poor choices.” It depends on the particular poor choice, I would say. Certainly one may overeat or drink too much or smoke or whatever, and then repent at leisure. And, indeed, we do have the right to pursue happiness, which pursuit often brings lessons in its wake.


    27 June 2008 at 6:46 pm

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