Decision-making for involuntary commitment in Brazil: elucidating misunderstandings between reasons and justification

The decision of whether to commit a patient involuntarily is one of the most complex tasks in psychiatry, and arguably represents the pinnacle of responsibility in the profession. Nevertheless, despite the importance of the subject, there is a gap in the literature regarding how psychiatrists deal with the legal and ethical criteria for involuntary hospitalization in Brazil.1-3

According to Law 10216/01, supplemented by Ministry of Health Ordinance no. 2391/GM/2002, involuntary hospitalization is that which occurs “without consent of the individual and at the request of a third party.”1 This means that any patient who does not provide written consent for admission, regardless of reason, must have his or her potential hospitalization communicated to the judicial authority for evaluation.4

In practice, this is done by completing a communication of involuntary psychiatric commitment form, which must be sent within 72 hours to the judicial authority.2 The form includes two major criteria in the evaluation of the patient: the reason for involuntary commitment and the justification for such commitment.

Given the overlapping complexity of assessing risk (which will be the reason for commitment) and evaluating a patient’s decision-making capacity (which will be the justification for involuntary commitment), it is imperative that these concepts be clear and that any misunderstandings be resolved.

Accordingly, determining whether a patient’s condition constitutes sufficient risk to effectively deprive them of freedom must be done on a case-by-case basis, taking into consideration not only a formal diagnosis, but also social support and the emotional conditions of family members to provide home care, or, alternatively, to advocate for involuntary commitment. This information is essential in the psychiatric decision-making process, since patient improvement is highly dependent on the involvement of family members in treatment.

Beyond simply evaluating whether a patient presents a risk to oneself, the psychiatrist must determine if the patient has ability to choose and bear responsibility for his or her actions, which will serve as the basis for justification of involuntary commitment when such ability is absent.

When a patient is brought to the psychiatrist by family members due to potentially self-injurious behavior, the psychiatrist should evaluate if that behavior is in fact a symptom of a mental disorder. In the absence of a diagnosed mental disorder, or if a mental disorder is present but does not deprive the patient of choice, involuntary hospitalization is not justified, because the patient’s autonomy must be respected unless there is an imminent risk of death.1-5

In addition to being necessary for scientifically based decision-making and from an ethical-legal standpoint, clarifying these concepts will lead to more accurate completion of the involuntary hospitalization form mentioned above. Additionally, access to epidemiological data from this form will allow subsequent epidemiological analyses, free of ideological biases, which would permit consistent evaluation of the scenario of involuntary hospitalization in Brazil.

Disclosure

The authors report no conflicts of interest.