COMMITTING THE INSANE

To the Editors of the CRIMSON:

I read your series of articles on the commitment procedures in the State of Massachusetts with great interest. I feel, however, that certain statements in the article are misleading and should be clarified.

As a resident in psychiatry who has had to use the civil commitment procedure fairly often, I would like to make it clear that most psychiatrists, myself included, would gladly give the responsibility for civil commitment to a judge and jury if this could be reasonably done. If someone could actually design a practical way to do this he would relieve us of a responsibility that we don't much like. The manpower and funds to carry out the procedures suggested as ideal are just not presently available.

It should also be pointed out that in the Commonwealth of Massachusetts, in practice, it takes two physicians to commit a person to a mental hospital for a ten day period of observation--one to fill out the Section 79 (Request for Observation) paper and the other to accept it. A physician may not request observation of a person at a hospital where he is employed and this provides a double check for the person committed for observation. While in practice most Section 79 papers are accepted by the admitting physician this is by no means always true.

The Section 79 paper expires after ten days. The patient's stay may then be extended for further observation on a Section 77 paper if the superintendent of the institution requests more time. This extension is limited to forty days and provides still further check. Finally, if after forty days the patient has not decided to stay voluntarily (and in my experience about nine out of ten patients do) the superintendent of the hospital may request a Section 51 commitment. This is all the doctor may do, as only a judge may commit somebody on a Section 51 paper. Any patient may be represented by counsel and have a detailed hearing, which is by no means always the rubber stamp which the article implies. The reason most patients are committed under this procedure is that in practice it is seldom used except in the most difficult of cases. It should also be pointed out that two independent psychiatrists actually make the report to the judge and not the psychiatrist who makes the request for the Section 51 proceedings. These psychiatrists are not permitted to have any affiliation with the institution in which the patient is hospitalized. At any time he is in the hospital a patient may call hs lawyer, day or night.

Finally, major mental illness is a painful and difficult problem for the patient and for the community. A person in the midst of a psychosis is not really (as the article and Dr. Szaz imply) free to choose whether or not to live or die for he is often impelled by totally unrealistic inner forces which are subject to reversal by both psychotherapy and chemotherapy. I don't feel a man should be permitted to kill himself because a voice which he hears in his head one week tells him this is his duty. I would not want for a friend the supposedly idealistic and well intentioned men who would give me the freedom to harm myself when I was not of sound mind. A law which would permit this must be considered equally uncaring and in essence sadistic.

Our present laws are not perfect and the new laws being proposed are by no means the ideal answer either. What is called for is a better dialogue between psychiatrists and legal scholars in order to create a realistic, workable, humane and clear set of laws which will truly protect the freedom of an individual (including freedom from the tyranny of actions taken while in the midst of psychosis). What is most important is that we do not forget the individual and his needs in efforts to create a theoretically perfect legal structure. E. Samuel Rofman, M.D.   Massachusetts Mental Health Center