Journal of Medical Law and Ethics (JMLE)

Too Sick for Freedom, Too Healthy for Treatment. Untreated Patients in Forensic Psychiatry: A Literature Review

James Karagianis, Benoit H. Mulsant, Ian Dawe, Rajiv Bhatla, Richard O’Reilly


Laws on the ability to treat incapable forensic psychiatry patients vary among jurisdictions. In Ontario, Canada, findings of treatment incapacity can be appealed, delaying treatment for months to years. The ethical implications of the right to refuse medical treatment versus the society’s obligation to ensure a patient receives treatment when detained by the State because of a treatable illness is a matter of considerable debate. Courts can order medical treatment to make a mentally ill accused person fit to stand trial, yet in many jurisdictions there are legal obstacles to the continuation of treatment after the court hearing. In forensic hospitals, assaults by involuntarily detained patients occur for a variety of reasons. We conducted a literature review to better understand the risks of treatment delays (due to refusal and legal proceedings) to hospitalized psychiatric patients and staff.



A literature search was undertaken using the following search terms: ‘forensic’, ‘seclusion’, ‘restraint’, ‘violen*’, ‘aggress*’, ‘assault*’, ‘inpatient’, ‘refus*’, ‘noncompliance’, ‘nonadherence’, ‘predict*’, ‘anosognosia’. Outcome data were extracted from relevant publications.



46 publications were initially identified, with 17 additional relevant publications identified through citations from these 46 papers. 20 studies and case series were reviewed. Legal treatment delays for forensic inpatients lasting several weeks were associated with an increased frequency and duration of seclusion, use of physical restraints, longer admissions, and more frequent rehospitalizations. Untreated patients had higher rates of making threats and perpetrating physical assaults and increased rates of being transferred to higher security hospitals.



Evidence suggests that treatment refusal among forensic psychiatric patients is associated with poor outcomes including an increase in aggression directed towards others including staff and other patients, longer hospital stays, and an increase in restrictive safety interventions such as seclusion and restraint. Anosognosia may contribute to treatment refusal and failure to recognize anosognosia as a symptom of schizophrenia may misguide laws that restrict treatment. Appeals of treatment incapacity very rarely result in reversal of the finding. These findings may have implications for stakeholders in Ontario and other places where involuntary treatment can be refused; legislators and advocates concerned with patient rights should consider them when promoting the right to refuse treatment. 



Publication bias might result in overemphasis of negative consequences of treatment refusal.

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