The Right to Refuse Treatment in Involuntary Psychiatric Care

Abstract

Involuntary commitment and the right to refuse treatment rest on two different legal tests -- dangerousness
and decision-making capacity -- that do not always align, leaving a persistent gap in how forced medication
is actually governed.
This review traces the U.S. case law behind the current framework, from O'Connor v. Donaldson through
Rogers v. Okin's independent-review requirement to Washington v. Harper's more permissive standard, and
examines why psychiatric symptoms complicate capacity assessment more than physical illness typically
does.
It then turns to the sharpest challenge to this framework: the UN Convention on the Rights of Persons with
Disabilities, which treats capacity-based substituted decision-making as discriminatory and calls for
supported decision-making instead, a standard most domestic law has not yet adopted.
We also assess psychiatric advance directives and Ulysses contracts as a third path letting patients bind
their future, less capable selves in advance, finding that uptake remains low and enforcement frameworks
remain underdeveloped.
We conclude that no single framework resolves this tension, and that closing the gap with the CRPD's
critique depends more on rigorous capacity assessment and independent review than on any single
doctrinal fix.