Ethical ambiguity: When to certify a psychiatric patient

The greatest difficulty I've had during my psychiatry sub-internship is deciding when to take away someone's personal freedom by placing them on a mental health hold (MHH) or a short-term certification (STC). My attending told me at the beginning of the rotation, "I want you to make decisions about your patients. We'll do what you want, so long as you can explain why you're doing it and you have your head screwed on straight."

This responsibility hit home a few weeks ago when I knocked on my attending's office door to talk with him about a patient. I was uncertain about whether to place this patient on a STC. My attending sat back in his chair and listened while I explored both sides of the argument.

On the one hand...

This is a middle-aged guy with an unclear history of psychosis who's experiencing paranoid delusions to the extent that he has isolated himself from the entire world, including his family. He has a history of attempting suicide, and there is evidence of increasingly bizarre and disorganized thoughts. According to the police who originally placed him on a MHH, the patient's apartment was a disaster. Charcoal briquettes were placed around the periphery of each room, bed and couch and lamps were turned upside down, curtains were turned inside out, and two pennies were placed in strange places like in the refrigerator and in the shower. This is a man who could certainly benefit from continued hospitalization and treatment.

On the other hand...

The patient does not want to stay in the hospital, does not want treatment, and does not believe he has a mental illness. He shows no depressive symptoms and denies wanting to hurt himself or other people. He sure has some bizarre and paranoid thoughts, and doesn't have a job, but he pulls in a Social Security disability check each month and is able to clothe and feed himself. He may or may not meet legal criteria for being "gravely disabled," which would justify holding him on a STC.

When I finished, my attending leaned forward, looked at me intently, and asked, "So, what are you going to do?" I understood what he was doing: pushing me to make a tough decision and stick by it. This is part of my education, the process of becoming a doctor.

"I don't know, that's why I came to you for advice."

"Do you think this patient is mentally ill and needs treatment?"

"Yes."

"Do you believe that he is a danger to himself or others?"

"No."

"Do you believe that he is gravely disabled?"

"Possibly."

My attending then advised me to remember that my primary responsibility is to my patients. As long as I believe that I am following the law, I should do what I think is necessary to take proper care of my patients and let the judge decide if our actions should be upheld.

"So, what are you going to do?" my attending asked again, this time with an amused smirk.

"I'm going to cert him."

Although he never explicitly said so, it was clear to me that my attending thought that we should keep this patient on a STC.  I made the decision, though, based on my gut feeling that my patient was indeed gravely disabled and would benefit from treatment.

The patient stayed for another week with nominal improvement of his paranoia and disorganization. He agreed to keep taking medications after he left the hospital. That was something.

Everything about this patient's case was ambiguous to me. Did I really help him by keeping him in the hospital against his will? Was I justified in holding him on a STC? Was he really gravely disabled? Sometimes there are no clear answers, and I just have to make a decision that seems best at the time. I feel better knowing that I would make the same decision again if I had to do it over.