Answer to Question 1
Mentally ill patients in the United States are considered to have three important rights: the right to treatment, the right to treatment in the least restrictive alternative environment, and the right to refuse treatment. The right to treatment was codified in the Wyatt decision, which expanded the individual's right to treatment by trained staff, under humane conditions, with individualized treatment plans. Mentally ill patients cannot simply be warehoused; they must receive treatment. The right to treatment in the least restrictive alternative environment is an attempt to balance paternalistic and libertarian concerns. The state provides mandatory care, but restricts individual liberties as little as possible. Unfortunately, community care centers that are less restrictive than hospitals are not always available. The most recent right is the right to refuse treatment. Several courts and state legislatures have concluded that mental health patients have the right to refuse treatment under certain conditions, although this right is on increasingly shaky ground. If a patient is competent to give informed consent, treatment can be refused. If the patient is incompetent, an independent guardian offers a substituted judgment based on what the patient would choose if he or she was competent (but this is not necessarily what is in the patient's best interest). Courts have ruled that a patient can be medicated involuntarily to reduce dangerous behavior, so the third right is limited in these cases.
Answer to Question 2
Many more people are institutionalized because of findings of incompetence than because of insanity rulings. Competence is a defendant's ability to understand the legal proceedings that are taking place against him and to participate in his own defense. The U.S. Supreme Court defined competence this way: The test must be whether he the defendant has sufficient present ability to consult with his attorney with a reasonable degree of rational understanding and a rational as well as factual understanding of proceedings against him. Competence refers to the defendant's current mental state and the defendant's ability to understand criminal proceedings. The defendant must show legal understanding, legal reasoning, and legal appreciation.
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