Nathaniel P. Morris & Robert A. Kleinman
The American Journal of Psychiatry
Vol 177, 12, 1115-1116.
Surprise medical billing, in which patients face unexpected out-of-pocket medical costs, has attracted widespread attention. As of March 2020, members of the U.S. House of Representatives and Senate were working on legislation to limit these billing practices. Surprise medical bills have various consequences for patients and families, including loss of income or savings, worsened credit scores, use of resources for legal counsel or litigation, and psychological stress. Patients can receive surprise medical bills for care they did not authorize, including treatment for loss of consciousness, cardiac arrest, traumatic injuries, and other emergencies where informed consent cannot be obtained before care. A related set of medical bills has not garnered much attention yet may rank among the most surprising for patients and families—bills for involuntary psychiatric care.
Billing patients for involuntary psychiatric care deserves more attention for several reasons. First, these patients may be held financially liable for care they did not authorize and even actively refused. Compared with most medical care, involuntary psychiatric care is different in that patients can be detained for evaluation and treatment against their expressed wishes. All U.S. states have statutes that authorize emergency and inpatient civil commitment, such as involuntary hospitalization on grounds of dangerousness to self or others due to a mental disorder, and a majority of states have provisions for outpatient civil commitment. These statutes are based on principles that under specific circumstances, individual and/or public benefits of managing someone’s mental health needs supersede that person’s rights to refuse psychiatric care. However, forcing someone to assume financial liability for involuntary psychiatric care may infringe upon additional liberties, including individuals’ abilities to consent to contracts and to allocate money. By shifting the balance of autonomy, justice, beneficence, and nonmaleficence associated with involuntary psychiatric care, these billing practices raise ethical concerns.