A profound but controversial effect

Kanuri Qawi’s unlikely 2004 court victory has had a lasting impact on California mental hospitals, adding to what one doctor calls a “culture of refusal,” as more patients reject their medication.

In the aftermath of Qawi’s lawsuit, hospital officials are now required to hold what are known as Qawi hearings and must demonstrate clearly that a patient paroled to the hospital is dangerous before they can force medication.

As a result, hospital officials say, patient assaults on staff and other patients have risen significantly.

Today, some hospital staffers say they feel as if they must gird themselves for battle at the beginning of their shifts. Doctors also say patients have suffered lasting, and avoidable, damage from psychotic breaks that might have been avoided with medication.

Officials at understaffed hospitals have been forced to hold hundreds of hearings -- more than 700 at Atascadero State Hospital near San Luis Obispo since 2004 -- as they try to prove that they need to force medication in the wake of Qawi’s case.

“We are always aware of his legacy,” said Dr. David Fennell, the outgoing Atascadero medical director.

The psychiatric community remains divided over forced use of the drugs -- and over how much of a role patients should have in determining the course of their own treatment.

Some, like Dr. E. Fuller Torrey, a well-known research psychiatrist, believe the “pendulum has swung too far.” What began as a well-intentioned campaign, they say, has saddled mental health providers with impractical restrictions -- particularly given studies suggesting that half of schizophrenics may lack awareness of their illness.

“They won’t take medicine because there is nothing wrong with them,” Torrey said.

But Grant Morris, a University of San Diego law professor, believes the onus should be on hospitals to determine whether a patient is competent to help shape his or her treatment.

“Is he refusing because he has ... suffered side effects?” he asked. “That is a rational judgment. We might disagree with it. But to say, ‘You’re mentally ill, I’m a doctor, I know more than you and I think this medication is going to improve your condition’ ... is an inadequate basis for forcing medication.”

Inside California’s mental hospitals, giving patients the right to challenge their medication may be a necessary “safeguard,” Fennell said. “But it is a compromise,” he said. “And like all compromises, not everyone is going to be thrilled with it. A lot of times, a family will say: ‘Please treat our son. He’s ill.’

“And I say: ‘I’m sorry. I can’t.’ I know it’s the best thing for him medically. But as a society we have decided you have the constitutional right to be very psychotic and medically ill -- and miserable.”