Editor’s note: This commentary is by Wilda L. White, who is the current chair of the Vermont Mental Health Crisis Response Commission and a former executive director of Vermont Psychiatric Survivors, a civil rights advocacy organization on behalf of people discriminated against because of mental illness. Before joining VPS, she was executive director of the Thelton E. Henderson Center for Social Justice at the University of California Berkeley School of Law.
Ron Powers’ commentary harkens back to that period in this nation’s history when white men denied African slaves personhood and treated them as property, a status the United States Supreme Court codified in its infamous Dred Scott decision. Powers would have the Vermont Supreme Court do the same but the target of his suggested oppression would be those diagnosed with mental illnesses.
Powers takes particular aim at people like me, that is, those who have experienced psychosis and have been diagnosed with so-called severe mental illness, which he calls a “uniquely accursed affliction.” According to Powers, a person experiencing psychosis is not a person or citizen but merely a disease and should therefore be denied the same right as other persons or citizens to retain control over health care decisions through the use of advance directives.
What apparently set Powers off is the Vermont Supreme Court’s recent decision, In re G.G. (2019 VT 83), in which the court upheld the validity of an advance directive properly executed by a 34-year-old man with a history of violence and a diagnosis of schizophrenia who declined to be involuntarily medicated during periods of incapacity.
An advance directive is a written document that lays out a person’s medical care preferences should a time come when the person becomes incapacitated and unable to make decisions.
By law, a properly executed advance directive can be disregarded only upon clear and convincing evidence that the individual lacked capacity at the time the advance directive was signed. Capacity is defined as a basic understanding of the diagnosed condition and the benefits, risks, and alternatives to the proposed health care.
In his commentary, Powers misrepresented that G.G. “wrote and signed his advance directive in 2017, a period in which he was in the care of the Brattleboro Retreat for a sixth time and was being administered the antipsychotic [Prolixin].” In fact, what is true is that G.G. wrote his advance directive while he was living in the community in his own apartment and held a job. G.G’s advance directive was witnessed by two individuals, one of whom was a psychiatric nurse, who affirmed that G.G. understood that he had been diagnosed with schizophrenia but disagreed with the diagnosis.
Before the case reached the Vermont Supreme Court, there was a trial court hearing during which G.G. testified that he did research and consulted with various persons before executing the advance directive. He stated that he was bothered by the side effects of antipsychotic medication and that he executed the advance directive to prevent such medications from being administered against his will when there was a claim that he was incompetent to make that decision. In his advance directive, G.G. prioritized the interventions he preferred in the following order: separation by distance; seclusion; physical restraints; seclusion and physical restraints; medication in pill, liquid, and injected form. G.G. also acknowledged and accepted that the preferences he expressed in his advance directive could result in his involuntary hospitalization.
Based on this evidence of G.G.’s capacity, the Vermont Supreme Court ruled that the trial court’s determination that G.G. lacked capacity to execute the advance directive was not supported by clear and convincing evidence. In effect, the Vermont Supreme Court upheld the validity of the advance directive.
Powers takes issue with the outcome because in his opinion G.G. is not fully a person because of his schizophrenia diagnosis and anosognosia, which he defines as “lack of insight” and describes as “a frequent traveling companion of schizophrenia.”
Anosognosia is a conjectural medical condition first coined by a Hungarian neurologist in 1914 to describe stroke victims who were unaware of their deficits, presumably because of pathophysiologic changes in the brain. However, there is no objective test of the condition and no anatomical finding that predicts a lack of insight. Psychiatry later borrowed the term to apply to people diagnosed with mental illness who refuse treatment based on the assumption that lack of awareness of one’s illness is the only reason a person would refuse psychotropics. Based on my own experience, I know this to be false.
During the time I experienced psychosis, I was well aware of my mental state and nonetheless refused antipsychotic medication because of the risks. I had witnessed the toll of such medication on my brother who has a diagnosis of schizophrenia and now suffers from diabetes, tardive dyskinesia, and end stage kidney disease.
Despite experiencing psychosis for more than a year and refusing anti-psychotic medication, I have never been hospitalized for psychosis and I have never physically harmed myself or others while experiencing psychosis. While I would have preferred not to have experienced psychosis, I have never felt “uniquely accursed.” Rather, I take my condition as the cards I was dealt and I am determined to play the best hand with them as I am able. I am proud of who I am and have been humbled and transformed by the experience of psychosis.
Powers, who lost a son to suicide, seems to believe that everyone diagnosed with schizophrenia is like his son. What is more the case is that about all those diagnosed with severe mental illness have in common is the discrimination and oppression to which we are subjected.
Powers wants this discrimination and oppression made into law, calling it a question of common sense. Common sense is the last refuge of those without a just basis for their position. Common sense is where our fears and implicit biases reside.
Fortunately, our state Supreme Court chose not to strip a whole class of people of their citizenship and personhood and return us to the days of Dred Scott. Rather, our state Supreme Court correctly applied the law and in doing so did the hard work of justice.