Hospitalization of the Dangerous Patient: Legal Pressures and Clinical Responses Paul S. Appelbaum, MD The mental health system is faced with a paradoxical situation relating to the prediction of dangerousness. Never has there been such widespread acknowledg- ment that mental health professionals lack the tools to make accurate appraisals of patients' future dangerousness. 1 Yet never has the mental health system been called on to predict dangerousness in so many contexts and for such a variety of purposes. 2 This article addresses one effect of the current focus on dangerousness in the mental health system: the increasing pressure to admit persons thought to be dangerous to others, but who traditionally would not have been considered appro- priate for inpatient psychiatric care. After reviewing the legal pressures that have led to this situation, several case examples illustrate problems that have resulted. An attempt is made to examine possible responses of the mental health system to the pressure to admit the dangerous patient and to analyze their likelihood of success. Legal Pressures for Admission of the Dangerous Patient Two trends - one in the law of civil commitment and one in the law of torts - have combined to create the current situation in which clinicians often feel compelled to admit dangerous patients who previously might have been refused hospitalization. Until the late 1960s, the dominant philosophy underlying involuntary hospi- talization of the mentally ill could have been described as "paternalistic benefi- cence." That is, state statutes generally provided for the commitment of those persons who were so ill as to require hospitalization, as a derivative of the state's obligation and desire to provide care for those who were believed to be unable to care adequately for themselves. 3 Although it was not uncommon for dangerous persons to be hospitalized under these statutes, they were not the dominant class of patients hospitalized, and at least theoretically, their dangerousness was signif- icant only as it was a manifestation of their need for care. Philosophical objections to a "paternalistic" commitment system began to develop strongly in the 1960s as psychiatry's expertise was called into question, the value of hospitalization was challenged, and most important, the mentally ill came to be seen as having rights that precluded beneficent state intervention, except in a small number of circumstances. These exceptions, it was argued, Dr. Appelbaum at the time this work was performed. was associate professor of psychiatry and law. University of Pittsburgh Schools of Medicine and Law; director. Law and Psychiatry Program. Western Psychiatric Insti- tute and Clinic. Correspondence: Dr. Appelbaum. Massachusetts Mental Health Center. 74 Fenwood Road. Boston. MA 02115. Bull Am Acad Psychiatry Law, Vol. 12, No.4, 1984 323