Do You Write the Letter?

Your patient is a 32 year-old man with a diagnosis of schizophrenia. Six years ago, he heard commands from Christopher Columbus to “find the New World”. As a result, for six months he travelled to various cities in the country by Greyhound bus. In bus depots, he asked everyone he met to bring him to “Ferdinand and Isabella”. When he ran out of money, he walked along the shoulders of highways, praying loudly to God to save him. He slept little during his quest, as “the spirit is willing, but the flesh is weak”. Sometimes he heard the voice of God telling him to walk into traffic, “for [his] faith was so strong that [he] knew that God would stop the cars. In one of the cars a blessed saint would invite [him] in and guide [him] to the New World.” One day, he followed this command. The cars did not stop. No saints were driving that day. Several cars crashed and one hit him. Miraculously, he sustained only minor injuries.

He was sent to a psychiatric hospital for treatment. He eventually returned home to live with his parents, as he does now. They ensure that he attends his appointments, goes to the clubhouse, and takes his medications. He receives a supplemental security income check every month for his condition.

You’ve been working with him for about two years. He still reports hearing the voice of Christopher Columbus, but he has learned to ignore the calls to find the New World. Sometimes he wonders if cars would stop for him if he walked into the street, but he doesn’t actually try this. He occasionally expresses remorse that his faith wasn’t strong enough to prevent the car crashes that resulted in his hospitalization.

He cooks simple meals, reads books, tends to the plants at the clubhouse, and walks around the city. His parents report that he takes good care of their pet dog. He runs errands independently. He is punctual for his appointments with you and is invested in his health: He used to smoke a pack of cigarettes a day, but now has cut down to three cigarettes a day. To lose weight, he has stopped drinking soda. He got a pedometer and tries to walk 5000 steps daily.

Now, he comes to your office with a summons for jury duty.

“Can you write me a letter so I don’t have to go?” he asks.

Do you write the letter for him?

Some people—physicians or otherwise—react strongly to this question: “Of course I would write the letter for him. Do I really want a guy with schizophrenia serving on a jury? He hears voices, he’s tried to find ‘the New World’—do I really want a guy with that kind of judgment deciding the fate of another person?”

Some people—physicians or otherwise—think twice: “All citizens should participate in civic duty. If a jury consists of ‘peers’, aren’t people with psychiatric conditions ‘peers’? This guy has minimal psychiatric symptoms right now. And just because he hears voices—that he says he can ignore—doesn’t mean that he is incapable of assessing evidence and making fair judgments.”

The courts, rightfully or not, defer to physicians to determine if an individual is fit for jury service. The courts usually request a letter or affidavit from a licensed physician to attest to the individual’s physical or mental disability.

The literature has little to say on this topic. A search for “jury duty” on Pubmed returns only 21 results. A search for “jury service” returns 15 results. Several articles discuss how professionals may excuse themselves from jury service. One relevant article is entitled, “Is it right to exclude people with a mental illness from jury service?“, but I cannot access this British article. (Update: A medical student kindly sent me this article—thank you! Take home message in the UK: Someone receiving any treatment for a psychiatric condition cannot sit on a jury. If a person fails to disclose this, he can be fined.)

Hemmens et al. published an article in 1999 entitled, “The consequences of official labels: an examination of the rights lost by the mentally ill and mentally incompetent ten years later“. In this article, they review state laws related to jury service, voting, holding public office, marriage, and parenting. They state that, as of 1999, 38 states restricted those with a mental illness from serving on a jury. (This number increased over a decade.) They surmise: “A possible explanation for why the right to serve on a jury is so frequently restricted may be the recognition by legislators that immediate, irreparable harm can occur in the trial setting than at the ballot box or in public office.”

A search on Ovid shows several doctoral dissertations on the anxiety and stress associated with jury selection and service. As stress may contribute to psychiatric decompensation, one could argue that people with mental illness should not serve on juries. (“First, do no harm.”) However, people with or without psychiatric diagnoses can demonstrate extraordinary resilience. No one yet has shown that people with psychiatric conditions experience more stress while on jury duty than people without psychiatric conditions.

There are organizations, such as The Center for Reintegration, that argue that people with psychiatric conditions should be allowed to participate in jury duty. They argue that this can reduce the stigma associated with mental illness and facilitate reintegration into society.

Back to your hypothetical patient: Do you write the letter for him?

People often want to separate medicine from politics. This, however, is exactly how physicians can become agents of social control.