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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?

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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.

The rows of fluorescent bulbs formed an indoor sun. Its cool rays illuminated the windowless psychiatric emergency room. This sun never rose and never set. Only the clocks betrayed that it was nearly three o’clock in the morning.

His left shoulder held the telephone receiver against his ear. The drone of the dial tone filled his head. His right hand floated above the keypad, then dropped back to the table.

He looked at the clock. A quiet sigh escaped from his lips. Lifting his right hand again, he willed his fingers to dial the number that was scribbled on the torn sheet of paper before him.

Instead, he hung up the phone.

He silently rehearsed what he would say if someone answered his call. Would he leave a message if no one picked up the phone? If yes, what would he say? If no, how long should he wait before calling again? Should he even call again? What if someone did answer the phone, but would not stop talking? Could he just hang up?

He shook his head, took a deep breath, picked up the phone, and listened to the drone of the dial tone. His fingers quickly punched in the phone number.

Please answer the phone.

Two rings. Three rings.

Please don’t answer the phone.

The ringing stopped.

“… hullo?”

He finally took another breath.

“Hello. My name is Dr. A and I’m calling from Big City Hospital. May I please speak to Mr. B?” Standard greeting.

“Yeah… that’s me.”

“I’m sorry to disturb you at this hour, Mr. B.” Standard disclaimer between the hours of 10:00pm and 7:00am.

“It’s okay.” Mr. B yawned.” “I was expecting this phone call.”

Dr. A frowned. This isn’t the first time he’s gotten a phone call at 3:00am about this.

“I’m calling about your sister. She’s here at the hospital, in the psychiatric emergency room. She’s okay.” Standard remark to prevent panic. People usually assumed the worst.

“Oh, that’s good.”

“Would you mind telling me what happened this evening?” Standard open-ended question to elicit a history.

“Sure.” Mr. B sounded bored, numb. Most people did at that hour.

His sister tried to open the door to her room. It was still locked.

At three o’clock in the morning, peace eluded them all.

Does it ever bother you to listen to people who want to kill themselves?” the medical student asked.

The attending psychiatrist glanced at the whiteboard.

The whiteboard was divided into five columns. The first showed the patient’s age; the second indicated the patient’s sex. A last name was in the third column. The fourth held the chief complaint, the reason why the person was in the psychiatric emergency room. The disposition—admit to or discharge from the hospital—occupied the fifth column.

Nearly a third of the patients had a chief complaint related to suicide.

“Yes; there are days when I feel exhausted from listening to people who say they want to die. That’s part of the work, though,” the attending said. He paused, then clicked through several screens on his computer. Pushing his chair away from the table, he said, “Come. Let’s take a walk. We’ll learn why we’re fortunate to listen to those who want to kill themselves.”

The attending unlocked the solid, windowless door. A camera attached to the ceiling watched them retreat down the hallway.

They walked through two sets of double doors into the medical emergency room. The attending paused in front of the whiteboard there. His eyes scanned the list.

“Follow me,” he said to the medical student.

They passed through hallways lined with occupied gurneys. A young woman with dark hair gingerly touched the intravenous line that was taped to her arm. An elderly man with rasping breaths gripped the side rails of his gurney. A man peeled bloody gauze away from his leg. Several people had curled their bodies underneath the thin white sheets, their eyes closed and their bodies still.

As the medical student and attending passed by the trauma bay, they slowed down. The attending pointed inside. Several nurses stood around a man lying on the gurney. Blood was splattered all over the floor tiles. Plastic bags, tubes of various sizes, and soiled white towels littered the room. Layers of gauze, some of it stained red, were wrapped around the man’s head. A mechanical ventilator heaved breaths into him. The heart monitor reported each beat with a hollow chirp.

While walking out of the room, a nurse greeted the attending with a nod. Upon seeing the medical student, the nurse murmured, “Gun shot wound to the head.”

“When people tell us they want to kill themselves, we have the opportunity to intervene,” the attending said as they walked away. “Some people, like that man, never give us that chance.”

In her right hand was a white plastic bag marked with a smiling yellow face. “Have a nice day” and “Thank you!” were printed on the front.

She had tied the handles of the bag into a square knot. The resulting loops dangled from her hooked fingers. The bag swung with each step she took while walking north on Park Avenue.

Her destination was an apartment between 73rd and 74th Streets. As taxis, cars, and delivery trucks raced past, she caught glimpses of the short grass, leafless trees, and stunted bushes that grew in the median of the avenue.

The plastic bag bumped against her leg and she reflexively extended her arm. Though she knew that the contents inside would not break or spill, she did not want to jostle the bag.

The doorman looked up when she walked into the building. Pewter stripes adorned the lapels and sleeves of his navy blue suit. The knot of his black necktie was crooked. He smiled at her in recognition.

“How you doin’ today, miss?” he asked, wrinkles appearing at the corners of his eyes as he smiled.

“Fine,” she said. “I’m here for apartment 13X. He’s expecting me.”

“Go on up,” the doorman said. Glancing at her plastic bag, he asked, “You got any lunch for me?”

“Not today,” she said, smiling.

“Next time, all right?” He winked at her.

She walked across the black and white checkered floor, underneath the chandelier that resembled a glass jellyfish, past the single pink orchid in the white ceramic vase, and stepped into the elevator. She felt the bag tap her leg again.

That was the portable flip-top sharps container that nudged her thigh. The brown paper sack inside the plastic bag also held a 3cc syringe with a 21-gauge by 1.5-inch needle, a pair of bright blue nitrile gloves, several small squares of gauze, one band-aid, three alcohol pads, and one container of hand sanitizer. The vial of antipsychotic medication waited inside its small box.

After exiting the elevator, she turned left, walked across the wooden floor of the hallway, and stopped in front of apartment 13X. She rapped on the black door three times.

“Who is it?” a muffled voice immediately responded.

“It’s Dr. Doe,” she said.

“Dr. Doe! Are you here to give me my injection?” he asked.

“Yes,” she said.

The locks on the door began to unlatch.

When she was sixteen years old, she said, “I wish old people would stay inside. They walk so slow. They take up too much space on the sidewalk. Who wants to see them with their canes and walkers, anyway? It’s so depressing.”

When she was forty years old, she said, “I like to see old people out and about. It’s nice to see that they are still active. When I’m that old, I hope I can still walk around like that.”

When she was seventy years old, she noticed that the youth walked impatiently around her. She said, “I used to make fun of old people when I was younger. I thought they were so slow and weak. Now I guess I am one of them.”

After crossing her arms in her lap, she looked up at the cloudless sky before glancing over her shoulder.

“Thank you for pushing my wheelchair,” she said.