Does the state have the right - even the responsibility - to lock up individuals who are mentally ill before they hurt someone?
Many in New Hampshire asked that question after two recent attacks by patients awaiting mental health treatment at Elliot Hospital's emergency department.
The same issue was at the heart of a legal battle nearly 50 years ago involving a New Hampshire man accused of plotting to kill then-President-elect John F. Kennedy.
Alexander de Nesnera is associate medical director at New Hampshire Hospital and an associate professor of psychiatry at Dartmouth's Geisel School of Medicine. Earlier this month, Gov. Maggie Hassan appointed him to a team looking into the state's "deeply strained mental health system," in light of the recent hospital attacks in Manchester.
De Nesnera said the system is designed to balance patients' civil liberties with public safety.
But it was not in place in 1960, when Richard Paul Pavlick of Belmont was charged with threatening Kennedy's life.
He was never convicted of a crime, but spent six years in jails and "mental" hospitals in several states before a New Hampshire judge ordered him released in 1966.
Authorities had dropped the criminal charges in 1964, but Pavlick was committed to the state hospital.
It was only after a reporter for the then-Manchester Union Leader, Arthur C. Egan Jr., wrote a seven-part series about Pavlick's case that a court hearing was finally scheduled.
De Nesnera has been researching the history of New Hampshire's commitment laws. What happened to Pavlick would not happen today - but it was common back then, he said.
"In the 1960s, there really was no maximum period of time that people could stay in the hospital," he said.
Then, patients were admitted to the state hospital either by judicial order or with the consent of hospital trustees at the request of certain individuals, including relatives, guardians, the board of selectmen, chief of police, or county commissioners, de Nesnera said.
In Pavlick's case, it was the Belmont selectmen who signed the commitment papers. Two physicians who examined Pavlick also signed the order, according to Egan's reporting.
Officials told Egan that an "arrangement" had been made that if Pavlick were ever brought to New Hampshire to face charges and those charges were dismissed, that he would then be committed. The presiding judge was never informed of that "arrangement."
In the decades since, de Nesnera said, "there are a lot of statutes that have been passed that look at ensuring patients' civil liberties are not trampled upon."
In 1987, lawmakers passed a statute that created rules for the involuntary commitment of individuals, he said.
Nowadays, he said, a patient typically is evaluated in an emergency room, where a clinician determines iwhether he is dangerous. If so, the person is sent to the state hospital on an involuntary emergency admission, or IEA.
A hearing must then be held before a district court judge at the hospital within three business days. The patient is represented by a lawyer, and the person who petitioned for the IEA - which could be a relative, friend, community mental health clinician or police officer - must testify.
If the judge finds the patient likely poses a danger to himself or others due to mental illness, that allows the hospital to keep him for up to 10 days, excluding Saturdays and Sundays.
Many patients do well in that time period, de Nesnera said, and are discharged.
But the hospital can ask a probate court judge for permission to keep a patient longer. "In New Hampshire, we can ask for a commitment of any time up to five years," de Nesnera said, noting in many states, the maximum commitment is one year.
A patient not only has legal representation during the hearing, but also is evaluated by an independent psychiatrist.
In Pavlick's day, de Nesnera said, there were no hearings scheduled to review such cases. "The only way that person could be discharged was by a judicial order."
In the early 1970s, things began to change, he said. The state passed laws requiring judicial review of commitment cases, and setting maximum commitment periods.
To keep someone at the state hospital, de Nesnera said, you have to prove he is both mentally ill and dangerous. And even if someone is involuntarily committed, he can't be treated against his will, he added.
New Hampshire also has "conditional discharge," in which a patient can be treated on an outpatient basis.
None of these protections were available to Richard Pavlick. But the late William Loeb, publisher of the Manchester Union Leader, argued they should have been.
In a front-page editorial published Dec. 9, 1966, Loeb explained the newspaper's position in the case:
"The newspaper is not pro-Pavlick. It is not against Pavlick. We are simply saying that the way this old gentleman, without any relatives and apparently few friends, has been shunted around the country for six long years without ever having his day in court is a disgraceful violation of HIS civil rights and would be an equally disgraceful violation if any OTHER individual had been so treated."
Loeb wrote that "it is vital to the survival of the American system of freedom that ANY individual, no matter how unpopular he may be, or no matter of what crime he may be accused, shall have a fair and impartial opportunity to be tried and to be found either guilty or not guilty."
When Pavlick finally got his mental competency hearing, the newspaper's counsel argued for his release. Reporter Egan testified in the man's defense, then covered the hearing himself.