by Jenna Ward

Sometimes, late at night, my brother sits in his darkened room watching television without any sound and laughing hysterically. His giggling is punctuated by one-sided, incoherent conversations that he holds with the voices he hears in his head.

Doug is 30 years old, and for the past 10 years he has suffered from schizophrenia, a fact which he neither acknowledges nor accepts. Whenever I tell someone about him, the person invariably nods, even if he or she has no idea that schizophrenia isn't multiple personalities or the result of bad parenting. Almost always, the first thing they ask me is, "Does he take medication?" It's not a bad question. In the past several years, there have been some real breakthroughs in drugs to treat schizophrenia. Scientists have come much closer to pinpointing the ways in which neurotransmitters such as dopamine and serotonin go awry in the brains of schizophrenics, and they are creating better medications to adjust the balance of chemicals. These drugs, which have names like risperidone and olanzapine and clozapine, are not a cure. Often they have miserable side effects, and they are only partially effective in combating the so-called "negative" symptoms of the disease, things like apathy, social awkwardness and emotional withdrawal. But the drugs can make it possible to live independently, to work and to interact with people, and to banish the hallucinations and voices.

The new drugs are one of the few causes for hope in an otherwise devastating affliction, but there is one problem - if your brain is sick, how is it able to recognize its own illness? This is not a hypothetical question. Consider that if your stomach hurts, the nerves in your body pass the information on to your brain, and it figures out what to do. But what about when the problem originates in the brain? How can one little piece of the mind hold itself apart, like some island of sanity, in order to make a self-diagnosis? Doug, like many other people who have schizophrenia, cannot or will not realize that something is wrong, and he refuses to take any medication. So for my family, it all becomes useless, all the groundbreaking research and fancy new drugs, because he will not help himself. Sometimes I want to just shake him and scream, "Don't you know? You don't have to be like this!" He is so lonely, so profoundly isolated from all that exists outside the cacophony in his skull. He has no friends, almost no human connection with anyone at all. He often imagines he smells horrible odors and sees vomit covering the television, his stereo, the carpet, his shoes. Conversations with him go like this: "Kansas, you know Kansas is actually in Dallas, because there is the road, and then you're in Texas and that's why Texas sports teams are so good. Never buy Campbell's. Chunky soup is really important. Never buy Campbell's."

But once upon a time, he was just my big brother who liked to tease me and taught me to water-ski and wanted to be an accountant. Now I barely remember that person. And there is nothing we can do about it - we have no way to force him to get help. If a person with schizophrenia refuses to take medication, the only recourse is to have him or her involuntarily committed. But you can only do that by proving the person is a danger to him or herself or others. I think we would have my brother committed if we could, and we watch for symptoms that would make this possible, but so far, he is just plain-old insane, not violent or dangerous. The system can only intervene when something goes terribly wrong, if Doug tries to harm himself or attacks my parents or a stranger. All we can do is wait for the crisis. "He may have to get worse before he gets better," Doug's psychiatrist told my mother. If or when he breaks down completely and lands in an institution, only then will we be able to force medicine into his body, medicine that may have the power to bring back the person we lost 10 years ago. And hopefully once he starts taking drugs, he'll recognize he needs them and continue to take them on his own. I imagine it will feel like coming down off a 10 year acid trip. But my brother has already lost a full decade of his life. Doug is in no position to make rational decisions about his own health care, and there should be some recourse other than acute crisis to allow for intervention.

I believe that another factor in assessing involuntary commitment should be the need for treatment. Doug may not be an immediate danger to himself or others, but he is clearly ill and highly unpredictable. I believe - and the statistics tend to support this - that at some point he will try to hurt himself or someone else. He needs medication now. What makes it more depressing is the knowledge that, as with so many illnesses, the chances of recovery from schizophrenia improve with early, aggressive treatment. We missed that chance with Doug.

Maybe things would have been different if we had been able to intervene when he first got sick. Some - the same civil libertarians with whom I normally side - would call this a victory, that a person has some right to be insane. I call it cruel and an enormous waste of human potential.