"The child's toys and the old man's reasons
Are the fruits of the two seasons.
The questioner who sits so sly
Shall never know how to reply."
Auguries of Innocence
Two fundamental facts distinguish psychiatry from the rest of medicine: the frustrating ambiguity of diagnosis (only partially resolvable by scientific advance because a good part of the ambiguity is philosophical in nature), and the possibility of compulsion that is always implicit in the endeavor. The two difficulties are related of course, for it is one thing to compel an allegedly incompetent person to undergo treatment for unambiguous disease (e.g. appendicitis), and quite another to force treatment for contestable syndromes. While other physicians may occasionally encounter incompetent patients (for whom they usually end up calling in a psychiatry consult), only in psychiatry is the distasteful potential for involuntary treatment always lurking in the background.
Some antipsychiatry fanatics seem to think that psychiatrists delight in forcing treatment on unsuspecting multitudes, but such individuals usually haven't spent much time around psychiatrists. Obviously there are dysfunctional outliers as there always are, but of all the factors that may lead someone to pursue psychiatry or clinical psychology, a joy in foisting treatment on those who don't want it is usually not among them. Arguably, due to the cultural craze for psychotropic medications, stoked not least by direct-to-consumer advertising, the pool of patients who need treatment but won't accept it is dwarfed by "patients" who seek treatment inappropriately or in the wrong places.
Since returning to a public system I have begun seeing the hard cases, of this variety at least, that is, those who are significantly, often grievously impaired by psychotic symptoms but who refuse treatment and do not warrant involuntary hospitalization. Families of such individuals often cannot comprehend how "the system" can allow people to refuse treatment and remain so evidently ill (and as one hapless mother I saw yesterday found out, everything changes in this respect when a patient turns 18). But personal freedom is the default setting here, to be overridden only in the most life-threatening of circumstances. Sure, there is the argument that the psychotic person is not really free, that it is the illness and not the person talking, but society does not have much confidence in psychiatrists' ability to make that sometimes subtle philosophical judgment in the absence of clear and present danger.
So the delusional fellow I saw yesterday who refused to take anything but trazodone seemed somewhat surprised when I didn't threaten him with meds or with commitment. I offered my clear recommendations and said I would see him back next week if he changes his mind (he probably won't, until he gets sick enough that someone does petition him back into the hospital). It doesn't make as good a story as One Flew Over the Cuckoo's Nest, but then again one shouldn't infer much about psychiatry from the big (or small) screen.