Those wondering why the mental health system did not keep Cho Seung-Hui, the Virginia Tech mass murderer, in a psychiatric hospital and “fix” him when it had the chance, or who look to the health care system to prevent the next mass shooting by a young man like him, do not understand that system, young men or America.

Troubled young men are the greased pigs of our patient populations; hard to lay healing hands on, and almost impossible to hold onto long enough to effectively treat against their will. They, and even healthy young men, generally avoid health care providers like the plague. This and other factors make it unlikely that our health care system can ever serve an effective role in protecting us from sick young men with guns.

Most young males get health care only if they cannot possibly avoid it, and even then often not until they are in deep doo-doo. Genital sores must have the typical young guy fearful that something is going to fall off before he overcomes his doc-a-phobia and gets help. He thinks preventive health care is taking aspirin for a hangover before he spends the night drinking, and an annual physical exam is checking his belly button once a year for accumulated lint.

In their late teens, young men I have seen frequently since their childhood disappear from my office, for many reasons. First, (this is so painful) they really don’t need me much any more; they are very healthy, can tough out just about any acute disease, and when they do need health care it is usually for an acute problem that does not last.

When they have chronic diseases, such as mental illness, they often get just enough care to get out of big trouble and then disappear again, in part because regular treatment for ill health may seem like giving control of their lives to someone else.

Young men don’t get pregnant; otherwise we could rope them in for Pap smears, birth control pills and prenatal care, and have access to their hearts and minds while we write their prescriptions and swab their cervices. Unlike young women, then, young men can stay off the health care grid unless they are so sick they cannot function.

Families are often unclear what constitutes mental illness in a teenage male and what is just normal moodiness and rejection of authority that is so common to adolescence. Parents often don’t know whether an apparently troubled son needs professional help or just to be left alone, whether he should be forced into treatment or just waited out while he “grows out of this phase.” Regardless of which it is, it is almost impossible for parents to force a teenage or adult son to do anything he does not want to do.

Many young men have no health insurance because it takes precious dollars out of their pockets, which in turn limits their use of health care services. Health insurance would cost them about the same every year as a large digital TV. They gamble they will stay healthy, and the odds are with them. Many state Medicaid programs have cut back on coverage for healthy young males, assuming young adult males are the least vulnerable of the poor, and in some ways, they are.

America and its health care system place a premium on patient freedom and autonomy; we rarely force people to get treatment for what ails them. It is therefore especially difficult to keep our therapeutic hands on those young men who clearly suffer from mental illness, even when they have been admitted to a psychiatric hospital for potentially dangerous delusional and paranoid thinking.

In most cases, a mentally ill patient can be committed to a hospital and forced into treatment against his will only for the (usually) short period he is a clear danger to himself or others. Once he is no longer a danger, he must be released, and can then stop his medications – even if the medications were correcting his dangerous thinking. Then, he must act as a danger again in order to be treated again against his will. Delusional and paranoid thought disorders may convince such patients that treatment is a conspiracy to control them, and that they are not the problem; everyone else is.

Some states have laws allowing a judge to order medication treatment of some mentally ill patients. The practice is still uncommon, however, because if we err in the care of millions of mentally ill adults in this country, we err on the side of their personal freedom, not on the side of society’s protection. We pay a price for that preference for freedom, sometimes in the form of shooting rampages and other acts of violence by people with mental illness.

Unless we are prepared to be much more coercive about treating troubled young men who do not seek treatment on their own, those of us in the health care system will be able to help some of them only when they break the law, and when prison or parole commands their participation in a healing process. Our police, courts and prisons will continue to be the main ‘health care system’ for such young men.

In a land full of guns, where a delusional young man can buy a semi-automatic killing machine and lots of hollow point ammo with a credit card, a few of these young men will continue to be America’s equivalent of suicide bombers. If we are lucky they will not take too many of us with them on their way to see the only physician certain to be in their futures: the coroner.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.