Rogers v. Commissioner of the Department of Mental Health

We are asked to respond to nine questions certified by the United States Court of Appeals for the First Circuit which focus on the right of involuntarily committed mental patients to refuse treatment, and the standards and procedures which must be followed to treat those patients with antipsychotic medication. 3 The basic conclusions we *491 reach are that a committed mental patient is competent and has the right to make treatment decisions until the patient is adjudicated incompetent by a judge. If a patient is adjudicated incompetent, a judge, using a substituted-judgment standard, shall decide whether the patient would have consented to the administration of antipsychotic drugs. Guardianship of Roe, 383 Mass. 415, 443-448 (1981). Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 750-755 (1977). No State interest justifies the use of antipsychotic drugs in a nonemergency situation without the patient’s consent. Antipsychotic drugs, which are used to prevent violence to third persons, to prevent suicide, or to preserve security, are being used as chemical restraints and must follow the strictures of G. L. c. 123, § 21, and the regulations promulgated pursuant to the statute. A patient may be treated with antipsychotic drugs against his will and without prior court approval to prevent the “immediate, substantial, and irreversible deterioration of a serious mental illness.” If a patient is medicated in order to avoid “immediate, substantial, and irreversible deterioration of a serious mental illness,” and the doctors expect to continue to treat the patient with antipsychotic medication over the patient’s objection, the doctors 4 must seek adjudication of incompetency, and, if the patient is adjudicated incompetent, the court must formulate a substituted-judgment treatment plan.

We summarize the facts and procedural background of the case. 5 On April 27, 1975, a class action was commenced *492 in the United States District Court for the District of Massachusetts against the defendant Commissioner of the Department of Mental Health (department) and numerous doctors and administrative staff members of the May and Austin Units of Boston State Hospital (hospital), pursuant to 42 U.S.C. § 1983 (1970). The seven named plaintiffs, all of whom had been committed to the hospital prior to commencement of the action, challenged the defendants’ practices of secluding and medicating patients against their will. Alleging that these practices infringed their rights under the United States Constitution and violated acceptable medical standards, the plaintiffs sought injunctive relief for the class and an award of damages for themselves in the Federal District Court.

Three days after the complaint was filed, a Federal District Court judge issued a temporary restraining order, prohibiting the seclusion and antipsychotic medication of hospital patients in nonemergency situations without the consent of the patient or a guardian. After trial, the judge denied damages because the defendants’ medication and seclusion practices were in accordance with acceptable medical standards. Rogers v. Okin, 478 F. Supp. 1342, 1380-1389 (D. Mass. 1979) (hereinafter cited as Rogers I).

However, the judge determined that mental patients not adjudicated incompetent have a constitutional right to refuse treatment in nonemergency situations, and that the same right extends to incompetent patients, for whom the treatment decision should be made by a guardian using a substituted judgment standard. Id. at 1361-1368. The judge therefore enjoined the defendants from forcibly medicating patients except in an “emergency,” which the judge defined as “circumstances in which a failure to [medicate *493 forcibly] would bring about a substantial likelihood of physical harm to the patient or others.” Id. at 1371. 6

The defendants appealed the decision enjoining forcible medication of patients absent an emergency. The plaintiffs cross appealed from the denial of their claims for damages. The Court of Appeals affirmed the denial of the damage claims, but vacated and remanded the issue of injunctive relief in light of its opinion. Rogers v. Okin, 634 F.2d 650 (1st Cir. 1980) (hereinafter cited as Rogers II).

In its opinion, the court concluded that the mentally ill have a constitutionally protected right to decide whether to be treated with antipsychotic drugs, id. at 653, and that involuntarily committed patients are presumed to be competent to assert that right in their own behalf, id. at 658-659. However, that court modified the trial judge’s decision in two respects. First, it determined that the “substantial likelihood of physical harm” standard, application of which the judge required prior to forcible administration of antipsychotic medication, is too narrow, and that the hospital physicians could use their discretion in deciding to administer drugs forcibly, after balancing the interests of the patients against the State’s police power interest in preventing violence within the institution. The court remanded for the District Court to design procedures to ensure that patient interests would be adequately protected. Id. at 656-657. Second, the Court of Appeals concluded that the judge’s definition of an “emergency” in which a patient could be treated against his will was too limited. The Court of Appeals expanded the meaning of emergencies to include those situations in which an incompetent patient’s health would significantly deteriorate without medication. Id. at 659-660. The case was remanded on this issue for the judge’s consideration of expeditious methods for determining incompetence when delay would be harmful. Id. Furthermore, the court held that the Commonwealth need not seek *494 individualized guardian approval for decisions to treat patients with antipsychotic drugs. Id. at 661.

The United States Supreme Court granted the defendants’ petition for a writ of certiorari, in which they sought review of the Court of Appeals’ decision on the issue of forcible medication of involuntarily committed patients. In mid-1982, the Supreme Court vacated the judgment and remanded the case to the Court of Appeals for a determination of the extent to which the patients’ substantive and procedural rights are protected under Massachusetts law, thus declining to reach the constitutional issues unnecessarily. Mills v. Rogers, 457 U.S. 291, 305 (1982). 7 On remand, the Court of Appeals certified nine questions to this court.

Questions 1, 2, and 3. Competence of involuntarily committed patients to make treatment decisions; judicial determination of incompetence. 8 “No person shall be deemed to be incompetent to manage his affairs, to contract, to hold professional or occupational or vehicle operators licenses or to make a will solely by reason of his admission or commitment in any capacity to the treatment or care of the [Mental Health] department or to any public or private facility.” *495 G. L. c. 123, § 25, inserted by St. 1970, c. 888, § 4. See 104 Code Mass. Regs. § 3.10 (2) (6) (1978). A judge may order the civil commitment of a person after a hearing only if he finds that the person is mentally ill and that the person’s failure to be committed would create a likelihood of serious harm. G. L. c. 123, §§ 7, 8. The Legislature defined “[ljikelihood of serious harm” as “(1) a substantial risk of physical harm to the person himself as manifested by evidence of threats of, or attempts at, suicide or serious bodily harm; (2) a substantial risk of physical harm to other persons as manifested by evidence of homicidal or other violent behavior or evidence that others are placed in reasonable fear of violent behavior and serious physical harm to them; or (3) a very substantial risk of physical impairment or injury to the person himself as manifested by evidence that such person’s judgment is so affected that he is unable to protect himself in the community and that reasonable provision for his protection is not available in the community.” G. L. c. 123, § 1, as amended through St. 1980, c. 571, § 1. There is no requirement that a person be incompetent in order to be committed.

The first two definitions of likelihood of serious harm “provide no adjudication of judgmental capacity; commitment is based on a determination of risk of physical harm to the individual or to others.” Rogers II, supra at 658. Put simply, such a commitment is for public safety purposes and does not reflect lack of judgmental capacity. The third definition, although more relevant to the person’s judgmental abilities, says nothing concerning his competence to make treatment decisions. A person may be competent to make some decisions, but not others. Matter of Moe, 385 Mass. 555, 567-568 (1982). See Developments in the Law — Civil Commitment of the Mentally Ill, 87 Harv. L. Rev. 1190, 1214 (1974). Furthermore, as the Court of Appeals noted, there is no way to pinpoint those patients committed under the third definition. Thus, “under the statutory scheme any given individual might have been committed despite the fact that he competently believed that treatment was not in *496 his best interests.” Rogers II, supra. In addition, the Federal District Court judge found that most patients “are able to appreciate the benefits, risks, and discomfort that may reasonably be expected from receiving psychotropic medication.” Rogers I, supra at 1361.

A determination of incompetence, on the other hand, is made by a judge who appoints a guardian only after he finds the person “incapable of taking care of himself by reason of mental illness.” G. L. c. 201, § 6, as amended through St. 1978, c. 478, § 94. Thus, the statutes, as worded, comprehend the competence of an involuntarily committed mental patient to make treatment decisions. The fact that G. L. c. 123, § 23, expressly authorizes patients to refuse psychosurgery and electroconvulsive treatment does not, as the defendants assert, exclude by implication the patients’ rights to make treatment decisions as to antipsychotic drugs. The right of an individual “to manage his own person” necessarily encompasses the right to make basic decisions with respect to “taking care of himself,” Fazio v. Fazio, 375 Mass. 394, 403 (1978), including decisions relating to the maintenance of physical and mental health. We think it clear that the right to make treatment decisions is an essential element of the patient’s general right “to manage his affairs.” 9 G. L. c. 123, § 25. “[A] finding [of incompetence], apart from evidence as to mental illness, should consist of *497 facts showing a proposed ward’s inability to think or act for himself as to matters concerning his personal health, safety, and general welfare . . . .” Fazio v. Fazio, supra at 403. Absent such a finding, a person is competent to “act for himself as to matters concerning his personal health,” including acceptance or refusal of medication. Id. 10 Thus, a person diagnosed as mentally ill and committed to a mental institution is still considered to be competent to manage his personal affairs. See Commonwealth v. Sires, 370 Mass. 541, 546 (1976); Mitchell v. Mitchell, 312 Mass. 165, 168 (1942); Leggate v. Clark, 111 Mass. 308, 309-310 (1873).

We conclude that a mental patient has the right to make treatment decisions and does not lose that right until the patient is adjudicated incompetent by a judge through incompetence proceedings. See G. L. c. 201, § 6. No other procedure is available for determining that a patient lacks the capacity to make treatment decisions. See Guardianship of Roe, supra at 431; Fazio v. Fazio, supra at 399; Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 755 (1977). Pursuant to G. L. c. 201, § 6, a judge may appoint a guardian for a person only if he finds after a hearing that the person “is incapable of taking care of himself by reason of mental illness. ” The statute provides for the appointment of temporary guardians, as well as for permanent guardians. See G. L. c. 201, § 14.

The defendants argue that they, as doctors, should be responsible for making treatment decisions for involuntarily committed patients, whether competent or not. We do not agree. “Every competent adult has a right ‘to forego treatment, or even cure, if it entails what for him are intolerable *498 consequences or risks however unwise his sense of values may be in the eyes of the medical profession.’ ” Harnish v. Children’s Hosp. Medical Center, 387 Mass. 152, 154 (1982), quoting Wilkinson v. Vesey, 110 R.I. 606, 624 (1972). 11 This right has constitutional and common law origins, Guardianship of Roe, supra at 433 n.9, which protect each person’s “strong interest in being free from nonconsensual invasion of his bodily integrity.” Superintendent of Belchertown State School v. Saikewicz, supra at 738-739. See Ingraham v. Wright, 430 U.S. 651, 673 (1977); Breithaupt v. Abram, 352 U.S. 432, 439 (1957); Davis v. Hubbard, 506 F. Supp. 915, 930-931 (N.D. Ohio 1980). Since by statute and by common law, involuntarily committed patients are competent until adjudicated incompetent, see supra, and because we have held that competent individuals have a right to refuse treatment, see Harnish v. Children’s Hosp. Medical Center, supra at 154, the defendants’ argument fails.

We conclude that a distinct adjudication of incapacity to make treatment decisions (incompetence) must precede any determination to override patients’ rights to make their own treatment decisions. See Matter of Moe, 385 Mass. 555, 567-568 (1982). Other courts have drawn similar conclusions. See, e.g., Rennie v. Klein, 653 F.2d 836, 846 (3d Cir. 1981), vacated and remanded, 458 U.S. 1119 (1982); Winters v. Miller, 446 F.2d 65, 68 (2d Cir.), cert. denied, 404 U.S. 985 (1971); New York City Health & Hosps. Corp. v. Stein, 70 Misc. 2d 944, 945 (N.Y. Sup. Ct. 1972); In re K.K.B., 609 P.2d 747, 749 (Okla. 1980); In re Yetter, 62 Pa. D. & C.2d 619, 623 (1973).

*499 Competency and substituted-judgment determinations may take place in the Probate Courts, see G. L. c. 215, § 6; in the Superior Court, see G. L. c. 214, § 1 (general equity jurisdiction of the Superior Court); G. L. c. 215, § 6 (concurrent jurisdiction of the Probate and Superior Courts as to “all matters relative to guardianship and conservatorship”); Custody of a Minor, 375 Mass. 733, 743-744 (1978); or in the Juvenile Courts or juvenile sessions of the District Courts, see G. L. c. 119, § 24; Custody of a Minor, supra at 742-743. Whatever the forum, the patient must be found incompetent before a judge may make a substituted-judgment decision. We note that, whenever possible, proceedings should be consolidated. See, e.g., Glick v. Greenleaf, 383 Mass. 290, 294-295 & n.7 (1981); G. L. c. 211B, § 9, inserted by St. 1978, c. 478, § 110 (power of Chief Administrative Justice to transfer judges and cases “as he deems will best promote the speedy dispatch of judicial business”). 12

Questions 4 and 5. The decision to treat incompetent mental patients with antipsychotic drugs. 13 In Massachusetts there is “a general right in all persons to refuse medical treatment in appropriate circumstances. The recognition of that right must extend to the case of an incompetent, as well as a competent, patient because the value of human *500 dignity extends to both. ... To protect the incompetent person within its power, the State must recognize the dignity and worth of such a person and afford to that person the same panoply of rights and choices it recognizes in competent persons.” Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 745-746 (1977). See Gaughan & LaRue, The Right of a Mental Patient to Refuse Antipsychotic Drugs in an Institution, 4 Law & Psychology Rev. 43, 74 (1978). Further, “if an incompetent individual refuses antipsychotic drugs, those charged with his protection must seek a judicial determination of substituted judgment.” Guardianship of Roe, supra at 434-435. 14 See Custody of a Minor (No. 1), 385 Mass. 697, 710 n.10 (1982). See also Matter of Moe, 385 Mass. 555, 565 (1982); Matter of Spring, 380 Mass. 629, 640 (1980); Custody of a Minor, 375 Mass. 733, 752-753 (1978); Superintendent of Belchertown State School v. Saikewicz, supra at 745-751.

A substituted-judgment decision is distinct from a decision by doctors as to what is medically in the “best interests” of the patient. Guardianship of Roe, supra at 435. “[T]he goal is to determine with as much accuracy as possible the wants and needs of the individual involved.” Superintendent of Belchertown State School v. Saikewicz, supra at 750. The decision “should be that which would be made by the incompetent person, if that person were competent, but taking into account the present and future incompetency of the individual as one of the factors which would necessarily enter into the decision-making process of the competent person,” id. at 752-753, and giving “the fullest possible expression to the character and circumstances of that individual,” id. at 747. Use of the substituted judgment standard is not *501 unique to Massachusetts. See, e.g., In re Boyd, 403 A.2d 744, 750-751 (D.C. 1979). The decision is not simply a question whether treatment is to be rendered, but also may entail a choice between alternative treatments. The doctor must offer treatment to the involuntarily committed patient, but, since it is the patient who bears the risks as well as the benefits of treatment by antipsychotic drugs, and must suffer the consequences of any treatment decision, the patient has the right to make that decision. 15 In short, treatment decisions are the patient’s prerogative solely.

“[Ojur prior cases have established that prior judicial approval is required before a guardian may consent to administering or withholding of proposed extraordinary medical treatment.” Matter of Moe, 385 Mass. 555, 559 (1982). Since we have decided that treatment with antipsychotic drugs is such an extraordinary treatment, 16 we necessarily conclude that court approval is mandatory before forcible *502 medication of an incompetent patient with those drugs in a nonemergency situation can take place.

The amici American Psychiatric Association and Massachusetts Psychiatric Society, arguing on behalf of the psychiatric profession, urge us not to require a substituted judgment by a judge for institutionalized incompetent mentally ill patients. They assert that if a substituted judgment is required before there can be forcible medication of involuntarily confined, incompetent patients, the decision as to substituted judgment should be made by a qualified physician and not a judge. This procedure, the so called medical model, would, the doctors claim, protect the incompetent patient’s civil rights to refuse treatment, 17 while providing the hospital with a qualified person who can make the substituted judgment decision at the hospital. See, e.g., A. Stone, Mental Health and Law: A System in Transition 65-66 (1975). The medical model is also advantageous, the doctors claim, because it provides flexibility and avoids the adversary quality of judicial proceedings. The doctors thus conclude that if a substituted-judgment is required, the medical model is the appropriate procedure for this court to follow. We do not agree. “No medical expertise is required [for making the substituted judgment decision], although medical advice and opinion is to be used for the same purposes and sought to the same extent that the incompetent individual would, if he were competent.” Guardianship of Roe, supra at 435. See Custody of a Minor (No. 1), 385 Mass. 697, 713-714 (1982); Matter of Moe, 385 Mass. 555, 559 (1982); Matter of Spring, 380 Mass. 629, 636 (1980); Superintendent of Belchertown State School v. Saikewicz, supra at 759.

The only relevant fact which differs between Guardianship of Roe and this case is that the incompetent patient in Guardianship of Roe was not institutionalized. The de *503 fendants argue that the mere fact of institutionalization and the needs of the hospital 18 should be sufficient to transfer the treatment decision authority from the judge to the doctors. “[I]f the doctrines of informed consent and right of privacy [that underlie the substituted judgment determination] have as their foundations the right to bodily integrity, see Union Pac. Ry. v. Botsford, 141 U.S. 250 (1891), and control of one’s own fate, then those rights are superior to the institutional considerations.” Superintendent of Belchertown State School v. Saikewicz, supra at 744. See Commissioner of Correction v. Myers, 379 Mass. 255, 265-266 (1979).

In Guardianship of Roe, 383 Mass. 415, 435-436 (1981), and in Matter of Spring, 380 Mass. 629, 637 (1980), we outlined the various factors to be considered in determining whether a judicial substituted-judgment decision is required. Five of these discussed in Guardianship of Roe, supra, were “(1) the intrusiveness of the proposed treatment, (2) the possibility of adverse side effects, (3) the absence of an emergency, (4) the nature and extent of prior judicial involvement, and (5) the likelihood of conflicting interests.”

The fact that a patient has been institutionalized and declared incompetent brings into play the factor of the likelihood of conflicting interests. See Guardianship of Roe, supra at 435-436. The doctors who are attempting to treat as well as to maintain order in the hospital have interests in conflict with those of their patients who may wish to avoid medication. 19 On the other hand, unlike the situation in *504 Guardianship of Roe, if an incompetent has a guardian, that guardian presumably is in a neutral position, since the guardian is not living with the patient at the time the guardian makes the treatment decisions. In Guardianship of Roe, supra at 443, we noted the difficulty in making a “substituted judgment determination . . . when the ward ... is living at home with other children.”

We conclude that, if a patient is declared incompetent, a court must make the original substituted-judgment treatment decision and should approve a substituted judgment treatment plan. See 104 Code Mass. Regs. § 3.08 (3) (1978). After adjudication of an involuntarily committed patient as incompetent, the judge may conduct a hearing on the appropriate treatment to be administered. See Davis v. Hubbard, 506 F. Supp. 915, 938-939 (N.D. Ohio 1980). The parties “must be given adequate notice of the proceedings, an opportunity to be heard in the trial court, and to pursue an appeal.” Matter of Moe, 385 Mass. 555, 566 (1982). To this end, a guardian ad litem should be appointed, and the opinions of experts gathered so that all views are available to the judge. Id. at 567. Saikewicz, supra at 756-758. The judge may delegate to a guardian the power to monitor the treatment process to ensure that the substituted-judgment treatment plan is followed. 20

*505 At least six factors must be considered by the judge in arriving at the substituted judgment decision. “In this search, procedural intricacies and technical niceties must yield to the need to know the actual values and preferences of the ward.” Guardianship of Roe, supra at 444. These six factors are detailed in Guardianship of Roe, supra, and we briefly restate them here.

First, the judge must examine the patient’s “expressed preferences regarding treatment.” Guardianship of Roe, supra at 444. If made while competent, such a preference “is entitled to great weight” unless the judge finds that the patient would have changed his opinion after reflection or in altered circumstances. Id. at 445. Even if he lacked the capacity to make his treatment decisions at the time, his expressed preference “must be treated as a critical factor in the determination of his ‘best interests,’” id., quoting Doe v. Doe, 377 Mass. 272, 277-279 (1979), since it is the patient’s true desire that the court must ascertain.

Second, the judge must evaluate the strength of the incompetent patient’s religious convictions, to the extent that they may contribute to his refusal of treatment. See Winters v. Miller, 446 F.2d 65 (2d Cir. 1971); In re Boyd, 403 A.2d 744 (D.C. 1979). “[T]he question to be addressed is whether certain tenets or practices of the incompetent’s faith would cause him individually to reject the specific course of treatment proposed for him in his present circumstances. . . . While in some cases an individual’s beliefs may be so absolute and unequivocal as to be conclusive in the substituted judgment determination, in other cases religious practices may be only a relatively small part of the aggregated considerations.” Guardianship of Roe, supra at 445-446.

Third, the impact of the decision on the ward’s family must be considered. In Guardianship of Roe, supra at 446, we indicated that this factor is primarily relevant when the patient is part of a closely knit family. The consideration of impact on the family includes the cost in money and time that the family must bear, together with any desire of the patient to minimize that burden. In addition, a patient *506 may be faced with “two treatments, one of which will allow him to live at home with his family and the other of which will require the relative isolation of an institution.” Id. The judge may then consider what affection and assistance the family may offer. However, the judge must be careful to ignore the desires of institutions and persons other than the incompetent “except in so far as they would affect his choice.” Id. at 447.

Fourth, the probability of adverse side effects must be considered. This includes an analysis of “the severity of these side effects, the probability that they would occur, and the circumstances in which they would be endured.” Id 21

Fifth, the prognosis without treatment is relevant to the substituted judgment decision. It is probable that most patients would wish to avoid a steadily worsening condition. However, the judge must again reach an individualized, subjective conclusion regarding this factor, after examining it from the “unique perspective,” Saikewicz, supra at 747, of the incompetent, Guardianship of Roe, supra at 447.

Sixth, the prognosis with treatment must be examined. The likelihood of improvement or cure enhances the likelihood that an incompetent patient would accept treatment, but it is not conclusive.

Finally, the judge may review any other factors which appear relevant. Guardianship of Roe, supra at 448. See, e.g., note 15, supra, and note 26, infra. After weighing the factors, the judge must reach a substituted-judgment treatment decision. If the judge decides to order treatment with antipsychotic drugs for a committed incompetent patient, the judge should “authorize a treatment program which *507 utilizes various specifically identified medications administered over a prolonged period of time. In such a case, the order should provide for periodic review to determine if the ward’s condition and circumstances have substantially changed.” Guardianship of Roe, supra at 448 n.19. Once the decisions of incompetency and substituted judgment have been made, 22 the burden shifts to the incompetent patient’s guardian to seek modification of the order, should such modification be needed before the time for periodic review.

Questions 6 and 7. “Police power” and the use of anti-psychotic drugs 23 The defendants assert that if they are unable to medicate, hospital administration becomes more difficult, lengths of stay increase, fewer patients can be treated, staff turnover increases and new personnel become more difficult to attract. The defendants also argue that the illness of one patient on a ward may be provocative, exacerbating the illness of other patients, and adversely affecting the doctors’ ability to treat. See Rennie v. Klein, 462 F. Supp. 1131, 1152 n.1 (D. N.J. 1978), remanded, 653 F.2d 836 (3d Cir. 1981), vacated and remanded, 458 U.S. 1119 (1982). In addition, they claim it is more difficult to conduct group therapy in an environment in which they cannot medicate with antipsychotic drugs. However, governmental interest “in permitting hospitals to care for those in their custody [is] not controlling, since a patient’s right of self-determination [is] normally . . . superior to such institutional considerations.” Commissioner of Correction v. Myers, 379 Mass. 255, 266 (1979). See Saikewicz, supra at 744.

*508 In Guardianship of Roe, supra at 437 n.11, we noted that “[c]ommentators and courts have identified abuses of anti-psychotic medication by those claiming to act in an incompetent’s best interests.” In Rogers I, supra at 1375-1376, 1378 & n.49, the judge found that patients were involuntarily medicated with antipsychotic drugs over their objection in nonemergency situations. Cf. id. at 1377 n.45. In Davis v. Hubbard, 506 F. Supp. 915, 926 (N.D. Ohio 1980), the judge found that seventy-three per cent of the patients of Lima (