Charles C. Rouse v. Dale C. Cameron, Superintendent, Saint Elizabeths Hospital

In this habeas corpus case appellant attacks his confinement in Saint Elizabeths Hospital. He was involuntarily committed1 in November 1962 by the Municipal Court, now the Court of General Sessions, upon finding him not guilty by reason of insanity of carrying a dangerous weapon, a misdemeanor for which the maximum imprisonment is one year.2 The District Court has held a hearing and denied relief in habeas corpus. It refused to consider appellant's contention that he has received no psychiatric treatment. The judge said:

My jurisdiction is limited to determining whether he has recovered his sanity. I don't think I have a right to consider whether he is getting enough treatment. * * *

* The principal issues raised by this appeal are whether a person involuntarily committed to a mental hospital on being acquitted of an offense by reason of insanity has a right to treatment that is cognizable in habeas corpus, and if so, how violation of this right may be established.

The purpose of involuntary hospitalization is treatment, not punishment.3 The provision for commitment rests upon the supposed "necessity for treatment of the mental condition which led to the acquittal by reason of insanity."4 Absent treatment, the hospital is "transform[ed] * * * into a penitentiary where one could be held indefinitely for no convicted offense, and this even though the offense of which he was previously acquitted because of doubt as to his sanity might not have been one of the more serious felonies"5 or might have been, as it was here, a misdemeanor.

Absence of treatment "might draw into question `the constitutionality of [this] mandatory commitment section' as applied."6 (1) Lack of improvement raises a question of procedural due process where the commitment is under D.C. Code § 24-301 rather than under the civil commitment statute,7 for under § 24-301 commitment is summary, in contrast with civil commitment safeguards.8 It does not rest on any finding of present insanity and dangerousness but, on the contrary, on a jury's reasonable doubt that the defendant was sane when he committed the act charged. Commitment on this basis is permissible because of its humane therapeutic goals.9 (2) Had appellant been found criminally responsible, he could have been confined a year, at most, however dangerous he might have been. He has been confined four years and the end is not in sight. Since this difference rests only on need for treatment,10 a failure to supply treatment may raise a question of due process of law. It has also been suggested that a failure to supply treatment may violate the equal protection clause.11 (3) Indefinite confinement without treatment of one who has been found not criminally responsible may be so inhumane as to be "cruel and unusual punishment."12

Impressed by the considerable constitutional problems that arise because "institutionalized patients often receive only custodial care,"13 Congress established a statutory "right to treatment" in the 1964 Hospitalization of the Mentally Ill Act. The Act provides:

A person hospitalized in a public hospital for a mental illness shall, during his hospitalization, be entitled to medical and psychiatric care and treatment. The administrator of each public hospital shall keep records detailing all medical and psychiatric care and treatment received by a person hospitalized for a mental illness and the records shall be made available, upon that person's written authorization, to his attorney or personal physician.14

It appears that this provision, like the one limiting the use of mechanical restraints,15 was intended to cover persons hospitalized under any statutory authorization. Other sections of the Act apply only to patients "hospitalized pursuant to [the 1964 Act],"16 or to "mentally ill persons,"17 which term is defined by the Act to exclude persons committed by court order in a criminal proceeding.18 Since there are no such limitations in the "right to treatment" provision set forth above, that right necessarily extends to involuntary commitment under D.C.Code § 24-301.^18a

Moreover, the considerations underlying the right to treatment provision in the 1964 Act apply with equal force to commitment under D.C.Code § 24-301. These considerations are reflected in the statement of Senator Ervin, sponsor of the bill in the Senate. He called mere custodial care of hospitalized persons "shocking" and stated that of all the areas in which reform is badly needed, the "right to treatment" was "perhaps the most critical." He further said:

Several experts advanced the opinion that to deprive a person of liberty on the basis that he is in need of treatment, without supplying the needed treatment, is tantamount to a denial of due process. [The Senate bill] * * * embodies provisions which will ameliorate this problem whereas existing law makes no provisions for safeguarding this right.19

Regardless of the statutory authority, involuntary confinement without treatment is "shocking." Indeed, there may be greater need for the protection of the right to treatment for persons committed without the safeguards of civil commitment procedures. Because we hold that the right to treatment provision applies to appellant, we need not resolve the serious constitutional questions that Congress avoided by prescribing this right.

The Group for the Advancement of Psychiatry has urged that "provisions that safeguard the patient's right to good treatment as opposed to simple custody" are an essential element of commitment laws.20 A right to treatment in some form is recognized by law in many states.21 The requirement in the 1964 Act that the hospital keep records detailing psychiatric care and treatment and make them available to the patient's attorney reinforces our view that Congress intended to implement the right to treatment by affording a judicial remedy for its violation.22

The patient's right to treatment is clear.23 We now consider how violation of the right may be established.

According to leading experts "psychiatric care and treatment" includes not only the contacts with psychiatrists but also activities and contacts with the hospital staff designed to cure or improve the patient.24 The hospital need not show that the treatment will cure or improve him but only that there is a bona fide effort to do so. This requires the hospital to show that initial and periodic inquiries are made into the needs and conditions of the patient with a view to providing suitable treatment for him,25 and that the program provided is suited to his particular needs. Treatment that has therapeutic value for some may not have such value for others. For example, it may not be assumed that confinement in a hospital is beneficial "environmental therapy"26 for all.27

The effort should be to provide treatment which is adequate in light of present knowledge. Some measures which have therapeutic value for the particular patient may be too insubstantial in comparison with what is available. On the other hand, the possibility of better treatment does not necessarily prove that the one provided is unsuitable or inadequate.28

It has been said that "the only certain thing that can be said about the present state of knowledge and therapy regarding mental disease is that science has not reached finality of judgment."29 But lack of finality cannot relieve the court of its duty to render an informed decision. Counsel for the patient and the government can be helpful in presenting pertinent data concerning standards for mental care,30 and, particularly when the patient is indigent and cannot present experts of his own,31 the court may appoint independent experts.32 Assistance might be obtained from such sources as the American Psychiatric Association, which has published standards33 and is continually engaged in studying the problems of mental care.34 The court could also consider inviting the psychiatric and legal communities to establish procedures by which expert assistance can be best provided.35

Continuing failure to provide suitable and adequate treatment cannot be justified by lack of staff or facilities. Congress considered a Draft Act Governing Hospitalization of the Mentally Ill prepared by the National Institute of Mental Health and the General Counsel of the Federal Security Agency, which contained the following provision:

Every patient shall be entitled to humane care and treatment and, to the extent that facilities, equipment, and personnel are available, to medical care and treatment in accordance with the highest standards accepted in medical practice. [Emphasis supplied.]

The italicized language was omitted in the present Act. This omission plainly evidences the intent to establish a broader right to treatment.36 As the Fourth Circuit Court of Appeals said of the right to treatment under Maryland's "defective delinquent" statute, "[d]eficiencies in staff, facilities, and finances would undermine * * * the justification for the law, and ultimately the constitutionality of its application." Sas v. State of Maryland, 334 F.2d 506, 517 (4th Cir. 1964).

We are aware that shortage of psychiatric personnel is a most serious problem today in the care of the mentally ill.37 In the opinion of the American Psychiatric Association no tax-supported hospital in the United States can be considered adequately staffed.38 We also recognize that shortage cannot be remedied immediately.39 But indefinite delay cannot be approved. "The rights here asserted are * * * present rights * * * and, unless there is an overwhelmingly compelling reason, they are to be promptly fulfilled." Watson v. City of Memphis, 373 U.S. 526, 533, 83 S.Ct. 1314, 1318, 10 L.Ed.2d 529 (1963).40

One who is "in custody in violation of the Constitution and laws" of the United States is entitled to relief in habeas corpus, and the court is required to "dispose of the matter as law and justice require."41 If the court finds that a mandatorily committed patient, such as appellant, is in custody in violation of the Constitution and laws, it may allow the hospital a reasonable opportunity to initiate treatment. In determining the extent to which the hospital will be given an opportunity to develop an adequate program, important considerations may be the length of time the patient has lacked adequate treatment, the length of time he has been in custody, the nature of the mental condition that caused his acquittal, and the degree of danger, resulting from the condition, that the patient would present if released. Unconditional or conditional release may be in order if it appears that the opportunity for treatment has been exhausted or treatment is otherwise inappropriate. It is unnecessary to detail the possible range of circumstances in which release would be the appropriate remedy.

The government says the record shows that appellant is receiving adequate treatment. Since the District judge found no right to treatment, he did not inquire into the question of adequacy. There was evidence that appellant voluntarily left group therapy several months before the hearing below. But there was no inquiry into such questions as the suitability of group therapy for his particular illness, whether his rejection of this therapy was a manifestation and symptom of his mental illness, and whether reasonable efforts were made either to deal with such rejection or to provide some other suitable treatment. Also, the government psychiatrist said that appellant was receiving "environmental therapy." But the suitability and adequacy of the "milieu" as therapy for this petitioner was not explored.

We think "law and justice require" that we remand for a hearing and findings on whether appellant is receiving adequate treatment, and, if not, the details and circumstances underlying the reason why he is not. The latter information is essential to determine whether there is "an overwhelmingly compelling reason" for the failure to provide adequate treatment.

The appellant challenges also the District Court's finding that he has not recovered his mental health. A person involuntarily committed and confined under D.C.Code § 24-301 is entitled to release if he has "recovered his sanity and will not in the reasonable future be dangerous to himself or others." That the "person so confined has some dangerous propensities does not, standing alone, warrant his continued confinement in a government mental institution under § 24-301 D.C.Code. The dangerous propensities * * * must be related to or arise out of an abnormal mental condition."42 The District Court's findings concerning mental illness and dangerous propensities are not to be disturbed unless they lack support in the record or rest on an erroneous legal principle.

Three psychiatrists gave conflicting testimony. Dr. Economon of Saint Elizabeths testified that appellant was suffering from "anti-social reaction" and described its symptoms. Dr. Marland, in private practice, and Dr. Bunge, of the Commission on Mental Health, testified that appellant was not suffering from mental illness. But we do not reach the question whether the record would have supported a finding of present mental illness and dangerous propensities. For the record shows that in assessing danger the District judge may have relied primarily on the nature of the offense with which the appellant had been charged in 1962 rather than his present condition. For example, the judge said to government counsel, after questioning him and Dr. Marland about the offense:

I venture to suggest, Mr. Silbert, that in these cases that arise out of a criminal proceeding it would be useful to know the facts of the crime in every case, even if you have to dig them up from the files of the Municipal Court, because I have to protect the public. That is the principal thing that I have to consider. I would consider myself derelict in my duty if I released him and then a few weeks later he shot somebody with a .45 Colt automatic. That is why I want to know how he came to be arrested for carrying a gun. He must have done something to call the attention of the police to the fact that he had a gun. The police don't just stop anybody on the street and say, have you got a gun.

* * * * * *

You could talk to the arresting Officer if he is still on the Force. He would probably remember how he came to arrest this man. I think those facts are important.

There is a big difference between releasing a man, say, who overdrew his bank account and one who had a gun. If you release a man who overdrew his bank account, the worst that can happen, he might do it again; but when you release a man who has been carrying a .45 automatic, that is a pretty serious matter.

The judge concluded: "In view of the fact that the original arrest involved a dangerous weapon, an extremely dangerous weapon, with a great deal of ammunition, the Court is not going to undertake to release him unconditionally and would have great hesitancy in releasing him even conditionally." The judge then continued the hearing pending a report from the Commission on Mental Health.

The Commission reported that appellant had "recovered" and that "further confinement would stifle his future development." The hearing resumed with the following colloquy:

Court: The court has before it the report of the Commission on Mental Health. Is this the case in which the petitioner was arrested in possession of a .45 caliber revolver?

Mr. Silbert: With 600 rounds of ammunition, too. This was at 1:45 in the morning at 14th & Harvard Sts. N.W.

The judge then pursued at length with Dr. Bunge, as he had with Dr. Marland, appellant's purpose in possessing a gun and ammunition. At the conclusion of the doctor's testimony the judge said:

I do want to ask you one question, Doctor. I am going to ask you that question in view of the fact that [petitioner] * * * was caught in the possession of a .45 pistol and 600 rounds of ammunition. My principal interest must be to protect the public. Would he be dangerous to himself or others, in your opinion, if he is released?

Dr. Bunge replied: "I don't believe he would be at this time."

The judge made plain not only his reliance on the offense charged, but also his doubt whether the appellant was mentally ill. He said to Dr. Economon, the only psychiatrist who thought him so:

Do you mean to say, Doctor, that to carry — of course I strongly disapprove of anybody carrying a .45 automatic unless he is in uniform and on duty, and * * * of anybody carrying 500 rounds of ammunition, * * * but, certainly, that is not a symptom of insanity, Doctor, because many sane people do those things.

* * * * * *

You know, we just couldn't accept any psychiatric testimony or theory to the effect that the commission of a crime is a sign of mental disease because if we accepted that our whole system of criminal law would have to break down.

* * * * * *

You practically ask us to take your opinion for the sum total of the tendencies and all the data, instead of enumerating the data so that we could test the conclusion that you reach.

Appellant may not be held in custody for an offense of which he was found not guilty.43 Since, as we have pointed out above, he may not be held unless his dangerous propensities "are related to or arise out of an abnormal mental condition"44 and since the case is being remanded for a hearing and findings concerning treatment, the District Court may reconsider and clarify its findings concerning illness and dangerous propensities.45

Reversed and remanded for further proceedings in accordance with this opinion.