Right to Treatment Flashcards
Quid pro quo w/r/t RTT
Give pt something in exchange for loss of freedom
Morton Birnbaum
1960 proposed constitutionally protected RTT for institutionalized MI persons based on substantive due process (committed no crime, so can’t be indefinitely institutionalized w/o medical tx)
1964 DC Hospitalization of the Mentally Ill Act
Person hospitalized in public hospital for MI shall be entitled to medical/psychiatric care and tx
1st Case that Recognized RTT
Rouse v. Cameron (DC COA 1966)
Rouse v. Cameron (DC COA 1966) FOTC
Found NGRI for carrying dangerous weapon (md, =< 1 yr)
Invol to St. Elizabeth’s
Filed habeas corpus
Dis. Court refused to consider contention that had received no tx
Rouse v. Cameron (DC COA 1966) Finding, Basis, and 3 Points
Bazelon recognized RTT based on D.C. statute, but also implied possible constitutional violations.
1. BONA FIDE. Not show that tx will cure/improve, but just bona fide effort to do so
2. Individualized tx plans (initial and periodic inquiries, view towards providing program suitable to his particular needs)
3. Lack of staff/facilities no excuse
Wyatt v. Stickney (AL Trial Court 1971) Background
Originally brought on behalf of pts at Bryce Hospital asking for injunction to prohibit hospital layoffs. Triggered investigation into deplorable conditions at Bryce
Wyatt v. Stickney (AL Trial Court 1971) Main Finding
Main Finding: To deprive of liberty under pretext of altruism/therapeutic then not provide violates due process.
Wyatt v. Stickney (AL Trial Court 1971) 3 Areas Deficient & Additional Point
- Humane psychological/physical environment
- Qualified staff (QMHP’s) in sufficient numbers to administer tx
- ITPs
Point: Agreed w/ Rouse v. Cameron, lack of staff/facilites no excuse
Wyatt v. Stickney (AL Trial Court 1971) 8 Components of Humane Psychological and Physical Environment
- Right to privacy/dignity
- Least restrictive conditions necessary
- Not deemed incompetent to manage affairs solely bc of admission to hospital
- Visitation/telephone comms
- Free from unnecessary/excessive meds
- Free from physical restraint/isolation except emergencies directed by QMHP
- Not subjected to research w/o informed consent
- Suitable opportunities for interaction with members of the opposite sex
Wyatt v. Aderholt (5th Cir COA 1974) (What it was, main finding, and 2 underpinnings)
Same as Wyatt v. Stickney, Aderholt just became superintended before appeal. MF: COA upheld constitutional RTT as in Donaldson v. O’Connor.
1. Confinement must bear some reasonable relationship to purpose of commitment (i.e., tx (Jackson v. Indiana))
2. QpQ theory involves treatment in exchange for loss of freedom
Donaldson v. O’Connor (5th C. COA 1974) FOTC
Donaldson committed to FL State Hospital 1957, dx paranoid schizophrenic, minimal tx in 15 years. Christian Scientist, refused meds/ECT. OT and grounds privileges denied. Donaldson alleged malicious/intentional confinement
Donaldson v. O’Connor (5th C. COA 1974) Outcome and Finding
Jury awarded compensatory and punitive damages against 2 docs
COA held civilly committed person has constitutional RTT “as will give him a reasonable opportunity to be cured or improve his mental condition”
Donaldson v. O’Connor (5th C. COA 1974) Constitutional Basis & 2 Underpinnings
2
O’Connor v. Donaldson (SCOTUS 1975) (what it is, main ruling)
Dr. O’Connor appealed to SCOTUS
SCOTUS said no constitutional basis for involuntarily holding if not dangerous to others and can live safely “with the help of willing and responsible family members or friends”
O’Connor v. Donaldson (SCOTUS 1975) RTT 2 implications
Didn’t fully address/recognize RTT: QpQ argument rejected, said couldn’t really equate constitutional RTT w/ due process
However, noted that 8th A argument could be used, free for harm from abuse, crowding, lack of supervision, improper meds, etc.
O’Connor v. Donaldson (SCOTUS 1975) Later case that 8th A RTT was relevant
Willowbrook
Ending of Most RTT Cases
Consent decrees rather than Court-imposed sanctions
Youngberg v. Romeo (SCOTUS 1982) FOTC
Romeo 33y/o severe ID at Pennhurst in PA. Mother concerned bc 63 injuries in 2yrs. Filed suit said constitutional right to safe conditions of confinement, freedom from bodily restraint, and right to training/habilitation
Youngberg v. Romeo (SCOTUS 1982) Ruling and 3 Interests
SCOTUS ruled did have 14th A Due Process rights to:
1. Reasonably safe conditions of confinement
2. Freedom from unreasonable bodily restraints
3. Minimally adequate training as reasonably to accomplish first 2 interests
Youngberg v. Romeo (SCOTUS 1982) Caveat & Name
Said courts in general shouldn’t second-guess experts in fields better informed, but liability only imposed when “such a substantial departure from accepted professional judgment…to demonstrate that the person responsible did not base decision on such judgment” PROFESSIONAL JUDGMENT STANDARD
Youngberg v. Romeo (SCOTUS 1982) Difference from Wyatt
No personal liability for staff if lack of tx due to lack of funds
Youngberg v. Romeo (SCOTUS 1982) RTT
None!
% Deinstitutionalization 1955 - 1995
92%
2 Historical Justification for Forced Meds
- Parens patriae: king’s power for general good, so for good of pt and their psychiatric condition
- Police powers: state’s right to protect citizens (pts/staff) from harm
3 Gutheil Arguments for Recognizing RTRT
- Competent person has right to control his/her own body
- Religious beliefs against should be respected
- Honor RTRT helps counter stigma/neg views of psychiatric pts/providers
5 Gutheil Arguments Against RTRT
- Increases risk of harm to pts/staff, disruptive
- Long stays
- Increased risk of chronic illness developing
- Can restore competence in multiple domains as opposed to “mind alteration”
- Pt will later thank doc
4 Constitutional Challenges Against Forced Meds
1st A: Free speech (right to generate thoughts/mentation) and religion
8th A
14th A: Due process (free from unjustified intrusions on personal security)
Penumbral: Right to privacy (right to be left alone)
“Treatment Drive Model” (what it is/other name and case)
Model of addressing tx refusal focuses on treatment needs: “needs-driven model”
Rennie v. Klein (3rd C. COA 1983)
Rennie v. Klein (3rd C. COA 1983) FOTC
Rennie 38M intelligent (pilot) but schizophrenia/BPAD early 30s, numerous hospitalizations/med refusals (threatened to kill Ford). 12th hosp Ancora State (NJ), got invol Prolixin when homicidal.
NJ DMH has Admin Bulletin 78-3 which provided refusing pt entitled to review by tx team then medical director
Rennie sued, claiming forced meds violated 1st A (mental processes) and 8th A
Rennie v. Klein (3rd C. COA 1983) Court Process & Findings (3.1)
- 3rd C. upheld const RTRT and least restrictive applied to meds, but also that state’s policy 78-3 was constitutionally sufficient & hearing not required.
- SCOTUS granted cert, but remanded to 3rd C. to reconsider in light of Youngberg v. Romeo’s “accepted professional judgment” consideration.
- 3rd C. reaffirmed RTRT and that policy was adequate, but said least restrictive was not mandated, rather “accepted professional judgment.”
Standard to measure RTRT was dangerousness to self or others.
Rennie v. Klein (3rd C. COA 1983) Key Point
Invol legally competent pts who refuses meds has right to professional medical review of treating psychiatrist’s decision of best for pt. This decision-making process left to medical prof’s judgment
Contrast b/w Rennie v. Klein (3rd C. COA 1983) vs. Rogers v. Okin (MA Dist. Co. 1979)
Decision-making left to medical professional’s judgment (treatment driven) vs. judicial review (rights driven)
Rogers v. Okin (MA Dist. Co. 1979) FOTC
Section 1983 class action lawsuit on behalf of Rubie Rogers (& other pts) by Mental Patients Liberation Front at Boston State Hospital again invol meds
Rogers v. Okin (MA Dist. Co. 1979) R&R (3.2)
Invol meds are Invasion of privacy and 1st A violation.
Invol pts have right to make tx decisions until adjudicated incompetent by judge.
Only emergency invol meds could be administered
Rights Driven Model (what it is and other term)
Model of tx refusal focuses on rights of pts to refuse tx
“Rotting with your rights on”
In the Matter of the Guardianship of Richard Roe III (MA SC 1981) FOTC
Richard Roe (pnym) HS student, schizophrenia, became violent/uncontrollable. Hospitalizations/arrests for A&B. Refused meds. Bc of Rogers v. Okin, recommended parents pursue guardianship. Probate judge found incomp and appointed father guardian, but g-a-litem (appointed to rep Richard) appealed to MA SC
In the Matter of the Guardianship of Richard Roe III (MA SC 1981) R&R
Agreed incompetent and needed guardian/father appro, but said father couldn’t make tx decisions. Said only a judge could conduct “detached but passionate investigation” necessary to decide non-emergency invol meds. Basically if incomp person refuses, parents/guardians must seek judicial determination of what they’d want, aka substituted judgment
In the Matter of the Guardianship of Richard Roe III (MA SC 1981) 6 Factors to Consider for Substituted Judgment
- Ward’s expressed pref
- Ward’s religious beliefs
- Impact on ward’s family
- Possibility of sfx
- Prognosis w/o tx
- Prognosis w/ tx
Rogers v. Commissioner (MA SC 1983) (What it is, Course (4), & Holdings)
Appeal of Rogers v. Okin (MA Dist. Co. 1979).
1st C. COA: Upheld but expanded emergency to include cases where needed to prevent “further suffering of that pt or rapid worsening of his clinical condition.
2. Appealed to SCOTUS, granted cert but remanded back to 1st C. COA in light of MA SC’s Richard Roe III ruling
3. 1st C. COA asked MA SC to render opinion
4. MA SC reiterated position from Roe for judicial decision based on substituted judgment
Utah Model (What it is and 5 Requirements)
Decision-Making Incompetence Required for Civil Commitment, so Lacks Competence for Tx Decisions
1. Pt has MI
2. Bc of MI, poses danger self/others (incl self-neglect)
3. Pt lacks ability to engage in rational decision-makin process regarding medical tx, inability to weigh possible risks of accepting/rejecting
4. Least restrictive
5. Local MH authority can provide adequate tx
Washington v. Harper (SCOTUS 1990) FOTC (4)
-Harper convicted inmate in WA, violent when not on meds.
-Forced meds required 3-person panel majority (incl psychiatrist).
-Harper filed Section 1983 suite of violations of procedural and substantive due process rights (14th A).
-WA COA overrode trial court decision and said antipsychotic admin required full judicial hearing with adversarial protections
Washington v. Harper (SCOTUS 1990) R&R
Said admin review panel rather than judicial hearing appropriate, due process not violated.
Applied Turner test and said administration constitutional as long as it was “reasonably related to legitimate penological interests”
Washington v. Harper (SCOTUS 1990) 3 Things NOT Required
- Consideration of less intrusive means
- Decisional incompetence
- Judicial decision before forcible medication
Sell v. United States (SCOTUS 1993) FOTC
Sell charged with Medicaid fraud & l8r attempted murder. Found IST delusional d/o. Ref meds. COA ruled gov’t interest in restoring competency was serious enough to override liberty interest. Sell appealed.
Sell v. United States (SCOTUS 1993) (Holding, 4 criteria, and additional point)
Invol meds to restore competency allowable in following circumstance:
1. Important gov’t interest at state
2. Medication substantially likely to restore competency and unlikely to have side effects that would interfere
3. Most appropriate method of competency restoration without less intrusive means
4. Medically appropriate “in patient’s best medical interest”
Should rarely be necessary bc gov’t should first utilize other grounds of invol meds, such as emergency for dangerousness or incompetence and guardian consent
State v. Perry (LA SC 1992) FOTC
Perry convicted/sentenced to death for murdering 5 family members. Became psychotic awaiting execution. Trial court found him incompetent and ordered DOC admin forced meds to restore competency
On appeal, SCOTUS remanded in light of Washington v. Harper (SCOTUS 1990)
State v. Perry (LA SC 1992) Ruling (3)
Affirmed Perry’s incompetency, but also couldn’t be medicated against his will to restore competency just to be executed bc “antithetical to basic principles of healing arts.” Also found violated cruel/unusual punishment and LA const R to privacy
Rates of Overriding Refusals
90-100%, regardless of standard
Summary of Refusal Characteristics/Outcomes (7)
- Higher disease severeity
- More likely to require seclusion/restraints
- Negative effects on milieu
- More negative view of tx
- Most refusals end with meds anyway
- Judicial review pretty much always results in meds
- Shorter refusal time w/ physician review instead of judicial
Nationwide Constitutionally Based RTT (& 4 possibilities)
None.
1. Judicial imposition for individual such as Rouse v. Camerona
2. Statistical standards as in Wyatt
3. Malpractice as in Donaldson v. O’Connor
4. Legislative BORs for pts
