457 U.S. 291 (U.S. S. Ct.); remanded sub nom., Rogers v. Okin, 738 F.2d 1; certifying questions to sub nom., Rogers v. Commissioner of Department of Mental Health, 458 N.E.2d 308
Brief(s) Filed: 9/81 (U.S. S.Ct) and 1/83 to (Mass. S.Ct.)
Court: Supreme Court of the United States; Supreme Judicial Court of Massachusetts
Year(s) of Decision(s): 1982 (U.S. S. Ct) & 1983 (Mass. S. Ct.)
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Whether a patient institutionalized in a state psychiatric facility has the right to refuse the administration of antipsychotic medication
Medication (Right to Refuse)
In 1975, several patients at Boston State Hospital filed a federal class action suit challenging certain of that hospital's medication and seclusion policies. The plaintiffs alleged that the state impermissibly followed a policy of forcibly medicating committed mental patients and as a consequence denied them their constitutionally protected right to refuse treatment. They sought an injunction against the hospital for all members of the class and money damages for the individuals who brought the suit. The state maintained that committed patients were per se incompetent to make treatment decisions — that both voluntary and involuntary patients had no constitutional right to refuse treatment in any situation, emergency or otherwise — and the state denied that any patient was forcibly medicated except in psychiatric emergencies. The district court held that: committed patients are presumed competent to make non-emergency treatment decisions, but involuntary patients could be forcibly medicated in emergencies where there was a substantial likelihood of physical harm to the patient, other patients or staff; voluntary patients had the same right to refuse medication as a committed patient; and the plaintiffs had a right to the requested injunction, but could not collect money damages. On appeal, the U.S. Court of Appeals for the First Circuit affirmed that persons generally had the right to decide for themselves whether to submit to antipsychotic drugs. However, the First Circuit rejected the lower court's standard for determining when medications could be given involuntarily. It opted for a balancing between the interests of the patient in refusing medication and the interest of the state in preventing violence. The physician was to perform the balancing test and make the ultimate medication decision. The First Circuit also upheld the trial court's holding that mental illness did not render a person incompetent to make treatment decisions. However, the court disagreed with the trial judge that forcible medication, absent an emergency, could be administered only after an adjudication of incompetence and approval by an appointed guardian. The First Circuit rejected the trial court's holding that voluntary patients could refuse medication, finding that a voluntary patient could either accept treatment or leave the hospital. The state petitioned the U.S. Supreme Court for review and it was granted. APA agreed to submit an amicus brief in support of the plaintiff mental patients. The brief was in support of the decisions by the lower courts — or in the alternative, APA suggested that Massachusetts law might provide alternative grounds for finding that mental patients have a right to refuse medications. The American Psychiatric Association took the contrary view, arguing that no such constitutional right exists. The Supreme Court remanded the case to the First Circuit for a determination of the rights of the parties under Massachusetts law. That decision was Rogers v. Okin. On remand, the First Circuit certified nine questions of Massachusetts law to the Supreme Judicial Court of Massachusetts.
APA submitted another brief in support of the plaintiffs to the Supreme Judicial Court of Massachusetts. The brief argued that: (1) the law of Massachusetts guarantees a right of personal autonomy and freedom from unauthorized bodily intrusions, a right offended by the involuntary administration of psychotropic drugs to (a) a person competent to make treatment decisions for himself, and (b) an incompetent person who would choose not to be medicated with such drugs if he were competent; (2) the civil commitment decision in Massachusetts is not equivalent to a judicial determination of incompetence to make treatment decisions, and the civil commitment decision is different from a determination that the Commonwealth may forcibly medicate an involuntarily committed person with psychotropic drugs; (3) a person competent to make treatment decisions should have an absolute right to refuse such medications; and (4) the question of competency can be made only by a court, not by hospital personnel, except (a) where a patient presents an imminent threat of physical harm to himself or others or (b) where the patient's mental condition would suddenly and irreversibly deteriorate without administration of the drugs. In that case, they may be administered on an interim basis until a court could make a determination of incompetence and a substituted judgment decision.
The Supreme Judicial Court of Massachusetts stated its appreciation for "the helpful analysis of the issues in amicus curiae briefs by . . . the American Psychological Association", among others, and ruled that involuntarily committed patients may be competent to make treatment decisions unless the patient's incompetence is determined by a judge. If so determined, the judge must make a substituted judgement decision deciding whether the patient would have consented to the medication if competent. A patient may also be treated with antipsychotic medication against his will without prior court approval to prevent the "immediate, substantial and irreversible deterioration of a serious mental illness" but a court must make a substituted judgement determination at the earliest possible opportunity.