Arnold v. Arizona Dept. of Health Services

• Citation: 775 P.2d 521,160 Ariz. 593
• Decision Date: 13 March 1989
• Docket Number: No. CV,CV
• Parties: Charles ARNOLD, Maricopa County Public Fiduciary, as guardian and next friend on behalf of John Goss; Nancy E. Elliston, as guardian, conservator and next friend on behalf of Clifton Dorsett and as next friend on behalf of Richard Schachterle and Susan Sitko; Terry Burch; and on behalf of all others similarly situated, Plaintiffs-Appellees, v. ARIZONA DEPARTMENT OF HEALTH SERVICES, Arizona State Hospital, and Maricopa County Board of Supervisors, Defendants-Appellants. 87-0454-T/AP.
• Court: Supreme Court of Arizona

Page 521

775 P.2d 521

160 Ariz. 593

Charles ARNOLD, Maricopa County Public Fiduciary, as guardian and next friend on behalf of John Goss; Nancy E. Elliston, as guardian, conservator and next friend on behalf of Clifton Dorsett and as next friend on behalf of Richard Schachterle and Susan Sitko; Terry Burch; and on behalf of all others similarly situated, Plaintiffs-Appellees, v. ARIZONA DEPARTMENT OF HEALTH SERVICES, Arizona State Hospital, and Maricopa County Board of Supervisors, Defendants-Appellants.

No. CV 87-0454-T/AP.

Supreme Court of Arizona, In Banc.

March 13, 1989.

Robert K. Corbin, Atty. Gen. by Anthony B. Ching, Sol. Gen., and Robert A. Zumoff, Asst. Atty. Gen., Phoenix, for State defendants-appellants.

Tom Collins, former Maricopa County Atty. by Gordon J. Goodnow, Jr. and Mariannina E. Preston, Deputy County Attys., Phoenix, for defendant-appellant Maricopa County.

Brown & Bain by Amy J. Gittler (formerly Director of Arizona Center for Law in the Public Interest) and Arizona Center for Law in the Public Interest by Tannis Fox, Phoenix, for plaintiffs-appellees.

Mental Health Law Project by Arlene S. Kanter, Washington, D.C., for amici curiae.

SARAH D. GRANT, Court of Appeals Judge, Department D.

I. PREFATORY STATEMENT

The issue presented is whether the state legislature, through various statutes, has mandated that state and county governments provide mental health care to the chronically mentally ill and whether those governments have breached that statutory duty.

We do not here consider any common law duty or obligation of the state or county to care for the chronically mentally ill but only construe the statutes by which the legislature has declared such a duty. Nor do we deal here with the question of funding. The legislature must fund whatever programs it has required and we are not presented with and do not answer the question of what happens if the legislature fails to do so.

The legislature may determine how government will interact with the governed. The constitution and the legislature set forth duties the state and counties have to the people. The legislature may create different duties based on differing needs of parts of the population. In Arizona, as is true elsewhere, a portion of the population is chronically mentally ill. The legislature's response to the particular needs of this portion of our population is the subject of this case.

We write today from the bottom rung of the ladder. The record before us demonstrates that Arizona is last among the states of this union in providing care and treatment for its indigent chronically mentally ill. ¹ This is the first case in the nation in which a trial court has ordered broad and all-encompassing relief for the CMI under a comprehensive state statutory design. The Director of the Arizona Department of Health Services (DHS), the Superintendent of the Arizona State Hospital (ASH), and the Maricopa County Board of Supervisors (the County) sought review in the court of appeals of the trial court's order to create a unified, cohesive, and well-integrated system of community health services for the CMI as mandated by Arizona health care statutes. This court accepted transfer of this appeal from the court of appeals, Division 1, at the request of that court pursuant to Rule 19(a)(3), Ariz.R.Civ.App.P., 17B A.R.S. This court has jurisdiction of this appeal pursuant to Rule 8, Ariz.R.P.Sp.Act, and A.R.S. § 12-2101. We affirm the orders of the trial court.

II. PROCEDURAL HISTORY

On March 26, 1981, the Arizona Center for Law in the Public Interest (the Center) filed this action on behalf of five chronically mentally ill individuals. The named plaintiffs--John Goss, Clifton Dorsett, Richard Schachterle, Susan Sitko and Terry Burch--alleged that the state and county defendants failed to provide them and a class of similarly situated CMI individuals with adequate community mental health

                [160 Ariz. 595] services.  The complaint sought relief under federal law, special action relief in the nature of mandamus pursuant to the Rules of Procedure for Special Actions, 17A A.R.S., and declaratory relief pursuant to A.R.S. § 12-1831 et seq.   The trial court dismissed the federal claims upon the defendants' motion.  On December 1, 1982, it certified the lawsuit as a class action pursuant to Rule 23(b)(2), Ariz.R.Civ.P., 17 A.R.S.  The case was tried to the court.  On January 16, 1985, following post-trial briefing, the trial court determined that the plaintiffs were entitled to judgment.  On June 24, 1985, the trial court signed an order including findings of fact and conclusions of law.  Following an evidentiary hearing, the trial court ordered the defendants to pay costs and attorney's fees.  A judgment was entered on August 1, 1986.  The defendants appealed
                

III. THE CHRONICALLY MENTALLY ILL

A.R.S. § 36-550(3) describes the CMI as:

[p]ersons, who as a result of a mental disorder as defined in § 36-501, paragraph 20, exhibit emotional or behavioral functioning which is so impaired as to interfere substantially with their capacity to remain in the community without supportive treatment or services of a long-term or indefinite duration. In these persons mental disability is severe and persistent, resulting in a long-term limitation of their functional capacities for primary activities of daily living such as interpersonal relationships, homemaking, self-care, employment and recreation.

According to the record chronic mental illness is an incurable illness, although attempts are made to manage it. This illness is characterized by an acute or psychotic phase and a residual phase. A patient in the psychotic phase often suffers hallucinations and delusions and exhibits bizarre behavior. A patient in the residual phase acts less bizarre, but is still unusually vulnerable to stress, which may cause a reversion to the psychotic phase. The residual stage patient is also very dependent, has difficulty relating to others and lacks skills needed for everyday living. The CMI are people whose emotional or behavioral functioning is so impaired as a result of mental illness that they cannot live in society without treatment and economic assistance for an indefinite length of time--often for the remainder of their lives. A.R.S. § 36-550(3). An estimated 4,500 CMI persons reside in Maricopa County. The Center's expert, Dr. Leonard Stein, estimates that only 10 to 15 percent of the CMI could be economically self-sufficient, even when receiving appropriate treatment in the community.

The record contains a thorough history of the treatment of chronic mental illness. According to Dr. Stein, the CMI first encountered problems receiving treatment in the United States in the mid-nineteenth century after the great wave of immigration from Europe. This over-taxed the limited resources available to care for the CMI, further compounded by the fact that no one had the legal responsibility for them. In response to this problem, social crusader Dorothea Dix lobbied for the creation of state hospitals for the mentally ill. As a result of her efforts, the state hospital system in this country began in the mid-nineteenth century.

Most CMI, including those in Arizona, were institutionalized in state hospitals until the mid-twentieth century. ASH reached its peak population in the early 1960's at 1,750 patients. Beginning in 1953, increased usage of psychotropic ² medication, which was effective in controlling the acute psychotic phase of chronic mental illness, allowed mental health institutions to release the CMI into the community. Outplacing of patients into the community, considered the first half of deinstitutionalization, accelerated during the 1960's and 1970's. See Westwood Homeowners' Ass'n v. Tenhoff, 155 Ariz. 229, 231, 745 P.2d 976, 978 (App.1987), review The second half of deinstitutionalization was the creation of a comprehensive, community-based system of care--a system that never really developed in most of the country. The parties to this lawsuit agree that the main elements of such a system should include a full continuum of care: medications, case management, day treatment, crisis stabilization, transportation, residential services, work adjustment, socialization, recreation, outreach, and mobile crises services. Because the psychotropic medications used to control the acute or psychotic phase of the illness are not at all effective in treating the residual impairments, the residual phase must be controlled through social skills training, case management, outreach and other modalities. Like many other major illnesses such as diabetes, cancer, high blood pressure and heart disease, chronic mental illness is not cured by any treatment, but it can be effectively managed. Non-compliance with treatment is a frequent symptom of chronic mental illness but is not an indicator that a CMI person would not benefit from appropriate mental health services.

[160 Ariz. 596] granted Dec. 15, 1987. The census at ASH dropped from 1,750 in 1962 to 450 in 1984.

IV. THE CLASS

The class consists of approximately 4,500 indigent CMI residents of Maricopa County who could reasonably benefit from appropriate medical services. All named plaintiffs are members of the class.

V. THE NAMED PLAINTIFFS

TERRY BURCH

Terry Burch, a high school and junior college graduate, has a long history of mental illness. His first psychotic episode occurred at 17. In his mid-30s at the time of trial, Burch is regarded as a classic casualty of an inadequate mental health care system.

His afflictions are legion. He has had problems with drugs and alcohol and has attempted suicide many times. He has sometimes lived on the street. Doctors diagnosed him as having a bipolar disorder, of the manic-depressive and schizo-affective type. Manifestations of his illness include poor judgment, insensitivity, impulsivity, and bizarre or socially unacceptable behavior such as making threatening arm movements...