Jarvis v. Levine, C2-86-1633

• Decision Date: 07 April 1987
• Docket Number: No. C2-86-1633,C2-86-1633
• Citation: 403 N.W.2d 298
• Parties: Homer JARVIS, individually and on behalf of all others similarly situated, Appellants, v. Leonard W. LEVINE, in his official capacity as Commissioner of Human Services, et al., Respondents.
• Court: Minnesota Court of Appeals

Page 298

403 N.W.2d 298

Homer JARVIS, individually and on behalf of all others similarly situated, Appellants, v. Leonard W. LEVINE, in his official capacity as Commissioner of Human Services, et al., Respondents.

No. C2-86-1633.

Court of Appeals of Minnesota.

April 7, 1987.

Review Granted July 2, 1987.

Syllabus by the Court

1. In nonemergency cases, a person institutionalized as mentally ill has a qualified right synonymous with his or her rights under the United States Constitution to refuse neuroleptic treatment.

2. An institutionalized mental patient's qualified right to refuse neuroleptic treatment in nonemergency cases is subject to the professional judgment of state hospital physicians to administer such medication pursuant to mandatory guidelines.

3. An institutionalized mental patient subjected to involuntary neuroleptic treatment who has exhausted administrative remedies is entitled to a post-medication judicial review, including award of damages, if a showing is made that mandatory guidelines were not followed or that the decision to medicate substantially departed from professional judgment, standards or practices.

4. Here, summary judgment was appropriate when the institutionalized mental patient did not offer evidence to dispute the conclusion that the medical director exercised professional judgment in overruling the Treatment Review Panel or to dispute the conclusion that his physician exercised professional judgment in initiating and continuing neuroleptic treatment.

Charles H. Thomas, Eugenia L. Hedlund, Mankato, Mark A. Bohnhorst, Michael W. Hagedorn, St. Paul, for appellants.

Hubert H. Humphrey III, Atty. Gen., Mary L. Stanislav, Kathy Meade Hebert, Sp. Asst. Attys. Gen., St. Paul, for respondents.

Heard, considered and decided by POPOVICH, C.J., and FOLEY and NIERENGARTEN, JJ.

OPINION

FOLEY, Judge.

This case involves the qualified right of a state hospital patient, involuntarily committed as mentally ill and dangerous, to refuse neuroleptic medication in nonemergency circumstances and the correlative duties of state officials prior to forced administration of such medication. Appellant Homer Jarvis commenced this action for damages pursuant to 42 U.S.C. Sec. 1983 and for declaratory and injunctive relief on behalf of himself and others similarly situated. ¹ Four claims are asserted in the complaint: (1) that the Minnesota Department of Human Service (DHS) employees failed to comply with the DHS Involuntary Medication Policy; (2) that failure to follow DHS policy violated appellant's constitutionally protected rights to liberty and privacy; (3) that the DHS violated appellant's statutory right to treatment; and (4) that the absence of judicial review prior to involuntary administration of medication violated appellant's procedural due process rights.

Respondents Leonard W. Levine, Dr. Brian Gottlieb and Dr. Steven Doheny, in their official capacities, moved for summary judgment on all counts and asserted that they were immune from damages. Appellant moved for partial summary judgment on the fourth count only, seeking a determination that he was entitled to judicial review of any future plan to medicate him with a major tranquilizer.

In June 1986, the trial court granted respondents' motion for summary judgment on all counts and denied appellant's motion for partial summary judgment. Judgment was subsequently entered. Appeal is taken from those portions of the judgment denying any right to judicial review of the medication decision in this case or future cases and the finding that respondents were immune from damages. We affirm as modified.

FACTS

Appellant was civilly committed as mentally ill and dangerous to the Minnesota Security Hospital in March 1977 following the shooting death of his sister. He has undergone four courses of involuntary neuroleptic medications since then. ² This case involves the most recent of these episodes.

Appellant's mental illness, diagnosed as paranoid schizophrenia, includes a fixed delusion that hospital personnel and court officials have conspired to commit him indefinitely. In particular, appellant believes that the neuroleptic medications he receives are harming and poisoning him. Appellant's illness has led to incidents of verbal abuse and physical violence, as well as threats against staff, family and others. Appellant is nonetheless considered intelligent and articulate, and his self-care skills are entirely intact. An essential feature of his condition is his lack of insight into his illness, specifically that he is ill or in need of professional help. As a result, for most of his stay at Security Hospital, appellant has refused to cooperate in treatment programming, group therapy, individual counseling and psychological interviews.

Neuroleptic Treatment from March 1977 to May 1982

Appellant was first placed on neuroleptic medication in March 1977. Within one month, he began complaining of tremors in his extremities, blurred vision, tiredness and difficulty with urination. In August 1977, medical reports note that appellant was experiencing severe stiffness of the joints and marked "akathesia," a state of inner restlessness which often causes constant repetitive motions, particularly of the extremities. Appellant's examining physician doubted that significant progress would be made, and medication was discontinued in the summer of 1978.

In November 1978, appellant was restarted on a different neuroleptic medication because of these previous side effects. After a few weeks on this alternate medication, appellant calmed down and became more content. The dosage was increased and supplemented with other drugs. In December 1979, Dr. J.C. Wohlrabe, a psychiatric consultant, noted that appellant appeared "much more content with himself in recent months than a year ago. His motor difficulties related to medication side effects are insignificant at present."

In February 1980, respondent Dr. Steven Doheny, a psychiatric consultant who later became appellant's treating physician, discontinued the neuroleptic medication for a trial period based on his finding of severe akathesia as well as the apparent inability of the drugs to penetrate appellant's delusional system. Appellant remained off neuroleptic medication for approximately one year.

The third course of neuroleptic treatment commenced in February 1981 and ended in May 1982 when appellant refused further medications. Psychiatric consultant Dr. Paul J. Melichar opted to discontinue rather than force the medication "with the full expectation that [appellant] will show a fairly rapid clinical deterioration."

In the intervening months, appellant sought to be transferred from Security Hospital to an open hospital. A special review board denied the petition, concluding that transfer could not be accomplished with a reasonable degree of safety to the public. In September 1984, a three-judge supreme court appeal panel upheld denial of the transfer. Of particular significance is the following notation by the appeal panel: ³

Throughout his hospitalization of seven years [appellant] has continued to be uncooperative, has been off his medication since May of 1982 and continues to be verbally hostile to others, patients and staff alike, and since he went off his medication in May of 1982, his existence of hostility has increased. He is presently in * * * a slow discharge unit and while efforts are made to involve him in the group treatment program, he continues to be uncooperative. Indeed, it is suggested that this type of mental illness enhances the propensity to not cooperate.

(Emphasis supplied.)

The appeal panel's decision was eventually affirmed by this court in Jarvis v. Levine, 364 N.W.2d 473 (Minn.Ct.App.1985). On December 6, 1984 (during pendency of the appeal in Jarvis v. Levine ), a fourth course of neuroleptic treatment was initiated. To implement this fourth regimen of treatment, adherence to the Involuntary Medication Policy contained within the Institutions Manual Guidelines (Manual) promulgated by the Department of Public Welfare in October 1981 was required. Compliance with these standards and whether such procedures comport with statutory and constitutional demands form the basis of this appeal.

Involuntary Medication Policy

The Involuntary Medication Policy sets forth substantive and procedural guidelines which must be followed by Minnesota state hospital personnel prior to involuntary administration of neuroleptic medication in nonemergency cases. ⁴

Substantive Requirements

Two predicate elements must be found in non emergency cases:

a. The patient lacks the ability to engage in a rational decision-making process regarding the acceptance of treatment and is unable to weigh the possible benefits and risks of treatment (the mere fact of disagreement about medication does not in itself constitute evidence of inability); and

b. The patient's behavior has been observed and documented and the patient is found to be suffering from a major mental illness with severe functional incapacity * * *.

Section XII-4030, 2.a. and 2.b. Once these prerequisite findings are made, one of two conditions must additionally be found to initiate neuroleptic treatment. Either:

(1) The patient has a documented history of clearly demonstrated reductions of symptoms during previous treatment with the [neuroleptic drug] and of clearly demonstrated deterioration of function when the [neuroleptic drug] was discontinued; or

(2) The nature of the documented behavior of a committed patient is sufficiently severe and of such duration that the known benefits clearly outweigh the possible risks of the medication.

Section XII-4030, 2.c. (1) and (2) (emphasis supplied).

If the second above condition is found, neuroleptic medications may be involuntarily administered for a trial period provided, however, that:

(a) The trial may not exceed 30 days in length; and

(b) At the end of 30 days the...