Rennie v. Klein

Citation653 F.2d 836
Decision Date20 July 1981
Docket Number79-2577,Nos. 79-2576,s. 79-2576
PartiesJohn E. RENNIE, Plaintiff on behalf of himself and all others similarly situated, Caroline Mauger, Eugenio Burgeos, Leon Rossi, Hazel Moncrief, Ernie Welker, Mary Jane Weiss, Margaret Mary McGrath, Joseph Kamienski, Intervenors, on behalf of themselves and all others similarly situated, Appellants/Cross-Appellees, v. Ann KLEIN, Commissioner, Department of Human Services; Michail Rotov, M. D., Director of the Division of Mental Health and Hospitals; Max Pepernik, M. D., Acting Medical Director at Ancora Psychiatric Hospital; Robert Wallis, Chief Executive Officer at Ancora Psychiatric Hospital; Engracio Balita, Consuelo Santos, Victor Ivanov, Gerald Abraham, Assistant Medical Directors at Ancora Psychiatric Hospital, Appellees/Cross-Appellants.
CourtUnited States Courts of Appeals. United States Court of Appeals (3rd Circuit)

John J. Degan, Atty. Gen. of N. J., Stephen Skillman, Asst. Atty. Gen., Steven Wallach (argued), Deputy Atty. Gen., Trenton, N. J., for appellees/cross-appellants.

Stanley C. Van Ness, Public Advocate, Sheldon Gelman, Asst. Deputy Public Advocate (argued), Trenton, N. J., for appellants/cross-appellees.

Joel I. Klein, Ellen S. Silberman, Susan L. Carney, Rogovin, Stern, & Huge, Washington, D. C., for amicus curiae, American Psychiatric Assn.

Christopher A. Hansen, Robert M. Levy, Mental Patients' Rights Project, New York Civil Liberties Union, New York City, Robert Plotkin, Mental Health Law Project, Washington, D. C., for amici curiae American Orthopsychiatric Assn., Mental Health Association, Am. Civil Liberties Union of N. J., Alliance for the Liberation of Mental Patients.

Argued April 22, 1980 before ALDISERT, WEIS and GARTH, Circuit Judges.

Reargued In Banc May 12, 1981 before SEITZ, Chief Judge, and ALDISERT, ADAMS, GIBBONS, HUNTER, WEIS, GARTH, HIGGINBOTHAM and SLOVITER, Circuit Judges.


WEIS, Circuit Judge. *

This appeal requires us to define the legal rights of the mentally ill with respect to the care and treatment supplied by the state. We hold that mental patients who are committed involuntarily to state institutions nevertheless retain a constitutional right to refuse antipsychotic drugs that may have permanently disabling side effects. The state may override that right when the patient is a danger to himself or others, but in non-emergency situations must first provide procedural due process. We further determine that the informal administrative procedures established by New Jersey meet constitutional standards, and accordingly, modify a district court injunction that required a formal adversary hearing and other measures before a patient's refusal can be overriden.

John Rennie has been a patient at the Ancora Psychiatric Hospital, a state institution in New Jersey, on numerous occasions since 1973. In several instances, powerful antipsychotic drugs have been administered to him against his will. He brought suit in the district court alleging several violations of his constitutional rights and later amended the complaint to assert a class action. The district court defined a qualified constitutional right to refuse treatment and issued a preliminary injunction directing New Jersey to establish an independent review mechanism that went beyond procedures already prescribed by the state.

Rennie is a forty year old divorced man, a former pilot and flight instructor. In 1971 he first showed symptoms of mental illness, which became more serious in 1973 when his twin brother was killed. Shortly thereafter, Rennie was admitted for the first time to Ancora, one of five hospitals for the mentally ill operated by the state of New Jersey. He was depressed and suicidal and was diagnosed as a paranoid schizophrenic. At various times during his stays, Rennie refused to accept prescribed drugs despite the hospital staff's insistence that it has a right to medicate him against his will. During his twelfth admission to Ancora, which began in August 1976 after an involuntary commitment proceeding, Rennie instituted Rennie's complaint charged the defendants with violating a number of his constitutional rights. 1 By agreement of the parties, the litigation has focused exclusively on motions for preliminary injunctions with respect to the right to refuse treatment, leaving other issues for future determination.

the suit that is the subject of this appeal.

After evidentiary hearings and other proceedings lasting almost a year, the district court issued its first opinion, which recognized a qualified constitutional right to refuse treatment. Rennie v. Klein, 462 F.Supp. 1131, 1144-45 (D.N.J.1978). The court held that four factors determine whether treatment may be refused: (1) the physical danger posed by the patient to other patients and the staff at the institution; (2) the patient's mental capacity to decide on his course of treatment; (3) the availability of less restrictive treatments; and (4) the risk of permanent side effects from the medication. See id. at 1145-46.

Finding that its hearings satisfied procedural due process insofar as Rennie was concerned, the court, nevertheless, felt it "appropriate to comment on ... the shortcomings of the state's new Bulletin 78-3 regarding psychotropic medication." 2 Id. at 1142. The state's failures to provide for an attorney and independent psychiatrists to assist the patient in asserting his right to refuse treatment were particularly faulted. Id. at 1147.

Rennie later moved to amend his complaint to include class action allegations. 3 The district court granted this motion and conditionally certified three subclasses. The first consists of persons who are or may be hospitalized at Ancora and asserts violations of the right to adequate treatment and safe confinement. The claims of this group have not yet been determined.

The second subclass consists of all adult patients involuntarily committed to any of the five state mental health facilities Ancora Psychiatric Hospital, Marlboro Psychiatric Hospital, Trenton Psychiatric Hospital, Greystone Park Psychiatric Hospital, and the Glen Gardner Center for Geriatrics. The third subclass is composed of all adult patients voluntarily committed to these five institutions. 4

Further proceedings focused on the motions by the latter two subclasses for a preliminary injunction to enforce a right to refuse treatment. Seventeen days of additional hearings were held and an opinion The court ruled that the procedures promulgated in Administrative Bulletin 78-3 were insufficient to protect the substantive constitutional right it had recognized. In the district court's opinion, review of the attending psychiatrist's recommendation by the medical director was inadequate because institutional pressures would prevent him from exercising independent judgment. Additionally, the failure to provide procedures for obtaining informed consent, including a written form signed by the patients, was cited. 476 F.Supp. at 1309-10.

was issued on September 14, 1979. Rennie v. Klein, 476 F.Supp. 1294 (D.N.J.1979). The district court reaffirmed its earlier conclusion that involuntarily committed patients have a substantive constitutional right to refuse medication and extended this right to voluntarily committed patients. The opinion concentrated, however, not on the substantive aspects of the right to refuse treatment, but on its procedural features.

The court issued a preliminary injunction that requires the state hospitals to hold hearings to determine whether patients may be medicated against their will. The state must also provide a "patient advocate" to represent patients at hearings, and must retain independent psychiatrists to make the ultimate determination at those hearings. In addition, consent forms are mandated and provisions for administering drugs in an emergency are outlined. The staffs are also directed to file monthly reports on implementation of the decree. 476 F.Supp. at 1313-15.

The parties cross-appeal from the district court's order. 5 The defendants contend that the district court erred in recognizing a constitutional right to refuse treatment. In the alternative, they argue that the procedures embodied in Administrative Bulletin 78-3 are sufficient to protect any such right.

The plaintiffs assert that the relief ordered by the district court is inadequate. They contend that independent psychiatrists retained by and responsible to the Commissioner of the Department of Human Services cannot be the neutral decisionmakers required by the due process clause. Similarly, an attack is leveled against the effectiveness of the system of patient advocates who, likewise, would be retained by and responsible to the defendant Commissioner. Finally, plaintiffs challenge the portion of the court's order that permits a doctor to medicate the patient by declaring him to be "functionally incompetent," a procedure they say can allow the circumvention of the mandatory review of all refusals of medication.


We first consider the appropriate scope of review. Generally, in an appeal from the grant of a preliminary injunction we are limited to determining whether there has been an abuse of discretion, an error of law, or a clear mistake in the consideration of the proof. Oburn v. Shapp, 521 F.2d 142, 147 (3d Cir. 1975). This narrow standard of review springs from the realization that the proof at a hearing for a preliminary injunction is abbreviated and that the trial court, under time pressures, may not have the opportunity for the more mature consideration of issues that is expected in usual adjudications. See United States Steel Corp. v. Fraternal Association of Steelhaulers, 431 F.2d 1046, 1048 (3d Cir. 1970).

Our review takes into account the factors that the district court considers in ruling on an application for a preliminary injunction. The moving party


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