Rogers v. Okin

Citation634 F.2d 650
Decision Date25 November 1980
Docket Number79-1649,Nos. 79-1648,s. 79-1648
PartiesRubie ROGERS et al., Plaintiffs, Appellees and Cross-Appellants, v. Robert OKIN, M.D. et al., Defendants, Appellants and Cross-Appellees.
CourtUnited States Courts of Appeals. United States Court of Appeals (1st Circuit)

Richard W. Cole, Roxbury, Md., with whom Robert Burdick, Clyde D. Bergstresser, Shubow, Stahlin & Bergstresser and Michael Haroz, Boston, Mass., were on brief, for Ruby Rogers, et al.

Stephen Schultz, Administrative and Legal Counsel, Boston, Mass., with whom, Francis X. Bellotti, Atty. Gen., Boston, Mass., was on brief, for Robert Okin, et al.

Joel I. Klein, Washington, D. C., with whom Ellen S. Silberman and Rogovin, Stern & Huge, Washington, D. C., were on brief, for American Psychiatric Association, amicus curiae.

Christopher A. Hansen, New York City, with whom Robert M. Levy, New York City, and Robert Plotkin, Washington, D. C., were on brief, for The American Orthopsychiatric Association, The Mental Health Association, the Civil Liberties Union of Massachusetts, and The Mental Patients' Liberation Front, amici curiae.

Thomas F. O'Hare, Wellesley, Mass., and Susan F. Kendall, Law Student, Boston, Mass., on brief, for The Mental Health Legal Advisors Committee, amicus curiae.

Patrick R. Carroll, Boston, Mass., and William T. McGrail, Clinton, Mass., on brief for The Massachusetts Hospital Association, Inc., amicus curiae.

Before COFFIN, Chief Judge, CAMPBELL, Circuit Judge, DAVIS, Judge, U.S. Court of Claims. *

COFFIN, Chief Judge.

These appeals are the latest stage in a lengthy and complex civil rights action concerning the practices at Massachusetts state mental health facilities. Plaintiffs are voluntary and involuntary psychiatric patients at Massachusetts state mental health facilities. Defendants are the state Commissioner of Mental Health and various hospital officials and physicians responsible for plaintiffs' care. The full factual background and procedural history are set forth in the published opinion of the district court, Rogers v. Okin, 478 F.Supp. 1342 (D.Mass.1979), and will not be repeated here. Two chief issues are raised in these cross-appeals from the district court judgment: I. Under what circumstances may state officials forcibly administer antipsychotic drugs to mental health patients without violating the Fourteenth Amendment? II. Did the district court correctly find that an award of monetary damages to plaintiffs under 42 U.S.C. § 1983 or various state causes of action was not warranted? On the latter issue, we fully concur with the judgment of the district court. With regard to the former, we are in substantial agreement with portions of the district court's reasoning, but find that several important aspects of the court's ruling require modification.

A. Nature of the Individual Right

We begin our analysis with what seems to us to be an intuitively obvious proposition: a person has a constitutionally protected interest in being left free by the state to decide for himself whether to submit to the serious and potentially harmful medical treatment that is represented by the administration of antipsychotic drugs. 1 The precise textual source in the Constitution of the protection of this interest is unclear, and the authorities directly supportive of the proposition itself are surprisingly few. Nevertheless, we are convinced that the proposition is correct and that a source in the Due Process Clause of the Fourteenth Amendment for the protection of this interest exists, most likely as part of the penumbral right to privacy, bodily integrity, or personal security. See Parham v. J. R., 442 U.S. 584, 626, 99 S.Ct. 2493, 2516, 61 L.Ed.2d 101 (1979) (Brennan, J., dissenting on other grounds); Rennie v. Klein, 462 F.Supp. 1131, 1144-45 (D.N.J.1978) (on motion for preliminary injunction); In Re KKB, 609 P.2d 747 (Okl.1980); Superintendent of Belchertown v. Saikewicz, 373 Mass. 728, 370 N.E.2d 417 (1977); cf. Ingraham v. Wright, 430 U.S. 651, 673, 97 S.Ct. 1401, 1413, 51 L.Ed.2d 711 (1977) ("Among the historic liberties (protected by the Due Process Clause) was a right to be free from ... unjustified intrusions on personal security."); Breithaupt v. Abram, 352 U.S. 432, 439, 77 S.Ct. 408, 412, 1 L.Ed.2d 448 (1957) ("right of an individual that his person be held inviolable"). See generally, Developments in the Law Civil Commitment of the Mentally Ill, 87 Harv.L.Rev 1190, 1194-96 (1974) (hereinafter cited as Developments ). 2

None of the parties or amici in this suit contest the correctness of this general proposition. With regard to the treatment of the mentally ill in state run institutions, however, defendants point to several state interests that, they claim, override the individual's protected interest and justify the forced administration of drugs. Additionally, defendants contend that within this context, the interests of the individuals to whom the state wishes to administer drugs are fundamentally different from those of individuals who are not mentally ill, and are not in fact inconsistent with the interests of the state. Plaintiffs, on the other hand, while conceding that the interests of the individual are not absolute and can be overridden in certain circumstances, argue that the mere fact that an individual suffers from mental illness and resides in a mental health facility does not constitute such a circumstance. In order to resolve this dispute between the parties, we first examine the various state interests involved.

B. State Interests

As we have indicated, neither defendants nor their amici argue that the state could forcibly administer antipsychotic drugs to a randomly selected "normal" individual. Unfortunately, the plaintiffs in this suit are far from "normal". Instead, suffering from various mental illnesses, they are in the words of the district court "victims of fate shortchanged by life." 478 F.Supp. at 1369. As a result of their afflictions, they are in many instances in desperate need of care and treatment, and, in some cases, are dangerous to either themselves or others. Because of their illnesses, some of these individuals are unable to make any meaningful choice as to whether they should accept treatment, including the administration of drugs. Given these circumstances, the state asserts primarily its police power and its parens partiae power as justifications for the forcible administration of antipsychotic drugs to those individuals who are in state run hospitals as a result of mental illness.

1. Police Power. The parties agree that the state has a legitimate interest in protecting persons from physical harm at the hands of the mentally ill. They also agree that this interest can justify the forcible administration of drugs to a mentally ill person whether or not that person has been adjudicated incompetent to make his own treatment decisions. The district court accordingly held that "a committed mental patient may be forcibly medicated in an emergency situation in which a failure to do so would result in a substantial likelihood of physical harm to that patient, other patients, or to staff members of the institution." 478 F.Supp. at 1365. 3 Plaintiffs have no complaint with this ruling. Defendants, however, have two basic complaints, which they raise on this appeal. First, defendants contend that the district court's definition of emergency is too narrow and should include situations in which "a patient requires the prompt initiation of medication to prevent further suffering by that patient or the rapid worsening of that person's clinical state." Since the state interests sought to be furthered by this proffered definition are its parens patriae interests the desire to treat the patient effectively we shall address that part of defendants' argument in Part I.B.2 of this opinion, infra.

Defendants' second basic complaint is that the necessity of finding a "substantial likelihood of physical harm ..." (see note 3, supra ) is an overly rigid and unworkable requirement. Defendants argue that some mentally ill patients have an identifiable capacity for spontaneous acts of violence but that it is not always possible to determine beforehand whether a specific patient is likely to commit such acts. This problem of prediction is increased, defendants claim, by the prospect that doctors will be second-guessed in section 1983 suits for damages. In sum, defendants assert that the overall effect of following the district court's standard is to increase the incidence of violent acts that otherwise would not occur had a less restrictive standard been used.

The district court rejected this complaint, finding that the actual experience of operating under the standard during the period covered by a temporary restraining order showed defendants' "gloomy forecast" to be "more dramatic than factual". To a certain extent it is clear that throughout this litigation defendants and their supporting amici have erroneously attributed acts of violence to the strictness of the court's standard. Nevertheless, it does appear that the district court may have overlooked or misconstrued evidence of specific acts of violence occurring as a result of defendants' difficulty in applying the court's standard.

For example, at one point during the trial, defendant Gill, director of the Austin Unit of the state hospital, testified that a particular patient on one occasion displayed indications of a possible proclivity towards violence. Defendant, who was aware of the patient's previous favorable medical reaction to the administration of drugs, testified that he would have forcibly medicated the patient as a precaution had he been free to do so. He stated, however, that the indications were not sufficiently clear to enable him to predict that the patient would be likely to commit violence without the medication. He therefore did not medicate the patient, who subsequently seriously injured a staff...

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