Involuntary Forced Medication

1
Involuntary Forced Medication

• Distinguish involuntary forced medication from
  involuntary hospitalization. The latter is the
  process of being hospitalized against your will,
  while the former is being involuntary medication
  after you are hospitalized.

2
Who can be forcibly medicated?

• Before we begin, keep in mind that a voluntarily
  admitted patient in the hospital may refuse
  medications, and is not eligible to be forcibly
  medicated against his or her will. These
  voluntarily admitted patients may chosen to
  accept medication.
• A person referred and committed to the hospital
  for evaluation of competence to stand trial
  and/or criminal responsibility is never eligible
  for forced medication. These pretrial criminal
  defendants may voluntarily accept medication.
• But how about a person who is involuntarily
  committed into the hospital? May this patient be
  medicated against his or her will?

3
What is the criteria for involuntarily medicating
a patient in the hospital?

• In Maryland, the courts have struggled with this
  issue since 1990.
• In 1990, patients in hospitals whom doctors
  wanted to medicate, but who refused the
  treatment, were referred to a clinical review
  panel composed of several hospital staff
  members. Panel staffers receive testimony from
  the treating psychiatrist of the merits of the
  medication treatment for the patient, and hear
  from the patient opposing the medication, and
  make a decision.

4
Williams v. Wilzack

• In 1990, the Court of Appeals, in Williams v.
  Wilzack, 319 Md. 485, found that the clinical
  review panel process failed to provide adequate
  procedural and substantive due process protection
  for the involuntary administration of drugs to
  mental patients.
• Under the old process, a Clinical Review Panel
  could forcibly medicate an involuntary patient
  even though the patient posed no danger to
  himself or others. The basis for medication was
  the benefit of the treatment analysis.
• Marylands highest court, the Court of Appeals,
  found defective procedures,
• no prior notice of the panel meeting
• the right to attend the meeting
• the right to introduce evidence
• the right to appeal
• Following Wilzack, the state relied upon a
  guardianship format.

5
New Standard

• The standards sought to incorporate procedural
  protections, but also it encouraged a negotiation
  process between the doctor and patient instead of
  focusing solely on whether to authorize forced
  medication. It also permitted patients the right
  to appeal.
• Involuntary medication procedures apply to
  involuntarily admitted patients, not voluntary
  patients.

6
Martin v. State facts

• On June 11, 1995, David Martin was taken to North
  Arundel Hospital ER by his brother
• He had walked across a busy road in Baltimore,
  and caused cars to screech to a halt
• Evaluated by two physicians, certified for
  admission to Crownsville
• Transported to Crownsville, and Dr. Silverine Sam
  interviewed him
• Psychotic Symptoms
• He was the chosen by God
• He does not have to eat food like all other
  humans
• He had to go to the trials and tribulations
• He had prior inpatient commitment at St.
  Elizabeths Hospital
• Diagnosed as suffering from Schizophrenia,
  Paranoid Type

7
Martins Administrative Law Judge Hearing

• Within 4 days, Martin was committed into the
  Crownsville Hospital Center at a hearing held at
  the hospital
• Martin found to be mentally ill and dangerous to
  himself
• Doctor testified, and there was no testimony to
  rebut the doctor
• Judge ruled against Martin

8
Clinical Review Panel ruled Martin to take meds

• Hospital psychiatrist prescribed Martin
  medication, but Martin refused to take the
  medication
• Martin denied that he had a mental disorder
• Martin was notified that on June 25, 1995 that a
  Clinical Review Panel would assess the need for
  him to take medication against his will
• Clinical Review Panel met on July 3, 1995found
• Martin suffered from religious delusions,
  believed that he was chosen by God
• Martin further believed he was forbidden to eat
  grape jelly or any other product of the vine.
• He was disruptive in ward meetings
• Martin suspected to have climbed out the ninth
  story window of a hotel prior to his
  hospitalization
• Martin had walked in traffic in Baltimore, and
  was almost hit
• Martin only eats once a day, losing weight

9
Martin appealed decision

• Dr. Sam testified for the state
• Mr. Martin was not violent toward other patients
  or staff nor did he require seclusion,
  restraints, suicidal or homicidal precautions, or
  emergency medications
• He did not have ground privileges at the
  hospital, he was confined and closely observed on
  locked ward
• He was suspicious, delusional, exhibited poor
  judgment
• Dr. Sam testified he would remain ill for long
  time, e.g. indefinitely, without meds, and he can
  not be safely discharged without meds now it is
  a shame to waste his life like that in the
  hospital.
• Dr. McDaniel, hired by Martin, agreed he met the
  criteria for involuntary hospitalization, in that
  he was psychotic, and could not care for himself
  outside the hospital setting, and he was a
  present danger to the community if released

10
Court upheld the Clinical Review Panel

• ALJ rejected Mr. Martins appeal, state made its
  case a preponderance of evidence.
• Held without the medication there was a risk of
  continued hospitalization because of remaining
  seriously mentally ill with no significant relief
  and that Martins psychiatric symptoms cause him
  to be a danger to others in the community and he
  would remain seriously ill for a significantly
  longer period of time with symptoms
• Court held, however, that Martin was not
  dangerous to self or others while inside the
  hospital
• Court held that the criteria for involuntary
  medication is based upon whether the individual
  were to be released into the community today,
  would that individual constitute a danger to
  himself or other persons in the community.

11
Further Appeals by Martin

• Mr. Martin appealed to the Circuit Court for
  A.A. the court sided with the ALJ opinion,
  against Martin.
• Mr. Martin appealed to the Court of Special
  Appeals they reversed, sided with Mr. Martin.
  The Court of Special Appeals, Maryland second
  highest court, held that to be forcibly medicated
  inside a hospital, an individual must be
  determined to be a danger to the himself or
  others in that facility to which the individual
  has been involuntarily committed.
• Marylands highest Court of Appeals was scheduled
  to hear the case.

12
Arguments to Marylands highest court by Martin

• Redundancy By defining dangerousness for
  purposes of involuntary medication as dangerous
  to self or others if released into the community,
  the court uses the same standard as that used for
  civil commitment.
• This is inappropriate, because it does represent
  a significant distinction, in that a person
  forcibly medicated is intruded upon by the state
  more so than one who is hospitalized but not
  forcibly medicated.
• The standard for civil commitment into a hospital
  is no different from the standard of forcible
  medication, suggesting that all persons committed
  into a hospital against their will are subject to
  involuntary medication. There is no distinction
  in the law.
• The preferred statutory requirement should be
  that a patient be currently dangerous to himself
  or others for involuntary medication, which has
  not been met. Section 10-708 was intended to
  apply to danger inside the hospital, not outside
  the hospital. (To do otherwise would obviate the
  need for a special standard applicable to
  involuntary medication. Finally, Martin relied
  upon upon prior decided cases, Greenhilll and
  Chapman, which required dangerousness in the
  hospital for involuntary medication.

13
States View before the high Court

• Martin was an involuntarily committed patient.
  If he is permitted to eventually leave the
  hospital without medication treatment, he would
  be exposed to a risk of harm which had triggered
  his admission into the hospital in the first
  place. This would amount to a revolving door in
  which involuntarily committed persons continued
  indefinitely in and out of the hospitals.
• There was no change in the patients condition
  since his admission into the hospital, he
  remained dangerous.
• The state disagreed with requirement that before
  involuntary medication patient must have shown
  dangerousness inside of hospital milieu. Rather,
  the court should not have substituted its
  judgment for that of the hospital staff.
• There is no obligation to find dangerousness
  inside the hospital under the statute the intent
  of the legislature was to forcibly medicated
  persons who without the medication would pose a
  substantial risk of indefinite hospitalization
  because of the likelihood that he or she will
  continue to to exhibit the mental illness
  symptoms that triggered the hospitalization in
  the first place. That should be the test.

14
Hospitals dilemma

• Hospitals faced an untenable position (catch 22)
  because they either keep a patient indefinitely
  whom they can not effectively treat (wasting
  scare resources), or they release a person who
  remains ill and will quickly become a problem in
  the community, who will likely have to return to
  the hospital.

15
Lower Courts response

• Lower court, Circuit Court in Anne Arundel
  County, had held for the hospital, stating, Once
  an individual is involuntarily committed to a
  mental health facility, the States interest
  becomes one of treating the individual where
  medically appropriate for the purpose of reducing
  the danger he poses to society. The state met
  its burden to show that an individual needs
  treatment for a condition which causes him to be
  a danger to himself or others while interacting
  with the community at large and not solely within
  the confines of Crownsville.
• The Court of Special Appeals had held, An
  involuntary committed patient may be forcibly
  medicated only upon it being determined that
  without medication the individual is a danger to
  the individual or to others in Crownsville...the
  legislature would have used future tense, not
  present tense in writing the code if it intended
  for the dangerousness to be applicable to release
  circumstances. If we were to interpret 10-708
  (g) 3 (I) as urged by the state, then 708 g 3 (I)
  and 10-632(d) 2 (iii) would be redundant.

16
ACLU Brief to Highest Court

• The vast majority of patients in hospitals
  consent to treatment.
• The dire consequences of warehousing
  non-medicated patients are unlikely to occur,
  given the constraints hospitals face on keeping
  patients.
• While psychotropic medication provide the most
  effective treatment for schizophrenia in the
  majority of cases, these drugs are not the
  antibiotics of mental illness. They often times
  merely control symptoms of illness, not cure
  them. There is no symptom relief for a
  substantial number of persons, e.g. 20-25 do not
  respond to treatment with drugs.10 of patients
  deteriorate while taking antipsychotic meds.
  Finally, there is no reliable way to predict one
  will be helped by medication
• Medication is a highly intrusive form of
  treatment with dangerous, irreversible, side
  effects like motor disturbances, akathisia,
  tardive dyskinesia, neuroleptic malignant
  syndrome, etc. Medication does not always result
  in effective treatment outcomes, especially when
  treatment is administered against the patients
  will patients attitude and expectations
  (subjective response) about treatment have
  consequences for the efficacy of treatment.

17
ACLU Brief (continued)

• Finally, forcing medication can create negative
  associations with medication that discourage
  people from voluntarily taking the meds after
  leaving the hospital or lead to total rejection
  of treatment
• The decision to refuse medication by mentally ill
  patient is often rational and therapeutically
  appropriate, and better than taking medication.
  Patient consent to treatment is required.
  Involuntary commitment to hospital does not
  render an individual incompetent to consent to
  treatment.
• There are side effects such as akinesia and
  akathisia have the inevitable effect of retarding
  social skill progress, making patients less
  employable, more likely institutionalized.
• Patient drug refusals can serve to strengthen the
  doctor patient alliance, an opportunity not an
  obstacle most refusers do not persist in
  refusing and feel better about taking the
  medication after dialogue with doctor.

18
American Psychiatric Association Brief

• It was the intention of legislature to allow a
  doctor to provide treatment for involuntary
  patient in circumstances in which the patient was
  found dangerous previously in IVA process,
  dangerous to self or others if released into
  community, and medication will likely prevent
  future dangerousness.
• Mental health professionals and mental hospitals
  are placed in the untenable position of being
  required to hold indefinitely an unmediated
  individual, who would only have the opportunity
  to recover if medicated, to the detriment of the
  individual. This results in an profound adverse
  impact upon patients in hospitals who do not
  accept medication.
• Un-medicated patients interfere with a doctors
  ability to treat individuals, and cause
  disruptions to the milieu.
• The brief cited Supreme Court opinion in
  Washington v. Harper (1990) for the proposition
  that three was little dispute in the psychiatric
  profession as to the efficacy of medication for
  mentally ill who are psychotic. 95 treated show
  improvement within 4-6 weeks.

19
APA Brief continued

• Without the medication the individual is at
  substantial risk of continued hospitalization
  because of (I) remaining seriously mentally ill
  with no significant relief of the mental illness
  symptoms that cause the individual to be a danger
  to the individual or to others (II) Remaining
  seriously mentally ill for a significant longer
  period of time with mental illness symptoms that
  cause the individual to be a danger to the
  individual or to others.
• Noted that Martin was forcibly medicated and
  discharged from Crownsville Hospital because his
  condition improved with medication
• The liberty interests of a patient, seen as a
  long perspective, are served by forcible
  medication, because in that way the patient may
  be released rather than be condemned to
  indefinite confinement. Warehousing patients
  does not support their liberty interests.

20
Assumptions made by Differing Parties

• ACLU denied the assumption that forced medication
  ever works instead it represented that
  medication causes side effects, does not work, or
  does not work well, efforts by psychiatry will
  fail without patient motivation and consent to
  treatment
• Physicians assumed that their medicine helps
  persons in all circumstances in which it is to be
  used, even in circumstances where the individual
  rejects it and expect that patients will respond
  thanks I needed that after their illness
  remits.
• Physicians assume that a patients rejection of
  medication is based upon irrational beliefs due
  to mental disorder, not rational decision.
• Patient assume that their decisions ought to
  supercede those of doctors that patients know
  what helps and should be permitted
  responsibility to care for self motivation to
  get better is increased with patient decision
  making.
• The psychiatrist and patient communication
  permits the patient to incorporate the doctors
  knowledge whereas non-consensual decision making
  leads to a bad result legally and clinically.

21
Court of Appeals opinion

• Court vacated the opinion of the lower court.
• Maryland does not have a clear precedent on this
  issue.