APA Weighs In on Cases Where Law Intersects With Psychiatry

What are the rights of pregnant women seeking treatment for substance use disorders and mental illness? Should physicians be allowed to ask patients about firearms in their homes? What kind of accommodations should police officers make for individuals they encounter who have serious mental illness?

Those are three questions to which APA’s Committee on Judicial Action has lent its expertise in court cases that represent compelling challenges for psychiatry.

Committee Chair Marvin Swartz, M.D., and committee members Paul Appelbaum, M.D., and Howard Zonana, M.D., presented facts and background information on three cases in which APA submitted friend-of-the-court briefs in a session titled “Psychiatry in the Courts: APA Confronts Legal Issues of Concern to the Field” at APA’s 2016 Annual Meeting in Atlanta.

Appelbaum, director of the Division of Law, Ethics, and Psychiatry at Columbia University, discussed the case New Jersey Division of Child and Family Services v. Y.N.

“Yvonne” had a history of substance use disorder, including use of painkillers bought on the street. During a medical visit, she learned that she was four months pregnant. A physician urged her to enter a treatment program for addiction, in which she participated through the end of her pregnancy. Upon delivery, the baby went through several days of withdrawal in the neonatal intensive care unit. Subsequently, the Division of Child and Family Services filed an abuse and neglect allegation on the basis of Yvonne’s drug use during pregnancy. The charges, upheld in appellate court, were appealed to the state Supreme Court.

Applebaum noted that a review of such cases found that 29 women in 19 states have been prosecuted on similar charges (although the charges have been upheld in only two states). “So this is not an insignificant issue,” he said.

APA entered a brief in the case, urging that adherence to a treatment plan recommended by a physician can never constitute neglect or wanton abuse or misconduct; that Yvonne should not be punished for entering a methadone treatment program for an addiction that predated her pregnancy; and that pregnant women should not be discouraged from entering methadone maintenance, the most effective treatment for opioid dependence.

When the state Supreme Court ruled, the APA opinion prevailed. “We believe that even the threat of proceedings against a pregnant woman for entering treatment can discourage women from seeking treatment, which leads to adverse events for both mother and offspring,” Appelbaum said. “From our view, the New Jersey Supreme Court decision represents a common-sense approach to statutory law and to a serious public health problem.”

Zonana, a professor of psychiatry and professor of law at Yale University, described the case Wollschlager v. Florida, an ongoing case involving a proposed state law, Firearm Owner Protection Act, which would bar physicians from asking patients about firearms in their homes. A three-judge panel of a circuit court upheld the law, and the full panel of the Circuit Court will hear an appeal.

APA, along with the AMA and numerous other medical groups, filed an amicus brief against the law, stating that discussion of gun safety is a legitimate public health concern and the law violates physician and patient First Amendment rights.

According to the brief, “the Act inhibits physicians from communicating with their patients about issues which may become relevant to their patients’ health and safety. It also inhibits physicians from making a reasonable, inoffensive notation in their patients’ medical records, even though such notation would cause no legally recognized harm to the patient (or anyone else). … Any benefits that might be attributable to the Act, to the extent they may exist at all, are far outweighed by the burdens the Act imposes on the First Amendment rights of physicians and their patients.”

Swartz, a professor of psychiatry and behavioral sciences at Duke University School of Medicine, described City and County of San Francisco v. Sheehan, which involved a mentally ill patient who lived in a group home and threatened to kill her social worker. The police were called, and the woman was shot several times and subdued. The patient later filed suit, claiming that the police infringed her rights under the Americans With Disabilities Act. After several court appeals, the case was sent to the U.S. Supreme Court.

The court remanded the case, and Swartz said it will likely resurface. He noted that there was a wide range of opinion—within the committee and APA—and it continues to be a difficult and challenging issue: what kind of accommodations should police officers make in encounters with individuals who are seriously mentally ill?

“We will continue to follow this case,” Swartz said. “We continue to think the right position is that there ought to be some reasonable accommodations in terms of using Crisis Intervention Teams and training officers about mental illness.” ■