State Can Forcibly Medicate Nonviolent Patients, Court Rules

The Ohio Supreme Court has ruled that involuntarily committed psychiatric patients can be forced to take antipsychotic drugs even if they are not a danger to themselves or others.

In a unanimous decision the justices agreed that once a court has declared a patient incompetent to make medical decisions and to give informed consent, the state can step in and force him or her to take medication when there is no “less-intrusive” form of “appropriate” treatment available and taking the medication “is in the patient’s best interest.”

In evaluating that best interest, the state must weigh a medication’s likely benefits to the patient against its side effects, which in the case of antipsychotic drugs, the court noted, can be severe and debilitating. The court cited tardive dyskinesia, neuroleptic malignant syndrome, and Parkinsonian syndrome as examples of these often irreversible side effects.

Justice Andrew Douglas, who wrote the decision, recognized the serious nature of depriving a person, including a severely psychotic one, of his or her liberty interests, which are guaranteed by the 14th Amendment to the Constitution. He noted that the justices strove to find a balance between paternalism and “compelling government interest” on the state’s part and the right to autonomy on the patient’s.

Douglas explained in the October 18 opinion that the justices “attempted to craft a decision that acknowledges a person’s right to refuse antipsychotic medication, and yet recognizes that mental illness sometimes robs a person of the capacity to make informed decisions.” He emphasized, however, that “it is clear that mental illness and incompetence are not one and the same.”

The judge acknowledged how these antipsychotic medications revolutionized the care of psychiatrically ill people beginning in the 1950s and how failing to compel some incompetent people to take them would signal a return to “the warehousing of those patients.” Douglas added, “Such a result is inhumane and, therefore, unacceptable.”

The court ruled that patients who refuse medication that the state wants to prescribe are entitled to make use of legal counsel and have an independent psychiatric evaluation before the forced medication regimen can be started. The evaluation is to be conducted by a “psychiatrist or a licensed psychologist and a licensed physician.”

Jonathan Dunn, M.D., president of the Ohio Psychiatric Association, said that he is “cautiously optimistic that this decision will work as the court intended.” He added that he hopes that this ruling “will be a step toward reducing the intense suffering that occurs when people are actively ill, and their illness interferes with their ability to obtain the treatment they need.”

The case, Steele v. Hamilton County Community Mental Health Board, began in July 1997 when Jeffrey Steele’s family called police after he began “seeing things and trying to fight imaginary foes.” Steele had a history of paranoid behavior and had often failed to see to his personal hygiene. Police took him to University of Cincinnati Hospital, where a physician, after determining he posed an imminent risk of physical harm to himself, filed an affidavit allowing the hospital to detain Steele. A probate court ordered him committed, and the university hospital eventually transferred him to a psychiatric facility where he could be better monitored and treated.

The transfer facility, the Pauline Warfield Lewis Center, then sought a court order allowing staff to give Steele antipsychotic medications against his will. This required another legal hearing at which three independent psychiatrists testified that Steele had schizophrenia, was not an immediate danger to himself or others, and lacked the capacity to give informed consent. They agreed as well that medication was the only effective treatment for his illness and that its benefits outweighed potential side effects.

The magistrate hearing the case rejected the center’s request to use forced medication based on a lack of evidence that Steele “represent[ed] a grave and immediate danger of serious physical harm to himself or others.” But the psychiatric center appealed on the grounds that Ohio law does not require a showing of imminent danger before medicating someone against his will.

The appeals court reversed the magistrate’s decision, stating that “an applicant [in this case the hospital] need not prove that an involuntarily committed patient poses a risk of danger to himself or others to obtain an order to forcibly medicate the patient, when the applicant has otherwise shown that medication is in the patient’s best interest, and when the patient lacks the capacity to give or withhold informed consent for such treatment.”

The Ohio Supreme Court agreed with the appeals court’s interpretation of the state law, pointing out as well that the state’s parens patriae power is also a legitimate consideration in the absence of an imminent threat of harm to self or others. A state has a right to intervene against an incompetent patient’s wishes when a citizen is unable to care for himself, the court said, and forcibly medicating an incompetent, involuntarily committed patient falls within this criterion.

Richard Ciccone, M.D., a forensic psychiatrist in Rochester, N.Y., and chair of APA’s Commission on Public Policy, Litigation, and Advocacy, said that he is “impressed with the judges’ insightful approach to mental illness and its treatment.”

He added that the Ohio decision should “send a message to psychiatrists in other states that we must clearly and concisely articulate the facts about mental illness, and when we do, judges will get the message.”

The Ohio court’s decision in Steele v. Hamilton County Community Mental Health Board [90 Ohio St.3d 176] is available on the Web at www.sconet.state.oh.us by clicking on “Current Case Summaries” and then “Summaries Archives.” Once in the archives, click on “October 18, 2000.” ▪