SAN FRANCISCO — In a decision that could affect thousands of the mentally ill, a state Court of Appeal ruled Wednesday that mental patients committed involuntarily to health facilities may legally refuse to take anti-psychotic drugs.
The three-member panel held unanimously that patients cannot be forced to undergo such treatment except in emergencies or when a judge--not just a physician--finds they are incapable of making an informed choice.
"Treatment with anti-psychotic drugs not only affects the patient's bodily integrity but the patient's mind, the 'quintessential zone of human privacy,' " Appellate Justice J. Anthony Kline wrote for the court.
The lawyer for a group of mental patients challenging forced treatment said the ruling would have "enormous impact," noting that about 100,000 people are involuntarily committed each year in California.
"The wholesale practice is that the physician makes the decision--presuming these people are mentally incompetent--and then says either take these drugs or we'll hold you down and inject you," said Morton P. Cohen, a law professor at Golden Gate University here. "Now, that practice will stop."
Cohen predicted, however, that relatively few patients would consistently refuse any drug treatment. "Negotiation over the particular drug and the amount can be very useful," he said.
An attorney for a hospital defending involuntary treatment denounced the ruling, saying it made no sense to allow the mentally ill to be forcibly committed and then to let them refuse the care for which they were detained.
"This decision could bring the mental health care system to its knees," said Ezra Hendon, an Oakland lawyer representing St. Mary's Hospital and Medical Center of San Francisco. "This is a potentially tragic medical decision made in the name of an abstract legal proposition. It robs the medical profession of the principal tool for treatment."
The decision may be appealed to the state Supreme Court, Hendon said. If the ruling is not overturned, it will be binding on trial courts throughout the state.
The dispute did not challenge involuntary commitment itself. Under the stringent guidelines of the Lanterman-Petris-Short Act, a person ordinarily may be detained in a mental health facility for from three days to 14 days.
What was at issue was whether an involuntarily committed patient had the right to refuse anti-psychotic drugs, which are used widely for treatment of severe mental and emotional disorders. Voluntary patients have such a right.
Use of such drugs in acute cases has greatly reduced the number of mentally ill requiring hospitalization and the frequency and length of such hospitalizations, according to experts in the field. By the same token, they are intentionally mind-altering and can produce adverse side-effects--such as blurred vision, dizziness, body tremors, drooling or grotesque movements of the face.
Issue of Consent
In a class-action suit against the hospital, lawyers for Eleanor Riese, a 44-year-old San Francisco woman, and other mental patients contended that the Lanterman-Petris-Short Act required their consent before they could be given anti-psychotic drugs.
A San Francisco Superior Court judge refused to rule in favor of Riese and the others. But the appeal court overturned the judge's holding in a 31-page opinion by Kline, joined by Appellate Justices Allison M. Rouse and John E. Benson.
The panel rejected the hospital's contention that because the act did not specifically grant the right to refuse anti-psychotic drugs, that right must be denied to patients.
The act repeatedly indicates that its failure to explicitly grant a right cannot be a basis for withholding that right, the court noted. Other provisions indicate that an involuntary commitment is not to be equated with the inability to participate in treatment decisions, the justices added.
While acknowledging that federal courts had left the treatment question primarily in the hands of physicians, the state was still free to grant greater rights to patients, the panel said.
Judge Must Decide
If a patient refuses to take the drug, it will be up to a judge to decide whether the patient is mentally competent to make that decision, the court said.
"The determination by a physician that an individual is mentally incompetent to refuse drug treatment cannot be exempted from judicial evaluation on the ground that the medical determination rests upon an unimpeachable scientific foundation," Kline wrote.
"The forcible administration of powerful mind-altering drugs also involves moral and ethical considerations not solely within the purview of the medical profession, and must be measured by the social consensus reflected in our laws," he said.
If a patient is held competent and refuses the drugs, he may not be forced to undergo such treatment, the justice said.
Unless incompetence is established, Kline continued, "it is the individual who must have the final say in respect to decisions regarding his mental treatment in order to ensure that the greatest possible protection is accorded his autonomy and freedom."
The ruling is not likely to have a particularly significant impact on treating the mental problems of the homeless, according to James J. Preis, executive director of Mental Health Advocacy Services Inc., a nonprofit public interest law firm in Los Angeles.
Preis noted that studies show most of the homeless have no contact with health authorities. Those who do and have received forced medication were able to stop taking drugs upon their release from health care facilities--and any treatment-effect would end soon thereafter, he pointed out.
"The solution to the problem of the homeless is not medicating them but in providing them money and help through support programs," he said.