Involuntary Forced Medication

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					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.
             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?
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.
                       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.
•   Maryland‟s highest court, the Court of Appeals, found defective
      – 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.
                         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.
                   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
• Transported to Crownsville, and Dr. Silverine Sam interviewed
• 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
       Martin‟s Administrative Law Judge
•   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
Clinical Review Panel ruled Martin to take meds

•   Hospital psychiatrist prescribed Martin medication, but Martin refused to take the
•   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, 1995…found:
     – 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
                  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
  Court upheld the Clinical Review Panel

• ALJ rejected Mr. Martin‟s 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 Martin‟s 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.
              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.
• Maryland‟s highest Court of Appeals was scheduled to hear the
     Arguments to Maryland‟s highest court by
•   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
•   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….
        State‟s 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 patient‟s 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.
                    Hospital‟s 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.
                   Lower Court‟s 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 State‟s 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.
             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
•   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 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 patient‟s will patient‟s attitude and
    expectations (subjective response) about treatment have
    consequences for the efficacy of treatment.
                  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
•   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
    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
•   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 doctor‟s 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.
           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
• Noted that Martin was forcibly medicated and discharged from
  Crownsville Hospital because his condition improved with
• 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.
       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 patient‟s 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
The psychiatrist and patient communication permits the patient to
   incorporate the doctor‟s knowledge whereas non-consensual decision
   making leads to a bad result legally and clinically.
             Court of Appeals opinion

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