LANDMARK CASES IN FORENSIC PSYCHIATRY:
Right to Refuse Treatment
Application of President and Directors of Georgetown College, 1964
Case Summary:
Jones was brought to Georgetown University Hospital by her husband for emergency treatment after losing a significant amount of blood. She refused a blood transfusion due to her religious beliefs as a Jehovah’s Witness.
Hospital applied to the District Court for approval to administer a transfusion over objection, which was denied.
Court of Appeals judge confirmed with doctors that a transfusion was necessary to save Jones’s life. Her husband remained unwilling to approve transfusion, but a court order would reprieve him of this responsibility. Jones was only able to communicate “against my will.”
Judge found Jones incompetent to make medical decisions and granted permission to override refusal.
Key Concepts:
Refusal of emergency medical treatment by an incompetent patient on the grounds of religious beliefs may be overridden.
Side Note, Unrelated to Case: Competent adults have the right to refuse medical treatment on the grounds of religious beliefs, however, parents may not refuse life-saving treatment for their children due to their religious beliefs.
Rennie v. Klein, 1978
Case Summary:
Rennie was involuntarily committed to a psychiatric hospital. He filed a class action suit, claiming a constitutional right to refuse antipsychotic medications.
The hospital did provide procedural protections, including meetings with the psychiatrist to explain indications, risks, and benefits, as well as approval from the medical director for continued refusal, with weekly medication reviews.
Court of appeals found a constitutional right to refuse treatment, ruling that medication must be the least restrictive alternative.
Case was reconsidered after Youngberg v. Romeo decision, with finding that the standard for overriding medication refusal for civilly committed patients who present a danger to others is professional judgment, and the procedural protections in place were adequate. LRA component was abandoned.
Key Concepts:
Civilly committed psychiatric patients have a right to refuse medication.
The standard for overriding refusal in situations of dangerousness to self/others is professional judgment, which is valid unless a substantial departure from accepted professional judgment, standards, or practice.
Treatment-Driven Model
Rogers v. Commissioner of Department of Mental Health, 1983
Case Summary:
Rogers was part of a class action suit over forced medication of civilly committed psychiatric patients.
Supreme Court of MA found that prior to overriding medication refusal for civilly committed patients, formal judicial competency and substituted judgment determinations are necessary..
Allowed for exceptions for emergencies, such as violence or preventing immediate, irreversible deterioration.
Key Concepts:
A court order and finding of incompetence is required for medication over objection for civilly committed patients in MA outside of emergency situations
Judge is the decision-maker
Rights-Driven Model
Washington v. Harper, 1990
Case Summary:
Harper was a prisoner incarcerated at a psychiatric hospital within the DOC. He began to refuse antipsychotic medications, and subsequently filed a Section 1983 claim, arguing violations of Equal Protection, Free Speech, and Due Process.
The prison’s procedures for overriding treatment refusal included findings of both mental illness and dangerousness/grave disability, as well as right to a hearing and ongoing reviews. There was no formal judicial hearing.
US Supreme Court found that a prisoner’s right to Due Process with respect to involuntary psychiatric medication must be balanced with prison safety and security. The prison’s Due Process protections were found to be adequate.
Key Concepts:
Under the Due Process Clause, a prisoner with a serious mental disorder may receive antipsychotic medication over objection if he represents a danger to self or others, and the medication is in his best interest.
Prisoners’ liberty interests must be balanced with prison safety and security.
A formal judicial hearing is not required prior to overriding treatment refusal, medical professionals may serves as the decision-makers for involuntary medication.
Hargrave v. Vermont, 2003
Case Summary:
Hargrave was under civil commitment at a VT state hospital. The hospital disregarded her existing Durable Power of Attorney refusing psychiatric medications, medicating her over objection in a non-emergent situation.
Hargrave sued, arguing discrimination because of mental illness and ADA violation
Court granted summary judgment in favor of Hargrave, noting that incompetent patients committed to a hospital for non-psychiatric reasons (such as TB treatment) would not have their medical decisions overridden, thus overriding only incompetent psychiatric patients’ medical decisions is discrimination.
Key Concepts:
Disregarding an incompetent patient with mental illness’ preferences for treatment as expressed in a validly executed Durable Power of Attorney is discrimination.
Patients may express a preference for refusing involuntary psychiatric medications in an advance directive.
Sell v. US, 2003
Case Summary:
Dr. Sell was a dentist found incompetent to stand trial on charges of fraud and attempted murder. Antipsychotic medications were administered over objection due to findings of dangerousness.
US Supreme Court found that involuntary medication is permissible to restore competency to stand trial if:
Important government interests are at stake
Treatment is medically appropriate
Treatment is likely to render defendant competent
Treatment is unlikely to cause side effects that will significantly interfere with ability to assist counsel
Treatment is necessary to further government interests, after consideration of less restrictive alternatives
Key Concepts:
Antipsychotic medications may be administered over objection to restore competency to stand trial under specific limited circumstances.