NYT: Court Rules Mental Patients May Reject Psychiatric Drugging

December 22, 1987 By KATHERINE BISHOP, SPECIAL TO THE NEW YORK TIMES

A panel of the State Court of Appeal has ruled that mental patients who are involuntarily committed to health facilities for short-term crisis care may refuse to take anti-psychotic medications.

In a unanimous ruling Wednesday, the court said patients could not be forced to take the medication unless a judge determined that they were incapable of making an informed decision about their medical care.

Forced administering of powerful mind-altering drugs "involves moral and ethical considerations not solely within the purview of the medical profession," the court said.

The ruling excludes those cases in which emergency intervention is needed to save the patient's life or prevent injury to the patient or others. It is expected to affect the treatment of tens of thousands of patients statewide.

California law provides a set of strict guidelines under which a person can be involuntarily committed for periods of 72 hours to 14 days. While detained, the person is frequently medicated, often by forcible injection. Drugs Substitute for Restraints

Commonly prescribed anti-psychotic medications, including Thorazine, Haldol, Mellaril, Stelazine and Prolixin, are most commonly used to treat chronic schizophrenia. Many mental health professionals believe the drugs eliminate the need for straitjackets and other physical restraints in the hospital and help control delusions and hallucinations that prevent the patient from functioning in the community.

In recent years, these drugs have come under increasing attack from advocates of mental patients' rights, in part because of side effects including drowsiness, restlessness, blurred vision and an irreversible involuntary movement of facial muscles known as tardive dyskinesia.

The case here involved St. Mary's Hospital and Medical Center of San Francisco, a private hospital that contracts with the city for some public patients. It was brought on behalf of patients including Eleanor Riese, 44 years old, who developed physical symptoms after the frequent administering of anti-psychotic medication.

In its ruling, the court said that while state law does not explicitly say that involuntary patients may refuse medication, it does extend to all patients the right to refuse medical treatment unless a judge finds after an evidentiary hearing that they are incompetent to make such a decision.

Morton P. Cohen, a lawyer and professor of law at Golden Gate University Law School in San Francisco who represented the patients, said that the people most likely to be treated with the drugs in a short-term care situation were either those experiencing a crisis such as suicidal feelings, or chronic patients, many of whom are among the homeless population, who can make decisions about their treatment even though they may be delusional. Case May Be Appealed

Ezra Hendon, the Oakland lawyer who represented the hospital, said the case may be appealed to the State Supreme Court.

"I think the decision is unfortunate because it proceeds from a fundamentally illogical premise that you can take people and treat them against their will and then give them the right to refuse treatment,"Mr. Hendon said.

It is not yet known how the courts will deal with the increased need for judges to make rapid determinations as to patients' competence.

* Copyright 2006 The New York Times Company

May 29, 1983 Ideas & Trends in Summary; Mental Patients Get Their Say In California By MARGOT SLADE AND WAYNE BIDDLE

The drugs used to treat serious mental illness can also incur harrowing side effects including body tremors, contortions and stupor. It is the dark side of institutional therapy and in lawsuits nationwide many patients are refusing to accept it. Efforts to reach agreements in New York, New Jersey and Massachusetts are pending in Federal appeals courts. But one major settlement is in and affirms a right to refuse drugs by patients confined involuntarily to California's mental hospitals.

The settlement, approved by Federal District Court Judge William H. Orrick earlier this month, applies to Napa State Hospital, but is to be extended to other state facilities after a year of monitoring by the court. Dr. Howard Gurevitz, president of the California Psychiatric Association, called it a "livable solution" since it "accepts the necessity for medical judgment" in treatment decisions.

The agreement requires doctors to advise involuntary patients of drug side effects and alternative treatments. Patients must give informed consent for drug use and can revoke consent at any time. A panel of outside doctors is to review cases in which physicians feel patients are incapable of giving informed consent or are "substantially deteriorating" and refuse treatment. The exceptions are emergencies in which drugs are administered to "preserve life or prevent serious bodily harm." Emergency decisions must be reviewed within three days.

Unlike treatment review processes proposed in other states, California's program defines a patient's capacity to refuse drugs. According to Prof. Mort Cohen of Golden State University Law School, the lead counsel for the Napa patients, "If refusal is a product of mental illness, the patient is not competent. But if refusal grows out of abhorrence to side effects, the patient is competent and cannot be medicated."

Dr. Paul S. Appelbaum, an assistant professor of psychiatry and law at the University of Pittsburgh, said California's settlement goes beyond most recent lower court decisions in other states, which recognize "a right to object to drugs and have their appropriateness reviewed, but not an absolute right of refusal."

* Copyright 2006 The New York Times Company