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Right to Refuse Medical Care

Prisoners have a liberty interest, protected by the Fourteenth Amendment, in not being treated against their will. The extent of this liberty interest was defined in Washington v. Harper,215 a case arising from a prisoner's objection to being given antipsychotic medications. The Washington prison system provided elaborate administrative protections before an inmate could be medicated against his will. The Washington Supreme Court rejected these administrative protections as inadequate and required that an inmate be given a full adversarial hearing before being treated against his will:

The [Washington Supreme] Court concluded that the "highly intrusive nature" of treatment with antipsychotic medications warranted greater procedural protections. ... It held that, under the Due Process Clause, the State could administer antipsychotic medication to a competent, non-consenting inmate only if, in a judicial hearing at which the inmate had the full panoply of adversarial procedural protections, the State proved by "clear, cogent, and convincing" evidence that the administration of antipsychotic medication was both necessary and effective for furthering a compelling state interest. (p. 1035)

Mr. Harper, the prisoner who brought this action, claimed that the prison authorities could not medicate him unless he was found to be mentally incompetent in an adversarial hearing. He further alleged that even if he was found to be incompetent, he could be medicated only if the fact finder determined that he would have consented to the medication had he been competent. The U.S. Supreme Court rejected these claims, finding that the prison's policy was constitutionally adequate. The Court's rationale for endorsing the prison's policy is relevant to the general problem of prison health because it accepts expert decision making as a substitute for adversarial decision making.

The Court reviewed the Washington Supreme Court's decision to determine what facts would support a decision to force antipsychotic medication on a prisoner and what procedural protections were necessary to determine those facts. It agreed that Harper had a liberty interest in not being medicated against his will. However, the Court held that this liberty interest was sufficiently protected by the prison's administrative proceeding, which required that a psychiatrist certify the treatment's appropriateness.

The Court's acceptance of expert decision making as a substitute for an adversary hearing seems to be rooted in the limited autonomy granted to prisoners. The Court found that a prisoner's right to refuse antipsychotic medication was limited by the conditions of his confinement. In particular, the Court found that the purpose of the prison's medication policy was "to diagnose and treat convicted felons, with the desired goal being that they will recover to the point where they can function in a normal prison environment."

The Court in Harper balanced the prisoner's best interests against the prison's interest in returning him to the general prisoner population and his punishment. The role of the expert decision maker, the prison psychiatrist, was to ensure that the prisoner was mentally ill and dangerous and that medication was appropriate to remedying these conditions. The protection of the prisoner's interests was left to the integrity of the prison psychiatrist. The Court's finding that expert decision making satisfied the prisoner's due process interests reflects the Court's general reticence to interfere in matters of prison safety and security.

Prisoners retain some right to refuse medical care after Harper, but this is severely circumscribed as compared with the rights of a nonprisoner patient. Prisoners may not refuse testing or treatment for a condition that would threaten the health and safety of the prison community, these including communicable diseases and treatable psychiatric conditions. Prisoners may also be forced to accept treatment that is necessary to protect their health from permanent injury. Prisoners with religious objections to medical treatment may be treated against these objections if the treatment is necessary to preserve prison discipline.

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