Mental Health Law

Brief - The Right to Medicate Involuntarily Committed Patients without Consent - Steele v. Hamilton Cty. Community Mental Health Bd., 90 Ohio St.3d 176, 736 N.E.2d 10 (Ohio 2000)

This is an important case dealing with the right to medicate mentally ill patients who are involuntarily committed to state facilities when the patient is unable or unwilling to consent to medication.  At the same time that most states have dramatically reduced their facilities for involuntary commitment, the courts have limited the right to medicate patients without their consent.  This can prevent treatment that would improve the patient's condition, and in the worst cases, dooms the patient to the "least restrictive alternative" of isolation and physical restriction.  Particularly difficult patients who are dangerous to themselves, and not to others, may be released to free up resources for patients who do not refuse medication and thus have at least some hope of improvement.

On July 26, 1997, appellant, Jeffrey Steele, was taken by a police officer to University of Cincinnati Hospital ("University Hospital") after appellant's family reported that appellant was "seeing things and trying to fight imaginary foes." After observing appellant, a hospital physician noted that appellant was "responding to internal stimuli," and the physician recommended that appellant be "hospitalized for [the] protection of others and for stabilization/treatment of psychosis." In accordance with Ohio civil commitment law, he was detained at University Hospital.  After 2 days of observation, R. Gregory Rohs, M.D., a University Hospital physician, filed an affidavit in the Court of Common Pleas of Hamilton County, Probate Division, stating that appellant, because of his mental illness, posed a substantial and immediate risk of physical impairment or injury to himself as manifested by evidence that he was unable to provide for his basic physical needs. Dr. Rohs's affidavit also stated that appellant had a history of odd and paranoid behaviors, including refusing to eat food prepared by his family, talking to himself, making threats to his family, forcing himself to throw up every morning, and failing to bathe or groom. While detained at University Hospital, appellant exhibited substantially identical behavior. The affidavit concluded that appellant was most likely suffering from paranoid schizophrenia.  The court ordered the detention continued and scheduled a commitment hearing and additional expert evaluation.  At the hearing, the probate court found, by clear and convincing evidence, that appellant was mentally ill, and the court ordered that appellant be committed and he was transferred to the Lewis Care Center.

On September 26, appellee, Hamilton County Community Mental Health Board, sought a court order permitting the Lewis Center employees to administer anti-psychotic medication to appellant without his informed consent. A hearing on the motion for forced medication was held on October 31.  At the hearing, three psychiatrists testified that appellant was suffering from a form of schizophrenia, that in the hospital environment appellant was not an immediate danger to himself or others, that appellant lacked the capacity to give or withhold informed consent, that anti-psychotic medication was the only effective treatment for appellant's illness, that the benefits of the medication outweighed the side effects, and that appellant's illness, without treatment, prevented him from being released from the hospital.  The magistrate denied the application, finding "that appellee had not shown by clear and convincing evidence that [appellant] represent[ed] a grave and immediate danger of serious physical harm to himself or others."  After additional proceedings, this refusal to allow medication was upheld by the court and this appeal was instituted.

The Ohio Supreme Court saw the issue as whether a probate court must find that an involuntarily committed mentally ill person is a danger to himself/herself or others before the court may issue an order permitting employees of the commitment facility to administer anti-psychotic medication to the patient against his/her wishes.  The court began its analysis by reviewing the standard cases that establish that patients should not be treated without their consent, but that there are circumstances where this rule must give way for the good of society or for the individual.  The court next reviewed the cases and articles on the difficult balance between the desire to treat a patients who are incompetent to consent to such treatment when the treatment might improve their situation, and the reality that the potential adverse effects of anti-psychotic medication makes this a very severe intrusion into personal autonomy.  Recognizing the difficulty entailed in this balancing, the court looked at two situations: when the patient poses a threat to others; and when the patient poses a threat to himself.  In the case where an emergency exists in which a failure to medicate a mentally ill person with anti-psychotic drugs would result in a substantial likelihood of physical harm to that person or others, medical personnel must make the determination whether the patient is an imminent danger to himself/herself or others, without a court hearing:  The court stressed that this is a limited power: "The requirement that medical personnel determine that there is an imminent danger of harm cannot be overemphasized. The police power may not be asserted broadly to justify keeping patients on anti-psychotic drugs to keep them docile and thereby avoid potential violence. Moreover, this governmental interest justifies forced medication only as long as the emergency persists. Furthermore, the medication must be medically appropriate for the individual and it must be the least intrusive means of accomplishing the state's interest, i.e., preventing harm. . . . A physician may order the forced medication of an involuntarily committed mentally ill patient with anti-psychotic drugs when the physician determines that (1) the patient presents an imminent danger of harm to himself/herself or others, (2) there are no less intrusive means of avoiding the threatened harm, and (3) the medication to be administered is medically appropriate for the patient."

The court then turned to the situation where the patient poses no severe imminent risk to self or others.  This is no longer a police power action but is an example of the parens patriae power to care for citizens who are unable to take care of themselves. Because this power turns on a person's inability to care for himself/herself, it is legitimately invoked in forced-medication cases only when the patient lacks the capacity to make an informed decision regarding his/her treatment: "The sine qua non for the state's use of its parens patriae power as justification for the forceful administration of mind-affecting drugs is a determination that the individual to whom the drugs are to be administered lacks the capacity to decide for himself whether he should take the drugs.". The court held that: "when an involuntarily committed mentally ill patient, who does not pose an imminent threat of harm to himself/herself or others, lacks the capacity to give or withhold informed consent regarding his/her treatment, the state's parens patriae power may justify treating the patient with anti-psychotic medication against his/her wishes."

The court went on to address a subtle issue in involuntary commitment, at least under the Ohio standards and those in some other states: the court's finding that an individual poses a threat to self or others and must be committed is separate from the determination that the person is mentally incompetent to make decisions such as consenting to medical treatment.  The court argues that making the commitment decision a de facto finding of incompetence is not essential and unnecessarily limits the patient's rights.  This is true once the court accepted that the parens patria power allows the court order treatment even for patients who have not been adjudged incompetent.  Before this decision, and in states that have not yet accepted this logic, allowing an involuntarily committed patient to veto treatment without review can actually undermine the patient long term autonomy.  (It is equally troublesome in states that allow patients adjudged incompetent to continue to make their treatment decisions unless overruled by a court.)

The court concluded by addressing the procedures required when determining whether the forced medication of a mentally ill person pursuant to the state's parens patriae power outweighs an involuntarily committed mentally ill person's interest in refusing anti-psychotic medication.  The court held that:

"[I]f the patient is not represented by an attorney, then an attorney must be appointed to represent the patient; an independent 'psychiatrist or a licensed clinical psychologist and a licensed physician' must be appointed to examine the patient, to evaluate the recommended treatment, and to report such findings and conclusions to the court regarding the patient's capacity to give or withhold informed consent as well as the appropriateness of the proposed treatment; and the patient, his/her attorney, and treating physicians must receive notice of all hearings and the patient must be provided the opportunity to be present at all hearings and to present and cross-examine witnesses. Of course, the court may implement additional procedures to protect the patient's rights as the court sees fit, such as the appointment of a guardian ad litem to represent the interests of the patient. . . .  Additional procedures, such as periodic hearings to reevaluate the patient's capacity and the efficacy of the treatment, will be necessary in those cases where an order is issued permitting the forced administration of drugs."

This case marks a major shift jurisprudentially for Ohio, but it may mean less in practice.  The procedural safeguards may be so costly as to encourage agencies to either petition to have the patients declared incompetent at the time of commitment, or to discharge them if they refuse treatment, rather than using scarce resources to satisfy the legal requirements for obtaining and maintaining a court order to treat.