Case Title: Steele v. Hamilton Cty. Community Mental Health Bd.

Citation: 2000-Ohio-47

Docket Number: 19991771

State: ohio

Court: Ohio Supreme Court

Date: 2000-10-18T00:00:00Z

Document:
[Cite as Steele v. Hamilton Cty. Community Mental Health Bd., 90 Ohio St.3d 
176, 2000-Ohio-47.] 
 
 
 
STEELE, APPELLANT, v. HAMILTON COUNTY COMMUNITY MENTAL HEALTH 
BOARD, APPELLEE. 
[Cite as Steele v. Hamilton Cty. Community Mental Health Bd. (2000), 90 Ohio 
St.3d 176.] 
Public welfare — Hospitalization of mentally ill persons — State’s interest in 
protecting its citizens outweighs an involuntarily committed mentally ill 
patient’s interest in refusing antipsychotic medication, when — 
Physician may order forced medication of an involuntarily committed 
mentally ill patient with antipsychotic drugs, when — Court may issue an 
order permitting hospital employees to administer antipsychotic drugs 
against the wishes of an involuntarily committed mentally ill person, 
when. 
1.  When an involuntarily committed mentally ill patient poses an imminent threat 
of harm to himself/herself or others, the state’s interest in protecting its 
citizens outweighs the patient’s interest in refusing antipsychotic 
medication.  Authority for invoking the state’s interest flows from the 
police power of the state. 
2.  Whether an involuntarily committed mentally ill patient poses an imminent 
threat of harm to himself/herself or others warranting the administration of 
antipsychotic drugs against the patient’s will is uniquely a medical, rather 
than a judicial, determination to be made by a qualified physician. 
3.  A physician may order the forced medication of an involuntarily committed 
mentally ill patient with antipsychotic 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 
 
 
2 
the threatened harm, and (3) the medication to be administered is 
medically appropriate for the patient. 
4.  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 antipsychotic 
medication against his/her wishes.  In re Milton (1987), 29 Ohio St.3d 20, 
29 OBR 373, 505 N.E.2d 255, modified. 
5.  Whether 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 treatment is uniquely a 
judicial, rather than a medical, determination. 
6.  A court may issue an order permitting hospital employees to administer 
antipsychotic drugs against the wishes of an involuntarily committed 
mentally ill person if it finds, by clear and convincing evidence, that (1) 
the patient does not have the capacity to give or withhold informed 
consent regarding his/her treatment, (2) it is in the patient’s best interest to 
take the medication, i.e., the benefits of the medication outweigh the side 
effects, and (3) no less intrusive treatment will be as effective in treating 
the mental illness. 
(No. 99-1771 — Submitted June 6, 2000 — Decided October 18, 2000.) 
APPEAL from the Court of Appeals for Hamilton County, No. C-980965. 
 
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 
 
 
3 
psychosis.”  In accordance with R.C. 5122.10, appellant was detained at 
University Hospital. 
 
On July 29, in accordance with R.C. 5122.11, 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.  Dr. Rohs’s affidavit 
indicated that, while appellant was hospitalized, appellant was withdrawn, did not 
maintain his hygiene, appeared to have disorganized thought processes, seemed to 
be responding to internal stimuli, refused medications, and appeared guarded and 
suspicious.  The affidavit concluded that appellant was most likely suffering from 
paranoid schizophrenia. 
 
In accordance with R.C. 5122.141, the probate court ordered a hearing, to 
be held on August 1, on Dr. Rohs’s affidavit.  The court further ordered that 
appellant was to be detained at University Hospital pending the outcome of the 
hearing.  Pursuant to R.C. 5122.14, the court appointed a psychiatrist, Cyma 
Khalily, M.D., as an independent expert to examine appellant and report her 
findings to the court.  An attorney was appointed to represent appellant.  See R.C. 
5122.15. 
 
At the conclusion of the August 1 hearing, the probate court found, by 
clear and convincing evidence, that appellant was mentally ill, and the court 
ordered that appellant be committed to a hospital.  R.C. 5122.15.  As a result of 
 
 
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the court’s ruling, appellant remained involuntarily hospitalized at University 
Hospital. 
 
Thereafter, University Hospital sought an order from the probate court 
permitting appellant’s transfer to the Pauline Warfield Lewis Center (“Lewis 
Center”).  The motion stated that the transfer was in appellant’s best interest 
because, due to his mental illness, appellant was unable to comply with his 
required treatment and he needed long-term treatment and/or forced medication 
care.  The probate court granted University Hospital’s motion, and appellant was 
transferred to the Lewis Center on August 12. 
 
On September 26, appellee, Hamilton County Community Mental Health 
Board, sought a court order permitting the Lewis Center employees to administer 
antipsychotic medication1 to appellant without his informed consent.  A hearing 
on the motion for forced medication was held on October 31. 
 
Three psychiatrists testified at the hearing: Dr. Michael Newton, 
appellant’s treating physician at the Lewis Center; Dr. Paul Keck of University 
Hospital; and Dr. Cyma Khalily, the psychiatrist appointed by the probate court.  
All three physicians 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 antipsychotic 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. 
 
At the conclusion of the October 31, 1997 hearing, the magistrate orally 
denied the motion for forced medication.  The magistrate’s decision was centered 
on his 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.” 
 
 
5 
 
Subsequently, the magistrate, on December 3, filed findings of fact and 
conclusions of law in support of his decision.  In part, the magistrate’s report 
concluded that, at the time of the hearing, appellant suffered from a form of 
schizophrenia that resulted in “a substantial disorder of thought [that] grossly 
impair[ed] his behavior and judgment,” requiring “treatment that include[d] in-
patient hospitalization and highly supervised care.”  The magistrate also found 
that appellant was not violent or suicidal or disruptive to the ward in any way.  In 
addition, the magistrate found that appellant lacked the capacity to give or 
withhold informed consent regarding treatment.  The magistrate concluded that 
appellant should not be forcibly medicated. 
 
Appellee, on December 15, filed objections to the magistrate’s findings of 
fact and conclusions of law, arguing that “a showing of dangerousness is not 
required by Ohio law or statute in order to grant the authority for forced 
medications.”  After hearing arguments on the objections, the probate judge, on 
February 19, 1998, remanded the matter to the magistrate “for clarification of the 
Magistrate’s Findings of Fact regarding the severity or gravity of [appellant’s] 
mental illness.” 
 
The magistrate’s rehearing was held on May 22 and May 29, 1998.  
Following the rehearing, the magistrate again denied appellee’s motion for court-
ordered medication of appellant.  On November 9,2 the probate judge filed an 
opinion and entry upholding the magistrate’s findings of fact and conclusions of 
law on rehearing.  In its opinion, the court held that Ohio policy only 
“authorize[d] the forced medication of psychotropic drugs upon a showing that 
the patient has a serious mental illness, is a danger to his or her self or to others 
within the institution, and the treatment is in the patient’s medical interest.”3 
 
On December 8, appellee appealed the probate court’s ruling to the Court 
of Appeals for Hamilton County.  The court of appeals reversed the judgment of 
the probate court and held that “an applicant need not prove that an involuntarily 
 
 
6 
committeed [sic] patient poses a risk of danger to himself or others to obtain an 
order to forcibly medicate the patient, when the applicant has otherwise shown 
that medication is in the patient’s best interest, and when the patient lacks the 
capacity to give or withhold informed consent for such treatment.” 
 
This cause is now before this court pursuant to the allowance of a 
discretionary appeal. 
__________________ 
 
D. Shannon Smith and James R. Bell, for appellant. 
 
Faulkner & Tepe and A. Norman Aubin, for appellee. 
 
Michael Kirkman, urging reversal for amicus curiae, Ohio Legal Rights 
Service. 
__________________ 
 
DOUGLAS, J.  The issue in this case is 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 antipsychotic medication to the patient against 
his/her wishes.  For the reasons that follow, we find that a court may issue an 
order permitting the administration of antipsychotic medication4 against a 
patient’s wishes without a finding that the patient is dangerous when the court 
finds by clear and convincing evidence that the patient lacks the capacity to give 
or withhold informed consent regarding treatment, the medication is in the 
patient’s best interest, and no less intrusive treatment will be as effective in 
treating the mental illness.  Accordingly, we affirm the judgment of the court of 
appeals. 
I 
 
The right to refuse medical treatment is a fundamental right in our 
country, where personal security, bodily integrity, and autonomy are cherished 
liberties.  These liberties were not created by statute or case law.  Rather, they are 
 
 
7 
rights inherent in every individual.  Section 1, Article I of the Ohio Constitution 
provides that “[a]ll men are, by nature, free and independent, and have certain 
inalienable rights, among which are those of enjoying and defending life and 
liberty, acquiring, possessing, and protecting property, and seeking and obtaining 
happiness and safety.”  (Emphasis added.)  Our belief in the principle that 
“[e]very human being of adult years and sound mind has a right to determine what 
shall be done with his own body,”  Schloendorff v. Soc. of N.Y. Hosp. (1914), 211 
N.Y. 125, 129, 105 N.E. 92, 93, is reflected in our decisions.  See, e.g.,  Nickell v. 
Gonzalez (1985), 17 Ohio St.3d 136, 17 OBR 281, 477 N.E.2d 1145 (setting out 
the test for establishing the tort of lack of informed consent); In re Milton (1987), 
29 Ohio St.3d 20, 29 OBR 373, 505 N.E.2d 255 (holding that potentially life-
saving treatment for cancer could not be forced upon mentally ill person who had 
the capacity to give or withhold informed consent). 
 
In Washington v. Harper (1990), 494 U.S. 210, 221, 110 S.Ct. 1028, 1036, 
108 L.Ed.2d 178, 198, the United States Supreme Court determined that persons 
suffering from a mental illness have a “significant liberty interest” in avoiding the 
unwanted administration of antipsychotic drugs.  That liberty interest is protected 
by the Due Process Clause of the Fourteenth Amendment to the United States 
Constitution, which provides that no state shall “deprive any person of life, 
liberty, or property, without due process of law.”  Id. at 221-222, 110 S.Ct. at 
1036, 108 L.Ed.2d at 198.  Likewise, Section 16, Article I of the Ohio 
Constitution encompasses due process language that provides substantially the 
same safeguards as does the Fourteenth Amendment. 
 
The right to refuse medication, however, is not absolute and it must yield 
when outweighed by a compelling governmental interest.  Cruzan v. Dir., Mo. 
Dept. of Health (1990), 497 U.S. 261, 278-279, 110 S.Ct. 2841, 2851-2852, 111 
L.Ed.2d 224, 241-242.  See, also, State v. Williams (2000), 88 Ohio St.3d 513, 
523, 728 N.E.2d 342, 353-354 (“[R]ights outlined in Section 1, Article I [of the 
 
 
8 
Ohio Constitution] will, at times, yield to government intrusion when necessitated 
by the public good”).  In order for us to determine whether a court must find a 
mentally ill person to be a danger to himself/herself or others before it may issue 
an order permitting forced medication, we must first determine which, if any, 
state interests outweigh the individual’s right to refuse medication. 
II 
 
The first step in our analysis is to examine the individual’s interest in 
avoiding forced medication through treatment with antipsychotic drugs.  We will 
then determine under what circumstances, if any, that interest must yield to 
competing governmental interests. 
 
The liberty interests infringed upon when a person is medicated against his 
or her wishes are significant.  “The forcible injection of medication into a 
nonconsenting person’s body represents a substantial interference with that 
person’s liberty.”  Harper, 494 U.S. at 229, 110 S.Ct. at 1041, 108 L.Ed.2d at 
203.  This type of intrusion clearly compromises one’s liberty interests in personal 
security, bodily integrity, and autonomy. 
 
The intrusion is “particularly severe” when the medications administered 
by force are antipsychotic drugs because of the effect of the drugs on the human 
body.  Riggins v. Nevada (1992), 504 U.S. 127, 134, 112 S.Ct. 1810, 1814, 118 
L.Ed.2d 479, 488.  Antipsychotic drugs alter the chemical balance in a patient’s 
brain producing changes in his or her cognitive processes.  Id. at 134, 112 S.Ct. at 
1814, 118 L.Ed.2d at 488; Harper, 494 U.S. at 229, 110 S.Ct. at 1041, 108 
L.Ed.2d at 203.  See, also, Winick, The Right to Refuse Mental Health Treatment 
(1997) 61-65 (“Winick”).  In fact, an alteration of a patient’s cognitive process is 
the intended result of the antipsychotic drugs.  The drugs are administered with 
the expectation that the resulting changes will “assist the patient in organizing his 
or her thought processes and regaining a rational state of mind.”  Harper, 494 
U.S. at 214, 110 S.Ct. at 1032, 108 L.Ed.2d at 193. 
 
 
9 
 
The interference with one’s liberty interest is further magnified by the 
negative side effects that often accompany antipsychotic drugs, some of which 
can be severe and/or permanent.  Riggins, 504 U.S. at 134, 112 S.Ct. at 1814, 118 
L.Ed.2d at 488; Harper, 494 U.S. at 229, 110 S.Ct. at 1041, 108 L.Ed.2d at 203; 
Winick at 72-75.  The most common side effects of the antipsychotic drugs are 
Parkinsonian syndrome, akathisia, dystonia, and dyskinesia.  Harper, 494 U.S. at 
229-230, 110 S.Ct. at 1041, 108 L.Ed.2d at 203; Mills v. Rogers (1982), 457 U.S. 
291, 293, 102 S.Ct. 2442, 2445, 73 L.Ed.2d 16, 19, fn. 1; Rivers v. Katz (1986), 
67 N.Y.2d 485, 490, 504 N.Y.S.2d 74, 76, 495 N.E.2d 337, 339, fn. 1; Winick at 
72-75; Gutheil & Appelbaum, “Mind Control,” “Synthetic Sanity,” “Artificial 
Competence,” and Genuine Confusion: Legally Relevant Effects of Antipsychotic 
Medication (1983), 12 Hofstra L.Rev. 77, 107. 
 
“Parkinsonian syndrome * * * consists of muscular rigidity, fine resting 
tremors, a masklike face, salivation, motor retardation, a shuffling gait, and pill-
rolling hand movements.  Akathisia is a feeling of motor restlessness or of a 
compelling need to be in constant motion * * *.  Dystonia involves bizarre 
muscular spasm, primarily of the muscles of the head and neck, often 
accompanied by facial grimacing, involuntary spasm of the tongue and mouth 
interfering with speech and swallowing, oculogyric crisis marked by eyes flipping 
to the top of the head in a painful upward gaze persisting for minutes or hours, 
convulsive movements of the arms and head, bizarre gaits, and difficulty walking.  
The dyskinesias present a broad range of bizarre tongue, face, and neck 
movements.” Winick at 72-73. 
 
Virtually all of these reactions are reversible within hours or days of 
discontinuing the antipsychotic medication.  Id. at 73.  However, tardive 
dyskinesia, which consists of slow, rhythmical, repetitive, involuntary movements 
of the mouth, lips, and tongue, is permanent and there is no known effective 
treatment for managing its symptoms.  Id. at 73-74; Harper, 494 U.S. at 230, 110 
 
 
10 
S.Ct. at 1041, 108 L.Ed.2d at 203; Rogers, 457 U.S. at 293, 102 S.Ct. at 2445, 73 
L.Ed.2d at 19, fn. 1. 
 
Experts disagree as to the percentage of patients who will develop tardive 
dyskinesia after being treated with antipsychotic drugs.  Winick at 74, fn. 69; 
Harper, 494 U.S. at 230, 110 S.Ct. at 1041, 108 L.Ed.2d at 203.  In Harper, the 
United States Supreme Court found sufficient evidence to support the finding that 
ten to twenty-five percent of patients treated with antipsychotic medication 
developed tardive dyskinesia and among that group, sixty percent had mild 
symptoms while ten percent demonstrated more severe symptoms.  Harper, 494 
U.S. at 230, 110 S.Ct. at 1041, 108 L.Ed.2d at 204. 
 
Another potential side effect of antipsychotic medication is neuroleptic 
malignant syndrome.  This is a rare but potentially deadly syndrome that develops 
quickly and leads to death in twenty-five percent of those who develop it.  Id., 494 
U.S. at 230, 110 S.Ct. at 1041, 108 L.Ed.2d at 203; Winick at 74. 
 
In light of the foregoing, it is clear why the United States Supreme Court 
recognized that a substantial liberty interest was at stake in these cases.  Whether 
the potential benefits are worth the risks is a personal decision that, in the absence 
of a compelling state interest, should be free from government intrusion. 
III 
 
We now turn to the second step of our analysis to determine whether, in 
some circumstances, a person’s liberty interest in refusing antipsychotic 
medication is outweighed by a competing government interest. 
A 
 
One state interest that is sufficiently compelling to override an individual’s 
decision to refuse antipsychotic medication is the state’s interest in preventing 
mentally ill persons from harming themselves or others.  Many courts have held 
that hospital personnel and prison officials may administer antipsychotic drugs to 
mentally ill persons to prevent harm.  See, e.g., Harper, supra; Riggins, supra; 
 
 
11 
Rennie v. Klein (C.A.3, 1983), 720 F.2d 266 (en banc); Rogers v. Okin (C.A.1, 
1984), 738 F.2d 1; Bee v. Greaves (C.A.10, 1984), 744 F.2d 1387, certiorari 
denied (1985), 469 U.S. 1214, 105 S.Ct. 1187, 84 L.Ed.2d 334; Large v. Superior 
Court (1986), 148 Ariz. 229, 714 P.2d 399 (en banc); Rivers, supra; Rogers v. 
Commr. of Mental Health (1983), 390 Mass. 489, 458 N.E.2d 308.  The state’s 
interest in protecting its citizens flows from the state’s police power.  The state’s 
right to invoke its police power in these cases turns upon the determination that an 
emergency exists in which a failure to medicate a mentally ill person with 
antipsychotic drugs would result in a substantial likelihood of physical harm to 
that person or others.  Because this power arises only when there is an imminent 
threat of harm, the decision whether to medicate the patient must be made 
promptly in order to respond before any injury occurs.  For this reason, there is no 
time for a judicial hearing and medical personnel must make the determination 
whether the patient is an imminent danger to himself/herself or others. 
 
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 antipsychotic 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. 
 
Accordingly, we hold that when an involuntarily committed mentally ill 
patient poses an imminent threat of harm to himself/herself or others, the state’s 
interest in protecting its citizens outweighs the patient’s interest in refusing 
antipsychotic medication.  Authority for invoking the state’s interest flows from 
the police power of the state.  Whether an involuntarily committed mentally ill 
patient poses an imminent threat of harm to himself/herself or others warranting 
 
 
12 
the administration of antipsychotic drugs against the patient’s will is uniquely a 
medical, rather than a judicial, determination to be made by a qualified physician.  
A physician may order the forced medication of an involuntarily committed 
mentally ill patient with antipsychotic 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. 
 
While this holding appears to be placing tremendous power and authority 
in the hands of individual physicians, we are nevertheless reminded that 
physicians are “dedicated to providing competent medical service with 
compassion and respect for human dignity.”  Principle I, American Medical 
Association Code of Medical Ethics (1994) XV.  “I will follow that system of 
regimen which, according to my ability and judgment, I consider for the benefit of 
my patients, and abstain from whatever is deleterious and mischievous.”  The 
Oath of Hippocrates, 38 Harvard Classics (1910) 3.  We are confident that 
properly trained, competent, and compassionate physicians will not abuse such 
power. 
 
In the case at bar, appellant’s treating physician testified that appellant was 
not an imminent danger to himself or others.  The hospital, therefore, was 
precluded from relying on the state’s police power to override appellant’s 
decision to refuse medication. 
B 
 
A second state interest recognized by many courts to be sufficiently 
compelling to override a mentally ill patient’s decision to refuse antipsychotic 
medication is the state’s parens patriae power.5  See, e.g., Rivers, supra; Rogers 
v. Okin (C.A.1, 1984), 738 F.2d 1; Davis v. Hubbard (N.D.Ohio 1980), 506 
F.Supp. 915; People v. Medina (Colo.1985), 705 P.2d 961 (en banc); Rogers v. 
Commr. of Mental Health, supra; In re K.K.B. (Okla.1980), 609 P.2d 747; 
 
 
13 
Steinkruger v. Miller (2000), 2000 S.D. 83, 612 N.W.2d 591; In re C.E. (1994), 
161 Ill.2d 200, 204 Ill.Dec. 121, 641 N.E.2d 345; In re Guardianship of Linda 
(1988), 401 Mass. 783, 519 N.E.2d 1296; Jarvis v. Levine (Minn.1988), 418 
N.W.2d 139; In re Mental Commitment of M.P. (Ind.1987), 510 N.E.2d 645; 
Opinion of the Justices (1983), 123 N.H. 554, 465 A.2d 484.  Today, we too adopt 
the view that the state’s parens patriae power can override a mentally ill patient’s 
decision to refuse antipsychotic medication. 
 
A state’s parens patriae power allows it to care for citizens who are 
unable to take care of themselves.  Addington v. Texas (1979), 441 U.S. 418, 426, 
99 S.Ct. 1804, 1809, 60 L.Ed.2d 323, 331.  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.  Davis, 506 F.Supp. at 935-936; Rivers, 67 
N.Y.2d at 496, 504 N.Y.S.2d at 80, 495 N.E.2d at 343 (“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.”).  Thus, we hold 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 antipsychotic medication against his/her wishes.  In re Milton, 
supra, is therefore modified. 
 
We recognize that this holding is inconsistent with our statement in Milton 
that “the state may not act in a parens patriae relationship to a mental hospital 
patient unless the patient has been adjudicated incompetent.”  (Emphasis added.)  
Id. at 23, 29 OBR at 376, 505 N.E.2d at 257-258. We no longer adhere to that 
absolutist position.6  “Traditionally, an adjudication of incompetency rendered an 
 
 
14 
individual generally incompetent—he was placed under total legal disability and 
a guardian was appointed to make all decisions on his behalf.  The law has 
moved strongly away from this notion of general incompetency in favor of an 
approach requiring adjudications of specific incompetency.  Under the more 
modern view, the law determines an individual to be incompetent to perform 
only particular tasks or roles, such as: to decide on hospitalization; to manage 
property; to consent to treatment; or to stand trial.  This adjudication of specific 
incompetency does not render the individual legally incompetent to perform 
other tasks or to play other roles.”  Winick, Competency to Consent to 
Treatment: The Distinction Between Assent and Objection (1991), 28 
Hous.L.Rev. 15, 22-24.  See, also, Appelbaum & Gutheil, Clinical Handbook of 
Psychiatry and the Law (2 Ed.1991) 225. 
 
We accept the concept of specific incompetency, at least in the context 
addressed herein.  Therefore, a person need not be adjudicated incompetent 
before the state’s parens patriae power is legitimately invoked in a forced 
medication case.  It is sufficient that the court find by clear and convincing 
evidence that the patient lacks the capacity to give or withhold informed consent 
regarding treatment.  We believe that requiring an adjudication of general 
incompetence in these cases would result in the unnecessary removal of additional 
civil rights particularly when a specific finding of lack of capacity regarding 
treatment is sufficient.  Furthermore, it allows the patient to avoid the added 
stigma that often attaches to a person who has been adjudicated incompetent. 
 
Perhaps contrary to common belief, a court’s determination that a person 
is mentally ill and subject to involuntary commitment in a hospital is not 
equivalent to a finding that the person is incompetent.  Milton, 29 Ohio St.3d at 
22, 29 OBR at 375, 505 N.E.2d at 257; Rivers, 67 N.Y.2d at 494-495, 504 
N.Y.S.2d at 79, 495 N.E.2d at 341-342; Appelbaum & Gutheil, Clinical 
Handbook of Psychiatry and the Law, at 220 (“The mere presence of psychosis, 
 
 
15 
dementia, mental retardation, or some other form of mental illness or disability is 
insufficient in itself to constitute incompetence.”).  In fact, a person’s involuntary 
commitment to a hospital due to a mental illness does not even raise a 
presumption that the patient is incompetent.  Milton, 29 Ohio St.3d at 22-23, 29 
OBR at 375, 505 N.E.2d at 257.  Under Ohio law, these patients retain all civil 
rights not specifically denied in the Revised Code or removed by an adjudication 
of incompetence.  Id. at 23, 29 OBR at 375, 505 N.E.2d at 257; R.C. 5122.301.  
The rights retained include, among others, the right to contract, hold a 
professional license, marry, obtain a divorce, make a will, and vote. R.C. 
5122.301; see Milton at 23, 29 OBR at 375, 505 N.E.2d at 257. 
 
Based on the foregoing, it is clear that mental illness and incompetence are 
not one and the same.  Therefore, the state may not rely on its parens patriae 
power to justify making treatment decisions for a mentally ill person simply 
because that person has been involuntarily committed.  Before invoking this 
power, the state must first prove by clear and convincing evidence that the patient 
lacks the capacity to give or withhold informed consent regarding treatment.  
Whether 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 treatment is uniquely a judicial, rather than a 
medical, determination.  If a court does not find that the patient lacks such 
capacity, then the state’s parens patriae power is not applicable and the patient’s 
wishes regarding treatment will be honored, no matter how foolish some may 
perceive that decision to be.7  Rogers v. Commr. of Mental Health, 390 Mass. at 
497-498, 458 N.E.2d at 314, quoting Harnish v. Children’s Hosp. Med. Ctr. 
(1982), 387 Mass. 152, 154, 439 N.E.2d 240, 242 (“ ‘Every competent adult has a 
right “to forego treatment, or even cure, if it entails what for him are intolerable 
consequences or risks however unwise his sense of values may be in the eyes of 
the medical profession.” ’ ”). 
 
 
16 
 
Conversely, when a court finds by clear and convincing evidence that a 
patient lacks the capacity to give or withhold informed consent regarding 
treatment, then the state’s interest in caring for its citizen overrides the patient’s 
interest in refusing treatment.  When, in addition, the court also finds by clear and 
convincing evidence that the benefits of the antipsychotic medication outweigh 
the side effects, and that there is no less intrusive treatment that will be as 
effective in treating the illness, then it may issue an order permitting forced 
medication of the patient.  Accordingly, we hold that a court may issue an order 
permitting hospital employees to administer antipsychotic drugs against the 
wishes of an involuntarily committed mentally ill person if it finds, by clear and 
convincing evidence, that (1) the patient does not have the capacity to give or 
withhold informed consent regarding his/her treatment, (2) it is in the patient’s 
best interest to take the medication, i.e., the benefits of the medication outweigh 
the side effects, and (3) no less intrusive treatment will be as effective in treating 
the mental illness. 
IV 
 
Because of the significant liberty interest affected when an individual is 
medicated against his/her will with antipsychotic medication, we do not come to 
this decision lightly.  We have attempted to craft a decision that acknowledges a 
person’s right to refuse antipsychotic medication, and yet recognizes that mental 
illness sometimes robs a person of the capacity to make informed treatment 
decisions.  Only when a court finds that a person is incompetent to make informed 
treatment decisions do we permit the state to act in a paternalistic manner, making 
treatment decisions in the best interest of the patient. 
 
We also note that, in making our decision, we took into consideration not 
only the potential severe side effects of antipsychotic drugs, but also the well-
documented therapeutic benefits of antipsychotic medication.  “ ‘Psychotropic 
medication is widely accepted within the psychiatric community as an 
 
 
17 
extraordinarily effective treatment for both acute and chronic psychoses, 
particularly schizophrenia.’ ”  Harper, 494 U.S. at 226, 110 S.Ct. at 1039, 108 
L.Ed.2d at 201, fn. 9, quoting Brief for American Psychological Association et al. 
as amici curiae.  See, also, Winick at 70.  Prior to the use of antipsychotic 
medication in the treatment of schizophrenia and related psychoses, persons 
suffering from these illnesses were placed in hospitals with little chance of being 
released.  Because these mental illnesses are frequently manifested by 
uncooperative behavior, psychotherapy is not an effective treatment.  Hospitals 
were, therefore, providing nothing more than custodial care to these patients.  
Since physicians began treating mental illnesses with antipsychotic medication in 
the 1950s, the number of mentally ill persons requiring long-term hospitalization 
has been greatly reduced.  Winick at 68-69; Gutheil & Appelbaum, 12 Hofstra 
L.Rev. at 99-101; Riese v. St. Mary’s Hosp. & Med. Ctr. (1987), 209 Cal.App.3d 
1303, 1310-1311, 271 Cal.Rptr. 199, 203. 
 
We believe that a failure to recognize the state’s parens patriae power in 
these cases would result in the warehousing of those patients who, against their 
best interest, refuse medication when they do not have the capacity to 
comprehend their decision.  We believe such a result is inhumane and, therefore, 
unacceptable. 
 
In the case at bar, the probate court found that appellant lacked the 
capacity to give or withhold informed consent regarding his treatment, thereby 
triggering the state’s parens patriae power.  The additional findings required by 
our holding, i.e., whether the medication is in the patient’s best interest and 
whether a less intrusive treatment would be as effective, must be made before a 
decision regarding forced medication of appellant can be made.  We do not, 
however, remand this case for those additional findings because, as indicated in 
appellant’s brief and at oral argument, appellant is voluntarily taking 
antipsychotic medication.8 
 
 
18 
V 
 
One last issue remains.  We indicated that the Due Process Clause of the 
Fourteenth Amendment to the United States Constitution protects each person’s 
liberty interest in refusing medication.  Up to this point, we have addressed 
mainly substantive due process issues, e.g., the factual circumstances that must 
exist before antipsychotic drugs may be administered to a patient against his/her 
wishes.  Although appellant did not raise any procedural due process issues in the 
instant case, we believe it advisable that we discuss the procedural due process 
that must be afforded in a forced medication proceeding, i.e., the procedures that 
must be followed in determining the pertinent facts. 
 
As indicated previously, when the state’s police power is invoked, a 
trained physician determines the relevant facts.  The physician is bound by his 
profession to follow the appropriate accepted medical guidelines when making 
his/her findings. 
 
We now turn to 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 antipsychotic medication.  We have stated that when a treating physician 
claims that the state’s parens patriae power permits forced medication, such 
determination is a uniquely judicial function.  Accordingly, if 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”9 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-
 
 
19 
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.  We 
realize that each forced medication case is unique and, therefore, we do not set 
specific guidelines other than to state that all court orders permitting the 
administration of antipsychotic drugs against a patient’s wishes should be 
periodically reviewed, and continued forced medication should be substantiated 
by competent medical evidence.  Appropriate motions to continue forced 
medication may be filed as the need arises.  A motion to continue forced 
medication is subject to the same procedural safeguards as an original motion for 
forced medication. 
 
As stated above, appellant did not argue that his procedural due process 
rights were violated in the instant case.  However, our review of the record 
indicates that the procedures followed by the probate court were sufficient. 
Conclusion 
 
For the reasons set forth above, we affirm the judgment of the court of 
appeals. 
Judgment affirmed. 
 
MOYER, C.J., RESNICK, F.E. SWEENEY and LUNDBERG STRATTON, JJ., 
concur. 
 
PFEIFER, J., concurs in part. 
 
COOK, J., concurs in judgment. 
FOOTNOTES: 
 
1. 
As used in this case, the term “antipsychotic medication” refers to 
medications such as Haldol, Prolixin, and Trilafon that are used in treating 
 
 
20 
psychoses, especially schizophrenia.  These drugs were introduced into psychiatry 
in the early 1950s and are effective in treating psychotic disorders because they 
can bring about chemical changes in the brain.  They also often produce adverse 
side effects, some of which may be controlled by additional medications.  The 
seriousness of the possible side effects of these types of drugs cannot be 
overstated.  For a full discussion, see Cichon, The Right to “Just Say No”: A 
History and Analysis of the Right to Refuse Antipsychotic Drugs (1992), 53 
La.L.Rev. 283, 297-311.  Appellee’s motion for forced medication of appellant 
included medication (Cogentin) to alleviate side effects caused by the 
antipsychotic medication. 
 
2. 
We set forth all of the pertinent dates of these proceedings to 
illuminate the lengthy delays, some necessary and some unnecessary, involved in 
these types of cases.  The necessity to make such cases priority matters is obvious. 
 
3. 
Psychotropic drugs are “compounds that affect the mind, behavior, 
intellectual functions, perception, moods, and emotions.”  Winick, The Right to 
Refuse Mental Health Treatment (1997) 61, citing Kaplan et al., Synopsis of 
Psychiatry: 
Behavioral 
Sciences 
and 
Clinical 
Psychiatry 
(1994) 
410.  
Antipsychotic drugs are a type of psychotropic drug.  Winick at 65; Gutheil & 
Appelbaum, “Mind Control,” “Synthetic Sanity,” “Artificial Competence,” and 
Genuine Confusion: Legally Relevant Effects of Antipsychotic Medication 
(1983), 12 Hofstra L.Rev. 77, 79. 
 
4. 
In this opinion we refer to medicating patients with antipsychotic 
drugs.  We wish to make clear that when a court is justified in allowing the 
administration of antipsychotic drugs against the patient’s wishes, it is also 
justified in allowing, against the patient’s wishes, the administration of those 
medications necessary to alleviate side effects of the antipsychotic drugs. 
 
5. 
Parens patriae means “parent of his or her country,” and refers to 
“[t]he state regarded as a sovereign; the state in its capacity as provider of 
 
 
21 
protection to those unable to care for themselves.”  Black’s Law Dictionary (7 
Ed.1999) 1137. 
 
6. 
While we no longer approve of the statement in Milton regarding 
when the parens patriae power may be invoked, we nevertheless recognize that 
the decision in Milton was proper and fully supported.  Milton was decided in the 
context of a religious objection by a competent individual, and the parens patriae 
power was not at issue in that decision. 
 
7. 
The exception is, of course, where the state’s police power is 
implicated. 
 
8. 
We recognize that an argument can be made that the question 
concerning appellant now before us is moot because he is voluntarily taking 
antipsychotic medications.  We find, however, that there is no evidence in the 
record that appellant has recovered from his mental illness or that he has been 
released from the Lewis Center.  Should appellant refuse antipsychotic 
medication in the future, which is possible given his medical condition, it is 
reasonable to expect that he would again be subject to an action for forced 
medication.  Thus, the issue is one that is capable of repetition, yet evading 
review, and as such it is not moot.  State ex rel. The Repository v. Unger (1986), 
28 Ohio St.3d 418, 420, 28 OBR 472, 474, 504 N.E.2d 37, 39.  See, also, 
Washington v. Harper (1990), 494 U.S. 210, 218-219, 110 S.Ct. 1028, 1035, 108 
L.Ed.2d 178, 196.  In any event, this case involves a matter of public or great 
general interest and, therefore, the court is vested with the jurisdiction to hear the 
appeal, even if the case were moot.  In re Appeal of Suspension of Huffer from 
Circleville High School (1989), 47 Ohio St.3d 12, 14, 546 N.E.2d 1308, 1310. 
 
9. 
The language in R.C. 5122.14 is used and now adopted in a 
different context. 
__________________ 
 
 
22 
 
PFEIFER, J., concurring in part.  I concur with the court’s holding and all 
of the syllabus paragraphs except paragraphs three and four.  In my view, 
paragraphs three and four of the syllabus answer important legal questions that are 
not present in this particular case.  I would save the resolution of those issues for a 
more appropriate case.  I am troubled by the notion that involuntarily committed 
mentally ill patients will have their lives greatly altered by potentially dangerous 
drugs with little recourse in the legal system.