Title: In re L.A.

State: vermont

Issuer: Vermont Supreme Court

Document:

In re L.A. (2005-368)

2006 VT 118

[Filed 17-Nov-2006]


       NOTICE:  This opinion is subject to motions for reargument under
  V.R.A.P. 40 as well as formal revision before publication in the Vermont
  Reports.  Readers are requested to notify the Reporter of Decisions,
  Vermont Supreme Court, 109 State Street, Montpelier, Vermont 05609-0801 of
  any errors in order that corrections may be made before this opinion goes
  to press.


                                 2006 VT 118

                                No. 2005-368


  In re L.A.                                     Supreme Court

                                                 On Appeal from
                                                 Washington Family Court

                                                 May Term, 2006


  Matthew I. Katz, J.

  John J. McCullough III and Laura A. Gans of Vermont Legal Aid, Inc.,
    Waterbury, for Appellant.

  William G. Sorrell, Attorney General, Montpelier, and David Bond, Assistant
    Attorney General, Burlington, for Appellee.


  PRESENT:  Reiber, C.J., Dooley, Johnson, Skoglund and Burgess, JJ.

        
       ¶  1.  JOHNSON, J.  Patient L.A. appeals from a family court
  decision granting the Commissioner of the Department of Health's petition
  for involuntary psychiatric medication.  Patient argues that the trial
  court erred by applying the wrong standard to determine whether he is
  competent to refuse medication.  The family court ruled that patient was
  incompetent because he refused beneficial medications.  We reverse and
  remand for a new hearing because the involuntary medication statute
  mandates that the family court decide whether patient is capable of making
  a decision about medication and appreciating its consequences.  Although
  the family court made findings about L.A.'s mental illness, it did not make
  findings about L.A.'s capacity to make the medication decision.   Patient
  also argues that the Religious Land Use and Institutionalized Persons Act
  (RLUIPA) protects him from an order for involuntary medication because the
  medications would interfere with the practice of his religious beliefs. 
  Because the Commissioner did not have a full opportunity to respond to this
  issue, and in light of our remand, we reserve judgment on patient's RLUIPA
  claim.  

       ¶  2.  Patient is a sixty-four-year-old man who has been diagnosed
  with bipolar disorder, currently manic with psychotic features, and
  alcoholism.  On April 15, 2005, patient was committed to the Vermont State
  Hospital (VSH) after having been arrested in Burlington for disorderly
  conduct.  Although doctors have prescribed patient a regimen of psychiatric
  medications, he has refused to take them throughout his commitment.  On
  June 29, 2005, the Commissioner filed a petition for involuntary medication
  pursuant to 18 V.S.A. § 7624.  As the statute requires, the family court
  held an evidentiary hearing on the issue of patient's competence. 18 V.S.A.
  § 7625(a).

       ¶  3.  At the hearing, the Commissioner presented the testimony of Dr.
  Munson, patient's treating psychiatrist at VSH.  Dr. Munson described
  patient's diagnoses and symptoms, including persistently elevated mood,
  hyperactivity, rapid speech, delusions, and threatening and sexually
  explicit interactions.  Dr. Munson testified that he believed patient would
  pose a danger to himself or others outside the hospital, but conceded that
  he did not believe patient was particularly dangerous in the controlled
  environment at VSH.  According to Dr. Munson, patient should be on a
  regimen of mood stabilizers, anti-psychotics, and side-effect medications. 
  He believes patient is incapable of rationally evaluating the risks and
  benefits of the medications, and is incompetent to make decisions regarding
  his medication. 
   
       ¶  4.  Patient testified on his own behalf at the hearing, and
  described his objections to taking the medications.  First, according to
  patient, he is "not a sick man."  Patient did testify, however, that he
  understands that Dr. Munson believes that he is sick and that the
  medications would help him.  He also acknowledged that the staff and even
  some of the patients at VSH have advised him that taking his medications
  would likely hasten his discharge.  According to patient's testimony,
  though, he is concerned about how the medications will "affect" him. 
  Patient described "a splendid relationship within [himself] and with the
  spiritual being that flows through [him]."  According to patient, the
  medications would affect his "expression," thereby hindering his spiritual
  life.  Finally, patient expressed concern about the physical side effects
  that accompany many psychiatric medications, including symptoms that mimic
  Parkinson's disease.   

       ¶  5.  The family court made several factual findings based on the
  evidence presented at the hearing.  The court found that patient suffers
  from bipolar disorder and alcoholism, and is delusional.  It listed certain
  of patient's specific delusions, such as his apparent beliefs that he is
  the Prophet Elijah, and that he controls a submarine capable of firing
  missiles.  The court also concluded that patient is dangerous at least some
  of the time.  Based on patient's psychiatric symptoms and the effectiveness
  of medication in treating them, the court found that patient's
  prescriptions were warranted.  Finally, the court concluded that patient
  did not demonstrate a specific religious objection to the medications. 
  According to the court: "Insofar as he refuses altogether the medications
  that might benefit him, Patient is not competent to make a decision
  regarding the proposed regimen of treatment."

                                     I.

       ¶  6.  Patient first argues that the family court used the wrong
  standard to determine that he is incompetent to refuse medication.  We
  agree that the family court failed to apply the standard articulated in the
  statute, "whether the person is able to make a decision and appreciate the
  consequences of that decision."  18 V.S.A. § 7625(c).   
   
       ¶  7.  Under 18 V.S.A. § 7624(a), the Commissioner may file a
  petition with the family court for the involuntary medication of patients
  who refuse to accept them.  The Commissioner bears the burden of proving
  patient's incompetence by clear and convincing evidence.  Id. § 7625(b). 
  The family court determines whether a person is competent to make decisions
  regarding medication based on "whether the person is able to make a
  decision and appreciate the consequences of that decision."  Id. § 7625(c). 
  The statute further provides, "[i]t is the intention of the general
  assembly to work towards a mental health system that does not require
  coercion or the use of involuntary medication."  Id. § 7629(c). 

       ¶  8.  If the court finds the patient competent, the petition is
  dismissed, and he may continue to refuse medication as he wishes.  Id. §
  7627(d).  If, on the other hand, the court finds the patient incompetent,
  the court goes on to:

    consider at a minimum, in addition to the person's expressed
    preferences, the following factors:

    (1) The person's religious convictions and whether they contribute   
    to the person's refusal to accept medication.

    (2) The impact of receiving medication or not receiving medication   
    on the person's relationship with his or her family or household        
    members whose opinion the court finds relevant and credible based   
    on the nature of the relationship.

    (3) The likelihood and severity of possible adverse side effects
    from the proposed medication.

    (4) The risks and benefits of the proposed medication and its
    effect on:

         (A) the person's prognosis; and

         (B) the person's health and safety, including any pregnancy

    (5) The various treatment alternatives available, which may or may   
    not include medication.

  Id. § 7627(c).  If the above factors support involuntary medication, "the
  court shall make specific findings stating the reasons for the involuntary
  medication by referencing those supporting factors."  Id. § 7627(e).
   
       ¶  9.  Thus, the statute outlines two steps in deciding whether
  involuntary medication is appropriate for a patient.  In the first step,
  the family court determines whether the patient is competent to refuse
  medication.   Second,  the court considers, based on the factors outlined
  in § 7627(e), the merits of involuntarily medicating the patient.  Whereas
  the first step is focused entirely on the patient's decision-making
  ability, the second step is focused on the potential benefits and risks of
  the medication.  Therefore, there may be circumstances in which a competent
  patient may refuse medication that would most likely benefit him. 
  Likewise, the family court could find a patient incompetent to refuse
  medication, yet still conclude that involuntary medication is not
  appropriate.

       ¶  10.  It is important to understand that, in the involuntary
  medication context, the competence inquiry is dictated by the statutory
  language.  The standard is different, and more difficult for the
  Commissioner to meet, from the standard for determining whether a person
  may be involuntarily committed because the statute focuses solely on the
  patient's decision-making abilities, as they may or may not be affected by
  mental illness-not the fact of the patient's diagnosis alone, or the merits
  of the psychiatrist's medical advice.  If a mere diagnosis were the end of
  the analysis, it would preclude the need for a petition procedure
  altogether. 
   
       ¶  11.  In this case, the family court concluded that "[i]nsofar as
  [patient] refuses altogether the medications that might benefit him,
  [p]atient is not competent to make a decision regarding the proposed
  regimen of treatment."  The court's reasoning, however, fails to address
  the first step in the involuntary medication analysis.  Every patient who
  is the subject of a petition for involuntary medication has refused
  prescribed medication.  Indeed, the statute applies only to patients who
  have refused medication.  18 V.S.A. § 7624.  Thus, the fact that patient
  has "refuse[d] altogether" the medication at issue can have no bearing on
  his competence; otherwise, the statutory inquiry into competence would be
  superfluous.  See Judicial Watch, Inc. v. State, 2005 VT 108, ¶ 14, 16
  Vt. L. Wk. 363,