IN THE COURT OF APPEALS OF THE STATE OF WASHINGTON

DIVISION II

In the Matter of the Detention of:

S.M.

No. 57820-4-II

UNPUBLISHED OPINION

Appellant.

LEE, J. — S.M. appeals an order authorizing the involuntary administration of 

antipsychotic medication. S.M. argues that the superior court commissioner violated S.M.’s due 

process rights when it failed to make a “medical appropriateness” finding and that the 

commissioner made an inadequate substituted judgment. Because a finding of medical 

appropriateness is not required in a civil commitment proceeding and the superior court 

commissioner appropriately identified a compelling state interest, the necessity of the treatment, 

and considered S.M.’s desires and concerns in making its substituted judgment, we affirm the 

order.

FACTS

A. BACKGROUND

In August 2021, S.M. was arrested and charged with second degree attempted arson. Police 

had responded to a 911 call of S.M. breaking out a car’s windows with a baseball bat. When the 

police arrived, S.M. was “‘screaming incoherent things’” and grabbed a pair of bolt cutters, with 

which he continued to hit the car. Clerk’s Papers (CP) at 8. The police then observed S.M. pull 

out a cigarette lighter and light it while holding it up to the open gas cap of the car. 

Filed

Washington State

Court of Appeals

Division Two

September 19, 2023
No. 57820-4-II

2

The superior court ordered S.M. to undergo a competency evaluation to determine if he 

could proceed to trial on his charge. Psychiatric staff determined that S.M. “lacked the requisite 

capacities to proceed to trial due to a diagnostic impression of Unspecified Schizophrenia.” CP at 

10. 

In September 2021, the superior court ordered S.M. to undergo a 45-day competency 

restoration period at Western State Hospital (WSH). After the 45-day competency restoration 

period, WSH determined that S.M. continued to lack capacity to proceed to trial. The superior 

court ordered an additional competency restoration period for 90 days. After 90 days, WSH 

determined S.M. still lacked capacity to proceed to trial. In his report, the WSH psychiatrist who 

evaluated S.M. wrote:

Based upon a review of [S.M.]’s available records, the current evaluation, and a 

review of risk factors, . . . he is currently at an elevated risk for reoffending and 

dangerous behavior. [S.M.]’s risk for both future dangerousness and re-offending 

would significantly increase should he engage in substance use or discontinue 

psychotropic medication. Further, if housed in an unstable setting with limited 

support or means to provide for himself, [S.M.] could experience increased stress 

and associated decompensation.

. . . [S.M. has] a history of arrests, convictions, and incarceration periods 

since at least 2014 in Arkansas, Oklahoma, Colorado, and California.

CP at 12 (emphasis and underlining in original).

In April 2022, S.M.’s attempted arson charge was dismissed and he underwent a civil 

commitment evaluation. In May 2022, S.M.’s treating psychiatrist and psychologist jointly filed 

a 180-day involuntary treatment petition on the basis of S.M.’s grave disability and his substantial 

likelihood of repeating criminal acts due to a behavioral health disorder. The superior court 

granted the petition. 
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In July 2022, S.M.’s treating psychiatrist, Dr. Nitin Karnik, filed a petition for involuntary 

treatment with antipsychotic medication (medication petition). The medication petition alleged 

that S.M. suffers from schizoaffective mania. The medication petition further stated that S.M. had

recently threatened, attempted or caused serious harm to others. Treatment with 

antipsychotic medication will reduce the likelihood that [S.M.] will cause serious 

harm to others; failure to treat [S.M.] with antipsychotic medication may result in 

the likelihood of serious harm or substantial (further) deterioration. 

[S.M.] has been displaying [d]elusions and paranoia. He [t]elephoned the 

White House threatening the US President and was subsequently interviewed by 

the Secret Service a few weeks ago. He has threatened [p]eers on the ward and also 

threatened staff.

CP at 35. 

According to Dr. Karnik, alternatives to antipsychotic medication, such as “milieu therapy” 

and “seclusion and/or restraints” would be more likely to prolong S.M.’s involuntary commitment 

or would be more intrusive to S.M.’s liberty and privacy interests. CP at 36. S.M. refused 

antipsychotic medications because he did not believe he needed any. S.M. did not express any 

religious objections to taking medication, and he has no known family members. 

B. MEDICATION HEARING 

In August 2022, the superior court commissioner held a hearing on the medication petition. 

Dr. Karnik and S.M. testified. 

1. Dr. Karnik’s Testimony

Dr. Karnik is a psychiatrist at WSH. Dr. Karnik had daily observations and interactions 

with S.M. Dr. Karnik testified that he had diagnosed S.M. with schizophrenia affective disorder. 

This diagnosis was based on S.M.’s presentation of delusional thinking and statements, including 

S.M.’s statements that he was a CIA and FBI agent. Dr. Karnik testified that S.M. also exhibited 

paranoid delusions and aggressive behavior: 
No. 57820-4-II

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[S.M.] has accused other patients about things that they may have said to him or 

things that . . . he thinks may have said about other peers or other staff, and he has 

assaulted peers in response to such delusional beliefs. . . . He has delusions and 

paranoia along with the mood component affective disorder where he becomes 

aggressive and angry and agitated.

Verbatim Rep. of Proc. (VRP) at 12.

Dr. Karnik observed S.M. remove a mirror from the ceiling of the ward and throw a sharp 

object at staff. S.M. has directly threatened to kill Dr. Karnik and made bizarre statements to Dr. 

Karnik, such as “‘You’re going to be deported to Qatar.’” VRP at 10. S.M. at one time called and 

made threats to the White House, which prompted the Secret Service to contact WSH and interview 

S.M. and WSH staff. Based on the nature of S.M.’s threats and assaultive behavior, Dr. Karnik 

speaks with S.M. only through plexiglass or with security present. Dr. Karnik also testified that 

WSH staff observed S.M. pick up a heavy, weighted chair and throw it from a height. S.M. has 

assaulted fellow patients and security at WSH, which resulted in S.M.’s placement in restraints 

and in seclusion. 

S.M. had been on antipsychotic medication from November 2021 to June 2022. However, 

S.M. had stopped taking medication approximately four to five weeks prior to the medication 

hearing, when S.M.’s detention at WSH switched from a competency restoration order to a civil 

commitment order. When S.M. had been on medication, the antipsychotic drug Zyprexa,1he had 

not exhibited physical aggression. Dr. Karnik sought to treat S.M. with Zyprexa, which would 

“eliminate delusions, eliminate hallucinations, eliminate paranoia.” VRP at 17. It would also 

function as a mood stabilizer. If Zyprexa was ineffective, Dr. Karnik also requested use of Haldol, 

 

1

 Zyprexa is the trade name for Olanzapine. The record refers to Zyprexa and Olanzapine 

interchangeably. 
No. 57820-4-II

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an older antipsychotic that controls delusions, paranoia, and aggression. Dr. Karnik noted that 

Haldol also has a mood stabilizing effect even though it is not approved as a mood stabilizer by 

the Food and Drug Administration (FDA). Dr. Karnik stated:

[Haldol] does not have an FDA label for a mood stabilizing effect because when 

the medication was first invented 40 years ago, they did not do the studies to prove 

that it works as a mood stabilizer and now it’s off label, generic, so there’s no 

money in trying to submit those studies; but we know that it works. 

VRP at 18. 

Dr. Karnik believed medication would help S.M. and hoped to stabilize S.M. sufficiently 

to allow him to be transferred to the less restrictive “civil side” of WSH. VRP at 19. WSH’s “civil 

side” has refused to accept S.M. based on “his dangerousness” and “his untreated status.” VRP at 

19. The ward where S.M. is currently housed is “a complete lockdown unit; it’s an extension of 

the jail.” VRP at 19. Dr. Karnik testified that without medication, S.M.’s “physical issues and the 

psychosocial issues would continue to deteriorate.” VRP at 22. Medication would help control 

any brain deterioration and assist S.M. in becoming “more goal-directed in his thinking, less 

delusional or at least to the point that the delusions would not make him act out in . . . an aggressive 

manner.” VRP at 22-23. 

Dr. Karnik discussed the medications with S.M., and both Dr. Karnik and a WSH 

pharmacist discussed the medications’ side effects with S.M. Side effects include muscle stiffness 

or tremors, and long-term effects may lead to increased appetite, which could ultimately cause 

high blood pressure, diabetes, and “‘metabolic syndrome.’” VRP at 20. However, Dr. Karnik 

stated that a dietitian is assigned to each ward to closely monitor patients’ cholesterol and blood 

sugar levels. Another potential side effect is tardive dyskinesia, a movement disorder. However, 

it is rare, and Dr. Karnik has not seen a new case of tardive dyskinesia in 20 years. Furthermore, 
No. 57820-4-II

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S.M. did not exhibit any side effects when he had previously taken Zyprexa, nor did he inform Dr. 

Karnik of side effects when they discussed medication. Dr. Karnik testified that S.M.’s only 

expressed reason for not wanting medication was simply that S.M. did not believe he needed any. 

Additionally, S.M. did not express any religious objections to medication to Dr. Karnik. 

2. S.M.’s Testimony

According to S.M., he did not see Dr. Karnik every day. S.M. expressed concern about 

side effects of antipsychotic medication. He testified that he suffered from headaches, insomnia, 

agitation, and leg restlessness as a result of taking Zyprexa. However, S.M. then appeared to state 

that he had such symptoms prior to taking Zyprexa. S.M. later stated that Zyprexa caused him 

“‘brain ring’” and “‘headache.’” VRP at 36. S.M. also expressed concern about dementia and 

memory loss as a result of taking Lithium, a mood stabilizer. 

Additionally, S.M. stated that he was concerned that Haldol was “FDA ‘not approved’ 

medicine.” VRP at 37. S.M. further stated, “Haldol’s got a lawsuit—a class-action lawsuit for 

billions and billions of dollars that gives men low testosterone, and then they produce man boobs; 

Haldol does. It changes the cortisol in the brain; that’s what Haldol does.” VRP at 38. S.M. did 

not understand why he was at WSH. During his testimony, S.M. continually attempted to ask Dr. 

Karnik confirmation questions about his treatment at WSH and how he might obtain a “fair and 

speedy trial.” VRP at 40. 

3. Commissioner’s Ruling and Order 

The superior court commissioner found by clear, cogent, and convincing evidence that the 

State had a compelling interest in involuntarily administering antipsychotic medication to S.M. 

The commissioner issued an order authorizing involuntary treatment with antipsychotic 
No. 57820-4-II

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medication and incorporated its oral ruling into the order. In its oral ruling, the commissioner 

stated in part:

The requested medication, the antipsychotic, in Dr. Karnik’s observation, 

did successfully treat and manage [S.M.]’s aggressive behavior and assaultiveness

without side effects that were verbalized to Dr. Karnik. . . . [R]esuming 

antipsychotic medication would, hopefully, address those assaultive and aggressive 

behaviors, again, such that [S.M.] could transfer to the civil ward which would be 

a less restrictive environment . . . with additional treatment and programming 

opportunities. . . .

Absent treatment with an antipsychotic to get [S.M.] more stabilized . . . the 

only other treatment options to address his current symptoms would be use of 

seclusion and restraints which are much more intrusive to [S.M.]’s liberty and, also, 

would likely lead to a prolonged commitment and a much longer period of 

commitment. 

As to [S.M.]’s own testimony regarding his concern for side effects, [S.M.]

discussed concern as to Lithium. Lithium is not an order being sought today. 

[S.M.] expressed concern that Haldol is not FDA approved or that understanding is 

inconsistent, in my view, with Dr. Karnik’s testimony; and the medication that is 

sought in the first place is Zyprexa, which Dr. Karnik testified the respondent had, 

previously, had a track record of success taking. 

I am persuaded that Dr. Karnik’s testimony establishes that [S.M.] has 

refused his prescribed antipsychotic medication, and in the period of refusal, he has 

been engaged in assaultive behavior and aggressive and threatening behavior, has 

deteriorated and further decompensated that is in a way that endangers his health 

and safety and that his detention would be substantially prolonged absent treatment 

with the antipsychotics and those alternative treatments of seclusion and restraints 

are significantly more intrusive to [S.M.] himself.

VRP at 47-48.

The written order also stated: “The Respondent would consent to being treated with 

antipsychotic medication if the Respondent were capable of making a rational decision concerning 

treatment and this Court is hereby substituting its judgment for that of the Respondent.” CP at 44. 

Additionally, the superior court commissioner noted that S.M. did not object to medication for any 
No. 57820-4-II

8

religious or moral reasons, and that there is no known objection from any family members as there 

was no evidence of S.M.’s family presented. 

S.M. appeals. 

ANALYSIS

S.M. appeals the superior court commissioner’s findings of fact, conclusions of law, and 

order authorizing involuntary treatment with antipsychotic medications. Specifically, S.M. argues 

that the commissioner violated his due process rights by failing to make a medical appropriateness 

finding and the commissioner inadequately substituted its judgment.2 We disagree. 

A. APPELLATE REVIEW

All acts and proceedings of court commissioners are subject to revision by the superior 

court. RCW 2.24.050. If a party does not move to revise within 10 days from the entry of the 

commissioner’s order, then a commissioner’s order becomes the order of the superior court. RCW 

2.24.050. This court reviews the superior court’s ruling, not the commissioner’s decision. In re

Det. of L.K., 14 Wn. App. 2d 542, 550, 471 P.3d 975 (2020). Here, because no party moved to 

revise the commissioner’s order, the commissioner’s order has become that of the superior court.3 

 

2

 S.M. assigns error to the commissioner’s findings of fact 4, 5, and 6, and conclusions of law 10, 

11, and 12. However, in the briefing of the issues, S.M. does not reference these specific 

assignments of error. A party’s failure to provide argument and citation to authority in support of 

an assignment of error precludes appellate consideration of an alleged error. Avellaneda v. State, 

167 Wn. App. 474, 485 n.5, 273 P.3d 477 (2012). Therefore, this opinion will address the actual 

arguments in S.M.’s brief.

3

 S.M.’s medication order has expired. However, this appeal is not moot because “an order to 

involuntarily administer antipsychotic medication . . . may have collateral consequences in future 

proceedings.” L.K., 14 Wn. App. 2d at 549; accord In re Det. of P.R., 18 Wn. App. 2d 633, 644, 

492 P.3d 236 (2021) (stating “the appeal of an order of involuntary administration of antipsychotic 

medicine is not moot because such an order may have collateral consequences in future 

proceedings.”).
No. 57820-4-II

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We review challenges to sufficiency of the evidence in a light most favorable to the State. 

In re Det. of P.R., 18 Wn. App. 2d 633, 644, 492 P.3d 236 (2021). When the standard is clear, 

cogent, and convincing, a heightened standard applies and the court’s findings “must be supported 

by evidence that makes the fact at issue highly probable.” Id. at 645. 

B. INVOLUNTARY MEDICATION ORDER

1. Legal Principles

Under the due process clauses of the Fourteenth Amendment of the U.S. Constitution and 

article 3, section 1 of the Washington Constitution, “[a] person has a liberty interest in avoiding 

the unwanted administration of antipsychotic medication.” Id. at 643; accord Washington v. 

Harper, 494 U.S. 210, 221, 110 S. Ct. 1028, 108 L. Ed. 2d 178 (1990) (an individual “possesses a 

significant liberty interest in avoiding the unwanted administration of antipsychotic drugs.”); State 

v. Lyons, 199 Wn. App. 235, 240, 399 P.3d 557 (2017) (“The liberty interest in avoiding the 

unwanted administration of antipsychotic drugs gives rise to both substantive and procedural due 

process considerations.”).

An involuntarily committed individual has a right to refuse antipsychotic medication. L.K., 

14 Wn. App. 2d at 548; see RCW 71.05.217(1)(j). However, “the State can limit this right if the 

state interest is sufficiently compelling and the proposed treatment is both necessary and effective 

to further that interest.” P.R., 18 Wn. App. 2d at 643. An involuntarily committed individual may 

not refuse medication if “it is determined that the failure to medicate may result in a likelihood of 

serious harm or substantial deterioration or substantially prolong the length of involuntary 

commitment and there is no less intrusive course of treatment than medication in the best interest 

of that person.” RCW 71.05.215(1).
No. 57820-4-II

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If the State wishes to involuntarily administer antipsychotic medication to an individual, 

RCW 71.05.217 outlines the procedural safeguards that must be followed in light of the liberty 

interest at stake. The petitioning party must prove by clear, cogent, and convincing evidence a 

compelling State interest that justifies overriding a patient’s lack of consent. RCW 

71.05.217(1)(j)(i). Furthermore, the court must make specific findings of fact concerning the 

existence of at least one compelling interest, the necessity of the treatment, and the individual’s 

desires regarding treatment. RCW 71.05.217(1)(j)(ii). A court must also find that “alternative 

forms of treatment are not available, have not been successful, or are not likely to be effective.” 

RCW 71.05.217(1)(j)(i). If an individual is unable to make a “rational and informed decision” 

about the medication, the court must make a “substituted judgment.” RCW 71.05.217(1)(j)(ii).

Washington courts have identified compelling State interests in “‘(1) the preservation of 

life; (2) the protection of interests of innocent third parties; (3) the prevention of suicide; and (4) 

maintenance of the ethical integrity of the medical profession.’” In re Det. of B.M., 7 Wn. App. 

2d 70, 79, 432 P.3d 459 (internal quotation marks omitted) (quoting In re Schuoler, 106 Wn.2d 

500, 508, 723 P.2d 1103 (1986)), review denied, 193 Wn.2d 1017 (2019). 

As to a court’s substituted judgment, “[t]he goal is not to do what most people would do, 

or what the court believes is the wise thing to do;” instead, the court must stand in the individual’s 

position and consider “what this particular individual would do if [they] were competent and 

understood all the circumstances.” In re Guardianship of Ingram, 102 Wn.2d 827, 839, 689 P.2d 

1363 (1984). Courts should also consider the risk of adverse side effects, the ability of the 

individual to cooperate with post-treatment therapy, the wishes of family and friends, and the 

individual’s religious or moral views, among other factors. Id. at 840. Medical professionals may 
No. 57820-4-II

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not “substitute their judgment for the procedures established by law to protect a person’s 

substantial liberty interest in refusing antipsychotic medication.” L.K., 14 Wn. App. 2d at 552. 

2. Due Process and Medical Appropriateness

S.M. argues that because “[d]ue process . . . requires a finding of medical appropriateness 

before ordering forced medication of an involuntarily committed person,” the superior court 

commissioner erred by not considering the potential side effects of the proposed medications. Br. 

of Appellant at 12. Because this is a civil commitment matter and not a criminal competency 

restoration matter, we disagree. 

Here, S.M. cites to several cases to support his contention regarding the requirement of 

finding medical appropriateness, including Riggins v. Nevada,

4 Lyons, and State v. Mosteller.5

 

Riggins, Lyons, and Mosteller all involve the involuntary administration of medication for 

competency restoration purposes so a defendant can stand trial. See generally Riggins, 504 U.S. 

at 129; Lyons, 199 Wn. App. at 237; Mosteller, 162 Wn. App. at 421. In such cases, courts consider 

the Sell factors, which include: “‘the efficacy, the side effects, the possible alternatives, and the 

medical appropriateness of a particular course of antipsychotic drug treatment.’” Lyons, 199 Wn. 

App. at 241 (quoting Sell v. United States, 539 U.S. 166, 183, 123 S. Ct. 2174, 156 L. Ed. 2d 197 

(2003)). 

However, the Sell factors apply “solely for trial competence purposes in certain instances.” 

Sell, 539 U.S. at 167; accord Lyons, 199 Wn. App. at 238 n.3 (“Sell establishes the requirements 

necessary for the State to obtain an order authorizing involuntary medication in order to restore 

 

4

 504 U.S. 127, 112 S. Ct. 1810, 118 L. Ed. 2d 479 (1992).

5

 162 Wn. App. 418, 254 P.3d 201, review denied, 172 Wn.2d 1025 (2011). 
No. 57820-4-II

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competency to stand trial.”); Mosteller, 162 Wn. App. at 424-25 (“In rare circumstances, the State 

can forcibly administer unwanted medications solely for trial competency purposes. To order the 

administration of medications in such situations, however, the trial court must consider certain 

factors, which are known as the Sell factors.” (internal citations omitted)). The issue of whether 

S.M. is competent to stand trial is not before this court. 

S.M. is civilly committed under chapter 71.05 RCW. The applicable statute, which S.M. 

agrees, is RCW 71.05.217. RCW 71.05.217(1)(j) outlines what is required to ensure due process 

for civilly committed individuals and requires: 

The court shall make specific findings of fact concerning: (A) The existence of one 

or more compelling state interest; (B) the necessity and effectiveness of the 

treatment; and (C) the person’s desires regarding the proposed treatment. If the 

patient is unable to make a rational and informed decision about consenting to or 

refusing the proposed treatment, the court shall make a substituted judgment for the 

patient as if he or she were competent to make such a determination. 

RCW 71.05.217(1)(j)(ii). RCW 71.05.217 does not require a court to make a “medical 

appropriateness” finding. Indeed, RCW 71.05.217 does not once mention “medical 

appropriateness.” See RCW 71.05.217. Accordingly, because S.M.’s competency to stand trial is 

not at issue and because RCW 71.05.217 does not require a medical appropriateness finding, the 

standards articulated in Riggins, Lyons, and Mosteller are inapplicable here.6 

 

6

 Even if the Sell factors were applicable, the record shows that the order includes an adequate 

medical appropriateness finding: 

The requested medication, the antipsychotic, . . . did successfully treat and 

manage [S.M.]’s aggressive behavior and assaultiveness without side effects that 

were verbalized to Dr. Karnik. . . . [R]esuming antipsychotic medication would, 

hopefully, address those assaultive and aggressive behaviors, again, such that 

[S.M.] could transfer to the civil ward which would be a less restrictive environment 

. . . with additional treatment and programming opportunities. . . .
No. 57820-4-II

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Because the superior court commissioner did not make a medical appropriateness finding, 

S.M. assumes that the commissioner did not follow procedure as outlined in RCW 71.05.217(1)(j). 

However, this assumption is not supported by the record. 

Here, the superior court commissioner discussed S.M.’s need for antipsychotic medication 

to help prevent his aggressive and assaultive behavior. The commissioner also articulated that the 

alternatives to antipsychotic medication, such as use of restraints and seclusion, would be more 

intrusive to S.M.’s liberty interests. Finally, the commissioner acknowledged S.M.’s concerns 

about medication side effects, noted that S.M.’s primary concern was for the side effects of 

Lithium, a medication that the State did not seek to administer. Additionally, the commissioner 

found Dr. Karnik’s testimony regarding Haldol more credible. “We do not disturb the superior 

court’s findings ‘if supported by substantial evidence which the lower court could reasonably have 

found to be clear, cogent and convincing.’” B.M., 7 Wn. App. 2d at 85 (quoting In re Det. of 

LaBelle, 107 Wn.2d 196, 209, 728 P.2d 138 (1986)). 

 

Absent treatment with an antipsychotic to get [S.M.] more stabilized . . . the 

only other treatment options to address his current symptoms would be use of 

seclusion and restraints which are much more intrusive to [S.M.]’s liberty and, also, 

would likely lead to a prolonged commitment and a much longer period of 

commitment.

VRP at 47-48. The order also addressed S.M.’s concern regarding side effects:

As to [S.M.]’s own testimony regarding his concern for side effects, [S.M.]

discussed concern as to Lithium. Lithium is not an order being sought today. 

[S.M.] expressed concern that Haldol is not FDA approved or that understanding is 

inconsistent, in my view, with Dr. Karnik’s testimony; and the medication that is 

sought in the first place is Zyprexa, which Dr. Karnik testified the respondent had, 

previously, had a track record of success taking.

VRP at 48.
No. 57820-4-II

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S.M. appears to assert that Dr. Karnik, instead of the superior court commissioner, made 

the “medical appropriateness finding,” which was error. Br. of Appellant at 15. S.M.’s contention 

is not supported by the record. Dr. Karnik, as S.M.’s treating psychiatrist, testified as an expert 

witness during the hearing and made a professional recommendation for S.M.’s treatment based 

on his firsthand knowledge of and interactions with S.M. 

Because the medication order is not for the purpose of S.M. standing trial and because 

RCW 71.05.217 does not require a medical appropriateness finding, the medical appropriateness 

standard is not applicable here. Further, because the order complied with RCW 71.05.217(1)(j)(ii), 

the commissioner did not violate S.M.’s due process rights.

3. Substituted Judgment

S.M. argues that the superior court commissioner’s substituted judgment was inadequate 

because “the commissioner should have engaged in a substantive review of both the known and 

unknown risks [of taking antipsychotic medication] to S.M.’s health” and “should have 

incorporated consideration of the risks and concerns expressed by S.M. into the balancing test 

required under” Ingram. Br. of Appellant at 19-20. We hold that the superior court 

commissioner’s substituted judgment incorporated the factors outlined in Ingram and is supported 

by substantial evidence.

During the hearing, Dr. Karnik testified about S.M.’s delusions and aggressive behavior. 

Dr. Karnik based his testimony on daily interactions with and observations of S.M. Dr. Karnik 

testified that S.M. regularly made threats to kill him, that S.M. had assaulted both fellow patients 

and security personnel at WSH resulting in use of restraints and seclusion, and that S.M. had 

thrown dangerous objects at WSH staff. Furthermore, S.M. made serious enough threats to the 
No. 57820-4-II

15

White House such that both he and WSH staff were contacted and interviewed by the Secret 

Service. 

S.M. had previously been on antipsychotic medication. Dr. Karnik testified that when S.M. 

had been on medication, he had not exhibited physical aggression. Dr. Karnik sought to treat S.M. 

with the same medication that he had been on, Zyprexa, which would help “eliminate delusions, 

eliminate hallucinations, eliminate paranoia.” VRP at 17. S.M. had previously not experienced 

any side effects from Zyprexa. Even so, both Dr. Karnik and a WSH pharmacist discussed with 

S.M. the need for antipsychotic medication, along with possible medication side effects. 

During the hearing, Dr. Karnik described at length the possible side effects of S.M.’s 

proposed treatment and stated that S.M. would be monitored closely and have his medication 

adjusted if needed. Dr. Karnik testified that he hopes to stabilize S.M. such that S.M. could be 

transferred to the less restrictive “civil side” of WSH. VRP at 19. Without medication, S.M.’s 

“physical issues and the psychosocial issues would continue to deteriorate.” VRP at 22. S.M. 

never informed Dr. Karnik of any side effects, and S.M.’s only expressed objection to 

antipsychotic medication was that he did not believe he needed it. 

The superior court commissioner found that the State had proven by clear, convincing, and 

cogent evidence S.M.’s need for antipsychotic medication. The commissioner listed out a timeline 

of incidents involving S.M. and his continued assaultive behavior when not taking medication. In 

the order’s written list of instances of S.M.’s aggression, the commissioner included “threatening 

statements about violence to Dr. Karnik,” punching a “peer in the face multiple times before [S.M.] 

could be restrained by staff,” and “remov[ing] a large mirror from a ceiling on the ward and 

[throwing] it at staff.” CP at 41-42. The commissioner also found that the preservation of life and 
No. 57820-4-II

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the protection of interests of innocent third parties are compelling State interests. B.M., 7 Wn. 

App. 2d at 79. The commissioner cited to Dr. Karnik’s testimony that when S.M. had previously 

been on medication, it was successful, and if S.M. resumed taking medication, he could move to a 

less restrictive ward with additional treatment opportunities. The commissioner noted that the 

only treatment alternatives available to S.M. “would be use of seclusion and restraints which are 

much more intrusive to [S.M.]’s liberty and, also, would likely lead to a prolonged commitment 

and a much longer period of commitment.” VRP at 47-48. 

The superior court commissioner also directly addressed S.M.’s desires regarding the 

medication. The commissioner noted that S.M. made no religious or moral objections to taking 

antipsychotic medication, nor was there any evidence of objections from family members. The 

commissioner cited to Dr. Karnik’s testimony and stated “that the only reason [S.M. has] given for 

not taking the medications is he doesn’t think he needs them and doesn’t wish to take them.” VRP 

at 45. The commissioner also noted that during the hearing, S.M. primarily expressed concerns 

over the side effects of Lithium, which was not at issue. As for S.M.’s concerns regarding Haldol, 

the commissioner found Dr. Karnik’s explanation of how Haldol was not FDA-approved as a mood 

stabilizer, but was approved as an antipsychotic, more credible. 

The record is clear that in making the substituted judgment, the superior court 

commissioner took into consideration evidence regarding S.M.’s behavior while on and off 

medication, the effect of the medication on S.M.’s commitment, the side effects of the medication, 

alternatives to medication, S.M.’s concerns regarding the medication, as well as the lack of any 

religious objections to the medication or evidence of objection from any family members. And in 

its written order, the commissioner wrote: “[S.M.] would consent to being treated with 
No. 57820-4-II

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antipsychotic medication if [S.M.] were capable of making a rational decision concerning 

treatment and this Court is hereby substituting its judgment for that of [S.M.].” CP at 44. 

Thus, the record shows that the superior commissioner’s substituted judgment considered 

the factors outlined in Ingram and is supported by substantial evidence. Accordingly, we hold that 

the commissioner did not err.

CONCLUSION

A finding of medical appropriateness is not required in a civil commitment proceeding and 

the superior court commissioner appropriately identified a compelling state interest, the necessity 

of the treatment, and considered S.M.’s desires and concerns in making its substituted judgment. 

Therefore, we affirm the order for involuntary administration of antipsychotic medication.

A majority of the panel having determined that this opinion will not be printed in the 

Washington Appellate Reports, but will be filed for public record in accordance with RCW 2.06.040, 

it is so ordered. 

Lee, J.

We concur:

Maxa, P.J.

Che, J.