Opinion ID: 432007
Heading Depth: 3
Heading Rank: 1

Heading: The Right to Treatment

Text: This court suggested some years ago that a constitutional right to treatment might well be an essential condition of the state's power of involuntary commitment. Schuster v. Herold, 410 F.2d 1071, 1087-89 (2d Cir.), cert. denied, 396 U.S. 847, 90 S.Ct. 81, 24 L.Ed.2d 96 (1969). Since then, numerous federal courts have acknowledged the existence of such a right. See, e.g., Scott v. Plante, 641 F.2d 117 (3d Cir.1981), vacated and remanded, 458 U.S. 1101, 102 S.Ct. 3474, 73 L.Ed.2d 1362, on remand, 691 F.2d 634 (3d Cir.1982); Welsch v. Likins, 373 F.Supp. 487 (D.Minn.1974), partially vacated on other grounds, 550 F.2d 1122 (8th Cir.1977); Wyatt v. Stickney, supra ; Davis v. Watkins, 384 F.Supp. 1196 (1974), supplemented sub nom. Davis v. Balson, 461 F.Supp. 842 (1978), supplemented sub nom. Davis v. Hubbard, 506 F.Supp. 915 (N.D.Ohio 1980); cf. Birnbaum, The Right to Treatment, 46 A.B.A.J. 499 (1960). The recognition of the right to treatment has been based upon several different grounds. [7] At bottom, however, courts have acknowledged that the massive curtailment of liberty associated with involuntary confinement, Humphrey v. Cady, 405 U.S. 504, 509, 92 S.Ct. 1048, 1052, 31 L.Ed.2d 394 (1972), dictates that the nature and duration of commitment bear some reasonable relation to the purpose for which the individual is committed. Jackson v. Indiana, 406 U.S. 715, 738, 92 S.Ct. 1845, 1858, 32 L.Ed.2d 435 (1972). If the justification for commitment rests, even in part, upon the need for care and treatment, as it does under New York law, see NYMHL §§ 9.01, 9.27(a), 9.37(a), then a State which commits must also treat. The Supreme Court has not directly addressed the question whether a constitutional right to treatment exists. See, e.g., Pennhurst State School and Hospital v. Halderman (Pennhurst I), 451 U.S. 1, 31, 101 S.Ct. 1531, 1547, 67 L.Ed.2d 694 (1981); O'Connor v. Donaldson, 422 U.S. 563, 573, 95 S.Ct. 2486, 2492, 45 L.Ed.2d 396 (1975). In Youngberg v. Romeo, 457 U.S. 307, 102 S.Ct. 2452, 73 L.Ed.2d 28 (1982), however, the Court did resolve a claim involving an institutionalized mentally retarded individual's right to habilitation  that is, to training and development of needed skills. Id. at 317, 102 S.Ct. at 2459. While the Youngberg Court refrained from deciding the existence of a right to treatment per se, see id. at 325-27, 102 S.Ct. at 2463-64 (Blackmun, J., concurring), its analysis can assist us in charting our course through the rough terrain of this case. [8] Youngberg involved an individual action by a mentally retarded resident of Pennhurst who claimed injury due to his own behavior, attacks by others, and excessive physical restraint by the staff. He asserted, and the Third Circuit agreed, that he possessed Fourteenth Amendment rights to safety, freedom of movement and training. Because the resident, Romeo, was so profoundly retarded that there was no realistic possibility of his ever leaving the institution, the Supreme Court addressed his right to training only to the extent necessary to protect his liberty interests in personal security and freedom from restraint. It held that the State was obligated to provide minimally adequate or reasonable training appropriate to Romeo's particular needs. Id. at 319, 102 S.Ct. at 2460. In determining the reasonableness of training provided by an institution, the Supreme Court said, courts must show deference to the judgment exercised by a qualified professional. Id. at 322, 102 S.Ct. at 2461. The majority elaborated: ... the [training] decision, if made by a professional, is presumptively valid; liability may be imposed only when the decision by the professional is such a substantial departure from accepted professional judgment, practice, or standards as to demonstrate that the person responsible actually did not base the decision on such a judgment. Id. at 323, 102 S.Ct. at 2462. The question suggested by Youngberg, then, is not what treatment was actually provided, but whether the treatment decision was professionally made and falls within the scope of professional acceptability. [9] With this formulation in hand, we can now return to the case at bar. Three of appellants' five proffered standards do not retain any viability under the Youngberg analysis. Standards (4) and (5) both turn on the disparity in quality of care between what appellants have dubbed upper tier general hospitals and lower tier state mental institutions. Assuming the alleged divergence exists, it does not bear on the question whether treatment by the latter is actually informed by professional judgment. Nor do media reports provide any systematic enlightenment in that respect, as standard (3) would suggest. Disapproval by JCAH and HHS, however, upon which standards (1) and (2) are predicated, does come closer to the mark. The court below held that JCAH accreditation criteria comport with or exceed due process requirements, and that JCAH accreditation is prima facie proof of adequate care. Woe v. Cuomo, supra, 559 F.Supp. at 1162. We agree that JCAH approval represents an exercise of professional judgment to which we must defer under Youngberg. This is true not solely because, as the district court stated, JCAH is a highly respected organization of psychiatric and medical professionals, and the value of its accreditation program has been recognized by Congress and the courts. Id. at 1164. It also has merit because many of the JCAH criteria bear directly on the likelihood that professional judgments will govern individual treatment decisions within the institution. JCAH standards address the existence, quality and specificity of patient treatment plans. They require clear procedures for the use of drug and other therapies, including written approval by a physician. They examine the availability of medical care in all respects, and the manner in which it is provided. The JCAH process thus seeks to assure that the facility itself is structured so that decisions will be professionally made. [10] We agree with appellants and the district court that JCAH accreditation is merely prima facie proof of adequacy, and that a court is not barred from probing behind it if presented with evidence that JCAH has, across-the-board or in a given instance, allowed its standards to slip below constitutional benchmarks. Youngberg did not suggest that the judgment of the state's professionals was necessarily conclusive. On the contrary, the Court indicated that the testimony of Romeo's experts should have been admitted as relevant to the professional acceptability of the training he was receiving. Youngberg, supra, 457 U.S. at 323 n. 31, 102 S.Ct. at 2462 n. 31. Thus, on a proper showing, a court should be prepared to allow inquiry into the adequacy of treatment even at an accredited facility. After scrutinizing this record, we find that appellants have made such a showing with respect to only one institution, South Beach Psychiatric Center. South Beach, although JCAH-accredited, lost its HHS certification in 1982. [11] The monitoring team's report which led to this action indicated numerous deficiencies which go directly to the professional judgment standard. A few excerpts will demonstrate: Psychological evaluations ... were conspicuously absent ... Individual comprehensive treatment plans (ITP) were absent ... drug interactions were not adequately monitored ... nurses were administering medications from unclear physicians' orders ... This survey was performed by a team of consultants recommended by the National Institute of Mental Health, and rebuts the presumption of adequacy which JCAH approval carries. Given these conflicting evaluations, we are compelled to conclude that the district judge erred in deciding, on a summary judgment motion, that appellants had failed to raise genuine issues of material fact as to the inadequacy of care at South Beach. Fed.R.Civ.P. 56; see Schering Corp. v. Home Insurance Co., 712 F.2d 4 (2d Cir.1983), and cases cited therein. Of course, where a facility lacks accreditation by JCAH, not even a prima facie showing of adequacy exists. At oral argument, the parties agreed that the other target of appellants' October 1982 motion, Manhattan Psychiatric Center, has since regained its accreditation. They also stated that Mid-Hudson Psychiatric Center, at least some proportion of whose residents are class members, had lost JCAH approval. Appellants claim that appellees failed to inform them or the district court of this fact. In any event, we believe the entry of summary judgment, denying appellants an opportunity to prove their allegations, would be inappropriate as to that or any other institution losing accreditation or approval prior to final judgment.