Opinion ID: 2178846
Heading Depth: 1
Heading Rank: 2

Heading: order for psychiatric evaluation and report

Text: NOW, on this 15th day of September, 1977, this matter having been brought to the attention of the court, and the court being fully advised of the charges against the defendant in the above captioned cause, and the present condition of the defendant; it is the considered opinion of this court that before further proceedings may be had an evaluation of the above-named defendant's physical and psychological state should be made by competent professionals in the fields of medicine and psychology in order that the court may be more fully advised and that the best interests of the parties and of justice may be realized. IT IS ORDERED, ADJUDGED AND DECREED that the above-named defendant, now in legal custody, be transported to 2 East, North Ward, Iowa Lutheran Hospital, there to undergo psychiatric and physical examination and evaluation by such doctors and staff of said hospital as may be appointed by the director of the Psychiatric Unit of said hospital and Dr. Michael Taylor and FURTHER, that a report of such examinations and evaluations, along with any conclusions of the examining physicians shall be made in writing to this court as soon as completed, at Defendant's expense with guard only if necessary. IT IS FURTHER ORDERED that the defendant at all times pertinent hereto is to remain under the custody of this court and that upon completion of said evaluations and examinations by the Psychiatric Unit of Lutheran Hospital the defendant shall be transported back to the immediate custody of the agency formerly charged with his or her custody and that this court shall be so notified in order that it may proceed with such further action as the laws of this state and the interests of justice might dictate. Later, when it appeared that Cole could not be admitted immediately to Iowa Lutheran, the following was added to the order: The defendant to be taken to Broad-lawns [hospital] until a room at Lutheran Hospital is available. The effect of this order, and of the medical relationship which followed it, are determinative on the issue of whether or not the defendant could assert the doctor-patient privilege. In court-ordered evaluations, the third requirement of the privilege is lacking; the communication is not for the purpose of treatment but to determine the existence of a fact or condition for the benefit of the court. See State v. District Court of Linn County, 218 N.W.2d at 643; State v. Bedel, 193 N.W.2d 121, 124 (Iowa 1971); State v. Mayhew, 170 N.W.2d 608, 615-16 (Iowa 1969). Therefore, [t]he physician-patient privilege does not arise where on order of the court a defendant is examined to determine his mental or physical condition. Mayhew, 170 N.W.2d at 615. Accord, McCormick's Handbook of the Law of Evidence § 99, at 214 (2d ed. 1972). [1] An examination of the order itself sheds considerable light on the subsequent relationship of Cole with Doctors Taylor and Varner. The order is entitled Order for Psychiatric Evaluation and Report, and in the body of the order it provides that before further proceedings may be had an evaluation of the above-named defendant's physical and psychological state should be made . . . in order that the court may be more fully advised and that the best interests of the parties and of justice may be realized. (Emphasis added.) The order clearly provided for evaluation and report to the court and made no provision for diagnosis or treatment. The defendant, while acknowledging that the order appears to be for evaluation and report, argues it was really only intended to provide for her safekeeping in order to avoid a possible suicide. We do not believe the intentions of the parties can be properly used to countermand the unambiguous provisions of a court order. 9 J. Wigmore, supra, § 2450, at 157; ([T]he [judicial] record being the sole embodiment of the judicial proceedings, no other materials or utterances, oral or written, can be set up in competition with it. In other words, but less correctly, the record is conclusive. ) (Emphasis in original.). [2] Cf. State v. Rouse, 290 N.W.2d 911, 916 (Iowa 1980) (impeachment of jury verdict proscribed by parol evidence rule). Nevertheless, we have examined the evidence which defendant says establishes that the order was for treatment and not for evaluation. At a hearing on the issuance of a subpoena to force Dr. Taylor to submit to a deposition, the magistrate who signed the order, an assistant county attorney, and defense attorneys all testified about the circumstances surrounding the entry of the order. Mr. Scalise testified that the reason for entering the order for hospitalization was to avoid a possible suicide by Cole if she went to jail and that the examination and evaluation provisions were in the order only because they were incorporated in a form order that we got out of somebody's desk. He testified [t]here was never any discussion or mention of the word evaluation, that's my recollection of it. There never was anything at all with respect to evaluation. Thomas Levis, an associate of Mr. Scalise, testified in about the same way, that the parties were preoccupied with Cole's safety and that there was no actual discussion of examination or evaluation of her. An assistant county attorney, Rod Ryan, was present at the time the order was entered. He testified that one consideration was defendant's safekeeping, but said it was also anticipated she would be examined and evaluated under the order. As to the defendant's argument that the examination and evaluation language was only used because it happened to be part of the stock form, Ryan testified that if one had been composed for this case, it would have been dictated almost along the same lines, but it just happened to be a form that we used. Magistrate McEniry testified in response to the question Did you anticipate in signing the order that she was going to be evaluated by the psychiatrist? that I assumed she would be examined by a psychiatrist. As part of that process I imagine she would have to be evaluated as well. Even if we were to consider the intentions of the parties, as appellant suggests, we do not believe the record supports her contention that [t]he record unquestionably shows that Kathleen Cole was sent to Lutheran Hospital for the primary, if not the sole purpose, of obtaining diagnosis and treatment. Even under her own evidence, the commitment was for her protection; no one testified she was committed for treatment. The analysis of this problem is somewhat complicated in light of Dr. Taylor's testimony that he actually treated the defendant after the shooting. A doctor may be examined as to a non-privileged evaluation of a defendant even though he has also been the defendant's treating doctor. People v. Abdul Karim Al-Kanani, 33 N.Y.2d 260, 264, 351 N.Y.S.2d 969, 970, 307 N.E.2d 43, 44 (1973); State v. Kulgis, 70 Wash.2d 168, 171, 422 P.2d 480, 482 (1967). Here the doctor testified both he and the defendant expected their relationship to be confidential, with the proviso that Dr. Taylor could release the information to her attorneys. Yet, it seems clear that Dr. Taylor was informed from the beginning that he would be evaluating the defendant under the court order. The assistant county attorney who accompanied the defendant to the hospital spoke with Dr. Taylor before he saw her, and Dr. Taylor indicated to [him] that he could not tell [him] anything at that time. Additionally, a copy of the order was left at the hospital. We are confronted, then, with the question of whether a doctor who knows he is to conduct an evaluation for the court may nevertheless establish a confidential relationship with the patient. We do not believe that a court order may be countermanded in that manner. We are also mindful of the decisions in some other states which hold that the existence of the privilege is determined by the actual, subjective understanding of the patient. Those decisions are premised on the recognition that use of the subjective test would prevent the privilege accorded the patient [from being] taken from her by trick or fraud. Smart v. Kansas City, 208 Mo. 162, 184, 105 S.W. 709, 717 (1907); accord, State v. Shaw, 106 Ariz. 103, 105-06, 471 P.2d 715, 718 (1970); State v. Sullivan, 60 Wash.2d 214, 224-25, 373 P.2d 474, 479 (1962). The only evidence of her subjective intent came in the form of her oral confirmation of her attorney's statement that she did not intend to waive her privilege; she did not testify to such fact. To turn the issue of the doctor-patient privilege on the subjective intent of a patient is unrealistic, in effect permitting him to await the outcome of the examination before announcing what his subjective intent was. Moreover, except in those cases in which an examination against the wishes of the defendant raises such issues as self-incrimination under the fifth amendment or effective assistance of counsel under the sixth, [3] it appears that a defendant's desires or expectations are not determinative on the issue of whether the doctor-patient privilege applies. [C]ourts have uniformly rejected the argument that the [doctor-patient] privilege simply prohibits compelling an accused to submit to an examination. McCormick, supra, § 134, at 286. The order clearly provided for examination, not treatment. The subjective intent or expectations of defendant in obtaining the order for commitment and in submitting to the ensuing examination cannot change that. The State is entitled to be treated fairly when dealing with a statutory privilege. See State v. Tensley, 249 N.W.2d 659, 662 (Iowa 1977) (attorney-client privilege) (we believe it would be unfair to permit the defense to elicit favorable aspects of the communication without permitting the prosecution an opportunity to elicit unfavorable aspects.). By the time the deposition of Dr. Taylor was sought and resisted, thereby making it obvious the defendant challenged the evaluation provisions of the order, the value of another examination would have been seriously depreciated by the passage of time. We do not believe the privilege may be used in this manner. A rule designed as a shield against improper dissemination of information for proper medical treatment would in effect become a sword in the hands of a litigant, frustrating a court's search for facts. It cannot be both. 8 J. Wigmore, supra, § 2388, at 855. A further observation by Wigmore is pertinent: The policy reasons behind the doctor-patient privilege are hardly served where, as here, it is not evidence of some dreaded or embarrassing disease which the defendant desires to have excluded but rather, evidence of her good health. Ibid. B. Waiver of the privilege. The State argues that, even if we find the privilege arose, the defendant waived it by putting her mental condition in issue. We need not address the issue, because we find no privilege existed. However, we discuss it briefly because of its importance in future cases. Wigmore has said that [a] waiver is to be predicated not only when the conduct indicates a plain intention to abandon the privilege, but also when the conduct (though not evincing that intention) places the claimant in such position, with reference to the evidence, that it would be unfair and inconsistent to permit the retention of the privilege. 8 J. Wigmore, supra, § 2388, at 855. The author illustrated the point, in the context of a civil suit, this way: By any other conclusion the law practically permits the plaintiff to make a claim somewhat as follows: I tender witnesses A, B and C, who will openly prove the severe nature of my injuries. But I object to the testimony of witness D, a physician called by the opponent to prove that my injury is not so severe as I claim, because it is extremely repugnant to me that my neighbors should learn the nature of my injury! Id. Accord, McCormick, supra, § 103, at 221. Several courts have held that a plea of insanity or diminished capacity waives the privilege by putting the matter in issue. See, e. g., Bailey v. State, 264 Ind. 505, 346 N.E.2d 741, 745 (1976); Lockridge v. State, 263 Ind. 678, 338 N.E.2d 275, 281-82 (1976); State v. Aucoin, 362 So.2d 503, 504-06 (La. 1978) (State called defendant's treating doctor; privilege held waived by raising issue of insanity); State v. Berry, 324 So.2d 822, 827-28 (La.1975) (waived by plea of insanity); accord, McCormick, supra, § 134, at 285-86 ([I]t is arguable that by asserting incompetency to stand trial or nonliability by reason of insanity the accused has, to a limited extent at least, waived his right to rely on his privilege in regard to those matters.); 8 J. Wigmore, supra, § 2380, at 855. We believe the defense of diminished capacity waived the privilege here, even if it had existed, for the simple reason it would be incongruous to allow a party to put a matter in issue and then deny access of an opposing party to relevant information concerning it. Id. Our modern concept of criminal trials favors full disclosure of facts, within constitutional limitations, on both sides of the table. The sporting theory of justice resulting from concealment and surprise is no longer the rule. See ABA Report, Standards for Criminal Justice, Discovery and Procedure Before Trial (Approved Draft 1970) at 35. Even the most restrictive authorities would say Cole would have waived the privilege by introducing evidence on it; our view that a waiver is effected by a plea of insanity or diminished capacity merely advances the timetable to permit adequate preparation and avoids the delay which might otherwise be required to meet the defense. See id. at 45 ([R]equiring disclosure [by defendant] in advance merely regulates the procedure by which he presents his case.). The waiver issue in this case is limited to the statutory doctor-patient privilege of section 622.10. We have not addressed the possible constitutional implications in a forced disclosure of doctor-patient communications, which have not been raised. Issues of constitutional proportion might arise, for example, if a patient's record, including details of the current or prior crimes, is sought to be used by the prosecution in its case in chief. We have said that a seemingly disinterested third party cannot elicit information from a defendant without affording him the same protection as if the interrogation had been by the police themselves. State v. Flaucher, 223 N.W.2d 239, 241 (Iowa 1974) (statements to doctor withdrawing blood for alcohol analysis); State v. Cullison, 215 N.W.2d 309, 315 (Iowa 1974) (statements to polygraph operator). A defendant's fifth-amendment rights would obviously be involved. See McCormick §§ 133-34, at 282-88. And if a defense attorney seeks an independent psychiatric evaluation in order to decide whether or not to assert an insanity or diminished capacity defense he might be faced with prosecutorial intervention in that process and the resulting issue of effective assistance of counsel under the sixth amendment. See United States v. Alvarez, 519 F.2d 1036, 1046-47 (3d Cir. 1975); Note, Protecting the Confidentiality of Pretrial Disclosures: A Survey of Standards, 51 N.Y.U.L.Rev. 409, 413-17 (1976). We point out these constitutional issues to contrast them to the statutory privilege with which we are dealing in this case and to establish parameters of the waiver rule announced herein. The constitutional issues must remain to be resolved as they arise. C. Magistrate's authority to order evaluation. The defendant seeks to avoid the effect of the order by arguing that the magistrate was without authority to enter an order for custody and evaluation. She argues that only a district court could enter such an order. The State counters that any objection to the magistrate's authority was waived because her attorney actively participated in its procurement. While we do not believe objections to subject matter jurisdiction could be waived by defendant, neither do we believe the admission of this evidence depends upon the authority of an issuing judge. The existence of a doctor-patient privilege does not rise or fall on the legality, or even the existence, of a court order for examination. See State v. Nowlin, 244 N.W.2d at 602 (non-privileged evaluation may result whether examination by court order or pursuant to private arrangement by defendant); McCormick, supra, § 99, at 213-14 (evaluation by arrangement of police officer, prosecutor, opposing party, or party's own attorney as well as by court order, may produce non-privileged evidence). The test is still whether the three elements of the privilege are established. State v. Nowlin, 244 N.W.2d at 602. An order such as the one here, though, furnishes strong evidence of the nature of the relationship which follows. It is upon that rationale that we have examined it here and have concluded that the doctor-patient privilege is inapplicable. In summary, we hold that because Dr. Taylor's and Dr. Varner's contacts with the defendant after September 15 were to conduct a court-ordered evaluation of her mental condition, no doctor-patient privilege arose with respect to that contact. The order for evaluation, because it is merely evidence of the relationship which followed, does not rest for its probative value upon either the court's authority to issue it nor upon any waiver of the jurisdictional objection on the part of the defendant. Where the privilege does not arise because the contact was for the purpose of conducting a court-ordered examination, it cannot be created by an understanding of the doctor and the patient that the communications will be confidential. Finally, we conclude that even if the privilege had existed, defendant waived it by placing the matter in issue. D. The hypothetical question. At trial Dr. Taylor was asked to assume certain facts and give his opinion as to whether the defendant was capable of forming specific intent, to counter defendant's claim of diminished responsibility. This has been a recognized method of producing medical or psychiatric evidence without regard to the doctor-patient privilege, the opinion presumably being based upon the facts presented by the examining lawyer and not upon any communications with the patient. Crago v. City of Cedar Rapids, 123 Iowa 48, 49, 98 N.W. 354, 355 (1904); 3 Wharton, supra, § 563, at 88; 8 J. Wigmore, supra, § 2382, at 841. However, if the witness is incapable of separating privileged facts from non-privileged facts in answering the hypothetical, application of the privilege will usually result in inadmissibility of the opinion. Id. The defendant contends this was the situation in this case. Dr. Taylor was called by the State and testified extensively. He was asked whether he could form an opinion of the defendant's M'Naughten sanity based only on information from a hypothetical and his post-arrest contact with her. He responded that he could, although he admitted that he could not form a medical diagnosis based only on that information. However, the diagnosis of her problem, if any, is not an issue. He testified that he could completely divorce his pre-arrest contact with the defendant in forming his opinion on her sanity. He was then questioned regarding the defense of diminished capacity; he testified he could form an opinion on her capacity based solely on the post-arrest contact. He admitted on defendant's voir dire that pre-arrest contact would necessarily affect [his] judgment with respect to her mental capacity. Upon further examination by the State, however, he testified that, based only on his contact with the defendant after the order of commitment, there was no indication that any condition existed which might have impaired her ability to premeditate and deliberate with the intent to kill. The appellant now contends that this pre-arrest treatment of the defendant so affected his testimony that a hypothetical-question approach could not avoid the bar of the patient privilege. The admissibility of opinion testimony rests with the trial court, and we will interfere only if there is manifest abuse of that discretion. Becker v. D & E Distributing Co., 247 N.W.2d 727, 733 (Iowa 1976). Here, it is true the doctor retracted some when pressed by the defendant's voir dire, but it should be pointed out that he said his opinion on diminished capacity would be affected by the pre-order treatment of Cole; he did not say the opinion could not be rendered without reference to his earlier exposure to her. In fact, upon further examination he said he could give such opinion without regard to the period preceding the evaluation order. We therefore do not believe the court abused its discretion in allowing the opinion on diminished capacity to be expressed in the context of the hypothetical question, because it was not shown to be dependent upon privileged information. E. Refusal to strike testimony of psychiatrist. As discussed in subdivision A, the State questioned Dr. Taylor at length about his examination of this defendant. Her attorney objected throughout his testimony on the basis of the doctor-patient privilege. Shortly after defendant's cross-examination of Dr. Taylor began, he was asked by her attorney about his treatment of Cole after the shooting. The following exchange ensued: [Dr. Taylor:] Mr. Sandre [one of defendant's attorneys], I explained my position on Thursday that I am unwilling, without Mrs. Cole's permission, to discuss any further content of any of my directions to her. [Mr. Sandre:] You understand, Doctor, I am talking about the period of time between the 15th day of September and the 30th day of September, 1977. You understand that? [Dr. Taylor:] Yes, I understand that. [Mr. Sandre:] And do I understand that you are unwilling to answer my questions that I propose to you with respect to that period of time in terms of your relation with Mrs. Cole? [Dr. Taylor:] You understand me correctly. [Emphasis added.] Defendant then moved to strike all of Dr. Taylor's testimony on the basis that she had been denied adequate cross-examination. The trial court refused to strike the testimony. Defendant's counsel again asked Dr. Taylor if he refused to answer the question; the witness responded I am not refusing to answer your questions, Mr. Sandre . .. She has not waived [her privilege], so I am unwilling to divulge any information that I have received from Mrs. Cole. A motion to strike the direct testimony was again denied. Dr. Taylor did not refuse to answer defendant's questions; he only refused to answer any more of them until the privilege (which we have previously decided did not actually exist) was waived by her. The defendant was the only party who could waive the privilege, if it had existed. She therefore had the key to unlock the evidence which she was seeking, and she refused to use it. This anomalous situation could have been resolved if she had merely given her consent to Dr. Taylor's testimony. She argues on appeal, however, that this would have waived the privilege in toto and would have been inconsistent with her position that all of Dr. Taylor's testimony was inadmissible under the privilege. However, for the reasons already discussed, the examination was not covered by the privilege; the defendant would have lost nothing by acceding to the doctor's request for permission to answer her own questions. The dilemma Cole now complains of, a choice between her sixth-amendment right to full cross-examination and exercising her doctor-patient privilege, is therefore non-existent; the latter option did not exist anyway. Further, not every refusal to answer by a witness on cross-examination requires the striking of his direct testimony; whether to strike it under such circumstances is largely left to the discretion of the trial court. See United States v. Cardillo, 316 F.2d 606, 613 (2d Cir. 1963). The fact the evidence sought is merely cumulative may be considered in making that decision. Cardillo, 316 F.2d at 613 (cumulative testimony regarding credibility of witness refusing to answer on self-incrimination grounds). Here, the questions at which the doctor began to balk involved the post-arrest examination period. The specific question posed was on the 15th day of September, 1977, when you saw Mrs. Cole in the hospital did you ever advise her of her rights against self-incrimination? The doctor refused to answer. Without asking any further questions of the witness, the defendant moved to strike. There is no showing, first, that self-incrimination was ever an issue, and defendant makes no attempt to show her failure to obtain an answer to that question prejudiced her defense. Second, the record does not reveal a serious effort to protect the confrontation rights of this defendant. There were several courses open to the defense: They could have relied on the trial court's ruling that they had already waived the privilege with respect to the latter period, reaffirmed only shortly before, or ask that the doctor be ordered to testify or found in contempt. (The record reveals a willingness of the doctor to comply with any such order.) Instead, defense counsel chose the course of action least likely to induce the doctor's testimony. See State v. Brown, 549 S.W.2d 336, 341 (Mo.1977) (The contempt sanction is coercive upon the witness himself but the sanction of striking all of the witness's testimony may or may not be coercive with respect to the witness.. . . [I]f the witness is not a party such a threat is not coercive as to the witness at all.). The defendant having failed to seek less drastic yet more effective sanctions, we hold the trial court did not abuse its discretion in refusing to strike the direct testimony of Dr. Taylor.