Opinion ID: 1679694
Heading Depth: 1
Heading Rank: 3

Heading: what constitutes an expression of understanding?

Text: In Jones, this court stated that the concepts of mental illness and competency are not synonymous. An individual may be psychotic, yet nevertheless capable of evaluating the advantages and disadvantages of taking psychotropic drugs and making an informed decision. Jones, 141 Wis. 2d at 728. Both the testimony of Virgil and the examining psychiatrists support the conclusion that Virgil was competent to refuse medication, even if he did not have a full scientific appreciation of the parameters of his mental illness. For example, Virgil testified at the February, 1993 hearing that, for him, there were no advantages to taking drugs such as Prolixin. Instead, there were many disadvantages, including the fact that when he took the medication it hindered his judgment and chemically tortured him. When asked if he had been involuntarily committed while taking Prolixin, Virgil answered yes. The testimony of the psychiatrists at the November, 1992 and February, 1993 hearings was essentially the same and had the effect of validating Virgil's conclusions: Virgil has expressed an understanding of the risks and benefits of, and the alternatives to, psychotropic medication. Clearly, Virgil met the only standard established in § 51.61(1)(g)4. However, the circuit court (at the February, 1993 hearing) and the court of appeals erred when they ignored the statutory standard and placed greater emphasis on the psychiatrists' testimony that Virgil was not competent to refuse medication because he did not have an appreciation of his own mental illness. [8] [6,7] When a circuit court is asked to determine a patient's competency to refuse medication or treatment pursuant to § 51.61(1)(g)4, Stats., it must presume that the patient is competent to make that decision. See § 51.20(13)(e), Stats. The petitioner has the burden of overcoming that presumption by showing incompetence by evidence that is clear and convincing. Id. The petitioner must establish that the patient is unable to express an understanding of the advantages and disadvantages of the medication or treatment, and the alternatives to accepting the particular medication or treatment offered, after the advantages, disadvantages and alternatives have been explained to him or her. See § 51.61(1)(g)4, Stats. Ultimately, if the petitioner is unable to meet that burden, the patient retains the right to exercise informed consent with regard to all medication and treatment. See §51.61(1)(g)3, Stats. [8] In making its decision, the circuit court must first be satisfied that the advantages and disadvantages of, and the alternatives to, medication have been adequately explained to the patient. Second, the court must consider the evidence of the patient's understanding, or the lack thereof, regarding the advantages, disadvantages, and alternatives. The evidence may include the actual testimony of the patient and the examining psychiatrist. Factors which the court should take into account in reaching its decision include: (a) Whether the patient is able to identify the type of recommended medication or treatment; (b) whether the patient has previously received the type of medication or treatment at issue; (c) if the patient has received similar treatment in the past, whether he or she can describe what happened as a result and how the effects were beneficial or harmful; (d) if the patient has not been similarly treated in the past, whether he or she can identify the risks and benefits associated with the recommended medication or treatment; and (e) whether the patient holds any patently false beliefs about the recommended medication or treatment which would prevent an understanding of legitimate risks and benefits. [9] The circuit court must maintain the distinction that this court recognized in Jones between a patient's mental illness and his or her ability to exercise informed consent. Jones, 141 Wis. 2d at 728. The focus of a hearing on the patient's right to exercise informed consent should not be upon whether the court, the psychiatrist or the County believes the patient's decision is the wrong choice. Rather, the focus must be upon whether the patient understands the implications of the recommended medication or treatment and is making an informed choice. In this case, even if Virgil's decision to refuse to take the Prolixin is a poor choice, it is his to make as long as he understands the implications of that decision. Simply because Virgil disagrees with the recommendation of the examining psychiatrist, he does not lose his right to refuse administration of the drug. The County still retains the right to medicate him if an emergency arises. See §51.61(1)(g)3, Stats. [10] Virgil did not contest the findings of mental illness, dangerousness or treatability [9] when the County initiated commitment proceedings. Rather, he argued that he was competent to exercise informed consent to refuse forced medication with psychotropic drugs. Applying the single standard articulated in § 51.61(1)(g)4, Stats., we conclude that the County failed to prove that Virgil was not competent to refuse medication, because Virgil was in fact capable of expressing an understanding of the advantages and disadvantages of, and the alternatives to, accepting the medication. By the Court. The decision of the court of appeals is reversed, and the cause is remanded to the circuit court with instructions to vacate the order permitting involuntary administration of medication and treatment.