Opinion ID: 2230457
Heading Depth: 2
Heading Rank: 1

Heading: need for a court order.

Text: The primary dispute in this case concerns the means by which the ward is to exercise his right to refuse treatment, a right which the ward possesses but is incapable of exercising personally. [9] The guardian's position is that the power to exercise this right on behalf of the ward is vested in the guardian simply by virtue of his appointment as guardian. The ward claims that he is entitled to a judicial determination of substituted judgment. The question is, then, who ought to exercise this right on behalf of the ward? We think that this question is best resolved by requiring a judicial determination in accordance with the substituted judgment doctrine. We have in the past stated our preference for judicial resolution of certain legal issues arising from proposed extraordinary medical treatment. Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 759 (1977). Matter of Spring, 380 Mass. 629, 635 (1980). See Rogers II, 634 F.2d 650 (1st Cir.1980), cert. granted, 451 U.S. 906 (1981). We reaffirm this preference in the circumstances shown here. While we are mindful that [t]he judicial model for factfinding for all constitutionally protected interests, regardless of their nature, can turn rational decision-making into an unmanageable enterprise, Parham v. J.R., 442 U.S. 584, 608 n. 16 (1979), the question presented today seems to require the process of detached but passionate investigation and decision that forms the ideal on which the judicial branch of government was created, Saikewicz, supra . The question presented by the ward's refusal of antipsychotic drugs is only incidentally a medical question. Absent an overwhelming State interest, a competent individual has the right to refuse such treatment. To deny this right to persons who are incapable of exercising it personally is to degrade those whose disabilities make them wholly reliant on other, more fortunate, individuals. In order to accord proper respect to this basic right of all individuals, we feel that if an incompetent individual refuses antipsychotic drugs, those charged with his protection must seek a judicial determination of substituted judgment. No medical expertise is required in such an inquiry, although medical advice and opinion is to be used for the same purposes and sought to the same extent that the incompetent individual would, if he were competent. We emphasize that the determination is not what is medically in the ward's best interests  a determination better left to those with extensive medical training and experience. The determination of what the incompetent individual would do if competent will probe the incompetent individual's values and preferences, and such an inquiry, in a case involving antipsychotic drugs, is best made in courts of competent jurisdiction. There is no bright line dividing those decisions which are (and ought to be) made by a guardian, from those for which a judicial determination is necessary. The tension which makes such a line so difficult to draw is apparent. There is an obvious need for broad, flexible, and responsive guardianship powers, but simultaneously there is a need to avoid the serious consequences accompanying a well-intentioned but mistaken exercise of those powers in making certain medical treatment decisions. We have recently identified the factors to be taken into account in deciding when there must be a court order with respect to medical treatment of an incompetent patient. Among them are at least the following: the extent of impairment of the patient's mental faculties, whether the patient is in the custody of a State institution, the prognosis without the proposed treatment, the prognosis with the proposed treatment, the complexity, risk and novelty of the proposed treatment, its possible side effects, the patient's level of understanding and probable reaction, the urgency of decision, the consent of the patient, spouse, or guardian, the good faith of those who participate in the decision, the clarity of professional opinion as to what is good medical practice, the interests of third persons, and the administrative requirements of any institution involved. Matter of Spring, supra at 637. Without intending to indicate the relative importance of these and other factors in all cases, it is appropriate to identify some of those factors which are weighty considerations in this particular case. They are: (1) the intrusiveness of the proposed treatment, (2) the possibility of adverse side effects, (3) the absence of an emergency, (4) the nature and extent of prior judicial involvement, and (5) the likelihood of conflicting interests. (1) The intrusiveness of the proposed treatment. We can identify few legitimate medical procedures which are more intrusive than the forcible injection of antipsychotic medication. [10] In general, the drugs influence chemical transmissions to the brain, affecting both activatory and inhibitory functions. Because the drugs' purpose is to reduce the level of psychotic thinking, it is virtually undisputed that they are mind-altering. Rogers I, supra at 1360. A single injection of Haldol, one of the antipsychotic drugs proposed in this case, can be effective for ten to fourteen days. The drugs are powerful enough to immobilize mind and body. Because of both the profound effect that these drugs have on the thought processes of an individual and the well-established likelihood of severe and irreversible adverse side effects, see Part II A (2) infra, we treat these drugs in the same manner we would treat psychosurgery or electroconvulsive therapy. Compare Plotkin, Limiting the Therapeutic Orgy: Mental Patients' Right to Refuse Treatment, 72 Nw. U.L. Rev. 461, 466-474 (1977), with id. at 474-479. Additionally, clinicians have encountered great difficulty in scientifically predicting a particular individual's response to a particular drug, and the results frequently appear paradoxical or idiosyncratic. Id. at 474-475. The record in this case indicates that if the drugs were mistakenly administered to a nonpsychotic individual, then that individual might develop a toxic psychosis, causing him to suffer symptoms of psychosis. While the actual physical invasion involved in the administration of these drugs amounts to no more than an injection, the impact of the chemicals upon the brain is sufficient to undermine the foundations of personality. While antipsychotic drugs can actually lessen the amount and intensity of psychotic thinking, among the most important reasons for their continued use is to control behavior. [11] Plotkin, supra at 478. [T]hese drugs have been intentionally used for disciplinary purposes, and they have been unintentionally misused as a result of either ignorance or inadequate resources. While psychotropic drugs may play a significant role in the treatment of psychiatric disorders, there is no wisdom in permitting their continued indiscriminate use upon unconsenting persons or upon persons who are uninformed as to their potential consequences. Id. at 478-479. (2) The possibility of adverse side effects. Although, as we establish above, the intended effects of antipsychotic drugs are extreme, their unintended effects are frequently devastating and often irreversible. The adverse side effects accompanying administration of antipsychotic drugs have been known since the late 1950's. Baldessarini & Lipinski, Risks vs. Benefits of Antipsychotic Drugs, 289 New England J. Med. 427, 428 (1973). `[T]oxic' effects regularly accompany the use of antipsychotic drugs to ameliorate schizophrenic symptoms. The most common results are the temporary, muscular side effects (extra-pyramidal symptoms) which disappear when the drug is terminated; dystonic reactions (muscle spasms, especially in the eyes, neck, face, and arms; irregular flexing, writhing or grimacing movements; protrusion of the tongue); akathesia (inability to stay still, restlessness, agitation); and Parkinsonisms (mask-like face, drooling, muscle stiffness and rigidity, shuffling gait, tremors). Additionally, there are numerous other nonmuscular effects, including drowsiness, weakness, weight gain, dizziness, fainting, low blood pressure, dry mouth, blurred vision, loss of sexual desire, frigidity, apathy, depression, constipation, diarrhea, and changes in the blood. Infrequent, but serious, nonmuscular side effects, such as skin rash and skin discoloration, ocular changes, cardiovascular changes, and occasionally, sudden death, have also been documented. The most serious threat phenothiazines [one type of antipsychotic drug] pose to a patient's health is a condition known as tardive dyskinesia. This effect went unrecognized for years because its symptoms are often not manifested until late in the course of treatment, sometimes appearing after discontinuation of the drug causing the condition. Tardive dyskinesia is characterized by involuntary muscle movements, often in the oral region. The associated rhythmic movements of the lips and tongue (often mimicking normal chewing, blowing, or licking motions) may be grotesque and socially objectionable, resulting in considerable shame and embarrassment to the victim and his or her family. Additionally, hypertrophy of the tongue and ulcerations of the mouth may occur, speech may become incomprehensible, and, in extreme cases, swallowing and breathing may become difficult. To date, tardive dyskinesia has resisted curative efforts, and its disabling manifestations may persist for years. There is little doubt that prolonged administration of psychoactive drugs plays a major role in the development of tardive dyskinesia. Individual susceptibility to the condition depends upon a variety of factors including increasing age, sex, and the existence of organic brain syndromes (footnotes omitted). Plotkin, supra at 475-477. Commentators and courts have found that antipsychotic drugs are high-risk treatment. [12] Tardive dyskinesia is the most important complication of long-term neuroleptic use. What was initially thought to be a rare clinical curiosity has become a significant public health hazard. Jeste & Wyatt, Changing Epidemiology of Tardive Dyskinesia: An Overview, 138 Am. J. Psych. 297, 297 (1981). [T]he risks of iatrogenically produced chronic neurologic disability are alarming. Baldessarini & Lipinski, supra at 428. See generally Jeste & Wyatt, supra; American College of Neuropsychopharmacology-Food and Drug Administration Task Force, Neurologic Syndromes Associated with Antipsychotic-Drug Use, 289 New England J. Med. 20 (1973); Crane, Tardive Dyskinesia in Patients Treated with Major Neuroleptics: A Review of the Literature, 124 Am. J. Psych. 40 (Feb. Supp. 1968). See also Scott v. Plante, 532 F.2d 939, 945 n. 8 (3d Cir.1976); Rogers I, supra at 1360; Rennie v. Klein, 462 F. Supp. 1131, 1136-1138 (D.N.J. 1978); In re Boyd, 403 A.2d 744, 752 (D.C. App. 1979). (3) The absence of an emergency. The evidence presented in the proceedings below makes it quite clear that the probate judge was not presented with a situation which could accurately be described as an emergency. We accept the dictionary definition of emergency: an unforeseen combination of circumstances or the resulting state that calls for immediate action. Webster's Third New Int'l Dictionary, at 741 (1961). Medical evidence showed that the ward apparently had been schizophrenic for four years, without more than slight or temporary improvement, and that without treatment his mental health could deteriorate. Expert testimony indicated that the prognosis for most individuals with untreated schizophrenia was gradual worsening. In an attempt to elicit an individual prognosis, counsel for the guardian posed a significant question to the expert. [I]s there a point in time, Doctor, where the failure to initiate treatment by drug therapy would result in [the ward's] condition being substantially impaired or irreparable impaired in terms of bringing any treatment to him that would help him? The doctor responded, Well, the longer one waits, the more chance there is of the condition becoming chronic. No follow-up questions were asked. We think that the possibility that the ward's schizophrenia might deteriorate into a chronic, irreversible condition at an uncertain but relatively distant date does not satisfy our definition of emergency, especially where, as here, the course of the illness is measured by years and no crisis has been precipitated. Cf. Rogers II, supra at 654; Rogers I, supra at 1364. We are not called upon here to decide under which circumstances an emergency might relieve a guardian from the obligation of seeking a judicial determination of substituted judgment which would otherwise be required. We do, however, emphasize that in determining whether an emergency exists in terms of requiring immediate action, the relevant time period to be examined begins when the claimed emergency arises, and ends when the individual who seeks to act in the emergency could, with reasonable diligence, obtain judicial review of his proposed actions. This time period will, of course, be brief  as we noted in Matter of Spring, supra at 642, expedited decision can be obtained when appropriate. We recognize that the interests of the patient himself would [not] be furthered by requiring responsible [parties] to stand by and watch him slip into possibly chronic illness while awaiting an adjudication. Rogers II, supra at 660. However, the evidence shows that this is not such a case  in fact, unless the course of a disease is measured by hours, there need never be such a case in the courts of this Commonwealth. We are certain that every judge recognizes that in any case where there is a possibility of immediate, substantial, and irreversible deterioration of a serious mental illness, even the smallest of avoidable delays would be intolerable. (4) The nature and extent of prior judicial involvement. For the past four years the ward has rejected antipsychotic medication on every occasion on which it has been offered, and there has been no judicial finding of incapacity relative to many of these occasions. It is possible that in some cases, although not in the instant case, a mentally ill ward may retain sufficient competence to make treatment decisions himself, thereby eliminating the need for a substituted judgment determination. [13] It has been held that patients involuntarily committed to State mental hospitals are entitled to a judicial determination of incapacity before they may be forcibly medicated with mind-altering drugs. [14] Rogers II, supra at 661. This is because the commitment decision itself is an inadequate predicate to the forcible administration of drugs to an individual where the purported justification for that action is the State's parens patriae power. Id. at 659. Cf. Boyd v. Board of Registrars of Voters of Belchertown, 368 Mass. 631, 635-636 (1975) (profound distinction between commitment and determination of incompetency). A person is presumed to be competent unless shown by the evidence not to be competent. [15] Lane v. Candura, 6 Mass. App. Ct. 377, 382 (1978). Similarly, in the absence of an independent finding of incompetency to make treatment decisions, we cannot assume that a mentally ill ward lacks the capacity to make a treatment decision of this magnitude. Cf. In re Grady, 81 N.J. 235, 265 (1981). In a case such as the one before us, some judicial involvement is unavoidable inasmuch as the judge must: (1) appoint the guardian, and (2) determine the ward's competency to make treatment decisions. This significant and inescapable prior judicial involvement eliminates much concern we might otherwise have about requiring a further judicial determination, since one of the factors we consider in deciding whether the guardian is to make the substituted judgment determination is the amount of additional time which will be needed to obtain a judicial determination. While this prior involvement is not conclusive in and of itself, it is a factor to be considered in determining whether a court order must be obtained. (5) The likelihood of conflicting interests. Decisions such as the one the guardian wishes to make in this case pose exceedingly difficult problems for even the most capable, detached, and diligent decisionmaker. We intend no criticism of the guardian when we say that few parents could make this substituted judgment determination  by its nature a self-centered determination in which the decisionmaker is called upon to ignore all but the implementation of the values and preferences of the ward  when the ward, in his present condition, is living at home with other children. Cf. Matter of Spring, 380 Mass. 629, 640 n. 3 (1980); In re Grady, supra at 252. Nor do we think that the father was not a suitable person to be appointed guardian. Those characteristics laudable in a parent might often be a substantial handicap to a guardian faced with such a decision but who might in all other circumstances be an excellent guardian. Cf. Ruby v. Massey, 452 F. Supp. 361, 365 n. 15 (D. Conn. 1978). A judicial determination also benefits the guardian, who otherwise might suffer from lingering doubts concerning the propriety of his decision. Each individual involved, when called upon to participate in the substituted judgment determination, is assisting in the attempt to determine the ward's values and preferences. The guardian will usually play a major role in this process. The formalities and discipline inherent in a judicial determination will impress upon all involved the need for objectivity and selflessness. We are convinced that in this case, as in other cases, the regularity of the procedure  guaranteed by a judicial determination  will ensure that objectivity which other processes might lack.