Opinion ID: 2631631
Heading Depth: 4
Heading Rank: 3

Heading: Least intrusive means requirement

Text: Although API acknowledges that its patient's best interests must be considered, it insists that the superior court's order must be affirmed because the current statutory scheme already meets this criterion by requiring the petitioning facility's physicians to determine, before they petition for authorization, that psychotropic drugs would be in their patient's best interests. [82] API maintains that, so long as doctors make this determination, there is no need for the court to give further consideration to the issue in deciding whether to authorize nonconsensual treatment. We disagree. In our view, before a state may administer psychotropic drugs to a non-consenting mentally ill patient in a non-emergency setting, an independent judicial best interests determination is constitutionally necessary to ensure that the proposed treatment is actually the least intrusive means of protecting the patient. API argues that its doctors can be trusted to adequately protect patients' constitutional interests and claims that this is the legislature's position, too. In API's view, the current statutory scheme reflects a legislative belief that doctors alone are the proper arbiters of patients' best interests. And API asserts that its medical staff properly arbitrated here by determining that psychotropics were in Myers's best interest and represented the least intrusive means available to advance the state's interest in her welfare. But the issue is not one of medical competence or expertise. As we have already seen, the right at stake herethe right to choose or reject medical treatmentfinds its source in the fundamental constitutional guarantees of liberty and privacy. The constitution itself requires courts, not physicians, to protect and enforce these guarantees. Ultimately, then, whether Myers's best interests will be served by allowing the state to make a vital choice that is properly hers presents a constitutional question; and though the answer certainly must be fully informed by medical advice received with appropriate deference, in the final analysis the answer must take the form of a legal judgment that hinges not on medical expertise but on constitutional principles aimed at protecting individual choice. Apart from this overarching need to ensure that courts ultimately decide constitutionally based questions, a secondary factor that militates in favor of independent judicial review of best-interests issues is the inherent risk of procedural unfairness that inevitably arises when a public treatment facility possesses unreviewable power to determine its own patients' best interests. Many cases describe the unavoidable tensions between institutional pressures and individual best interests that can arise in this setting: The doctors who are attempting to treat as well as to maintain order in the hospital have interests in conflict with those of their patients who may wish to avoid medication .... Economic considerations may also create conflicts[.] [83] Courts and commentators alike have documented numerous instances in which these tensions have actually resulted in abuse by those claiming to act in [a patient's] best interests. [84] And even in institutional settings such as prisons, where judicial review of treatment decisions has traditionally not been required, case law strongly suggests that at a minimum, a formal system of independent administrative review may be necessary to guarantee patients' basic due process rights. [85] Notably, in Alaska, no formal system for independent internal review exists for best interests determinations made by treating physicians at state institutions like API because, despite an express statutory mandate, the Department of Health and Social Services has not yet adopted regulations establishing formal procedures and standards for treating mental patients with psychotropic drugs. [86] As the Minnesota Supreme Court pointed out in addressing the need for judicial determination of patients' best interests, When medical judgments collide with a patient's fundamental rights, ... it is the courts, not the doctors, who possess the necessary expertise.... [T]he final decision to accept or reject a proposed medical procedure and its attendant risks is ultimately not a medical decision, but a personal choice.[ [87] ] The Supreme Judicial Court of Massachusetts reached the same conclusion, emphasizing that a judicial resolution of best interests is crucial precisely because decisions based on personal choice often make little sense from a strictly medical perspective: The defendants argue that they, as doctors, should be responsible for making treatment decisions for involuntarily committed patients, whether competent or not. We do not agree. Every competent adult has a right to `[forgo] treatment, or even cure, if it entails what for him are intolerable consequences or risks however unwise his sense of values may be in the eyes of the medical profession.'[ [88] ] And Ohio's Supreme Court has similarly described the task of deciding an involuntarily committed mentally ill person's interest in refusing [psychotropic] medication as a uniquely judicial function. [89] The Minnesota Supreme Court aptly underscored the constitutional underpinnings for its decision that this issue must be directed to the courts: The court's responsibility for the patient does not end at commitment. Commitment to an institution does not deprive an individual of all legal rights, ... especially fundamental rights guaranteed by our Constitution. It would be both unreasonable and unnecessary for the courts to become involved in every post-commitment treatment decision; [but] it is equally clear that the courts cannot abdicate all responsibility for protecting a committed person's fundamental rights merely because some degree of medical judgment is implicated.[ [90] ] We agree with these decisions and join them in concluding that the right to refuse psychotropic medication is a fundamental right, though not an absolute one; that the ultimate responsibility for providing adequate protection of that right rests with the courts; and that adequate protection of that right can only be ensured by an independent judicial determination of the patient's best interests considered in light of any available less intrusive treatments. [91]