Opinion ID: 384352
Heading Depth: 2
Heading Rank: 3

Heading: Voluntary Patients

Text: 36 One point that our analysis leaves unaddressed is whether patients who voluntarily enter a state mental health facility have a right to refuse antipsychotic medication. The district court held that the voluntary patient has the same right to refuse treatment in a non-emergency as does the involuntary patient. 478 F.Supp. at 1368. The court apparently rejected defendants' argument that voluntary patients can be forced to choose between leaving the hospital and accepting prescribed treatment. 37 In so holding, the district court in effect found that Massachusetts citizens have a constitutional right upon voluntary admittance to state facilities to dictate to the hospital staff the treatment that they are given. The district court cited no authority for this finding, and we know of none. Massachusetts law provides for the voluntary admission of mental health patients who are in need of care and treatment ... providing the admitting facility is suitable for such care and treatment. Mass.Gen.Laws Ann. ch. 123 § 10(a). The statute does not guarantee voluntary patients the treatment of their choice. Instead, it offers a treatment regimen that state doctors and staff determine is best, and if the patient thinks otherwise, he can leave. 10 We can find nothing even arguably unconstitutional in such a statutory scheme.II. 38 The district court found that plaintiffs Wadsworth, Rogers, Hunt, Bybel, and Colleran were all forcibly medicated prior to issuance of the temporary restraining order in 1975 in situations that did not comply with the district court's definition of an emergency. The court also found that plaintiffs Wadsworth, Warner, Bolden, Hunt, and Bybel were placed in seclusion during the same time period in situations that did not constitute emergencies. 11 The court further held that none of these instances warranted an award of damages. Plaintiffs appeal from this last holding, contending that damages were warranted under 42 U.S.C. § 1983 and various state tort laws. A. Section 1983 39 1. Forcible Medication. Under Wood v. Strickland, 420 U.S. 308, 322, 95 S.Ct. 995, 1000, 43 L.Ed.2d 214 (1975), defendants can be held liable for damages under section 1983 only if they acted with such an impermissible motivation or with such disregard of ... clearly established constitutional rights that (their actions) cannot reasonably be characterized as being in good faith. Id. The district court's finding that defendants acted in subjective good faith, i. e., did not have an impermissible motivation is certainly supported by the record. See 478 F.Supp. at 1382. Indeed, one of the few points clearly established by the record is that defendants believed that they were acting legally and in the best interests of plaintiffs. 40 The court's finding that defendants acted with objective good faith, i. e., not in violation of clearly established constitutional rights, was also correct. Whatever might be said concerning the extent of plaintiffs' right to refuse medication within the institutional context, that right was certainly not clearly established before 1975. See also 478 F.Supp. at 1383 n. 58. 41 2. Seclusion. Defendants contend that plaintiffs' constitutional rights were not violated by the seclusion practices employed at the state hospitals, and thus argue that the denial of damages under section 1983 was certainly correct. Because we hold that the district court did not err in finding that the defendants acted in good faith, we need not decide whether plaintiffs' constitutional rights were in fact violated. 12 42 As with the medication issue, there is nothing to suggest that the district court clearly erred in finding that the defendants acted in subjective good faith. Nor did the court err in finding objective good faith. Plaintiffs cannot point to a single precedent holding that civilly committed mental health patients have a substantive constitutional right not to be placed in seclusion except in emergencies as defined by the district court. They instead argue that the Massachusetts statute, Mass.Gen.Laws Ann. ch. 123 § 21, and the defendants' own regulations clearly established that plaintiffs had a state-created liberty interest in being free from nonemergency seclusion. From this assertion, plaintiffs reason that defendants should have known that they were violating plaintiffs' constitutional right not to be deprived of a state-created liberty interest without due process. 43 The Massachusetts statute, however, is not as clear on its face as plaintiffs claim. The statute states that restraint may be used only in cases of emergency such as the occurrence of, or serious threat of, extreme violence, personal injury, or attempted suicide .... Id. (emphasis added). It is thus not clear that the definition of emergency set forth is exclusive, nor is it clear that the term personal injury encompasses only physical, as opposed to mental, injury. More importantly, the statute does not explicitly prohibit the use of seclusion for therapeutic purposes, and therefore, given the difficulty and complexity of the task defendants faced, it may not have been unreasonable to regard this portion of the statute as totally inapplicable to efforts aimed at curing patients. Finally, not every violation of a state law or agency regulation constitutes a denial of a constitutionally protected liberty or property interest, see Haines v. Kerner, 492 F.2d 937, 941 n. 8 (7th Cir. 1974). Even if such an interest were clearly implicated in this case, it is far from clear that the procedures employed in taking it away were insufficient. Cf. Parham v. J. R., 442 U.S. 584, 608-609, 99 S.Ct. 2493, 2507, 61 L.Ed.2d 101 (1979) (due process required, but satisfied by decision by staff physician). In sum, we simply cannot see how the district court erred in finding that defendants did not (ignore) or disregard ... settled, indisputable law .... Wood v. Strickland, 420 U.S. 308, 321-22, 95 S.Ct. 992, 1000, 43 L.Ed.2d 214 (1975). B. State Law Claims 44 Plaintiffs also attempted to recover damages under various state intentional tort theories including false imprisonment and assault and battery. 13 The district court rejected the application of these theories to the facts of this case, finding that under Massachusetts law, the actions of doctors in state mental health facilities are to be judged by the principles of malpractice law as long as the doctors act in good faith. The court found that defendants acted in good faith and in accordance with accepted medical practices. Plaintiffs contend that the district court erred in so refusing to find defendants liable under the intentional tort theories. We disagree. 45 In the case of Belger v. Arnot, 344 Mass. 679, 183 N.E.2d 866 (1972), on which the district court relied, the Massachusetts Supreme Judicial Court noted that the statutory scheme providing for the commitment of mentally ill individuals necessarily implied that hospital officials instrumental in the procuring of a commitment are immune from actions for false imprisonment if they acted in good faith and nonnegligently. Id. at 684-85, 183 N.E.2d 866. See also Karjavaninen v. Bushwell, 289 Mass. 419, 426, 194 N.E. 295 (1935). The very same statutory scheme also provides for the treatment of individuals who are committed, Mass.Gen.Laws Ann. ch. 123 § 2, and Massachusetts courts have indicated that treatment can-and should-be administered forcibly in certain situations, Nason v. Superintendent of Bridgewater State Hospital, 353 Mass. 604, 608 & 610 n. 7, 233 N.E.2d 908 (1968). It therefore seems apparent to us, as it did to the district court, that Massachusetts courts would hold that defendants are immune from intentional tort actions arising from treatment decisions as long as they acted in good faith and nonnegligently. 46 The district court's finding that defendants did not act negligently is adequately supported by the record as discussed in the court's opinion. Plaintiffs argue, however, that the record does not support a finding of good faith. Largely for the reasons set forth in the section of this opinion concerning plaintiffs' federal claims, Part II.A., supra, we reject this argument. With regard to the particular application of state law, we repeat only the point that it cannot be said that in acting as they did defendants clearly exceeded their authority under the Massachusetts statute. The statutory scheme itself contains no indication that the forcible administration of antipsychotics was prohibited. While it does place limitations on the use of restraints, the limitations are ambiguous, see Part II.A.2. of this opinion, supra, and it was not unreasonable for defendants to regard them as inapplicable to actions taken for therapeutic purposes. Cf. Nason v. Superintendent of Bridgewater State Hospital, 353 Mass. 604, 614, 233 N.E.2d 908 (1968) (appropriate treatment is to be determined by competent doctors in their best judgment within the limits of permissible medical practice ...). 47 In conclusion, we find it worth noting that in an important respect this case differs from the traditional, adversary model of private litigation. Plaintiffs and defendants, as well as the various amici, share in large part the primary goal of assuring that adequate care and treatment are provided to patients in state hospitals. As is evident from this opinion, we have not accepted absolutist positions advanced by either the parties or amici. Accepting the premise that application of the Constitution to the setting of a state mental health institution requires the most sensitive combination of deference to professional judgment and respect for competent individual judgment as to personal autonomy, we have demonstrated our conviction that such a balance is most likely to be achieved through a variety of procedural devices designed for their suitability to this kind of institutional life rather than for their similarity to judicial models. The record of exploration and evaluation of such safeguards has yet to be made. And the making of a record that will advance the interests of all concerned demands that the parties, despite their differences in views, work together on remand in a less absolutist and more pragmatic way to develop constitutionally valid, mutually acceptable, and workable solutions to the difficult issues remaining in this case. 48 Judgment affirmed in part, reversed in part, and vacated and remanded for further proceedings in accordance with this opinion.