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

Heading: Myers's Constitutional Challenge

Text: Myers argues that, as interpreted in the superior court's order, the provisions governing authorization of treatment with psychotropic medications violate the Alaska Constitution's guarantees of liberty and privacy. We agree. The Alaska Constitution's opening provision, article I, section 1, declares, This constitution is dedicated to the principles that all persons have a natural right to life, liberty, the pursuit of happiness, and the enjoyment of the rewards of their own industry. [40] Article I then sets out more specific provisions guaranteeing individual liberty and privacy in sections 7 and 22. Section 7 addresses liberty: No person shall be deprived of life, liberty, or property, without due process of law. [41] Section 22 guarantees privacy: The right of the people to privacy is recognized and shall not be infringed. [42] Although the federal constitution sets the minimum protections afforded to individual liberty and privacy interests, the Alaska Constitution often provides more protection. [43] We have specifically recognized that Alaska's guarantee of privacy is broader than the federal constitution's: Since the citizens of Alaska, with their strong emphasis on individual liberty, enacted an amendment to the Alaska Constitution expressly providing for a right to privacy not found in the United States Constitution, it can only be concluded that the right is broader in scope than that of the Federal Constitution.[ [44] ] We have similarly declared Alaska's constitutional guarantee of individual liberty to be more protective. [45] We determine the boundaries of individual rights guaranteed under the Alaska Constitution by balancing the importance of the right at issue against the state's interest in imposing the disputed limitation. [46] When a law places substantial burdens on the exercise of a fundamental right, we require the state to articulate a compelling [state] interest [47] and to demonstrate the absence of a less restrictive means to advance [that] interest. [48] But when the law interferes with an individual's freedom in an area that is not characterized as fundamental, we require the state to show a legitimate interest and a close and substantial relationship between its interest and its chosen means of advancing that interest. [49]
In the past we have recognized that Alaska's constitutional rights of privacy and liberty encompass the prerogative to control aspects of one's personal appearance, [50] privacy in the home, [51] and reproductive rights. [52] We have noted that few things [are] more personal than one's own body, [53] and we have held that Alaska's constitutional right to privacy clearly ... shields the ingestion of food, beverages or other substances. [54] Because psychotropic medication can have profound and lasting negative effects on a patient's mind and body, we now similarly hold that Alaska's statutory provisions permitting nonconsensual treatment with psychotropic medications implicate fundamental liberty and privacy interests. [55] We are hardly the first court to reach this conclusion. A number of state supreme courts have declared that the right to refuse psychotropic medication is fundamental; we find their opinions to be both instructive and persuasive. [56] In Rogers v. Commissioner of the Department of Mental Health, the Supreme Judicial Court of Massachusetts held that a committed mental patient could not be forcibly medicated with antipsychotic drugs unless a court determined both that he was incompetent and that he would have consented to the administration of the drugs if he was competent. [57] Although the court's opinion relied on Massachusetts's statutory and common law, rather than on interpretation of the state constitution, the court emphasized the constitutional and common law origins of [e]very competent adult['s] ... 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.' [58] The court further emphasized that mentally ill patients have dignity and worth equal to other individuals; on this basis, the court held that a committed mental patient is entitled to an independent judicial determination of whether the patient would have consented to treatment with psychotropic drugs. [59] And the court explicitly rejected the argument that a substituted judgment determination of this kind could safely be left to the treating doctors rather than the courts. [60] In Rivers v. Katz , the New York Court of Appeals similarly located a person's right to control his medical treatment in state common law but went on to declare that [t]his fundamental common-law right is coextensive with the patient's liberty interest protected by the due process clause of our State Constitution. [61] It wrote, In our system of a free government, where notions of individual autonomy and free choice are cherished, it is the individual who must have the final say in respect to decisions regarding his medical treatment in order to insure that the greatest possible protection is accorded his autonomy and freedom from unwanted interference with the furtherance of his own desires[.][ [62] ] While acknowledging the state's police power to forcibly medicate mental patients in emergency situationsa situation not at issue in the case before usthe court held that in New York, decisions to forcibly medicate persons in all other circumstances must be made by the courts. [63] If the court concludes that the patient lacks the capacity to determine the course of his own treatment, the court must [then] determine whether the proposed treatment is narrowly tailored to give substantive effect to the patient's liberty interest, taking into consideration all relevant circumstances, including the patient's best interests, the benefits to be gained from the treatment, the adverse side effects associated with the treatment and any less intrusive alternative treatments. [64] The Minnesota Supreme Court reached a similar result in Jarvis v. Levine. [65] It held that Minnesota's constitutional guarantee of privacy begins with protecting the integrity of one's own body and includes the right not to have it altered or invaded without consent. Commitment to an institution does not eliminate this right. When intrusive treatment is proposed, the `professional judgment' of medical personnel insufficiently protects this basic human right. [66] Thus, in Minnesota, the forcible medication of a committed mental patient requires both a judicial finding of incapacity to give informed consent and a judicial hearing to determine the necessity and reasonableness of the treatment. [67] Most recently, the Ohio Supreme Court held in Steele v. Hamilton County Community Mental Health Board that the state could forcibly medicate a mental patient under its parens patriae authority only after a court had found, by clear and convincing evidence, that (1) the patient does not have the capacity to give or withhold informed consent regarding his/her treatment, (2) it is in the patient's best interest to take the medication, i.e., the benefits of the medication outweigh the side effects, and (3) no less intrusive treatment will be as effective in treating the mental illness. [68] Ruling that the right to refuse medical treatment is a fundamental right in our country, where personal security, bodily integrity, and autonomy are cherished liberties, the court emphasized that [t]hese liberties were not created by statute or case law ... [r]ather, they are rights inherent in every individual that find explicit protection under the Ohio Constitution. [69] Given the nature and potentially devastating impact of psychotropic medications [70] as well as the broad scope of the Alaska Constitution's liberty and privacy guaranteeswe now similarly hold that the right to refuse to take psychotropic drugs is fundamental; and we further hold that this right must extend equally to mentally ill persons, so that the mentally ill are not treated as persons of lesser status or dignity because of their illness. [71] When no emergency exists, then, the state may override a mental patient's right to refuse psychotropic medication only when necessary to advance a compelling state interest and only if no less intrusive alternative exists. [72]
API argues that medicating Myers would serve two compelling state interests: it would prevent Myers from harming herself or others, and would ameliorate Myers's condition. These interests, API argues, find legitimate sources in two traditional state powers: the state's police power and its parens patriae duty. [73]
API argues that the state's police power is implicated here because the superior court found that Myers was a danger to herself and others. Just as citizens have a right to some protection from the state, API argues, the state has a legitimate and compelling interest in the physical safety of its citizens. In API's view, this interest is sufficient to overcome a patient's right to refuse psychotropic medication. In an emergency situation, API might be correct. Indeed, the Supreme Court of Ohio has so held, ruling that the police power can justify medication when the state perceives an imminent threat of harm. [74] But that is not the situation here. As already mentioned, this case centers on the use of psychotropic medication in non-emergency situations. [75] And API has not maintained that Myers posed an imminent threat of harm to herself or anyone else after she was committed for treatment at API. In these circumstances, the state's power of civil commitment sufficed to meet its police-power interest, so we fail to see how the issue of medication implicates the state's police power at all: If there is no emergency, hospital personnel are in no danger; the only purpose of forcible medication in these circumstances would be to help the patient. But the basic premise of the right to privacy is the freedom to decide whether we prefer to be helped, or to be left alone.[ [76] ] Indeed, it seems noteworthy that the statutory provision that governs petitions to administer psychotropics in non-emergency situations makes no mention of the police power, and does not require a treatment facility to make any showing of institutional risk or danger to others as a condition for authorizing treatment. [77] The applicable statutes allow medication to be authorized without any findingjudicial or medical that the patient poses a danger. [78] The state's police powerits power to protect others from Myersthus provides no justification, compelling or otherwise, for API to override Myers's choice to accept or refuse psychotropic medication.
API proposes a second compelling interest: the state's parens patriae obligationits duty to protect Myers from herself. The doctrine of parens patriae refers to the inherent power and authority of the state to protect the person and property of an individual who lack[s] legal age or capacity. [79] Because the superior court found Myers incapable of making informed decisions about her mental illness, API reasons that the state must be permitted to make those decisions for her. [80] We readily agree that the state's parens patriae obligation does give it a compelling interest in administering psychotropic medication to unwilling mental patients in some situations. [81] But this simply raises the difficult question: does the current statutory scheme use an overly intrusive means to attain the state's interest by failing to require an independent judicial determination of the patient's best interests? To answer this question, we turn to the third step of the constitutional balancing test, the least intrusive alternative requirement.
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]
Having determined that courts must engage in best-interest inquiries, we believe that some discussion is in order concerning appropriate criteria to guide courts on this issue. Evaluating whether a proposed course of psychotropic medication is in the best interests of a patient will inevitably be a fact-specific endeavor. At a minimum, we think that courts should consider the information that our statutes direct the treatment facility to give to its patients in order to ensure the patient's ability to make an informed treatment choice. [92] As codified in AS 47.30.837(d)(2), these items include: (A) an explanation of the patient's diagnosis and prognosis, or their predominant symptoms, with and without the medication; (B) information about the proposed medication, its purpose, the method of its administration, the recommended ranges of dosages, possible side effects and benefits, ways to treat side effects, and risks of other conditions, such as tardive dyskinesia; (C) a review of the patient's history, including medication history and previous side effects from medication; (D) an explanation of interactions with other drugs, including over-the-counter drugs, street drugs, and alcohol; and (E) information about alternative treatments and their risks, side effects, and benefits, including the risks of nontreatment[.][ [93] ] Considering these factors will be crucial in establishing the patient's best interests as well as in illuminating the existence of alternative treatments. [94] And here, too, we find the work of other state courts to be helpful. The Supreme Court of Minnesota has held that in order to determine the necessity and reasonableness of a treatment, courts should balance [a] patient's need for treatment against the intrusiveness of the prescribed treatment. [95] Factors that the Minnesota court believed should be considered included: (1) the extent and duration of changes in behavior patterns and mental activity effected by the treatment; (2) the risks of adverse side effects; (3) the experimental nature of the treatment; (4) its acceptance by the medical community of the state; and (5) the extent of intrusion into the patient's body and the pain connected with the treatment.[ [96] ] We find these approaches to be sensible. Finally, we note that the parties have disputed the standard of proof that the state should be required to meet in establishing the patient's best interests. API argues for a preponderance of the evidence standard, but it offers no legal authority to support that position. Other courts that have required best-interests determinations in this area have uniformly adopted the clear and convincing standard. [97] Moreover, our existing statutory scheme already adopts this standard for findings required to authorize psychotropic medication. [98] We see no reason to dilute the standard governing the best-interests determination, and hold that the clear and convincing evidence standard controls the issue.
Myers separately argues that we should follow the example of the Supreme Judicial Court of Massachusetts and require courts authorizing medication to make an additional finding applying the substituted judgment approach. [99] The substituted-judgment approach would require courts to attempt to determine what course of treatment an incompetent patient would likely choose if currently capable of making an informed decision. But unlike the statutory scheme at issue in Massachusetts cases, our own statutes incorporate provisions designed to achieve the same goals as the substituted-judgment approach, but by a slightly different path. As already mentioned above, when a treatment facility files a petition for authorization to treat a mentally ill patient with psychotropic drugs, Alaska law requires the appointment of a visitor to help gather relevant information for the hearing. One of the two core duties assigned to the visitor under AS 47.30.839(d) is to investigate, document, and report any prior statementsoral or writtenthat the patient might have made while competent that expressed wishes regarding medication. [100] Moreover, as also described above, if the information gathered and documented by the visitor enables the court to find that the patient has expressed a prior competent desire not to be medicated, then the court may not authorize treatment; this emerges from the language of AS 47.30.839(g), which requires the court to order treatment only if it finds that a patient is presently incompetent and that the patient was incompetent at the time of any previously expressed wishes reported by the visitor: (g) If the court determines that the patient is not competent to provide informed consent and, by clear and convincing evidence, was not competent to provide informed consent at the time of previously expressed wishes documented [by the visitor] under (d)(2) of this section, the court shall approve the facility's proposed use of psychotropic medication. [ [101] ] Because neither party has briefed or addressed this provision on appeal, and because Myers did not attempt to rely on it below, [102] we need not decide its exact scope and meaning, and express no opinion on the point here. At least arguably, though, it might be read to give courts authority to deny a petition if the patient made prior competent statements expressing a desire not to be medicated; and if so, it would seem to serve a similar purpose to that of the substituted-judgment approach advocated by Myers. Since the meaning of this provision is not at issue here and remains open for future consideration, and since the provision may ultimately be interpreted as performing many of the same functions as the substituted-judgment approach, we see no present need to decide Myers's argument urging us to adopt that approach.