Opinion ID: 1703516
Heading Depth: 2
Heading Rank: 1

Heading: Substantive Due Process Requirements

Text: ¶ 18 A court's task in a challenge based on substantive due process involves a definition of th[e] protected constitutional interest, as well as identification of the conditions under which competing state interests might outweigh it. Washington v. Harper, 494 U.S. 210, 220, 110 S.Ct. 1028, 108 L.Ed.2d 178 (1990) (internal quotation marks and citing reference omitted). The precise context presented herethe constitutionality of a statute authorizing an order to compel medication of a person committed pursuant to ch. 971is one of first impression for Wisconsin state courts. Wood urges us to find persuasive guidance in Enis v. Department of Health and Social Services, 962 F.Supp. 1192, 1202-03 (W.D.Wis.1996), in which the federal district court held that Wis. Stat. § 971.17(3)(c) was unconstitutional. As an initial matter, federal district court cases are not binding authority on this court. See State v. Mechtel, 176 Wis.2d 87, 94-95, 499 N.W.2d 662 (1993). Moreover, in our view, Enis is not persuasive. Although we agree with aspects of that court's analysis, we decline to adopt much of its reasoning or its bottom line, for the reasons explained herein. Rather, we look to several of the United States Supreme Court's cases assessing orders to compel medication in other contexts. ¶ 19 In Washington v. Harper , Harper, a mentally ill prisoner, challenged the constitutionality on due process grounds of a Washington state prison policy that authorized an order to compel medication of incompetent mentally ill prisoners, if the state established by a medical finding, that a mental disorder exists [that] is likely to cause harm if not treated and that the medication sought was in the prisoner's medical interests. 494 U.S. at 222, 110 S.Ct. 1028. ¶ 20 The United States Supreme Court first defined Harper's substantive right, finding that he had a significant liberty interest in refusing the administration of antipsychotic drugs. Id. at 221, 110 S.Ct. 1028. That right, however, was tempered by other interests, including his medical needs and the legitimate needs of the institution in maintaining security and safety within its prisons. In light of those interests, the court held that the policy is a rational means of furthering the State's legitimate objectives. Its exclusive application is to inmates who are mentally ill and who, as a result of their illness, are gravely disabled or represent a significant danger to themselves or others. The drugs may be administered for no purpose other than treatment, and only under the direction of a licensed psychiatrist. There is considerable debate over the potential side effects of antipsychotic medications, but there is little dispute in the psychiatric profession that proper use of the drugs is one of the most effective means of treating and controlling a mental illness likely to cause violent behavior. Id. at 226, 110 S.Ct. 1028. ¶ 21 Two years later, the United States Supreme Court in Riggins v. Nevada, 504 U.S. 127, 112 S.Ct. 1810, 118 L.Ed.2d 479 (1992), addressed the constitutionality of an order compelling medication to a person detained for trial. In that case, the detainee, Riggins, was charged with murder and robbery and was subject to an order to compel medication during the trial. Id. at 129-30, 112 S.Ct. 1810. Riggins sought to suspend the order during his trial, where administration of the drug was not necessary to render him competent to stand trial and where he sought to show the jury his demeanor and true mental state. Id. at 130, 112 S.Ct. 1810. The district court denied that motion. At trial, Riggins presented an insanity defense, but the jury found him guilty and set his sentence at death. Id. at 131, 112 S.Ct. 1810. ¶ 22 The Court in Riggins extended the application of the holding in Harper to pretrial detainees, concluding that the state cannot compel administration of antipsychotic medication to such persons absent a finding of the state's overriding justification to administer the drugs and a determination of medical appropriateness. Because the state did not demonstrate such an overriding justification, the Court reversed the defendant's conviction. Id. at 135, 112 S.Ct. 1810. However, the Court indicated that, given the unique circumstances of penal confinement, id. at 134, 112 S.Ct. 1810, one way that a state could demonstrate an overriding justification was if it proved that the treatment was medically appropriate and, in light of less intrusive alternatives, that it was necessary for the detainee's or others' safety, id. at 135, 112 S.Ct. 1810. ¶ 23 The federal district court in Enis largely relied on Harper and Riggins in reaching its conclusion that Wis. Stat. § 971.17(3)(c) was unconstitutional. In that case, Enis, who was mentally ill, had been found NGI and was subsequently determined to be incompetent to refuse medication under § 971.17(3)(c). He brought suit under 42 U.S.C. § 1983 and moved for summary judgment on his claim for injunctive and declaratory relief. The district court granted Enis's motion, concluding that a finding of present dangerousness and present need for medication [to] justify the significant intrusion represented by the forced administration of psychotropic medication is required under a statutory scheme providing for the forced medication of committed individuals based on a finding of NGI. Enis, 962 F.Supp. at 1199. The district court held that Wis. Stat. § 971.17(3)(c) was unconstitutional to the extent that it did not require a finding of the person's present dangerousness or that no such finding was made as to Enis. Id. ¶ 24 Thirteen years after the Supreme Court decided Harper, eleven years after it decided Riggins, and seven years after the district court issued Enis, the United States Supreme Court again addressed requirements for compelled medication orders in Sell v. United States, 539 U.S. 166, 123 S.Ct. 2174, 156 L.Ed.2d 197 (2003). At issue in Sell was the constitutionality of a law permitting a court to order forcible antipsychotic medication to a defendant in order to restore him to competency to stand trial for a nonviolent crime. In that case, the Court determined that Harper and Riggins stood for the standard that a court could order a mentally ill defendant to be medicated without his or her consent if (1) the treatment was medically appropriate, (2) the treatment was substantially unlikely to have side effects that could undermine the fairness of trial, and (3) less intrusive alternatives had been considered. Sell, 539 U.S. at 179, 123 S.Ct. 2174. In other words, a finding of dangerousness was just one way to support a forced medication order; however, it was not a required element of an involuntary medication statutory scheme in all contexts. ¶ 25 To summarize, Harper, Riggins, and Sell compel the following conclusions. First, a person competent to make medical decisions has a significant liberty interest in avoiding forced medication of psychotropic drugs. See Harper, 494 U.S. at 221, 110 S.Ct. 1028. Second, in light of that interest, the state may not order the administration of psychotropic drugs to a mentally ill individual unless it demonstrates an overriding justification to administer the drugs and a determination of medical appropriateness. See Riggins, 504 U.S. at 135, 112 S.Ct. 1810. The incursions that substantive due process permits largely depend on what the state's overriding interest entails. For example, in the context of a mentally ill inmate or detainee in a jail or prison, where the safety and security of the institution is the state's interest, one way the state can establish an overriding justification addressing that interest is to demonstrate that the person is dangerous to self or others and, considering less intrusive alternatives, that medication is in the person's medical interest. See Riggins, 504 U.S. at 134-35, 112 S.Ct. 1810; Harper, 494 U.S. at 225-26, 110 S.Ct. 1028. In other contexts, however, such as when the state seeks to administer medication to render a nonviolent detainee competent to stand trial, dangerousness need not be demonstrated; rather, a finding that the administration of drugs will affect the defendant's rights to a fair trial is sufficient. See Sell, 539 U.S. at 180-81, 123 S.Ct. 2174. ¶ 26 Here, Wood argues that Wis. Stat. § 971.17(3)(c) violates due process facially and as applied. He asserts that, as the court of appeals noted in its certification opinion, the state has not fully articulated what its overriding interest is in medicating a committed person who has been found NGI of a crime. He acknowledges that the State has an interest in maintaining safety in an institutional context such as Mendota, but argues that to invoke that interest, the State would first need to demonstrate the person's present dangerousness within the facility, a finding that the statute does not require and that the circuit court did not expressly make in this instance. He further argues that an institution such as Mendota is equipped to deal with patients who would be a danger beyond its confines. Because of that, Wood argues that the State needs to show that a patient is dangerous in the context of the institution. ¶ 27 The State responds that it has at least two overriding interests in medicating an individual adjudged NGI for a violent crime. First, the State has a prospective interest in protecting society, inasmuch as individuals adjudged NGI are committed precisely because their mental illness caused them to engage in criminal behavior. Given that premise, the State argues that its interest is to treat that person in a manner that prepares him or her for a safe return to society. Second, the State argues that it has an interest in maintaining the safety and functionality of the institutional environment, which it cannot and should not be forced to address solely by equipping the institutions to deal with people who behave unpredictably and dangerously. ¶ 28 Given those justifications, the State further argues that in cases involving a person committed after being found NGI, a finding of dangerousness is not necessary because the judgment of NGI and decision to institutionalize that individual demonstrates that the person suffers from a mental illness that, if left untreated, causes him or her to be dangerous. See Wis. Stat. § 971.15(1)(d) (no culpability for criminal conduct where a mental disease causes the person to lack substantial capacity either to appreciate the wrongfulness of his or her conduct or conform his or her conduct to the requirements of law); § 971.17(3)(a) (The court shall order institutional care if it finds by clear and convincing evidence that conditional release of the person would pose a significant risk of bodily harm to himself or herself or to others or of serious property damage.). Further, it argues that even if a finding of dangerousness is required, the record here is sufficient to support such a finding in this case based on Wood's past crimes and consistent unsuitability for conditional release.
¶ 29 Before we address the parties' arguments, a brief overview of Wisconsin's involuntary medication and treatment statutes is helpful to aid the discussion. There are several contexts in which a court may order the involuntary medication of a committed person in Wisconsin. For example, Wis. Stat. § 51.20 governs the involuntary medication and treatment of civilly committed individuals as well as criminal commitments. See also Wis. Stat. § 51.37. Wis. Stat. § 971.14(3)(dm) provides for the involuntary medication of defendants where there is a question of competency to stand trial. Wis. Stat. § 971.17(3)(c), the provision at issue here, specifically applies to the involuntary medication of persons committed after being adjudged NGI for a crime. We briefly consider that process. ¶ 30 A defendant charged with a criminal offense may plead NGI. Wis. Stat. § 971.06(1)(d). If the defendant is so found, the court enters a judgment of NGI and issues a commitment order under § 971.17. In the order, the court commits the defendant to the custody of DHFS and specifies that he or she is to be placed in an institution if the court finds by clear and convincing evidence that conditional release of the person would pose a significant risk of bodily harm to himself or herself or to others or of serious property damage. Wis. Stat. §§ 971.165(2), 971.17(3)(a). In making that determination, the court may consider, among other things, the nature and circumstances of the crime, the person's mental history and present mental condition, where the person will live, how the person will support himself or herself, what arrangements are available to ensure that the person has access to and will take necessary medication, and what arrangements are possible for treatment beyond medication. Wis. Stat. § 971.17(3)(a). If the court does not make such a finding of a significant risk, it must order conditional release. Id. ¶ 31 After the person has been committed to an institution, it sometimes becomes necessary to make a decision about forcibly medicating him or her. If the state proves by clear and convincing evidence that the committed person is not competent to refuse medication, the court may issue an order permitting the institution to administer medication and treatment without the person's consent. Wis. Stat. § 971.16(3) sets forth the circumstances under which the institution may obtain such an order if, because of mental illness, developmental disability, alcoholism or drug dependence, and after the advantages and disadvantages of and alternatives to accepting the particular medication or treatment have been explained to the defendant, one of the following is true: (a) The defendant is incapable of expressing an understanding of the advantages and disadvantages of accepting medication or treatment and the alternatives. (b) The defendant is substantially incapable of applying an understanding of the advantages, disadvantages and alternatives to his or her mental illness, developmental disability, alcoholism or drug dependence in order to make an informed choice as to whether to accept or refuse medication or treatment. ¶ 32 With that statutory context in mind, we address the parties' arguments. Given the case law, we agree with the parties that the scope of substantive due process protections required depends upon what the State's overriding interest is in administering psychotropic medications to a patient against his or her will. As an initial matter, it appears that the parties agree that the State has an interest in maintaining safety, security, and functionality within the institution. Indeed, that interest is well-established. See Riggins, 504 U.S. at 135, 112 S.Ct. 1810; Harper, 494 U.S. at 225-26,110 S.Ct. 1028. We agree with the State, however, that it has at least one other interest in medicating NGI individuals. Based on the operation of the statutory scheme, adjudging an individual NGI has the effect of holding that, because of mental illness, the individual commits crimes for which he or she lacks substantial capacity either to appreciate the wrongfulness of his or her conduct or conform his or her conduct to the requirements of law. Wis. Stat. § 971.15(1). In that way, institutions holding individuals adjudged NGI have a somewhat different interest than a prison would. In an institution such as Mendota, that interest is in treating the underlying mental illness in order to prevent more criminal behavior and prepare the individual for conditional release and for eventual release from the commitment. ¶ 33 In light of that overriding interest and the nature of original proceedings in which a defendant is adjudged NGI, we do not believe that a finding of present dangerousness is required when considering whether to issue an order to forcibly medicate such an individual. See Sell, 539 U.S. at 181-82, 123 S.Ct. 2174 (a finding of dangerousness is not required where the relevant state interest is unrelated to institutional safety and security). The express findings required in Wis. Stat. § 971.17(3)(c) and articulated in § 971.16(3) are that the person cannot express an understanding of the advantages, disadvantages, and alternatives to medication or treatment or that he or she has such an understanding but cannot apply it to his or her mental illness in order to make an informed choice. We are satisfied that those findings strike the appropriate balance between the State's overriding interest in medicating a forensic NGI patient and that patient's interest in having the ability to refuse medication or treatment. ¶ 34 Even if we were to conclude that the State's interest in preparing NGI patients for conditional release was not acceptable, there remains its overriding interest in the safety and security of the institution. Assuming, based on Harper, that that interest requires a finding of present dangerousness, we are satisfied that Wis. Stat. § 971.17(3), at a minimum, implicitly provides for such a finding. We reach that conclusion based on the language of § 971.17(3)(a) that includes requirements for a determination of dangerousness at the time of commitment, the language of § 971.17(3)(c) requiring a doctor's examination and report when an institution seeks an order to medicate the patient involuntarily, and the language of § 971.17(4)(d) setting forth requirements for periodic reviews, which include a dangerousness determination. Those express requirements, taken together, provide for at least an implicit finding of dangerousness that serves as a basis for a court considering whether to issue an order to medicate. ¶ 35 The statutory language of Wis. Stat. § 971.17(3)(a) requires a finding that is the equivalent of one of dangerousness at time of commitment. As we noted previously, that statute provides: The court shall order institutional care if it finds by clear and convincing evidence that conditional release of the person would pose a significant risk of bodily harm to himself or herself or to others or of serious property damage. Wis. Stat. § 971.17(3)(a). In other words, a person found NGI will be placed in institutional care in the first place only if the court finds clear and convincing evidence of a significant risk, which appears to be the equivalent of dangerousness. ¶ 36 Additionally, if the institution files a motion seeking an order to compel medication, the statute further requires a licensed physician to examine the individual and to issue a written report indicating that the person needs medication or treatment and that the person is not competent to refuse medication or treatment. Wis. Stat. § 971.17(3)(c). We are satisfied that such an assessment further encompasses an assessment of a significant risk. Considering that absent a finding of substantial riskthe equivalent of dangerousnessindividuals committed under § 971.17(3) are granted conditional release, the doctor's examination and report under paragraph (c) necessarily requires at least an implicit finding that the person remains dangerous enough to justify continued institutional care. ¶ 37 Finally, the court must reassess dangerousness when the committed individual petitions for conditional release, which the statute permits such an individual to do every six months. When a committed individual petitions for conditional release, Wis. Stat. § 971.17(4)(d) provides that the court must grant the petition for such release: unless it finds by clear and convincing evidence that the person would pose a significant risk of bodily harm to himself or herself or to others or of serious property damage if conditionally released. Again, making that determination, the court considers the same factors as it did with the initial commitment, such as the nature of the crime and that person's history of mental illness to inform its determination. ¶ 38 Those requirements, taken together, create at least an implicit finding of dangerousness, if not an express finding, that serves as a basis for a court to consider granting a motion for an involuntary medication order. In other words, those findings of dangerousness based on the original commitment under § 971.17(3) and based on the denial of a petition for conditional release under § 971.17(4)(d) continue to be present until they are changed or upset. With such a basis present, a court evaluating a motion for an involuntary medication order need not make separate or independent findings of dangerousness. ¶ 39 For those reasons, we are satisfied that Wis. Stat. § 971.17(3)(c) facially satisfies substantive due process protections.
¶ 40 Wood further argues that AD-11-97 fails to comport facially with substantive due process because it does not adequately require a finding of dangerousness before institutional staff may seek an order to medicate or administer medication pursuant to such an order. The State disagrees. It asserts that due process does not require an express finding of dangerousness before seeking an order or administering psychotropic medications to persons committed under ch. 971. It further contends that, to the extent that due process does require such a finding, the directive sets forth standards for a finding of dangerousness that comport with the requirements set forth in Harper. We agree with the State. Due process does not require a finding of dangerousness under the circumstances presented here; however, if it did, we are satisfied that AD-11-97 provides adequate standards for a finding of dangerousness, as explained herein. ¶ 41 As noted previously, AD-11-97 is the protocol for staff at Mendota and Winnebago Mental Health Institute to follow when deciding whether to seek an order to medicate a patient at one of those facilities and whether to administer medication to that patient pursuant to such an order. The directive first requires a treatment team, made up at least of the patient's psychiatrist, a non-physician clinician and a member of the Nursing Staff, to assess the patient's situation before seeking the order. [10] The team must conclude that the patient meets all four of the following criteria: (1) the patient is not competent to refuse medication; (2) medication serves the patient's medical interests; (3) the patient meets the `dangerousness' standard; and (4) no acceptable alternative means are available to address the patient's dangerousness. [11] Furthermore, AD-11-97 requires the treatment team, should it begin medicating a patient pursuant to an order, to conclude that the patient continues to satisfy all four criteria at the appropriate review schedule, which is to occur six months after the ordered treatment begins and annually thereafter. [12] ¶ 42 Those four required findings, like the requirements in Wis. Stat. § 971.17(3)(c), more than adequately address the concern of protecting the individual's liberty interest, while recognizing the State's interest in medicating and treating individuals who are not competent to make their own treatment decisions. Indeed, Wood does not argue otherwise; rather, as noted previously, he focuses on the requirement for a finding of dangerousness and argues that the standards found in AD-11-97 are inadequate. Again, even if we were to assume that due process requires an express finding of dangerousness, the third requirement provides a more than adequate standard. ¶ 43 To satisfy the third requirement, the treatment team is to determine that there is a current risk of harm to self or others if medication [is] not administered. [13] The directive then provides six possible consequences that the treatment team, if it concludes they are likely to occur, must use as a basis for the finding of dangerousness: a. The patient may suffer significant psychological harm, for example[,] mental anguish, pain, suffering, fear, anxiety or desperation, if medication was not administered; b. The patient may cause physical harm to others in the facility if medication was not administered, considering the patient's history of physical violence and treatment history; c. There may be harm to the prospects for successful treatment of the patient's mental condition if medication was not administered, for example, the patient's mental condition may become increasingly resistant to treatment the longer the patient does not take medications; d. The patient may cause self-harm if medication was not administered, considering the patient's history of self-abuse, treatment history and the potential effectiveness of medication in addressing the behavior; e. The patient may suffer significant deterioration to his or her health or safety if medication was not administered, considering the effect of the patient's mental condition on the patient's ability or willingness to receive care that is essential for health or safety; AND/OR f. The patient may cause physical harm to others outside the facility if medication was not administered, considering the patient's history of physical violence, the patient's treatment history, the proximity of the patient's probable release date, the likelihood of adequately treating the patient's mental condition without medications before release, and the adequacy of means available in the community to prevent the patient from causing harm to others. [14] ¶ 44 Wood argues that the standards are facially overbroad and vague in several respects. [15] Essentially, Wood objects to the (1) breadth of general symptoms considered, particularly in consequences a and e; (2) the content of consequence c, which he argues does not relate to a finding of dangerousness; and (3) the permissible consideration of past physical violence in consequences b, d, and f. ¶ 45 We disagree with Wood that the symptoms listed are overbroad. While the symptoms in consequences a and e, listed singly, may be not uncommon symptoms, those paragraphs frame the symptoms as causing a risk of significant psychological harm and significant deterioration to the patient's health and safety. That context, in our view, raises those symptoms to a level beyond those occurring in patients not in need of involuntary medical intervention. Moreover, the content of consequence c, which addresses whether medication is necessary to ensure the future effectiveness of medication and treatment, is related to dangerousness, inasmuch as unsuccessful treatment of the patient's mental illness results in a risk to the patient's safety, as well as the public's, given that the patient will be released eventually from the institution. Finally, past violence is relevant to a finding of current dangerousness. Although we agree with the district court's statement in Enis that when a finding of dangerousness is required, that finding must show present dangerousness, nothing in Harper, Riggins, or Sell precludes a court from considering the individual's past crimes when assessing present dangerousness. Indeed, where a person's past acts of violence were products of mental illness, consideration of the nature and seriousness of those past violent crimes is vital to assessing the level of danger posed when the mental illness is untreated. ¶ 46 In summary, we are satisfied that a finding of dangerousness is not required to order the involuntary medication of an individual committed under Wis. Stat. § 971.17. By that reasoning, Wis. Stat. § 971.17(3)(c) and AD-11-97 cannot be deemed to be facially invalid based on substantive due process requirements. Moreover, even if a finding of dangerousness is required, the directive requires an express finding of dangerousness and the statute implicitly contains the equivalent of an express requirement. Hence, they are not facially invalid.
¶ 47 We next turn to Wood's argument that, based on substantive due process grounds, the provisions in question here are invalid as applied to him. We disagree with his position. As an initial matter, given our determination herein that a finding of dangerousness is not required in this situation, and that Wis. Stat. § 971.17(3)(c) and AD-11-97 comport with substantive due process requirements, nothing in the record indicates that the court did not take the steps required by § 971.17(3)(c) in issuing its order. Additionally, nothing contradicts evidence that Mendota staff established all four criteria required by AD-11-97 when determining whether to file a motion for the hearing to compel medication. Moreover, there is nothing specific to Wood's situation or any of the facts presented here that suggests that the application of the statute or directive violated his substantive due process rights. ¶ 48 Additionally, we are persuaded that the treatment team's finding of dangerousness is supported by evidence in the record, and that that standard was not vague. As noted above, the directive requires the treatment team at Mendota to agree that the person for whom it is seeking the order is dangerous, based on the six provided consequences. Dr. Smith testified that the team considered all six consequences listed in the directive, but found three to be most applicable and of most concern, notably, consequence a, related to Wood's history of serious dangerousness based on his criminal behavior that occurred when his illness was not adequately treated; consequence b, related to the significant mental anguish and anxiety caused by the increased delusions his illness was causing; and consequence c, related to the fact that the symptoms of schizophrenia, if left untreated, grow progressively more difficult to treat and eventually become untreatable. ¶ 49 Wood asserts that consequence a is an improper consideration in assessing his present dangerousness. He argues that the only evidence of his propensity to act violently comes from two crimes committed over 10 and 31 years ago. Further, he emphasizes that there is no evidence that he has engaged in violent incidents in his past 10 years residing at Mendota. In Wood's view, those circumstances cannot lead to an adequate finding of present dangerousness. ¶ 50 The fact that Wood may not have engaged in overtly violent acts while at Mendota certainly could mitigate against a finding of present dangerousness; however, that evidence alone is not dispositive. Indeed, the evidence in the record is sufficient to support the treatment team's conclusion that Wood is presently dangerous. Wood's past crimes were unquestionably violent. He was found NGI for a brutal murder  beating his stepfather to death with a brick  while suffering from delusions caused by his then-untreated mental illness. He was also found NGI of sexual assault of another patient in an institutional setting. Except for a period of seven years, he has been institutionalized for the past 30 years, and he continues to deny culpability for his crimes. Moreover, his history in dealing with his mental illness further supports the conclusion that he remains dangerous. He has a pattern of refusing to increase medication to levels needed to manage his symptoms and he has shown a severe lack of insight regarding his needs and behavior. Most compellingly, he was deemed by staff at Mendota to be deteriorating rapidly. Dr. Smith cited evidence that Wood had surreptitiously stopped taking all medication and was beginning to engage in behavior that, if it continued to escalate, would jeopardize staff and other patients. Finally, each of the seven petitions for conditional release that Wood filed during his time at Mendota failed, chiefly because of evidence that he remains a risk. ¶ 51 Accordingly, we are satisfied that Wis. Stat. § 971.17(3)(c) and AD-11-97 are valid on substantive due process grounds, both facially and as applied to Wood.