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

Heading: Procedural Due Process Challenges

Text: ¶ 52 As noted previously, patients have a liberty interest in avoiding the administration of medication against their will. State v. Anthony D.B., 2000 WI 94, ¶ 27, 237 Wis.2d 1, 614 N.W.2d 435. The primary procedural due process protection required in light of that liberty interest is periodic review of the order to compel medication. Id. That review need not be judicial, so long as there are adequate alternative procedures in place. See Harper, 494 U.S. at 231-33, 110 S.Ct. 1028. ¶ 53 For example, in Harper, the United States Supreme Court upheld a medication policy applied to mentally ill prisoners that required several aspects of review. First, at the time that the institution seeks the order to compel medication, an inmate is entitled to a hearing before a special committee made up of a psychiatrist, a psychologist, and the superintendent of the institution, none of whom are involved in the inmate's treatment or diagnosis. Id. at 215, 110 S.Ct. 1028. Second, the committee is required to review the inmate's case within 14 days of involuntary treatment. Id. at 216 & n. 4, 110 S.Ct. 1028. Thereafter, the treating psychiatrist is required to prepare and submit biweekly reports to the department medical director, and a new hearing is required every six months. Id. ¶ 54 In light of Harper, this court in Anthony D.B. evaluated whether a statute authorizing orders to compel medication of persons committed pursuant to Wis. Stat. ch. 980 satisfied procedural due process requirements. 237 Wis.2d 1, ¶ 8, 614 N.W.2d 435. In that case, we held that the annual review of the commitment order itself necessarily must include a review of the order to medicate. In doing so, we emphasized several points that are relevant here: First, invoking Harper, we noted the importance of an independent review of the medical order. Id., ¶ 30. Second, we held that the patient has a right to petition for judicial review of the order. Id., ¶ 33. Finally, we concluded that an order for compelled medication would expire if it did not receive periodic review. Id., ¶ 34. ¶ 55 Here, Wood argues that Wis. Stat. § 971.17(3)(c) contains no provision for periodic review and hence must fail facially and as applied. He likewise argues that to the extent that AD-11-97 contains provisions requiring periodic review, those provisions are constitutionally inadequate, both facially and as applied. We disagree.
¶ 56 We are satisfied that Wis. Stat. § 971.17(3)(c) is facially valid on procedural due process grounds for two primary reasons. ¶ 57 First, the statute requires that the court grant a conditional release hearing, which the committed person may request every six months. Wis. Stat. § 971.17(4). Although that review is not specific to the medication order, we are satisfied that it must necessarily include a review of the medication order. See, e.g., Anthony D.B., 237 Wis.2d 1, ¶ 31, 614 N.W.2d 435 (holding that by reading the statute governing involuntary medication of prisoners under ch. 51 together with ch. 980, a review of an order to compel medication is required). ¶ 58 Second, we believe that other language in Wis. Stat. § 971.17 implicitly requires periodic review. Specifically, the portions of the statute requiring that whoever administers the medication or treatment to the person shall observe appropriate medical standards, Wis. Stat. § 971.17(3)(b)-(c), would include periodic review of the order. As a general matter, we assume that a doctor observing appropriate medical standards will not administer medication without a patient's consent if the patient is capable of consenting, the medication is not in the patient's best interest, the patient is not dangerous, or there are less intrusive means to treat the patient. Accord Harper, 494 U.S. at 222 n. 8, 110 S.Ct. 1028 ([W]e will not assume that physicians will prescribe [antipsychotic] drugs for reasons unrelated to the medical needs of the patients[.]). The ethical code governing the medical profession supports that assumption in its general statement that [p]hysicians should not provide, prescribe or seek compensation for medical services that they know are unnecessary. Am. Med. Ass'n, Code of Medical Ethics, Current Opinions, Opinion 2.19 at 81 (2008-09 ed.). More specifically, in relation to court-initiated medical treatment, the code provides, Physicians can ethically participate in court-initiated medical treatments only if the procedure being mandated is therapeutically efficacious and is therefore undoubtedly not a form of punishment or solely a mechanism of social control .... In accordance with ethical practice, physicians should treat patients based on sound medical diagnoses, not court-defined behaviors. Id., Opinion 2.065 at 28 (emphasis added). ¶ 59 At the very least, we understand appropriate medical standards to require compliance with internal practice policies of the institution, which in this case are embodied in AD-11-97. As we explain herein, AD-11-97, facially and as applied by the staff at Mendota in practice, more than adequately safeguards procedural due process protections. [16]
¶ 60 We begin by looking at the relevant provisions contained within AD-11-97. The directive provides that administrative review of the order must occur six months after the order to treat was issued (regardless of whether staff actually began administering the medication). [17] After that initial review, reviews are to occur annually. [18] The treatment team conducts those reviews, during which the team must conclude that all four criteria are met, thus justifying the patient's involuntary medication. [19] ¶ 61 The directive also sets forth patient appeal rights. If a court issues an order to treat a patient involuntarily and the four criteria are clearly established in the order, the patient has a right to judicial review, not administrative review, for the first six months after the order is issued. [20] Thereafter, when the treatment team holds administrative reviews of the order  as we noted previously, initially six months after the court issues the order and annually thereafter  the patient may appeal the treatment team's determination at those reviews to an independent review panel. [21] The directive requires that panel to be made up of: at least [three] members consisting of a combination of the following facility staff, none of whom are members of the patient's treatment team: a physician; a psychologist; and, the facility Director or designee. [22] At that hearing, the treatment team has the burden to show by a preponderance of the evidence that all four criteria required either to begin or to continue administration of psychotropic medication have been satisfied. The panel may further ask questions of the patient and of a member of the treatment team. The panel then issues its decision within five days. If it concludes by a majority that includes the physician member that all four criteria have been met, the panel will uphold the order to medicate. Otherwise, it will reverse or modify the decision to medicate the patient involuntarily. [23] ¶ 62 Wood asserts that AD-11-97 does not comport with procedural due process requirements facially in two respects. First, in his view, the directive fails because the treatment team, which is made up of staff involved with the patient's day-to-day care, conducts the initial determination and administrative review. He argues that due process requires an independent decisionmaker to review the order. He cites for support Harper, 494 U.S. at 233, 110 S.Ct. 1028, in which the United States Supreme Court observed that the policy in question adequately addressed the independence of the decisionmaker.... None of the hearing committee members may be involved in the inmate's current treatment or diagnosis. He also invokes Anthony D.B., 237 Wis.2d 1, ¶¶ 30-31, 614 N.W.2d 435, in which we emphasized the importance of an independent review of the medical order. ¶ 63 Second, Wood asserts that the frequency of the review is inadequate to safeguard procedural due process protections. He compares the reviews required here (at six months and then annually thereafter) with those mandated by the policy in Harper (initial review within 14 days and then every six months thereafter, with the administering physician submitting biweekly reports) to support his proposition that the reviews here do not occur with sufficient frequency to satisfy procedural due process. ¶ 64 As to the first argument related to independent review, we disagree that due process requires the type of independent decisionmaker that Wood advocates. As the State points out, reading on from that portion of Harper that Wood quotes, the Supreme Court expressly explains that it did not require an independent decisionmaker to review the decision to medicate. In the absence of record evidence to the contrary, we are not willing to presume that members of the staff lack the necessary independence to provide an inmate with a full and fair hearing.... In previous cases involving medical decisions implicating similar liberty interests, we have approved use of similar internal decisionmakers.... [I]t is only by permitting persons connected with the institution to make these decisions that courts are able to avoid unnecessary intrusion into either medical or correctional judgments. Harper, 494 U.S. at 233-35, 110 S.Ct. 1028 (quoting Vitek v. Jones, 445 U.S. 480, 496, 100 S.Ct. 1254, 63 L.Ed.2d 552 (1980)) (citations omitted). Moreover, even if an independent decisionmaker is required, we are satisfied that that requirement is addressed by the directive's provision for further review of the treatment team's decisions by an independent panel, none of whom are members of the patient's treatment team. ¶ 65 As to the alleged infrequency of review, we also reject that argument. The fact that the reviews required by the policy in Harper occur more frequently than they do under the policy here does not necessarily compel the conclusion that less frequent reviews violate procedural due process. Indeed, we have held that periodic annual review of orders to compel medication on persons committed under Wis. Stat. chap. 980 sufficiently satisfies due process. See Anthony D.B., 237 Wis.2d 1, ¶ 31, 614 N.W.2d 435. We are persuaded that the review protocol required by the directive occurs with sufficient frequency. ¶ 66 In sum, we are satisfied that AD-11-97 is not facially invalid on procedural due process grounds. Here, the directive requires that the treatment team members agree that the patient is not competent to refuse medication, that medication is in his or her best interest to medicate voluntarily, that without it he or she presents a current risk of harm to self or others, and that there are not acceptable alternative means to address the dangerousness. More significantly, once the order is in place, the team implements it only after again being satisfied that those four criteria have been met. Administrative review occurs six months after the issuance of the order, regardless of whether the patient has been administered the medication, and annually thereafter. Further, the patient has the right to appeal the initial order to a circuit court and to appeal the administrative reviews to an independent panel. In our view, those requirements adequately provide procedural due process protections to a patient who is subject to an order for involuntarily medication. [24]
¶ 67 Wood does not develop a separate argument from his facial challenge that Wis. Stat. § 971.17(3)(c) is unconstitutional on procedural due process grounds as applied to him. He does not put forth any evidence that Mendota did not comply with the review provisions, as we identified them above, or that application of those review provisions to him is unconstitutional. Hence, we cannot conclude that the statute was applied unconstitutionally to him. ¶ 68 Likewise, Wood does not put forth any evidence that Mendota staff did not follow the protocol for seeking the order to medicate involuntarily or for review of that order as set forth in AD-11-97, or that application of that protocol to him would in any way violate his rights to procedural due process. The record contains evidence that the treatment team at Mendota properly did all that the directive required of it. Further, Dr. Smith testified that he and the nursing staff monitor a patient's reaction to medication on a daily basis. He stated that in Wood's case, Wood consistently identifies the side effects he experiences, the staff responds to those complaints, and the staff further regularly tests Wood's blood to ensure that he is not experiencing one rare, but serious, potential side effect that his particular medication may produce. ¶ 69 Accordingly, we are satisfied that neither Wis. Stat. § 971.17(3)(c) nor AD-11-97 violates procedural due process as applied to Wood.