Opinion ID: 2230457
Heading Depth: 2
Heading Rank: 3

Heading: the accommodation of overriding state interests.

Text: There are circumstances in which the fundamental right to refuse extremely intrusive treatment must be subordinated to various State interests. (1) The State interests involved. Among the State interests which we have identified in our prior cases are: (1) the preservation of life; (2) the protection of the interests of innocent third parties; (3) the prevention of suicide; and (4) maintaining the ethical integrity of the medical profession. Saikewicz, supra at 741. These four State interests are not exhaustive, and other State interests may also deserve consideration. For example, in Commissioner of Correction v. Myers, 379 Mass. 255 (1979), we held that the State's interests in orderly prison administration was a sufficient countervailing State interest to compel an inmate to submit to hemodialysis. Id. at 265-266. The present case is unlike Myers in that the ward is not in the custody of a State institution, and therefore those legitimate State concerns dealing with the preservation of institutional order and the maintenance of efficiency are not relevant here. Cf. Commissioner of Correction v. Myers, supra ; Rogers I, supra at 1368-1371. In the present case the judge found that the State had a vital interest in seeing that its residents function at the maximum level of their capacity and that this interest outweighed the rights of the individual. We disagree. While the State, in certain circumstances, might have a generalized parens patriae interest in removing obstacles to individual development, this general interest does not outweigh the fundamental individual rights here asserted. [20] The preservation of life, the most significant of the asserted State interests, Saikewicz, supra at 741, is not assertable in this case, as the proposed treatment is not intended to prolong life. There is no evidence that the ward is suicidal, nor is there evidence that medical ethics are seriously implicated. In the past we have interpreted the phrase the protection of the interests of innocent third parties as representing the State's interest in protecting minor children from the emotional and financial consequences of the decision of a competent adult to refuse life-saving or life-prolonging treatment. [21] Id. at 741-743. We have identified this as a State interest of considerable magnitude. Equally deserving of such regard is the State interest in preventing the infliction of violence upon members of the community [22] by individuals suffering from severe mental illness. This is a second aspect of the State interest in protecting innocent third parties. Although few would question that this interest is capable of overriding the individual's right to refuse treatment, a substantial question remains as to the likelihood of violence which must be established in order to support forced administration of antipsychotic medication. (2) The standard of proof required to justify administration of antipsychotic drugs to an unconsenting, noninstitutionalized individual. Once it is recognized that the State's interest in the prevention of violence is capable of overriding the individual's right to refuse, it must also be recognized that the character of the government intrusion then changes. The primary purpose of the treatment is not to implement the substituted judgment of the incompetent, nor is it intended to administer treatment thought to be in his best interests. It bears emphasis that public safety then becomes the primary justification for such treatment. Under these circumstances antipsychotic drugs function as chemical restraints forcibly imposed upon an unwilling individual who, if competent, would refuse such treatment. Examined in terms of personal liberty, such an infringement is at least the equal of involuntary commitment to a State hospital. Accordingly, we think that the same standard of proof is applicable in both involuntary commitment and involuntary medication proceedings. In order to commit an individual to a State hospital without his consent, the likelihood of serious harm must be established beyond a reasonable doubt. Superintendent of Worcester State Hosp. v. Hagberg, 374 Mass. 271, 275-277 (1978). In G.L.c. 123, § 1, as amended through St. 1980, c. 571, § 1 (the statute governing involuntary commitment), the likelihood of serious harm is defined as (1) a substantial risk of physical harm to the person himself as manifested by evidence of threats of, or attempts at, suicide or serious bodily harm; (2) a substantial risk of physical harm to other persons as manifested by evidence of homicidal or other violent behavior or evidence that others are placed in reasonable fear of violent behavior and serious physical harm to them; or (3) a very substantial risk of physical impairment or injury to the person himself as manifested by evidence that such person's judgment is so affected that he is unable to protect himself in the community and that reasonable provision for his protection is not available in the community. Absent criminal conduct, this statutory definition establishes the earliest moment at which the State may intervene to deny an individual his liberty based upon a prediction of future harmfulness. The State may not justify its intervention on a lower standard merely because it proposes to utilize antipsychotic drugs rather than physical restraints. (3) The extended substituted judgment determination. Since the standard of proof is the same for both involuntary commitment and involuntary administration of antipsychotic medication, in any case where the State's interest in preventing violence in the community has been found sufficient to override the individual's right to refuse treatment, two means are then available for protecting this State interest. [23] In such cases, that lesser intrusive means of restraint which adequately protects the public safety is to be used. [24] The right to the least intrusive means is derived from the right to privacy, which stands as a constitutional expression of the sanctity of individual free choice and self-determination as fundamental constituents of life. Saikewicz, supra at 742. In order to satisfy the least intrusive means test, the incompetent is entitled to choose, by way of substituted judgment, between involuntary commitment and involuntary medication. Such an extended substituted judgment proceeding differs from the substituted judgment determination we describe in Part II B, supra, only in that the outcome is limited to involuntary commitment or involuntary medication. [25]