Opinion ID: 2062379
Heading Depth: 1
Heading Rank: 2

Heading: substantive legal issuesthe competing interests

Text: Relying primarily on this court's reference in In re A.C., 573 A.2d 1235, 1243 (D.C.1990) (en banc), to the tenet common to all [5] medical treatment cases: that any person has the right to make an informed choice, if competent to do so, to accept or forego medical treatment, Khiem contends that the trial judge's order unlawfully overrode his common law right to bodily integrity. [6] He claims that before authorizing psychotropic medication, the trial judge was required to make a determination whether Khiem was competent to decide whether such medication should be administered to him. Khiem further maintains that if the judge found him not to be competent to make that decision, then the judge was obliged to apply the principle of substituted judgment to ascertain what Khiem's wishes would have been if he had been competent to decide. See A.C., supra, 573 A.2d at 1249-51; In re Boyd, 403 A.2d 744, 750-52 (D.C.1979). Extracting A.C. from its context, [7] Khiem evidently maintains that in light of our decision in that case, trial judges are now without authority, as a matter of local common law, to order any medical treatment over a patient's objection, whether that objection is interposed directly by the patient or indirectly through the substituted judgment process. This rule, according to Khiem, is absolute; the court in A.C., he insists, recognized no limits on who is protected by this common law principle. Our decision in A.C., as Khiem interprets it, would effectively enable a criminal defendant in his position to determine unilaterally whether he may be brought to trial. We discern nothing in A.C. which would support such a one-sided doctrine. Khiem's bold approach derives any vitality which it may have from the court's use in the A.C. opinion of the words all, 573 A.2d at 1243, and every, id. at 1247. We recently reiterated in United States v. Alston, 580 A.2d 587, 594 n. 12 (D.C.1990), that this type of argument is predicated on a misconception of the nature and uses of judicial precedent, and therefore makes far too much out of too little: In Kraft v. Kraft, 155 A.2d 910 (D.C. 1959), the court pointed out that: It is well to remember that significance is given to broad and general statements of the law only by comparing the facts from which they arise with those facts to which they supposedly apply. 155 A.2d at 913. See also Armour & Co. v. Wantock, 323 U.S. 126, 132-33, 65 S.Ct. 165, 168, 89 L.Ed. 118 (1944), where the Supreme Court aptly stated: It is timely again to remind counsel that words of our opinions are to be read in the light of the facts of the order under discussion. To keep opinions within reasonable bounds precludes writing into them every limitation or variation which might be suggested by the circumstances of cases not before the Court. General expressions transposed to other facts are often misleading. (Emphasis added.) This court specifically noted in A.C., supra, 573 A.2d at 1245-46, that the right to accept or reject medical treatment is not absolute. We commented that our discussion of the circumstances in which a patient's wishes may be overridden, even in the context of the case then before us, presupposed a major bodily invasion, and we explicitly declined to draw the line between major and minor surgery. Id. at 1246 & n. 10. We found it unnecessary to decide, see A.C., supra, 573 A.2d at 1246 & n. 11, whether Hughes v. United States, 429 A.2d 1339 (D.C.1981) and United States v. Crowder, 177 U.S.App.D.C. 165, 543 F.2d 312 (1976), cert. denied, 429 U.S. 1062, 97 S.Ct. 788, 50 L.Ed.2d 779 (1977), both upholding as reasonable minor surgical intrusions under the skin to remove bullets from criminal suspects, would be decided differently in light of Winston v. Lee, 470 U.S. 753, 105 S.Ct. 1611, 84 L.Ed.2d 662 (1985), in which the Supreme Court rejected the government's request to recover a bullet from a defendant's chest by major surgery requiring a general anesthetic. Our discussion in the A.C. opinion of those cases necessarily recognized that law enforcement interests might be implicated in other cases, but we refrained from opinion on questions unrelated to the merits of the case before us. This court thus explicitly left open in A.C. the very kinds of issues which Khiem now claims to be foreclosed by that decision. A.C. was not about, and could not decide, how much weight should be given in the judge's calculus to the government's interest in bringing to trial an accused who has been indicted for premeditated murder. The United States never had the opportunity in A.C. to present that law enforcement interest for the court's consideration. A.C. may not be converted, by barristerial ingenuity or judicial alchemy, into a sweeping rejection of contentions which were neither before the court nor relevant to the issues then at hand. We therefore cannot give A.C. the significance for the present controversy which Khiem attributes to it.
As we indicated in A.C., the common law liberty interest in one's own bodily integrity is an important one. The Supreme Court, speaking through Chief Justice Rehnquist, recently reiterated its view, initially articulated more than a century ago, that [n]o right is held more sacred, or is more carefully guarded, by the common law, than the right of every individual to the possession and control of his own person, free from all restraint or interference of others, unless by clear and unquestionable authority of law. Cruzan v. Missouri Dep't of Health, 497 U.S. 261, ___, 110 S.Ct. 2841, 2846, 111 L.Ed.2d 224 (1990) (quoting Union Pac. R. Co. v. Botsford, 141 U.S. 250, 251, 11 S.Ct. 1000, 1001, 35 L.Ed. 734 (1891)); see also Schloendorff v. Society of New York Hospital, 211 N.Y. 125, 129-30, 105 N.E. 92, 93 (1914) (Cardozo, J.). That right embraces a significant liberty interest in avoiding the unwanted administration of antipsychotic drugs, Harper, supra, 494 U.S. at 221, 110 S.Ct. at 1036 for [t]he forcible injection of medication into a nonconsenting person's body represents a substantial interference with that person's liberty. Id. at 229, 110 S.Ct. at 1041; accord, Riggins v. Nevada, ___ U.S. ___, ___, 112 S.Ct. 1810, 1815, 118 L.Ed.2d 479 (1992). We also agree with Khiem that his rights under the common law were not extinguished by his commitment to the lawful custody of the hospital. In Harper, supra, the Court recognized that a mentally ill individual who has been sentenced to imprisonment retains a right, both under state law and under the Due Process Clause of the Fourteenth Amendment, to be free from the arbitrary administration of antipsychotic medication. Id. at 221, 110 S.Ct. at 1036. See also Boyd, supra, 403 A.2d at 750-52 (ordering substituted judgment inquiry where civilly committed incompetent individual raised religious objection to administration of psychotropic drugs). But our recognition of this important aspect of individual autonomy in a free society does not lead us to accord it the absolute and preemptive character which Khiem claims for it. The government cannot intrude upon Khiem's bodily integrity without a showing of overriding justification and medical appropriateness. Riggins, supra, ___ U.S. at ___, 112 S.Ct. at 1815. Once such a showing has been made, however, Khiem enjoys common law or due process protection only from an unreasonable or arbitrary determination that involuntary medication is appropriate. See Harper, supra, 494 U.S. at 221, 110 S.Ct. at 1036; Charters, supra, 863 F.2d at 305. Dean Prosser has remarked in a different but related context that [a]s with `medical paternalism,' the notion of patient sovereignty can be carried too far. W. PAGE KEETON, PROSSER AND KEETON ON THE LAW OF TORTS, § 32, at 190 n. 60 (5th ed. 1984). Khiem's common law interest, like his due process protections, must be weighed against any legitimate interests asserted by the state, Harper, supra, 494 U.S. at 223, 110 S.Ct. at 1037, and a reasoned accommodation must be made between the competing interests. Id. at 236, 110 S.Ct. at 1044. [8] Moreover, Khiem having been lawfully committed to the hospital, the extent of his rights must be assessed in the context of his confinement. Id. at 222, 110 S.Ct. at 1037; Charters, supra, 863 F.2d at 305. The statute under which Khiem was committed, D.C.Code § 24-301(a) (1989), provides that the court may commit an apparently incompetent criminal defendant to a mental hospital for care and treatment in order to enable him to regain his competency. See Williams v. Overholser, 104 U.S.App.D.C. 18, 20, 259 F.2d 175, 177 (1958). It would surely be incongruous, in light of § 24-301(a), to hold that the court, after committing an accused for treatment to render him competent so that he can stand trial for the offenses with which he has been charged, is obliged to withhold treatment at the accused's sole option. The Corporation Counsel contends in his brief that § 24-301(a) abrogates any common law right of [committed defendants] to refuse treatment. He claims that under that provision, courts may review treatment decisions by the hospital only to make sure that it has made a permissible and reasonable decision in view of the relevant information and within a broad range of discretion. See Tribby v. Cameron, 126 U.S.App.D.C. 327, 328, 379 F.2d 104, 105 (1967). Khiem responds that a statute in derogation of the common law must be strictly construed, and that common law rights remain in effect unless expressly repealed or modified. See United States v. Jackson, 528 A.2d 1211, 1215 (D.C.1987); O'Connor v. United States, 399 A.2d 21, 26 (D.C.1979). In our view, however, the common law provides Khiem with essentially the same rights as those recognized by the court in Tribby, but no more. Section 24-301(a), as heretofore construed, is thus not in derogation of the common law. Finally, Khiem contends that the prosecution is required to prove that its interest in medicating him over his objection is so compelling that no reasonable alternative exists. The availability of reasonable alternatives to the proposed treatment, if shown, would be a relevant factor in the overall inquiry, but this does not necessarily mean that the government must set up and then shoot down every conceivable alternative method of accommodating the claimant's constitutional [or common law] complaint. Harper, supra, 494 U.S. at 225, 110 S.Ct. at 1038 (quoting Turner v. Safley, 482 U.S. 78, 90-91, 107 S.Ct. 2254, 2262, 96 L.Ed.2d 64 (1987)). In any event, as we show below, the law enforcement interest asserted by the government in the present case, which involves two alleged murders, is an especially compelling one. Riggins, supra, ___ U.S. at ___, 112 S.Ct. at 1815.
Having assessed Khiem's liberty interest, we turn now to the competing interest asserted by the United States. As Justice Brennan wrote in his concurring opinion in Illinois v. Allen, 397 U.S. 337, 347, 90 S.Ct. 1057, 1063, 25 L.Ed.2d 353 (1970), [t]he safeguards that the Constitution accords to criminal defendants presuppose that government has a sovereign prerogative to put on trial those accused in good faith of violating valid laws. Constitutional power to bring an accused to trial is fundamental to a scheme of `ordered liberty' and prerequisite to social justice and peace.[ [9] ] Accord, Riggins, supra, ___ U.S. at ___, 112 S.Ct. at 1815, quoting Allen in the context of an involuntary medication issue raised in a murder case; State v. Law, 270 S.C. 664, 674, 244 S.E.2d 302, 307 (1978) (same). [T]he community's interest in fairly and accurately determining guilt or innocence ... is of course of great importance. Winston, supra, 470 U.S. at 762, 105 S.Ct. at 1617-18. Since it has been impossible for several years to bring Khiem to trial to determine his guilt or innocence without first administering psychotropic medication, the government's interest is a fundamental one and of a very high order indeed. In Winston, the Court treated as important (though not as controlling) the government's interest in obtaining a bullet from a criminal suspect's chest. That bullet would, however, have represented but one part of the evidence against the defendant. Id., 470 U.S. at 765, 105 S.Ct. at 1619. [10] In the present case, it appears to be beyond dispute that if Khiem is not treated with psychotropic medication, the prosecution will not be able to bring him to trial at all. The societal interest at issue is therefore considerably greater than that presented by the government in the bullet recovery cases. As the Supreme Court noted in Riggins, supra, ___ U.S. at ___, 112 S.Ct. at 1815, after quoting the Allen concurrence to emphasize that the government's opportunity to bring an accused to trial is fundamental to a scheme of ordered liberty, the State might have been able to justify medically appropriate, involuntary treatment with the drug by establishing that it could not obtain an adjudication of Riggins' guilt or innocence by using less intrusive means. The ACLU argues in its amicus brief that the government's interest is largely symbolic, because even if Khiem is convicted, he will in all likelihood return in short order to some form of institutional psychiatric care. We cannot agree with the ACLU's characterization. We note that Khiem has asked the court to terminate his commitment and that he emphatically denies that he is a danger to himself or to anyone else. An individual may not be civilly committed unless it is demonstrated that he is likely to injure himself or others. See D.C.Code § 21-521 (1989); In re Melton, 597 A.2d 892, 896-97 (D.C.1991) (en banc). Accordingly, if all of the declarations on Khiem's behalf were taken at face value, and if his legal contentions were to prevail, he might soon be a free man without his guilt or innocence of two murders having first been established, and this could continue indefinitely unless he regained his competency to stand trial. Unless we view the trial of homicide cases, the deterrence and punishment of crime, and the incapacitation of criminals as insignificant, the government's law enforcement interest in determining whether Khiem murdered his parents is far more than merely symbolic.
Although the issue does not appear to have been squarely decided in this jurisdiction, most of the courts which have been asked to do so have upheld the involuntary administration of psychotropic drugs to restore or maintain a defendant's competency for trial. In holding that the hospital may treat Khiem with such medication without his consent, the trial judge relied not only on Harper but also on Charters. In Charters, the United States Court of Appeals for the Fourth Circuit, sitting en banc, affirmed a trial court order authorizing the involuntary treatment with psychotropic medication of a mentally ill defendant who had been indicted for allegedly threatening the President of the United States. Charters had been found incompetent and committed to a prison mental health facility for psychiatric examination and treatment. The court held that although an individual so committed was not thereby stripped of all of his liberty interests, those interests which he retained were afforded protection only against arbitrary and capricious state action, and were adequately secured by the exercise of the professional judgment of the prison facility's medical personnel. 863 F.2d at 304-05. The court recognized that the government's interest in maintaining a pretrial detainee in a competent condition to stand trial was a legitimate incident of institutionalization to which Charters' interest must yield. Id. at 305-06. [11] In State v. Law, supra , the Supreme Court of South Carolina rejected a contention very similar to that made by Khiem here: Counsel for the appellant apparently takes the position that under no circumstances can medication be administered a defendant without his consent. They contend that such would be violative of his bodily integrity. We do not feel that such an absolute right exists. It is our view that medication may be administered without the consent of a defendant under compelling circumstances, including those where the medication is necessary to render a defendant competent to stand trial. 270 S.C. at 674, 244 S.E.2d at 307 (emphasis added). [12] Accord, Ybarra v. State, 103 Nev. 8, 13, 731 P.2d 353, 356 (1987) (the majority of courts that have considered the issue have held that competency may be attained through the use of [involuntary] medication); State v. Lover, 41 Wash. App. 685, 689, 707 P.2d 1351, 1353 (1985) (psychotropic medication may be administered without the consent of a defendant to render him or her competent to stand trial) (citing Law, supra, 270 S.C. at 674, 244 S.E.2d at 307); State v. Hayes, 118 N.H. 458, 389 A.2d 1379, 1382 (1978) (the trial court may compel the defendant to be under medication at least four weeks prior to trial if the jury is [appropriately] instructed...); see also People v. Hardesty, 139 Mich.App. 124, 362 N.W.2d 787, 793 (1985). [13] Khiem relies on Bee v. Greaves, 744 F.2d 1387 (10th Cir.1984) for the proposition that his interest in bodily integrity trumps all competing state interests. As the court explained in Bee, the jail contends that it was entitled to inject Bee forcibly with thorazine in order to keep him competent for trial. As we noted initially, however, the state court found after a hearing that Daniel H. Bee is not mentally ill and is competent to stand trial. Rec., vol. I, at 132 (emphasis added). Given this determination, the state's asserted interest in keeping Bee competent to stand trial is not implicated in this case; therefore it cannot serve to override Bee's interest in avoiding forcible medication with antipsychotic drugs. Id. at 1395 (emphasis in original as to words is competent, added as to remainder). The issue raised here by Khiem was thus not before the court in Bee. [14] Khiem also relies on Boyd, supra, in which this court applied the substituted judgment principle to an incompetent patient who had been civilly committed and who objected on religious grounds to the administration of psychotropic medication to her. There was no allegation, however, that Ms. Boyd had committed serious crimes and that it was necessary to bring her to trial. The governmental interest which we find controlling here was not presented in the Boyd case. We are persuaded by the reasoning of Charters, Law, and other decisions authorizing psychotropic treatment without the accused's consent in cases such as this. Accordingly, we reject Khiem's common law claim.