Opinion ID: 2230457
Heading Depth: 1
Heading Rank: 3

Heading: the limits of our decision.

Text: In this opinion we have established that a guardian may be appointed for an individual upon a showing that it is more likely than not that the individual is unable to care for himself by reason of mental illness. In addition we have held that, where no emergency exists, antipsychotic medication may be forcibly administered to a noninstitutionalized individual only in accordance with a court order. We have set forth guidelines delineating the circumstances in which a judge is to direct the administration of such treatment. These circumstances are: (1) where a judicial substituted judgment determination indicates that the incompetent individual would, if competent, accept antipsychotic drugs, or (2) where there exists a State interest of sufficient magnitude to override the individual's right to refuse. If the asserted State interest is the prevention of violent conduct by noninstitutionalized mentally ill individuals, then, upon a showing equivalent to that necessary to commit an individual against his will, the State is entitled to force the individual to choose, by way of substituted judgment, either involuntary commitment or medication with antipsychotic drugs. While we emphasize those conclusions we have reached and the circumstances in which they are to be utilized, it is prudent to note that our guidelines are not directed toward a single case but rather identify the decisionmaking processes necessary to reach outcomes in a type of case. It is apparent from our decision today that the right of an individual to refuse treatment is not absolute but is, rather, a right to be counterbalanced against State interests. The proper balance to be struck in a given situation can only be determined after examining the specifically defined and precisely articulated interests of those who are or will be actually affected by the decision. The weight to be afforded these interests is impossible to predetermine, and the balance will vary according to the circumstances of those asserting the interests. For these reasons, we decline to strike the balance in any individual case. Specifically, we decline to rule on the right of patients confined against their will to State hospitals to refuse antipsychotic medication. We do not mean to imply that these patients' rights are wholly unprotected or that their circumstances are entirely dissimilar to those we have discussed. We do suggest, however, that it would be imprudent to establish prematurely the relative importance of adverse interests when each may be capable of being controlling and each draws its importance from the circumstances in which it is asserted. The ward in this case, though institutionalized at the time the temporary guardian was appointed, is currently living at home and has done so for many months. Indeed, the two occasions on which he was institutionalized were for observation and report pursuant to G.L.c. 123, §§ 15 ( b ) and 16 ( a ), and were not involuntary civil commitments. The guardian cannot now institutionalize the ward unless he establishes beyond a reasonable doubt that failure to commit would create a likelihood of serious harm. Doe v. Doe, 377 Mass. 272 (1979). No antipsychotic medication has yet been administered to him. In addition to observing that it would be improper to establish the extent to which persons other than a noninstitutionalized individual in a nonemergency situation are entitled to a judicial substituted judgment determination, we wish to emphasize as well that in this case we treat the ward's right to a determination only in so far as it concerns antipsychotic medication. The spectrum of medical care available to individuals and the diverse circumstances in which it may be administered do not permit us to make universal rules in anticipation of cases involving different treatment or different circumstances. Even when a medical treatment decision is confined to a single set of circumstances, it is often difficult to formulate and apply a uniform and predictable standard. Compare Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728 (1977), with Matter of Dinnerstein, 6 Mass. App. Ct. 466 (1978). See also Matter of Spring, 380 Mass. 629, 637 (1980). Our guidelines make clear that if the guardian seasonably petitions the Probate Court for an order directing the administration of antipsychotic medication to the ward, then the petition should receive prompt and full consideration. Since no such request was before the probate judge, his order authorizing involuntary treatment was premature. We therefore vacate the order in so far as it allows the ward to be medicated over his objection. The remainder of the order, appointing Richard Roe, Jr., as guardian of his son, Richard Roe, III, is affirmed. So ordered.