Opinion ID: 2062379
Heading Depth: 1
Heading Rank: 4

Heading: procedural due process issues

Text: Finally, Khiem claims that the hospital and the trial court denied him procedural protections guaranteed by the Due Process Clause of the Fifth Amendment. He maintains that the government's law enforcement interest in attempting to restore his competency is insufficient to support the trial judge's order; we have rejected that contention in Part II of this opinion and do not revisit it here. Khiem also contends (1) that the trial judge erred in deferring to the hospital's psychiatric judgment when the principal question before him was a legal one rather than a medical one; (2) that the hospital's procedures were fatally defective because they did not provide Khiem with an adversarial hearing; (3) that it was error for the court to order the administration of psychotropic drugs over Khiem's objection in the absence of expert testimony to a reasonable degree of medical certainty that the medication would probably render Khiem competent to stand trial; and (4) that the hospital's decision to medicate was arbitrary and capricious, and should not have been approved by the court. We address each of these contentions in turn.
Khiem's claim that the trial judge should not have deferred to the hospital's judgment under the circumstances of this case raises the most difficult of the procedural issues which have been presented for our review. Although substantial evidence was presented to support a finding that administration of psychotropic medication to Khiem was warranted even aside from the government's law enforcement interest, see n. 11, supra, the sequence of events in this record demonstrates that the treatment was precipitated by Khiem's incompetency and by the court's reasonable perception that all reasonable steps should be taken to render him competent to stand trial. Psychiatrists are experts in determining the desirability of a proposed course of treatment as a means for achieving a given medical objective, and in identifying and appraising the medical risks that such a course of treatment may entail. [17] Their expertise does not, however, extend to determining how much weight should be given to the needs of law enforcement authorities who seek to bring an incompetent patient to trial and who ask the court to override his liberty interest in his bodily integrity. The reasons for the court to apply a deferential standard of review are at their zenith when only the patient's medical interests are at issue. They are logically less compelling when non-medical factors must be included in the decision-making calculus. Nevertheless, it has been held that a substantial measure of deference to psychiatric judgments is appropriate even where, as here, governmental interests of a nonmedical nature are being weighed against the patient's interests. In Harper, supra, 494 U.S. at 231, 110 S.Ct. at 1042, the Supreme Court analyzed the issue as follows: Notwithstanding the risks that are involved, we conclude that an inmate's interests are adequately protected, and perhaps better served, by allowing the decision to medicate to be made by medical professionals rather than a judge. The Due Process Clause has never been thought to require that the neutral and detached trier of fact be law trained or a judicial or administrative officer. (Citation and internal quotation marks omitted.) Though it cannot be doubted that the decision to medicate has societal and legal implications, the Constitution does not prohibit the State from permitting medical personnel to make the decision under fair procedural mechanisms. (Emphasis added.) The Court added that it could not ignore the fact that requiring judicial hearings will divert scarce prison resources, both money and the staff's time, from the care and treatment of mentally ill inmates. Id. at 232, 110 S.Ct. at 1042; see also Charters, supra, 863 F.2d at 307-312. [18] In the present case, as in Harper and Charters, an informed medical judgment on the benefits and risks of the proposed treatment is central to the weighing and accommodation of the competing interests, and the reasoning of the courts in Harper and Charters applies in full measure. [19] Even if we were to conclude, contrary to the quoted passages from Harper and Charters, that the societal and legal implications of the issue before the trial judge warranted less deference to the hospital's recommendation than the judge accorded it, any error would not be prejudicial to Khiem. The trial court obviously recognized the importance of the government's law enforcement interest; indeed, it was Judge Shuker's allusion to that interest that set in motion the events which culminated in the entry by Judge Scott of the order now on appeal. [20] Moreover, if the decision as to the weight to be accorded to that interest is a legal one, as Khiem suggests, then it is ultimately one which this court must make. [21] Realistically, we have already made it, for we have held in this opinion that on this record the government's law enforcement interest outweighs Khiem's interest in bodily integrity, especially in light of the safeguards for which the trial court's order provides. Khiem asks us to remand the case but, under these circumstances, a remand would serve no useful purpose. As we recently had occasion to observe en banc, [t]o remand the case simply for the purpose of requiring the judge to make the prescribed finding now would be a symbolic rather than a practical act, which we view as unnecessary and as incompatible with good judicial husbandry. Melton, supra, 597 A.2d at 908 (citations and internal quotation marks omitted).
Khiem contends that the procedures utilized by the hospital in this case fail to meet applicable constitutional requirements. We do not agree. The procedures for the involuntary administration of medication are governed by CMHS [22] Policy 50000.430 2A (April 18, 1990). This detailed nine-page single-spaced document provides in pertinent part that medication may be administered to a patient in accordance with this Policy [only] if the patient has been afforded a consultation with the Patient Advocate, and an independent administrative review of the treating physician's decision to involuntarily administer medication has been performed. A patient also has the right to request a review by the Chief Clinical Officer, or the administration ... medical director if he/she is not satisfied with the recommendation resulting from administrative review. The CMHS Policy provides the patient with notice of the proposed involuntary treatment, and assures that the patient is advised of his rights pursuant to it. The Patient Advocate is a mental health professional who is trained to advocate the patient's interest. The Advocate meets with the patient, informs him of the nature of the proposed treatment, and advises him of his procedural rights. It is also the Advocate's responsibility to convey the patient's concerns to the hospital's Medical Director. The CMHS Policy provides two levels of independent administrative review of the treating physician's recommendation. The first level of review is conducted by the Medical Director of the Division where the patient is housed. The second review is by the Chief Clinical Officer. Neither of these reviewing officials is a member of the patient's treatment team. The regime at the hospital is similar in most respects to that approved by the Supreme Court in Harper, supra, 494 U.S. at 228-35, 110 S.Ct. at 1040-44. It is true, as Khiem points out, that the procedure at issue in Harper included an adversarial hearing. [23] The Court gave no indication, however, that such a hearing was constitutionally required. Indeed, in Parham v. J.R., 442 U.S. 584, 607, 99 S.Ct. 2493, 2507, 61 L.Ed.2d 101 (1979), the Supreme Court held in a somewhat comparable context that, although such a hearing may be required as a matter of state law, due process is not violated by the use of informal, traditional medical investigative techniques. In Charters, supra, the court, relying on Parham, explicitly held that no adversarial hearing is constitutionally required. [24] We reach the same conclusion in this case. [25]
Khiem contends that the hospital's decision was arbitrary because, according to him, no doctor has testified, to a reasonable degree of medical certainty, that the proposed treatment will probably render Mr. Khiem competent to stand trial. He apparently bases this contention on Jackson v. Indiana, 406 U.S. 715, 92 S.Ct. 1845, 32 L.Ed.2d 435 (1972). Jackson does not support his claim. The question in Jackson was whether a criminal defendant may be committed indefinitely solely on account of his lack of capacity to stand trial. The Court held that a person so detained cannot be held more than the reasonable period of time necessary to determine whether there is a substantial probability that he will attain that capacity in the foreseeable future. Id. at 738, 92 S.Ct. at 1858. In the absence of a showing of such a substantial probability, the defendant must be released or civil commitment proceedings must be instituted. Id. This eminently sensible holding provides no support for Khiem's claim that physicians may not inaugurate a course of treatment without advance assurance of probable success. Indeed, Jackson addressed neither the question of involuntary medication nor the scope of a court's review of medical judgments. In Harper, on the other hand, the Supreme Court held that the proper standard for reviewing governmental conduct in this kind of situation is to determine its reasonableness. 494 U.S. at 222-23, 110 S.Ct. at 1037. [T]his basic regimebase-line decision committed to medical professionals, subject to judicial review for arbitrarinesshas recently been upheld as comporting with due process.... Charters, supra, 863 F.2d at 308 (citations omitted).
Khiem also contends that the hospital's treatment decision must fail the test of rationality and lack of arbitrariness because the decision by the hospital's medical personnel was not made exclusively in the patient's medical interest. In Harper, however, the court made it clear beyond peradventure that the determination whether to medicate does not turn exclusively on the patient's interests, but also requires consideration of legitimate state interests. Id., 494 U.S. at 223-26, 110 S.Ct. at 1037-39. The government's law enforcement interest in this case is a significant one, see Part II D, supra, and we hold that it was proper to consider it. This is not a case in which a court authorized the hospital to perform complex brain surgery on an individual charged with disorderly conduct. Rather, the hospital has recommended psychotropic treatment of limited duration, which is to be closely monitored, to permit a determination through the judicial process as to whether Khiem committed two premeditated murders. The judge heard medical testimony which, if credited by him, established that the proposed treatment was consistent with sound medical practice. His decision to follow the hospital's recommendation was neither arbitrary nor irrational.