Document: 457 U.S. 291 102 S.Ct. 2442 73 L.Ed.2d 16 Mark J. MILLS et al., Petitionersv.Rubie ROGERS al. No. 80-1417. Argued Jan. 13, 1982. Decided June 18, Syllabus Respondents, present or former mental patients at a Massachusetts state hospital, instituted class action against petitioner officials and staff of the hospital in Federal District Court, alleging that forcible administration antipsychotic drugs to violated rights protected by Constitution. The court held enjoy constitutionally liberty privacy interests deciding for themselves whether submit drug therapy; under law an involuntary commitment provides no basis inference legal "incompetency" make such decision; without consent either patient guardian who has been adjudicated incompetent, patient's may be overridden only emergency. Court Appeals affirmed part reversed part. It agreed with Court's first two holdings above, but reached different conclusions as circumstances which might override interests. reserved on remand, task developing mechanisms ensure adequate procedural protection This granted certiorari determine involuntarily committed constitutional right refuse treatment drugs. Shortly thereafter Supreme Judicial ruled rights—under both common Constitution—of noninstitutionalized incompetent Held: Appeals' judgment is vacated, case remanded court's consideration, instance, correct disposition this affected intervening decision. Pp. 298-306. (a) Assuming (as parties agree) Constitution recognizes interest avoiding unwanted drugs, substantive issue remains definition interest, well identification conditions competing outweigh it. There also concerning minimum procedures required determining individual's actually outweighed particular instance. As practical matter issues are intertwined questions law, create protections broader than those If so, minimal requirements would not controlling, need identified order duties persons within State. 298-300. (b) While record unclear respondents' position effect their asserted federal rights, brief they clearly assert state-law arguments alternative grounds affirming "substantive" "procedural" decisions Appeals. In applying policy unnecessary issues, it clear which, if any, now must decided resolve controversy between parties. Because its greater familiarity better situated how state-court decision have changed any changes affect case. 304-306. 634 F.2d 650, 1 Cir., vacated remanded. Stephen Schultz, Bridgeport, Conn., petitioners. Richard Wayne Cole, Boston, Mass., respondents. Justice POWELL delivered opinion Court. 2 * litigation began April 27, 1975, when respondent Rubie Rogers six other filed suit various May Austin Units Boston State Hospital. plaintiffs all were institution. During period institutionalization had forced accept drugs.1 Alleging these United States, plaintiffs—respondents here sought compensatory punitive damages injunctive relief.2 3 certified action. See v. Okin, 478 F.Supp. 1342, 1352, n.1 (Mass.1979). Although denying relief damages, therapy.3 found "commitment" law. Id., 1361-1362.4 Until judicial finding incompetency made, concluded, wishes generally respected. 1365-1368. Even rendered determination incompetency, forfeited, exercised his behalf court-appointed guardian. 1364. Without guardian, held, emergency.5 4 First Circuit 650 (1980). undergo 653.6 accepted trial conclusion presumptively competent own behalf. id., 657-659. conclusions, however, patient. 5 weighed patient: police power maintaining institution preventing violence, see 655, parens patriae alleviating sufferings illness providing effective treatment, 657. State, powers, administer medication forcibly upon "the prevent violence situation outweighs possibility harm medicated individual" "reasonable alternatives antipsychotics [have been] out." 656. Criticizing imposing what regarded more rigid standard, hospital's professional substantial discretion impending emergency requires medication.7 "police power" standard accord patients."8 6 With respect State's distinction incompetent. Where judicially "incompetent" law,9 will justify necessary further deterioration health. 660. appointed nonemergency patients. patients, prescription voluntarily individual himself . he competent" decide. 661.10 undesired procedurally "incompetency."11 on-the-scene still before could administered Ibid.12 7 involved potentially broad significance,13 we certiorari. Okin Rogers, 451 906, 101 1972, 68 293 (1981). II A. 8 principal question drugs.14 aspects. F.2d, 656, 661; Rennie Klein, 653 836, 841 (CA3 1981). agree drugs.15 respect, involves Youngberg Romeo, 307, 319-320, 2452, 2460, 28; Bell Wolfish, 441 520, 560, 99 1861, 1885, 60 447 (1979); Roe Wade, 410 113, 147-154, 93 705, 724, 727, 35 147 (1973); Jacobson Massachusetts, 197 11, 25-27 (1905). concerns Parham J.R., 442 584, 606, 2493, 2506, 61 Mathews Eldridge, 424 319, 335, 96 893, 903, 47 18 (1976). 9 theory able define scope federally reference law.16 Having done then proceed adjudicate Due Process Clause alone. Cf. Vitek Jones, 445 480, 491-494, 100 1254, 1262-1264, 63 552 For purposes actual obligations, cannot avoided. Within our system provided minimum. recognize extensive independently Greenholtz Nebraska Penal Inmates, 1, 7, 12, 2100, 2106, 668 Oregon Hass, 420 714, 719, 95 1215, 1219, 43 570 (1975); Brennan, Constitutions Protection Individual Rights, 90 Harv.L.Rev. 489 (1977). possessed person living 10 creates directly Constitution, mandated protect fail state-created entitled Clause, see, e.g., supra, 488, 1261; S.Ct., 2103, full due process depend created Moreover, confer extend beyond minimally States. does B 11 Roughly five months after case, shortly certiorari, announced Guardianship Roe, 383 Mass. 415, 421 N.E.2d 40 (1981) (Roe ). mentally Expressly resting Constitution,17 Massachusetts' highest " 'decid[ing] serious harmful medical represented drugs.' 433, n. 9, N.E.2d, 51, 9.18 again apparently States—that importance can overcome "an overwhelming interest." 434, 51. forfeit virtue becoming rather "substituted judgment" Ibid. Defining one "[n]o expertise required," 435, 52, substituted instance,19 except possibly cases emergency.20 C 12 stated was limited involving 417, 441-442, 452-455, 42, 55, 61-62.21 Nonetheless, respondents argued influence hand.22 We agree. 13 Especially wake distinctly possible adjudged Compare 51 (protected continues even becomes incompetents determined), Addington Texas, 418, 429-430, 1804, 1811, 323 (1979) (because "who suffering from debilitating illness" "wholly liberty," because complexities psychiatric diagnosis "render certainties virtually reach," "practical considerations" require "a compromise prove protects individual"). broader, affords Massachusetts. 14 Procedurally, quite court, relevant survive scrutiny Clause. 483 ("We preference resolution certain arising proposed extraordinary treatment. ."), U.S., 322-323, 2462 ("[T]here certainly reason think judges juries qualified appropriate professionals making [treatment] decisions"), 608, 16, 2507, (Courts "unduly burde[n] legitimate efforts states deal difficult social problems. model factfinding interests, regardless nature, turn rational decisionmaking into unmanageable enterprise").23 Again hypothesis dispositive 15 Finally, itself unchanged nature weight asserted. To identify balanced look See, 148 151, nn. 48-50, 724 726, 48-50; Ingraham Wright, 430 651, 661-663, 97 1401, 1407-1408, 711 Here view underlying predicate weighing being put doubt, altered, Roe.24 D presented respondents, did argue existence claim claimed interests.25 Brief especially 61, 71-72, 92-95. 17 answered, inappropriate us attempt weigh derived settled avoid issues. City Mesquite Aladdin's Castle, Inc., 455 283, 294, 1070, 1077, 71 152 (1982); New York Transit Authority Beazer, 440 568, 582-583, 22, 1355, 1364, 59 587 Poe Ullman, 367 497, 502-509, 81 1752, 1755-1759, 989 (1961); Ashwander TVA, 297 288, 341, 347-348, 56 466, 483, 80 L.Ed. 688 (1936) (Brandeis, J., concurring). supported, although always required, prohibition advisory opinions. States Hastings, 296 188, 193, 218, 220, (1935) (review supported another subject examination represent expression abstract opinion"). restraint, uncertain say confidence adjudication based solely us. And, additional cause hesitation, reading left doubt extent below degree rest subsequently altered foundations. 19 Accordingly, instance revision call certification Bellotti Baird, 428 132, 150-151, 2857, 2867-2868, 49 844 (1976).26 consider abstention appropriate. Colorado River Water Conservation Dist. 800, 813-819, 1236, 1244-1247, 20 therefore proceedings consistent opinion. 21 So ordered. used litigation, term "antipsychotic drugs" refers medications Thorazine, Mellaril, Prolixin, Haldol treating psychoses, schizophrenia. 1359-1360 (Mass.1979), aff'd rev'd part, (CA1 1980). Sometimes called "major tranquilizers," compounds introduced psychiatry early 1950's. Cole & Davis, Antipsychotic Drugs, Freedman, H. Kaplan B. Sadock, Comprehensive Textbook Psychiatry II, pp. 1921-1922 (2d ed. 1975). disputed "mind-altering." Their effectiveness resides capacity achieve effects. Citing authorities, petitioners essential disorders, preservation institutional needed therapy. Petitioners 17-41, 54-100. Respondents dispute claim, support authorities. emphasize carry significant risk adverse side These include neurological syndromes parkinsonisms, characterized mask-like face, retarded volitional movements, tremors; akathisia, clinical restlessness; dystonic reactions, including grimacing muscle spasms; tardive dyskinesia, disease mild form around mouth. Tardive dyskinesia disabling most severe forms. F.Supp., 1360; Byck, Drugs Treatment Psychiatric Disorders, L. Goodman Gilman, Pharmalogical Basis Therapeutics 152, 169 (5th statutory challenges secluding will. 1352. complaint additionally claims tort 1383. prevented seclusion where violence. 1371, 1374. Neither decision, nor denial claims, intimate [antipsychotic] medication" "basic privacy" 1366. derive provision, observe "concept embodies Amendment concerns." relying reasoned produce ideas fundamental cherished communicate comparable protection." 1367. Under torts, emerged doctrines trespass battery, applied unauthorized touchings physician. Superintendent Belchertown School Saikewicz, 373 728, 738-739, 370 (1977); W. Prosser, Law Torts § (4th 1971). argued—as continue argue—that conducted Mass.Gen.Laws Ann., ch. 123 (West Supp. 1982-1983), provide sufficient warrant over objections rejecting argument relied principally language statutes regulations Department Mental Health. 1359, 1361 (citing Health Regulation 221.02 ("No shall deprived manage affairs admission facility there incompetent"), 123, 25 1982-1983) deemed capacity. .")). appears engaged independent leading same conclusion: "The evidence persuades that, do suffer least some impairment relationship reality, appreciate benefits, risks, discomfort reasonably expected receiving psychotropic medication." 1361. defined failure medicate "would result likelihood physical th[e] patient, members institution." 1365. termed "intuitively obvious" free decide drugs." 653. "precise textual source unclear," ibid., concluded Fourteenth exists, likely penumbral privacy, bodily integrity, personal security." examine implicated. erred requiring construed overly simplistic mathematical calculation "quantitative" harm. asserted, minimum, made physician each medicated." A number distinguish standards governing determinations decisions. survey December 1977, Plotkin, Limiting Therapeutic Orgy: Patients' Right Refuse Treatment, 72 Nw.U.L.Rev. 461, 504-525 Second civil raise presumption incompetence. Winters Miller, 446 65 (1971). viewed holding 661 ("In so holding, imply .). But followed ultimate citation case: "Cf. Saikewicz," 417 Saikewicz apply approve painful profoundly man incapable giving informed consent. 738-741, 424-425. analysis having "constitutional privacy," 739, 424, thus creating basis. determination, probate 1982-1983); 201, §§ 6, (appointment powers guardians). suggested, nonjudicial satisfy process. 659-660. instructed develop safeguards 661. Constitutional recent cases, 836 1981), Davis Hubbard, 506 915 (ND Ohio On raised, supra; Shapiro, Legislating Control Behavior Control: Autonomy Coercive Use Organic Therapies, S.Cal.L.Rev. 237 (1974). Pet. Cert. 1. appear concede freedom invasion, 43-47, deny "fundamental." They balancing test compelling administering 54-68. parties, assume discussion retain cf. O'Connor Donaldson, 422 563, 2486, 45 396 (1975), implicated Only "assuming" course comparison countervailing 9. quoted formulation 653, quotation right, source. noted Amendment. continued stating reliance three bases, them cited Okin: "inherent mistakes abuses guardians, whose authority comes Commonwealth," "common law" bodies. 52: probe values preferences, inquiry, [and patient], best courts jurisdiction." "ward possesses exercising personally" "primary dispute" ought exercise ward." "relevant" "not exclusive" factors should guide lower courts: "(1) ward's expressed preferences regarding treatment; (2) religious beliefs; (3) impact family; (4) probability effects; (5) consequences refused; (6) prognosis treatment." 444, 57. emphasized "must 'give fullest character circumstances' "this subjective objective determination." (citation footnote omitted). 440-441, 54-55. 432, 50 ("because necessity similar establish guidelines criteria determination"), 453-454, 62 mean [involuntarily committed] patients' wholly unprotected entirely dissimilar discussed. suggest, imprudent prematurely relative ."). 22 motion dismiss certify October 1981. merits, affirm 23 prior separate proceedings, 658-659, "in many respects goes Amendment," 659 (footnote taken step procedure every believes therapy 24 explicitly considered 449, 59, judge "vital" "seeing residents function maximum level capacity," ibid. interest. 657-661. primarily grounds, original raising guarantees interrelated bases relief. Complaint 75-1610-T (D.Mass.) (filed Apr. briefs Appeals, unambiguously Plaintiff-Appellants 79-1649, p. 44 ("Massachusetts entitlement emergencies ."); Plaintiff-Appellees 79-1648, 54 ("[T]he requirement receive non-emergency application authority") (emphasis 26 Rules Sup.Jud.Ct. Rule 1:03.

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