Court Opinion

ID: 9479894
Source: CourtListenerOpinion
Date Created: 2023-08-05 07:31:49.395581+00
Date Added: 2024-06-11T17:47:20.783899
License: Public Domain

*983JOHN R. GIBSON, Circuit Judge,
dissenting.
The court today, under the guise of recognizing a qualified right for these mentally ill prisoners to refuse treatment, condemns them to nothing more than warehousing. The continuation of their serious mental disorders, which is a necessary consequence of the court’s decision, is nothing less than cruel and unusual punishment. In reaching this decision, the court selectively reads not only the Supreme Court precedent, neatly excising and discarding the most significant portion of it, but also the medical evidence before the magistrate and district court. I would affirm the judgment of the district court.
I.
The court reads Youngberg v. Romeo, 457 U.S. 307, 102 S.Ct. 2452, 73 L.Ed.2d 28 (1982), as concerned only with the assurance of safety for the patient, other inmates, and attending personnel. This is the touchstone of its ultimate decision which is based upon whether the patient can function adequately in a prison setting without presenting the danger to himself, other inmates, or staff. The reasoning of Youngberg, however, is far broader.
In Youngberg, the Supreme Court pointed to the state’s concession of a duty to provide “adequate food, shelter, clothing, and medical care.” Id. at 315, 102 S.Ct. at 2457-58. Then, after referring to the duty to provide reasonable safety, the court considered when restraint by the state would be deemed proper. The Court stated that:
[The State] may not restrain residents except when and to the extent professional judgment deems this necessary to assure such safety or to provide needed training. In this case, therefore, the State is under a duty to provide respondent with such training as an appropriate professional would consider reasonable to ensure his safety and to facilitate his ability to function free from bodily restraints. It may well be unreasonable not to provide training when training could significantly reduce the need for restraints or the likelihood of violence.
Respondent thus enjoys ly protected interests in conditions of reasonable care and safety, reasonably nonrestrictive confinement conditions, and such training as may be required by these interests. Such conditions of confinement would comport fully with the purpose of respondent’s commitment.
Id. at 324, 102 S.Ct. at 2462.
It is apparent that the court today chooses not to recognize those obligations set out in Youngberg, beyond safety considerations. In this case we deal not with physical restraints, nor the training necessary for a permanently retarded individual, as in Youngberg, but rather with a different purpose for commitment and confinement, namely treatment of serious psychiatric illness, and medication as its necessary component. In recognizing only safety concerns in its analysis, the court totally ignores the requirement of Youngberg that the patient inmate be given such services as required by the purpose of his commitment. Id.
The Youngberg Court also points to the procedures required and appropriate in this case, namely the exercise of professional judgment in the determination of proper treatment for the individuals. It defined a professional decisionmaker as “a person competent, whether by education, training or experience, to make the particular decision at issue.” Id. at 323 n. 30,102 S.Ct. at 2462 n. 30. The Court noted that “[l]ong-term treatment decisions normally should be made by persons with degrees in medicine or nursing, or with appropriate training in areas such as psychology, physical therapy, or the care and training of the retarded.” Id. Further, the Court has recognized that professional decisionmakers should be given a presumption of correctness because they are better qualified to decide the medical issues presented in such cases. Id. at 323, 102 S.Ct. at 2462. See also Parham v. J.R., 442 U.S. 584, 607-08, 99 S.Ct. 2493, 2506-07, 61 L.Ed.2d 101 (1979); Bell v. Wolfish, 441 U.S. 520, 544, 99 S.Ct. 1861, 1876-77, 60 L.Ed.2d 447 (1979).
*984II.
The court also fails to understand the nature of the proceeding in the district court. The statutes in issue in this case were enacted following the decision of the Supreme Court in Vitek v. Jones, 445 U.S. 480, 100 S.Ct. 1254, 63 L.Ed.2d 552 (1980). It is true, as the court points out, that the statute authorizing the proceeding before us, 18 U.S.C. § 4245, is directed at determining the need for treatment rather than to resolving the specific issue of whether there can be forcible administration of psychotropic medication. Yet the decision that there should be treatment necessarily involves considering what treatment is appropriate and required. The hearing in this ease involved both issues.
In United States v. Charters, 863 F.2d 302 (4th Cir.1988) (en banc), the Fourth Circuit considered a case which involved the very issue before us: forcible medication of a psychiatric patient in a federal correctional institution. Judge Phillips’ decision for the Charters court sets out the procedure which I believe to be appropriate, and which I believe was followed in this case. This opinion also discusses in detail the reasons supporting this approach. The court states:
It is therefore settled that in appropriate circumstances government may properly commit base-line decisions to “deprive” persons of certain liberty (or property) interests to appropriate professionals exercising their specialized professional judgments rather than to traditional judicial or administrative-type adjudicative processes. This occurs when the conflicting interests — individual and governmental — can only be assessed in those terms, and even when, as is usual, the exercise of professional judgment necessarily involves some interpretation of the disputable “meaning” of clinical “facts.”
More specifically, precisely this basic regime — base-line decision committed to medical professionals, subject to judicial review for arbitrariness — has recently been upheld as comporting with due process both by the Supreme Court and this court.
Id. at 308 (citations omitted). Judge Phillips then observed, citing Parham, that while medical and psychiatric diagnosis is fallible, there is “no reason to suppose that it [would be] more so than would be the comparable diagnosis of a judge or hearing officer.” Id.
It is true that Charters involved an individual found to be mentally incompetent, incompetent to stand trial, and to present a public danger to the officers and interest of the United States. I do not believe, however, that this distinction affects the applicability of the reasoning in Charters to this case. Here a hearing has been held to determine whether Holmes and Watson are in need of treatment and, if so, the nature of the treatment. The decision rendered, while not directed to the issue of competency, specifically addressed their mental states and the need for treatment of those conditions. The court in Charters, in discussing the need for an additional hearing to determine competency as a part of the procedure desired, pointed to the possibility of conflicting mental conditions. In that case, Charters had been found incompetent to stand trial, but could have been found, under the proposed regime in that case, competent to determine whether he should receive medication. Id. at 310. In noting the subtle distinction between these mental states, the court stated that “[t]o suppose that it is a distinction that can be fairly discerned and applied by even the most skilled judges on the basis of an adversarial fact-finding proceeding taxes credulity.” Id. Further, the court stated: “The resulting threat of wholly inconsistent or highly anomalous adjudications is palpable, and poses high risks to the integrity and trustworthiness of the courts’ already perilous involvement — out of necessity — in the adjudication of complex states of mental pathology.” Id.
Much of the court’s discussion today deals with the threat of side effects from medication. Again, Charters is instructive by pointing to differing views within the medical profession. In that case, two ami-*985ci1 took opposing positions. The Charters court concluded that "[tjhese differences that we are told exist within the scientific community simply serve to emphasize that the side-effects question is simply and unavoidably an element of the ultimate ‘best interests’ medical decision.” Id. at 311. Accordingly, the court was “satisfied that as an element of the ultimate ‘best interests’ medical decision, the side-effects threat can better be assessed and reviewed within the government’s proposed regime than by an adversarial adjudicative process.” Id.
In weighing the respective interests of the patient to make an informed judgment and the government to care for the patient, the Charters court stated:
As with the potential for side-effects, we are satisfied that the patient’s competence to make an informed judgment in this matter is properly treated as simply another factor in the ultimate medical decision to administer the medication involuntarily.
Finally to be weighed in the balance is the governmental interest at stake, and the administrative and fiscal burdens that would be imposed by Charters’ proposed regime. It has to be recalled that the government’s role here is not that of punitive custodian of a fully competent inmate, but benign custodian of one legally committed to it for medical care and treatment — specifically for psychiatric treatment. In this relationship the government is under a specific statutory duty to attempt to restore mental competency so that the patient may be returned to the free society.
Id. at 311-12.
In discussing the professional judgment standard, the Charters court noted:
Again, fairly specific guidance has been provided by the Supreme Court. The basic principle is that a legally institutionalized mental patient is entitled to the exercise of “professional judgment” by those who have the responsibility for making medical decisions that affect his retained liberty interests. This is the process due such a person in this particular circumstance, and its nature dictates both the way in which the decision is to be made by the responsible professionals and how it is to be reviewed if presented to the courts for that purpose.
The decision may be based upon accepted medical practices in diagnosis, treatment and prognosis, with the aid of such technical tools and consultative techniques as are appropriate in the profession.
Id. at 312 (citations omitted).
With respect to the scope of judicial review of the professional judgment standard, the court recognized that:
The “professional judgment” standard also dictates the scope of judicial review. Under that standard, the question presented by a judicial 'challenge such as Charters’ is not whether the treatment decision was the medically correct or most appropriate one. It is only whether the decision was made by an appropriate professional in the exercise of professional judgment; i.e., not arbitrarily. Due process is denied under this standard only if the decision was reached by such a “substantial departure from accepted professional judgment, practice, or standards as to demonstrate that the person responsible actually did not báse the decision on such a judgment.”
Id. at 313 (quoting Youngberg, 457 U.S. at 323, 102 S.Ct. at 2462) (citations omitted).
III.
I am convinced that the procedures outlined in Charters have been followed in this case, and thus the sole question before the magistrate, the district court, and this court on appeal is whether the exercise of professional judgment was arbitrary. This is precisely the issue decided in the orders we are called upon to review. Unfortunately, the court today has approached this *986case in a far different manner. It either decides, or remands to the district court to decide, the question involved rather than having the court determine whether the exercise of professional judgment was arbitrary. Further, the court has given substantial weight to the written opinions of the various doctors, but has, for the most part, ignored the testimony at the hearing. I believe that when the entire record is considered, it becomes apparent that professional judgment has been properly exercised in this case, and that the record fully supports a decision that the medical judgment to force medication was not arbitrary.
As the court today affirms as to Watson, a result with which I concur, it is necessary only to examine the record with respect to Holmes. The evidence demonstrates that Holmes has a lessened capacity for making his own decisions. The physicians’ testimonies bear this out. Dr. Butts states that Holmes’ fear of side effects is not rational, but, nevertheless, is integrated in his delusional system. (Tr. 38). Dr. Snow confirms that Holmes’ fear of side effects from the medication, and accordingly his desire to refuse medication, is a part of his delusional belief. (Tr. 61).
The court today places great emphasis on the fact that Holmes was functioning adequately in the structured environment of an institution. There is, however, much evidence to the contrary. Dr. Butts described two altercations involving Holmes, one that occurred shortly after Holmes had arrived at the facility in which Holmes had sustained injuries, (Tr. 39), and another that took place when Holmes was moved from a very controlled ward to a more open one. (Tr. 39-41). Further, in his report in the record, Dr. Conroy, a psychologist, stated that Holmes, when in confrontational situations, becomes extremely defensive, that a stressful or pressured situation will break through his fragile defenses, and that he then becomes loose, rambling, tangential, and very illogical. (App. at 11). As his behavior escalates, Holmes has difficulty controlling his verbalizations or slowing his speech, and delusions of a grandiose or persecutory nature become evident. (App. at 11). Dr. Conroy also referred to Holmes' increasing hostility during one of their interviews.
I believe that the proper standard, as I have said, is that the decisions of medical professionals concerning appropriate medical treatment of a patient with a serious and chronic illness, such as Holmes, should be subject to judicial review only for arbitrariness. The testimony before the magistrate clearly established that the decision in this case was not arbitrary. Dr. Conroy, a psychologist, recommended medications and stated that clinically the treatment would go nowhere unless psychotropic medication was used and that, without medication, Holmes would simply be warehoused the rest of his life. (Tr. 20). Con-roy also stated that the majority of persons forcibly medicated have a fear of medication, but that medication is, nevertheless, helpful in allaying their anxieties, and that the patients improve. (Tr. 20). Finally, she concluded that treatment less intrusive than psychotropic medicine would not be effective based upon Holmes’ history prior to and during his treatment at the Medical Center. (Tr. 21).
Dr. Butts, a psychiatrist, also stated that other treatment modalities would not be effective without medication and a highly structured environment. Butts observed that Holmes’ prognosis is very gloomy, and while he has benefited from the controlled environment without the addition of appropriate medication, he will never have the opportunity to be well. Further, Butts noted that the fear of medication is part of Holmes’ delusional system and a feature of the disease process itself. (Tr. 38). Butts concluded that the administering act, if properly done, would not be as traumatic as Holmes’ dread of it and, would give Holmes optimum opportunity for relief of his symptoms. (Tr. 44-45).
Dr. Snow, a psychiatrist who testified on Holmes’ behalf, was very clear in her report that medication was desirable. She stated specifically that it would be worthwhile for him to take the medication. (Tr. 64-65). Snow’s only reason for not recommending medication is that Holmes’ fear is firmly rooted in his mind as part of his *987She stated that she delusional belief, would try to obtain his willingness or cooperation to take the medication, and thought it would do him a lot of good, and make him feel better. (Tr. 61). Snow also noted that the medication decision could exacerbate his condition. (Tr. 61). The physician agreed that this created a catch-22 situation, in that Holmes probably would not get better unless he was medicated, but could not be medicated because he might get worse. (Tr. 61-62). Dr. Snow stated that it was possible to work with such an individual. She added, however, that if she were unable to change Holmes’ delusional system without medication, and medication was not used, it would be unfortunate because he would be limiting his own freedom and ability to live comfortably in the community. (Tr. 62). She noted simply that someone with his delusions and distrust of authority would have nothing but interpersonal problems within the community. (Tr. 62). Snow concluded that Holmes’ fear of medication was greatly exaggerated and that the patient stresses only the detriment or risk of the medication and does not recognize that a number of people have been helped by it. (Tr. 64-65).
Dr. Burstin, a clinical psychologist, also testified on behalf of Holmes. He admitted that the issue of medication was more properly decided by a psychiatrist. Accordingly, Burstin stated that he would refer Holmes to a psychiatrist to determine if medication was the appropriate treatment. (Tr. 72-74). If the psychiatrist gave an opinion that the medication would make Holmes more treatable, Burstin opined that he would not necessarily disagree, but simply noted that this issue would not be in his province. (Tr. 74).
The record also contains considerable discussion of side effects of the medication, particularly from Dr. Butts and Dr. Snow. Their testimony is that the serious side effects occur in only a small percentage of the cases. (Tr. 45, 60).
I believe that the record before the magistrate and district court is sufficient to support determinations that Watson and Holmes are in need of medical treatment and that the medical decisions pertaining to them were not arbitrary. There was substantial evidence that forced medication is desirable from the standpoint of the overall treatment and well-being of Holmes, and that his delusions are part of the disease process and are such to prevent him from making a fully informed choice. The record before the magistrate was such that we cannot conclude that the medical decision made by the hospital authorities was arbitrary or contrary to accepted medical judgment.
I would affirm the judgment of the district court.

. In Charters, the American Psychological Association supported the patient’s position, while the American Psychiatric Association supported the position held by the government. 863 F.2d at 311.