Court Opinion

ID: 9564504
Source: CourtListenerOpinion
Date Created: 2023-08-21 19:01:54.078984+00
Date Added: 2024-06-11T09:18:27.798147
License: Public Domain

EHRLICH, Judge,
concurring in part, dissenting in part:
I join the majority regarding this court’s jurisdiction as well as with the determination that the Mental Health Services Act, Ariz. Rev.Stat.Ann. (“A.R.S.”) sections 36-501 et seq., does not require clear and convincing evidence of current behavior demonstrating the patient’s persistent or acute disability in cases where the petitioner provides other clear and convincing evidence of the disability. I respectfully dissent, however, from the majority’s decision that this patient’s persistent and acute disability was not sufficiently shown.
Section 36-540(A) required the trial court to find, by clear and convincing evidence, that (1) the patient was persistently and acutely disabled and (2) that he was either unwilling or unable to accept voluntary treatment. There is no real dispute as to the latter finding; the patient’s consistent denial that he suffered from a mental disorder and refusal to accept needed medical treatment was clearly supported by the evidence.
“Persistently or acutely disabled” means a mental disorder which satisfies all of the following criteria:
(a) If not treated has a substantial probability of causing the person to suffer or continue to suffer severe and abnormal mental, emotional or physical harm that significantly impairs judgment, reason, behavior or capacity to recognize reality.
(b) Substantially impairs the person’s capacity to make an informed decision regarding treatment and this impairment causes the person to be incapable of understanding and expressing an understanding of the advantages and disadvantages of accepting treatment and understanding and expressing an understanding of the alternatives to the particular treatment offered after the advantages, disadvantages and alternatives are explained to that person.
(c) Has a reasonable prospect of being treatable by outpatient, inpatient or combined inpatient and outpatient treatment.
A.R.S. § 36-501(29).
The majority agrees that the undisputed testimony provided by Drs. Torio and Shinkoda satisfied the first criterion. Inasmuch as both doctors asserted that any harm that would result would be due to unsupervised treatment and medication, the same evidence also fulfills the third criterion. Thus, I part company with the majority only on the issue of whether this very same evidence satisfied the second criterion. I believe that it does.
This court has explained that section 36-501(29)(b) “focuses on the mentally-ill individual’s decision-making process rather than on the content of the decision.” In re Maricopa No. MH-90-00566, 173 Ariz. 177, 184, 840 P.2d 1042, 1049 (App.1992); accord In re Alleged Mentally Disordered Person, 175 Ariz. 221, 225, 854 P.2d 1207, 1211 (App.1993). In other words, the section focuses on two central issues:
(1) Whether the mentally-ill individual’s ability to make an informed decision regarding treatment is substantially impaired; and
(2) Whether the individual is able to understand the treatment and treatment alternatives after the advantages and disadvantages of treatment and the alternatives to treatment, as well as their advantages and disadvantages, “are explained to that person.”
See Matter of Pima County Mental Health Serv., 176 Ariz. 565, 567, 863 P.2d 284, 286 (App.1993). In the present case, I believe that the clear and convincing evidence compels an affirmative response to both questions.
Examining the efforts which evaluating physicians must make to answer these questions, Division Two of this court, in affirming a finding of acute disability, held that, when the patient, diagnosed there as a paranoid schizophrenic with a long history of mental illness, evinces a noncooperative attitude and an unwillingness to communicate with psychiatrists, and behaves in a hostile, even threatening, manner, the “mental health officials *449[need not] engage in a confrontation with ... or ... physically restrain [the patient] in order to fulfill the letter of [section 36-501(29)(b) ].” Id. at 568, 863 P.2d at 287.
The circumstances of this case are analogous. While not diagnosed as a paranoid schizophrenic, the patient had, at one time, been recognized as suffering from Schizophreniform Disorder and, at the times relevant to this appeal, was diagnosed as suffering from a bi-polar disorder with grandiose and paranoid delusions. Dr. Torio testified that her attempts to talk to the patient were met with vulgar and sarcastic remarks, as well as agitated and threatening behavior. She further stated that, whenever a patient became agitated, she concluded the session. Dr. Torio’s statements confirm that this patient was unwilling to recognize his mental disorder and need to take medications, and hostile toward those who attempted to explain to him why treatment and medicinal stabilization were necessary. Further efforts on Dr. Torio’s part to engage the patient as to his treatment and alternatives was unnecessary.
Unlike the majority, I do not find this record “unclear” as to whether the patient’s reaction was “so severe that it thwarted any attempt to discuss treatment alternatives.” To the contrary, the record is replete with examples of the patient’s hostility toward the mention of his problems and the need for the medical and pharmacological interventions required to treat him. The record illustrates the patient’s verbal abuse, threatening demeanor and nonresponsiveness, all qualities which, as the majority acknowledges, would “prevent the physicians from making any reasonable effort to fulfill the statutory [section 36-501(29)(b) ] requirement.” Short of a physical confrontation with or physical restraint of this patient, and then with no guarantee of success, literal compliance with section 36—501(29)(b) was not possible and therefore should not be deemed necessary.
All of the expert evidence introduced at the hearing makes inescapable the conclusion that only two options existed for this patient: He could be treated in a supervised setting or he could be released, with the likelihood that he would stop taking his medication and once again become a danger to himself and others. The patient’s long history of mental illness and his numerous involuntary hospitalizations all but confirmed the outcome of the latter alternative. Any existing doubt was erased by Drs. Torio and Shinkoda when they noted that the hospitalizations occurred after the patient left a supervised-treatment setting, began neglecting to take his medication and relapsed into substance abuse. Nothing in the record remotely disputes or even contradicts these assessments. In this case, then, section 36-501(29)(b) required only that the doctors explain to the patient that he needed supervised treatment. Given the patient’s history and the likelihood of harm befalling him or others, no viable alternatives existed.
The majority, in examining the persuasiveness of Dr. Shinkoda’s affidavit, also faults the use of pre-printed form affidavits. Specifically, the majority questions the lack of any other, objective evidence that the doctor formed his opinion after having explained the treatment and treatment alternatives to the patient. I find no such fault. With due regard for the liberty interests of mentally-ill individuals, I believe that the majority’s concerns only serve to undermine the statutory role which the two evaluating physicians played in the process of petitioning for court-ordered treatment. See A.R.S. § 36-539(B).
As an initial matter, the implication that Dr. Shinkoda, or any other evaluating physician, formed his opinion without first explaining the nature of the treatment and treatment alternatives is, quite simply, an implication that he violated the law. This court rightly accords deference to the opinions and ethical standards of experts. Only when evidence calls the expert opinion into question are we more circumspect in our deference. See DePasquale v. Superior Court (Thrasher), 181 Ariz. 333, 890 P.2d 628 (App.1995). However, such is not the case here; the testimony and affidavits of Drs. Torio and Shinkoda are undisputed by any other credible medical evidence.
The pre-printed affidavit form, far from being the “rubber stamp” implied by the majority, is actually a quite thorough document. The form sets forth verbatim the *450statutory requirements that the physicians must meet in order to prevail on a petition for court-ordered treatment. To say that the marking of an “X” on the form next to a preprinted statement of section 36—501(29)(b) might result in ambiguities and omissions is to say that the doctors are, at best, unsure and, at worst, indifferent to their obligations under the statute. I will not, without some evidence to the contrary, blithely question the actions and opinions of these physicians. Moreover, there are other safeguards built into the document that should serve to satisfy the statute and the liberty concerns of the majority. For example, the requirement that the doctors explain their findings on the form, again under the specific requirements of subsection (b), provides a further assurance of their observance of the statutory mandates. Also, the form itself is not limited to a pre-printed statement of section 36-501(29); it totals six pages and requires the doctors to provide an exhaustive explanation of the patient’s past history and evaluations, current diagnoses and treatments, and recommendations for future treatment. In sum, there is nothing in this record to indicate that the requirements of section 36-501(29)(b) were not “strictly adhered to.” Matter of Alleged Mentally Disordered Person, 889 P.2d at 1091.
Court-ordered treatment for the mentally-ill is a balance between the equally compelling liberty interests of the mentally-ill individual and the state’s interest in ensuring the safety of the individual and the public. The statutory scheme, reliant in large measure upon the expert opinions of evaluating physicians, is a thoughtful mechanism for balancing these concerns. To question the opinions of the medical experts, in the absence of conflicting evidence, upsets this statutory balance. I believe that the trial court erred in dismissing AS.H.’s petition for court-ordered treatment and, therefore, respectfully dissent.