The State Cannot Force Medications on Committed Patients Who Are No Longer Considered Dangerous

Facts of the Case

In New Jersey, a person can be civilly committed after a probable-cause hearing for up to 20 days on grounds of dangerousness due to a mental illness and unwillingness to accept treatment. At a hearing held within the 20 days, the state must show that there are grounds for continued commitment, including dangerousness, by clear and convincing evidence. Patients have rights to counsel, to be present, to present evidence, and to cross-examine witnesses. If the patient is committed, the state retains the burden of persuasion at periodic hearings. If dangerousness is not shown, the court can discharge the patient or enter a judgment of “conditional extension pending placement” (CEPP). Patients on CEPP status, while not meeting New Jersey's commitment standard, must remain in the hospital until appropriate placement is available. Their status is reviewed within 60 days of the CEPP order and then periodically. The courts had never decided whether civilly committed patients have a constitutional right to refuse medication. However, New Jersey adopted Administrative Bulletin 78–3 after a patient's challenge to involuntary medication in nonemergency situations (Rennie v. Klein, 462 F. Supp. 1131 (D.N.J. 1978)). The Rennie procedures provide a mechanism for adjudicating treatment refusals. The three-stage process includes psychoeducation, a treatment team meeting, and evaluation by the facility's medical director or designee. If that psychiatrist concurs on clinical grounds, the facility staff can forcibly medicate, with weekly review.

In August 2010, Disability Rights New Jersey, a nonprofit organization advocating for civil and legal rights of New Jersey citizens with disabilities, filed a complaint in federal district court. The plaintiffs alleged that the Rennie process was unconstitutional, violating the Americans with Disabilities Act (ADA) and the Rehabilitation Act of 1973. The complaint requested relief, asserting that the Rennie process was a “rubber stamp” for the hospital to medicate patients involuntarily. It asked the court to order the state to provide judicial hearings for administration of involuntary medication in nonemergent situations for due process protection, including the requirement that the facility involuntarily medicate only patients who are incompetent to make medical decisions and know their rights.

In June 2012, while the lawsuit was pending, the state replaced the Rennie process with two comprehensive policies governing forcible medication in emergent (AB 5:04A) and nonemergent (AB 5:04B) situations. Under the emergency policy, a patient can be forcibly medicated for up to 3 days while imminently dangerous, but must be reassessed every 24 hours. Under the nonemergency policy, an involuntarily committed patient can be forcibly medicated only when the untreated mental illness poses a serious risk of harm to self, others, or property. The policy also specified procedures for forcible medication in nonemergent situations, including submission of a medication administration report by the treating psychiatrist, followed by a review hearing within 5 days before a three-person panel appointed by the medical director of the hospital. According to the policy, a patient has the right to be notified of the hearing, attend the hearing, testify, present evidence and witnesses, cross-examine witnesses, have legal counsel and an expert witness present, and be assisted by an advocate. After the hearing, involuntary medication is authorized only if the chair and one other panel member agree that the substantive standard is satisfied. The patient has the right to appeal the decision to the medical director and, upon denial, medication is administered. That decision may be appealed to the Appellate Division of the New Jersey Superior Court. The initial approval of forcible medication is valid for 14 days, and the treating psychiatrist must report the medication response within 12 days. Another panel can authorize involuntary medication for up to 90 days, wherein the treating psychiatrist must provide biweekly follow-up reports. If, at the end of 90 days, the patient continues to refuse treatment, the process is repeated. This policy was applicable to all civilly committed patients, including those who had CEPP status. Disability Rights claimed that the new policy also violated the ADA, the Rehabilitation Act, and the Due Process Clause of the Fourteenth Amendment.

The district court held that New Jersey's new policy withstood Disability Rights' challenges except those pertaining to patients on CEPP. The court rejected the ADA and Rehabilitation Act claims because the policy was a legitimate safety requirement permitted by federal regulation. There was also adequate justification for deferential treatment of these patients because justification for treatment was not based on disability, but on the finding of dangerousness. The district court held further that the nonemergent procedure cannot be applied to patients who have CEPP status, because these patients have already been found nondangerous, and any relapse of their illness leading to dangerousness can be addressed through the emergent-situations policy.

The district court also rejected Disability Rights' due process claims pertaining to patients who were not on CEPP on the grounds that the policy was “strikingly similar” to the procedure the U.S. Supreme Court endorsed in Washington v. Harper, 494 U.S. 210 (1990). This decision permitted the state to treat dangerous incarcerated inmates with serious mental illness against the inmates' wishes. The district court agreed with Disability Rights and held that the state had “no interest in continuing to forcibly medicate” patients judged CEPP (Disability Rights, p 300). Disability Rights and the state filed appeals and the U.S. Court of Appeals for the Third Circuit reviewed the matter.

Ruling and Reasoning

The appellate court affirmed the district court's decision. New Jersey's policy, the court said, fulfilled the Due Process Clause, ADA, and Rehabilitation Act requirements as they applied to civilly committed patients in psychiatric state hospitals. The new policy outlines adequate procedures to administer medication involuntarily to such patients in nonemergency situations. However, patients who no longer fulfill civil commitment requirements but remain in the hospital pending appropriate placement cannot be forcibly administered medications in nonemergent situations.

In arriving at its decision, the court relied on the balancing test articulated in Mathews v. Eldridge, 424 U.S. 319 (1976). The test guides determinations of whether individuals have received due process. It balances governmental against individual interests based on three factors: how the governmental action will affect private interests; the risk of erroneous deprivation of the particular interest; and the government's interest. In cases of patients with CEPP status, using the Mathews test, the court noted that these patients have a substantial interest in avoiding unwarranted administration of psychotropic medication. In accordance with Harper, the court reasoned: Psychotropic medication alters and regulates the patient's cognitive processes and can trigger serious side effects. A patient's interest in avoiding such an invasion of his bodily integrity can only be greater when a court of law has already declared him fit to return to life in the community [Disability Rights, p 309]. The court also noted that the risk of an erroneous result is much higher if patients on CEPP are forcibly medicated without a hearing. Thus, “[w]hen New Jersey applies the policy to a CEPP patient, it effectively vacates a court's prior determination that the patient is not dangerous” (Disability Rights, p 309). The state's interest in refusing patients on CEPP a judicial hearing is minimal. The court found that New Jersey's updated policy violated due process rights of patients with CEPP status who had a legitimate interest in avoiding forcible medication. If the state believes that a patient has now become dangerous, a civil commitment hearing must follow.