Boundaries of Absolute Immunity for Clinicians

Facts of the Case

In April 2010, Mr. and Mrs. Thomas learned their minor daughter (M.T.) had alledgedly had a sexual relationship with a friend's older brother. They contacted the Lea County Sheriff's Department to investigate the claim; however, during the interview, M.T. expressed suicidal ideation, which the officers determined to be valid. She was transported to a local hospital where she was interviewed by hospital staff and a representative from the New Mexico Child, Youth, and Families Department (CYFD). Because of concerns for her safety, CYFD urged the parents to admit her to UNMCPC for psychiatric observation. On April 13, she was admitted, although UNMCPC staff noted that her suicidal claims had been an attempt to divert attention from the sexual abuse investigation. Regardless, her treating psychiatrist (Dr. Del Fabbro) believed that M.T. had genuine hallucinations and depression, with possible schizophrenia. Dr. Del Fabbro contacted Mrs. Thomas requesting consent to administer psychotropic medications. Mrs. Thomas again refused, citing the desire to explore alternative treatments. On April 16, Dr. Del Fabbro contacted Mrs. Thomas and repeated the request to administer psychotropic medications, and permission was again denied.

On April 20, a psychological evaluation was conducted by Dr. Mary Kaven, who diagnosed major depressive disorder, borderline personality disorder, and early-onset schizophrenia in M.T. M.T's therapist, Dr. Jill Straits, contacted Mrs. Thomas and revealed the findings of the evaluation, telling Mrs. Thomas that the doctors also believed M.T. had an intellectual disability due to the combination of schizophrenia, mental disability, and childhood petit mal seizures. Throughout the hospitalization, Mrs. Thomas informed different treatment staff that her daughter was not a behavioral problem and was an honor roll student. On April 26, Dr. Del Fabbro again contacted Mrs. Thomas requesting permission to administer medications, which Mrs. Thomas denied. In the following several days, Dr. Strait contacted CYFD two times and ultimately accused Mrs. Thomas of medical neglect for not allowing the administration of medications.

On April 29, Mrs. Thomas met with the treatment providers but reported that she did not believe her daughter was suicidal or had hallucinations; she again refused consent for medication. Dr. Del Fabbro informed Mrs. Thomas that she did not believe Mrs. Thomas was competent to make medical decisions on her child's behalf. Following the interaction, Dr. Del Fabbro placed M.T. on a medical hold to prevent her from being released and then contacted CYFD to report medical neglect by M.T.'s parents for failing to consent to medication. Dr. Del Fabbro then petitioned for involuntary residential treatment with the state court and a hearing was scheduled. However, before the hearing on May 5, Dr. Strait contacted Mrs. Thomas, telling her to pick up her daughter immediately because their insurance carrier would no longer cover the treatment costs. The clinicians indicated that there was an adequate safety plan to discharge M.T., who was discharged on May 6. The commitment order was discontinued at that time.

Mr. and Mrs. Thomas filed suit under 42 U.S.C. § 1983 (2000) against the treating clinicians, citing Fourteenth Amendment rights to familial association and to direct their child's medical care. The clinicians cited their right to absolute immunity (i.e., complete immunity from legal retaliation) and qualified immunity (i.e., immunity from liability for civil damages as long as constitutional or statutory rights were not violated) and filed a motion to dismiss. The United States District Court for the District of New Mexico granted the motion, and the case was dismissed. Mr. and Mrs. Thomas appealed to the Tenth Circuit Court of Appeals.

Ruling and Reasoning

The Tenth Circuit held that treating physicians were not entitled to absolute immunity. The court ruled that Mr. and Mrs. Thomas' claim that allegations of medical neglect, which interfered with their right to direct their child's medical care, were not clearly established and their assertion that their right to familial association was violated when the defendants initiated a temporary medical hold was justified. Regarding absolute immunity, the court stated that this concept is applied to prosecutorial activities that are connected to the “judicial phase of the criminal process” (Thomas, p. 1191, quoting Imbler v. Pachtman, 424 U.S. 409 (1976)). To determine the applicability of absolute immunity, the court uses a functional approach and looks at the actions being performed, not the individual who is performing them. In addition, the court stated that the farther the function is from the judicial process, the less likely that absolute immunity will apply (Snell v. Tunnell, 920 F.2d 673 (10th Cir. 1990)). In the present case, the clinicians placed M.T. on a seven-day hold to prevent her possible discharge. The petition for involuntary commitment was filed five days later, and M.T. was discharged during that time. The court determined that Mr. and Mrs. Thomas were not injured by the commitment petition because it was never enacted. Instead, they were affected by the emergency medical hold, which was not by judicial order, and therefore did not qualify for absolute immunity. The court ruled that per the New Mexico Children's Code, treating clinicians who believe that a minor patient is going to be discharged against their best interests should contact a children's court attorney to issue an involuntary treatment order, thereby making the process judicial. The role of the clinician is to initiate a legal action by contacting the child's court attorney, who subsequently can petition to pursue involuntary commitment. The clinicians failed to follow these procedures and the failure additionally removed absolute immunity safeguards. The Tenth Circuit briefly addressed qualified immunity, but stated that this concept is usually applied to a summary judgment stage, not a dismissal stage. As there was insufficient information to make a determination, the issue was remanded.

Regarding the parents' right to direct their child's medical care, the court stated that the right is not absolute and “[W]hen a child's life or health is endangered by her parents' decisions, in some circumstances a state may intervene without violating the parents' constitutional rights” (Thomas, p. 1195, quoting PJ ex rel. Jensen v. Wagner, 603 F.3d 1182 (10th Cir. 2010)). However, Mr. and Mrs. Thomas argued that the allegations of neglect amounted to a violation of their right to direct their child's care and thus caused them harm. The court stated that M.T. was not committed to involuntary residential treatment, and therefore no violation of the parents' right to direct their child's medical care had occurred. The lower court had originally dismissed this claim, and the Tenth Circuit Court affirmed the dismissal.

Finally, Mr. and Mrs. Thomas claimed that their right to familial association was violated when the clinicians placed M.T. on an emergency medical hold and pursued involuntary residential treatment. The court again stated that the question was not about involuntary commitment, because there had been none. Instead the question pertained to the matter of the medical hold. The court stated that it did not appear the M.T. would have posed an imminent threat for suicide had she been discharged. In fact, on the day the petition for commitment was issued, there was no documentation showing M.T.'s risk for suicide. In order for the medical hold to be constitutionally justified and subsume the right to familial association, an imminent risk of suicide must be present. The court ruled that it was the clinicians' responsibility to show the imminence or seriousness of M.T.'s suicidal threats during the seven-day emergency hold, which they had not done. M.T. was released as soon as staff at UNMCPC discovered that insurance would not cover the cost of her treatment. As a result, the court determined that the clinicians had violated clearly established laws regarding the right of familial association.