Jurasek v. Utah State Hospital, 158 F. 3d 506 (10th Cir. 1998)
Key Issue: "The Due Process clause allows a state hospital to forcibly medicate a mentally ill patient who has been found incompetent to make medical decisions if the patient is dangerous to himself or others and the treatment is in the patient's medical interests."
The U.S. Tenth Circuit Court of Appeals upheld the federal district court's grant of summary judgment in favor of Utah State Hospital on the grounds that the hospital's medical review procedures were adequate to forcibly medicate a mentally ill patient who was gravely disabled (and hence dangerous to himself) and who had been found -- as a precondition for commitment -- incompetent to make his own medical decisions.
Jan Jurasek, suffering from paranoid schizophrenia, was committed to Utah State Hospital in April 1991. Originally committed for six months, his commitment was extended by the courts and in 1997, when the federal district court made its decision, was still hospitalized. From the beginning Jurasek objected to treatment with psychotropic drugs, bringing suit in September 1991 both for injunctive relief from forced medication and for damages. He argued that in being subjected to forced medication his Fourteenth Amendment due process and First Amendment free expression rights under the Constitution were being violated.
The hospital had varied its policies on involuntary medication since 1991, but at the time of the court hearing, patients could be forcibly injected with psychotropic drugs if the hospital's involuntary medication hearing committee, composed of a psychiatrist, psychologist and the hospital program administrator, decided "the patient is, or will be, gravely disabled and in need of medication treatment or continuing medication treatment" or "without the medication treatment or continuing medication treatment, the patient poses or will pose, a likelihood of serious harm to himself/herself, others, or their property."
The federal district court granted summary judgment in favor of the hospital and the Circuit Court of Appeals upheld the lower court's decision, agreeing there was "no genuine issue as to any material fact."
The Circuit Court quoted from the U.S. Supreme Court's decision in Washington v. Harper (1990) in which the Court ruled that the state could "treat a prison inmate who has a serious mental illness with antipsychotic drugs against his will if the inmate is dangerous to himself or others and the treatment is in the inmate's medical interest." The Circuit Court dismissed the argument that a civilly committed individual was entitled to greater due process protection than a prisoner on the grounds that treatment was not punishment: therefore there was no need "to provide involuntarily committed patients with greater due process protection than prisoners." The Circuit Court noted that "unlike prisoners, involuntarily committed patients have been adjudicated incompetent in a prior formal proceeding, thereby minimizing the potential for any abuse."
The Circuit Court responded to Jurasek's objection that he had been treated on the grounds of grave disability (rather than because he was dangerous) by noting that the U.S. Supreme Court decision in Riggins v. Nevada (1992) "implicitly authorizes the forced medication of involuntarily committed individuals designated as 'gravely disabled' under the definition at issue here" and that in any event under the hospital's policy, "gravely disabled" included a determination that the patient was dangerous to himself. The Court was satisfied with the hospital's policy of appointing an involuntary medication hearing committee.
As for Jurasek's claim that he was entitled to a separate hearing to adjudicate his competency to make medical decisions, the Circuit Court disagreed. It asserted that the commitment court's finding, when it committed Jurasek for six months and when it extended his commitment after the six months were up, that Jurasek "lacked the ability to engage in a rational decision making process regarding the acceptance of mental treatment' constitutes a finding that Jurasek is incompetent to make medical decisions on his own behalf."
In response to Jurasek's argument that treatment was not in his medical best interests because he did not respond to medication, the Circuit Court noted that the hospital conceded the drugs were not effective in curtailing his psychotic symptoms but did have the effect of decreasing their intensity. The Court ruled: "The fact that a particular method of treatment fails to yield the type of results officials envisioned does not mean the treatment is inconsistent with the patient's medical best interests. In sum, the evidence in the record is uncontroverted that psychotropic drugs have been, at all times, at least partially beneficial in Jurasek's treatment."
This is an extremely important decision. A federal circuit court of appeals, in a case involving a civilly committed patient (not a prisoner), has affirmed a hospital's right to medicate a gravely disabled patient involuntarily when it finds this to be in his medical best interests. The case thus runs counter to the tenor of a series of decisions in state courts over the past two decades which have steadily expanded the right of civilly committed patients to refuse treatment. It is a mark of the significance of the case that the Bazelon Center for Mental Health Law in Washington (formerly the Mental Health Law Project), the chief legal proponent for expanding the rights of mental patients to refuse treatment, acted as Jurasek's attorney.
The case is significant for another reason. Utah is the only state where the court must find the patient incompetent to make his own treatment decisions as a condition for committing him. Utah commitment statutes stipulate that the court can only commit a patient whom it finds "lack[s] the ability to engage in a rational decisionmaking process regarding the acceptance of mental treatment." Utah Code Ann 62 A-12-234(c) (Supp.1992). In other states the patient's presumed legal competence to make his own treatment decisions, even after he has been committed, has been the lever used by advocates of expanding rights of mental patients to throw up impediments to involuntary treatment, notably by requiring new court hearings on the issue of the patient's competence, with their attendant expense and long delays. In its decision, the Circuit Court of Appeals repeatedly emphasized that Jurasek had been found incompetent to make his own treatment decisions both at the time of his initial commitment and when his commitment was extended by the court. The Jurasek decision thus means that state laws requiring a court finding that the patient is incompetent to make treatment decisions as a condition for commitment will stand up to a federal constitutional test.
The landmark Jurasek decision is testimony to the importance of changing the laws of other states to conform to the key characteristic of Utah law: to provide that the court must find the patient incompetent to make his own treatment decisions during the initial commitment proceedings. It should serve as a wake up call to advocates for treatment to push for the incorporation of this provision in the laws of the other 49 states. The Jurasek decision is also interesting for what it does not contain-- there is no litany of the terrible side effects of psychotropic drugs or the supposed corrosive effects of the drugs on personality and the ability to think. These have become almost standard in judicial decisions in right to refuse treatment cases, a product of the bench's dependence for its understanding of mental illness on articles in law journals, almost all of them written by members of the civil libertarian mental health bar. The Circuit Court's attitude in this case is the more interesting in that no one claimed that the medications, in Jurasek's case, did more than dampen his psychosis -- administered over six years, they had not improved his condition sufficiently for him to leave the hospital.
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