Rennie v. Klein, 462 F. Supp. 1131
Key Issue: An involuntarily committed mental patient has a qualified constitutional right to refuse psychotropic medication
An involuntarily committed patient who has not been found incompetent, absent an emergency, has a qualified right to refuse psychotropic medication. New Jersey's administrative policies, which provide for a second psychiatric opinion in the case of refusing patients, give adequate scope for the exercise of that right to satisfy constitutional requirements.
This case, the first to establish an involuntarily committed patient's right to refuse medication, was brought in December 1977 by 38 year old John Rennie, a patient at Ancora State Hospital in New Jersey. A former pilot and flight instructor, described as highly intelligent, Rennie did not show signs of mental illness until he was 31. His first hospitalization occurred in 1973 and in the following years he became a revolving door patient, with one of the reasons, trial judge Stanley Brotman noted, "his failure to continue taking medications after he has left the hospital's custody." Variously diagnosed as suffering from paranoid schizophrenia and manic-depression, Rennie had persistent religious delusions (he thought he was Christ) and suicidal ideas. His eighth hospitalization was initiated after he threatened to kill President Ford. On subsequent hospitalizations he became increasingly abusive and assaultive.
In late December 1977, during his twelfth hospitalization, a lengthy one beginning on August 10, 1976 (in which various drugs were tried with uneven results), Rennie sued in federal district court to enjoin the hospital from administering psychotropic medications to him in the absence of an emergency. (Office of the Public Advocate brought the case one branch of state government was suing another.) Judge Brotman describes the precipitating factors in his decision. Earlier in the month, Rennie had become homicidal and staff felt his condition was deteriorating. To prevent Rennie from harming other patients, staff and himself, the treatment team administered prolixin decanoate, an injectable long-acting drug, on the basis that, given his history of failing to take medication once released, it would be the easiest drug on which to maintain him post-release. Following initiation of the prolixin regime, Rennie's condition improved markedly.
Judge Brotman responded to Rennie's appeal for an injunction by a compromise: rather than enjoining the hospital from giving him any medication, he insisted the prolixin be lowered to a minimum maintenance dosage, which staff psychiatrists considered insufficient. He then conducted fourteen days of hearings between January 13 and April 28, 1978.
Several months after issuing his initial ruling (asserting a right to refuse treatment grounded in a constitutional right to privacy), Judge Brotman expanded the case into a class action, including all involuntarily committed patients at the five mental health facilities operated by the state and held an additional seventeen days of hearings.
Federal District Judge Stanley Brotman dismissed the argument of Rennie's counsel that forced medication violated the First Amendment (by interfering with his mental processes) and the Eighth Amendment (constituting cruel and unusual punishment). However, he ruled that the right to refuse treatment can be based on an "emerging right of privacy" broad enough to include the "right to protect one's mental processes from governmental interference." Judge Brotman asserted that the uncertainty of psychiatric diagnoses gave weight toward "leaving the final decision with the patient rather than deferring to doctors." "Whether the potential benefits are worth the risks is a uniquely personal decision which, in the absence of a strong state interest, should be free from state coercion."
Nevertheless, said Judge Brotman, the right to refuse was not absolute. Other patients in the hospital had the right to protection from harm from an assaultive patient like Rennie. The state's parens patriae powers also came into play, but only to the extent a factfinder determined that the patient's refusal was based on the underlying illness. The more the patient lacked insight the greater the impetus to override his right to autonomy.
In March 1978, in an attempt to provide a mechanism for a limited right to refuse treatment, the Division of Mental Health promulgated Administrative Bulletin 78-3, which provided that a refusing patient (who had not been found legally incompetent) would be entitled to review of his case by the treatment team and then, if he still refused, by the medical director or his designee. Particularly when there was disagreement, the medical director was authorized to retain an independent psychiatric consultant.
In his decision Judge Brotman indicated he was not satisfied with this mechanism, stipulating that a refusing patient was entitled to a due process hearing conducted by an independent psychiatrist. Judge Brotman also asserted that the principle of the least restrictive alternative should be extended to medication: hearing officers should insist that the least restrictive medications should be tried prior to more intrusive medications. The basis on which medications would be ranked in order of intrusiveness is not specified, although Judge Brotman clearly found lithium less intrusive than the psychotropic drugs.
On expanding the case into a class action suit several months after his initial decision, Judge Brotman reiterated his finding that all involuntary patients in New Jersey state hospitals had a right to a due process hearing before drugs could be administered against their will and this time established specific procedures. Prior to being given medication, patients would have to sign consent forms that explained their side effects. Hospitals had to employ "patient advocates" who would act as "informal counsel" to patients wishing to refuse treatment in hearings before independent psychiatrists. Judge Brotman established a category of "functionally incompetent" patients -- patients who were not legally incompetent but could be certified by their physician as "unable to provide knowledgeable consent to treatment."
Judge Brotman's decisions were appealed. The Third Circuit Court upheld the existence of a qualified constitutional right to refuse treatment as well as Judge Brotman's order that the least restrictive alternative concept by applied to choice of medications. On the other hand, it determined that the state's administrative policy (reflected in Bulletin 78-3) was constitutionally sufficient (and the hearings demanded by Judge Brotman were not required).
The U.S. Supreme Court granted certiorari but then remanded the case to the Third Circuit with instructions to reconsider it in light of the high court's decision in Youngberg v. Romeo (which concerned a severely retarded young man's "right to treatment)." In part the Third Circuit reaffirmed its earlier findings that there was a qualified right to refuse and New Jersey's administrative bulletin made adequate provision for the exercise of that right. But it ruled that in light of the Supreme Court's decision in Youngberg, least restrictive alternative was not a concept that could be mandated for treatment. The Supreme Court had called for treatment based on "accepted professional judgment" in Youngberg, and the Third Circuit ruled that this meant psychiatrists should be free to make treatment decisions on that basis.
The Third Circuit remanded to the district court where it all began, which then simply ordered all parties to comply with Administrative Bulletin 78-3.
At the end of the day (when the review process was over) Rennie v. Klein established that an involuntarily committed, legally competent patient who refused medication had a right to professional medical review of the treating psychiatrist's decision. In contrast to the Rogers case, which provided for judicial review, Rennie left the decision-making process to medical professionals.
The end-result of the Rennie case was to establish a reasonable mechanism for dealing with patients who refused treatment. That mechanism was established by the Department of Mental Health through its Administrative Bulletin 78-3 at the beginning of the case, and if Judge Brotman had accepted it at the time, the end-result would have been achieved at the outset and not required five years of litigation. Critics have pointed out that the method has flaws -- it gives the final decision to a person who often has only a single contact with the patient and who will have no responsibility for the patient's care. But proponents have argued that in practice the New Jersey model leads to more "negotiations" between patient and psychiatrist, that is, psychiatrists are more ready to listen to the patient's complaints about medication and adapt to them, sometimes with lower doses, sometimes with trials of alternative medication. Unfortunately, despite the Supreme Court's backing for the professional judgment standard, it is not the Rennie, but the Rogers model, which shifts psychiatric decision-making from the medical to the legal profession, that has become prevalent.
But if the Rennie case had a reasonable conclusion, at the trial level it was a nightmare, showing how judicial micro-management of what was properly medical decision-making produced chaos. While he made obeisance to the effectiveness of anti-psychotic medications (which was repeatedly affirmed by medical experts during the hearings), in his rulings Judge Brotman was clearly far more sensitive to the negative side effects of medications than to the destructive impact of the illnesses they addressed. Indeed he said in his decision (in the class action suit) that as a result of the right to refuse "a significant number of patients will receive less or no medication, frequently to their benefit." It was this underlying attitude that led him to mandate the principle of least restrictive alternative for medication decisions (fortunately eliminated on final remand to the Third Circuit). Psychiatrists were not to give patients the most effective treatment but the "least intrusive" one. In the Rennie case, Judge Brotman in effect became chief psychiatrist, calling together various psychiatrists who had examined Rennie, picking and choosing between their recommendations, always with the goal of selecting what he arbitrarily decided was the "least intrusive" medication.
As Rennie's condition deteriorated, psychiatrists ran back and forth to Judge Brotman. Rennie grew progressively worse and eventually rejected lithium (which he agreed to take for awhile) as well. By November 1978 he was acutely psychotic, manic and assaultive, and spent most of his time in restraints. In December 1978, a year after the case was brought, the hospital was administering thorazine on an emergency basis (he had also become so dehydrated doctors testified his life was in danger). This time, when Rennie again sought a restraining order against the hospital's medicating him, Judge Brotman decided that Rennie was not just motivated by a rational dislike of side effects of the medication but by "an irrational desire to rebel against the hospital and its doctors." He determined there was no less restrictive alternative to thorazine "other than constant restraints." For the hospital, for other patients, for staff, and above all for Rennie himself, Judge Brotman's yearlong experiment of wearing a white coat over his black robes in pursuit of the chimera of the least restrictive treatment was a disaster.
There was one good feature of Judge Brotman's decision that
has unfortunately not subsequently been widely utilized. Judge Brotman established a
category of "functionally incompetent" patients. These were patients who had not
been found incompetent by the courts but whom the psychiatrist determined were unable to
make their own treatment decisions because of lack of insight into their illness. This is
precisely the situation of a great many psychiatric patients and recognizing this and
providing a simple way to identify and then treat these patients would go a long way in
reducing the arbitrary roadblocks that have been thrown up to treatment for those most in
need of it.
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