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 fromforced 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 theConstitution were being violated.
The hospital had varied its policies on involuntarymedication since 1991, but at the time of the court hearing, patients could be forciblyinjected with psychotropic drugs if the hospital’s involuntary medication hearingcommittee, composed of a psychiatrist, psychologist and the hospital programadministrator, decided “the patient is, or will be, gravely disabled and in need ofmedication treatment or continuing medication treatment” or “without themedication treatment or continuing medication treatment, the patient poses or will pose, alikelihood of serious harm to himself/herself, others, or their property.”
The federal district court granted summary judgment infavor 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’sdecision 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 drugsagainst his will if the inmate is dangerous to himself or others and the treatment is inthe inmate’s medical interest.” The Circuit Court dismissed the argument that acivilly committed individual was entitled to greater due process protection than aprisoner on the grounds that treatment was not punishment: therefore there was no need”to provide involuntarily committed patients with greater due process protection thanprisoners.” The Circuit Court noted that “unlike prisoners, involuntarilycommitted patients have been adjudicated incompetent in a prior formal proceeding, therebyminimizing the potential for any abuse.”
The Circuit Court responded to Jurasek’s objection that hehad 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 individualsdesignated as ‘gravely disabled’ under the definition at issue here” and that in anyevent under the hospital’s policy, “gravely disabled” included a determinationthat the patient was dangerous to himself. The Court was satisfied with the hospital’spolicy of appointing an involuntary medication hearing committee.
As for Jurasek’s claim that he was entitled to a separatehearing to adjudicate his competency to make medical decisions, the Circuit Courtdisagreed. It asserted that the commitment court’s finding, when it committed Jurasek forsix 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 theacceptance of mental treatment’ constitutes a finding that Jurasek is incompetent to makemedical decisions on his own behalf.”
In response to Jurasek’s argument that treatment was not inhis medical best interests because he did not respond to medication, the Circuit Courtnoted that the hospital conceded the drugs were not effective in curtailing his psychoticsymptoms but did have the effect of decreasing their intensity. The Court ruled: “Thefact that a particular method of treatment fails to yield the type of results officialsenvisioned does not mean the treatment is inconsistent with the patient’s medical bestinterests. In sum, the evidence in the record is uncontroverted that psychotropic drugshave been, at all times, at least partially beneficial in Jurasek’s treatment.”
This is an extremely important decision. A federal circuitcourt of appeals, in a case involving a civilly committed patient (not a prisoner), hasaffirmed a hospital’s right to medicate a gravely disabled patient involuntarily when itfinds this to be in his medical best interests. The case thus runs counter to the tenor ofa series of decisions in state courts over the past two decades which have steadilyexpanded the right of civilly committed patients to refuse treatment. It is a mark of thesignificance 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 therights of mental patients to refuse treatment, acted as Jurasek’s attorney.
The case is significant for another reason. Utah is theonly state where the court must find the patient incompetent to make his own treatmentdecisions as a condition for committing him. Utah commitment statutes stipulate that thecourt can only commit a patient whom it finds “lack[s] the ability to engage in arational decisionmaking process regarding the acceptance of mental treatment.” UtahCode Ann 62 A-12-234(c) (Supp.1992). In other states the patient’s presumed legalcompetence to make his own treatment decisions, even after he has been committed, has beenthe lever used by advocates of expanding rights of mental patients to throw up impedimentsto involuntary treatment, notably by requiring new court hearings on the issue of thepatient’s competence, with their attendant expense and long delays. In its decision, theCircuit Court of Appeals repeatedly emphasized that Jurasek had been found incompetent tomake his own treatment decisions both at the time of his initial commitment and when hiscommitment was extended by the court. The Jurasek decision thus means that state lawsrequiring a court finding that the patient is incompetent to make treatment decisions as acondition for commitment will stand up to a federal constitutional test.
The landmark Jurasek decision is testimony to theimportance of changing the laws of other states to conform to the key characteristic ofUtah law: to provide that the court must find the patient incompetent to make his owntreatment decisions during the initial commitment proceedings. It should serve as a wakeup call to advocates for treatment to push for the incorporation of this provision in thelaws of the other 49 states. The Jurasek decision is also interesting for what it does notcontain– there is no litany of the terrible side effects of psychotropic drugs or thesupposed corrosive effects of the drugs on personality and the ability to think. Thesehave become almost standard in judicial decisions in right to refuse treatment cases, aproduct of the bench’s dependence for its understanding of mental illness on articles inlaw journals, almost all of them written by members of the civil libertarian mental healthbar. The Circuit Court’s attitude in this case is the more interesting in that no oneclaimed 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 toleave the hospital.