Opinion issued July 16, 2009
In The
Court of Appeals
For The
First District of Texas
NO. 01-09-00205-CV
M.H., Appellant
V.
THE STATE OF TEXAS FOR THE BEST INTEREST AND PROTECTION OF M.H., Appellee
On Appeal from the County Court at Law
Cherokee County, Texas
Trial Court Cause No. 37240
MEMORANDUM OPINION
Appellant M.H. appeals a trial court order authorizing the administration of psychoactive medications to her. In two issues, M.H. argues that the evidence presented at the hearing was legally and factually insufficient to sustain the trial court's order.
We affirm the judgment of the trial court.
Background
M.H. was involuntarily committed to the Rusk State Hospital for Bipolar I disorder with severe manic and psychotic features. Dr. Larry Hawkins, M.H.'s treating physician, reviewed M.H.'s medical records and found that M.H. had previously used the following classes of medications: anti-depressants, anti-psychotics, mood stabilizers, and sedatives. He also found that M.H.'s symptoms improved after she used the medications. Dr. Hawkins twice attempted to discuss the proposed treatment with M.H., but she refused to allow him to administer it. He filed an application with the trial court to authorize him to administer the proposed treatment.
The trial court hearing on the application began on January 27, 2009. At the hearing, the State presented testimony from Dr. Hawkins. Dr. Hawkins testified that the proposed treatment was in M.H.'s best interest and that she lacked the capacity to make a decision regarding administration of psychoactive medications. He testified that M.H. has a "very manic illness, and the mania itself has some grandiosity and hyper-religious character to it." M.H. was arrested because she caused a public disturbance at a convenience store by loudly preaching at customers. After the public disturbance, police took M.H. to a hospital. M.H. was transferred and committed to Rusk State Hospital.
Dr. Hawkins testified that M.H. told him she had a religious objection to the proposed treatment. She told Dr. Hawkins that she is a Jehovah's Witness and that the proposed treatment conflicts with Witness doctrine. Dr. Hawkins testified that M.H. was inconsistent in her religious objections to the medications, however, because she allowed him to administer psychoactive medications to help her sleep. He also testified that M.H. is "verbally aggressive." Also, she is a danger to herself because she incites other people to potential violence, due to her verbal aggression. As Dr. Hawkins was testifying, M.H. exclaimed that his testimony was "all documented lies." Dr. Hawkins then testified that, on January 26, 2009, M.H. participated in a Bible discussion with other Rusk patients and created a disturbance during the discussion. M.H. then exclaimed that Dr. Hawkins had "just grieved the holy spirit. He just took it to Jehovah."
On cross-examination, M.H.'s attorney asked Dr. Hawkins if M.H. "indicated to you that she is a Native American" and that "in the culture in which she was raised, natural remedies were used as an alternative to medications." Dr. Hawkins testified that M.H. did not indicate to him that her ethnic background was Native American and that her background had influenced her decision to refuse the proposed treatment. Dr. Hawkins testified that M.H. proposed that he administer natural remedies instead of the psychoactive medications. He stated that "natural remedies don't help mania" and that the proposed treatment would help M.H.'s manic episodes. Dr. Hawkins also testified that he was unable to discuss the risks and benefits of the medications with M.H. because "she becomes quite agitated." During his testimony, M.H. interjected that she was not manic, psychotic, or delusional. She stated that Dr. Hawkins' treatment was "medical malpractice and insurance fraud." M.H. also stated that the trial court was "guilty of grieving the holy spirit" and that she would appeal the trial court's order to the supreme court. The trial court ordered that M.H. be removed from the courtroom. M.H. did not testify at the hearing. The trial court issued an order authorizing administration of psychoactive medications. M.H. gave notice of appeal.
Legal and Factual Sufficiency of the Evidence M.H. does not contest the trial court's order that she receive inpatient mental health services. She challenges only a subsequent trial court order authorizing the administration of psychoactive medications. She argues in two issues that the evidence is legally and factually insufficient to show by clear and convincing evidence either that she lacked the capacity to make a decision regarding the administration of the proposed medication or that the proposed medication plan was in her best interest.
Standard of Review
In a legal sufficiency review when the burden of proof is clear and convincing evidence, the court should look at all the evidence in the light most favorable to the finding to determine whether a reasonable trier of fact could have formed a firm belief or conviction that its finding was true. In re J.F.C., 96 S.W.3d 256, 266 (Tex. 2002); see also State v. Addington, 588 S.W.2d 569, 570 (Tex. 1979) ("Clear and convincing evidence is defined as that measure or degree of proof that will produce in mind of the trier of fact firm belief or conviction as to truth of allegations sought to be established"); State ex rel. E.G., 249 S.W.3d 728, 730-31 (Tex. App.--Tyler 2008, no pet.). Looking at the evidence in the light most favorable to the judgment means that we must assume that the fact finder resolved disputed facts in favor of its finding if a reasonable fact finder could do so. In re J.F.C. 96 S.W.3d at 266. We should disregard all evidence that a reasonable fact finder could have disbelieved or found to have been incredible. Id. If, after conducting a legal sufficiency review, we determine that no reasonable fact finder could have formed a firm belief or conviction that the matter to be proven was true, we must conclude that the evidence is legally insufficient. Id.
In a factual sufficiency review, we must give due consideration to evidence that the fact finder could reasonably have found to be clear and convincing. Id. [T]he inquiry must be "whether the evidence is such that a fact finder could reasonably form a firm belief or conviction about the truth of the State's allegations." Id. (quoting In re C.H., 89 S.W.3d 17, 25 (Tex. 2002)). We should consider whether disputed evidence is such that no reasonable fact finder could have resolved the disputed evidence in favor of the finding. Id. If, in light of the entire record, the disputed evidence that no reasonable fact finder could have credited in favor of the finding is so significant that a fact finder could not reasonably have formed a firm belief or conviction about the truth of the State's allegations, then the evidence is factually insufficient. Id. We should detail in our opinion why we conclude that a reasonable fact finder could not have credited disputed evidence in favor of the finding. Id. at 266-67.
Texas Health and Safety Code Section 574.106
Texas Health and Safety Code section 574.106 states, in relevant part:
(a) The court may issue an order authorizing the administration of one or more classes of psychoactive medication to a patient who:
(1) is under a court order to receive inpatient mental health services; (1) or
(2) is in custody awaiting trial in a criminal proceeding and was ordered to receive inpatient mental health services in the six months preceding a hearing under this section.
(a-1) The court may issue an order under this section only if the court finds by clear and convincing evidence after the hearing:
(1) that the patient lacks the capacity to make a decision regarding the administration of the proposed medication and treatment with the proposed medication is in the best interest of the patient; or
(2) if the patient was ordered to receive inpatient mental health services by a criminal court with jurisdiction over the patient, that:
(A) the patient presents a danger to the patient or others in the inpatient mental health facility in which the patient is being treated as a result of a mental disorder or mental defect as determined under Section 574. 1065; (2) and
(B) treatment with the proposed medication is in the best interest of the patient.
(b) In making the finding that treatment with the proposed medication is in the best interest of the patient, the court shall consider:
(1) the patient's expressed preferences regarding treatment with psychoactive medication;
(2) the patient's religious beliefs;
(3) the risks and benefits, from the perspective of the patient, of taking psychoactive medication;
(4) the consequences to the patient if the psychoactive medication is not administered;
(5) the prognosis for the patient if the patient is treated with psychoactive medication;
(6) alternative, less intrusive treatments that are likely to produce the same results as treatment with psychoactive medication; and
(7) less intrusive treatments likely to secure the patient's agreement to take the psychoactive medication.
Tex. Health & Safety Code Ann. § 574.106 (Vernon Supp. 2008).
Capacity to Make Decision
M.H. argues that the State failed to prove by clear and convincing evidence that she did not have the capacity to make a decision regarding the administration of the proposed medication as required by section 574.106 (a-1)(1). She argues that her ability to state her name during the court proceedings indicates "an awareness of her situation as well as an ability to express her preferences and make a decision whether to undergo the proposed treatment." She also argues that the State's expert, Dr. Hawkins, failed to explain why he determined that M.H. lacked the capacity to make a decision regarding her medication.
Capacity in this context means the patient's ability to understand the nature and consequences of a proposed treatment, including the benefits, risks, and alternatives therefrom, and to make a decision whether to undergo that treatment. Tex. Health and Safety Code Ann. § 574.101(1)(A), (B) (Vernon 2003); see In re C.S., 208 S.W.3d 77, 84 (Tex. App.--Fort Worth 2006, pet. denied) (holding evidence legally sufficient to establish that patient lacked capacity to make decision regarding administration of proposed medications and that treatment with proposed medications was in her best interest, so as to authorize administration of psychoactive medications, when physician testified that while on medications patient did not require restraint and could be put in less restrictive setting, that patient suffered from delusions, that if treated with medication she might benefit from better quality of life, that her prognosis under treatment was positive, and that alternative to proposed treatment was electroconvulsive therapy); State ex rel. T.M., No. 12-05-00389, 2006 WL 1419416 , at *4 (Tex. App.--Tyler May 24, 2006, no pet.) (holding evidence factually sufficient to support trial court order authorizing administration of psychoactive medication when evidence of alleged mentally ill individual's belief that he did not need psychoactive medication and his religious preferences was not so significant that reasonable trier of fact could not have reconciled evidence in favor of its finding and formed firm belief or conviction that alleged mentally ill person lacked capacity to make decision regarding administration of proposed psychoactive medications and that proposed medications were in his best interest).
Here, the State's expert, Dr. Larry Hawkins, testified that he was M.H.'s treating physician. He testified that M.H. refused to take her medication because "she lacks the capacity to make a rational decision" regarding the proposed treatment of psychoactive medication. He testified that M.H. suffers from "Biopolar I, manic, severe, with psychotic features." He stated that when he initially attempted to discuss the proposed treatment with M.H., she told him that she could not take the medication due to her religious beliefs. M.H. claimed that she was a Jehovah's Witness and that the proposed treatment was inconsistent with Witness doctrine. However, Dr. Hawkins testified that hyper-religiosity is a feature of M.H.'s mental illness. Dr. Hawkins further testified that M.H. had been arrested because of a public disturbance she caused due to verbal aggression related to her behavior.
Dr. Hawkins further testified that M.H. is a danger to herself because her verbal aggression creates potentially violent responses from other people. He testified that M.H. has used the proposed treatment of medications previously and that the treatment had previously "[given] her the chance to become more well and in remission of her symptoms and her illness." He also testified that M.H.'s proposed alternative of "natural remedies" was ineffective.
On cross-examination, Dr. Hawkins testified that M.H. decided to take psychoactive medication for sleep. He also testified that he was unaware of her ethnic background as a Native American and its influence on her decision to take natural remedies rather than psychoactive medications.
Considering all the evidence in the light most favorable to the findings, we conclude that the evidence was legally sufficient to allow a reasonable fact finder to form a firm belief or conviction that M.H. lacked the capacity to make a decision regarding a proposed treatment of psychoactive medications. See Tex. Health & Safety Code Ann. § 574.106; In re J.F.C., 96 S.W.3d at 266; State ex rel. T.M., 2006 WL 1419416, at *3. Because M.H. presented no evidence disputing that she had lacked the capacity to make a decision regarding the proposed treatment, we conclude that the evidence was also factually sufficient to allow a fact finder to form a firm belief or conviction that appellant lacked capacity to make a decision. In re J.F.C., 96 S.W.3d at 266; State ex rel. T.M., 2006 WL 1419416 , at *4.
Best Interest of the Patient
M.H. also contends that the evidence presented at trial was legally and factually insufficient to prove that the proposed treatment with psychoactive medications was in her best interest. She argues that the trial court failed to consider her stated preferences, her religious beliefs, and the risks and benefits of the proposed treatment. See Tex. Health & Safety Code Ann. § 574.106(b)(1), (2), (3).
Here, the proposed treatment included the following classes of psychoactive medications: anti-depressants, anti-psychotics, mood stabilizers, and sedatives. The State's expert, Dr. Hawkins, presented testimony that M.H. had previously been admitted to inpatient mental health care and had been prescribed the medications proposed here. He testified that M.H. was discharged in a short period of time after the psychoactive medications were administered to her. Dr. Hawkins also testified that M.H.'s preferred treatment of natural remedies would be ineffective for her condition and that M.H. was inconsistent about whether to use psychoactive medications. M.H. had explained that her religious belief precluded her from using psychoactive medications, but she had agreed to use a psychoactive medicine designed as an aid for sleep. Dr. Hawkins testified that M.H. would benefit from the proposed treatment of psychoactive medications because she would "stay exactly the same as you see her right now" without the medications. He further testified that there were no alternative medications or treatments for her Bipolar I disorder with manic and psychotic features.
On cross-examination, Dr. Hawkins testified that, in her current state, M.H. is a danger to herself because her verbal aggression may incite other people to harm her. M.H. presented no evidence to dispute Dr. Hawkins's testimony. Considering the evidence in the light most favorable to the trial court order, we conclude that a reasonable fact finder could have formed a firm belief that the proposed treatment was in M.H.'s best interest. Tex. Health & Safety Code Ann. § 574.106; In re J.F.C. 96 S.W.3d at 266; In the Matter of C.S., 208 S.W.3d at 84-85; State ex rel. T.M., 2006 WL 1419416 , at *4. We hold, therefore, that the evidence presented at the hearing was legally and factually sufficient to support the trial court's order.
We overrule M.H.'s two issues.
Conclusion
We affirm the judgment of the trial court.
Evelyn V. Keyes
Justice
Panel consists of Justices Keyes, Hanks, and Bland.
1. See Tex. Health & Safety Code Ann. § 574.022 (Vernon 2003).
2.
(1) an assessment of the patient's present mental condition;
(2) whether the patient has inflicted, attempted to inflict, or made a serious threat of inflicting substantial physical harm to the patient's self or to another while in the facility; and
(3) whether the patient, in the six months preceding the date the patient was placed in the facility, has inflicted, attempted to inflict, or made a serious threat of inflicting substantial physical harm to another that resulted in the patient being placed in the facility.
Tex. Health & Safety Code Ann. § 574.1065 (Vernon Supp. 2008).