In re L.A. (2005-368)
2006 VT 118
[Filed 17-Nov-2006]
NOTICE: This opinion is subject to motions for reargument under
V.R.A.P. 40 as well as formal revision before publication in the Vermont
Reports. Readers are requested to notify the Reporter of Decisions,
Vermont Supreme Court, 109 State Street, Montpelier, Vermont 05609-0801 of
any errors in order that corrections may be made before this opinion goes
to press.
2006 VT 118
No. 2005-368
In re L.A. Supreme Court
On Appeal from
Washington Family Court
May Term, 2006
Matthew I. Katz, J.
John J. McCullough III and Laura A. Gans of Vermont Legal Aid, Inc.,
Waterbury, for Appellant.
William G. Sorrell, Attorney General, Montpelier, and David Bond, Assistant
Attorney General, Burlington, for Appellee.
PRESENT: Reiber, C.J., Dooley, Johnson, Skoglund and Burgess, JJ.
¶ 1. JOHNSON, J. Patient L.A. appeals from a family court
decision granting the Commissioner of the Department of Health's petition
for involuntary psychiatric medication. Patient argues that the trial
court erred by applying the wrong standard to determine whether he is
competent to refuse medication. The family court ruled that patient was
incompetent because he refused beneficial medications. We reverse and
remand for a new hearing because the involuntary medication statute
mandates that the family court decide whether patient is capable of making
a decision about medication and appreciating its consequences. Although
the family court made findings about L.A.'s mental illness, it did not make
findings about L.A.'s capacity to make the medication decision. Patient
also argues that the Religious Land Use and Institutionalized Persons Act
(RLUIPA) protects him from an order for involuntary medication because the
medications would interfere with the practice of his religious beliefs.
Because the Commissioner did not have a full opportunity to respond to this
issue, and in light of our remand, we reserve judgment on patient's RLUIPA
claim.
¶ 2. Patient is a sixty-four-year-old man who has been diagnosed
with bipolar disorder, currently manic with psychotic features, and
alcoholism. On April 15, 2005, patient was committed to the Vermont State
Hospital (VSH) after having been arrested in Burlington for disorderly
conduct. Although doctors have prescribed patient a regimen of psychiatric
medications, he has refused to take them throughout his commitment. On
June 29, 2005, the Commissioner filed a petition for involuntary medication
pursuant to 18 V.S.A. § 7624. As the statute requires, the family court
held an evidentiary hearing on the issue of patient's competence. 18 V.S.A.
§ 7625(a).
¶ 3. At the hearing, the Commissioner presented the testimony of Dr.
Munson, patient's treating psychiatrist at VSH. Dr. Munson described
patient's diagnoses and symptoms, including persistently elevated mood,
hyperactivity, rapid speech, delusions, and threatening and sexually
explicit interactions. Dr. Munson testified that he believed patient would
pose a danger to himself or others outside the hospital, but conceded that
he did not believe patient was particularly dangerous in the controlled
environment at VSH. According to Dr. Munson, patient should be on a
regimen of mood stabilizers, anti-psychotics, and side-effect medications.
He believes patient is incapable of rationally evaluating the risks and
benefits of the medications, and is incompetent to make decisions regarding
his medication.
¶ 4. Patient testified on his own behalf at the hearing, and
described his objections to taking the medications. First, according to
patient, he is "not a sick man." Patient did testify, however, that he
understands that Dr. Munson believes that he is sick and that the
medications would help him. He also acknowledged that the staff and even
some of the patients at VSH have advised him that taking his medications
would likely hasten his discharge. According to patient's testimony,
though, he is concerned about how the medications will "affect" him.
Patient described "a splendid relationship within [himself] and with the
spiritual being that flows through [him]." According to patient, the
medications would affect his "expression," thereby hindering his spiritual
life. Finally, patient expressed concern about the physical side effects
that accompany many psychiatric medications, including symptoms that mimic
Parkinson's disease.
¶ 5. The family court made several factual findings based on the
evidence presented at the hearing. The court found that patient suffers
from bipolar disorder and alcoholism, and is delusional. It listed certain
of patient's specific delusions, such as his apparent beliefs that he is
the Prophet Elijah, and that he controls a submarine capable of firing
missiles. The court also concluded that patient is dangerous at least some
of the time. Based on patient's psychiatric symptoms and the effectiveness
of medication in treating them, the court found that patient's
prescriptions were warranted. Finally, the court concluded that patient
did not demonstrate a specific religious objection to the medications.
According to the court: "Insofar as he refuses altogether the medications
that might benefit him, Patient is not competent to make a decision
regarding the proposed regimen of treatment."
I.
¶ 6. Patient first argues that the family court used the wrong
standard to determine that he is incompetent to refuse medication. We
agree that the family court failed to apply the standard articulated in the
statute, "whether the person is able to make a decision and appreciate the
consequences of that decision." 18 V.S.A. § 7625(c).
¶ 7. Under 18 V.S.A. § 7624(a), the Commissioner may file a
petition with the family court for the involuntary medication of patients
who refuse to accept them. The Commissioner bears the burden of proving
patient's incompetence by clear and convincing evidence. Id. § 7625(b).
The family court determines whether a person is competent to make decisions
regarding medication based on "whether the person is able to make a
decision and appreciate the consequences of that decision." Id. § 7625(c).
The statute further provides, "[i]t is the intention of the general
assembly to work towards a mental health system that does not require
coercion or the use of involuntary medication." Id. § 7629(c).
¶ 8. If the court finds the patient competent, the petition is
dismissed, and he may continue to refuse medication as he wishes. Id. §
7627(d). If, on the other hand, the court finds the patient incompetent,
the court goes on to:
consider at a minimum, in addition to the person's expressed
preferences, the following factors:
(1) The person's religious convictions and whether they contribute
to the person's refusal to accept medication.
(2) The impact of receiving medication or not receiving medication
on the person's relationship with his or her family or household
members whose opinion the court finds relevant and credible based
on the nature of the relationship.
(3) The likelihood and severity of possible adverse side effects
from the proposed medication.
(4) The risks and benefits of the proposed medication and its
effect on:
(A) the person's prognosis; and
(B) the person's health and safety, including any pregnancy
(5) The various treatment alternatives available, which may or may
not include medication.
Id. § 7627(c). If the above factors support involuntary medication, "the
court shall make specific findings stating the reasons for the involuntary
medication by referencing those supporting factors." Id. § 7627(e).
¶ 9. Thus, the statute outlines two steps in deciding whether
involuntary medication is appropriate for a patient. In the first step,
the family court determines whether the patient is competent to refuse
medication. Second, the court considers, based on the factors outlined
in § 7627(e), the merits of involuntarily medicating the patient. Whereas
the first step is focused entirely on the patient's decision-making
ability, the second step is focused on the potential benefits and risks of
the medication. Therefore, there may be circumstances in which a competent
patient may refuse medication that would most likely benefit him.
Likewise, the family court could find a patient incompetent to refuse
medication, yet still conclude that involuntary medication is not
appropriate.
¶ 10. It is important to understand that, in the involuntary
medication context, the competence inquiry is dictated by the statutory
language. The standard is different, and more difficult for the
Commissioner to meet, from the standard for determining whether a person
may be involuntarily committed because the statute focuses solely on the
patient's decision-making abilities, as they may or may not be affected by
mental illness-not the fact of the patient's diagnosis alone, or the merits
of the psychiatrist's medical advice. If a mere diagnosis were the end of
the analysis, it would preclude the need for a petition procedure
altogether.
¶ 11. In this case, the family court concluded that "[i]nsofar as
[patient] refuses altogether the medications that might benefit him,
[p]atient is not competent to make a decision regarding the proposed
regimen of treatment." The court's reasoning, however, fails to address
the first step in the involuntary medication analysis. Every patient who
is the subject of a petition for involuntary medication has refused
prescribed medication. Indeed, the statute applies only to patients who
have refused medication. 18 V.S.A. § 7624. Thus, the fact that patient
has "refuse[d] altogether" the medication at issue can have no bearing on
his competence; otherwise, the statutory inquiry into competence would be
superfluous. See Judicial Watch, Inc. v. State, 2005 VT 108, ¶ 14, 16
Vt. L. Wk. 363, 892 A.2d 191 (stating that we will not interpret a statute
in a way that renders language surplusage).
¶ 12. Nor can it be relevant to the court's consideration of
patient's competence that the medications "might benefit" him. As
discussed above, the involuntary-medication analysis does not reach the
issue of whether medication is beneficial until the court has first
determined that a patient is incompetent to make a medication decision.
J.L. v. Miller, 174 Vt. 288, 291, 817 A.2d 1, 3 (2002) (noting that "upon a
finding of incompetence, the family court is required to determine whether
involuntary medication is supported by the factors enumerated in §
7627(c)"). The fact that the medication might benefit him-as is generally
expected of medication-cannot be enough to conclude that patient is
incompetent. The Legislature intended the statute as a step toward a
wholly voluntary system of psychiatric medication. 18 V.S.A. § 7629(c).
As long as patient can understand the consequences of refusing medication,
the statute permits him to do so, even if refusing medication will be to
his detriment. In other words, a person who is competent to make a
medication decision within the meaning of the statute has the same right as
any other person to refuse beneficial medication.
¶ 13. The Commissioner argues that § 7625(c) includes the inherent
condition that a patient's decision must be rational, and that the family
court implicitly determined that patient's decision was irrational. The
Commissioner asserts that we approved such a standard in In re R.L., 163
Vt. 168, 657 A.2d 180 (1995). In that case, we reviewed the family court's
decision regarding a patient's involuntary commitment to VSH. The patient
contested the Commissioner's petition for involuntary commitment on the
grounds that he was willing to accept treatment at VSH voluntarily. We
reasoned that the family court could consider the patient's capacity to
consent to treatment, including whether he was capable of making reasonable
judgments, in deciding whether voluntary commitment was appropriate. Id.
at 174-75, 657 A.2d at 184-85.
¶ 14. The Commissioner's reliance on In re R.L. in this case is
misplaced. Here, instead of involuntary commitment, we consider
involuntary medication, which is governed by an entirely different
standard. Whereas involuntary commitment ultimately depends on whether a
person has mental illness and poses a danger of harm to himself or others,
involuntary medication depends on a person's ability to make decisions and
appreciate their consequences. Compare 18 V.S.A. § 7101(17) (governing
involuntary commitment) with id. § 7625(c) (governing involuntary
medication). (FN1) The facts underlying a patient's involuntary commitment
cannot alone support involuntary medication. In this and many other cases,
involuntary commitment is a prerequisite to the Commissioner's petition for
involuntary medication. (FN2) Id. § 7624(a). Involuntary medication is an
even further intrusion on a patient's autonomy than involuntary commitment,
and the standards we have applied to commitment determinations are
inapposite.
¶ 15. We agree with the Commissioner, however, that the
consequences patient must be able to appreciate must be real, and not
imaginary or delusional. Nevertheless, the statute requires only that
patient appreciate those consequences, not that he make the best decision
in light of those consequences, or that he agree with his psychiatrist.
The family court and the Commissioner appear to assume that there is only
one competent choice patient could make-to follow his doctor's advice and
accept medication. Neither the court nor the Commissioner attempt to
discern what patient perceives as the consequences of his decision to
refuse medication. If patient's disagreement with his psychiatrist were
sufficient to find him incompetent, the family court would have to grant
every petition for involuntary medication filed by the Commissioner.
¶ 16. Without conceding that the family court employed the wrong
standard, the Commissioner urges us to consider the decision as a whole,
and rely on the court's findings to affirm its conclusion that patient is
incompetent. See Caledonia-Record Pub. Co. v. Vt. State Coll., 2003 VT 78,
¶ 7, 175 Vt. 438, 833 A.2d 1273 (noting that we may affirm a judgment where
the correct result was reached for the wrong reason). The court's
findings, however, are inadequate to support such a conclusion. The
court's findings regarding patient's delusions, and his illness in general,
have an impact on the competence determination only insofar as they reflect
his ability to make decisions. 18 V.S.A. § 7625(c). Because mental
illness and psychotic symptoms are almost invariably present in the context
of involuntary medication petitions, the court must do more than list
patient's symptoms; it must specifically examine how they affect his
decision-making capabilities.
¶ 17. The court made no specific findings about patient's ability to
make a decision or to appreciate the consequences of that decision, such as
patient's fear of developing known physical side effects from the
medication. Moreover, although the court addressed the factors in §
7624(c) in great detail, these factors do not enter the analysis until the
court has first made a finding that patient is incompetent. Supra, ¶¶
8-11. Certain of the court's other findings are irrelevant to either the
competence standard or the factors in § 7624(c). We can find nothing in
the court's decision that would support any determination as to whether
patient is competent to refuse medication under the statute. Accordingly,
we reverse. In light of the possibility that patient's condition may have
changed during the pendency of this appeal, we remand for a new hearing
regarding patient's competence.
II.
¶ 18. Patient next asserts that his medication refusal is protected
by the federal Religious Land Use and Institutionalized Persons Act
(RLUIPA) because involuntary medication would impede his religious
exercise. RLUIPA provides in relevant part:
No government shall impose a substantial burden on the religious
exercise of a person residing in or confined to an institution . .
. even if the burden results from a rule of general applicability,
unless the government demonstrates that imposition of the burden
on that person-
(1) is in furtherance of a compelling governmental interest; and
(2) is the least restrictive means of furthering that compelling
governmental interest.
42 U.S.C. § 2000cc-1(a). "Religious exercise," under the statute,
"includes any exercise of religion, whether or not compelled by, or central
to, a system of religious belief." Id. § 2000cc-5(7)(A). To sustain a
claim or defense under RLUIPA, the party raising the issue must first make
a prima facie case that government action substantially burdens his
religious exercise. Having done so, the government bears the burden of
persuasion on all elements, except whether the challenged government action
indeed substantially burdens the party's exercise of religion. Id. §
2000cc-2(b). Because RLUIPA is predicated on Congress' Commerce Clause and
Spending Clause powers, the statute applies only to burdens that would
affect interstate or foreign commerce, or programs receiving federal funds.
Id. § 2000cc-1(b).
¶ 19. The Commissioner advances several arguments, both procedural
and substantive, in response to patient's RLUIPA claim. First, the
Commissioner argues that patient failed to raise the statute in a timely
manner, thereby waiving the issue. The Commissioner also argues that
patient has not presented facts to show that RLUIPA's jurisdiction, under
either the Commerce Clause or Spending Clause, is triggered. See Prater v.
City of Burnside, 289 F.3d 417, 433 (6th Cir. 2002) (noting that claimant
"may not rely upon RLUIPA unless it first demonstrates that the facts of
the present case trigger one of the bases for jurisdiction provided in the
statute"). Even if patient's defense is properly before the Court, the
Commissioner asserts that patient has not identified any specific religious
exercise that involuntary medication will burden. According to the
Commissioner, patient's claimed religious beliefs are actually
manifestations of his mental illness. Finally, to the extent that
patient's religious exercise is burdened, the Commissioner argues that the
burden of involuntary medication is not substantial, and is justified by
the State's compelling interests.
¶ 20. The family court concluded that patient's opposition to
psychiatric medication did not "constitute[] a religious exercise as that
phrase is used in the Act." The court analyzed patient's RLUIPA argument
concurrently with its analysis of patient's "religious convictions"-one of
the factors the court was required to consider after finding patient
incompetent, but before ordering involuntary medication-under 18 V.S.A. §
7627(c)(1). The court looked to the Oxford American Dictionary's
definition of religion, concluding that "religion" means "belief in a
personal God or gods entitled to obedience and worship; expression of this
in worship; particular system of faith and worship; thing that one is
devoted to." Applying this definition, the court concluded that it had "no
clue as to whether [patient] believes in God or gods," and thus concluded
that RLUIPA and 18 V.S.A. § 7627(c)(1) were inapplicable. Ultimately, the
court concluded, patient's beliefs were "secular in nature, not religious,"
and thus, involuntary medication would not burden patient's exercise of
religion.
¶ 21. Despite the court's decision to rule on this issue, we need
not address the merits of patient's RLUIPA claim, as we agree with the
Commissioner that patient failed to raise the issue in a timely manner.
Patient's counsel mentioned RLUIPA for the first time during his closing
argument. As a result, the Commissioner lacked notice of this claim, and
was unable examine the witnesses, or present any other evidence, in a
manner that would address the elements of RLUIPA. Notice was especially
important in this context because of the shifting burdens of production and
persuasion facing patient and the Commissioner regarding the various RLUIPA
elements. In this sense, RLUIPA was similar to an affirmative defense,
which must ordinarily be raised in a party's responsive pleading. V.R.C.P.
8(c). "Rule 8(c) is a notice provision, intended to prevent unfair
surprise at trial." Merrilees v. Treasurer, 159 Vt. 623, 623, 618 A.2d
1314, 1315 (1992) (mem.). Although 18 V.S.A. § 7624 does not provide for
any responsive pleading to a petition for involuntary medication, and thus,
Rule 8(c) is not technically applicable here, the policy underlying the
rule is nonetheless implicated. To allow full development of the requisite
facts and arguments, patient should have raised his RLUIPA claim at the
earliest opportunity.
¶ 22. Despite this waiver, patient may raise his RLUIPA argument
again on remand if he so chooses. With adequate notice, the Commissioner
will have an opportunity to present jurisdictional objections and
substantive evidence in response to patient's argument. Similarly, patient
will have an opportunity to argue, as he has in his appellate brief, in
favor of a more expansive interpretation of religious exercise than the
dictionary definition employed by the family court in its original
decision. See, e.g., Thomas v. Review Bd. of Indiana Employment Sec. Div.,
450 U.S. 707, 714 (1981) (stating that "[t]he determination of what is a
'religious' belief or practice is more often than not a difficult and
delicate task" which should not "turn upon a judicial perception of the
particular belief or practice in question; religious beliefs need not be
acceptable, logical, consistent, or comprehensible to others"); United
States v. Seeger, 380 U.S. 163, 185 (1965) (considering "whether the
beliefs professed . . . are sincerely held and whether they are, in [the
believer's] own scheme of things, religious"); United States v. Ballard,
322 U.S. 78, 86 (1944) ("Religious experiences which are as real as life to
some may be incomprehensible to others."). Thus, on remand, the notice
concerns we have addressed above will no longer prevent the family court's
full consideration of patient's religious concerns in light of both sides'
arguments. See Merrilees, 159 Vt. at 623, 618 A.2d at 1315 (noting that
Rule 8(c) need not apply where notice considerations are not implicated).
Reversed and remanded for further proceedings consistent with the
views expressed herein.
FOR THE COURT:
______________________________
Associate Justice
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Footnotes
FN1. We decided In re R.L. in 1995, prior to the Legislature's current
expression of its intent to achieve a more voluntary treatment system.
18 V.S.A § 7629(c).
FN2. The Commissioner may also commence involuntary medication actions for
persons who have previously been committed to the hospital, and are
currently out of the hospital on an order of non-hospitalization, or for
persons committed to the custody of the Commissioner of Corrections, and
for whom the Commissioner of Corrections and the Department of
Developmental and Mental Health Services agree that involuntary medication
would be appropriate. 18 V.S.A. § 7624(a).