Article by Grant H. Morris
An assessment of Supreme Court decisionmaking on civil commitment issues during the last decade necessitates a review of significant medical and legal events that occurred before 1975. In the mid- to late-1950s, Thorazine and other psychoactive drugs were introduced into the large institutions that housed the seriously mentally ill people in our country. The rapid acceptance of tranquilizing drugs as the treatment of choice enabled hospitals to unlock their doors and led to the development of community mental health centers as the focal point for treatment. This medical progress had a significant impact on the civil commitment process and on the very concept of civil commitment. A decision to confine involuntarily a mentally ill person for in-patient treatment was no longer a life sentence. Rather, crisis intervention resulted in short-term confinement of the patient only until the mental condition was stabilized. The patient was quickly returned to society—at least until another crisis required further involuntary detention and a recycling of the process. This change in treatment philosophy caused the mentally ill to become a far more visible population.
In the 1960s lawyers and doctors were startled by the writings of Thomas Szasz. Szasz asserted that the medical model is inappropriately applied to conditions of living that had heretofore been considered mental ‘illnesses.’ He questioned the propriety of psychiatrists acting as agents of the state to achieve involuntary confinement of their patients. The psychiatric abolitionist movement inspired lawyers to reexamine the whole theoretical basis of civil commitment: Should society have the power to confine citizens involuntarily who have not committed crimes, and if so, should such confinement be achievable without crimes, due process safeguards required in our criminal process? United States Senate subcommittee hearings conducted in the early 1970's documenting psychiatric abuses to repress political dissent in the Soviet Union heightened our concern that civil commitment in the United States should be appropriately circumscribed, or even eliminated.
In the late 1960s and early 1970s, law reformers enthusiastically acclaimed landmark appellate court decisions dealing with issues involved in the civil commitment process. For example, in Lake v. Cameron, the District of Columbia Circuit Court of Appeals ruled that a person whose mental condition meets involuntary civil commitment criteria may not be confined in a mental institution if alternative treatment is available that is less restrictive of the individual's liberty. Chief Judge Bazelon, writing for the majority, imposed on the government the burden of exploring possible alternatives to institutionalization. In Bolton v. Harris, that same court granted individuals acquitted of crimes by reason of insanity the procedural safeguards utilized for civil commitment. Specifically, the court construed the District of Columbia's mandatory commitment statute to authorize only a temporary detention of the insanity acquittee to examine the individual's current mental condition. Upon completion of the examination, a new hearing was required to determine whether the acquittee's mental condition warranted involuntary confinement utilizing the jurisdiction's civil commitment criteria. In 1972, a federal district court in Lessard v. Schmidt accorded prospective patients a broad panoply of procedural protections in the civil commitment process. These protections included notice and an opportunity to be heard, a probable cause hearing within forty-eight hours of detention, a burden of proof beyond a reasonable doubt, right to counsel, the privilege against self incrimination, and the exclusion of hearsay evidence.
The courts, however, did not focus their attention solely on the process of involuntary civil commitment. In Rouse v. Cameron, decided in 1966, Chief Judge Bazelon declared that because the purpose of involuntary hospitalization is treatment, not punishment, the hospital has a duty to furnish adequate treatment, and the patient has a legal right to receive that treatment. This right to treatment is enforceable by a writ of habeas corpus. Six years later, a federal district court decided Wyatt v. Stickney. The court accepted as appropriate a class action alleging inadequate treatment brought on behalf of all patients at an Alabama mental hospital. Chief Judge Frank Johnson, writing for the court, announced a conditional basis for the right to treatment and issued a decree establishing and ordering the implementation of standards that were deemed medical and constitutional minimums. The standards were designed to establish a humane psychological and physical environment, to provide qualified staff in sufficient numbers, and to insure individualized treatment plans. The standards were not mere generalizations of these desired goals but, instead, established extremely specific requirements.
The first appellate decisions that recognized a mental patient's right to refuse treatment were also decided prior to 1975. For example, in Winters v. Miller, the Second Circuit Court of Appeals held that an involuntarily confined Christian Scientist mental patient stated a valid claim under the Federal Civil Rights Statute for damages resulting from forced medication in violation of her right to freedom of religion under the First Amendment.
Even those few cases involving the rights of the mentally ill that reached the Supreme Court in the decade prior to 1975 resulted in landmark decisions that were praised by law reformers. For example, in Baxstrom v. Herold, the Court ruled that a mentally ill convict who had been transferred from prison to a maximum security mental hospital while serving his criminal sentence had to be released from that institution upon expiration of that sentence unless he was accorded all of the procedural protections that are provided to those committed through the civil commitment process. In holding that Johnnie K. Baxstrom had been denied equal protection of the laws, Chief Justice Earl Warren reasoned that the statutory procedure authorizing the Commissioner of Mental Hygiene to commit Baxstrom through an administrative judgment denied Baxstrom the possibility of a jury review of the propriety of his commitment, a right that was available to all other persons civilly committed in New York. Additionally, the statute unconstitutionallly deprived Baxstrom of a judicial hearing to determine whether he was dangerously mentally ill. Under New York law, a civil patient could not be transferred from a civil mental hospital to a maximum security mental hospital administered by the Department of Correction unless the patient first was judicially determined to be dangerously mentally ill. Because Baxstrom was no longer a sentence-serving convict, he was entitled to this procedural safeguard. All nine Supreme Court Justices agreed with the result in Baxstrom.
The following year, in Specht v. Patterson, the Court ruled that a person convicted of a sex crime for which the maximum sentence was ten years could not be sentenced under the state's Sex Offenders Act for an indeterminate term of one day to life without notice and a full hearing. Imposition of the indeterminate sentence required a finding that the defendant posed a threat of bodily harm to the public. Because this new finding of fact could not be assumed from the commission of the underlying offense, due process required that the defendant ‘be present with counsel, have an opportunity to be heard, be confronted with witnesses against him, have the right to cross-examine, and to offer evidence of his own.’ The Court's decision was unanimous, and Justice Douglas wrote the opinion of the Court.
In its 1972 decision in Jackson v. Indiana, the Supreme Court invalidated a statute that permitted an indeterminate, and potentially lifetime commitment of a developmentally disabled deaf-mute who had been found incompetent to stand trial. The Court extended the Baxstrom principle to incompetent criminal defendants, stating: ‘If criminal conviction and imposition of sentence are insufficient to justify less procedural and substantive protection against indefinite commitment than that generally available to all others, the mere filing of criminal charges surely cannot suffice.’ The state had denied incompetent criminal defendants equal protection of the laws by subjecting them to a more lenient commitment standard and to a more stringent release standard than that applicable to all others undergoing civil commitment. Further, the Court held that due process is violated by an indefinite commitment of a criminal defendant based solely on lack of capacity to stand trial. An incompetent defendant can only be held for a reasonable period of time necessary to determine whether he or she is likely to become mentally competent in the foreseeable future. If restoration to competency is not likely, the customary civil commitment proceedings that authorize the indefinite commitment of any other citizen must be utilized, or the defendant must be released. Justice Blackmun wrote the opinion of the Court, with no justices dissenting.
The Jackson decision was also significant for the Court's language intimating its willingness to hear cases involving commitment and treatment issues. The Court cited empirical data showing that many defendants committed as incompetent prior to trial are, in fact, never tried. The Court expressed doubt ‘whether the rationale for pretrial commitment—that care or treatment will aid the accused in attaining competency—is empirically valid.’ After making these statements, the Court noted: ‘However, very few courts appear to have addressed the problem.’ Elsewhere in the opinion, the Court discussed the various justifications for the involuntary commitment of the mentally ill. Justice Blackmun then remarked: ‘Considering the number of persons affected, it is perhaps remarkable that the substantive constitutional limitations on this power have not been more frequently litigated.’
Other language in Jackson tended to support the emerging legal right to treatment of involuntarily confined civil patients. The Court ruled that even if incompetent criminal defendants may be detained because of the probability that they will attain the capacity to stand trial in the foreseeable future, nevertheless, each defendant's ‘continued commitment must be justified by progress toward that goal.’ The Court noted: ‘At the least, due process requires that the nature and duration of commitment bear some reasonable relation to the purpose for which the individual is committed.’ If this requirement of progress were applied to those civilly committed because they need care and treatment, then continued confinement of such individuals could be justified only by a showing that treatment in the hospital setting improves the individual's mental condition. The goal of release to the community must be achievable through the treatment given.
These were heady times indeed. Notwithstanding changes in the Court's personnel, lawyers were at least guardedly optimistic that major law reform could be achieved through Supreme Court decisionmaking. Perhaps it is only against this background—one in which the courts were both formulating and rapidly accepting legal rights of the mentally ill—that disappointment was so certain to follow.
Between 1975 and 1985, the Supreme Court decided three cases involving ‘pure’ civil commitment issues. The first, O'Connor v. Donaldson, involved the criteria for involuntary commitment of the mentally ill. The second, Addington v. Texas, involved procedures for civil commitment, and the third, Parham v. J.R., involved both the criteria and the procedure for commitment of one subcategory—mentally ill children. The Court decided at least four other cases involving ‘impure’ civil commitment issues. These cases involved individuals who were either sentence-serving convicts or who were somehow involved in the criminal justice process. To the extent that these cases may influence future Supreme Court decisionmaking on civil commitment issues, they will be included in the discussion.
About the Author
Grant H. Morris. Professor of Law, University of San Diego. A.B. 1962, J.D. 1964, Syracuse University; LL.M. 1971, Harvard University.
Citation
60 Tul. L. Rev. 927 (1986)