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holding that potentially life-saving treatment for cancer could not be forced upon mentally ill person who had the capacity to give or withhold informed consent
Summary of this case from Steele v. Hamilton Cty. Comm. Mental Health Bd.Opinion
No. 86-1218
Decided February 20, 1987.
Civil rights — First Amendment — Section 7, Article I, Ohio Constitution — Freedom of religion — Faith healing — Right of legally competent adult to refuse medical treatment which is arguably life-extending, recognized.
O.Jur 3d Constitutional Law § 508. O.Jur 3d Incompetent Persons § 41.
1. The First Amendment to the United States Constitution and Section 7, Article I of the Ohio Constitution safeguard an individual's freedom to both choose and employ religious beliefs and practices.
2. The state may not compel a legally competent adult to submit to medical treatment which would violate that individual's religious beliefs even though the treatment is arguably life-extending.
APPEAL from the Court of Appeals for Franklin County.
This case arises from an application filed with the Court of Common Pleas of Franklin County, Probate Division, requesting authorization to perform medical treatment on appellant, Nancy Milton. The application, which was filed pursuant to R.C. 5122.271 by Dr. Lewis A. Lindner, the Chief Medical Officer of the Central Ohio Psychiatric Hospital (hereinafter "hospital"), alleged that appellant was unable to give informed, intelligent, and knowing consent for surgery. Dr. Lindner petitioned for an order requiring appellant to submit to radiation treatments, transfusions and possible surgery, stating that without these treatments, the patient would suffer an early death.
R.C. 5122.271, which is applicable to mental hospital patients, provides as follows:
"(A) Except as provided in divisions (C), (D), (E), and (F) of this section, the chief medical officer or, in a nonpublic hospital, the attending physician responsible for a patient's care shall provide all information, including expected physical and medical consequences, necessary to enable any patient of a hospital for the mentally ill to give a fully informed, intelligent, and knowing consent, the opportunity to consult with independent specialists and counsel, and the right to refuse consent for any of the following:
"(1) Surgery;
"(2) Convulsive therapy;
"(3) Major aversive interventions;
"(4) Sterilization;
"(5) Any unusually hazardous treatment procedures;
"(6) Psycho-surgery.
"(B) No patient shall be subjected to any of the procedures listed in divisions (A)(4) to (6) of this section until both his informed, intelligent, and knowing consent and the approval of the court have been obtained, except that court approval is not required for a legally competent and voluntary patient in a nonpublic hospital.
"(C) * * *
"If a patient is physically or mentally unable to receive the information required for surgery under division (A)(1) of this section and has no guardian, then the information, the recommendation of the chief medical officer, and the concurring judgment of a licensed physician who is not a full-time employee of the state may be provided to the court in the county in which the hospital is located, which may approve the surgery. Before approving the surgery, the court shall notify the legal rights service that is created by section 5123.60 of the Revised Code, and shall notify the patient of his rights to consult with counsel, to have counsel appointed by the court if he is indigent, and to contest the recommendation of the chief medical officer.
"* * *
"(G)(1) Unless there is substantial risk of physical harm to himself or others, or other than under division (D) or (E) of this section, this chapter does not authorize any form of compulsory medical, psychological, or psychiatric treatment of any patient who is being treated by spiritual means through prayer alone in accordance with a recognized religious method of healing without specific court authorization."
Dr. Lindner testified that appellant had cancer of the uterus which was in "a relatively advanced stage," and that there was a possibility she might be cured by medical treatment. Nevertheless, he estimated that even if she did receive the prescribed medical treatment, there was less than a fifty percent chance that she would be free of cancer for five years or more. At a minimum, he believed the treatment would arrest the tumor and considerably prolong appellant's life. Dr. Lindner further testified that appellant's death from the cancer was almost inevitable if she did not receive this medical treatment.
A hearing on the application was conducted in the probate court. The hospital called two witnesses at this hearing, Dr. Lewis Lindner and Dr. Eugene Green, a psychiatrist. Dr. Green testified that appellant was alert, responsive, did not appear confused, and could function in many areas of everyday life. Dr. Lindner stated that she was of normal intelligence.
The first hearing on Dr. Lindner's application was before a probate court referee who recommended that the hospital be permitted to perform the requested treatment without appellant's consent. No transcript of that hearing appears in the record. Appellant filed objections to this recommendation, and the probate court heard the matter de novo.
Appellant, a fifty-three-year-old patient of the hospital, refused to consent to this medical treatment primarily because it conflicted with her belief in faith healing. Dr. Lindner claimed that appellant's stated reasons for refusing consent constituted a psychotic delusion and that she was unable to understand and appreciate the information necessary to either provide informed consent or to refuse such consent. Dr. Lindner asserted that appellant's entire belief system was delusional because she had a fixed long-standing delusion that she was the spouse of Rev. LeRoy Jenkins, a faith healer and evangelist who is well known in the central Ohio area.
Dr. Green testified that appellant had stated that her primary reason for refusing medical treatment was her belief in spiritual healing, but she also indicated to him that a secondary reason for her refusal was that she had a background in nursing and desired to avoid the adverse side effects which she knew to be attendant to radiation treatments. He concluded, "I had the feeling again and again that in her hierarchy of beliefs, number one was [the] omnipotence of faith healing. This was her business. * * * This was God's business and we shouldn't tamper with it. We should believe and be healed."
Dr. Lindner conceded that appellant has never been adjudicated incompetent and that the hospital had accepted, without question as to her competency, her informed consent for all prior treatments at the hospital, including the biopsy through which the malignant tumor was diagnosed.
The trial court found that appellant had the mental capability to understand the nature of her illness and the contemplated treatment, but held that since appellant was not receiving spiritual treatment from Rev. Jenkins, the court could intervene. Therefore, the trial court authorized the requested medical treatment. The court of appeals affirmed, holding that appellant's beliefs in faith healing "* * * by all rational evaluation, constitute a delusion."
This cause is now before this court pursuant to the allowance of a motion to certify the record.
Anthony J. Celebrezze, Jr., attorney general, and J. Michael Evans, for appellee Department of Mental Health.
Ronald L. Smith, for appellant.
G. Michael Kirkman and Bruce A. Campbell, urging reversal for amicus curiae, American Civil Liberties Union of Ohio Foundation, Inc.
This is a case of first impression in Ohio. Several difficult and delicate questions are before us, including whether a state acting through its courts may compel an individual to submit to medical treatment which is arguably life-extending in derogation of that individual's religious beliefs. We must also decide whether the court below infringed upon appellant's constitutional right of religious freedom in citing the essence of her belief in faith healing as evidence of her lack of capacity to provide informed consent to medical treatment. We believe these questions should be resolved in favor of appellant and, thus, we reverse the holding of the appellate court.
At the outset, we emphasize that at no time has any court found appellant to be incompetent under state law. Appellant is a voluntary patient of the hospital. However, even if she were to be involuntarily committed, that commitment would not be tantamount to a finding of incompetency. Commitments to a mental institution and adjudications of incompetency are distinct legal proceedings which determine separate issues and often lead to different results. Commitment proceedings focus on proof of dangerousness as the primary determinant of the need for commitment, while incompetency adjudications evaluate a person's cognitive ability to make decisions. "[A] finding of `mental illness' * * * and commitment to a hospital, does [ sic] not raise even a presumption that the patient is `incompetent' or unable adequately to manage his own affairs." Winters v. Miller (C.A. 2, 1971), 446 F.2d 65, 68. Thus, a person who is not in a mental institution may be found to be incompetent, and a person properly committed to a mental institution may be legally competent.
Incompetency adjudications measure a person's cognitive ability to make a lawful decision regardless of its economic effect on others. In contrast, the major justification for involuntary commitment is protection of society or of the incapacitated individual. See Brakel, Parry Weiner, The Mentally Disabled and the Law (3 Ed. 1985) 374. R.C. 2111.01 defines an incompetent as "any person who by reason of advanced age, improvidence, or mental or physical disability * * * or mental illness, is incapable of taking proper care of himself or his property * * *."
Persons admitted to mental hospitals retain all civil rights not specifically denied by statutes or removed by separate adjudications of incompetency. R.C. 5122.301. These civil rights include the right to sue or defend in one's own name, sell or dispose of property, marry, draft a will, freely practice one's religion, and refuse medical treatment for religious reasons. See Winters v. Miller, supra. In Winters, a case factually similar to our own, a Christian Scientist, who was committed to a mental hospital, but who had not been adjudicated incompetent, refused to consent to medical treatment on the basis of her religious beliefs. The court discussed the requirement that only a "[`] grave and immediate danger to interests which the state may lawfully protect [']" ( id. at 69) can justify a state's interference with the freedom of religion and held that "there is no evidence in the record that would indicate that in forcing the unwanted medication on Miss Winters the state was in any way protecting the interest of society or even any third party." Id. at 70. Thus, it is apparent that the state may not act in a parens patriae relationship to a mental hospital patient unless the patient has been adjudicated incompetent.
The fact that appellant has a long-standing delusion that she is Rev. Jenkins' wife and that he will perchance heal her infirmities simply does not strip appellant of her constitutional rights to freely select and adhere to the religion of her choice. The testimony of Dr. Green, the hospital's own witness, supports a conclusion that appellant's belief in spiritual healing stands on its own, without regard to her delusion. Dr. Green explained that appellant's psychosis was "pretty much limited to delusional imaginations" and that "[c]ertain other parts of her seem pretty much intact."
Dr. Green testified that appellant could receive the information necessary to consent or not consent to the medical treatment in an intelligent and informed capacity. He noted that she is aware that she has a malignant tumor, but she believes that she will be cured through faith healing. She also made it very clear to Dr. Green that she was a faith healer and did not believe in other methods of treatment. Her belief in spiritual healing is long-standing. She informed Dr. Green that Rev. Jenkins had cured her blindness (which was thought to be hysterical blindness) in the past. Dr. Green explained that he felt spiritual healing is the prime thing in appellant's life and she believes that it would be almost a sin to try anything else.
The First Amendment to the United States Constitution and Section 7, Article I of the Ohio Constitution safeguard an individual's freedom to both choose and employ religious beliefs and practices. See Bd. of Edn. of Cincinnati v. Minor (1872), 23 Ohio St. 211, 250. A person's religious beliefs are protected absolutely. Cantwell v. Connecticut (1940), 310 U.S. 296, 303. The state may not interfere with the expression of belief, nor may it "compel behavior offensive to religious principles." (Emphasis deleted.) School Dist. of Abington Twp. v. Schempp (1963), 374 U.S. 203, 250 (Brennan, J., concurring).
Section 7, Article I of the Ohio Constitution provides:
"All men have a natural and indefeasible right to worship Almighty God according to the dictates of their own conscience. No person shall be compelled to attend, erect, or support any place of worship, or maintain any form of worship, against his consent; and no preference shall be given, by law, to any religious society; nor shall any interference with the rights of conscience be permitted."
The First Amendment to the United States Constitution provides as follows:
"Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof * * *."
The Free Exercise Clause of the First Amendment applies to the states through Fourteenth Amendment. Cantwell v. Connecticut (1940), 310 U.S. 296, 303-304. See, also, School Dist. of Abington Twp. v. Schempp (1963), 374 U.S. 203.
While religiously inspired acts do not receive absolute protection, "* * * [o]nly the gravest abuses, endangering paramount interests, give occasion for permissible limitation." Thomas v. Collins (1945), 323 U.S. 516, 530; Sherbert v. Verner (1963), 374 U.S. 398, 406; see, also, Wisconsin v. Yoder (1972), 406 U.S. 205, 215. Freedom of religion may be infringed "only to prevent grave and immediate danger to interests which the State may lawfully protect." West Virginia State Bd. of Edn. v. Barnette (1943), 319 U.S. 624, 639.
Appellee does not suggest any state interest sufficient to justify interfering with appellant's religiously inspired refusal to consent to medical treatment. Appellee argues that appellant's delusion that she was Rev. Jenkins' spouse negated her religious views and made her entire belief in faith healing a delusion. The court of appeals looked to the content of appellant's religious beliefs and found that her belief in faith healing constituted a delusion. We do not accept this contention.
There is a dichotomy between modern medicine which is scientific and based upon provable theories and religion which is inherently mystical, intangible and a matter of individual faith. Yet, the Ohio and United States Constitutions mandate that when the dictates of modern medicine and religious beliefs collide, the conflict be resolved by leaving the medical treatment decision to the individual. As the court stated in United States v. Ballard (1944), 322 U.S. 78, 86, freedom of religion "embraces the right to maintain theories of life and of death and of the hereafter which are rank heresy to followers of the orthodox faiths. * * * Men may believe what they cannot prove. They may not be put to the proof of their religious doctrines or beliefs. Religious experiences which are as real as life to some may be incomprehensible to others."
While there may be a variety of opinions as to the efficacy of spiritual healing through faith, the courts below acknowledged that it is a form of religious belief and practice. We recognize that extending constitutional protection to a belief in spiritual healing and other religiously motivated refusals to accept medical treatment can be very troubling to those who do not share these beliefs, since, in cases such as this one, the patient may die as a result of refusing the recommended treatment. "* * * But freedom to differ is not limited to things that do not matter much. That would be a mere shadow of freedom. The test of its substance is the right to differ as to things that touch the heart of the existing order. If there is any fixed star in our constitutional constellation, it is that no official, high or petty, can prescribe what shall be orthodox in * * * religion * * * or force citizens to confess by word or act their faith therein." West Virginia Bd. of Edn. v. Barnette, supra, at 642.
Other jurisdictions have also recognized that an individual's decision to forego traditional medical care and rely on faith healing is encompassed within the freedom of religion. For example, in In re Estate of Brooks (1965), 32 Ill.2d 361, 373, 205 N.E.2d 435, 442, the Illinois Supreme Court held that compulsory medical treatment, which was in violation of the patient's religious beliefs, no matter how well intentioned, violated the First Amendment's Free Exercise Clause, absent a showing of a substantial state interest. The court reasoned: "Even though we may consider appellant's beliefs unwise, foolish, or ridiculous, in the absence of an overriding danger to society we may not permit interference therewith * * * for the sole purpose of compelling her to accept medical treatment forbidden by her religious principles, and previously refused by her with full knowledge of the probable consequences. In the final analysis, what has happened here involves a judicial attempt to decide what course of action is best for a particular individual, notwithstanding that individual's contrary views based upon religious convictions. Such actions cannot be constitutionally countenanced." Id.
Similarly, in In re Osborne (D.C.App. 1972), 294 A.2d 372, a Jehovah's Witness refused to consent for religious reasons to the administration of blood transfusions. The court found that the patient had validly and knowingly chosen this course for his life and there was no compelling state interest which justified overriding that decision. See, also, Holmes v. Silver Cross Hospital (N.D. Ill. 1972), 340 F. Supp. 125; In re Melideo (1976), 88 Misc.2d 974, 390 N.Y. Supp. 2d 523. Cf. Raleigh Fitkin-Paul Morgan Memorial Hosp. v. Anderson (1964), 42 N.J. 421, 201 A.2d 537.
Appellee also suggests that appellant's beliefs are not entitled to protection because she is not a member of any specific religious denomination or sect and is not being treated in accordance with a recognized method of healing. The trial court noted that if appellant were receiving spiritual treatment from Jenkins the court would have been precluded from ordering the medical treatment. However, since she was not actively receiving such spiritual treatment, the court reasoned that it was under no compulsion to recognize appellant's wishes in this matter. Such a distinction is patently in conflict with appellant's constitutional rights. Religious freedom is one of "`absolute equality before the law, of all religious opinions and sects * * *. The government is neutral, and, while protecting all, it prefers none, and it disparages none.'" (Emphasis deleted.) School Dist. of Abington Twp. v. Schempp, supra, at 215. "In such an intensely personal area, * * * the claim of the * * * [believer] that his belief is an essential part of a religious faith must be given great weight." United States v. Seeger (1965), 380 U.S. 163, 184.
Appellant has expressed a long-standing belief in spiritual healing, and great weight must be given to her statement of her personal beliefs. We cannot evaluate the "correctness" or propriety of appellant's belief. Absent the most exigent circumstances, courts should never be a party to branding a citizen's religious views as baseless on the grounds that they are non-traditional, unorthodox or at war with what the state or others perceive as reality.
The testimony of Dr. Green supports our conclusion that appellant's belief in spiritual healing stands on its own, without regard to any delusion. We can probe no further. Appellant's religious freedom to believe and act according to the dictates of her belief in spiritual healing prevents a court from ordering treatment against her will that would violate her religious beliefs. Thus, we hold that the state may not compel a legally competent adult to submit to medical treatment which would violate that individual's religious beliefs even though the treatment is arguably life-extending. Therefore, the probate court's determination was erroneous and the judgment of the court of appeals upholding it is reversed.
See footnote 6, supra.
We emphasize that this case involves a religiously motivated choice by an adult. It does not present, and therefore we do not address, the issue of a parent who seeks to deny medical treatment for a child on religious grounds. See, e.g., Jehovah's Witnesses in the State of Washington v. King Cty. Hosp. Unit No. 1 (W.D. Wash. 1967), 278 F. Supp. 488, affirmed (1968), 390 U.S. 598, rehearing denied (1968), 391 U.S. 961.
Appellant also questions the probate court's expansion of the term "surgery" in R.C. 5122.271 to include "radiation treatments." R.C. 5122.271(C) provides that the probate court may approve of surgery for mental hospital patients in the absence of their consent. Appellee contends, and the probate court found, that this term "surgery" encompassed radiation treatments. However, because appellant's belief in faith healing entitled her to protection under the United States and Ohio Constitutions, she cannot be compelled to undergo any medical treatment and, thus, we need not address this issue.
Judgment reversed.
MOYER, C.J., SWEENEY, DOUGLAS and H. BROWN, JJ., concur.
LOCHER and HOLMES, JJ., dissent.
While I am in complete agreement with the syllabus law and the discussion of such law as contained in the majority opinion, I must dissent therefrom in that I feel the majority has completely misconstrued the facts of this matter and the holding of the lower courts in applying such syllabus law.
I am in agreement that the state may not compel the medical treatment of a person who is capable of making the determination of granting or denying the consent for a surgical activity where such determination is based upon a religious belief, even though such belief is strange or incomprehensible to others. However, where the facts show that an individual is so confused in the thinking process that such belief is not rationally formulated and is an outworking of a psychosis, as held by the trial court and the court of appeals here, then the question is not one of a religious infringement but is instead one of the degree of mental instability.
Both of the testifying psychiatrists agreed that her refusal of medical treatment sprang from her belief that she was the wife of LeRoy Jenkins. While her thinking remained undisturbed in other areas, this fixed delusion had already placed her in one life-threatening situation, i.e., police had discovered her living unsheltered in the open fields. It is the very nature of a psychosis that an ordinary part of the personality becomes the medium of expression for the illness. When a belief becomes fixed as part of such illness, then the patient becomes incapable of rationally assessing danger relative to the fixation. This would be true whether the belief occurred as the more typical paranoid delusion manifesting itself in intense fear and/or violence or, as here, in a delusion based upon ordinarily held religious beliefs. Just as the illness has nothing to do with appellant's beliefs, so also the diagnosis of illness is not a value judgment of her beliefs.
Here the probate court and trial court reasonably found that Nancy Milton was unable because of her confused mental condition to give an informed, intelligent and knowing consent for her surgery. Such a finding should be appealed to this court without the esoteric, constitutional free-exercise-of-religion discussion. Appellant has expressed quite enough to demonstrate to the lower courts, and certainly to this court, that she is incapable of making her own medical determination. She has asserted that she is married to LeRoy Jenkins, and that this member of the T.V. and now radio clergy would heal her maladies. However, Jenkins has, by way of press announcement in The Columbus Dispatch, publicly removed himself from this appellant and stated that she needs help from others.
It is my view that Nancy Milton does need help from others, and that the probate court and the court of appeals properly recognized that such help should be forthcoming from the medical profession as appropriately prescribed. Accordingly, I would affirm the probate court and the court of appeals.
LOCHER, J., concurs in the foregoing dissenting opinion.
I agree with the dissent of Justice Holmes and wish to add a few observations of my own.
Nancy Milton was mentally incapable of receiving information concerning her condition and of consenting to surgery. Dr. Lewis A. Lindner testified at the hearing that the patient had totally denied having a tumor to begin with, and that later she refused to accept that she had it — in spite of her being able to feel it growing in her pelvic area. Dr. Lindner added that her stated reason for refusal was that she was the wife of Rev. LeRoy Jenkins, and that she believed he "would come to the hospital and take her away and heal her supernaturally." It is evident that these psychotic delusions have created an impenetrable "wall" which prevents her from admitting she has the tumor and from consenting to the surgery. For her to consent to surgery would be to deny her belief that LeRoy Jenkins would come and take her away to be healed. Nancy Milton is incapable of surmounting this mental wall created by her own delusions. In conclusion, I am convinced that her refusal to consent to surgery is the result of her delusions concerning LeRoy Jenkins rather than her belief in faith healing.
Accordingly, I dissent.