Vermont Supreme Court Reports
IN RE L.A., 2006 VT 118 In re L.A No. 2005-368, May Term,
2006 Supreme Court of Vermont November 17, 2006
On Appeal from Washington Family Court 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.
JOHNSON, J.
¶ 1. 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
[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).