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RENNIE v. KLEIN

November 9, 1978

John E. RENNIE, Plaintiff,
v.
Ann KLEIN, Commissioner of Human Services, Michail Rotov, Director, Division of Mental Health and Hospitals, Richard Wilson, Chief Executive Officer of Ancora Psychiatric Hospital, Max Pepernik, Acting Medical Director of Ancora Psychiatric Hospital, Edward Wallace, Assistant Administrator of Ancora Psychiatric Hospital, and Josefina Bugaoan, Assistant Medical Director of Ancora Psychiatric Hospital, Defendants



The opinion of the court was delivered by: BROTMAN

This matter is before the court on the motion of plaintiff, John E. Rennie, for a preliminary injunction pursuant to Fed.R.Civ.P. 65. Plaintiff is an involuntary patient of Ancora Psychiatric Hospital, a state institution. He seeks to enjoin the defendant psychiatrists and officials at Ancora from forcibly administering drugs to him in the absence of an emergency situation. The complaint is grounded on 42 U.S.C. § 1983, with jurisdiction pursuant to 28 U.S.C. § 1343. The following are the court's findings of fact and conclusions of law, Fed.R.Civ.P. 52.

FINDINGS OF FACT

 I. Procedural History

 The complaint in this action was filed on December 22, 1977. While the complaint is stated in six counts, plaintiff essentially charged defendants with violations of four rights: (1) the right to refuse medication in non-emergent circumstances, (2) the right to treatment, (3) the right of access to counsel, and (4) the right to be free from physical abuse while in custody.

 On the same date, counsel for Mr. Rennie, Sheldon Gelman of the New Jersey Public Advocate's Office, and counsel for the state officials, Steven D. Wallach, Deputy Attorney General, appeared in chambers on an application for a temporary restraining order. The parties agreed that only the issue of the right to refuse medication would be considered on the motion for a preliminary injunction. In an order prepared that day and filed December 30th, it was ordered that plaintiff not be medicated against his will beyond a maintenance dosage except in emergencies. Counsel agreed, after consultation with the state psychiatrists, that a maintenance dosage would be 15 mg. of prolixin hydrochloride per day. Dr. Marvin Greenberg, plaintiff's expert, was named temporary consultant to the court.

 On January 13, 1978, hearings on the motion for preliminary injunction began. The court conducted fourteen days of hearings; the final day was April 28, 1978. Testimony was taken from hospital officials and employees; three Ancora psychiatrists, Dr. Rotov, Director of the state Division of Mental Health and Hospitals, three psychiatrists from outside the state system produced by plaintiff, and two outside psychiatrists produced by defendant. *fn1" Counsel were then allowed to prepare proposed findings and briefs.

 During the lengthy course of these hearings, plaintiff attempted suicide by swallowing an overdose of pills on April 10, 1978. Transcript, Volume X, page 5, April 12, 1978 (hereafter cited in the form Tr. X, 5, 4/12/78). Defendants moved to remove the temporary restraining order on April 12. Instead, the court reserved decision and requested that all doctors involved in Mr. Rennie's case convene on April 14, to attempt to reach a consensus on the future course of plaintiff's treatment. The psychiatrists agreed that plaintiff should be treated immediately with an antidepressant medication, followed by the use of lithium carbonate when his depression lifted. There was disagreement over when an antipsychotic drug should be used. On the representation that the lithium antidepressant regime would be commenced and that plaintiff consented thereto, the temporary restraining order was dissolved by order dated April 18, 1978.

 On May 19, 1978, plaintiff brought the parties before this court seeking to restrain the hospital's use of thorazine, another psychotropic drug. Since the April 28 hearing, it was reported that the hospital gave Mr. Rennie every possible chance on lithium but that he was dangerous to himself, other patients, and the staff. After placing Mr. Rennie in restraints for three days, the decision was made to medicate him with thorazine. Relief was denied plaintiff pending briefing by the parties and the issuance of this opinion, unless plaintiff was prepared to put forward further medical testimony. Thus, while the issue as to prolixin may be moot, defendants have used other drugs of the same type since April. Since the testimony indicates that the benefits and detrimental side effects of all psychotropic drugs are similar, the case as a whole is not moot.

 II. The Plaintiff's Personal History

 John Rennie is a highly intelligent *fn2" 38 year old white divorced male. Before his psychiatric difficulties began, he worked as a pilot and a flight instructor. His first symptoms of mental illness appeared in December 1971. Def. Exh. 2, Case History. Serious problems commenced early in 1973, in the wake of his twin brother's death in an airplane accident.

 His medical history is lengthy and can only be highlighted here. His first admission to Ancora Psychiatric Hospital was on April 1, 1973. He was depressed and suicidal, and diagnosed as a paranoid schizophrenic. Mellaril, an antipsychotic drug, was given, and plaintiff was released on April 5 to the Fairmont Farms Hospital, a private facility. Def. Exh. 2; Testimony of Dr. Ortanez, Tr. II, 100, 1/19/78.

 There followed a revolving door series of readmissions and releases. His second admission was from May 2, 1973 to June 1, 1973, with plaintiff exhibiting similar suicidal ideas and religious delusions. By his third admission, from February 18 to February 26, 1974, he began to exhibit some aggressive and abusive symptoms. Thorazine, another antipsychotic drug, was used. Delusions that he was Christ continued in the fourth admission in March 1974. Tr. II, 102-04.

 Subsequent admissions showed further trials of different medicines. During the sixth admission, from April 9 to May 7, 1974 on a voluntary commitment, there is the first indication of a refusal to take medication. He was discharged against medical advice. His eighth admission, on a voluntary commitment from August 26 to September 10, 1974, was initiated when the Secret Service brought him to state authorities after he threatened to kill President Ford. His behavior again was abusive and assaultive. This type of assaultive behavior continued during his ninth admission from September 18 to October 12, 1974, so that the hospital placed him on homicidal precautions. Def. Exh. 2; Testimony of Dr. Ortanez, Tr. II, 100-04. He was also on homicidal precautions during his tenth admission in January 1975. His eleventh admission was involuntary and lengthy, from November 16, 1975 to June 9, 1976. His behavior was erratic, alternating between being depressed and suicidal to manic and homicidal. There was a suicide attempt on December 14 by an overdose of mellaril. Ortanez, Tr. II, pp. 37-38. Both psychotropic drugs, such as haldol, mellaril and prolixin decanoate, as well as lithium, were utilized. During this hospitalization, his diagnosis for a time was changed to manic depressive illness. Def. Exh. 2.

 Throughout this period, plaintiff was inconsistent in his attitude toward the various medications, refusing at times and cooperating at others. Ortanez, Tr. III, 101. One of many causes of his repeated discharges and readmissions is his failure to continue taking medications after he has left the hospital's custody.

 Plaintiff's twelfth and present admission to Ancora began on August 10, 1976, pursuant to an involuntary commitment. N.J.S.A. 30:4-27. Although committed, he has never been declared incompetent. See N.J.S.A. 30:4-24.2(c). The admitting diagnosis was manic depressive illness, circular type. He was placed on lithium and on suicidal and homicidal precautions. Later psychotropic drugs were added. Again, at various times, medication was refused. In December 1976, the Public Advocate's Office became involved in Mr. Rennie's case. After conversation with Mr. Gelman, the hospital agreed that medication would not be forced against the patient's will. Following an injection of prolixin decanoate on January 5, 1977, plaintiff became extremely psychotic and threatened suicide. During 1977, plaintiff was shifted between a number of medications, including thorazine, prolixin, etrafon, haldol, elavil, and lithium. Frequent incidents of fights with other patients and attendants were reported. Suicidal and delusional periods were also reported.

 One particular incident prior to the commencement of this lawsuit should be noted. On November 17, 1977, plaintiff reported that evening shift attendants beat him with sticks while he was tied to a bed. The next day he pointed out the sticks, which were hidden at the nurses' station. Tr. IX, 7, 4/12/78. The investigation that followed resulted in the suspension of one employee for three days. Plaintiff and the attendant remained together in the same ward. Tr. IX, 45; Tr. II, 81.

 In brief fashion, this summarizes plaintiff's history to December 1977, when this suit was commenced. The events of that month will be discussed further, Infra.

 III. Ancora Psychiatric Hospital

 Ancora Psychiatric Hospital is a state facility for the mentally ill in Hammonton, New Jersey. It has been accredited by the Joint Commission on Accreditation of Hospitals. Dr. Ortanez and Dr. Bugaoan were the patient's treating psychiatrists during the time relevant to this litigation.

 During most of his current admission, plaintiff has been housed in a barren, bleak ward; it has been described as more like a prison than a hospital. Greenberg, Tr. I, 46-7. Plaintiff sometimes has difficulty obtaining a pillow for his bed. His days contain long blocks of unproductive and unstructured time. Testimony of John Rennie, Tr. XIV, 165-67, 4/28/78. In general, doctors at Ancora do not have sufficient time for each patient. Testimony of Dr. Josefina Bugaoan, Tr. V, 61-63, 1/17/78. However, as a result of this lawsuit, the doctors are spending more time with Mr. Rennie. Tr. V, 64-65.

 IV. The Medication

 A. Benefits of Psychotropic Drugs

 Prolixin or Fluphenazine belongs to a group of chemicals variously described as antipsychotic or psychotropic drugs. It comes in long-acting (prolixin decanoate) and short-acting (prolixin hydrochloride) form. Prolixin Decanoate is the only psychotropic drug to come in a form that will last approximately two weeks. Bugaoan, Tr. IV, 124, 1/16/78; Zander, Prolixin Decanoate: A Review of the Research, in 2 Mental Disability L.Rep. 37 (1977).

 Many other major tranquilizers exist which are very similar to prolixin hydrochloride, both in therapeutic action and side effect. Plotkin, Limiting the Therapeutic Orgy: Mental Patients' Right to Refuse Treatment, 72 Nw.U.L.Rev. 461, 475 (1977). These include thorazine, mellaril, haldol and trilafon. There is no evidence supporting the superiority of any one of these drugs. Bozzuto, Use of antipsychotic agents for schizophrenia, 1977 Drug Therapy 40.

 In the past twenty years, psychotropic drugs have played an increasingly important role in the treatment of mental illness, and are now widely used. Psychotropic drugs tend to shorten hospital stays and allow patients to function in the community. Many consider use of these drugs necessary in any treatment program, especially for schizophrenics. Winick, Psychotropic Medication and Competence to Stand Trial, 1977 Am.B.Found.Res.J. 769, 773-74; Zander, Supra. Dr. Stinnett went so far as to testify that the failure to treat an acutely psychotic patient with drugs would be malpractice, Tr. XI, 85; See also, Tr. II, 145 (quoting a 1976 National Institute of Mental Health report); Cf. Whitree v. State, 56 Misc.2d 693, 290 N.Y.S.2d 486, 501 (1968); Nason v. Superintendent of the Bridgewater State Hospital, 353 Mass. 604, 233 N.E.2d 908, 910 (1968).

 More studies exist demonstrating the efficacy of the psychotropic drugs in the treatment of schizophrenia than for any other mode of treatment. DuBose, Of the Parens Patriae Commitment Power and Drug Treatment of Schizophrenia: Do the Benefits to the Patient Justify Involuntary Treatment?, 60 Minn.L.Rev. 1149, 1167 (1976). Defendants offered a number of studies establishing the efficacy of prolixin in the treatment of schizophrenics. May, et al., Schizophrenia A Follow-up Study of Results of Treatment, 33 Arch. Gen'l Psychiatry, 474, 474-78, 481-86 (1976); Bozzuto, supra at 44; E. Spohn, et al., Phenothiazine Effects on Psychological and Psychophysiological Dysfunction in Chronic Schizophrenics, 34 Arch. Gen'l Psychiatry 633 (1977). See also Zander, Supra.

 Of course, the research is not conclusive. Double blind testing is difficult because a placebo group will not experience the usual side effects. Thus the patient and the testers may know that he is unmedicated. Also no studies can conclusively compare the pain of schizophrenic mental states and physical side effects of medication simply because both are subjective experiences. Zander, Supra at 41; Stinnett, Tr. XI, 81. Furthermore, new studies raise questions about recidivism and the efficacy of using psychotropic medication in every case. Gunderson, Drugs and Psychosocial Treatment of Schizophrenia Revisited, Dec. 1977 Psychiatry Digest 25; Simpson, et al., Psychotic Exacerbation Produced by Neuroleptics, 37 Diseases of the Nervous System 367 (1976). Patients do react idiosyncratically to any particular psychotropic drug. Plotkin, Supra at 475.

 However, the court can appropriately make certain generalizations even at this stage of scientific knowledge. Psychotropic drugs are effective in reducing thought disorder in a majority of schizophrenics. With first admission patients, success rates of as high as 95% Have been obtained. See May, Supra ; DuBose, Supra at 1176. Success rates are less impressive with chronic patients. DuBose, Supra at 1173. However, no other treatment modality has achieved equal success in the treatment of schizophrenics. Cf. Bugaoan, Tr. IX, 153-54 (quoting from Hollister, Choice of Antipsychotic Drugs, 127 Amer.J. Psychiatry 104, 104 (1970)).

 Furthermore, psychotropic drugs are required in order for some patients to effectively participate in and benefit from other types of therapy, such as individual or group psychotherapy and occupational therapy. Comment, Forced Drug Medication of Involuntarily Committed Mental Patients, 20 St. Louis U.L.J. 100, 112 (1975); Winick, Supra At 781; Ortanez, Tr. III, 92; Testimony of Dr. Max Pepernik, Tr. VII, 29, 2/24/78.

 In sum, psychotropic drugs are widely accepted in present psychiatric practice. A. Brooks, Law, Psychiatry and the Mental Health System 878 (1974). They are the treatment of choice for schizophrenics today. Cf. Testimony of Dr. Bertram Pepper, Tr. VIII, 32, 3/27/78; Pepernik, Tr. VII, 16.

 B. Side Effects of Psychotropic Drugs

 A number of short term autonomic side effects have commonly been reported. These include blurred vision, dry mouth and throat, constipation or diarrhea, palpitations, skin rashes, low blood pressure, faintness and fatigue. Winick, Supra at 782 n. 66; Plotkin, Supra at 476; DuBose, Supra at 1203; Bugaoan, Tr. V, 84. These side effects tend to diminish after a few weeks. Ortanez, Tr. II, 139; Pepernik, Tr. VII, 23. Sudden death may also be a side effect in rare cases. Stinnett, Tr. XI, 50; Pepper, VIII, 24.

 Among the extrapyramidal side effects, the two most common are akinesia and akathesia. Akinesia refers to a state of diminished spontaneity, and feeling of weakness and muscle fatigue. Zander, supra; Rifkin, et al., Fluphenazine Decanoate, Oral Fluphenazine, and Placebo in Treatment of Remitted Schizophrenics, 34 Arch. Gen'l Psychiatry 1215, 1216 (1977). Patients with severe cases of akinesia had to be dropped from the Rifkin study of prolixin. Akathesia is a subjective state and refers to an inability to be still; a motor restlessness which may produce a shaking of the hands or arms or feet or an irresistible desire to keep walking or tapping the feet. Pepper, Tr. VIII, 22; Zander, Supra ; Winick, Supra ; Bugaoan, Tr. IV, 36. Both of these side effects are temporary and terminate either during or after the drug regime; the effects can also be treated with anticholinergic or antiparkinsonian drugs such as cogentin. Stinnett, Tr. XI, 95; DuBose, Supra at 1203. However cogentin has side effects of its own, including blurred vision and salivation. Pepper, VIII, 28.

 A potential permanent side effect of prolixin and other antipsychotic medication is tardive dyskinesia. Tardive dyskinesia is characterized by rhythmical, repetitive, involuntary movements of the tongue, face, mouth, or jaw, sometimes accompanied by other bizarre muscular activity. Winick, Supra ; Zander, Supra ; DuBose, Supra ; Greenberg, Tr. I, 28. The risk of this disorder is greatest in elderly patients, especially women, and is associated with prolonged use. Zander, Supra at 40.

 Finally, it should be mentioned that British researchers have suggested a link between prolixin and suicidal depression. Zander, Supra. It is too early for scientists, much less the court, to draw any firm conclusions from this research. Stinnett, Tr. XI, 37.

 C. Lithium Carbonate

 As lithium is another drug previously used and presently recommended by some doctors in Mr. Rennie's case, a short discussion is appropriate. Lithium carbonate is now established as the most effective treatment available for mania, an affective disorder marked by extreme elation, hyperactivity, grandiosity, and accelerated thinking and speaking. It also prevents the recurrence of both the manic and depressive episodes which alternately afflict patients with bipolar manic-depression. Winick, Supra at 787; Pepper, Tr. VIII, 40; Testimony of Dr. Richard F. Limoges, Tr. XII, 27-29, 4/20/78. However, in a bipolar case, an antidepressant such as tofranil, amitripyene or imipramine must be added to prevent depression. Tr. VIII, 40; Tr. XII, 29.

 V. The Appropriate Treatment for Mr. Rennie

 A. Plaintiff's Condition as of December 1977

 It is at this juncture appropriate to resume the history of Mr. Rennie and the events which raised the forced medication issue. In early December 1977, the staff of Ancora felt that plaintiff was highly homicidal, and that his general condition was deteriorating. Bugaoan, Tr. III, 137-39. On December 5, a meeting was convened attended by Dr. Bugaoan, Dr. Pepernik, Dr. Ortanez, and the members of plaintiff's treatment team to discuss the situation. Ex. D-2; Bugaoan, Tr. IV, 94. The next day, Dr. Pepernik sought and received permission from the Attorney General's office to administer medication without consent. At a hospital treatment team meeting on December 7, a multi-modal treatment plan for plaintiff was formulated, including the administration of prolixin hydrochloride. The decision to compel medication was made to prevent plaintiff from harming other patients, staff, and himself and to ameliorate his delusional thinking pattern. Prolixin was chosen because, in the decanoate form, it is the only injectable long-acting drug. Tr. IV, 121. It was thought that in the post-hospitalization period, it would be easiest to maintain Mr. Rennie on prolixin decanoate, with one injection every two weeks, since he had a history of failing to continue his medication once released. In the month following the initiation of the prolixin regime, Mr. Rennie's condition improved markedly. Ex. D-2; Tr. II, 129-30. After his dosage was lowered to 15 mg/day by the court order of December 30, it was reported that his behavior was controllable. However the staff psychiatrists felt the dosage to be insufficient to treat his thought disorder. Tr. III, 86.

 B. Plaintiff's Diagnosis

 Obviously, before drugs can be prescribed, plaintiff's condition must be known. Perhaps the question most contested during the hearings was plaintiff's proper diagnosis. While psychotropic drugs are generally regarded as the treatment of choice for schizophrenia, lithium, with an antidepressant, is the treatment of choice for manic depression. As plaintiff is presently willing to take lithium, *fn4" this case would be moot if manic depression were the consensus diagnosis.

 As noted earlier, at various times during plaintiff's prior hospitalizations, diagnoses of both schizophrenia and manic depression were offered. There is a thin line between these two illnesses. Pepper, Tr. XIV, 78, 4/28/78. No expert indicated any medical agreement as to whether the two disorders arise from different environmental causes, or represent different physiological states within the brain. Instead, the testimony concentrated on symptomatology. Furthermore, there was little testimony on how the psychopharmacological substances work in the brain. This emphasis on symptoms and lack of certainty about causation and physiopathology demonstrates the tentativeness of much psychiatric diagnosis as compared to the usual physical diagnosis. The experts who testified concerning Mr. Rennie's disorder are in great disagreement. Drs. Heller and Bugaoan believe plaintiff is schizophrenic. Tr. XII, 40. Drs. Ortanez and Pepernik give a diagnosis of schizophrenia, affective type. Tr. III, 71, Tr. X, 109, but Ortanez agrees that plaintiff has also shown a manic depression symptoms at times. Tr. III, 75. Dr. Stinnett diagnoses plaintiff as manic depressive, but offers schizo-affective disorder as a possible alternative diagnosis. Tr. XI, 15. Finally, Drs. Limoges and Pepper feel that plaintiff suffers only from manic depression. Tr. XII, 32; VIII, 31.

 There is much overlap between the two diagnoses and disagreement among experts. Manic depression is basically a mood disorder, while schizophrenia is primarily a thought disorder, characterized by delusions, hallucinations, and faulty logic. However, manic depressives can also show thought disorders at the manic end of the mood swing. But, true schizophrenia is characterized by sustained rather than episodic periods of thought disorder. Further, a manic depressive's periods of thought disorder will be tied to his mood swings, unlike a schizophrenic's cognitive dysfunctions. In addition, schizophrenics can show mood disorder as a secondary symptom. This is called schizophrenia, affective type, or schizo-affective disorder. Stinnett, Tr. XI, 20; Ortanez, Tr. III, 71.

 The problem facing the doctors diagnosing Mr. Rennie is obviously complex. Simplified for the lawyer's mind, one of the key inquiries is whether Rennie's assertions that he is the "alpha omega," Tr. VII, 25, or Christ, are firm and fixed schizophrenic delusions or mere grandiosity characteristic of his manic euphoria. Dr. Limoges believes the latter and thus would only prescribe lithium and an antidepressant to combat plaintiff's manic depression. Tr. XII, 26, 118-19.

 Dr. Stinnett however testified that while his diagnosis was manic depression, the distinction is largely academic. He found the symptoms to warrant both antipsychotic medication and lithium. An antipsychotic was deemed necessary both to curb the patient's perceived delusions and to control the destructive aspects of his behavior. Tr. XI, 22-23. While Dr. Ortanez lacks Dr. Stinnett's experience and expertise, *fn5" as the treating physician Dr. Ortanez also believed that both antipsychotics and lithium would be appropriate based on his perception of combined symptoms.

 A little knowledge can be dangerous, and this court is hesitant to diagnose mental illness and prescribe medication. But it is possible to draw these conclusions. Plaintiff is acutely psychotic at times. Stinnett, Tr. XI, 135. Aside from his adverse reaction to psychotropics, the best course of treatment for Mr. Rennie would combine psychotropic medication with lithium and an antidepressant. However, the position that he has no fixed delusions, thus making use of a psychotropic unnecessary, is, at the least, a reasonable proposition.

 C. Use of Pharmaco-therapy as the Sole Therapy

 Defendants have produced at least one study, May, Supra, demonstrating that drugs alone are an effective means of curing schizophrenia. Testimony has also indicated that drugs must be used initially to bring Mr. Rennie into contact with reality before any other therapy may be usefully employed. Bugaoan, Tr. III, 143; Stinnett, Tr. XI, 16; Heller, Tr. XIII, 33.

 However, the court rejects any solution to the problems of this case which would allow Mr. Rennie to be treated with an antipsychotropic drug alone. Dr. Stinnett expressed in the strongest possible terms that both pharmacotherapy and psychotherapy would have to be used to improve Mr. Rennie's conditions and not one without the other. The court fully accepts Dr. Stinnett's recommendation. Dr. Pepper concurred in stating that medicine cannot be successful outside of a good total treatment plan. Tr. VIII, 34. Only in the context of a trusting relationship achieved through psychotherapy can medicine be employed in a rational way. Tr. XI, 16.

 D. Plaintiff's Reaction to Psychotropics

 John Rennie suffers from many of the side effects described above. He experiences blurred vision and a dry mouth. Rennie, Tr. XIV, 144, 4/28/78. On thorazine, his blood pressure has dropped. Tr. I, 35. He also suffers from akathesia on prolixin, getting uncontrollable tremors. Tr. XIV, 144. This, and the fact that he feels his senses are dulled, are his two principal reasons for refusal of prolixin. Tr. I, 35. Despite the hospital's assertion that Mr. Rennie has faked akathesia, Bugaoan, Tr. IV, 125 this court is convinced that the akathesia is real and extremely unpleasant. Pepper, Tr. VIII, 22; Heller, Tr. XIII, 22. The hospital doctors are to be faulted for ignoring plaintiff's subjective reports of akathesia while on prolixin. Stinnett, Tr. XI, 55.

 E. The Efficacy of Forced Medication

 As noted above, a trusting relationship or therapeutic alliance between psychiatrist and patient is essential for a drug regimen to succeed. Stinnett, Tr. XI, 16; Limoges, XII, 73. Plaintiff has demonstrated that psychotropic drugs are less efficacious in a hostile or negative environment. Stinnett, XI, 35, 108; Pepper, VIII, 57. As a corollary to this, even if the best drug is prescribed, if the patient is unwilling to accept it, the positive effects are greatly lessened, especially in terms of long range benefits. Pepper, Tr. VIII, 76; Limoges, Tr. 72; O'Connor v. Donaldson, 422 U.S. 563, 579, 95 S. Ct. 2486, 45 L. Ed. 2d 396 (1975) (Burger, C. J., concurring).

 F. Plaintiff's Competency to Make Medication Decisions

 John Rennie's psychiatric problems are of a cyclical nature, so that on some days he is psychotic. Dr. Pepper testified that plaintiff's refusal of prolixin is not a product of his mental disorder. Tr. XIV, 123. However, Dr. Stinnett found that during his examination on February 25, 1978, Mr. Rennie was not capable of making a decision on treatment in his best interests. Tr. XI, 112. The court feels that Dr. Pepernik's assessment is most accurate, and that Mr. Rennie's wishes should be taken into account on any treatment decision. But the court finds that his capacity to participate in the refusal of medicine or the choice of medicine is somewhat limited, depending on the day. Tr. VII, 24; Cf. Shwed, Protecting the Rights of the Mentally Ill, 64 A.B.A.J. 564, 566 (1978); Comment, Forced Drug Medication, supra at 113. The court does believe that Mr. Rennie's reports of his subjective reactions to particular drugs are generally accurate.

 CONCLUSIONS OF LAW

 I. Introduction New Jersey Law

 A New Jersey state court has recently been faced with a factual situation very similar to this case. In re Hospitalization of B, 156 N.J.Super. 231, 383 A.2d 760 (Law Div.1977) involved an involuntarily committed patient who was refusing prolixin. B had not responded to all conventional therapies, and the treating physician sought the court's permission to administer a psychotropic drug. B had not been declared incompetent. N.J.Ct.R. 4:83.

 Looking to the New Jersey statutes, the court quoted N.J.S.A. 30:4-24.2(d)(1), which states that:

 
No medication shall be administered unless at the written order of a physician. Notation of each patient's medication shall be kept in his treatment records. At least weekly, the attending physician shall review the drug regimen of each patient under his care. All physician's orders or prescriptions shall be written with a termination date, which shall not exceed 30 days. Medication shall not be used as punishment, for the convenience of staff, as a substitute for a treatment program, or in quantities that interfere with the patient's treatment program. Voluntarily committed patients shall have the right to refuse medication.

 Based on this statute the court held that involuntarily committed patients do not have the right to refuse medication. Involuntary patients "are protected by nothing more than the court's review, the occasional consultation of an independent expert and the promised administrative procedure." 156 N.J.Super. at 238, 383 A.2d at 764. Thus, plaintiff is ...


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