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,
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.
Mr. Rennie also has shown wormlike movements of the tongue. This is a preliminary symptom which is possibly indicative that tardive dyskinesia may develop if medication is continued. Pepper, Tr. XIV, 34. Thus, there is a risk of permanent damage from psychotropic medication in Mr. Rennie's case, and Mr. Rennie requires extremely close monitoring if these drugs are to be continued.
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 proceeding under § 1983 to determine if the state scheme is constitutionally defective.
New Jersey does recognize the emerging right to treatment of mental patients. N.J.S.A. 30:4-24.1; State v. Carter, 64 N.J. 382, 393-04, 316 A.2d 449 (1974); See also Wyatt v. Aderholt, 503 F.2d 1305 (5th Cir. 1974).
II. Standards on a Preliminary Injunction
Generally, four factors are to be considered on an application for a preliminary injunction: (1) whether the moving party has shown that it is likely to prevail on the merits, (2) whether the movant has demonstrated that he would be irreparably harmed if the preliminary injunction is denied, (3) whether the grant of the injunction would harm other interested parties to a greater extent than it would benefit movant, and (4) whether the public interest would be served. A. O. Smith Corp. v. F. T. C., 530 F.2d 515, 525 (3rd Cir. 1976). Defendants argue that there can be no showing of probability of success on the merits where novel legal issues are raised.
Certainly the issue of a federal right to refuse medication is novel and complex. However, the case has not followed the usual course of a preliminary injunction hearing. Hearings have been held on fourteen dates over a period of four months. The court has heard testimony from nine psychiatrists. Counsel have aided the court with excellent briefs. Thus, while more information is always desirable, the court feels that it should not avoid a consideration of the merits in this instance merely because the issues are novel.
Defendants argue that this court should abstain in this case so as to allow a state appellate court to consider the issue. Abstention is only appropriate in narrowly limited special circumstances. Zwickler v. Koota, 389 U.S. 241, 248, 88 S. Ct. 391, 19 L. Ed. 2d 444 (1967). It is proper when a federal constitutional claim is premised on an unsettled question of state law and where a state court decision on the state law issue might avoid the constitutional problem. Frederick L. v. Thomas, 557 F.2d 373, 381 (3rd Cir. 1977).
In this case, the state statute is clear. N.J.S.A. 30:4-24.2(d)(1) provides that voluntary patients may refuse medication, and thus by implication, involuntary patients may not. A recent state case, In re Hospitalization of B, supra, has settled the point. The fact that an appellate court has not decided the issue is not dispositive.
Furthermore, abstention is discretionary. Frederick L., supra at 382. It would be inequitable to send plaintiff back to state court at this stage of the proceedings. Therefore, the court will not abstain.
IV. The Federal Constitutional Issues
The plaintiff alleges numerous constitutional grounds in support of his position. These claims generally track the course charted in Scott v. Plante, 532 F.2d 939 (3rd Cir. 1976). See also Souder v. McGuire, 423 F. Supp. 830 (M.D.Pa.1976). Scott, a patient of Trenton State Hospital, had five pro se complaints dismissed by the district court. One claim challenged the involuntary administration of medications, including thorazine, mellaril, and trilafon. The Third Circuit, in reversing the motion to dismiss, outlined in dictum how such a claim could establish a constitutional deprivation.
. . . (Existing) case law points to at least three n9 conceivable deprivations that may accompany the involuntary administration of such substances by state officers acting under color of state law to inmates confined in a state institution. . . . (T)he involuntary administration of drugs which affect mental processes . . . could amount, under an appropriate set of facts, to an interference with Scott's rights under the first amendment. See Mackey v. Procunier, 477 F.2d 877 (9th Cir. 1973); Kaimowitz v. Dep't of Mental Health, Civ.No. 73-19434-AW (Mich. Cir. Ct., Wayne County, July 10, 1973). Moreover, on this record we must assume that Scott, though perhaps properly committable, has never been adjudicated an incompetent who is incapable of giving an informed consent to medical treatment. Under these circumstances due process would require, in the absence of an emergency, that some form of notice and opportunity to be heard be given to Scott or to someone standing In loco parentis to him before he could be subjected to such treatment. Finally, under certain conditions, Scott's claim may raise an eighth amendment issue respecting cruel and unusual punishment. See Knecht v. Gillman, 488 F.2d 1136 (8th Cir. 1973); Mackey v. Procunier, supra at 878.