This case involves two substituted judgment proceedings on petitions filed, following the precedent of Rogers v. Commissioner of the Dept. of Mental Health, 390 Mass. 489 (1983), and cases decided in its wake, in respect to the administration of antipsychotic medications to L.H. L.H. appeals from a decree and findings of the Probate and Family Court that she was not competent to make medical decisions and would benefit from a proposed treatment plan to use the antipsychotic drug Risperdal, and that she would consent to use of that drug were she competent. L.H. also appeals from the judge's subsequent allowance of a motion to reinstate and to modify the treatment plan to allow for the administration by injection of Risperdal. The two appeals were consolidated here.
L.H. argues on appeal that there was insufficient evidence that the administration of antipsychotic medication was appropriate. In addition, L.H. argues that her trial counsel rendered ineffective assistance. We affirm.
For the reasons addressed in part 1, we conclude that the evidence in these substituted judgment proceedings and the probate judge's findings established by a preponderance that L.H. was in need of treatment with antipsychotic drugs. See G. L. c. 190B, § 5-306A. See generally Guardianship of Erma, 459 Mass. 801, 802 n.2 (2011) (discussing substituted judgment in context of involuntary administration of antipsychotic drugs). For the reasons addressed in part 2, we decline to reach the ineffective assistance of counsel claims in these direct appeals. First, such claims are not fully developed on this trial record and were not further developed in a motion for new trial. Second, based on the extant record that underlies the direct appeals, nothing has been made to appear that the standard of prejudice would be met in this particular case. A showing of prejudice is the governing standard for ineffective assistance claims in civil cases involving fundamental liberty interests in the administration of antipsychotic medication, such as presented in this case. See generally Poe v. Sex Offender Registry Bd., 456 Mass. 801, 813 (2010), quoting from Commonwealth v. Mahar, 442 Mass. 11, 15 (2004) (prejudice in ineffectiveness claims is "a `reasonable probability' that `but for counsel's unprofessional errors, the result of the proceeding would have been different'").
On November 30, 2009, LHCC staff members Mark O'Flaherty and John Handren (collectively, petitioners) filed a petition in the Probate and Family Court seeking appointment of a guardian for L.H. pursuant to G. L. c. 190B, § 5-303. The petition later was amended to include a proposed antipsychotic treatment plan. Because L.H. challenges the commencement of the proceedings in the first instance, we note that Dr. Anthony Joseph, a psychiatrist, completed and signed the statutorily required medical certificates and supporting documentation, all of which were filed with the court as the proceedings began. These documents, including the medical affidavit and treatment plan, detail L.H.'s physical and mental condition at the time the proceedings were commenced and, we conclude, justified the petition undertaken.
A hearing was held on August 30, 2010. The witnesses included Dr. Joseph of LHCC; Dr. David Rosmarin, an independent forensic psychiatrist retained by L.H.'s court-appointed counsel; L.H.; and her court-appointed temporary guardian.
Regarding L.H.'s prognosis if left untreated, Dr. Joseph predicted that she would "continue the way she is," and added that he "would be very concerned about what kind of facility she would end up in in New York, how long they would keep her."
The second psychiatric expert witness, Dr. Rosmarin, who had been retained by counsel for L.H., also stated medical opinions that tended to support the position that L.H. would benefit from the proposed treatment plan. Dr. Rosmarin had examined L.H. at length, and had spoken with LHCC staff in detail. This psychiatrist diagnosed L.H. as having a personality disorder with obsessive compulsive symptoms and suggested she could benefit from treatment with antipsychotic medicine, although at a lower dose than was proposed: "This lady needs very careful management but with a very careful behavioral plan in concert possibly with two kinds of medications. One would be a very low dose of antipsychotic. I don't have an objection to that."
The guardian testified he had met with L.H., consulted with LHCC staff, and spoken with L.H.'s sister on three or four occasions. Based on those discussions, the guardian stated, "I think she needs some supervision and she needs some medication."
At the conclusion of the hearing, the judge found "that the testimony of the two physicians that have been proffered to the court today are really not diametrically opposed. They both appear to me to agree that treatment is needed, continuation of the guardianship is warranted and that the treatment plan as proposed, actually by both physicians, in my opinion, involves both medical treatment, a psychotropic drug treatment, together with a behavioral treatment."
In his findings of fact, the judge acknowledged L.H.'s stated preference against the proposed antipsychotic medication, but found, listing the Rogers decisional factors,
Accordingly, the judge authorized the proposed treatment plan (with modifications proposed by Dr. Rosmarin and accepted by Dr. Joseph) and appointed a permanent guardian and Rogers monitor for L.H. The judge scheduled the treatment plan for review on December 6, 2010, the date the order was set to expire. The plan expired on schedule on December 6, 2010.
On September 1, 2011, staff of LHCC, as the petitioners, filed a motion in the Probate and Family Court to reinstate the Rogers order and to modify it to allow an injectable form of the antipsychotic medication to be administered because L.H. was refusing to take Risperdal orally. The testimony at this hearing reflected L.H.'s persistent mental disabilities. Dr. Joseph provided a diagnosis similar to his medical opinion at the August, 2010, hearing, i.e., that L.H. suffered from "atypical psychosis" with symptoms manifested as "paranoia, agitation, [and] dysphoria.... Poor insight and judgment around the treatment of her mental illness."
Dr. Joseph also supported the modification of the treatment plan modification to include injectable medication, stating, "Most likely she would become much less paranoid, much less agitated and would have a much improved quality of life in terms of her sense of well being and satisfaction." The prognosis
As she had at the August, 2010, hearing, L.H. strenuously objected to antipsychotic treatment, stating, "I was refusing to take the Risperdal because of the unbearable side effects.... I'd rather be dead than go through that."
The judge allowed the motion to reinstate the Rogers order and to continue the treatment plan, and to modify the order for treatment to allow for an injectable form of drug administration.
As previously noted, this appeal concerns both the petition for guardianship and the order for administration of antipsychotic medication, as well as the reinstatement order with the modification for administration of the drug by injection.
2. Ineffective assistance of counsel. In this appeal, L.H. also
We bear in mind Supreme Judicial Court precedent that patients faced with the administration of antipsychotic drugs under a substituted judgment standard are entitled to the effective assistance of counsel. "[I]n a proceeding that involves a person's liberty or a fundamental liberty interest, in which a person has a right to appointed counsel, from whatever source,[
First, the trial record alone — absent further development by a new trial motion — does not provide us the necessary background to evaluate the attorney's tactical choices, nor his interaction with L.H., the client. On the one hand, criticism of counsel's performance is warranted, including his weak direct and cross-examination practice and an ambivalent closing argument. But then, we do not have before us what rationale drove counsel's trial strategy, nor how that strategic approach was affected by L.H.'s psychiatric expert, who seemed to share the opinion (with the petitioners' expert) that L.H. would benefit from the administration of Risperdal. Nor do we have before us information concerning counsel's dealings with an incapacitated client, and what strategic choices may have been considered by counsel in light of what would be the tone and the substance of the testimony. For example, was there consideration by counsel that to allow Dr. Rosmarin to speak about a reduced dosage of Risperdal might be a fall-back position to avoid the larger dosage advocated by Dr. Joseph? Evidence that may contradict an incapacitated person's testimony that she is adverse to any medication does not per se give rise to ineffective assistance of counsel or (as discussed infra) prejudice in the ultimate judgment. In short, absent what might have been probed in a new trial motion, we cannot discern on this record alone what tactical choices and what client issues may have factored into counsel's performance.
As stated in Patton, 458 Mass. at 128, in cases such as this, where the record is inchoate, the preferred mode to give backdrop for appellate review might have been by a motion for new trial, which, if denied, could be joined with a direct appeal. Such a new trial motion was not filed or adjudicated in this case. As the court wrote in Patton:
Second, and more significantly as to why we decline to reach the ineffective assistance of counsel challenge in these direct appeals, is that what does exist in the record does not reflect that a different result would have obtained, and that there was prejudice in the findings and orders. In this respect, although Supreme Judicial Court precedent looks to the Saferian criminal standard in assessing ineffective assistance of counsel in a civil case involving fundamental privacy issues and the administration of antipsychotic drugs in a Rogers context, the Saferian standard is modified to focus on prejudice. See Commonwealth v. Saferian, 366 Mass. 89, 96 (1974). The Supreme Judicial Court has so stated as follows:
Poe, 456 Mass. at 812-813.
In this case, even given counsel's less-than-stellar performance, the evidence and the record of the proceedings, in our opinion, does not come close to meeting this legal standard of prejudice. To the contrary, taking the record as is, there is much strength in the evidence that supports the judge's decisions on substituted judgment to administer antipsychotic medications.
Decree entered September 3, 2010, affirmed.
Order reinstating and expanding Rogers order, entered September 9, 2011, affirmed.
With a significant loss of liberty and her own bodily integrity at stake, L.H., though represented by appointed counsel throughout these proceedings, was left without an advocate for her interests, and was forced to express those interests herself in the face of cross-examination, expert testimony, and argument against her by her own counsel. While L.H. repeatedly asserted that the side effects of the antipsychotic medication caused "anxiety [and] despair," felt like "torture," and that she would "rather be dead" than take it, her counsel took the position of the adversary, Lowell Health Care Center (LHCC), specifically, two staff members of LHCC (collectively, petitioners). Just as L.H.'s counsel and expert advocated, the August 30, 2010, hearing resulted in orders for her guardianship and for the involuntary administration of an antipsychotic drug, Risperdal. The majority maintains that despite this predicament, L.H. was not deprived of the effective assistance of counsel because the record does not reveal whether her counsel's actions were strategic and, in any case, because there was ample evidence to support the Probate and Family Court judge's decisions. I disagree. When a client's interests are not represented by her attorney and a judge's decision relies upon testimony and argument arising from the client's attorney's deficient representation,
A. L.H.'s attorney knew his client's interests. Over the course of three hearings, L.H. made her position clear to counsel and to the judge. At an abbreviated hearing on August 16, 2010, L.H. expressed her unequivocal opposition to the administration of antipsychotic medications. At the hearing on August 30, 2010, she testified that she had taken a low dose of Risperdal a few years earlier for a several-month period and had experienced "severe side effects" including loss of bladder control, vision problems, pain, anxiety, and despair. She added, "I'd rather you kill me than go through that again." L.H. also indicated that as
B. Right to refuse medical treatment. Under Massachusetts law, every person has the right to accept or to reject medical treatment, even when the decision is contrary to the express wishes of qualified medical personnel acting in what they consider to be the person's best interests. See Superintendent of Belchertown State Sch. v. Saikewicz, 373 Mass. 728, 738-739, 745 (1977); Guardianship of Roe, 383 Mass. 415, 433-435 (1981); Harnish v. Children's Hosp. Med. Center, 387 Mass. 152, 154 (1982). "No right is held more sacred, or is more carefully guarded, by the common law, than the right of every individual to the possession and control of his own person, free from all restraint and interference of others, unless by clear and unquestionable authority of law." Union Pac. Ry. Co. v. Botsford, 141 U.S. 250, 251 (1891).
This right is enjoyed equally by those who may be incompetent as well as by the competent "because the value of human dignity extends to both.... To protect the incompetent person within its power, the State must recognize the dignity and worth of such a person and afford to that person the same panoply of rights and choices it recognizes in competent persons." Rogers v. Commissioner of the Dept. of Mental Health, 390 Mass. 489, 499 500 (1983), quoting from Saikewicz, 373 Mass. at 745-746. When, due to mental illness, a person lacks the capacity to consent to medical treatment, the methodology to preserve and to implement free choice and self-determination is substituted judgment. In proceedings both for guardianship and for treatment based on substituted judgment, a judge has an obligation to determine, whenever it is possible, the allegedly incapacitated person's "desires and intentions." Guardianship of Zaltman, 65 Mass.App.Ct. 678, 685 (2006). In fact, the incapacitated person's personal preference is regarded as a "critical factor" in the judge's decision:
Id. at 685-686 (citations omitted).
The law acknowledges that there are differing degrees of incapacitation, that among those who are found to be incapacitated and in need of guardianship there are persons who have "decision-making capability" as to some though not all of their personal affairs, and that "a mentally ill person may still possess the faculties to have an informed opinion about her treatment." Id. at 687 (citations omitted). See Matter of Spring, 8 Mass.App.Ct. 831, 838 (1979), S.C., 380 Mass. 629 (1980) ("when a person becomes incompetent to formulate a lucid judgment he is not thereby stripped of the right of choice enjoyed by others in the making of treatment decisions"). In short, L.H. had a right to assert her refusal of treatment, and to have that refusal considered by the judge.
C. Counsel's duty to represent L.H.'s interests. Although L.H.'s right to counsel is based on provisions of the Massachusetts Uniform Probate Code, specifically, G. L. c. 190B, §§ 5-106(a) and 5-306A(a), her counsel's obligations are defined by common and constitutional law, and rules established by the Supreme Judicial Court.
1. Case law. An observation in the very helpful amicus brief, submitted jointly by the Mental Health Legal Advisors Committee, the Disability Law Center, and the Center for Public Representation, deserves emphasis: "[e]mpirical studies establish that the quality of counsel is the single most important factor determining the disposition of hearings related to involuntary medical care."
In Matter of M.R., the New Jersey Supreme Court explained why it is vital that the lawyer represent the stated interests of a client who may be under a disability:
Id. at 176-177.
2. Massachusetts Rules of Professional Conduct. Supreme Judicial Court Rule 3:07, as appearing in 426 Mass. 1303 (1998), i.e., the Rules of Professional Conduct, directly addresses the obligations of counsel in cases "when a client's capacity to make adequately considered decisions ... is diminished... because of ... mental impairment." Mass.R.Prof.C. 1.14(a), as appearing in 452 Mass. 1301 (2008). Rule 1.14 provides that "the lawyer shall, as far as reasonably possible, maintain a normal client-lawyer relationship with the client." This means that when an attorney represents a client with diminished capacity due to mental illness, counsel still has the duties to provide competent representation, see Mass.R.Prof.C. 1.1, 426 Mass. 1308 (1998); to seek the lawful objectives of the client, see Mass.R.Prof.C. 1.2, 426 Mass. 1310 (1998); to act reasonably diligently and to represent her zealously, see Mass.R.Prof.C. 1.3, 426 Mass. 1313 (1998); to maintain communications with and advise the client, see Mass.R.Prof.C. 1.4, 426 Mass. 1314 (1998); and to maintain client confidences as far as reasonably possible, see Mass.R.Prof.C. 1.6, 426 Mass. 1435 (1998).
3. Committee for Public Counsel Services performance standards. A third source of important guidance to Massachusetts lawyers who face the challenge of representing a client with diminished capacity due to mental illness in substituted judgment proceedings is the Committee for Public Counsel Services (CPCS). Pursuant to G. L. c. 211D, §§ 6(b) and 9, CPCS has promulgated "performance standards governing the representation of indigent adults in guardianship proceedings under G. L. c. 190B (including `substituted judgment' matters) and in authorization to treat proceedings under G. L. c. 123" (CPCS guidelines), which "describe the steps which must, at a minimum, be taken by an attorney" assigned to represent an adult client in guardianship proceedings as well as in proceedings seeking the authority to administer antipsychotic medication. Guideline 1 states that counsel for L.H. "must oppose the [substituted judgment] petition and present `all reasonable alternatives' to the proffered treatment."
Under both Mass.R.Prof.C. 1.14 and the CPCS guidelines, any differences notwithstanding, a lawyer in a guardianship case must oppose the petition and must zealously advocate for the client. More specifically, pursuant to guideline 12, the lawyer must "(a) file any and all appropriate motions and legal memoranda, including but not limited to motions regarding the assertion of privileges and confidential relationships, and the admission, exclusion or limitation of evidence; (b) present and cross-examine witnesses, and provide evidence in support of the client's position; (c) make any and all appropriate evidentiary objections and offers of proof, so as to preserve the record on appeal; and (d) take any and all other necessary and appropriate actions to advocate for the client's interests."
The adversarial model does not place counsel for a mentally
D. Counsel failed to represent L.H.'s interests. My analysis of counsel's representation focuses on two hearings: one held on August 30, 2010, and a second held on September 1, 2011. At both hearings, L.H.'s counsel actively worked against her interests.
1. August 30, 2010, hearing. At this hearing, counsel for the petitioners informed the judge that in addition to a permanent guardianship, they also sought approval to treat L.H. with Risperdal. One of the petitioners' witnesses was Dr. Anthony Joseph, a psychiatrist. On cross-examination of Joseph, L.H.'s counsel went farther than petitioners' counsel and elicited information about Joseph's role at LHCC, his interactions with L.H., her medical and psychiatric history, and the basis for his opinion that she required antipsychotic medication. When prompted by L.H.'s counsel, Joseph gave examples of her paranoid behavior from his personal interactions with her, such as her belief that staff persons at LHCC had tried to harm her. Joseph also was given the opportunity to expand upon his own recommended treatment using antipsychotic medication and to explain how it would have only a few side effects.
Counsel for L.H. also called Dr. David Rosmarin as an expert witness. With Rosmarin's testimony, counsel severely damaged his client's position. Contrary to L.H.'s explicit and consistent wishes, her counsel elicited from Rosmarin his view that she was not credible, that she presently was incapable of living independently in the community, that she needed to have a guardian, and that she needed behavioral treatment and antipsychotic medication. Rosmarin testified, in a narrative style, that L.H. suffers from MS, and added that she was "intentionally uncooperative on physical exam" and was "malingering additional effects of weakness." He noted that L.H. did not have significant cognitive impairment from MS, but "contrary to her testimony" she was
In his closing argument, L.H.'s counsel conceded his client's position. He argued that "she needs behavioral treatment more than and perhaps instead of the antipsychotic medications." However, he then agreed with the judge that L.H.'s expert indeed had testified that she also needed antipsychotic medication, adding only that Rosmarin favored a lower dose of it than Joseph.
The lack of opposition by L.H.'s counsel and expert was the basis for the judge's determination. At the hearing, the judge stated that "the testimony of the two physicians that have been proffered to the court today are really not diametrically opposed. They both appear to me to agree that treatment is needed, continuation of the guardianship is warranted, and that the treatment plan as proposed, actually by both physicians, in my opinion, involve both medical treatment, a psychotropic drug treatment, together with a behavioral treatment."
2. September 1, 2011, hearing. On September 1, 2011, the judge conducted a hearing on the petitioners' motion to reinstate the Rogers order which had expired in December, 2010.
Counsel also failed to object to the hearsay testimony by Thomas B. Concannon, the guardian and Rogers monitor. When asked if he had "an opinion with regard to the proposed amendment to put the intramuscular Risperdal on the Rogers treatment," he answered, without objection, "From talking to the social workers, I think it's worth trying."
The final witness to testify was L.H. After repeating some of her earlier complaints, and being assured by the judge that she had been heard, L.H.'s lawyer addressed this remark to his client: "You need to understand that he's not listening to anything more. I told you you had to stop. I said stand up, speak up, shut up." The judge ruled that, based on the testimony of the three witnesses, the Rogers order was reinstated and expanded.
E. Prejudice to L.H. by counsel's failure to represent her interests. Ordinarily, a claim of ineffective assistance of counsel will not be considered for the first time on appeal. Commonwealth v. Zinser, 446 Mass. 807, 811 (2006). However, "when the factual basis of the claim appears indisputably on the trial record," the rule is more flexible. Commonwealth v. Keon K., 70 Mass.App.Ct. 568, 573-574 (2007). See generally Commonwealth v. Frisino, 21 Mass.App.Ct. 551 (1986). See also In re V.V., 349 S.W.3d 548, 587-588 (Tex. App. 2010) (noting "shocking brevity" of petitioner's parental rights termination trial; among counsel's numerous failings was failure to object to prejudicial evidence offered against client). As noted supra, counsel for L.H. (1) failed to object to prejudicial hearsay testimony by Concannon; (2) failed to object to Concannon's unqualified expert opinion that L.H. "needs some medication"; (3) enhanced the weight of the testimony by Joseph on direct examination as to L.H.'s incapacity and need for antipsychotic medication by filling in the missing gaps through cross-examination of Joseph;
Just as "unauthorized concessions of guilt" may constitute presumptive prejudice for purposes of ineffective assistance claims in criminal cases, Commonwealth v. Velez, 77 Mass.App.Ct. 270, 277 n.9 (2010), prejudice should be found in guardianship proceedings involving a request for a Rogers order in which the client has unequivocally and consistently opposed the administration of antipsychotics, but L.H.'s counsel, in effect, concedes that she would benefit from the administration of some dose of antipsychotic medication.
Nothing useful would be accomplished by remanding this case for a factual inquiry by the judge because the decisions made by L.H.'s counsel were contrary to the express wishes of his client, and thus manifestly unreasonable. See Commonwealth v. Satterfield, 373 Mass. 109, 115 (1977) (there may be cases "where the defense was so botched" that there would be no value in factual inquiry as to prejudice).
F. Conclusion. In Commonwealth v. Saferian, 366 Mass. 89 (1974), the Supreme Judicial Court rightly warned that if the doctrine of ineffective assistance of counsel developed into a
To ensure that the right to effective assistance of counsel does not become a hollow promise, it is imperative that we order a new trial when, as in this case, the record demonstrates that court-appointed counsel not only failed to advocate for his client's interests, but became an advocate for the very position his client opposed. For the within reasons, I respectfully dissent.
Rogers, 390 Mass. at 505-506 (citations omitted).
L.H. did not voice any religious objections to the drug or reference the opinions of kin, both of which are relevant factors in an analysis under Rogers.