## Facts

- Voluntary and involuntary patients at units of a state hospital challenged seclusion and administration of antipsychotic medication without consent.
- The case arose during federal litigation concerning the forcible administration of antipsychotic drugs to involuntarily committed patients.
- A federal appellate court certified nine questions of Massachusetts law concerning (i) competency to refuse treatment and (ii) standards and procedures for forced antipsychotic medication.
- The Supreme Judicial Court of Massachusetts answered the certified questions as a statement of governing state-law rules; it did not resolve liability or damages.

## Issues

1. Whether involuntary civil commitment alone constitutes a determination that the patient is incompetent to make treatment decisions.
2. Who may determine incompetence, and what process is required.
3. Which Massachusetts courts may decide incompetence and authorize treatment using substituted judgment.
4. What substantive standard applies before an incompetent, involuntarily committed patient may be forcibly medicated with antipsychotic drugs.
5. What procedures must be followed before court-approved forced medication may occur.
6. Whether any state interest permits nonemergency forced administration of antipsychotic drugs to a competent patient who refuses.
7. When antipsychotic medication may be administered without consent as an emergency “chemical restraint.”
8. How an “emergency” is defined for purposes of immediate forced medication.
9. What must occur if clinicians intend to continue forced medication beyond the emergency period.

## Decision

- Involuntary civil commitment does not, by itself, establish incompetence to make treatment decisions.
- Incompetence cannot be determined by physicians; it requires a judicial determination made pursuant to applicable statutes.
- Probate Court, Superior Court, Juvenile Court, and the juvenile session of a District Court may make incompetence and substituted-judgment determinations for mental patients.
- For an involuntarily committed patient adjudicated incompetent, a judge must decide—using substituted judgment—whether the patient would consent to antipsychotic medication, and should approve a treatment plan after notice and hearing; the guardian monitors implementation.
- No state interest justifies administering antipsychotic drugs in a nonemergency situation without the competent patient’s consent.
- Antipsychotic drugs used to prevent violence, suicide, or to preserve institutional security function as chemical restraints and must comply with statutory restraints requirements.
- Emergency medication without prior court approval is permitted only to prevent the immediate, substantial, and irreversible deterioration of a serious mental illness.
- If continued medication over objection is expected after emergency administration, clinicians must seek adjudication of incompetence and, if incompetence is found, obtain a court-ordered substituted-judgment treatment plan.

## Legal Principles

- Civil commitment does not eliminate a patient’s decisional capacity; competence is presumed unless and until a judge rules otherwise.
- A judicial finding of incompetence is a prerequisite to nonemergency forced antipsychotic medication; medical staff may not unilaterally declare incompetence for treatment purposes.
- When incompetence is adjudicated, the court must apply substituted judgment—deciding what the patient would choose—before authorizing antipsychotic medication and approving a specific treatment plan after notice and hearing.
- A guardian’s role includes oversight of the court-approved treatment plan rather than serving as the primary decision-maker for forced medication.
- Nonemergency state interests (including parens patriae and institutional concerns) are insufficient to override a competent patient’s refusal of antipsychotic drugs.
- Emergency forced medication is narrowly limited and may be used only to avert immediate, substantial, and irreversible deterioration of serious mental illness; ongoing treatment requires prompt judicial involvement.

## Conclusion

The court established that committed mental patients retain the right to refuse antipsychotic medication unless a judge finds them incompetent and, in nonemergencies, authorizes treatment through a substituted-judgment order with procedural safeguards; emergency medication is allowed only under a tightly limited deterioration standard and cannot be extended without court action.


Rogers v. Comm'r of the Dep't of Mental Health, 458 N.E.2d 308 (Mass. 1983)