University of Miami Law Review Volume 44 Number 1 Article 2 9-1-1989 The Right to Refuse Mental Health Treatment: A First Amendment Perspective Bruce J. Winick Follow this and additional works at: https://repository.law.miami.edu/umlr Part of the First Amendment Commons Recommended Citation Bruce J. Winick, The Right to Refuse Mental Health Treatment: A First Amendment Perspective, 44 U. Miami L. Rev. 1 (1989) Available at: https://repository.law.miami.edu/umlr/vol44/iss1/2 This Article is brought to you for free and open access by the Journals at University of Miami School of Law Institutional Repository. It has been accepted for inclusion in University of Miami Law Review by an authorized editor of University of Miami School of Law Institutional Repository. For more information, please contact [email protected]. University of Miami Law Review VOLUME 44 SEPTEMBER 1989 NUMBER 1 The Right to Refuse Mental Health Treatment: A First Amendment Perspective* BRUCE J. WINICK** I. INTRODUCTION .......................................................... 2 II. THE ORIGINS AND SCOPE OF THE FIRST AMENDMENT ................... 9 III. CONSTRUING "FREEDOM OF SPEECH": DOES THE FIRST AMENDMENT PROTECT MENTAL PROCESSES? ............................................ 14 A. The Supreme Court's Methodology: Deriving Corollary Rights from Freedom of Speech ............................................... 14 B. Supreme Court Protectionfor "Freedom of Belief" "Freedom of Mind," and "Freedom of Thought" ... .................................... 17 C. Freedom to Believe Distinguishedfrom Freedom to Act ................ 19 D. When Government Attempts to Impose Orthodoxy of Belief ............. 22 E. First Amendment Protection of Private Thoughts ...................... 27 F. The First Amendment Right to Receive Information and Ideas .......... 29 G. Freedomfrom Intrusion into Mental Processes as an Indispensable Condition for Freedom of Expression ................................ 30 IV. MENTAL PROCESSES AND THE VALUES OF THE FIRST AMENDMENT ....... 33 V. ARGUMENTS AGAINST FIRST AMENDMENT PROTECTION FOR MENTAL PROCESSES .............................................................. 41 A. Does the First Amendment Protect Insane or Disordered Thoughts? ...... 41 B. Is the First Amendment Implicated by Treatment that Restores Mental Processes to a "Normal" or "Healthy" State? ......................... 58 * Copyright 1989 by Bruce J. Winick. I am grateful to Ken Casebeer, Don Jones, Richard Mendales, Bernie Oxman, and Steve Winter for helpful comments and suggestions. ** Bruce J. Winick is a Professor of Law at the University of Miami School of Law. This Article is adapted from a chapter of the author's forthcoming book, THE RIGHT TO REFUSE TREATMENT: CONSTITUTIONAL LIMITATIONS ON MENTAL HEALTH AND CORRECTIONAL THERAPY. Professor Winick has previously addressed these issues in a number of published articles. See Winick, The Right to Refuse Psychotropic Medication: Current State of the Law and Beyond, in THE RIGHT To REFUSE ANTIPSYCHOTIC MEDICATION 7 (D. Rapoport & J. Parry eds. 1986); Winick, Legal Limitations on Correctional Therapy and Research, 65 MINN. L. REV. 331 (1981); Winick, A PreliminaryAnalysis of Legal Limitations on Rehabilitative Alternatives to Corrections and on CorrectionalResearch, in NEW DIRECTIONS IN THE REHABILITATION OF CRIMINAL OFFENDERS 328 (S. Martin, L. Sechrest & R. Redner eds. 1981) (National Academy of Sciences); Winick, PsychotropicMedication and Competence to Stand Trial, 1977 AM. B. FOUND. RES. J. 769, 810-14. 2 UNIVERSITY OF MIAMI LAW REVIEW [Vol. 44:1 VI.' JUDICIAL RECOGNITION OF A FIRST AMENDMENT RIGHT TO REFUSE TREATMENT: THE LOWER COURT DECISIONS ............................. 60 VII. MENTAL HEALTH TREATMENT TECHNIQUES AND THE FIRST AMENDMENT: A CONTINUUM OF INTRUSIVENESS ..................................... 63 A . Psychosurgery ................................................... 64 B. Electronic Stimulation of the Brain ................................. 66 C. Electroconvulsive Therapy ......................................... 67 D. Psychotropic M edication .......................................... 68 1. ANTIPSYCHOTIC DRUGS ........................................ 69 2. ANTIDEPRESSANT DRUGS ......................................... 76 3. ANTIANXIETY DRUGS ............................................. 76 4. LITHIUM ..... ................................................... 77 E. Behavior Therapy ................................................ 80 1. POSITIVE REINFORCEMENT TECHNIQUES ......................... 81 2. AVERSIVE THERAPY ........................................... 82 3. OTHER BEHAVIORAL TREATMENT TECHNIQUES ................... 82 F. Psychotherapy and Other Verbal Techniques .......................... 83 1. PSYCHOTHERAPY ................................................. 83 2. COUNSELING PROGRAMS FOR OFFENDERS ........................ 84 VIII. THE BURDEN IMPOSED ON GOVERNMENT TO JUSTIFY ABRIDGMENTS OF FIRST AMENDMENT RIGHTS ............................................. 90 IX. CONCLUSION. ........................................................... 101 I. INTRODUCTION One of the most significant issues facing the United States Supreme Court in its 1989 Term is the extent to which the Constitu- tion recognizes a right to refuse mental health treatment.' Involun- tary treatment, provided in mental hospitals, prisons, and increasingly in the community as a condition for release from these institutions, has produced an expanding body of case law 2 and commentary3 con- 1. Washington v. Harper, 109 S. Ct. 1337 (1989), granting cert. to Harper v. State, 110 Wash. 2d 873, 759 P.2d 358 (1988) (en banc). 2. E.g., United States v. Charters, 863 F.2d 302 (4th Cir. 1988) (en banc) (antipsychotic drugs); Bee v. Greaves, 744 F.2d 1387 (10th Cir. 1984), cert. denied, 469 U.S. 1214 (1985) (antipsychotic drugs); Lojuk v. Quandt, 706 F.2d 1456 (7th Cir. 1983) (electroconvulsive therapy); Rennie v. Klein, 653 F.2d 836 (3d Cir. 1981) (en banc), vacated and remanded, 458 U.S. 1119 (1982), on remand, 720 F.2d 266 (3d Cir. 1983) (en banc) (psychotropic drugs); Rogers v. Okin, 634 F.2d 650 (1st Cir. 1980), vacated and remanded sub nom. Mills v. Rogers, 457 U.S. 291 (1982), on remand, 738 F.2d 1 (1st Cir. 1984) (psychotropic drugs); Scott v. Plante, 532 F.2d 939 (3d Cir. 1976), vacated and remanded, 458 U.S. 1101, on remand, 691 F.2d 634 (3d Cir. 1982) (psychotropic drugs); Knecht v. Gillman, 488 F.2d 1136 (8th Cir. 1973) (aversive conditioning); Riese v. St. Mary's Hosp. & Medical Center, 196 Cal. App. 3d 1388, 243 Cal. Rptr. 241 (1987), appeal dismissed, 259 Cal. Rptr. 669, 774 P.2d 698 (1989) (psychotropic drugs); In re Mental Commitment of M.P., 500 N.E.2d 216 (Ind. 1986), superseded, 510 N.E.2d 645 (1987) (antipsychotic drugs); Kaimowitz v. Michigan Dep't of Mental Health, Civ. No. 73-19434-AW (Mich. Cir. Ct. [Wayne Cty.] July 10, 1973), excerpted at 42 U.S.L.W. 2063 (July 31, 1973), reprinted in A. BROOKS, LAW, PSYCHIATRY AND THE MENTAL HEALTH SYSTEM 902 (1974) (psychosurgery); Rivers v. Katz, 67 N.Y.2d 485, 504 N.Y.S.2d 74, 495 N.E.2d 337 (1986) (antipsychotic drugs); Harper v. State, 110 Wash. 2d 873, 759 P.2d 358 (1988) (en banc), cert. granted, 109 S. Ct. 1337 (1989) (antipsychotic drugs). 3. Eg., R. SCHWITZGEBEL, LEGAL ASPECTS OF THE ENFORCED TREATMENT OF 1989] RIGHT TO REFUSE TREATMENT cerning the "right to refuse treatment." Psychotropic drugs, which by definition affect mental processes, intellectual functioning, and per- ception, mood, and emotion,4 is the treatment technique that usually provokes the controversy, and the one most easily administered on an involuntary basis. In 1982 the Supreme Court considered the right to refuse treatment in Mills v. Rogers,5 in which the Court reviewed a class-wide injunction restricting the involuntary administration of psychotropic medication at the Boston State Hospital. The Court, however, avoided resolving this difficult issue, remanding the case to determine whether an intervening state court decision grounded in state law had rendered unnecessary resolution of the federal constitu- tional questions.' Lower federal courts and state courts have contin- OFFENDERS, (DHEW Pub. No. (ADM) 79-831, 1979); Appelbaum, The Right to Refuse Treatment with Antipsychotic Medications.: Retrospect and Prospect, 145 AM. J. PSYCHIATRY 413 (1988); Brooks, The Constitutional Right to Refuse Antipsychotic Medications, 8 BULL. AM. ACAD. PSYCHIATRY & L. 179 (1980); Friedman, Legal Regulation of Applied Behavior Analysis in Mental Institutions and Prisons, 17 ARIZ. L. REV. 39 (1975); Plotkin, Limiting the Therapeutic Orgy: Mental Patients'Right to Refuse Treatment, 72 Nw. U.L. REV. 461 (1977); Shapiro, Legislating the Control of Behavior Control: Autonomy and the Coercive Use of Organic Therapies, 47 S. CAL. L. REV. 237 (1974); Wexler, Token and Taboo. Behavior Modification, Token Economies and the Law, 61 CALIF. L. REV. 81 (1973); Winick, Legal Limitations on CorrectionalTherapy and Research, 65 MINN. L. REV. 331 (1981); Winick, The Right to Refuse PsychotropicMedication: CurrentState of the Law and Beyond, in THE RIGHT TO REFUSE ANTIPSYCHOTIC MEDICATION 7 (D. Rapoport & J. Parry eds. 1986) [hereinafter The Right to Refuse Psychotropic Medication]; Note, Conditioning and Other Technologies Used to "Treat?" "Rehabilitate?" "Demolish?" Prisoners and Mental Patients, 45 S. CAL. L. REV. 616 (1972); Comment, Madness and Medicine: The Forcible Administration of Psychotropic Drugs, 1980 Wis. L. REV. 497. Some