In re Mary Ann P.
JUSTICE FITZGERALD delivered the opinion of the court:
This appeal concerns the operation of section 2–107.1 of the Mental Health and Developmental Disabilities Code (Code) (
BACKGROUND
On March 13, 2000, the State filed a petition in the circuit court of Kane County, pursuant to section 2–107.1 of the Code, seeking an order authorizing the involuntary administration of psychotropic medication to respondent, Mary Ann P., for a period of 90 days. The petition was signed by Dr. Donna Luchetta, respondent‘s treating psychiatrist at the Elgin Mental Health Center (EMHC) from December 1998 to June 2000. The petition listed six medications: Zeprexa, Orap, Haldol, Haldol decanoate, Cogentin, and Ativan. On the preprinted petition form, Zeprexa was listed as the “1st choice,” and the other five medications were listed as “Alternatives.” The petition also identified a dosage range for each drug and the tests and procedures necessary for administration of the drugs.
At the hearing on the State‘s petition, Dr. Luchetta testified that respondent had been transferred from Northwest Community Hospital to the EMHC on December 28, 1998, and involuntarily admitted on the petition of her mother. This was not the first time respondent had been admitted to the EMHC. According to Dr. Luchetta, respondent suffers from paranoid schizophrenia, a psychotic disorder marked by paranoid and somatic delusions, disorganized thought processes, and impaired social and occupational functioning. Dr. Luchetta described respondent‘s delusions and the ways in which her ability to function had deteriorated.
Dr. Luchetta further testified that, beginning in July or August 1999, as the result of a prior court proceeding, respondent was involuntarily administered psychotropic medication. Prolixin was initially administered but was discontinued after it caused parkinsonism, a temporary syndrome characterized by symptoms similar to those associated with Parkinson‘s disease. In late August 1999, Zеprexa was administered, which lessened respondent‘s delusions. In September 1999, Orap was also administered, which significantly diminished respondent‘s delusions. While medicated, and for a short time afterwards, respondent was pleasant, appropriate, and well-engaged. Respondent was able to participate successfully in EMHC workshops. She was no longer agitated, hostile, intrusive, or argumentative. Respondent told Dr. Luchetta that she felt better. Toward the end of the involuntary medication period in October 1999, respondent told Dr. Luchetta that she would like a trial period without medication. Subsequently, in November 1999, her medications were tapered off. On several occasions thereafter, Dr. Luchetta recommended that respondent resume medication. Respondent refused every treatment recommendation, and by March 2000 she was again psychotic and delusional. At the time of the hearing, respondent was unable to work and provide for her own basic needs.
Dr. Luchetta testified at length about the benefits and potential side effects of each medication listed in the petition. Dr. Luchetta stated that Zeprexa was her “first choice” in medication. She explained that Zeprexa is a relatively new atypical antipsychotic drug that resolves psychosis by changing the balance of natural substancеs in the nervous system, particularly dopamine. Possible side effects include weight gain, constipation, dry mouth, hypotension, and a movement disorder known as tardive dyskinesia. Dr. Luchetta‘s second medication choice was Orap. Although Orap is prescribed primarily for the treatment of Tourette‘s Syndrome or tic disorders, it also resolves psychosis by decreasing the amount of dopamine in the system. Orap can also induce tardive dyskinesia. Dr. Luchetta testified that, during the period in 1999 when respondent was being treated with Zeprexa and Orap, she experienced minimal side effects and did not exhibit any signs of tardive dyskinesia.
The next two medications listed in the petition were Haldol, a typical antipsychotic medication, and Haldol decanoate, the injectable form of Haldol. Dr. Luchetta testified that Haldol decanoate can last up to four weeks in the patient‘s system and is beneficial in cases where the patient is unwilling to take medication on a daily basis. Haldol can produce significant side effects, including tardive dyskinesia, which occurs in approximately one of 100 patients, and neuroleptic malignant syndrome, a condition that adversely affects regulation of a person‘s body temperature and occurs in approximately one of 1,000 patients. Haldol can also produce parkinsоnism and extrapyramidal side affects, i.e., acute muscle contracture. Dr. Luchetta stated that the drug Cogentin, also listed in the petition, blocks some of these extrapyramidal side effects. The most common side effect of Cogentin is blurred vision, a condition that can be monitored.
The final medication listed in the petition was Ativan, a mild tranquilizer. Dr. Luchetta testified that administration of a small amount of Ativan can greatly reduce the dosages of antipsychotic medications administered and, in turn, prevent many of the side effects. The antianxiety effects of Ativan, which is available in injectable form, also help persuade an otherwise unwilling patient to take mediсations, such as Zeprexa and Orap, which are in tablet or liquid form.
In addition, Dr. Luchetta testified that the side effects of any medication can be monitored through observation and testing, including a complete blood count, a thyroid function test, urinalysis, a comprehensive metabolic profile, and an electrocardiogram. The medications would be administered in the lowest effective dose. It was Dr. Luchetta‘s opinion that the benefits of the medications outweigh the harmful side effects and that respondent lacks the capacity to make a reasoned or informed decision about such treatment. On several occasions Dr. Luchetta attempted to discuss with respondent the advantages and disadvantages of the medications listed in the petition, but respondent refused to discuss treatment, or responded by swearing, walking away, or talking about an unrelated matter. Finally, Dr. Luchetta testified that less restrictive services, such as an outpatient program or counseling, are not viable options.
Dr. Nageswara Rao Nagarakanti, respondent‘s treating psychiatrist at the time of the hearing, also testified. He agreed with the medication recommendations set forth in the petition and had attempted, on three or four occasions, to discuss these medications with respondent. She denied having a mental illness and told Dr. Nagarakanti that she did not need any medication. In light of her psychosis, Dr. Nagarakanti did not believe that respondent had the ability to understand the advantages and disadvantages of the medications.
The State called respondent as its final witness. She testified that she had been “abducted, drugged and detained” at the EMHC by a man she had never met. Upon questioning by the State, respondent recounted her cancer-related surgery and stated that she had seen no proof that the cancer had not recurred. Dr. Luchetta had earlier testified that respondent had cervical cancer in 1982, but that a test performed in September 1999 showed normal results. When asked about other physical ailments, respondent testified that the EMHC had sent her to a dentist, she had teeth removed, and she was given an overdose of penicillin or some other medication. Respondent stated that, rather than being treated at the EMHC, she should have been taken to an oncologist for an examination of the lump in her throat.
Respondent further testified that Dr. Nagarakanti only wants to sell her drugs and that “[w]hen something does not agree with what [Dr. Luchetta‘s] diagnosis is, it disappears.” Respondent stated that she observed her case worker and other people going through her medical records and “things being discarded into the garbage.”
Respondent also made reference to being restrained at the EMHC and described various incidents in which she had been injured by other patients. She indicated that the EMHC staff is not responsive when such incidents occur.
Finally, respondent testified that she did not want to be medicated because it caused her pain, although she also stated that the pain occurs both on and off the medication. She also indicated that the medication made her dry and constipated, caused her nose to bleed, blurred her vision, and impaired her concentration.
Respondent called no witnesses and the trial court denied her motion for a directed verdict. Following deliberations, the jury returned a vеrdict in favor of the State and against respondent, finding her to be “someone who qualifies for the involuntary administration of psychotropic medication.” The trial court entered an order authorizing the administration of psychotropic medication for a period not to exceed 90 days. The order listed the six medications and dosage ranges. Respondent appealed, arguing that she was denied her right to due process when the trial court improperly instructed the jury under the 1998 version of section 2–107.1, and when the trial court gave the jury a general verdict form that did not permit it to specify which medications were appropriate.
With one justice dissenting, the appellate court reversed. No. 2–00–1130 (unpublished order under Supreme court Rule 23). Citing In re Nancy M., 317 Ill. App. 3d 167 (2000), the appellate court held that the jury was required to specify in its verdict which medications were appropriate, and that the general verdict form “failed to show that the jury clearly intended to authorize the administration of all six medications listed in the trial court‘s subsequent written order.” The dissenting justice disagreed, citing the reasons set forth in his dissent in In re Frances K., 322 Ill. App. 3d 203, 211-13 (2001) (Grometer, J., dissenting). In that case, the dissenting justice criticized Nancy M., stating that, “under the holding of Nancy M., the jury is, in effect, being asked to prescribe the medication and treatment” and that “[s]uch a requirement *** goes far beyond the clear legislative scheme.” Frances K., 322 Ill. App. 3d at 213. The appellate court found it unnecessary to consider respondent‘s argument that the jury was instructed under the wrong version of section 2–107.1.
We allowed the State‘s petition for leave to appeal (see 177 Ill. 2d R. 315(a)), and allowed the Illinois State Medical Society and the Illinois Psychiatric Society to file an amicus curiae brief in support of the State (see 155 Ill. 2d R. 345).
ANALYSIS
I
At the outset, we observe that this case is moot. Section 2–107.1 provides that an order authorizing the administration of involuntary treatment shall, in no event, be effective for more than 90 days.
First, the procedures which must be followed and the proofs that must be made before a court may authorize involuntary treatment to recipients of mental health services are matters of a public nature and of substantial public concern. See generally In re C.E., 161 Ill. 2d 200, 213-19 (1994) (discussing the state‘s parens patriae interest in furthering the treatment of mentally ill persons and the liberty interests implicated where treatment is involuntarily administered). The question we consider here–whether the Code permits selective authorization of psychotropic medication–is likewise a matter of substantial public concern. Second, an authoritative determination is desirable in light of the conflict in the case law on this issue. Compare Nancy M., 317 Ill. App. 3d at 178-79 (holding that the jury was required to make findings, either in special interrogatories or in its verdict, as to whether the benefits of a particular medication outweighed the harm), and Frances K., 322 Ill. App. 3d at 209-10 (following Nancy M. and holding that the verdict form, which did not include any space for the jury to determine the medications or doses to be administered, required reversal), with In re R.W., 332 Ill. App. 3d 901, 911 (2002) (holding that section 2–107.1 does not require a specialized verdict addressing each particular medication), petition for leave to appeal pending No. _____. Finally, because of the relatively short duration of involuntary treatment orders, the circumstances present in this case will recur. Review is, therefore, appropriate.
II
Section 2–107.1 of the Code sеts forth the standards and procedures that must be satisfied for the administration of “[a]uthorized involuntary treatment” to adult recipients of mental health services. “Authorized involuntary treatment” is defined as “psychotropic medication or electro-convulsive therapy [ECT], including those tests and related procedures that are essential for the safe and effective administration of the treatment.”
Proceedings under section 2–107.1 are initiated by the filing of a petition in the circuit court. The court is required to hold an evidentiary hearing on the petition within the prescribed period. See
“(A) That the recipient has a serious mental illness or developmental disability.
(B) That because of said mental illness or developmental disability, the recipient exhibits any one of the following: (i) deterioration of his or her ability to function, (ii) suffering, or (iii) threatening behavior.
(C) That the illness or disability has existed for a period marked by the continuing presence of the symptoms set forth in item (B) of this subdivision (4) or the repeated episodic occurrence of these symptoms.
(D) That the benefits of the treatment outweigh the harm.
(E) That the recipient lacks the capacity to make a reasoned decision about the treatment.
(F) That other less restrictive services have been explored and found inappropriate.
(G) If the petition seeks authorization for testing and other procedures, that such testing and procedures are essential for the safe and effective administration of the treatment.”
405 ILCS 5/2–107.1(a–5)(4) (West 2000).
The focus of this appeal is factor (D): “That the benefits of the treatment outweigh the harm.”
Consistent with the appellate court‘s decision, respondent maintains that a special verdict form is required in a section 2–107.1 hearing so that the jury may selectively authorize the involuntary administration of only those medications it has determined are more beneficial than harmful. See Nancy M., 317 Ill. App. 3d at 178-79; Frances K., 322 Ill. App. 3d at 209-10. The State argues that section 2–107.1 only requires the jury to pass on the propriety of the treatment as a whole and that the legislature did not intend fоr jurors to “pick and choose” among the medicinal components of the treatment. According to the State, the use of a special verdict form, listing specific medications and dosages, would allow the jury to invade the province of qualified and knowledgeable physicians. See Frances K., 322 Ill. App. 3d at 213 (Grometer, J., dissenting); R.W., 332 Ill. App. 3d at 911 (finding the dissent in Francis K. persuasive). Whether section 2–107.1 permits selective authorization of psychotropic medication, and thus requires the use of a special verdict form, is a matter of statutory construction. Our review, therefore, proceeds de novo. People ex rel. Devine v. $30,700 United States Currency, 199 Ill. 2d 142, 148-49 (2002).
The primary rule of statutory construction is to ascertain and give effect to the intent of the legislature. Belleville Toyota, Inc. v. Toyota Motor Sales, U.S.A., Inc., 199 Ill. 2d 325, 342 (2002); Lulay v. Lulay, 193 Ill. 2d 455, 466 (2000). The most reliable indicatоr of the legislature‘s intent is the language used in the statute, which must be given its plain and ordinary meaning. Where the statutory language is clear and unambiguous, it will be given effect without resort to other aids of construction. Lulay, 193 Ill. 2d at 466. Based on the plain language of section 2–107.1, we hold that the statute does not permit selective authorization of psychotropic medication.
Section 2–107.1(a–5)(4)(D) requires the fact finder to consider, inter alia, whether the benefits of the recommended “treatment” outweigh the harm.
Respondent contends that because the statute does not expressly prohibit selective authorization, it is impliedly allowed. We disagree. Statutes should be construed in a manner that avoids absurd, unreasonable, unjust or inconvenient results. In re B.C., 176 Ill. 2d 536, 543 (1997); Collins v. Board of Trustees of the Firemen‘s Annuity & Benefit Fund, 155 Ill. 2d 103, 110 (1993). Construing the statute to permit selective authorization of only certain medications would permit the jury to substitute a treatment different from the one recommended by the testifying physician and set forth in the petition. As this court has recognized, however, the diagnosis and treatment of mental health disorders is a ” ‘highly specialized area of medicine which is better left to the experts.’ ” C.E., 161 Ill. 2d at 229, quoting In re Ingersoll, 188 Ill. App. 3d 364, 368 (1989). Indeed, section 2–107.1 vests the physician authorized to administer the involuntary treatment “complete discretion” not to administer the treatment.
The appellate court‘s decision in Nancy M., cited by respondent as well as the appellate court below, does not persuade us that selective authorization is permitted under the statute. In Nancy M., the circuit court, following a jury trial, entered an order authorizing the involuntary administration of three psychotropic medications. The appellate court reversed, agreeing with the respondent that the verdict form should have listed each requested medication and that the general verdict form failed to afford the jurors an opportunity to determine which medication the respondent should have been involuntarily administered. Nancy M., 317 Ill. App. 3d at 176-79. The Nancy M. decision, in turn, was based on the reasoning and analysis in In re Len P., 302 Ill. App. 3d 281 (1999). In Len P., the respondent challenged the trial court‘s involuntary treatment order because it failed to specify the drugs to be administered and the dosages, contrary to the express requirements of the Code. See
Plainly, the issue addressed in Len P. is not the same issue we address in the instant case. Len P. considered only whether the circuit court‘s treatment order must be reversed where neither the order, nor the trial transcript, provided the required specificity as to the medications and dosages. Here, we consider whether the statute permits the fact finder in a section 2–107.1 proceeding to parse the recommended treatment and selectively authorize only certain requested medications. Because Nancy M. relied on Len P., and Len P. considered a different issue than the one raised in this case, Nancy M. does not provide a sound basis for construing section 2–107.1 in the manner advanced by respondent and set forth in the appellate court‘s order. Further, to the extent Nancy M. and subsequent cases conflict with our holding today, they are overruled.
Respondent also argues that the statute‘s requirement that treatment orders specify the medications and dosages authorizеd is evidence that the legislature intended selective authorization of medication. We disagree. In light of the substantially invasive nature of involuntary treatment, the liberty interests implicated when a person is medicated against his or her will, and the potential for misuse of psychotropic medication (see C.E., 161 Ill. 2d at 213-15), we believe that the specificity requirement for involuntary treatment orders reflects the legislature‘s legitimate concern that only qualified health care professionals, familiar with the respondent‘s mental and physical status, be permitted to administer the treatment and that the respondent, as well as the treaters, be notified of the exact nature of the treatment authorized. See Williams, 305 Ill. App. 3d at 510-11; Miller, 301 Ill. App. 3d at 1072; accord In re Cynthia S., 326 Ill. App. 3d 65, 68-69 (2001). That the legislature has prudently provided for specificity in treatment orders entered by the trial court does not lead to the conclusion, however, that the legislature intended a similar requirement in the verdict form so that the jury may decide which of the medicinal components of the proposed treatment should be administered.
We note first that the legislature has employed different language in the subsection requiring specificity in treatment orders and the subsection addressing the findings necessary before involuntary treatment may be authorized. The subsection setting forth the requirements for treatment orders states:
“An order issued under this subsection *** shall designate the persons authorized to administer the authorized involuntary treatment under the standards and procedures of this subsection ***. Those persons shall have complete discretion not to administer any treatment authorized under this Section. The order shall also specify the medications and the anticipated range of dosages that have been authorized.”
405 ILCS 5/2–107.1(a–5)(6) (West 2000).
In contrast, the subsection addressing the findings required before involuntary treatment may be authorized states that “involuntary treatment shall not be administered to the recipient unless it has been determined by clear and convincing evidence that *** the benefits of the treatment outweigh the harm.”
In addition, we note that the legislature has seen fit to amend the Code numerous times, and that the legislature amended section 2–107.1 in 1997, adding the express requirement that treatment orders specify the medications and dosages. See Pub. Act 90–538, eff. December 1, 1997. Had the legislature also intended to permit selective authorization of medicatiоn, it could have done so. The legislature has not seen fit to amend the statute in this fashion, and we will not, under the guise of statutory construction, inject this provision into the statute. See People ex rel. Devine, 199 Ill. 2d at 150-51 (court will not depart from plain language of statute by reading into it exceptions, limitations or conditions not expressed by the legislature); People v. Tucker, 167 Ill. 2d 431, 437 (1995) (court would not rewrite statute under guise of statutory construction).
Respondent argues in the alternative that section 2–107.1 of the Code must be construed in harmony with other statutes relating to the same subject matter. See People v. Maya, 105 Ill. 2d 281, 286-87 (1985). Respondent directs our attention to the Powers of Attorney for Health Care Law (
The Powers of Attorney for Health Care Law allows an individual, the “principal,” to designate a “trusted agent *** to make personal and health care decisions” in the event the principal becomes disabled.
The Mental Health Treatment Preference Declaration Act allows an “adult of sound mind” to make an advance “declaration of preferences or instructions regarding mental health treatment.”
Respondent contends that the foregoing statutes, and section 2–107.1, all relate to the provision of health care treatment and should be construed in a single fashion. Specifically, respondent contends that the fact finders in a section 2–107.1 proceeding, like the “surrogate decision makers” in the foregoing statutes, must be allowed to selectively authorize only some of the medications comprising the prescribed treatment plan.
Although the Powers of Attorney for Health Care Law, the Mental Health Treatment Preference Declaration Act, and the Code each provide a mechanism for making treatment decisions where an individual is deemed incapable of doing so, the jury in a section 2–107.1 proceeding functions differently than an individual‘s “trusted agent” (
Respondent additionally argues that prohibiting selective authorization of medication could result in a petitioner requesting authority to administer an “unlimited” number of medications, thus “forcing” fact finders to condone a physician‘s “mere experimentation.” Although we are aware of the potential for misuse of psychotropic medication (see C.E., 161 Ill. 2d at 215), we do not share respondent‘s fear that mental health patients will be subjected to “mere experimentation” if trial judges and juries are not allowed to selectively choose which medications should be administered. The specificity requirement for involuntary treatment orders (
Because we hold that section 2–107.1 of the Code does not permit selective authorization of psychotropic medication, we also hold that a special verdict form, listing each individual medication and accompanying dosage range, is not required in a section 2–107.1 proceeding. Thus, a general verdict form, like the one used in this case, comports with the statute. By signing the general verdict form, the jury necessarily found that the State had proved each of the factors set forth in section 2–107.1, including that “the benefits of the treatment outweigh the harm.”
III
As a final matter, we consider whether remand to the appellate court is appropriate. As indicated earlier, respondent raised two issues in the appellate court. Based on the appellate court‘s ruling on the selective-authorization issue, the court found it unnecessary to consider respondent‘s argument that she was denied due process when the trial court instructed the jury pursuant to the 1998 version of section 2–107.1, rather than, presumably, the version in effect at the time of the proceeding in 2000. Respondent has not pressed this argument before this court and we find it unnecessary to remand this matter to the appellate court for consideration of this issue.
A reviewing court‘s determination of whether the jury was properly instructed can have no effect on the outcome of the case in light of the significant time that has passed since the 90-day treatment order was entered. Thus, the issue is moot. See Barbara H., 183 Ill. 2d at 490-91. Further, it is highly unlikely that the claimed error would recur. Thus, it does not qualify for review under the recognized exceptions to the mootness doctrine. See In re A Minor, 127 Ill. 2d at 257-58. Assuming arguendo that this issue was appropriate for review, based on our examination of the record, the claimed error in the jury instructions would not have affected the outcome of the proceeding.
CONCLUSION
As discussed above, we conclude that (i) the issue of selective authorization of psychotropic medication under section 2–107.1 of the Code qualifies for review under the public interest exception to the mootness doctrine; (ii) the Code cannot reasonably be construed to permit selective authorization of psychotropic medication and, thus, a special verdict form is not required in a section 2–107.1 proceeding; and (iii) remand to the appellate court is unnecessary. Consequently, we reverse the judgment of the appellate court and affirm the judgment of the circuit court.
Appellate court judgment reversed;
circuit court judgment affirmed.