Appellees filed a class action in Federal District Court against
the Pennsylvania Secretary of Public Welfare and the directors of
three state mental health facilities, seeking declaratory and
injunctive relief and contending that Pennsylvania's procedures for
the voluntary admission of mentally ill and mentally retarded
children to a state hospital violated the Due Process Clause of the
Fourteenth Amendment. Holding that the State's procedures were
insufficient to satisfy the Due Process Clause, and that only a
formal adversary hearing could suffice to protect children in
appellees' class from being needlessly confined in mental
hospitals, the District Court concluded that specified procedures
were required before any child could be admitted voluntarily to a
mental hospital.
Held:
1. The risk of error inherent in the parental decision to have a
child institutionalized for mental health care is sufficiently
great that some kind of inquiry should be made by a "neutral
factfinder" to determine whether the statutory requirements for
admission are satisfied. That inquiry must carefully probe the
child's background and must also include an interview with the
child. It is also necessary that the decisionmaker have the
authority to refuse to admit any child who does not satisfy the
medical standards for admission. Finally, the child's continuing
need for commitment must be reviewed periodically.
Parham v.
J.R., ante, p.
442 U. S. 584,
controlling. P.
442 U. S.
646.
2. Pennsylvania's procedures comply with these due process
requirements. No child is admitted without at least one and often
more psychiatric examinations by an independent team of mental
health professionals whose sole concern is whether the child needs
and can benefit from institutional care. The treatment team
interviews the child and parents and compiles a full background
history. If the treatment team concludes that institutional care is
not in the child's best interest, it must refuse the child's
admission; every child's condition is reviewed at least every 30
days. Pp.
442 U. S.
646-650.
459 F. Supp.
30, reversed and remanded.
Page 442 U. S. 641
BURGER, C.J., delivered the opinion of the Court, in which
WHITE, BLACKMUN, POWELL, and REHNQUIST, JJ., joined. STEWART, J.,
filed a statement concurring in the judgment,
post, p.
442 U. S. 650.
BRENNAN, J., filed an opinion concurring in part and dissenting in
part, in which MARSHALL and STEVENS, JJ., joined,
post, p.
442 U. S.
650.
MR. CHIEF JUSTICE BURGER delivered the opinion of the Court.
This appeal raises issues similar to those decided in
Parham
v. J.R., ante, p.
442 U. S. 584, as
to what process is due when the parents or guardian of a child seek
state institutional mental health care.
I
This is the second time we have reviewed a District Court's
judgment that Pennsylvania's procedures for the voluntary admission
of mentally ill and mentally retarded children to a state hospital
are unconstitutional. In the earlier suit, five children who were
between the ages of 15 and 18 challenged the 1966 statute pursuant
to which they had been admitted to Haverford State Hospital.
Pa.Stat.Ann., Tit. 50, §§ 4402, 4403 (Purdon 1969). After a
three-judge District Court, with one judge dissenting, declared the
statute unconstitutional,
Bartley v.
Kremens, 402 F.
Supp. 1039 (ED Pa.1975), the Pennsylvania Legislature amended
its mental health code with regard to the mentally ill. The
amendments placed
Page 442 U. S. 642
adolescents over the age of 14 in essentially the same position
as adults for purposes of a voluntary admission. Mental Health
Procedures Act of 1976, § 201, Pa.Stat.Ann., Tit. 50, § 7201
(Purdon Supp. 1978). Under the new statute, the named plaintiffs
could obtain their requested releases from the state hospitals
independently of the constitutionality of the 1966 statute, and we
therefore held that the claims of the named plaintiffs were moot.
Kremens v. Bartley, 431 U. S. 119,
431 U. S. 129
(1977). We then remanded the case to the District Court for
"reconsideration of the class definition, exclusion of those whose
claims are moot, and substitution of class representatives with
live claims."
Id. at
431 U. S.
135.
On remand, 12 new plaintiffs, appellees here, were named to
represent classes of mentally ill and mentally retarded children.
Nine of the children were younger than 14, and constituted all of
those who had been admitted to the State's hospitals for the
mentally ill in accordance with the 1976 Act at the time the suit
was brought; three other children represented a class of patients
who were 18 and younger and who had been or would be admitted to a
state hospital for the mentally retarded under the 1966 Act and
1973 regulations implementing that Act. All 12 children had been
admitted on the application of parents or someone standing
in
loco parentis with state approval after an independent medical
examination.
The suit was filed against several named defendants, the
Pennsylvania Secretary of Public Welfare, and the directors of
three state owned and operated facilities. The District Court,
however, certified a defendant class that consisted of
"'directors of all mental health and mental retardation
facilities in Pennsylvania which are subject to regulation by the
defendant Secretary of Public Welfare.'"
459 F. Supp.
30, 40 n. 37 (ED Pa.1978). [
Footnote 1]
Page 442 U. S. 643
Representatives of the nine mentally ill children sought a
declaration that the admission procedures embodied in § 201
[
Footnote 2] of the
Pennsylvania Mental Health Procedures Act of 1976, Pa.Stat.Ann.,
Tit. 50, § 7201 (Purdon Supp. 1978), which subsequently have been
expanded by regulations promulgated by the Secretary of Public
Welfare, 8 Pa.Bull. 2432
et seq. (1978), violated their
procedural due process rights and requested the court to issue an
injunction against the statute's future enforcement. The three
mentally retarded children presented the same claims as to § § 402
[
Footnote 3] and 403 [
Footnote 4] of the
Page 442 U. S. 644
Mental Health and Mental Retardation Act of 1966, Pa.Stat.Ann.,
Tit. 50, §§ 4402 and 4403 (Purdon 1969), and the regulations
promulgated thereunder. [
Footnote
5]
The District Court certified two subclasses of plaintiffs
[
Footnote 6]
Page 442 U. S. 645
under Fed.Rule Civ.Proc. 23, and held that the statutes
challenged by each subclass were unconstitutional. It held that the
State's procedures were insufficient to satisfy the Due Process
Clause of the Fourteenth Amendment.
The District Court's analysis in this case was similar to that
used by the District Court in
J.L. v.
Parham, 412 F.
Supp. 112 (MD Ga.1976),
reversed and remanded sub nom.
Parham v. J.R., ante, p.
442 U. S. 584. The
court in this case concluded that these children had a
constitutionally protected liberty interest that could not be
"waived" by their parents. This conclusion, coupled with the
perceived fallibility of psychiatric diagnosis, led the court to
hold that only a formal adversary hearing could suffice to protect
the children in appellees' class from being needlessly confined in
mental hospitals.
To further protect the children's interests, the court concluded
that the following procedures were required before any child could
be admitted voluntarily to a mental hospital:
"1) 48-hour notice prior to any hearing;"
"2) legal counsel 'during all significant stages of the
commitment process';"
"3) the child's presence at all commitment hearings;"
"4) a finding by an impartial tribunal based on clear and
convincing evidence that the child required institutional
treatment;"
"5) a probable cause determination within 72 hours after
admission to a hospital;"
"6) a full hearing, including the right to confront and
cross-examine witnesses, within two weeks from the date of the
initial admission."
App. 1097a-1098a. [
Footnote
7]
Appellants, all of the defendants before the District Court,
appealed the judgment. We noted probable jurisdiction, and
Page 442 U. S. 646
consolidated the case with
Parham v. J.R., ante, p.
442 U. S. 584. 437
U.S. 902.
II
(a) Much of what we said in
Parham v. J.R. applies with
equal force to this case. The liberty rights and interests of the
appellee children, the prerogatives, responsibilities, and
interests of the parents, and the obligations and interests of the
State are the same. Our holding as to what process is due in
Parham controls here, particularly:
"We conclude that the risk of error inherent in the parental
decision to have a child institutionalized for mental health care
is sufficiently great that some kind of inquiry should be made by a
'neutral factfinder' to determine whether the statutory
requirements for admission are satisfied. . . . That inquiry must
carefully probe the child's background using all available sources,
including, but not limited to, parents, schools, and other social
agencies. Of course, the review must also include an interview with
the child. It is necessary that the decisionmaker have the
authority to refuse to admit any child who does not satisfy the
medical standards for admission. Finally, it is necessary that the
child's continuing need for commitment be reviewed periodically by
a similarly independent procedure."
Parham v. J.R., ante at
442 U. S.
606-607. The only issue is whether Pennsylvania's
procedures for the voluntary commitment of children comply with
these requirements.
(b) Unlike in
Parham v. J.R., where the statute being
challenged was general, and thus the procedures for admission were
evaluated hospital by hospital, the statute and regulations in
Pennsylvania are specific. Our focus here is on the codified
procedures declared unconstitutional by the District Court.
The Mental Health Procedures Act of 1976 and regulations
promulgated by the Secretary describe the procedures for the
Page 442 U. S. 647
voluntary admission for inpatient treatment of mentally ill
children. Section 201 of the Act provides that "a parent, guardian,
or person standing
in loco parentis to a child less than
14 years of age" may apply for a voluntary examination and
treatment for the child. After the child receives an examination
and is provided with temporary treatment, the hospital must
formulate "an individualized treatment plan . . . by a treatment
team." Within 72 hours, the treatment team is required to determine
whether inpatient treatment is "necessary" and why. Pa.Stat.Ann.,
Tit. 50, § 7205 (Purdon Supp. 1978). The hospital must inform the
child and his parents both of the necessity for institutional
treatment and of the nature of the proposed treatment.
Ibid.
Regulations promulgated under the 1976 Act provide that each
child shall be reexamined and his or her treatment plan reviewed
not less than once every 30 days.
See § 7100.108(a), 8
Pa.Bull. 2436 (1978). The regulations also permit a child to object
to the treatment plan, and thereby obtain a review by a mental
health professional independent of the treatment team. The findings
of this person are reported directly to the director of the
hospital, who has the power and the obligation to release any child
who no longer needs institutional treatment.
The statute indeed provides three methods for release of a child
under the age of 14 from a mental hospital. First, the child's
parents or guardian may effect his release at will. Pa.Stat.Ann.,
Tit. 50, § 7206(b) (Purdon Supp. 1978). Second, "any responsible
party" may petition the juvenile court if the person believes that
treatment in a less restrictive setting would be in the best
interests of the child.
Ibid. If such a petition is filed,
an attorney is appointed to represent the child's interests and a
hearing is held within 10 days to determine "what inpatient
treatment, if any, is in the minor's best interest."
Ibid.
Finally, the director of the hospital may release any child
whenever institutional treatment is no longer medically indicated.
§ 7206(c).
Page 442 U. S. 648
The Mental Health and Mental Retardation Act of 1966 regulates
the voluntary admission for inpatient hospital habilitation of the
mentally retarded. The admission process has been expanded
significantly by regulations promulgated in 1973 by Pennsylvania's
Secretary of Public Welfare. 3 Pa.Bull. 1840 (1973). Unlike the
procedure for the mentally ill, a hospital is not permitted to
admit a mentally retarded child based solely on the application of
a parent or guardian. All children must be referred by a physician,
and each referral must be accompanied by a medical or psychological
evaluation. In addition, the director of the institution must make
an independent examination of each child, and if he disagrees with
the recommendation of the referring physician as to whether
hospital care is "required," the child must be discharged. Mentally
retarded children or anyone acting on their behalf may petition for
a writ of habeas corpus to challenge the sufficiency or legality of
the "proceedings leading to commitment." Pa.Stat.Ann., Tit. 50, §
4426 (Purdon 1969).
Any child older than 13 who is admitted to a hospital must have
his rights explained to him and must be informed that a status
report on his condition will be provided periodically. The older
child is also permitted to object, either orally or in writing, to
his hospitalization. After such objection, the director of the
facility, if he feels that hospitalization is still necessary, must
institute an involuntary commitment proceeding under § 406 of the
Act, Pa.Stat.Ann., Tit. 50, § 4406 (Purdon 1969).
What the statute and regulations do not make clear is how the
hospital staff decides that inpatient care is required for a child.
The director of Haverford State Hospital for the mentally ill was
the sole witness called by either side to testify about the
decisionmaking process at a state hospital. She described the
process as follows:
"[T]here is an initial examination made by the psychiatrist, and
is so designated as an admission note on the
Page 442 U. S. 649
hospital record. Subsequently, for all adolescents on the
Adolescent Service at Haverford State Hospital, there are routine
studies done, such as an electroencephalogram, a neurological
examination, a medical examination, and a complete battery of
psychological tests and school evaluation, as well as a psychiatric
evaluation. When all their data has been compiled, an entire staff
conference is held, which is called a new case conference, at which
point the complete case is reexamined and it is decided whether or
not the child needs hospitalization, and at that same time, as
well, an adequate treatment course is planned."
App. 112a. In addition to the physical and mental examinations
that are conducted for each child within the institutions, the
staff compiles a substantial "pre-admission background information"
file on each child. [
Footnote
8] After the child is admitted, there is a periodic review of
the child's condition by the staff. His status is reviewed by a
different social worker at least every 30 days. Since the State
places a great deal of emphasis on family therapy, the parents or
guardians are met with weekly to discuss the child's case.
Id. at 113a.
We are satisfied that these procedures comport with the due
process requirements set out earlier. No child is admitted without
at least one and often more psychiatric examinations by an
independent team of mental health professionals whose
Page 442 U. S. 650
sole concern under the statute is whether the child needs and
can benefit from institutional care. The treatment team not only
interviews the child and parents, but also compiles a full
background history from all available sources. If the treatment
team concludes that institutional care is not in the child's best
interest, it must refuse the child's admission. Finally, every
child's condition is reviewed at least every 30 days. This program
meets the criteria of our holding in
Parham. [
Footnote 9] Accordingly, the judgment
of the District Court that Pennsylvania's statutes and regulations
are unconstitutional is reversed, and the case is remanded for
further proceedings consistent with this opinion.
Reversed and remanded.
For the reasons stated in his opinion concurring in the judgment
in
Parham v. J.R., ante p.
442 U. S. 621,
MR. JUSTICE STEWART concurs in the judgment.
[
Footnote 1]
Appellants argue that the State's regulation of admission to
private hospitals is insufficient to constitute state action for
purposes of the Due Process Clause of the Fourteenth Amendment.
They, however, did not contest the District Court's definition of
the defendant class, which included directors of both public and
private facilities. In light of our holding that Pennsylvania's
procedures comport with due process, we do not decide whether the
District Court correctly found state action.
[
Footnote 2]
Section 201 provides in part:
"A parent, guardian, or person standing
in loco
parentis to a child less than 14 years of age may subject such
child to examination and treatment under this act, and in so doing
shall be deemed to be acting for the child."
[
Footnote 3]
Section 402 provides:
"(a) Application for voluntary admission to a facility for
examination, treatment and care may be made by:"
"
* * * *"
"(2) A parent, guardian or individual standing
in loco
parentis to the person to be admitted, if such person is
eighteen years of age or younger."
"(b) When an application is made, the director of the facility
shall cause an examination to be made. If it is determined that the
person named in the application is in need of care or observation,
he may be admitted."
[
Footnote 4]
Section 403 provides:
"(a) Application for voluntary commitment to a facility for
examination, treatment and care may be made by:"
"
* * * *"
"(2) A parent, guardian or individual standing
in loco
parentis to the person to be admitted, if such person is
eighteen years of age or younger."
"(b) The application shall be in writing, signed by the
applicant in the presence of at least one witness. When an
application is made, the director of the facility shall cause an
examination to be made. If it is determined that the person named
in the application is in need of care or observation, he shall be
committed for a period not to exceed thirty days."
[
Footnote 5]
The 1973 regulations provide in part:
"1. . . . [M]entally retarded juveniles may be referred by
either a pediatrician, or general physician or psychologist;"
"2. This referral must be accomplished by a psychiatric
evaluation and that report must indicate with specificity the
reasons that the person requires institutional care; however, a
medical or psychological evaluation may accompany the referral of a
mentally retarded juvenile;"
"3. The Director of the Institution . . . shall have conducted
an
independent examination of the proposed juvenile, and
if his results disagree with the professional's opinion, the
Director . . . shall discharge the juvenile;"
"
* * * *"
"5. Within 24 hours after the juvenile's admission, every youth
who is at least 13 years of age must receive written notification
(which he signs) explaining his rights indicating that he will be
given a status report periodically of his condition; that he can
contact by telephone or by mail his parents or the person who
requested his admission; and that he will be furnished with the
number of counsel . . . that he can call for representation . . .
;"
"6. In the event that a juvenile whose chronological age is 13
or older objects (either orally or in writing) to remaining in the
Institution, the Director . . .
if he feels it is necessary for
the youth to remain, may continue the institutionalization for
two business days during which time he shall notify the applicant
and the referral unit so that either party may institute a 460
[involuntary commitment] proceeding. . . ."
3 Pa.Bull. 1840 (1973).
[
Footnote 6]
One subclass consisted of "all juveniles under the age of
fourteen who are subject to inpatient treatment under Article II of
the 1976 Act." 459 F. Supp. at 41. The other subclass was "mentally
retarded juveniles age eighteen or younger."
Id. at 42.
Appellants argue that the District Court failed to heed our
admonition in remanding this case previously that it should
"
stop, look, and listen' before certifying a class in order to
adjudicate constitutional claims." Kremens v. Bartley,
431 U. S. 119,
431 U. S. 135
(1977). Given our disposition of the merits of this appeal, we need
not decide whether these subclasses satisfy the requirements of
Fed.Rule Civ.Proc. 23.
[
Footnote 7]
Judge Broderick dissented from the judgment of the majority. In
his view, the majority "has prescribed
an overdose' of due
process." 459 F. Supp. at 53.
[
Footnote 8]
Appellees argue that not much weight should be accorded to these
files because the record does not make clear whether they were used
in making the admission decision. The District Court, however,
found that "virtually all of the information was received by the
admitting facilities prior to admission." 459 F. Supp. at 36 n. 15.
The court did acknowledge that it was not clear to what extent the
information was used, but nonetheless admitted all of the records
into evidence. Since it was available, we, like the District Court,
assume the information served as a factual basis for some portions
of the diagnoses of the children at the time of their admission to
the hospitals.
[
Footnote 9]
Although the District Court briefly described the situation of
each of the children in appellees' class, it did not indicate the
process for each of their admissions. We cannot determine on the
record before us whether each child's admission conformed to our
due process standards. Just as in
Parham, individual
members of appellees' class are free to argue on remand that their
particular commitments violated those standards.
Also, we note that, as in
Parham, we are faced only
with the issue of what process is due at the initial admission, and
thus we are not deciding what post-admission procedures are
constitutionally adequate to continue a voluntary commitment. The
District Court had no reason to consider that issue, and indeed,
from our reading of appellees' complaint, there does not appear to
be any specific challenge to the State's review procedures.
However, we leave it to the District Court on remand to determine
what further proceedings are necessary.
MR. JUSTICE BRENNAN, with whom MR. JUSTICE MARSHALL and MR.
JUSTICE STEVENS join, concurring in part and dissenting in
part.
For the reasons stated in my opinion in
Parham v. J.R.,
ante p.
442 U.S. 625
(concurring in part and dissenting in part), I
Page 442 U. S. 651
agree with the Court that Pennsylvania's pre-admission
psychiatric interview procedures pass constitutional muster. I
cannot agree, however, with the Court's decision to pretermit
questions concerning Pennsylvania's post-admission procedures.
See ante at
442 U. S. 650
n. 9. In my view, these procedures should be condemned now.
Pennsylvania provides neither representation nor reasonably
prompt post-admission hearings to mentally retarded children 13
years of age and younger. For the reasons stated in my opinion in
Parham v. J.R., I believe that this is
unconstitutional.
As a practical matter, mentally retarded children over 13 and
children confined as mentally ill fare little better. While, under
current regulations, these children must be informed of their right
to a hearing and must be given the telephone number of an attorney
within 24 hours of admission,
see 459 F. Supp.
30, 49, 51 (ED Pa.1978) (Broderick, J., dissenting),* the
burden of contacting counsel and the burden of initiating
proceedings is placed upon the child. In my view, this placement of
the burden vitiates Pennsylvania's procedures. Many of the
institutionalized children are unable to read, write, comprehend
the formal explanation of their rights, or use the telephone.
See App. 1019a (testimony of L. Glenn). Few, as a
consequence, will be able to take the initiative necessary for them
to secure the advice and assistance of a trained representative.
Few will be able to trigger the procedural safeguards and hearing
rights that Pennsylvania formally provides. Indeed, for most of
Pennsylvania's institutionalized children the recitation of rights
required by current regulations will amount to no more than a
hollow ritual. If the children's constitutional rights to
representation and to a fair hearing are to be guaranteed in
substance as well as in form,
Page 442 U. S. 652
and if the commands of the Fourteenth Amendment are to be
satisfied, then waiver of those constitutional rights cannot be
inferred from mere silence or inaction on he part of the
institutionalized child.
Cf. Johnson v. Zerbst,
304 U. S. 458,
304 U. S. 464
(1938). Pennsylvania must assign each institutionalized child a
representative obliged to initiate contact with the child and
ensure that the child's constitutional rights are fully protected.
Otherwise, it is inevitable that the children's due process rights
will be lost through inadvertence, inaction, or incapacity.
See 459 F. Supp. at 44 n. 47;
Bartley v.
Kremens, 402 F.
Supp. 1039, 1050-1051 (ED Pa.1975).
*
See also Pa.Stat.Ann., Tit. 16, § 9960.6(c) (Purdon
Supp. 1979) (Pennsylvania Public Defender obliged to represent
institutionalized children in commitment and related
proceedings).