Appellees, children being treated in a Georgia state mental
hospital, instituted in Federal District Court a class action
against Georgia mental health officials. Appellees sought a
declaratory judgment that Georgia's procedures for voluntary
commitment of children under the age of 18 to state mental
hospitals violated the Due Process Clause of the Fourteenth
Amendment, and requested an injunction against their future
enforcement. Under the Georgia statute providing for the voluntary
admission of children to state regional hospitals, admission begins
with an application for hospitalization signed by a parent or
guardian and, upon application, the superintendent of the hospital
is authorized to admit temporarily any child for "observation and
diagnosis." If, after observation, the superintendent finds
"evidence of mental illness" and that the child is "suitable for
treatment" in the hospital, the child may be admitted "for such
period and under such conditions as may be authorized by law."
Under Georgia's mental health statute, any child who has been
hospitalized for more than five days may be discharged at the
request of a parent or guardian, and the hospital superintendent,
even without a request for discharge, has an affirmative duty to
release any child
"who has recovered from his mental illness or who has
sufficiently improved that the superintendent determines that
hospitalization of the patient is no longer desirable."
The District Court held that Georgia's statutory scheme was
unconstitutional because it failed to protect adequately the
appellees' due process rights and that the process due included at
least the right after notice to an adversary-type hearing before an
impartial tribunal.
Held: The District Court erred in holding
unconstitutional the State's procedures for admitting a child for
treatment to a state mental hospital, since, on the record in this
case, Georgia's medical factfinding processes are consistent with
constitutional guarantees. Pp.
442 U. S.
598-621.
(a) Testing challenged state procedures under a due process
claim requires a balancing of (i) the private interest that will be
affected by
Page 442 U. S. 585
the official action; (ii) the risk of an erroneous deprivation
of such interest through the procedures used, and the probable
value, if any, of additional or substitute procedural safeguards;
and (iii) the state's interest, including the function involved and
the fiscal and administrative burden that the additional or
substitute procedural requirement would entail.
Cf. Mathews v.
Eldridge, 424 U. S. 319,
424 U. S. 335;
Smith v. Organization of Foster Families, 431 U.
S. 816,
431 U. S.
848-849. Pp.
442 U. S.
599-600.
(b) Notwithstanding a child's liberty interest in not being
confined unnecessarily for medical treatment, and assuming that a
person has a protectible interest in not being erroneously labeled
as mentally ill, parents -- who have traditional interests in and
responsibility for the upbringing of their child -- retain a
substantial, if not the dominant, role in the decision, absent a
finding of neglect or abuse. However, the child's rights and the
nature of the commitment decision are such that parents do not
always have absolute discretion to institutionalize a child; they
retain plenary authority to seek such care for their children,
subject to an independent medical judgment.
Cf. Pierce v.
Society of Sisters, 268 U. S. 510;
Wisconsin v. Yoder, 406 U. S. 205;
Prince v. Massachusetts, 321 U. S. 158;
Meyer v. Nebraska, 262 U. S. 390.
Planned Parenthood of Central Missouri v. Danforth,
428 U. S. 52,
distinguished. Pp.
442 U. S.
600-604.
(c) The State has significant interests in confining the use of
costly mental health facilities to cases of genuine need, in not
imposing unnecessary procedural obstacles that may discourage the
mentally ill or their families from seeking needed psychiatric
assistance, and in allocating priority to the diagnosis and
treatment of patients as soon as they are admitted to a hospital,
rather than to time-consuming pre-admission procedures. Pp.
442 U. S.
604-606.
(d) 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,
see Goldberg v. Kelly,
397 U. S. 254,
397 U. S. 271;
Morrissey v. Brewer, 408 U. S. 471,
408 U. S. 489,
and to probe the child's background. The decisionmaker must have
the authority to refuse to admit any child who does not satisfy the
medical standards for admission. The need for continuing commitment
must be reviewed periodically. Pp.
442 U. S.
606-607.
(e) Due process does not require that the neutral factfinder be
law-trained or a judicial or administrative officer; nor is it
necessary that the admitting physician conduct a formal or
quasi-formal adversary hearing or that the hearing be conducted by
someone other than the admitting physician. While the medical
decisionmaking process may
Page 442 U. S. 586
not be error-free, nevertheless the independent medical
decisionmaking process, which includes a thorough psychiatric
investigation followed by additional periodic review of a child's
condition, will identify children who should not be admitted; risks
of error will not be significantly reduced by a more formal,
judicial-type hearing. Pp.
442 U. S. 607-613.
(f) Georgia's practices, as described in the record, comport
with minimum due process requirements. The state statute envisions
a careful diagnostic medical inquiry to be conducted by the
admitting physician at each regional hospital. Georgia's procedures
are not "arbitrary" in the sense that a single physician or other
professional has the "unbridled discretion" to commit a child to a
regional hospital. While Georgia's general administrative and
statutory scheme for the voluntary commitment of children is not
unconstitutional, the District Court, on remand, may consider any
individual claims that the initial admissions of particular
children did not meet due process standards, and may also consider
whether the various hospitals' procedures for periodic review of
their patients' need for institutional care are sufficient to
justify
continuing a voluntary commitment. Pp.
442 U. S.
613-617.
(g) The differences between the situation where the child is a
ward of the State of Georgia and the State requests his admission
to a state mental hospital, and the situation where the child's
natural parents request his admission, do not justify requiring
different procedures at the time of the child's initial admission
to the hospital. Pp.
442 U.S.
617-620.
412 F.
Supp. 112, reversed and remanded.
BURGER, C.J., delivered the opinion of the Court, in which WHITE
BLACKMUN, POWELL, and REHNQUIST, JJ., joined. STEWART, J., filed an
opinion concurring in the judgment,
post, p.
442 U. S. 621.
BRENNAN, J., filed an opinion concurring in part and dissenting in
part, in which MARSHALL and STEVENS, JJ., joined,
post, p.
442 U.S. 625.
Page 442 U. S. 587
MR. CHIEF JUSTICE BURGER delivered the opinion of the Court.
The question presented in this appeal is what process is
constitutionally due a minor child whose parents or guardian seek
state administered institutional mental health care for the child,
and, specifically, whether an adversary proceeding is required
prior to or after the commitment.
I
(a) Appellee [
Footnote 1] J.
R., a child being treated in a Georgia state mental hospital, was a
plaintiff in this class action [
Footnote 2] based on 42 U.S.C. § 1983, in the District
Court for the Middle District of Georgia. Appellants are the
State's Commissioner
Page 442 U. S. 588
of the Department of Human Resources, the Director of the Mental
Health Division of the Department of Human Resources, and the Chief
Medical Officer at the hospital where appellee was being treated.
Appellee sought a declaratory judgment that Georgia's voluntary
commitment procedures for children under the age of 18, Ga.Code §§
88-503.1, 88-503.2 (1975), [
Footnote 3] violated the Due Process Clause of the
Fourteenth Amendment, and requested an injunction against their
future enforcement.
A three-judge District Court was convened pursuant to 28 U.S.C.
§§ 2281 (1970 ed.) and 2284. After considering expert and lay
testimony and extensive exhibits, and after visiting two of the
State's regional mental health hospitals, the District Court held
that Georgia's statutory scheme was unconstitutional because it
failed to protect adequately the appellees' due process rights.
J. L. v. Parham, 412 F.
Supp. 112, 139 (1976).
To remedy this violation, the court enjoined future commitments
based on the procedures in the Georgia statute. It also commanded
Georgia to appropriate and expend whatever amount was "reasonably
necessary" to provide nonhospital facilities deemed by the
appellant state officials to be the
Page 442 U. S. 589
most appropriate for the treatment of those members of
plaintiffs' class,
n 2,
supra, who could be treated in a less drastic, nonhospital
environment. 412 F. Supp. at 139.
Appellants challenged all aspects of the District Court's
judgment. We noted probable jurisdiction, 431 U.S. 936, and heard
argument during the 1977 Term. The case was then consolidated with
Secretary of Public Welfare v. Institutionalized Juveniles,
post, p.
442 U. S. 640, and
reargued this Term.
(b) J.L., a plaintiff before the District Court who is now
deceased, was admitted in 1970 at the age of 6 years to Central
State Regional Hospital in Milledgeville, Ga. Prior to his
admission, J.L. had received outpatient treatment at the hospital
for over two months. J.L.'s mother then requested the hospital to
admit him indefinitely.
The admitting physician interviewed J.L. and his parents. He
learned that J.L.'s natural parents had divorced, and his mother
had remarried. He also learned that J.L. had been expelled from
school because he was uncontrollable. He accepted the parents'
representation that the boy had been extremely aggressive, and
diagnosed the child as having a "hyperkinetic reaction of
childhood."
J.L.'s mother and stepfather agreed to participate in family
therapy during the time their son was hospitalized. Under this
program, J L. was permitted to go home for short stays. Apparently
his behavior during these visits was erratic. After several months,
the parents requested discontinuance of the program.
In 1972, the child was returned to his mother and stepfather on
a furlough basis,
i.e., he would live at home, but go to
school at the hospital. The parents found they were unable to
control J.L. to their satisfaction, and this created family stress.
Within two months, they requested his readmission to Central State.
J.L.'s parents relinquished their parental rights to the county in
1974.
Although several hospital employees recommended that J.L.
Page 442 U. S. 590
should be placed in a special foster home with "a warm,
supported, truly involved couple," the Department of Family and
Children Services was unable to place him in such a setting. On
October 24, 1975, J.L. (with J.R.) filed this suit requesting an
order of the court placing him in a less drastic environment
suitable to his needs.
(c) Appellee J.R. was declared a neglected child by the county
and removed from his natural parents when he was 3 months old. He
was placed in seven different foster homes in succession prior to
his admission to Central State Hospital at the age of 7.
Immediately preceding his hospitalization, J.R. received
outpatient treatment at a county mental health center for several
months. He then began attending school, where he was so disruptive
and incorrigible that he could not conform to normal behavior
patterns. Because of his abnormal behavior, J.R.'s seventh set of
foster parents requested his removal from their home. The
Department of Family and Children Services then sought his
admission at Central State. The agency provided the hospital with a
complete sociomedical history at the time of his admission. In
addition, three separate interviews were conducted with J.R. by the
admission team of the hospital.
It was determined that he was borderline retarded, and suffered
an "unsocialized, aggressive reaction of childhood." It was
recommended unanimously that he would "benefit from the structured
environment" of the hospital, and would "enjoy living and playing
with boys of the same age."
J.R.'s progress was reexamined periodically. In addition,
unsuccessful efforts were made by the Department of Family and
Children Services during his stay at the hospital to place J.R. in
various foster homes. On October 24, 1975, J.R. (with J.L.) filed
this suit requesting an order of the court placing him in a less
drastic environment suitable to his needs.
(d) Georgia Code § 88-503.1 (1975) provides for the
voluntary
Page 442 U. S. 591
admission to a state regional hospital of children such as J.L.
and J.R. Under that provision, admission begins with an application
for hospitalization signed by a "parent or guardian." Upon
application, the superintendent of each hospital is given the power
to admit temporarily any child for "observation and diagnosis." If,
after observation, the superintendent finds "evidence of mental
illness" and that the child is "suitable for treatment" in the
hospital, then the child may be admitted "for such period and under
such conditions as may be authorized by law."
Georgia's mental health statute also provides for the discharge
of voluntary patients. Any child who has been hospitalized for more
than five days may be discharged at the request of a parent or
guardian. § 88-503.3(a) (1975). Even without a request for
discharge, however, the superintendent of each regional hospital
has an affirmative duty to release any child
"who has recovered from his mental illness or who has
sufficiently improved that the superintendent determines that
hospitalization of the patient is no longer desirable."
§ 88-503.2 (1975).
Georgia's Mental Health Director has not published any statewide
regulations defining what specific procedures each superintendent
must employ when admitting a child under 18. Instead, each regional
hospital's superintendent is responsible for the procedures in his
or her facility. There is substantial variation among the
institutions with regard to their admission procedures and their
procedures for review of patients after they have been admitted. A
brief description of the different hospitals' procedures [
Footnote 4] will demonstrate the
variety of
Page 442 U. S. 592
approaches taken by the regional hospitals throughout the
State.
Southwestern Hospital in Thomasville, Ga., was built in 1966.
Its children and adolescent program was instituted in 1974. The
children and adolescent unit in the hospital has a maximum capacity
of 20 beds, but, at the time of suit, only 10 children were being
treated there.
The Southwestern superintendent testified that the hospital has
never admitted a voluntary child patient who was not treated
previously by a community mental health clinic. If a mental health
professional at the community clinic determines that hospital
treatment may be helpful for a child, then clinic staff and
hospital staff jointly evaluate the need for hospitalization, the
proper treatment during hospitalization, and a likely release date.
The initial admission decision thus is not made at the
hospital.
After a child is admitted, the hospital has weekly reviews of
his condition performed by its internal medical and professional
staff. There also are monthly reviews of each child by a group
composed of hospital staff not involved in the weekly reviews and
by community clinic staff people. The average stay for each child
who was being treated at Southwestern in 1975 was 100 days.
Atlanta Regional Hospital was opened in 1968. At the time of the
hearing before the District Court, 17 children and 21 adolescents
were being treated in the hospital's children and adolescent
unit.
The hospital is affiliated with nine community mental health
centers, and has an agreement with them that "persons will be
treated in the comprehensive community mental health centers in
every possible instance, rather than being hospitalized." The
admission criteria at Atlanta Regional for voluntary and
involuntary patients are the same. It has a formal policy not
Page 442 U. S. 293
to admit a voluntary patient unless the patient is found to be a
threat to himself or others. The record discloses that
approximately 25% of all referrals from the community centers are
rejected by the hospital admissions staff.
After admission, the staff reviews the condition of each child
every week. In addition, there are monthly utilization reviews by
nonstaff mental health professionals; this review considers a
random sample of children's cases. The average length of each
child's stay in 1975 was 161 days.
The Georgia Mental Health Institute (GMHI) in Decatur, Ga., was
built in 1965. Its children and adolescent unit housed 26 children
at the time this suit was brought.
The hospital has a formal affiliation with four community mental
health centers. Those centers may refer patients to the hospital
only if they certify that "no appropriate alternative resources are
available within the client's geographic area." For the year prior
to the trial in this case, no child was admitted except through a
referral from a clinic. Although the hospital has a policy of
generally accepting for 24 hours all referrals from a community
clinic, it has a team of staff members who review each admission.
If the team finds "no reason not to treat in the community" and the
deputy superintendent of the hospital agrees, then it will release
the applicant to his home.
After a child is admitted, there must be a review of the
admission decision within 30 days. There is also an unspecified
periodic review of each child's need for hospitalization by a team
of staff members. The average stay for the children who were at
GMHI in 1975 was 346 days.
Augusta Regional Hospital was opened in 1969, and is affiliated
with 10 community mental health clinics. Its children and
adolescent unit housed 14 children in December, 1975.
Approximately 90% of the children admitted to the hospital have
first received treatment in the community, but not all of them were
admitted based on a specific referral from a clinic.
Page 442 U. S. 594
The admission criterion is whether "the child needs
hospitalization," and that decision must be approved by two
psychiatrists. There is also an informal practice of not admitting
a child if his parents refuse to participate in a family therapy
program.
The admission decision is reviewed within 10 days by a team of
staff physicians and mental health professionals; thereafter, each
child is reviewed every week. In addition, every child's condition
is reviewed by a team of clinic staff members every 100 days. The
average stay for the children at Augusta in December, 1975 was 92
days.
Savannah Regional Hospital was built in 1970, and it housed 16
children at the time of this suit. The hospital staff members are
also directors of the community mental health clinics.
It is the policy of the hospital that any child seeking
admission on a nonemergency basis must be referred by a community
clinic. The admission decision must be made by a staff
psychiatrist, and it is based on the materials provided by the
community clinic, an interview with the applicant, and an interview
with the parents, if any, of the child.
Within three weeks after admission of a child, there is review
by a group composed of hospital and clinic staff members and people
from the community, such as juvenile court judges. Thereafter, the
hospital staff reviews each child weekly. If the staff concludes
that a child is ready to be released, then the community committee
reviews the child's case to assist in placement. The average stay
of the children being treated at Savannah in December, 1975, was
127 days.
West Central Hospital in Columbus, Ga., was opened in December,
1974, and it was organized for budgetary purposes with several
community mental health clinics. The hospital itself has only 20
beds for children and adolescents, 16 of which were occupied at the
time this suit was filed.
There is a formal policy that all children seeking admission to
the hospital must be referred by a community clinic. The hospital
is regarded by the staff as "the last resort in treating
Page 442 U. S. 595
a child"; 50% of the children referred are turned away by the
admissions team at the hospital.
After admission, there are staff meetings daily to discuss
problem cases. The hospital has a practicing child psychiatrist who
reviews cases once a week. Depending on the nature of the problems,
the consultant reviews between 1 and 20 cases. The average stay of
the children who were at West Central in December, 1975, was 71
days.
The children's unit at Central State Regional Hospital in
Milledgeville, Ga., was added to the existing structure during the
1970's. It can accommodate 40 children. The hospital also can house
40 adolescents. At the time of suit, the hospital housed 37
children under 18, including both named plaintiffs.
Although Central State is affiliated with community clinics, it
seems to have a higher percentage of nonreferral admissions than
any of the other hospitals. The admission decision is made by an
"admissions evaluator" and the "admitting physician." The evaluator
is a Ph.D. in psychology, a social worker, or a mental
health-trained nurse. The admitting physician is a psychiatrist.
The standard for admission is "whether or not hospitalization is
the more appropriate treatment" for the child. From April, 1974, to
November, 1975, 9 of 29 children applicants screened for admission
were referred to noninstitutional settings.
All children who are temporarily admitted are sent to the
children and adolescent unit for testing and development of a
treatment plan. Generally, seven days after the admission, members
of the hospital staff review all of the information compiled about
a patient "to determine the need for continued hospitalization."
Thereafter, there is an informal review of the patient
approximately every 60 days. The patients who were at Central State
in December, 1975, had been there, on the average, 456 days. There
is no explanation in the record for this large variation from the
average length of hospitalization at the other institutions.
Page 442 U. S. 596
Although most of the focus of the District Court was on the
State's mental hospitals, it is relevant to note that Georgia
presently funds over 50 community mental health clinics and 13
specialized foster care homes. The State has built seven new
regional hospitals within the past 15 years, and it has added a new
children's unit to its oldest hospital. The state budget in fiscal
year 1976 was almost $150 million for mental health care. Georgia
ranks 22d among the states in per capita expenditures for mental
health and 15th in total expenditures. [
Footnote 5]
The District Court nonetheless rejected the State's entire
system of providing mental health care on both procedural and
substantive grounds. The District Court found that 46 children
could be "optimally cared for in another, less restrictive,
non-hospital setting if it were available." 412 F. Supp. at
124-125. These "optimal" settings included group homes, therapeutic
camps, and home-care services. The Governor of Georgia and the
chairmen of the two Appropriations Committees of its legislature,
testifying in the District Court, expressed confidence in the
Georgia program and informed the court that the State could not
justify enlarging its budget during fiscal year 1977 to provide the
specialized treatment settings urged by appellees in addition to
those then available.
Having described the factual background of Georgia's mental
health program and its treatment of the named plaintiffs, we turn
now to examine the legal bases for the District Court's
judgment.
II
In holding unconstitutional Georgia's statutory procedure for
voluntary commitment of juveniles, the District Court first
determined that commitment to any of the eight regional
Page 442 U. S. 597
hospitals [
Footnote 6]
constitutes a severe deprivation of a child's liberty. The court
defined this liberty interest in terms of both freedom from bodily
restraint and freedom from the "emotional and psychic harm" caused
by the institutionalization. [
Footnote 7] Having determined that a liberty interest is
implicated by a child's admission to a mental hospital, the court
considered what process is required to protect that interest. It
held that the process due "includes at least the right after notice
to be heard before an impartial tribunal." 412 F. Supp. at 137.
In requiring the prescribed hearing, the court rejected
Georgia's argument that no adversary-type hearing was required,
since the State was merely assisting parents who could not afford
private care by making available treatment similar to that offered
in private hospitals and by private physicians. The court
acknowledged that most parents who seek to have their children
admitted to a state mental hospital do so in good faith. It,
however, relied on one of appellees' witnesses who expressed an
opinion that "some still look upon mental hospitals as a
dumping ground.'" Id. at 138. [Footnote 8] No specific
Page 442 U. S. 598
evidence of such "dumping," however, can be found in the
record.
The District Court also rejected the argument that review by the
superintendents of the hospitals and their staffs was sufficient to
protect the child's liberty interest. The court held that the
inexactness of psychiatry, coupled with the possibility that the
sources of information used to make the commitment decision may not
always be reliable, made the superintendent's decision too
arbitrary to satisfy due process. The court then shifted its focus
drastically from what was clearly a procedural due process analysis
to what appears to be a substantive due process analysis, and
condemned Georgia's "officialdom" for its failure, in the face of a
state-funded 1973 report [
Footnote
9] outlining the "need" for additional resources to be spent on
nonhospital treatment, to provide more resources for
noninstitutional mental health care. The court concluded that there
was a causal relationship between this intransigence and the
State's ability to provide any "flexible due process" to the
appellees. The District Court therefore ordered the State to
appropriate and expend such resources as would be necessary to
provide nonhospital treatment to those members of appellees' class
who would benefit from it.
III
In an earlier day, the problems inherent in coping with children
afflicted with mental or emotional abnormalities were dealt with
largely within the family.
See S. Brakel & R. Rock,
The Mentally Disabled and the Law 4 (1971). Sometimes parents were
aided by teachers or a family doctor. While some parents no doubt
were able to deal with their disturbed
Page 442 U. S. 599
children without specialized assistance, others, especially
those of limited means and education, were not. Increasingly, they
turned for assistance to local, public sources or private
charities. Until recently, most of the states did little more than
provide custodial institutions for the confinement of persons who
were considered dangerous.
Id. at 5-6; Slovenko, Criminal
Justice Procedures in Civil Commitment, 24 Wayne L.Rev. 1, 3 (1977)
(hereinafter Slovenko).
As medical knowledge about the mentally ill and public concern
for their condition expanded, the states, aided substantially by
federal grants, [
Footnote
10] have sought to ameliorate the human tragedies of seriously
disturbed children. Ironically, as most states have expanded their
efforts to assist the mentally ill, their actions have been
subjected to increasing litigation and heightened constitutional
scrutiny. Courts have been required to resolve the thorny
constitutional attacks on state programs and procedures with
limited precedential guidance. In this case, appellees have
challenged Georgia's procedural and substantive balance of the
individual, family, and social interests at stake in the voluntary
commitment of a child to one of its regional mental hospitals.
The parties agree that our prior holdings have set out a general
approach for testing challenged state procedures under a due
process claim. Assuming the existence of a protectible property or
liberty interest, the Court has required a balancing of a number of
factors:
"First, the private interest that will be affected by the
official action; second, the risk of an erroneous deprivation of
such interest through the procedures used, and the probable value,
if any, of additional or substitute procedural safeguards; and
finally, the Government's interest, including the function involved
and the fiscal and administrative burdens that the additional or
substitute
Page 442 U. S. 600
procedural requirement would entail."
Mathews v. Eldridge, 424 U. S. 319,
424 U. S. 335
(1976), quoted in
Smith v. Organization of Foster
Families, 431 U. S. 816,
431 U. S.
848-849 (1977).
In applying these criteria, we must consider first the child's
interest in not being committed. Normally, however, since this
interest is inextricably linked with the parents' interest in and
obligation for the welfare and health of the child, the private
interest at stake is a combination of the child's and parents'
concerns. [
Footnote 11]
Next, we must examine the State's interest in the procedures it has
adopted for commitment and treatment of children. Finally, we must
consider how well Georgia's procedures protect against
arbitrariness in the decision to commit a child to a state mental
hospital.
(a) It is not disputed that a child, in common with adults, has
a substantial liberty interest in not being confined unnecessarily
for medical treatment, and that the state's involvement in the
commitment decision constitutes state action under the Fourteenth
Amendment.
See Addington v. Texas, 441 U.
S. 418,
441 U. S. 425
(1979);
In re Gault, 387 U. S. 1,
387 U. S. 27
(1967);
Specht v. Patterson, 386 U.
S. 605 (1967). We also recognize that commitment
sometimes produces adverse social consequences for the child
because of the reaction of some to the discovery that the child has
received psychiatric care.
Cf. Addington v. Texas, supra
at
441 U. S.
425-426.
This reaction, however, need not be equated with the community
response resulting from being labeled by the state as delinquent,
criminal, or mentally ill and possibly dangerous.
See ibid.; In
re Gault, supra at
387 U. S. 23;
Paul v. Davis, 424 U. S. 693,
424 U. S.
711-712 (1976). The state, through its voluntary
commitment procedures, does not "label" the child; it provides
a
Page 442 U. S. 601
diagnosis and treatment that medical specialists conclude the
child requires. In terms of public reaction, the child who exhibits
abnormal behavior may be seriously injured by an erroneous decision
not to commit. Appellees overlook a significant source of the
public reaction to the mentally ill, for what is truly
"stigmatizing" is the symptomatology of a mental or emotional
illness.
Addington v. Texas, supra at
441 U. S. 429.
See also Schwartz, Myers, & Astrachan, Psychiatric
Labeling and the Rehabilitation of the Mental Patient, 31 Archives
of General Psychiatry 329 (1974). [
Footnote 12] The pattern of untreated, abnormal behavior
-- even if nondangerous -- arouses at least as much negative
reaction as treatment that becomes public knowledge. A person
needing, but not receiving, appropriate medical care may well face
even greater social ostracism resulting from the observable
symptoms of an untreated disorder. [
Footnote 13]
However, we need not decide what effect these factors might have
in a different case. For purposes of this decision, we assume that
a child has a protectible interest not only in being free of
unnecessary bodily restraints but also in not being labeled
erroneously by some persons because of an improper decision by the
state hospital superintendent.
(b) We next deal with the interests of the parents who have
decided, on the basis of their observations and independent
professional recommendations, that their child needs
institutional
Page 442 U. S. 602
care. Appellees argue that the constitutional rights of the
child are of such magnitude, and the likelihood of parental abuse
is so great, that the parents' traditional interests in and
responsibility for the upbringing of their child must be
subordinated at least to the extent of providing a formal adversary
hearing prior to a voluntary commitment.
Our jurisprudence historically has reflected Western
civilization concepts of the family as a unit with broad parental
authority over minor children. Our cases have consistently followed
that course; our constitutional system long ago rejected any notion
that a child is "the mere creature of the State" and, on the
contrary, asserted that parents generally "have the right, coupled
with the high duty, to recognize and prepare [their children] for
additional obligations."
Pierce v. Society of Sisters,
268 U. S. 510,
268 U. S. 535
(1925).
See also Wisconsin v. Yoder, 406 U.
S. 205,
406 U. S. 213
(1972);
Prince v. Massachusetts, 321 U.
S. 158,
321 U. S. 166
(1944);
Meyer v. Nebraska, 262 U.
S. 390,
262 U. S. 400
(1923). Surely, this includes a "high duty" to recognize symptoms
of illness and to seek and follow medical advice. The law's concept
of the family rests on a presumption that parents possess what a
child lacks in maturity, experience, and capacity for judgment
required for making life's difficult decisions. More important,
historically it has recognized that natural bonds of affection lead
parents to act in the best interests of their children. 1 W.
Blackstone, Commentaries *447; 2 J. Kent, Commentaries on American
Law *190.
As with so many other legal presumptions, experience and reality
may rebut what the law accepts as a starting point; the incidence
of child neglect and abuse cases attests to this. That some parents
"may at times be acting against the interests of their children,"
as was stated in
Bartley v. Kremens, 402 F.
Supp. 1039, 1047-1048 (ED Pa.1975),
vacated and
remanded, 431 U. S. 119
(1977), creates a basis for caution, but is hardly a reason to
discard wholesale those pages of human experience that teach that
parents generally do act in the
Page 442 U. S. 603
child's best interests.
See Rolfe & MacClintock
348-349. The statist notion that governmental power should
supersede parental authority in all cases because some parents
abuse and neglect children is repugnant to American tradition.
Nonetheless, we have recognized that a state is not without
constitutional control over parental discretion in dealing with
children when their physical or mental health is jeopardized.
See Wisconsin v. Yoder, supra at
406 U. S. 230;
Prince v. Massachusetts, supra at
321 U. S. 166.
Moreover, the Court recently declared unconstitutional a state
statute that granted parents an absolute veto over a minor child's
decision to have an abortion.
Planned Parenthood of Central
Missouri v. Danforth, 428 U. S. 52
(1976). Appellees urge that these precedents limiting the
traditional rights of parents, if viewed in the context of the
liberty interest of the child and the likelihood of parental abuse,
require us to hold that the parents' decision to have a child
admitted to a mental hospital must be subjected to an exacting
constitutional scrutiny, including a formal, adversary,
pre-admission hearing.
Appellees' argument, however, sweeps too broadly. Simply because
the decision of a parent is not agreeable to a child, or because it
involves risks, does not automatically transfer the power to make
that decision from the parents to some agency or officer of the
state. The same characterizations can be made for a tonsillectomy,
appendectomy, or other medical procedure. Most children, even in
adolescence, simply are not able to make sound judgments concerning
many decisions, including their need for medical care or treatment.
Parents can and must make those judgments. Here, there is no
finding by the District Court of even a single instance of bad
faith by any parent of any member of appellees' class. We cannot
assume that the result in
Meyer v. Nebraska, supra, and
Pierce v. Society of Sisters, supra, would have been
different if the children there had announced a preference to learn
only English or a preference to go to a public, rather than a
church,
Page 442 U. S. 604
school. The fact that a child may balk at hospitalization or
complain about a parental refusal to provide cosmetic surgery does
not diminish the parents' authority to decide what is best for the
child.
See generally Goldstein, Medical Care for the Child
at Risk: On State Supervention of Parental Autonomy, 86 Yale L J.
645, 664-668 (1977); Bennett, Allocation of Child Medical Care
Decisionmaking Authority: A Suggested Interest Analysis, 62
Va.L.Rev. 285, 308 (1976). Neither state officials nor federal
courts are equipped to review such parental decisions.
Appellees place particular reliance on
Planned
Parenthood, arguing that its holding indicates how little
deference to parents is appropriate when the child is exercising a
constitutional right. The basic situation in that case, however,
was very different;
Planned Parenthood involved an
absolute parental veto over the child's ability to obtain an
abortion. Parents in Georgia in no sense have an absolute right to
commit their children to state mental hospitals; the statute
requires the superintendent of each regional hospital to exercise
independent judgment as to the child's need for confinement.
See supra at
442 U. S.
591.
In defining the respective rights and prerogatives of the child
and parent in the voluntary commitment setting, we conclude that
our precedents permit the parents to retain a substantial, if not
the dominant, role in the decision, absent a finding of neglect or
abuse, and that the traditional presumption that the parents act in
the best interests of their child should apply. We also conclude,
however, that the child's rights and the nature of the commitment
decision are such that parents cannot always have absolute and
unreviewable discretion to decide whether to have a child
institutionalized. They, of course, retain plenary authority to
seek such care for their children, subject to a physician's
independent examination and medical judgment.
(c) The State obviously has a significant interest in
confining
Page 442 U. S. 605
the use of its costly mental health facilities to cases of
genuine need. The Georgia program seeks first to determine whether
the patient seeking admission has an illness that calls for
inpatient treatment. To accomplish this purpose, the State has
charged the superintendents of each regional hospital with the
responsibility for determining, before authorizing an admission,
whether a prospective patient is mentally ill and whether the
patient will likely benefit from hospital care. In addition, the
State has imposed a continuing duty on hospital superintendents to
release any patient who has recovered to the point where
hospitalization is no longer needed.
The State in performing its voluntarily assumed mission also has
a significant interest in not imposing unnecessary procedural
obstacles that may discourage the mentally ill or their families
from seeking needed psychiatric assistance. The
parens
patriae interest in helping parents care for the mental health
of their children cannot be fulfilled if the parents are unwilling
to take advantage of the opportunities because the admission
process is too onerous, too embarrassing, or too contentious. It is
surely not idle to speculate as to how many parents who believe
they are acting in good faith would forgo state-provided hospital
care if such care is contingent on participation in an adversary
proceeding designed to probe their motives and other private family
matters in seeking the voluntary admission.
The State also has a genuine interest in allocating priority to
the diagnosis and treatment of patients as soon as they are
admitted to a hospital, rather than to time-consuming procedural
minuets before the admission. [
Footnote 14] One factor that must
Page 442 U. S. 606
be considered is the utilization of the time of psychiatrists,
psychologists, and other behavioral specialists in preparing for
and participating in hearings, rather than performing the task for
which their special training has fitted them. Behavioral experts in
courtrooms and hearings are of little help to patients.
The
amici brief of the American Psychiatric Association
et al. points out at page 20 that the average staff
psychiatrist in a hospital presently is able to devote only 475 of
his time to direct patient care. One consequence of increasing the
procedures the state must provide prior to a child's voluntary
admission will be that mental health professionals will be diverted
even more from the treatment of patients in order to travel to and
participate in -- and wait for -- what could be hundreds -- or even
thousands -- of hearings each year. Obviously the cost of these
procedures would come from the public moneys the legislature
intended for mental health care.
See Slovenko 34-35.
(d) We now turn to consideration of what process protects
adequately the child's constitutional rights by reducing risks of
error without unduly trenching on traditional parental authority
and without undercutting "efforts to further the legitimate
interests of both the state and the patient that are served by"
voluntary commitments.
Addington v. Texas, 441 U.S. at
441 U. S. 430.
See also Mathews v. Eldridge, 424 U.S. at
424 U. S. 335.
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.
See Goldberg v.
Kelly, 397 U. S. 254,
397 U. S. 271
(1970);
Morrissey v. Brewer, 408 U.
S. 471,
408 U. S. 489
(1972). That inquiry must carefully
Page 442 U. S. 607
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. [
Footnote 15]
We are satisfied that such procedures will protect the child
from an erroneous admission decision in a way that neither unduly
burdens the states nor inhibits parental decisions to seek state
help.
Due process has never been thought to require that the neutral
and detached trier of fact be law trained or a judicial or
administrative officer.
See Goldberg v. Kelly, supra at
397 U. S. 271;
Morrissey v. Brewer, supra at
408 U. S. 489.
Surely, this is the case as to medical decisions, for "neither
judges nor administrative hearing officers are better qualified
than psychiatrists to render psychiatric judgments."
In re
Roger S., 19 Cal. 3d
921, 942, 569 P.2d 1286, 1299 (1977) (Clark, J., dissenting).
Thus, a staff physician will suffice, so long as he or she is free
to evaluate independently the child's mental and emotional
condition and need for treatment.
It is not necessary that the deciding physician conduct a formal
or quasi-formal hearing. A state is free to require such a hearing,
but due process is not violated by use of informal, traditional
medical investigative techniques. Since well established medical
procedures already exist, we do not undertake to outline with
specificity precisely what this investigation must involve. The
mode and procedure of medical
Page 442 U. S. 608
diagnostic procedures is not the business of judges. What is
best for a child is an individual medical decision that must be
left to the judgment of physicians in each case. We do no more than
emphasize that the decision should represent an independent
judgment of what the child requires and that all sources of
information that are traditionally relied on by physicians and
behavioral specialists should be consulted.
What process is constitutionally due cannot be divorced from the
nature of the ultimate decision that is being made. Not every
determination by state officers can be made most effectively by use
of "the procedural tools of judicial or administrative
decisionmaking."
Board of Curators of Univ. of Missouri v.
Horowitz, 435 U. S. 78,
435 U. S. 90
(1978).
See also Greenholtz v. Nebraska Penal Inmates,
ante at
442 U. S. 13-14;
Cafeteria Restaurant Workers v. McElroy, 367 U.
S. 886,
367 U. S. 895
(1961). [
Footnote 16]
Page 442 U. S. 609
Here, the questions are essentially medical in character:
whether the child is mentally or emotionally ill, and whether he
can benefit from the treatment that is provided by the state. While
facts are plainly necessary for a proper resolution of those
questions, they are only a first step in the process. In an opinion
for a unanimous Court, we recently stated in
Addington v.
Texas, 441 U.S. at
441 U. S. 429,
that the determination of whether a person is mentally ill "turns
on the
meaning of the facts which must be interpreted by
expert psychiatrists and psychologists."
Although we acknowledge the fallibility of medical and
psychiatric diagnosis,
see O'Connor v. Donaldson,
422 U. S. 563,
422 U. S. 584
(1975) (concurring opinion), we do not accept the notion that the
shortcomings of specialists can always be avoided by shifting the
decision from a trained specialist using the traditional tools of
medical science to an untrained judge or administrative hearing
officer after a judicial-type hearing. Even after a hearing, the
nonspecialist decisionmaker must make a medical-psychiatric
decision. Common human experience and scholarly opinions suggest
that the supposed protections of an adversary proceeding to
determine the appropriateness of medical decisions for the
commitment and treatment of mental and emotional illness may well
be more illusory than real.
See Albers, Pasewark, &
Meyer, Involuntary Hospitalization and Psychiatric Testimony: The
Fallibility of the Doctrine of Immaculate Perception, 6
Cap.U.L.Rev. 11, 15 (1976). [
Footnote 17]
Page 442 U. S. 610
Another problem with requiring a formalized, factfinding hearing
lies in the danger it poses for significant intrusion into the
parent-child relationship. Pitting the parents and child as
adversaries often will be at odds with the presumption that parents
act in the best interests of their child. It is one thing to
require a neutral physician to make a careful review of the
parents' decision in order to make sure it is proper from a medical
standpoint; it is a wholly different matter to employ an adversary
contest to ascertain whether the parents' motivation is consistent
with the child's interests.
Moreover, it is appropriate to inquire into how such a hearing
would contribute to the successful long-range treatment of the
patient. Surely there is a risk that it would exacerbate whatever
tensions already exist between the child and the parents. Since the
parents can and usually do play a significant role in the treatment
while the child is hospitalized, and even more so after release,
there is a serious risk that an adversary confrontation will
adversely affect the ability of the parents to assist the child
while in the hospital. Moreover, it will make his subsequent return
home more difficult. These unfortunate results are especially
critical with an emotionally disturbed child; they seem likely to
occur in the context of an adversary hearing in which the parents
testify. A confrontation over such intimate family relationships
would distress the normal adult parents, and the impact on a
disturbed child almost certainly would be significantly greater.
[
Footnote 18]
Page 442 U. S. 611
It has been.suggested that a hearing conducted by someone other
than the admitting physician is necessary in order to detect
instances where parents are "guilty of railroading their children
into asylums" or are using "voluntary commitment procedures in
order to sanction behavior of which they disapprov[e]." Ellis,
Volunteering Children: Parental Commitment of Minors to Mental
Institutions, 62 Calif.L.Rev. 840, 850-851 (1974).
See also
J.L. v. Parham, 412 F. Supp. at 133; Brief for Appellees 38.
Curiously, it seems to be taken for granted that parents who seek
to "dump" their children on the state will inevitably be able to
conceal their motives, and thus deceive the admitting psychiatrists
and the other mental health professionals who make and review the
admission decision. It is elementary that one early diagnostic
inquiry into the cause of an emotional disturbance of a child is an
examination into the environment of the child. It is unlikely, if
not inconceivable, that a decision to abandon an emotionally
normal, healthy child and thrust him into an institution will be a
discrete act leaving no trail of circumstances. Evidence of such
conflicts will emerge either in the interviews or from secondary
sources. It is unrealistic to believe that trained psychiatrists,
skilled in eliciting responses, sorting medically relevant facts,
and sensing motivational nuances will often be deceived about the
family situation surrounding
Page 442 U. S. 612
a child's emotional disturbance. [
Footnote 19] Surely a lay, or even law-trained,
factfinder would be no more skilled in this process than the
professional.
By expressing some confidence in the medical decisionmaking
process, we are by no means suggesting it is error-free. On
occasion, parents may initially mislead an admitting physician, or
a physician may erroneously diagnose the child as needing
institutional care either because of negligence or an overabundance
of caution. That there may be risks of error in the process affords
no rational predicate for holding unconstitutional an entire
statutory an administrative scheme that is generally followed in
more than 30 states. [
Footnote
20]
"[P]rocedural
Page 442 U. S. 613
due process rules are shaped by the risk of error inherent in
the truthfinding process as applied to the generality of cases, not
the rare exceptions."
Mathews v. Eldridge, 424 U.S. at
424 U. S. 344.
In general, we are satisfied that an independent medical
decisionmaking process, which includes the thorough psychiatric
investigation described earlier, followed by additional periodic
review of a child's condition, will protect children who should not
be admitted; we do not believe the risks of error in that process
would be significantly reduced by a more formal, judicial-type
hearing. The issue remains whether the Georgia practices, as
described in the record before us, comport with these minimum due
process requirements.
(e) Georgia's statute envisions a careful diagnostic medical
inquiry to be conducted by the admitting physician at each regional
hospital. The
amicus brief for the United States explains,
at pages 7-8:
"[I]n every instance, the decision whether or not to accept the
child for treatment is made by a physician employed by the State. .
. . "
"That decision is based on interviews and recommendations by
hospital or community health center staff. The staff interviews the
child and the parent or guardian who brings the child to the
facility . . . , [and] attempts are
Page 442 U. S. 614
made to communicate with other possible sources of information
about the child. . . ."
Focusing primarily on what it saw as the absence of any formal
mechanism for review of the physician's initial decision, the
District Court unaccountably saw the medical decision as an
exercise of "unbridled discretion." 412 F. Supp. at 136. But
extravagant characterizations are no substitute for careful
analysis, and we must examine the Georgia process in its setting to
determine if, indeed, any one person exercises such discretion.
In the typical case, the parents of a child initially conclude
from the child's behavior that there is some emotional problem --
in short, that "something is wrong." They may respond to the
problem in various ways, but generally the first contact with the
State occurs when they bring the child to be examined by a
psychologist or psychiatrist at a community mental health
clinic.
Most often, the examination is followed by outpatient treatment
at the community clinic. In addition, the child's parents are
encouraged, and sometimes required, to participate in a family
therapy program to obtain a better insight into the problem. In
most instances, this is all the care a child requires. However, if,
after a period of outpatient care, the child's abnormal emotional
condition persists, he may be referred by the local clinic staff to
an affiliated regional mental hospital.
At the regional hospital, an admissions team composed of a
psychiatrist and at least one other mental health professional
examines and interviews the child -- privately in most instances.
This team then examines the medical records provided by the clinic
staff and interviews the parents. Based on this information, and
any additional background that can be obtained, the admissions team
makes a diagnosis and determines whether the child will likely
benefit from institutionalized
Page 442 U. S. 615
care. If the team finds either condition not met, admission is
refused.
If the team admits a child as suited for hospitalization, the
child's condition and continuing need for hospital care are
reviewed periodically by at least one independent medical review
group. For the most part, the reviews are as frequent as weekly,
but none is less often than once every two months. Moreover, as we
noted earlier, the superintendent of each hospital is charged with
an affirmative statutory duty to discharge any child who is no
longer mentally ill or in need of therapy. [
Footnote 21]
As with most medical procedures, Georgia's are not totally free
from risk of error in the sense that they give total or absolute
assurance that every child admitted to a hospital has a mental
illness optimally suitable for institutionalized treatment. But it
bears repeating that
"procedural due process rules are shaped by the risk of error
inherent in the truthfinding process as applied to the generality
of cases, not the rare exceptions."
Mathews v. Eldridge, supra, at
424 U. S.
344.
Georgia's procedures are not "arbitrary" in the sense that a
single physician or other professional has the "unbridled
discretion" the District Court saw to commit a child to a regional
hospital. To so find on this record would require us to assume that
the physicians, psychologists, and mental health professionals who
participate in the admission decision, and who review each other's
conclusions as to the continuing validity of the initial decision,
are either oblivious or indifferent to the child's welfare -- or
that they are incompetent. We note, however, the District Court
found to the contrary; it was
"impressed by the conscientious, dedicated, state-employed
Page 442 U. S. 616
psychiatrists who, with the help of equally conscientious,
dedicated state-employed psychologists and social workers,
faithfully care for the plaintiff children. . . ."
412 F. Supp. at 138.
This finding of the District Court also effectively rebuts the
suggestion made in some of the briefs
amici that hospital
administrators may not actually be "neutral and detached" because
of institutional pressure to admit a child who has no need for
hospital care. That such a practice may take place in some
institutions in some places affords no basis for a finding as to
Georgia's program; the evidence in the record provides no support
whatever for that charge against the staffs at any of the State's
eight regional hospitals. Such cases, if they are found, can be
dealt with individually; [
Footnote 22] they do not lend themselves to class action
remedies.
We are satisfied that the voluminous record as a whole supports
the conclusion that the admissions staffs of the hospitals have
acted in a neutral and detached fashion in making medical judgments
in the best interests of the children. The State, through its
mental health programs, provides the authority for trained
professionals to assist parents in examining, diagnosing, and
treating emotionally disturbed children. Through its hiring
practices, it provides well staffed and well equipped hospitals and
-- as the District Court found -- conscientious public employees to
implement the State's beneficent purposes.
Although our review of the record in this case satisfies us that
Georgia's general administrative and statutory scheme for the
voluntary commitment of children is not
per se
Page 442 U. S. 617
unconstitutional, we cannot decide on this record whether every
child in appellees' class received an adequate, independent
diagnosis of his emotional condition and need for confinement under
the standards announced earlier in this opinion. On remand, the
District Court is free to, and should, consider any individual
claims that initial admissions did not meet the standards we have
described in this opinion.
In addition, we note that appellees' original complaint alleged
that the State had failed to provide adequate periodic review of
their need for institutional care, and claimed that this was an
additional due process violation. Since the District Court held
that the appellees' original confinement was unconstitutional, it
had no reason to consider this separate claim. Similarly, we have
no basis for determining whether the review procedures of the
various hospitals are adequate to provide the process called for or
what process might be required if a child contests his confinement
by requesting a release. These matters require factual findings not
present in the District Court's opinion. We have held that the
periodic reviews described in the record reduce the risk of error
in the initial admission, and thus they are necessary. Whether they
are sufficient to justify continuing a voluntary commitment is an
issue for the District Court on remand. The District Court is free
to require additional evidence on this issue.
IV
(a) Our discussion in
442 U. S. Some
members of appellees' class, including J.R., were wards of the
State of Georgia at the time of their admission. Obviously their
situation differs from those members of the class who have natural
parents. While the determination of what process is due varies
somewhat when the state, rather than a natural parent, makes the
request for commitment, we conclude that the differences
Page 442 U. S. 618
in the two situations do not justify requiring different
procedures at the time of the child's initial admission to the
hospital.
For a ward of the state, there may well be no adult who knows
him thoroughly and who cares for him deeply. Unlike with natural
parents, where there is a presumed natural affection to guide their
action, 1 W. Blackstone, Commentaries *447; 2 J. Kent, Commentaries
on American Law * 190, the presumption that the state will protect
a child's general welfare stems from a specific state statute.
Ga.Code § 24A-101 (1978). Contrary to the suggestion of the
dissent, however, we cannot assume that, when the State of Georgia
has custody of a child, it acts so differently from a natural
parent in seeking medical assistance for the child. No one has
questioned the validity of the statutory presumption that the State
acts in the child's best interest. Nor could such a challenge be
mounted on the record before us. There is no evidence that the
State, acting as guardian, attempted to admit any child for reasons
unrelated to the child's need for treatment. Indeed, neither the
District Court nor the appellees have suggested that wards of the
State should receive any constitutional treatment different from
children with natural parents.
Once we accept that the State's application for a child's
admission to a hospital is made in good faith, then the question is
whether the medical decisionmaking approach of the admitting
physician is adequate to satisfy due process. We have already
recognized that an independent medical judgment made from the
perspective of the best interests of the child after a careful
investigation is an acceptable means of justifying a voluntary
commitment. We do not believe that the soundness of this
decisionmaking is any the less reasonable in this setting.
Indeed, if anything, the decision with regard to wards of the
State may well be even more reasonable in light of the
Page 442 U. S. 619
extensive written records that are compiled about each child
while in the State's custody. In J R.'s case, the admitting
physician had a complete social and medical history of the child
before even beginning the diagnosis. After carefully interviewing
him and reviewing his extensive files, three physicians
independently concluded that institutional care was in his best
interests.
See supra at
442 U. S.
590.
Since the state agency having custody and control of the child
in loco parentis has a duty to consider the best interests
of the child with respect to a decision on commitment to a mental
hospital, the State may constitutionally allow that custodial
agency to speak for the child, subject, of course, to the
restrictions governing natural parents. On this record, we cannot
declare unconstitutional Georgia's admission procedures for wards
of the State.
(b) It is possible that the procedures required in reviewing a
ward's need for continuing care should be different from those used
to review the need of a child with natural parents. As we have
suggested earlier, the issue of what process is due to justify
continuing a voluntary commitment must be considered by the
District Court on remand. In making that inquiry, the District
Court might well consider whether wards of the State should be
treated with respect to continuing therapy differently from
children with natural parents.
The absence of an adult who cares deeply for a child has little
effect on the reliability of the initial admission decision, but it
may have some effect on how long a child will remain in the
hospital. We noted in
Addington v. Texas, 441 U.S. at
441 U. S.
428-49, that "the concern of family and friends
generally will provide continuous opportunities for an erroneous
commitment to be corrected." For a child without natural parents,
we must acknowledge the risk of being "lost in the shuffle."
Moreover, there is at least some indication that J.R.'s commitment
was prolonged because the Department of Family and Children
Services had difficulty finding a foster
Page 442 U. S. 620
home for him. Whether wards of the State generally have received
less protection than children with natural parents, and, if so,
what should be done about it, however, are matters that must be
decided in the first instance by the District Court on remand,
[
Footnote 23] if the court
concludes the issue is still alive.
V
It is important that we remember the purpose of Georgia's
comprehensive mental health program. It seeks, substantively and at
great cost, to provide care for those who cannot afford to obtain
private treatment, and procedurally to screen carefully all
applicants to assure that institutional care is suited to the
particular patient. The State resists the complex of procedures
ordered by the District Court because, in its view, they are
unnecessary to protect the child's rights, they divert public
resources from the central objective of administering health care,
they risk aggravating the tensions inherent in the family
situation, and they erect barriers that may discourage parents from
seeking medical aid for a disturbed child.
On this record, we are satisfied that Georgia's medical
factfinding processes are reasonable and consistent with
constitutional guarantees. Accordingly, it was error to hold
unconstitutional the State's procedures for admitting a child for
treatment to a state mental hospital. The judgment is
Page 442 U. S. 621
therefore reversed, and the case is remanded to the District
Court for further proceedings consistent with this opinion.
Reversed and remanded.
[
Footnote 1]
Pending our review, one of the named plaintiffs before the
District Court, J.L., died. Although the individual claim of J.L.
is moot, we discuss the facts of this claim because, in part, they
form the basis for the District Court's holding.
[
Footnote 2]
The class certified by the District Court, without objection by
appellants, consisted
"of all persons younger than 18 years of age now or hereafter
received by any defendant for observation and diagnosis and/or
detained for care and treatment at any 'facility' within the State
of Georgia pursuant to"
Ga.Code § 88-503.1 (1975). Although one witness testified that,
on any given day, there may be 200 children in the class, in
December, 1975, there were only 140.
[
Footnote 3]
Section 88-503.1 provides:
"The superintendent of any facility may receive for observation
and diagnosis . . . any individual under 18 years of age for whom
such application is made by his parent or guardian. . . . If found
to show evidence of mental illness and to be suitable for
treatment, such person may be given care and treatment at such
facility and such person may be detained by such facility for such
period and under such conditions as may be authorized by law."
Section 88-503.2 provides:
"The superintendent of the facility shall discharge any
voluntary patient who has recovered from his mental illness or who
has sufficiently improved that the superintendent determines that
hospitalization of the patient is no longer desirable."
Section 88-503 was amended in some respects in 1978, but
references herein are to the provisions in effect at the time in
question.
[
Footnote 4]
Although the State has eight regional hospitals, superintendents
from only seven of them were deposed. In addition, the District
Court referred to only seven hospitals in its list of members of
the plaintiff class. Apparently, the eighth hospital, Northwest
Regional in Rome, Ga., had no children being treated there. The
District Court's order was issued against the State Commissioner of
the Department of Human Resources, who is responsible for the
activities of all eight hospitals, including Northwest
Regional.
[
Footnote 5]
The source for these data is National Association of State
Mental Health Program Directors, State Report: State Mental Health
Agency Expenditures (Aug. 1, 1978).
[
Footnote 6]
The record is very sparse with regard to the physical facilities
and daily routines at the various regional hospitals. The only
hospital discussed by appellees' expert witness was Central State.
The District Court visited Central State and one other hospital,
but did not discuss the visits in its opinion.
[
Footnote 7]
In both respects, the District Court found strong support for
its holding in this Court's decision in
In re Gault,
387 U. S. 1 (1967).
In that decision, we held that a state cannot institutionalize a
juvenile delinquent without first providing certain due process
protections.
[
Footnote 8]
In light of the District Court's holding that a judicial or
quasi-judicial body should review voluntary commitment decisions,
it is at least interesting to note that the witness who made the
statement quoted in the text was not referring to parents as the
people who "dump" children into hospitals. This witness opined that
some juvenile court judges and child welfare agencies misused the
hospitals. App. 768.
See also Rolfe & MacClintock, The
Due Process Rights of Minors "Voluntarily Admitted" to Mental
Institutions, 4 J. Psychiatry & L. 333, 351 (1976) (hereinafter
Rolfe & MacClintock).
[
Footnote 9]
This study was conducted by the Study Commission on Mental
Health Services for Children and Youth, and was financed by the
State of Georgia. The Commission was made up of eight distinguished
scholars in the field of mental health. They spent six months
studying the five regional hospitals that were in existence at that
time.
[
Footnote 10]
See, e.g., Community Health Centers Act, 77 Stat. 290,
as amended, 42 U.S.C. § 2689
et seq.
[
Footnote 11]
In this part of the opinion, we will deal with the issues
arising when the natural parents of the child seek commitment to a
state hospital. In
442 U. S. we will
deal with the situation presented when the child is a ward of the
state.
[
Footnote 12]
See also Gove & Fain, The Stigma of Mental
Hospitalization, 28 Archives of General Psychiatry 494, 500 (1973);
Phillips, Rejection of the Mentally Ill: The Influence of Behavior
and Sex, 29 Am.Sociological Rev. 679, 686-687 (1964). Research by
Schwartz, Myers, and Astrachan and that of Gove and Fain found
"that the stigma of mental hospitalization is not a major problem
for the ex-patient." Schwartz, Myers, & Astrachan, Psychiatric
Labeling and the Rehabilitation of the Mental Patient, 31 Archives
of General Psychiatry 329, 333 (1974).
[
Footnote 13]
As Schwartz, Myers, and Astrachan concluded:
"Discharge [from a mental hospital] before disturbed behavior is
well controlled may advance the patient into an inhospitable world
that can incubate the chronicity that was to be avoided in the
first place."
Id. at 334.
[
Footnote 14]
Judge Friendly has cogently pointed out:
"It should be realized that procedural requirements entail the
expenditure of limited resources, that, at some point, the benefit
to individuals from an additional safeguard is substantially
outweighed by the cost of providing such protection, and that the
expense of protecting those likely to be found undeserving will
probably come out of the pockets of the deserving."
Friendly, "Some Kind of Hearing," 123 U.Pa.L.Rev. 1267, 1276
(1975).
See also Wheeler v. Montgomery, 397 U.
S. 280,
397 U. S. 282
(1970) (dissenting opinion).
[
Footnote 15]
As we discuss more fully later,
infra at
442 U.S. 617, the District Court did
not decide and we therefore have no reason to consider at this time
what procedures for review are independently necessary to justify
continuing a child's confinement. We merely hold that a subsequent,
independent review of the patient's condition provides a necessary
check against possible arbitrariness in the initial admission
decision.
[
Footnote 16]
Relying on general statements from past decisions dealing with
governmental actions not even remotely similar to those involved
here, the dissent concludes that, if a protectible interest is
involved then there must be some form of traditional, adversary,
judicial, or administrative hearing either before or after its
deprivation. That result is mandated, in their view, regardless of
what process the state has designed to protect the individual and
regardless of what the record demonstrates as to the fairness of
the state's approach.
The dissenting approach is inconsistent with our repeated
assertion that "due process is
flexible, and calls for
such procedural protections as the particular situation demands."
Morrissey v. Brewer, 408 U. S. 471,
408 U. S. 481
(1972) (emphasis added). Just as there is no requirement as to
exactly what procedures to employ whenever a traditional
judicial-type hearing is mandated,
compare Goss v. Lopez,
419 U. S. 565
(1975);
Wolff v. McDonnell, 418 U.
S. 539 (1974);
Morrissey v. Brewer, supra, with
Goldberg v. Kelly, 397 U. S. 254
(1970), there is no reason to require a judicial-type hearing in
all circumstances. As the scope of governmental action expands into
new areas creating new controversies for judicial review, it is
incumbent on courts to design procedures that protect the rights of
the individual without unduly burdening the legitimate efforts of
the states to deal with difficult social problems. The judicial
model for factfinding for all constitutionally protected interests,
regardless of their nature, can turn rational decisionmaking into
an unmanageable enterprise.
[
Footnote 17]
See Albers & Pasewark, Involuntary Hospitalization:
Surrender at the Courthouse, 2 Am.J.Community Psychology 287, 288
(1974) (mean hearing time for 21 of 300 consecutive commitment
cases was 9.2 minutes); Miller & Schwartz, County Lunacy
Commission Hearings: Some Observations of Commitments to a State
Mental Hospital, 14 Social Prob. 26 (1966) (mean time for hearings
was 3.8 minutes); Scheff, The Societal Reaction to Deviance:
Ascriptive Elements in the Psychiatric Screening of Mental Patients
in a Midwestern State, 11 Social Prob. 401 (1964) (average hearing
lasted 9.2 minutes).
See also Cohen, The Function of the
Attorney and the Commitment of the Mentally Ill, 44 Texas L.Rev.
424 (1966).
[
Footnote 18]
While not altogether clear, the District Court opinion
apparently contemplated a hearing preceded by a written notice of
the proposed commitment. At the hearing the child presumably would
be given an opportunity to be heard and present evidence, and the
right to cross-examine witnesses, including, of course, the
parents. The court also required an impartial trier of fact who
would render a written decision reciting the reasons for accepting
or rejecting the parental application.
Since the parents in this situation are seeking the child's
admission to the state institution, the procedure contemplated by
the District Court presumably would call for some other person to
be designated as a guardian
ad litem to act for the child.
The guardian, in turn, if not a lawyer, would be empowered to
retain counsel to act as an advocate of the child's interest.
Of course, a state may elect to provide such adversary hearings
in situations where it perceives that parents and a child may be at
odds, but nothing in the Constitution compels such procedures.
[
Footnote 19]
In evaluating the problem of detecting "dumping" by parents, it
is important to keep in mind that each of the regional hospitals
has a continuing relationship with the Department of Family and
Children Services. The staffs at those hospitals refer cases to the
Department when they suspect a child is being mistreated, and thus
are sensitive to this problem. In fact, J.L.'s situation is in
point. The family conflicts and problems were well documented in
the hospital records. Equally well documented, however, were the
child's severe emotional disturbances and his need for
treatment.
[
Footnote 20]
Alaska Stat.Ann. § 47.30.020 (1975); Ariz.Rev.Stat.Ann. §§
36-518, 36-519 (1974); Ark.Stat.Ann. § 59 405(b) (1971); Cal.Welf.
& Inst. Code Ann. § 6000 (West Supp. 1979); D.C.Code § 21-511
21-512 (1973); Fla.Stat. § 394.465(1)(a) (Supp. 1979); Ga.Code §§
88 503.1, 88-503.2 (1978); Haw. Rev.Stat. § 334-60(a)(2) (1976)
(only for child less than 15); Idaho Code §§ 66-318, 66-320 (Supp.
1978) (parent may admit child under 14, but child over 16 may
obtain release); Ill.Rev.Stat., ch. 91 1/2, §§ 3-502, 3-503 (Supp.
1978); Ind.Code § 16-14-9.1-2 (1976); Kan.Stat.Ann. §§ 59-2905,
59-2907 (Supp. 1978); Ky.Rev.Stat. § 202 A. 020 (1977);
La.Rev.Stat.Ann. § 28:57(C) (West Supp. 1979); Md.Ann.Code, Art.
59, §11(g) (Supp. 1978) (parental consent permissible only to some
facilities); Mass.Gen.Laws Ann., ch. 123, § 10(a) (West Supp.1979);
Mich.Comp.Laws § 330.1415 (1976) (child may object within 30 days
and receive a hearing); Miss.Code Ann. § 41-21103(1) (Supp. 1978)
(certificate of need for treatment from two physicians required);
Mo.Rev.Stat. §§ 202.115(1)(2), 202.115(2)(2) (1978); Nev.Rev.Stat.
§§ 422 A. 560, 433 A. 540 (1975); N.Y. Mental Hyg. Law § 9.13
(McKinney 1978) (parent may admit, but child may obtain own
release); N.D.Cent.Code § 25-03.1-04 (Supp. 1977); Ohio Rev.Code
Ann. § 5122.02(b) (Supp. 1978); Okla.Stat., Tit. 43A, § 184 (1971);
Ore.Rev.Stat. § 426.220(1) (1977); Pa.Stat.Ann., Tit. 50, § 7201
(Purdon Supp. 1978-1979) (only for child less than 14);
R.I.Gen.Laws § 26-2-8 (Supp. 1978) (requires certificate of two
physicians that child is insane); S.C.Code § 44-17-310(2) (Supp.
1978); S.D. Comp.Laws Ann. § 27A-8-2 (1976); Tenn.Code Ann. §
33-601(a)(1) (1977); Utah Code Ann §§ 647-29, 64-7-31(2) (1953);
Wash.Rev.Code § 72.23.070(2) (1978) (child over 13 also must
consent); W.Va.Code § 27-4-1(b) (1976) (consent of child over 12
required); Wyo.Stat. § 25-3-106(a)(i) (1977).
[
Footnote 21]
While the record does demonstrate that the procedures may vary
from case to case, it also reflects that no child in Georgia was
admitted for indefinite hospitalization without being interviewed
personally and without the admitting physician's checking with
secondary sources, such as school or work records.
[
Footnote 22]
One important means of obtaining individual relief for these
children is the availability of habeas corpus. As the appellants'
brief explains,
"Ga.Code § 88-502.11 . . . provides that at any time, and
without notice, a person detained in a facility, or a relative or
friend of such person, may petition for a writ of habeas corpus to
question the cause and legality of the detention of the
person."
Brief for Appellants 36-37.
[
Footnote 23]
To remedy the constitutional violation, the District Court
ordered hearings to be held for each member of the plaintiff class,
see n 2,
supra. For 46 members of the class found to be treatable
in "less drastic" settings, the District Court also ordered the
State to expend such moneys as were necessary to provide
alternative treatment facilities and programs. While the order is
more appropriate as a remedy for a substantive due process
violation, the court made no findings on that issue. The order
apparently was intended to remedy the procedural due process
violation it found. Since that judgment is reversed, there is no
basis for us to consider the correctness of the remedy.
MR. JUSTICE STEWART, concurring in the judgment.
For centuries, it has been a canon of the common law that
parents speak for their minor children. [
Footnote 2/1] So deeply imbedded in our traditions is
this principle of law that the Constitution itself may compel a
State to respect it.
Meyer v. Nebraska, 262 U.
S. 390;
Pierce v. Society of Sisters,
268 U. S. 510.
[
Footnote 2/2] In ironic contrast,
the District Court in this case has said that the Constitution
requires the State of Georgia to disregard this established
principle. I cannot agree.
Page 442 U. S. 622
There can be no doubt that commitment to a mental institution
results in a "massive curtailment of liberty,"
Humphrey v.
Cady, 405 U. S. 504,
405 U. S. 509.
In addition to the physical confinement involved,
O'Connor v.
Donaldson, 422 U. S. 563, a
person's liberty is also substantially affected by the stigma
attached to treatment in a mental hospital. [
Footnote 2/3] But not every loss of liberty is
governmental deprivation of liberty, and it is only the latter that
invokes the Due Process Clause of the Fourteenth Amendment.
The appellees were committed under the following section of the
Georgia Code:
"Authority to receive voluntary patients -- "
"(a) The superintendent of any facility may receive for
observation and diagnosis any individual 18 years of age, or older,
making application therefor, any individual under 18 years of age
for whom such application is made by his parent or guardian and any
person legally adjudged to be incompetent for whom such application
is made by his guardian. If found to show evidence of mental
illness and to be suitable for treatment, such person may be given
care and treatment at such facility and such person may be detained
by such facility for such period and under such conditions as may
be authorized by law."
Ga.Code § 88-503.1 (1975). Clearly, if the appellees in this
case were adults who had voluntarily chosen to commit themselves to
a state mental hospital, they could not claim that the State had
thereby deprived them of liberty in violation of the Fourteenth
Amendment. Just as clearly, I think, children on whose
Page 442 U. S. 623
behalf their patients have invoked these voluntary procedures
can make no such claim.
The Georgia statute recognizes the power of a party to act on
behalf of another person under the voluntary commitment procedures
in two situations: when the other person is a minor not over 17
years of age and the party is that person's parent or guardian, and
when the other person has been "legally adjudged incompetent" and
the party is that person's guardian. In both instances, two
conditions are present. First, the person being committed is
presumptively incapable of making the voluntary commitment decision
for himself. And second, the parent or guardian is presumed to be
acting in that person's best interests. [
Footnote 2/4] In the case of guardians, these
presumptions are grounded in statutes whose validity nobody has
questioned in this case. Ga.Code § 49-201 (1978). [
Footnote 2/5] In the case of parents, the
presumptions are grounded in a statutory embodiment of
long-established principles of the common law.
Thus, the basic question in this case is whether the
Constitution requires Georgia to ignore basic principles so long
accepted by our society. For only if the State in this setting is
constitutionally compelled always to intervene between parent and
child can there be any question as to the constitutionally required
extent of that intervention. I believe this basic question must be
answered in the negative. [
Footnote
2/6]
Page 442 U. S. 624
Under our law, parents constantly make decisions for their minor
children that deprive the children of liberty, and sometimes even
of life itself. Yet surely the Fourteenth Amendment is not invoked
when an informed parent decides upon major surgery for his child,
even in a state hospital. I can perceive no basic constitutional
differences between commitment to a mental hospital and other
parental decisions that result in a child's loss of liberty.
I realize, of course, that a parent's decision to commit his
child to a state mental institution results in a far greater loss
of liberty than does his decision to have an appendectomy performed
upon the child in a state hospital. But if, contrary to my belief,
this factual difference rises to the level of a constitutional
difference, then I believe that the objective checks upon the
parents' commitment decision, embodied in Georgia law and
thoroughly discussed,
ante at
442 U. S.
613-617, are more than constitutionally sufficient.
To be sure, the presumption that a parent is acting in the best
interests of his child must be a rebuttable one, since certainly
not all parents are actuated by the unselfish motive the law
presumes. Some parents are simply unfit parents. But Georgia
clearly provides that an unfit parent can be stripped of his
parental authority under laws dealing with neglect and abuse of
children. [
Footnote 2/7]
This is not an easy case. Issues involving the family and issues
concerning mental illness are among the most difficult that courts
have to face, involving as they often do serious problems of policy
disguised as questions of constitutional
Page 442 U. S. 625
law. But when a state legislature makes a reasonable definition
of the age of minority, and creates a rebuttable presumption that
in invoking the statutory procedures for voluntary commitment a
parent is acting in the best interests of his minor child, I cannot
believe that the Fourteenth Amendment is violated. This is not to
say that in this area the Constitution compels a State to respect
the traditional authority of a parent, as in the
Meyer and
Pierce cases. I believe, as in
Prince v.
Massachusetts, 321 U. S. 158,
that the Constitution would tolerate intervention by the State.
[
Footnote 2/8] But that is a far
cry from holding that such intervention is constitutionally
compelled.
For these reasons I concur in the judgment.
[
Footnote 2/1]
See 1 W. Blackstone, Commentaries *452-453; 2 J. Kent,
Commentaries on American Law *203-206; J. Schouler, A Treatise on
the Law of Domestic Relations 335-353 (3d ed. 1882); G. Field, The
Legal Relations of Infants 63-80 (1888).
"It is cardinal with us that the custody, care and nurture of
the child reside first in the parents, whose primary function and
freedom include preparation for obligations the state can neither
supply nor hinder."
Prince v. Massachusetts, 321 U.
S. 158,
321 U. S.
166.
"The history and culture of Western civilization reflect a
strong tradition of parental concern for the nurture and upbringing
of their children. This primary role of the parents in the
upbringing of their children is now established beyond debate as an
enduring American tradition."
Wisconsin v. Yoder, 406 U. S. 205,
406 U. S.
232.
"Because he may not foresee the consequences of his decision, a
minor may not make an enforceable bargain. He may not lawfully work
or travel where he pleases, or even attend exhibitions of
constitutionally protected adult motion pictures. Persons below a
certain age may not marry without parental consent."
Planned Parenthood of Central Missouri v. Danforth,
428 U. S. 52,
428 U. S. 102
(STEVENS, J., concurring in part and dissenting in part).
Cf. Stump v. Sparkman, 435 U.
S. 349,
435 U. S. 366
(dissenting opinion).
[
Footnote 2/2]
"The child is not the mere creature of the State; those who
nurture him and direct his destiny have the right, coupled with the
high duty, to recognize and prepare him for additional
obligations."
Pierce v. Society of Sisters, 268 U.S. at
268 U. S. 535.
[
Footnote 2/3]
The fact that such a stigma may be unjustified does not mean it
does not exist. Nor does the fact that public reaction to past
commitment may be less than the reaction to aberrant behavior
detract from this assessment. The aberrant behavior may disappear,
while the fact of past institutionalization lasts forever.
[
Footnote 2/4]
This is also true of a child removed from the control of his
parents. For the juvenile court then has a duty to "secure for him
care as nearly as possible equivalent to that which [his parents]
should have given him." Ga.Code § 24A-101 (1978) .
[
Footnote 2/5]
"The power of the guardian over the person of his or her ward
shall be the same as that of the parent over his or her child, the
guardian standing in his or her place; and in like manner it shall
be the duty of the guardian to protect and maintain, and, according
to the circumstances of the ward, to educate him or her."
[
Footnote 2/6]
Planned Parenthood of Central Missouri v. Danforth,
428 U. S. 52, was
an entirely different case. The Court's opinion today discusses
some of these differences,
ante at
442 U. S. 604,
but I think there is a more fundamental one. The
Danforth
case involved an expectant mother's right to decide upon an
abortion -- a personal substantive constitutional right.
Roe v.
Wade, 410 U. S. 113;
Doe v. Bolton, 410 U. S. 179. By
contrast, the appellees in this case had no substantive
constitutional right not to be hospitalized for psychiatric
treatment.
[
Footnote 2/7]
See MR. JUSTICE BRENNAN's opinion,
post at
442 U.S. 630-631, and n.
16.
[
Footnote 2/8]
The
Prince case held that the State may
constitutionally intervene in the parent-child relationship for the
purpose of enforcing its child labor law.
If the State intervened, its procedures would, of course, be
subject to the limitations imposed by the Fourteenth Amendment.
MR. JUSTICE BRENNAN, with whom MR. JUSTICE MARSHALL and MR
JUSTICE STEVENS join, concurring in part and dissenting In
part.
I agree with the Court that the commitment of juveniles to state
mental hospitals by their parents or by state officials acting
in loco parentis involves state action that impacts upon
constitutionally protected interests, and therefore must be
accomplished through procedures consistent with the constitutional
mandate of due process of law. I agree also that the District Court
erred in interpreting the Due Process Clause to require
pre-confinement commitment hearings in all cases in which parents
wish to hospitalize their children. I disagree, however, with the
Court's decision to pretermit questions concerning the
post-admission procedures due Georgia's institutionalized
juveniles. While the question of the frequency of post-admission
review hearings may properly be deferred, the
Page 442 U. S. 626
right to at least one post-admission hearing can and should be
affirmed now. I also disagree with the Court's conclusion
concerning the procedures due juvenile wards of the State of
Georgia. I believe that the Georgia statute is unconstitutional in
that it fails to accord pre-confinement hearings to juvenile wards
of the State committed by the State acting
in loco
parentis.
I
RIGHTS OF CHILDREN COMMITTED TO MENTAL INSTITUTIONS
Commitment to a mental institution necessarily entails a
"massive curtailment of liberty,"
Humphrey v. Cady,
405 U. S. 504,
405 U. S. 509
(1972), and inevitably affects "fundamental rights."
Baxstrom
v. Herald, 383 U. S. 107,
383 U. S. 113
(1966). Persons incarcerated in mental hospitals are not only
deprived of their physical liberty, they are also deprived of
friends, family, and community. Institutionalized mental patients
must live in unnatural surroundings under the continuous and
detailed control of strangers. They are subject to intrusive
treatment which, especially if unwarranted, may violate their right
to bodily integrity. Such treatment modalities may include forced
administration of psychotropic medication, [
Footnote 3/1] aversive conditioning, [
Footnote 3/2] convulsive therapy, [
Footnote 3/3] and even psychosurgery. [
Footnote 3/4] Furthermore, as the Court
recognizes,
see ante at
442 U. S. 600,
persons confined in mental institutions are stigmatized as
Page 442 U. S. 627
sick and abnormal during confinement and, in some cases, even
after release. [
Footnote 3/5]
Because of these considerations, our cases have made clear that
commitment to a mental hospital "is a deprivation of liberty which
the State cannot accomplish without due process of law."
O'Connor v. Donaldson, 422 U. S. 563,
422 U. S. 580
(1975) (BURGER, C.J., concurring).
See, e.g., McNeil v.
Director, Patuxent Institution, 407 U.
S. 245 (1972) (defective delinquent commitment following
expiration of prison term);
Specht v. Patterson,
386 U. S. 605
(1967) (sex offender commitment following criminal conviction);
Chaloner v. Sherman, 242 U. S. 455,
242 U. S. 461
(1917) (incompetence inquiry). In the absence of a voluntary,
knowing, and intelligent waiver, adults facing commitment to mental
institutions are entitled to full and fair adversary hearings in
which the necessity for their commitment is established to the
satisfaction of a neutral tribunal. At such hearings, they must be
accorded the right to
"be present with counsel, have an opportunity to be heard, be
confronted with witnesses against [them], have the right to
cross-examine, and to offer evidence of [their] own."
Specht v. Patterson, supra at
386 U. S.
610.
These principles also govern the commitment of children.
"Constitutional rights do not mature and come into being
magically only when one attains the state-defined age of majority.
Minors, as well as adults, are protected by the Constitution. and
possess constitutional rights.
See, e.g., Breed v. Jones,
421 U. S.
519 (1975);
Goss v. Lopez, 419 U. S.
565 (1975);
Tinker v. Des Moines School Dist.,
393 U. S.
503 (1969);
In re Gault, 387 U. S. 1
(1967)."
Planned Parenthood of Central Missouri v. Danforth,
428 U. S. 52,
428 U. S. 74
(1976).
Indeed, it may well be argued that children are entitled to more
protection than are adults. The consequences of an erroneous
commitment decision are more tragic where children
Page 442 U. S. 628
are involved. Children, on the average, are confined for longer
periods than are adults. [
Footnote
3/6] Moreover, childhood is a particularly vulnerable time of
life, [
Footnote 3/7] and children
erroneously institutionalized during their formative years may bear
the scars for the rest of their lives. [
Footnote 3/8] Furthermore, the provision of satisfactory
institutionalized mental care for children generally requires a
substantial financial commitment [
Footnote 3/9] that too often has not been forthcoming.
[
Footnote 3/10] Decisions of the
lower courts have chronicled the inadequacies of existing mental
health facilities for children.
See, e.g., New York State Assn.
for Retarded Children v. Rockefeller, 357 F.
Supp. 752, 756 (EDNY 1973) (conditions at Willowbrook School
for the Mentally Retarded are "inhumane," involving "failure to
protect the physical safety of [the] children," substantial
personnel shortage, and "poor" and "hazardous" conditions);
Wyatt v. Stickney, 344 F.
Supp. 387, 391 (MD Ala.1972),
aff'd sub nom. Wyatt v.
Aderholt, 503 F.2d 1305 (CA5 1974) ("grossly substandard"
conditions at Partlow School for the Mentally Retarded lead to
"hazardous and deplorable inadequacies in the institution's
operation"). [
Footnote 3/11]
In addition, the chances of an erroneous commitment
Page 442 U. S. 629
decision are particularly great where children are involved.
Even under the best of circumstances, psychiatric diagnosis and
therapy decisions are fraught with uncertainties.
See O'Connor
v. Donaldson, supra at
422 U. S. 584
(BURGER, C.J., concurring). These uncertainties are aggravated
when, as under the Georgia practice, the psychiatrist interviews
the child during a period of abnormal stress in connection with the
commitment, and without adequate time or opportunity to become
acquainted with the patient. [
Footnote 3/12] These uncertainties may be further
aggravated when economic and social class separate doctor and
child, thereby frustrating the accurate diagnosis of pathology.
[
Footnote 3/13]
These compounded uncertainties often lead to erroneous
commitments, since psychiatrists tend to err on the side of medical
caution, and therefore hospitalize patients for whom other
dispositions would be more beneficial. [
Footnote 3/14] The National Institute of Mental Health
recently found that only 36 of patients below age 20 who were
confined at St. Elizabeths Hospital actually required such
hospitalization. [
Footnote 3/15]
Of particular relevance to this case, a Georgia study Commission on
Mental Health Services for Children and Youth concluded that more
than half of the State's institutionalized children were not in
need of confinement if other forms of care were made available or
used. Cited in
J.L. v. Parham, 412 F.
Supp. 112, 122 (MD Ga.1976).
Page 442 U. S. 630
II
A
Notwithstanding all this, Georgia denies hearings to juveniles
institutionalized at the behest of their parents. Georgia
rationalizes this practice on the theory that parents act in their
children's best interests, and therefore may waive their children's
due process rights. Children incarcerated because their parents
wish them confined, Georgia contends, are really voluntary
patients. I cannot accept this argument.
In our society, parental rights are limited by the legitimate
rights and interests of their children.
"Parents may be free to become martyrs themselves. But it does
not follow they are free, in identical circumstances, to make
martyrs of their children before they have reached the age of full
and legal discretion when they can make that choice for
themselves."
Prince v. Massachusetts, 321 U.
S. 158,
321 U. S. 170
(1944). This principle is reflected in the variety of statutes and
cases that authorize state intervention on behalf of neglected or
abused children [
Footnote 3/16]
and that,
inter alia, curtail parental authority to
alienate their children's property, [
Footnote 3/17] to withhold necessary medical treatment,
[
Footnote 3/18] and to deny
children exposure to ideas
Page 442 U. S. 631
and experiences they may later need as independent and
autonomous adults. [
Footnote
3/19]
This principle is also reflected in constitutional
jurisprudence. Notions of parental authority and family autonomy
cannot stand as absolute and invariable barriers to the assertion
of constitutional rights by children. States, for example, may not
condition a minor's right to secure an abortion on attaining her
parents' consent, since the right to an abortion is an important
personal right and since disputes between parents and children on
this question would fracture family autonomy.
See Planned
Parenthood of Central Missouri v. Danforth, 428 U.S. at
428 U. S.
75.
This case is governed by the rule of
Danforth. The
right to be free from wrongful incarceration, physical intrusion,
and stigmatization has significance for the individual surely as
great as the right to an abortion. Moreover, as in
Danforth, the parent-child dispute at issue here cannot be
characterized as involving only a routine childrearing decision
made within the context of an ongoing family relationship. Indeed,
Danforth involved only a potential dispute between parent
and child, whereas here a break in family autonomy has actually
resulted in the parents' decision to surrender custody of their
child to a state mental institution. In my view, a child who has
been ousted from his family has even greater need for an
independent advocate.
Additional considerations counsel against allowing parents
unfettered power to institutionalize their children without
Page 442 U. S. 632
cause or without any hearing to ascertain that cause. The
presumption that parents act in their children's best interests,
while applicable to most childrearing decisions, is not applicable
in the commitment context. Numerous studies reveal that parental
decisions to institutionalize their children often are the results
of dislocation in the family unrelated to the children's mental
condition. [
Footnote 3/20]
Moreover, even well-meaning parents lack the expertise necessary to
evaluate the relative advantages and disadvantages of inpatient, as
opposed to outpatient, psychiatric treatment. Parental decisions to
waive hearings in which such questions could be explored,
therefore, cannot be conclusively deemed either informed or
intelligent. In these circumstances, I respectfully suggest, it
ignores reality to assume blindly that parents act in their
children's best interests when making commitment decisions and when
waiving their children's due process rights.
B
This does not mean States are obliged to treat children who are
committed at the behest of their parents in precisely the same
manner as other persons who are involuntarily committed. The
demands of due process are flexible and the parental commitment
decision carries with it practical implications that States may
legitimately take into account. While, as a general rule, due
process requires that commitment hearings precede involuntary
hospitalization, when parents seek to hospitalize their children,
special considerations militate in favor of postponement of formal
commitment proceedings and against mandatory adversary
pre-confinement commitment hearings.
Page 442 U. S. 633
First, the prospect of an adversary hearing prior to admission
might deter parents from seeking needed medical attention for their
children. Second, the hearings themselves might delay treatment of
children whose home life has become impossible and who require some
form of immediate state care. Furthermore, because adversary
hearings at this juncture would necessarily involve direct
challenges to parental authority, judgment, or veracity,
pre-admission hearings may well result in pitting the child and his
advocate against the parents. This, in turn, might traumatize both
parent and child and make the child's eventual return to his family
more difficult.
Because of these special considerations, I believe that States
may legitimately postpone formal commitment proceedings when
parents seek inpatient psychiatric treatment for their children.
Such children may be admitted, for a limited period, without prior
hearing, so long as the admitting psychiatrist first interviews
parent and child and concludes that short-term inpatient treatment
would be appropriate.
Georgia's present admission procedures are reasonably consistent
with these principles.
See ante at
442 U. S.
613-616. To the extent the District Court invalidated
this aspect of the Georgia juvenile commitment scheme and mandated
pre-confinement hearings in all cases, I agree with the Court that
the District Court was in error.
C
I do not believe, however, that the present Georgia juvenile
commitment scheme is constitutional in its entirety. Although
Georgia may postpone formal commitment hearings, when parents seek
to commit their children, the State cannot dispense with such
hearings altogether. Our cases make clear that, when protected
interests are at stake, the "fundamental requirement of due process
is the opportunity to be heard
at a meaningful time and in a
meaningful manner.'" Mathews
Page 442 U. S. 634
v. Eldridge, 424 U. S. 319,
424 U. S. 333
(1976), quoting in part from
Armstrong v. Manzo,
380 U. S. 545,
380 U. S. 552
(1965). Whenever prior hearings are impracticable, States must
provide reasonably prompt post-deprivation hearings.
Compare
North Georgia Finishing, Inc. v. Di-Chem, Inc., 419 U.
S. 601 (1975),
with Mitchell v. W. T. Grant
Co., 416 U. S. 600
(1974).
The informal post-admission procedures that Georgia now follows
are simply not enough to qualify as hearings -- let alone
reasonably prompt hearings. The procedures lack all the traditional
due process safeguards. Commitment decisions are made
ex
parte. Georgia's institutionalized juveniles are not informed
of the reasons for their commitment; nor do they enjoy the right to
be present at the commitment determination, the right to
representation, the right to be heard, the right to be confronted
with adverse witnesses, the right to cross-examine, or the right to
offer evidence of their own. By any standard of due process, these
procedures are deficient.
See Wolff v. McDonnell,
418 U. S. 539
(1974);
Morrissey v. Brewer, 408 U.
S. 471 (1972);
McNeil v. Director, Patuxent
Institution, 407 U. S. 245
(1972);
Specht v. Patterson, 386 U.S. at 610.
See also
Goldberg v. Kelly, 397 U. S. 254,
397 U. S.
269-271 (1970). I cannot understand why the Court
pretermits condemnation of these
ex parte procedures which
operate to deny Georgia's institutionalized juveniles even "some
form of hearing,"
Mathews v. Eldridge, supra at
424 U. S. 333,
before they are condemned to suffer the rigors of long-term
institutional confinement. [
Footnote
3/21]
The special considerations that militate against
pre-admission
Page 442 U. S. 635
commitment hearings when parents seek to hospitalize their
children do not militate against reasonably prompt post-admission
commitment hearings. In the first place, post-admission hearings
would not delay the commencement of needed treatment. Children
could be cared for by the State pending the disposition
decision.
Second, the interest in avoiding family discord would be less
significant at this stage, since the family autonomy already will
have been fractured by the institutionalization of the child. In
any event, post-admission hearings are unlikely to disrupt family
relationships. At later hearings, the case for and against
commitment would be based upon the observations of the hospital
staff and the judgments of the staff psychiatrists, rather than
upon parental observations and recommendations. The doctors urging
commitment, and not the parents, would stand as the child's
adversaries. As a consequence, post-admission commitment hearings
are unlikely to involve direct challenges to parental authority,
judgment, or veracity. To defend the child, the child's advocate
need not dispute the parents' original decision to seek medical
treatment for their child, or even, for that matter, their
observations concerning the child's behavior. The advocate need
only argue, for example, that the child had sufficiently improved
during his hospital stay to warrant outpatient treatment or
outright discharge. Conflict between doctor and advocate on this
question is unlikely to lead to family discord.
As a consequence, the prospect of a post-admission hearing is
unlikely to deter parents from seeking medical attention for their
children, and the hearing itself is unlikely so to traumatize
parent and child as to make the child's eventual return to the
family impracticable.
Nor would post-admission hearings defeat the primary purpose of
the state juvenile mental health enterprise. Under the present
juvenile commitment scheme, Georgia parents do not enjoy absolute
discretion to commit their
Page 442 U. S. 636
children to public mental hospitals.
See ante at
442 U. S.
614-615. Superintendents of state facilities may not
accept children for long-term treatment unless they first determine
that the children are mentally ill and will likely benefit from
long-term hospital care.
See ibid. If the superintendent
determines either condition is unmet, the child must be released or
refused admission, regardless of the parents' desires.
See
ibid. No legitimate state interest would suffer if the
superintendent's determinations were reached through fair
proceedings with due consideration of fairly presented opposing
viewpoints, rather than through the present practice of secret,
ex parte deliberations. [
Footnote 3/22]
Nor can the good faith and good intentions of Georgia's
psychiatrists and social workers, adverted to by the Court,
see
ante at
442 U. S.
615-616, excuse Georgia's
ex parte procedures.
Georgia's admitting psychiatrists, like the school disciplinarians
described in
Goss v. Lopez, 419 U.
S. 565 (1975),
"although proceeding in utmost good faith, frequently act on the
reports and advice of others; and the controlling facts and the
nature of the conduct under challenge are often disputed."
Id. at
419 U. S. 580.
See App. 188-190, testimony of Dr. Messinger. Here, as in
Goss, the
"risk of error is not at all trivial, and it should be guarded
against if that may be done without prohibitive cost or
interference with the . . . process. . . . '[F]airness can rarely
be obtained by secret, one-sided determination
Page 442 U. S. 637
of facts decisive of rights. . . .' 'Secrecy is not congenial to
truth-seeking and self-righteousness gives too slender an assurance
of rightness. No better instrument has been devised for arriving at
truth than to give a person in jeopardy of serious loss notice of
the case against him and opportunity to meet it.'"
Goss v. Lopez, supra at
419 U. S. 580,
quoting in part from
Joint Anti-Fascist Refugee Committee v.
McGrath, 341 U. S. 123,
341 U. S. 170,
341 U. S.
171-172 (1951) (Frankfurter, J., concurring).
III
RIGHTS OF CHILDREN COMMITTED BY THEIR STATE
GUARDIANS
Georgia does not accord prior hearings to juvenile wards of the
State of Georgia committed by state social workers acting
in
loco parentis. The Court dismisses a challenge to this
practice on the grounds that state social workers are obliged by
statute to act in the children's best interest.
See ante
at
442 U. S.
619.
I find this reasoning particularly unpersuasive. With equal
logic, it could be argued that criminal trials are unnecessary,
since prosecutors are not supposed to prosecute innocent
persons.
To my mind, there is no justification for denying children
committed by their social workers the prior hearings that the
Constitution typically requires. In the first place, such children
cannot be said to have waived their rights to a prior hearing
simply because their social workers wished them to be confined. The
rule that parents speak for their children, even if it were
applicable in the commitment context, cannot be transmuted into a
rule that state social workers speak for their minor clients. The
rule in favor of deference to parental authority is designed to
shield parental control of child rearing from state interference.
See Pierce v. Society of Sisters, 268 U.
S. 510,
268 U. S. 535
(1925). The rule cannot be invoked in defense of unfettered state
control of child rearing or to immunize from review the decisions
of state social workers.
Page 442 U. S. 638
The social worker-child relationship is not deserving of the
special protection and deference accorded to the parent-child
relationship, and state officials acting
in loco parentis
cannot be equated with parents.
See O'Connor v. Donaldson,
422 U. S. 563
(1975);
Wisconsin v. Yoder, 406 U.
S. 205 (1972).
Second, the special considerations that justify postponement of
formal commitment proceedings whenever parents seek to hospitalize
their children are absent when the children are wards of the State
and are being committed upon the recommendations of their social
workers. The prospect of pre-admission hearings is not likely to
deter state social workers from discharging their duties and
securing psychiatric attention for their disturbed clients.
Moreover, since the children will already be in some form of state
custody as wards of the State, pre-hospitalization hearings will
not prevent needy children from receiving state care during the
pendency of the commitment proceedings. Finally, hearings in which
the decisions of state social workers are reviewed by other state
officials are not likely to traumatize the children or to hinder
their eventual recovery.
For these reasons, I believe that, in the absence of exigent
circumstances, juveniles committed upon the recommendation of their
social workers are entitled to pre-admission commitment hearings.
As a consequence, I would hold Georgia's present practice of
denying these juveniles prior hearings unconstitutional.
IV
Children incarcerated in public mental institutions are
constitutionally entitled to a fair opportunity to contest the
legitimacy of their confinement. They are entitled to some champion
who can speak on their behalf and who stands ready to oppose a
wrongful commitment. Georgia should not be permitted to deny that
opportunity and that champion simply because the children's parents
or guardians wish them
Page 442 U. S. 639
to be confined without a hearing. The risk of erroneous
commitment is simply too great unless there is some form of
adversary review. And fairness demands that children abandoned by
their supposed protectors to the rigors of institutional
confinement be given the help of some separate voice.
[
Footnote 3/1]
See Winters v. Miller, 446 F.2d 65 (CA2),
cert.
denied, 404 U.S. 985 (1971);
Scott v. Plante, 532
F.2d 939 (CA3 1976);
Souder v. McGuire, 423 F.
Supp. 830 (MD Pa.1976).
[
Footnote 3/2]
See Knecht v. Gillman, 488 F.2d 1136 (CA8 1973);
Mackey v. Procunier, 477 F.2d 877 (CA9 1973).
[
Footnote 3/3]
See Wyatt v. Hardin, No. 3195-N (MD Ala., Feb. 28, June
26, and July 1, 1975);
Price v. Sheppard, 307 Minn. 250,
239 N.W.2d
905 (1976);
Nelson v. Hudspeth, C.A. No. J75-40 (R)
(SD Miss., May 16, 1977).
[
Footnote 3/4]
See Kaimowitz v. Michigan Dept. of Mental Health, 42
U.S.L.W. 2063 (Cir.Ct.Wayne Cty., Mich., 1973).
[
Footnote 3/5]
See generally Note, Civil Commitment of the Mentally
Ill, 87 Harv.L.Rev. 1190, 1200 (1974).
[
Footnote 3/6]
See Dept. of HEW, National Institute of Mental Health,
Biometry Branch, Statistical Note 90, Utilization of Psychiatric
Facilities by Persons 18 Years of Age, Table 8, p. 14 (July
1973).
[
Footnote 3/7]
See J. Bowlby, Child Care and the Growth of Love 80
(1953); J. Horrocks, The Psychology of Adolescence 156 (1976); F.
Elkin, Agents of Socialization in Children's Behavior 357, 360 (R.
Bergman ed.1968).
[
Footnote 3/8]
See B. Flint, The Child and the Institution 14-15
(1966); H. Leland & D. Smith, Mental Retardation: Present and
Future Perspectives 86 (1974); N. Hobbs, The Futures of Children
142-143 (1975).
[
Footnote 3/9]
See Joint Commission on Mental Health of Children,
Crisis in Child Mental Health: Challenge for the 1970's, p. 271
(1969).
[
Footnote 3/10]
See R. Kugel & W. Wolfensberger, Changing Patterns
in Residential Services for the Mentally Retarded 22 (1969).
[
Footnote 3/11]
See also Wheeler v. Glass, 473 F.2d 983 (CA7 1973);
Davis v. Watkins, 384 F.
Supp. 1196 (ND Ohio 1974);
Welsch v.
Likins, 373 F.
Supp. 487 (Minn.1974).
[
Footnote 3/12]
See J. Simmons, Psychiatric Examination of Children 1,
6 (1974); Lourie & Rieger, Psychiatric and Psychological
Examination of Children, in 2 American Handbook of Psychiatry 19
(2d ed 1974).
[
Footnote 3/13]
See Joint Commission on Mental Health of Children,
supra, 442
U.S. 584fn3/9|>n. 9, at 267.
[
Footnote 3/14]
See T. Scheff, Being Mentally Ill: A Sociological
Theory (1966); Ennis & Litwack, Psychiatry and the Presumption
of Expertise: Flipping Coins in the Courtroom, 62 Calif.L.Rev. 693
(1974).
[
Footnote 3/15]
See Dept. of HEW, National Institute of Mental Health,
Biometry Branch, Statistical Note 115, Children and State Mental
Hospitals 4 (Apr.1975).
[
Footnote 3/16]
See generally S. Katz, When Parents Fail (1971); M.
Midonick & D. Besharov, Children, Parents and the Courts:
Juvenile Delinquency, Ungovernability, and Neglect (1972); Wald,
State Intervention on Behalf of "Neglected" Children: A Search for
Realistic Standards, 27 Stan.L.Rev. 985 (1975).
[
Footnote 3/17]
See, e.g., Martorell v. Ochoa, 276 F. 99 (CA1
1921).
[
Footnote 3/18]
See, e.g., Jehovah's Witnesses v. King County
Hospital, 278 F.
Supp. 488 (WD Wash.1967),
aff'd, 390 U.
S. 598 (1968);
In re Sampson, 65 Misc.2d 658,
317 N.Y.S.2d 641 (Fam.Ct.Ulster County, 1970),
aff'd, 37
App.Div.2d 668, 323 N.Y.S.2d 253 (1971),
aff'd, 29 N.Y.2d
900, 278 N.E.2d 918 (1972);
State v. Perricone, 37 N.J.
463, 181 A.2d 751 (1962). Similarly, more recent legal disputes
involving the sterilization of children have led to the conclusion
that parents are not permitted to authorize operations with such
far-reaching consequences.
See, e.g., A.L. v. G.R.H., 163
Ind.App. 636,
325 N.E.2d
501 (1975);
In re M.K.R., 515 S.W.2d
467 (M.1974);
Frazier v. Levi, 440 S.W.2d 393
(Tex.Civ.App. 1969).
[
Footnote 3/19]
See Commonwealth v. Renfrew, 332 Mass. 492,
126
N.E.2d 109 (1955);
Meyerkorth v. State, 173 Neb. 889,
115 N.W.2d
585 (1962),
appeal dism'd, 372 U.
S. 705 (1963);
In re Weberman, 198 Misc. 1055,
100 N.Y.S.2d 60 (Sup.Ct.1950),
aff'd, 278 App.Div. 656,
102 N.Y.S.2d 418,
aff'd, 302 N.Y. 855, 100 N.E.2d 47,
appeal dism'd, 342 U. S. 884
(1951).
[
Footnote 3/20]
Murdock, Civil Rights of the Mentally Retarded: Some Critical
Issues, 48 Notre Dame Law. 133, 138 (1972); Vogel & Bell, The
Emotionally Disturbed Child as the Family Scapegoat, in a Modern
Introduction to the Family 412 (1968).
[
Footnote 3/21]
The National Institute of Mental Health has reported:
"[T]housands upon thousands of elderly patients now confined on
the back wards of . . . state [mental] institutions were first
admitted as children thirty, forty, and even fifty years ago. A
recent report from one state estimates that one in every four
children admitted to its mental hospitals 'can anticipate being
permanently hospitalized for the next 50 years of their
lives.'"
Joint Commission on Mental Health of Children,
supra,
442
U.S. 584fn3/9|>n. 9, at 5.
[
Footnote 3/22]
Indeed, post-admission hearings may well advance the purposes of
the state enterprise. First, hearings will promote accuracy and
ensure that the superintendent diverts children who do not require
hospitalization to more appropriate programs. Second, the hearings
themselves may prove therapeutic. Children who feel that they have
received a fair hearing may be more likely to accept the legitimacy
of their confinement, acknowledge their illness, and cooperate with
those attempting to give treatment. This, in turn, would remove a
significant impediment to successful therapy.
See Katz,
The Right to Treatment -- An Enchanting Legal Fiction?, 36
U.Chi.L.Rev. 755, 76769 (1969);
O'Connor v. Donaldson,
422 U. S. 563,
422 U. S. 579
(1975) (BURGER, C.J., concurring).