442 U.S. 584
PARHAM, COMMISSIONER, DEPARTMENT
OF HUMAN RESOURCES OF GEORGIA, ET AL. v.
J. R. ET AL.
APPEAL FROM THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF
No. 75-1690.
Argued December 6, 1977. Reargued October 10, 1978.
Decided June 20, 1979.
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. 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 [442
U.S. 584, 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 burdens that the additional or substitute procedural requirement
would entail. Cf. Mathews v. Eldridge, 424
U.S. 319, 335 ; Smith v. Organization of Foster Families, 431
U.S. 816, 848 -849. Pp. 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. 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 preadmission procedures. Pp. 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, 271 ; Morrissey v. Brewer, 408
U.S. 471, 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. 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 [442 U.S. 584, 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. 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. 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. 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. 621. BRENNAN, J., filed an opinion concurring in part
and dissenting in part, in which MARSHALL and STEVENS, JJ., joined, post, p.
625.
R. Douglas Lackey, Assistant Attorney General of Georgia, reargued the cause
for appellants. With him on the briefs on the original argument were Arthur K.
Bolton, Attorney General, Robert S. Stubbs II, Executive Assistant Attorney
General, Don A. Langham, First Assistant Attorney General, Michael J. Bowers,
Senior Assistant Attorney General, and Carol Atha Cosgrove, Assistant Attorney
General.
John L. Cromartie, Jr., reargued the cause for appellees. [442 U.S. 584, 587] With
him on the brief on the original argument was Gerald R. Tarutis. *
[ Footnote
* ] Briefs of amici curiae urging affirmance were filed by William B.
Spann, Jr., John H. Lashly, and Daniel L. Skoler for the American Bar
Association; by Stephen P. Berzon, Marian Wright Edelman, and Paul R. Friedman
for the American Orthopsychiatric Association et al.; by Joel I. Klein for the
American Psychiatric Association et al.; by Robert L. Walker for the Child
Welfare League of America; by Stanley C. Van Ness for the Department of the
Public Advocate, Division of Mental Health Advocacy of New Jersey; and by
Robert S. Catz for the Urban Law Institute.
Solicitor General McCree, Assistant Attorney General Days, Brian K.
Landsberg, and Mark L. Gross filed a brief for the United States as amicus
curiae.
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.
(a) Appellee 1
J. R., a child being treated in a Georgia state mental hospital, was a
plaintiff in this class action 2
based on 42 U.S.C. 1983, in the District Court for the Middle District of
Georgia. Appellants are the State's Commissioner [442 U.S. 584, 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), 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 [442 U.S. 584, 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. 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. [442 U.S. 584, 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 socio-medical 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 re-examined 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 [442 U.S. 584, 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 4
will demonstrate the variety of [442
U.S. 584, 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 [442 U.S. 584, 593] 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. [442
U.S. 584, 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 [442
U.S. 584, 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. [442 U.S. 584,
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. 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.
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 [442
U.S. 584, 597] hospitals 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. 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. 8
No specific [442 U.S. 584,
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
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.
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 [442 U.S. 584, 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, 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 [442 U.S. 584, 600] procedural
requirement would entail." Mathews v. Eldridge, 424
U.S. 319, 335 (1976), quoted in Smith v. Organization of Foster Families, 431
U.S. 816, 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. 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, 425 (1979); In re Gault, 387 U.S. I, 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 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 23; Paul v.
Davis, 424
U.S. 693, 711 -712 (1976). The state through its voluntary commitment
procedures does not "label" the child; it provides a [442 U.S. 584, 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 429. See also Schwartz, Myers, &
Astrachan, Psychiatric Labeling and the Rehabilitation of the Mental Patient,
31 Archives of General Psychiatry 329 (1974). 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. 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 [442
U.S. 584, 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, 535 (1925). See also Wisconsin v. Yoder, 406
U.S. 205, 213 (1972); Prince v. Massachusetts, 321
U.S. 158, 166 (1944); Meyer v. Nebraska, 262
U.S. 390, 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 [442 U.S.
584, 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 230; Prince
v. Massachusetts, supra, at 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, [442 U.S. 584, 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 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 [442 U.S. 584, 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. 14
One factor that must [442 U.S.
584, 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 47% 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 430 . See also Mathews v. Eldridge, 424
U.S., at 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, 271 (1970); Morrissey v. Brewer, 408
U.S. 471, 489 (1972). That inquiry must carefully [442 U.S. 584, 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. 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 271; Morrissey v. Brewer, supra, at 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 [442 U.S. 584, 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, 90 (1978). See also Greenholtz v. Nebraska Penal Inmates, ante, at
13-14; Cafeteria & Restaurant Workers v. McElroy, 367
U.S. 886, 895 (1961). 16
[442 U.S. 584, 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 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, 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). 17
[442 U.S. 584, 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. 18
[442 U.S. 584, 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 [442 U.S.
584, 612] a child's emotional disturbance. 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 and administrative
scheme that is generally followed in more than 30 states. 20
"[P]rocedural [442 U.S.
584, 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 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 [442 U.S. 584, 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 [442 U.S.
584, 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 reviewed group. For the most part, the reviews
are as frequent as weekly, but none are 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. 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 truth-finding
process as applied to the generality of cases, not the rare exceptions."
Mathews v. Eldridge, supra, at 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
[442 U.S. 584, 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; 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 [442 U.S.
584, 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.
(a) Our discussion in Part III was directed at the situation where a child's
natural parents request his admission to a state mental hospital. 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 [442 U.S. 584, 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 [442 U.S. 584, 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 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 428 -429, 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 [442 U.S. 584, 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, 23
if the court concludes the issue is still alive.
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 [442 U.S. 584, 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 the
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 [442 U.S. 584, 592] 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 Part
IV, 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 [442
U.S. 584, 606] deserving." Friendly, "Some Kind of
Hearing," 123 U. Pa. L. Rev. 1267, 1276 (1975). See also Wheeler v.
Montgomery, 397
U.S. 280, 282 (1970) (dissenting opinion).
[ Footnote
15 ] As we discuss more fully later, infra, at 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, 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 fact finding 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 [442 U.S. 584, 610] 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 [442
U.S. 584, 611] 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. 202A.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. 41-21-103 (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. 422A.560, 433A.540 (1975); N. Y. Mental
Hyg. Law 9.13 [442 U.S. 584, 613]
(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 64-7-29, 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. 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 . 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. [442
U.S. 584, 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, 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. 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 [442 U.S. 584, 623] behalf
their parents 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. 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). 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. 6
[442 U.S. 584, 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 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. 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 [442 U.S. 584, 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. 8
But that is a far cry from holding that such intervention is
constitutionally compelled.
For these reasons I concur in the judgment.
[ Footnote
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, 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, 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, 102 (STEVENS, J., concurring in part and dissenting in part).
Cf. Stump v. Sparkman, 435
U.S. 349, 366 (dissenting opinion).
[ Footnote
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 535 .
[ Footnote
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
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
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
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 [442 U.S. 584,
624] these differences, ante, at 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
7 ] See MR. JUSTICE BRENNAN'S opinion, post, at 630-631, and n. 16.
[ Footnote
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 preconfinement
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 postadmission procedures due Georgia's institutionalized
juveniles. While the question of the frequency of postadmission review hearings
may properly be deferred, the [442
U.S. 584, 626] right to at least one postadmission 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
preconfinement hearings to juvenile wards of the State committed by the State
acting in loco parentis.
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, 509 (1972), and inevitably affects "fundamental
rights." Baxstrom v. Herald, 383
U.S. 107, 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, 1
aversive conditioning, 2
convulsive therapy, 3
and even psychosurgery. 4
Furthermore, as the Court recognizes, see ante, at 600, persons confined in
mental institutions are stigmatized as [442 U.S. 584, 627] sick and abnormal during
confinement and, in some cases, even after release. 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, 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, 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 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, 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 [442 U.S.
584, 628] are involved. Children, on the average, are confined
for longer periods than are adults. 6
Moreover, childhood is a particularly vulnerable time of life 7
and children erroneously institutionalized during their formative years may
bear the scars for the rest of their lives. 8
Furthermore, the provision of satisfactory institutionalized mental care
for children generally requires a substantial financial commitment 9
that too often has not been forthcoming. 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"). 11
In addition, the chances of an erroneous commitment [442 U.S. 584, 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 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. 12
These uncertainties may be further aggravated when economic and social
class separate doctor and child, thereby frustrating the accurate diagnosis of
pathology. 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. 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. 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). [442
U.S. 584, 630]
RIGHTS OF CHILDREN COMMITTED BY
THEIR PARENTS
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, 170 (1944). This principle is reflected in the variety of
statutes and cases that authorize state intervention on behalf of neglected or
abused children 16
and that, inter alia, curtail parental authority to alienate their
children's property, 17
to withhold necessary medical treatment, 18
and to deny children exposure to ideas [442 U.S. 584, 631] and experiences they may later
need as independent and autonomous adults. 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,