The Boston State Hospital Case (Rogers v. Okin): A Legal, Ethical, and Medical Morass

THE BOSTON STATE HOSPITAL CASE (ROGERS v. OKIN): A LEGAL, ETHICAL, AND MEDICAL MORASS LOUIS LASAGNA* The case of Rogers v. Okin, also known as the Boston State Hospital case, consumed 72 trial days. The proceedings fill some 8,000 pages of transcript, and an additional 2,300 pages of posttrial briefs were filed. Over 50 witnesses testified. When Judge Joseph L. Tauro of the U.S. District Court, District of Massachusetts, finally rendered his 162-page opinion [1], 51A years after the filing of a civil-rights action by plaintiffs, neither side was satisfied with the outcome, and appeals were promptly filed by both. On November 25, 1980,Judge Coffin wrote an opinion for the First Circuit Court responding to these appeals, affirming the lower court'sjudgment in part, reversing it in part, and remanding the case for further proceedings in accordance with his opinion [2]. This litigation is of extreme importance, being one in a series of suits in recent years with far-reaching implications for the mentally ill, for psychiatry, and for society at large. Because the case focuses the issues, it deserves careful scrutiny and analysis. In the discussion that follows, I shall approach these issues with the orientation not of a lawyer, but of a physician. Background On April 27, 1975, some patients at Boston State Hospital (BSH) sought to enjoin certain seclusion and medication practices at the hospital and to recover damages from those responsible for such practices. The court issued a temporary restraining order prohibiting nonemergency seclusion and medication of both voluntary and involuntary The author is grateful for financial support provided by the Henry J. Kaiser Family Foundation during the time this paper was prepared at the Center for Advanced Study in the Behavioral Sciences, Stanford, California. *Department of Pharmacology and Toxicology, University of Rochester School of Medicine, Rochester, New York 14642.© 1982 by The University of Chicago. All rights reserved. 003 1-5982/82/2503-0279$0 1 .00 382 Louis Lasagna · Boston State Hospital Ca patients without their informed consent (or that of a guardian, in the case of an incompetent). When it became clear that irreconcilable differences precluded solution of the complex issues involved, a trial on the merits was scheduled. It finally commenced in December 1977 and ended in January 1979. The named plaintiffs were seven in number; the class of plaintiffs included all such patients similarly situated. The specific plaintiffs were chronically ill; most had a history of violent behavior and had been repeatedly admitted to mental hospitals. The defendants were, with one exception, physicians. Five had held positions of administrative responsibility at BSH, and eight had been resident physicians there. The last defendant was a licensed psychologist , who had served as a ward supervisor at the hospital. The Boston State Hospital Facility One should not ignore the setting for the putative abuses. The hospital is a multiunit facility which at that time had academic ties to two Boston medical schools. The Austin Unit (as it was then called) was built after World War I, as a maximal security ward for 160 female patients. InJudge Tauro's words, "It is a drab, gloomy, poorly lighted structure in a state of chronic disrepair. . . . Plumbing problems were constant, often resulting in basement flooding and the odor ofsewage through the building. . . ." The May Unit (which no longer exists today) was also "in chronic disrepair. The heating system was particularly unreliable." Admission Procedures The standards for admission to BSH, as to all state-run mental institutions in Massachusetts, are defined by statute. Patients needing treatment for mental illness are encouraged to volunteer for commitment , which can be done directly by the patient (if 16 years or older) or by a parent or guardian. Such voluntary patients may be discharged upon request, after giving 3 days' notice to hospital authorities. Ifa physician states that a person is likely to suffer serious harm due to mental illness if not hospitalized, an involuntary 10-day commitment may be obtained. If, during these 10 days, it seems likely that discharge will lead to serious harm, the hospital may petition the court for civil commitment. The court can order the patient committed for up to 1...