T.N. AKA T.D. v. State ( 2013 )

Affirmed and Memorandum Opinion filed November 5, 2013.
In The
Fourteenth Court of Appeals
NO. 14-13-00012-CV
NO. 14-13-00014-CV
T.N. AKA T.D., Appellant
V.
THE STATE OF TEXAS, Appellee
On Appeal from the Probate Court
Galveston County, Texas
Trial Court Cause Nos. MH4182 & MH4182A
MEMORANDUM OPINION
In a single issue, appellant T.N. challenges the factual sufficiency of the
evidence supporting an order permitting the involuntary administration of
psychoactive medication. He argues that the probate court failed to address
specifically his religious objection to involuntary medication, thereby violating
section 574.106(b) of the Texas Health and Safety Code. Appellant contends that
his religious objection required the trial court not only to consider his religious
beliefs, but also to make an on-the-record finding as to those beliefs. We disagree
because the Health and Safety Code contains no requirement for such findings, and
factually sufficient evidence supports the trial court’s order. We therefore affirm.
BACKGROUND
Appellant is a twenty-year-old male diagnosed with catatonic schizophrenia.
The State, for appellant’s ―best interest and protection,‖ filed a motion to place him
in protective custody and applied for an order allowing the administration of
psychoactive medication. See Tex. Health & Safety Code Ann. Ch. 574 (West
2010 & Supp. 2013). The trial court held hearings on both the protective-custody
motion and the application to administer psychoactive medication.1
At appellant’s protective-custody hearing, Dr. Michael Stone, a board-
certified psychiatrist and appellant’s attending physician, testified that appellant
had been hospitalized on at least two prior occasions. In each of those instances,
appellant refused medications and was discharged. When appellant came to Dr.
Stone’s hospital, he was in a catatonic state of extreme withdrawal. He held
postures for long periods of time without moving, he refused to communicate with
medical staff, and he would not eat or drink. Dr. Stone worried this immobility
would compromise appellant’s blood flow and break down his muscles. The
doctor administered medications on an emergency basis, and some of the
symptoms began to remit. Without medication, according to Dr. Stone, appellant
could have died. At the same hearing, appellant stated that he believed neither that
he was ill nor that he should be administered psychoactive medications.
1
The protective-custody motion and medication application were assigned separate cause
numbers in the trial court, and because appellant appealed the final orders in both cases, received
separate cause numbers in this Court as well. Appellant filed identical briefs in both appeals,
however, and his single issue challenges only the medication order. We therefore limit our
analysis to that issue.
2
In the medication hearing that followed, appellant indicated a religious
objection to psychoactive medication. When asked why he did not wish to take the
recommended medication, appellant responded, ―[t]he voice of God lets me know
to refuse all medications.‖ He went on to say that God was not commanding him
to refuse medication, but rather ―asking and convincing‖ him to do so.
Appellant testified that he is a medical missionary and should rely only on
natural remedies. When asked if he understood that upon admission to the hospital
he was severely ill, with lab tests showing risk of muscle and kidney damage,
appellant attributed his state to not being fed and being held against his will. When
asked whether he believed religious consequences would befall him were he forced
to take medication, appellant answered ―No. It’s not like I’m going to be wiped out
or anything like that. It’s just I have free choice. I have the free will and free
choice not to do that.‖
The trial court issued an order allowing psychoactive medication to be
forcibly administered to appellant. It indicated that ―after considering all of the
evidence,‖ including stipulated medical evidence and Dr. Stone’s testimony, it
found appellant was ―incapable of making medical treatment decisions‖ and that
―it would be in [his] best interest to be treated with psychoactive medication.‖2
This appeal followed. See Tex. Health & Safety Code Ann. § 574.108(a) (West
2010) (authorizing appeal of order).
2
The trial court’s medication order expired near the end of March 2013, but its expiration
does not moot this appeal. See State v. K.E.W., 315 S.W.3d 16, 20 (Tex. 2010) (―The expiration
of the time for which [the patient] was ordered to receive services does not require the appeal to
be dismissed for mootness.‖); State v. Lodge, 608 S.W.2d 910, 911–12 (Tex. 1980) (appeal of
civil commitment not moot because of ―collateral consequences‖ exception to mootness
doctrine).
3
ANALYSIS
Appellant does not challenge the probate court’s order on legal sufficiency
grounds. Nor does he request relief under the First Amendment of the United
States Constitution or Article I, Section 6 of the Texas Constitution. He also
presents no argument based on the Texas Religious Freedom Restoration Act.3
Instead, his sole issue on appeal is the factual sufficiency of the evidence submitted
to the trial court. And even within that issue, appellant’s chief complaint is that the
trial court failed to adequately consider his ―religious beliefs‖ as the Health and
Safety Code requires. See Tex. Health & Safety Code Ann. § 574.106(b)(2) (West
2010). We disagree.
I. Standard of review
An order to administer psychoactive medication requires clear and
convincing evidence that, among other things, ―the proposed medication is in the
best interest of the patient.‖ Id. § 574.106(a-1)(1). We will sustain a factual
sufficiency challenge to the order if the fact finder ―could not reasonably have
formed a firm conviction or belief‖ that medication is in the patient’s best interest.
See In re C.H., 89 S.W.3d 17, 27 (Tex. 2002).
In determining whether a fact finder could reasonably form a firm conviction
or belief, we must give due consideration to any evidence the fact finder could
reasonably have found to be clear and convincing. In re J.F.C., 96 S.W.3d 256,
3
In its brief, the State argues that the trial court complied with the Texas Religious
Freedom Restoration Act (Act). See Tex Civ. Prac. & Rem. Code Ann. § 110.004 (West 2011).
Appellant has never mentioned this Act, however. Thus, we have no occasion to address the Act
in this case. See Voice of Cornerstone Church Corp. v. Pizza Prop. Partners, 160 S.W.3d 657,
672 n.10 (Tex. App.—Austin 2005, no pet.) (when party ―did not raise the [ ] Act below in its
pleadings, summary-judgment response, or [trial] briefing‖ and made ―only a single passing
reference to [the Act] in its [appellate] brief,‖ court had no occasion to consider the Act’s
application).
4
266 (Tex. 2002). But ―there is no requirement that the evidence be unequivocal or
undisputed.‖ State v. Addington, 588 S.W.2d 569, 570 (Tex. 1979) (per curiam).
II. The evidence introduced at the medication hearing is factually sufficient
to support the order.
In determining whether psychoactive medication is in a patient’s best
interest, a court shall consider several factors, including ―the patient’s religious
beliefs.‖ Id. § 574.106(b)(2). In this case, the court spent most of the medication
hearing listening to appellant testify about his religious beliefs. The trial court
placed no limitation on appellant’s counsel in the direct examination of appellant.
Nor did it limit the State’s cross-examination of appellant regarding his beliefs.
Dr. Stone also testified about appellant’s religious beliefs. The doctor
explained that if appellant had religious issues with medication, he would
―certainly do everything [he could] to honor those wishes.‖ The doctor testified
that he had been unaware of appellant’s beliefs prior to the hearing and that
appellant’s religious convictions were ―a separate issue from him not being able to
perceive his illness.‖ In its ―Order to Administer Psychoactive Medication,‖ the
Court stated that it had ―consider[ed] all of the evidence.‖
Even though the trial court excluded no evidence regarding appellant’s
religious beliefs and stated that it ―consider[ed] all of the evidence,‖ appellant
contends that the trial court failed to consider his religious beliefs. Appellant
focuses upon a portion of the trial court’s order that reads as follows:
The Court relied on the following evidence:
 doctor’s testimony
patient’s testimony
 stipulation of evidence
(emphasis added). Appellant argues that the trial court’s failure to check that it
5
―relied on‖ the ―patient’s testimony‖ indicates that the trial court did not consider
appellant’s testimony regarding his religious beliefs. We disagree.
We construe orders using the same rules of interpretation that apply to other
written instruments. Payless Cashways, Inc. v. Hill, 139 S.W.3d 793, 795 (Tex.
App.—Dallas 2004, no pet.). ―If an order is unambiguous, we must construe the
order in light of the literal meaning of the language used.‖ Id.
Here, the fact that the trial court did not ―rel[y] on‖ appellant’s testimony in
concluding that his best interest required treatment with psychoactive medication
does not mean that the trial court did not consider this evidence at all. ―To rely‖
means ―to find support: depend.‖ Webster’s Third New International Dictionary
1919 (1993). The trial court’s finding that it was in appellant’s best interest to be
medicated did not ―find support‖ in appellant’s testimony that taking the
medication violated his religious beliefs.
To the contrary, the court found that despite appellant’s professed religious
beliefs, clear and convincing evidence established that his best interest required
psychoactive medication. It does not follow that, as appellant argues, the trial
court disregarded his testimony entirely in violation of the Health and Safety Code.
Indeed, such a construction conflicts with the order’s plain language, which
explicitly states that the court considered all of the evidence.
We conclude that the trial court’s unlimited admission of religious-belief
evidence, as well as its statement that it considered all of the evidence, establish
that the court considered appellant’s religious beliefs as the Health and Safety
Code mandates.4 The Health and Safety Code did not require specific findings on
4
See M.H. v. State ex rel. M.H., No. 01-09-00205-CV, 2009 WL 2050988, at *4–*5
(Tex. App.—Houston [1st Dist.] July 16, 2009, no pet.) (mem. op.) (rejecting argument that trial
court failed to consider patient’s stated preferences, religious beliefs, and the risks and benefits
of proposed treatment where there was evidence that, despite these factors, treatment was in
6
all of the factors in section 574.106(b). In re R.S.C., 921 S.W.2d 506, 515 (Tex.
App.—Fort Worth 1996, no writ).
Moreover, clear and convincing evidence supported the trial court’s finding
that administering psychoactive medication was in appellant’s best interest. Dr.
Stone testified that appellant’s abstention from psychoactive drugs had caused such
severe catatonia that tests showed evidence of muscle breakdown. If appellant had
not received psychoactive medication upon his admission to the hospital, Dr. Stone
testified that intravenous fluids would have been necessary. Fluids would not have
abated appellant’s catatonia, however, so appellant’s muscles could have continued
to deteriorate, and the untreated catatonia may have ultimately proved fatal. This
was strong evidence that appellant’s best interest required continued treatment with
psychoactive medication. Dr. Stone also testified that, now that he knew of
appellant’s religious preferences, he would ―certainly do everything [he could] to
honor those wishes.‖
The severe health consequences of not treating appellant with psychoactive
medication, together with Dr. Stone’s sensitivity to appellant’s religious
convictions, provide clear and convincing evidence that authorizing the doctor to
administer psychoactive medication was in appellant’s best interest. Cf. State ex
rel. D.P., 12-03-00005-CV, 2003 WL 21998759, at *7 (Tex. App.—Tyler Aug. 20,
2003, no pet.) (trial court is not required to defer to patient’s preference on the
subject of psychoactive drugs).
patient’s best interest); In re Prot. of M.E.S., No. 04-02-00614-CV, 2003 WL 1240002, at *4
(Tex. App.—San Antonio Mar. 19, 2003, no pet.) (mem. op.) (when ―each of the factors—other
than [patient’s] religious beliefs—[wa]s encompassed by the expert testimony[,]‖ ―the trial court
considered the statutorily-mandated factors‖); State ex rel. D.P., No. 12-03-00005-CV, 2003 WL
21998759, at *6–7 (Tex. App.—Tyler Aug. 20, 2003, no pet.) (mem. op.) (when doctor’s
testimony encompassed all factors except religious beliefs, ―the trial court met the obligations
imposed on it by Section 574.106‖).
7
CONCLUSION
Having held that the evidence in the record was factually sufficient to
produce a firm belief or conviction that administering psychoactive medication
was in appellant’s best interest, we affirm the trial court’s order.
/s/ J. Brett Busby
Justice
Panel consists of Justices Boyce, Jamison, and Busby.
8