537 N.W.2d 358, 66 A.L.R.5th 707

Supreme Court of North Dakota.

STATE of North Dakota ex rel. Timothy SCHUETZLE, Warden North Dakota State
Penitentiary, Plaintiff and Appellee,

v.

August T. VOGEL, Defendant and Appellant.

Civ. No. 950095.

Sept. 22, 1995.

*358 Jean R. Mullen (argued), Assistant Attorney General, Attorney General's Office, Bismarck, for plaintiff and appellee.
*359 Lynn M. Boughey (argued), and Rozanna Larson, Boughey Law Firm, Minot, for defendant and appellant.


MESCHKE, Justice.

August T. Vogel appeals from a declaratory judgment allowing State Penitentiary officials to require Vogel to submit to diabetes monitoring of his blood sugar count and, if ordered by a physician, to forcibly administer food, insulin and other medications to Vogel to prevent deterioration of his health or premature death. We affirm.

Vogel is a 64-year-old penitentiary inmate with a release date of 2016 from his 90-year sentence for first degree murder. He was diagnosed with diabetes mellitus in 1982 and, by 1992, was regularly taking insulin on his own, with monitoring by the penitentiary nurses. In January 1993, the Parole Board granted Vogel an education release to attend Bismarck State College, and he was transferred to the Missouri River Correctional Center (MRCC), a minimum security facility, while he attended school. Under penitentiary rules, inmates can be placed at the MRCC if they are on work release, education release, or within two years of their release from the penitentiary. Vogel was also permitted to work at the Radisson Inn for practical experience to fulfill an educational requirement.
After completing his college coursework in May 1994, Vogel continued working at the Radisson Inn pending Parole Board review. In September, the Parole Board denied Vogel work release, and he was not given a parole date within the next two years. He was returned to the penitentiary on September 12, 1994 to continue serving his sentence.

The day after his return to the penitentiary, Vogel would not eat or take his insulin. Warden Timothy Schuetzle moved Vogel to the infirmary for observation, and informed him that if his health deteriorated to a dangerous condition, Vogel would be forcibly injected with insulin. Vogel requested and received a grievance hearing.

At the hearing, Vogel expressed his anger at being moved back to the penitentiary. When asked if a compromise could be reached, Vogel said he would resume eating and taking medication for his diabetes if a letter of apology were sent to his employer at the Radisson Inn explaining his absence, if he were returned to the MRCC, if he got his job back, and if he received $1,000 for "punitive" damages. Schuetzle contacted Vogel's employer for him, but denied the other requests, explaining to Vogel why they could not be granted. In an effort to placate Vogel, Schuetzle also offered to help him prepare a parole plan to present to the Parole Board in two years. Vogel refused. His grievance was denied.

Vogel was committed twice, in September and October 1994, to the Jamestown State Hospital for mental evaluation. The State Hospital concluded Vogel was competent and not suicidal. The treating psychiatrist reported Vogel "is a very stubborn, angry man who because of his life sentence ... has very little to lose and thus has asserted his control by refusing to eat at times and by refusing to take the insulin for his diabetes." Although he began eating again, Vogel continues to refuse to take his insulin.

Schuetzle brought this declaratory action to determine whether Vogel, as an inmate, could refuse medical care and, if so, whether his refusal waived his Eighth Amendment right to be free from cruel and unusual punishment. At the trial, Vogel testified that he refused to take insulin in September because he believed he was being harmed by taking too much insulin. The warden, medical director, and doctor for the penitentiary also testified. The doctor testified that, based on Vogel's varying blood sugar levels, Vogel was not controlling his diabetes through nonmedicinal alternatives. The doctor opined that Vogel's refusal to take insulin would increase his risk of heart attack, diabetic coma, kidney failure, eye problems, pain and numbness, and premature death at some point in the future. The medical director testified that an untreated diabetic's possible future need for cardiac bypass surgery and renal dialysis would be "extremely costly" to the penitentiary.
The trial court found a "serious medical need" for Vogel to continue with proper medication for his diabetes and concluded that *360 Vogel had not shown he was being overmedicated with insulin. The court found that Vogel is a "very stubborn man" who "is competent to make determinations about his medical care." The court further found, however, that Vogel's refusals to eat and to take his insulin were "an attempt to manipulate the system and an act of blackmail against prison officials" and that Vogel would have resumed eating and taking insulin if he had been permitted to return to the MRCC and to his job at the Radisson Inn. The court found that Vogel's current refusals to take insulin and be monitored stemmed from his "anger or defiance because he was not permitted to be housed at the MRCC or to work at the Radisson." Weighing Vogel's right to refuse medical treatment against the state's "legitimate penological interests in controlling inmate discipline and in preventing prisoners from blackmailing prison officials in order to gain specific advantages," the court concluded the state's interests "must prevail."

The court therefore ruled that Schuetzle could require Vogel to submit to monitoring of his blood sugar count and could administer food, insulin, or other medications ordered by a physician if necessary to prevent deterioration of his health or premature death. The court also ruled that the state would not be liable for any deterioration of Vogel's condition that occurred as a result of his voluntary refusal to eat or take medication for his diabetic condition.

On appeal, Vogel asserts that, as a competent prison inmate, he has an absolute right to refuse medical treatment regardless of his reasons for doing so. We disagree.

We first explain what is not present in this case. We are not faced with an individual in a persistent vegetative state who can be kept alive only by extraordinary means, or one who is in the last stages of a terminal illness. Compare, e.g., Matter of Quinlan, 70 N.J. 10, 355 A.2d 647, cert. denied sub nom. Garger v. New Jersey, 429 U.S. 922, 97 S.Ct. 319, 50 L.Ed.2d 289 (1976) (persistent vegetative state); Superintendent of Belchertown v. Saikewicz, 373 Mass. 728, 370 N.E.2d 417 (1977) (acute myeloblastic monocytic leukemia); NDCC 23-06.4-11(1) ("Death resulting from the withholding or withdrawal of life-prolonging treatment, nutrition, or hydration pursuant to a declaration and in accordance with this chapter does not constitute, for any purpose, a suicide or homicide."). Rather, this individual, by a deliberate course of conduct, will most likely cause himself serious harm or prematurely end his life, although relatively nonintrusive treatments for his disease would significantly reduce the likelihood of complications and resultant harm or death.

A competent person has a constitutionally protected liberty interest to refuse unwanted medical treatment. Cruzan v. Director, Missouri Dept. of Health, 497 U.S. 261, 278, 110 S.Ct. 2841, 2851, 111 L.Ed.2d 224 (1990). A person's interest in personal autonomy and self-determination is a fundamentally commanding one, with well-established legal and philosophical underpinnings. See, e.g., Thor v. Superior Court (Andrews), 5 Cal.4th 725, 21 Cal.Rptr.2d 357, 362-365, 855 P.2d 375, 380-383 (1993). But this right, like other constitutionally protected interests, is not absolute. As Cruzan, 497 U.S. at 279, 110 S.Ct. at 2852 (quoting Youngberg v. Romeo, 457 U.S. 307, 321, 102 S.Ct. 2452, 2461, 73 L.Ed.2d 28 (1982)), explains, whether a person's constitutionally protected liberty interest in refusing unwanted medical treatment has been violated " 'must be determined by balancing his liberty interests against the relevant state interests.' "

Ignoring the most relevant state interest here, Vogel would have us analyze this case apart from the prison setting where it arises. In a non-prison setting, the state interests that are generally identified as countervailing (but often subordinate) to the scope of a patient's autonomy include preserving life, preventing suicide, maintaining the integrity of the medical profession, and protecting innocent third persons. See Thor, 21 Cal.Rptr.2d at 365, 855 P.2d at 383. In the case of a prison inmate, though, the state has an "important interest in maintaining the confinement of the prisoner and the integrity of its correctional system [that] must also be considered" in the balance. Matter of Adoption of J.S.P.L., 532 N.W.2d 653, 662 (N.D.1995). See also *361 Washington v. Harper, 494 U.S. 210, 222, 110 S.Ct. 1028, 1037, 108 L.Ed.2d 178 (1990) ("The extent of a prisoner's right under the [Due Process] Clause to avoid the unwanted administration of antipsychotic drugs must be defined in the context of the inmate's confinement."). Compare Sandin v. Conner, 515 U.S. 472, 115 S.Ct. 2293, 132 L.Ed.2d 418 (1995) (limiting prison inmates' recognizable liberty interests that are afforded procedural due process protection). As Dept. of Public Welfare v. Kallinger, 134 Pa.Commw. 415, 580 A.2d 887, 889 (1990), explains, as a convict, Vogel's rights are necessarily limited and restricted "because of the unique nature and requirements of prison custody."

Courts cannot condone a prisoner's manipulation of his medical circumstances to the detriment of a state's interest in prison order, security, and discipline. See Thor, 21 Cal.Rptr.2d at 371, 855 P.2d at 389; Commissioner of Correction v. Myers, 379 Mass. 255, 399 N.E.2d 452, 458 (1979); In re Caulk, 125 N.H. 226, 480 A.2d 93, 96 (1984); Von Holden v. Chapman, 87 A.D.2d 66, 450 N.Y.S.2d 623, 625 (1982); Kallinger, 580 A.2d at 890; State ex rel. White v. Narick, 170 W.Va. 195, 199, 292 S.E.2d 54, 58 (1982). [FN1] Thus, the "purpose" for refusing unwanted medical treatment "is a factor which prison officials may legitimately consider in determining whether [the refusal] is likely to be a disruptive influence, or otherwise detrimental to the effective administration of the ... prison system." Jones v. North Carolina Prisoners' Labor Union, Inc., 433 U.S. 119, 126 n. 4, 97 S.Ct. 2532, 2538 n. 4, 53 L.Ed.2d 629 (1977). Because the state's interest in orderly prison administration is the controlling factor here, we need not address other possible state interests in assessing the scope of this patient's autonomy.
FN1. In Zant v. Prevatte, 248 Ga. 832, 286 S.E.2d 715 (1982), the Supreme Court of Georgia held that a hunger-striking prisoner, who began fasting to obtain transfer out of the Georgia prison system for fear of his safety, had the right to die by refusing food and medical treatment. We, like every court that has considered Zant, refuse to follow it.