Justices uphold electroconvulsive therapy for civilly committed patient

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Leah Graeber has been civilly committed several times in the past 25 years, and a psychiatrist petitioned the district court to authorize electroconvulsive therapy (ECT). Affirming the lower court, a divided Minnesota Supreme Court upheld the Minnesota Court of Appeals’ finding that this treatment was necessary and reasonable.

Graeber has a long history of civil commitment, going back to 2001. Her current commitment started in 2011 after she was found incompetent to proceed in a criminal vehicular homicide case. Graeber allegedly lost control of her vehicle while speeding, striking an oncoming car, killing an 11-year-old boy and severely injuring his family. During a competency evaluation, she claimed that the child was not dead and that she was God.

Graeber was diagnosed with schizoaffective disorder, bipolar type, featuring psychosis and grandiose delusions. Additionally, she was diagnosed with multiple controlled-substance disorders. Pursuant to Minn. Stat. § 253B.18, a district court committed her as mentally ill and dangerous. Her commitment became indeterminate in 2012. She has since resided at the state’s secure hospital in St. Peter.

In 2023, a psychiatrist petitioned the district court for authorization to administer ECT to Graeber. The psychiatrist cited persistent psychotic symptoms, elevated mood with agitation, lack of insight, and occasional verbal aggression. After exhausting medication and therapy options, the psychiatrist deemed ECT the least restrictive treatment. The petition was made under Minn. Stat. § 253B.03, subd. 6(b)(3), which allows court authorization of treatment when patients cannot consent.

Two court-appointed examiners evaluated Graeber. One concluded that ECT was reasonable and necessary to address her delusional thoughts and disorganized thinking. The other anticipated stabilization of mood and potential reduction of psychotic symptoms, and determined that Graeber’s refusal of treatment was based on delusion. The examiner emphasized that ECT was virtually the only option likely to achieve meaningful improvement.

Upon reviewing the examiners’ findings and hearing testimony, the district court authorized ECT. The court found Graeber’s symptoms persistent despite attempts to help. The court applied the Price/Jarvis balancing test. Under this test, courts must determine if instrusive treatment both “necessary and reasonable.” Applying the balancing test, the district court concluded that ECT was necessary and reasonable, and it authorized a specified course of treatments.

Graeber appealed the district court’s authorization of ECT, arguing that it erred by not separately analyzing whether the treatment was necessary to preserve her life or health under Minn. Stat. § 253B.03, subd. 6. Under this statute, civilly committed individuals can consent to ECT or other treatments that are “necessary to preserve the life or health” of committed patients.

The Court of Appeals rejected her argument, reasoning that the Price/Jarvis balancing test already incorporates the medical-necessity requirement and that the district court’s findings under each of the six Price factors were supported by clear and convincing evidence. The appellate court affirmed that ECT was both necessary and reasonable.

Graeber argued that Minn. Stat. § 253B.03, subd. 6(b), requires a court to first find that treatment is “ecessary to preserve her life or health before applying the Price/Jarvis balancing test. She interpreted “preserve” narrowly. Graeber argued that ECT could not be authorized because her health would not deteriorate without it.

The court rejected Graber’s argument, finding that, on her view, it would merely maintain the status quo for civilly committed patients with serious and persistent mental illness. “Under Graeber’s interpretation, a court could never authorize an intrusive mental health treatment to improve a civilly committed person’s mental health, no matter how badly the person’s mental health had deteriorated,” wrote Justice Sarah Hennesy. “This cannot be a reasonable interpretation of this statute.”

The court also affirmed the validity of the Price/Jarvis balancing test. It concluded that Graeber’s argument for a separate threshold requirement under Minn. Stat. § 253B.03, subd. 6(b), is unnecessary because the Price/Jarvis balancing test already addresses the statutory concern of whether treatment is “necessary to preserve the life or health” of a committed patient.

However, Justices Karl Procaccini, Paul Thissen, and Theodora Gaïtas dissented. Procaccini authored the dissent, which was joined by the two other justices. They would conclude that Minn. Stat. § 253B.03, subd. 6(b), which requires that treatment be necessary to preserve the life or health of any committed patient, sets a separate threshold that hospitals must meet before petitioning a court to provide intrusive treatments like ECT.

Procaccini concluded that subsuming the statutory threshold requirement into the balancing test was incorrect.

“Because each poses a different question and requires a substantively distinct analysis, answering one question does not necessarily answer the other,” Procaccini reasoned. “The constitutional balancing test simply does not address the statutory threshold requirement that the treatment be ‘necessary to preserve the life or health’ of the patient. In this sense, subsuming the statutory threshold requirement within the constitutional balancing test is like replacing a hurdle with a seesaw.”