Summary
In Leight, the Court considered the viability of an action under the MHPA against medical providers who considered, but did not initiate, an involuntary emergency examination under Section 302 of the MHPA, 50 P.S. § 7302, against an outpatient named Shick.
Summary of this case from Matos v. Geisinger Med. Ctr.Opinion
No. 35 WAP 2019
12-22-2020
Kathryn F. LEIGHT and John L. Leight, Her Husband, Appellants v. UNIVERSITY OF PITTSBURGH PHYSICIANS, UPMC, University of Pittsburgh of the Commonwealth System of Higher Education, Susan Shick, and Phillip L. Clark, Administrator of the Estate of John F. Shick, Deceased, Appellees
OPINION
In this discretionary appeal, we consider the viability of a cause of action by a third party against, inter alia , physicians under the Mental Health Procedure Act ("MHPA" or "Act"). For the reasons explained below, we find that physicians are not liable under the MHPA for considering, but not formalizing the prerequisites for, an involuntary emergency examination. Accordingly, we affirm the order of the Superior Court.
50 P.S. §§ 7101 -7503.
This appeal arises from a tragic shooting incident on March 8, 2012, wherein John F. Shick, a 30-year-old adult, living independently, killed one person and injured several others at Western Psychiatric Institute and Clinic ("WPIC") in Pittsburgh. The injured persons included WPIC receptionist, Appellant Kathryn Leight. Subsequently, Ms. Leight and her husband John Leight (collectively, "Appellants"), filed a complaint against various defendants as described infra .
By way of background, the General Assembly enacted the MHPA in 1976. The purpose of the MHPA is to establish procedures to effectuate the Act's policy — assuring the availability of adequate treatment to those who are mentally ill. 50 P.S. § 7102. The legislature, through the MHPA, and in conformity with principles of due process, sought to assure the availability of voluntary and involuntary treatment "where the need is great and its absence could result in serious harm to the mentally ill person or to others." Id . Indeed, treatment under the MHPA can be broadly conceptualized as two types, voluntary and involuntary. The General Assembly stressed that treatment on a voluntary basis is preferable to involuntary treatment, and, in all instances, the least restrictive approach consistent with adequate treatment should be utilized. Id . Critical to the resolution of the instant appeal, and as discussed below in greater detail, the scope of the MHPA is limited, as it establishes rights and procedures only for the involuntary treatment of mentally ill persons, whether inpatient or outpatient, and for the voluntary inpatient treatment of mentally ill persons. Thus, the voluntary treatment of outpatients falls outside the scope of the MHPA.
In furtherance of the policy of the MHPA, the General Assembly also provided limited immunity for certain individuals providing care to the mentally ill. Specifically, 50 P.S. § 7114 protects from civil and criminal liability those individuals and institutions that provide treatment to mentally ill patients, and, thus, promotes the statutory goal of ensuring such treatment remains available. Dean v. Bowling Green-Brandywine , ––– Pa. ––––, 225 A.3d 859, 869 (2020). This immunity protection, however, does not insulate individuals from liability for acts of willful misconduct or gross negligence. 50 P.S. § 7114.
Generally speaking, a medical professional has no duty under the common law to control the conduct of a patient or warn or protect a third party from a threat by a patient in his or her care, except under certain limited circumstances. See generally Maas v. UPMC Presbyterian Shadyside , ––– Pa. ––––, 234 A.3d 427 (2020) ; Emerich v. Philadelphia Center for Human Development, Inc. , 554 Pa. 209, 720 A.2d 1032 (1998). However, in tort cases, a duty may be imposed, not only by the common law, but also through statute. Based upon Section 114, our Court has found an affirmative duty exists under the MHPA which requires mental health professionals and institutions to avoid willful misconduct or gross negligence in the treatment of mental health patients, and imposes civil liability for a breach of that duty. Goryeb v. Commonwealth, Department of Public Welfare , 525 Pa. 70, 575 A.2d 545, 548-49 (1990) (finding a party participating in a decision to examine, treat, or discharge a mentally ill patient under the MHPA who commits willful misconduct or gross negligence can be liable for such decision or for any of its consequences); see also Sherk v. Dauphin , 531 Pa. 515, 614 A.2d 226, 232 (1992) (plurality).
Finally, as this appeal arises in the context of preliminary objections, as explained below in greater detail, we must accept the allegations contained in the complaint, as amended, to understand the circumstances giving rise to this appeal and to analyze Appellants’ claims under the MHPA. With this background, we consider the appeal sub judice .
In their complaint, Appellants asserted, in relevant part, that Shick began experiencing behavior that suggested he was suffering from severe mental illness in February 2005, when Shick, then 24 years old, was residing in New York City. He was involuntarily committed and released on multiple occasions, with his final release while living in New York in June 2008. Thereafter, in April 2009, Shick was admitted to the chemistry program at Portland State University in Oregon as a doctoral student and graduate teaching assistant for the fall 2009 semester, and moved to Portland. While in Oregon, Shick was involuntarily committed in December 2009, and ultimately released in May 2010. He was expelled from the University.
In March 2011, Shick was accepted into Duquesne University's doctoral program in the Department of Biological Sciences in Pittsburgh, and was granted a graduate teaching assistantship. Approximately three months later, in June 2011, Shick established a patient-primary care physician relationship with University of Pittsburgh Physicians ("UPP"), and, specifically, with UPP doctors at University of Pittsburgh Medical Center's ("UPMC") Shadyside Family Health Center ("Shadyside Family"). Shick provided Shadyside Family with authorizations to obtain his prior treatment records, which revealed he had suffered from severe mental illness. At Shadyside Family, Shick initially complained to Dr. Thomas Weiner of neck and ankle pain, elevated cholesterol, and depression, for which Dr. Weiner prescribed, inter alia , physical therapy. Thus began an ongoing series of visits through the fall of 2011, during which Shick asserted various ailments – including headaches; neck, shoulder, chest, back, and ankle pain; belching; vomiting; and depression – for which Dr. Weiner prescribed a number of tests, treatments, and remedies.
On October 21, 2011, Dr. Weiner first recorded his impression that Shick's complaints of pain might be due to mental illness, that another psychiatric diagnosis besides depression was very likely, and that he may benefit from a psychiatric referral at some point. On November 4, 2011, Shadyside Family staff set up an appointment for Shick to be evaluated by WPIC personnel. Five days later, on November 9, 2011, Shick underwent a psychiatric diagnostic evaluation by a WPIC licensed clinical social worker. At the evaluation, Shick denied prior psychiatric treatment and denied his prior history of psychiatric symptoms, but explained that a psychologist friend had told him that he was bipolar and acknowledged that he had been discharged from the doctoral program at Duquesne as the result of harassment charges due to his unacceptable interactions with women.
After various interactions with medical personnel at Shadyside Family, and a referral for Shick to visit the UPMC gastrointestinal clinic, on November 26, 2011, Dr. Weiner called and spoke with Shick to advise him of abnormal blood work, and noticed Shick's "pressured speech." Appellants’ Second Amended Complaint at ¶ 204. As a result, Dr. Weiner encouraged him to be treated by a psychiatrist, which, at that time, Shick rejected. Two days later, however, on November 28, 2011, Shick underwent the recommended evaluation by UPP psychiatrist Jatinder Babbar, M.D., at WPIC. At the evaluation, Shick denied prior psychiatric treatment, avoided questions, exhibited disorganized thinking, and denied suicidal or homicidal ideations. Dr. Babbar called Shick's mother, Susan Shick, who advised the physician that Shick had five prior psychiatric admissions, including the admission in Portland in 2010. As, according to Shick's mother, the medication Abilify and individual psychiatric therapy had been effective in the past, Dr. Babbar strongly encouraged Shick to start that medication and begin therapy, which Shick refused to do. At that time, Dr. Babbar diagnosed Shick as schizophrenic and noncompliant with his medications.
On November 29, 2011, Dr. Weiner sent an email to UPP psychiatrist Stephanie Richards, M.D., who was on the staff of Shadyside Family, explaining his observations regarding Shick's behavior. After visits to various gastroenterology physicians, on December 23, 2011, Shick was seen by Dr. Weiner about his elevated potassium level. Shick stated his belief that he had the ability to control his own potassium level. Shick also complained of regular severe headaches and pain, which he was unable to characterize. Shick then accused Dr. Weiner of "being like his mother" in asking about the pain, and said he could articulate his pain only in essay form, which he would provide to Dr. Weiner in February, for Dr. Weiner to edit. Appellants’ Second Amended Complaint at ¶ 226. Dr. Weiner recommended that Shick begin taking anti-psychotic medication, and Shick responded in a grandiose and dismissive fashion. Dr. Weiner recognized that the physical pain complaints were "most likely" psychosomatic due to Shick's schizophrenia, and then referred him to Dr. Richards, and again recommended anti-psychotic medications, which Shick refused, while continuing to deny his schizophrenia and prior treatment for it. Appellants’ Second Amended Complaint at ¶ 228.
On January 25, 2012, Shick was first evaluated by UPP primary care physician Dr. James Jarvis, of Stull, Jarvis and Spinola Internal Medicine Associates-UPMC. Shick complained of ankle pain, two ischemic strokes, diabetes, pancreatic and liver diseases and peptic ulcer disease, indicated his belief that Simvastatin provided him pain relief, and requested a prescription for the pain treatment drug Tramadol. Dr. Jarvis, after checking his chart, recognized that Shick's overriding issue was clearly psychiatric in nature, and refused to treat him, referring him to the doctors who had already ordered numerous tests. After Shick refused to undergo a prescribed CT scan, Dr. Weiner noted that Shick was "floridly psychotic," but, ultimately, Dr. Weiner did "not think [Shick] meets criteria for [involuntary commitment] but [was going to discuss the matter with a psychiatrist, and that Shick] believes he suffered an ‘ischemic stroke ’ and this was due to inadequate statin dose." Appellants’ Second Amended Complaint at ¶ 276.
Thereafter, Shick was treated by Dr. Ya'aqov Abrams from Squirrel Hill Family Health Center with complaints of vomiting and abdominal pain, and requested specific testing for treatment of his self-diagnosed pancreatitis and diabetes. Dr. Abrams, using an authorization executed by Shick and information provided by him, had available for review copies of Shick's prior medical records from a Portland physician, Dr. Iverson, which reflected a diagnosis of depression. Thereafter, Shick began a series of visits to the UPMC Presbyterian Hospital emergency department and to various physicians, complaining of numerous physical ailments. On February 8, 2012, Shick returned to see Dr. Abrams with complaints of diabetes and demanding certain medication. Dr. Abrams explained that his lab results did not confirm Shick's suspicion of diabetes, and, instead, suggested Shick see a psychiatrist, and offered him a referral. Shick became angry and left the office.
The next day, February 9, 2012, Shick returned to Shadyside Family to see Dr. Jason Kirby, demanding testing. Dr. Kirby's impression was that Shick was acutely psychotic and delusional, noting that he refused psychological evaluation or medications, but that he should be monitored for possible commitment. Dr. Kirby spoke with Shadyside Family's director, UPP family practitioner Gregory Gallick, D.O., who, in turn, spoke with Philip Phelps, UPMC's Director of Behavioral Science curriculum, about involuntary mental health evaluation, treatment, and commitment; Phelps advised Dr. Gallick that Shick was not a candidate.
The next day, February 10, Shick appeared at Shadyside Family to have blood drawn for testing, and brandished a baseball bat in a threatening manner, upsetting a nurse. Dr. Weiner contacted resolve Crisis Services ("resolve") a mental health crisis intervention service, advised resolve's Jeffery McFadden that Shick had come into Shadyside Family that morning brandishing a baseball bat, and was becoming increasingly psychotic and intimidating during recent visits, including one episode in which Shick was removed from the practice by UPMC security. McFadden dispatched a mobile team from resolve to take Shick to WPIC for a mental health wellness check and possible commitment. The mobile team went to Shick's home and attempted to assess him, but he refused, advising that they were not welcome and shutting the door to his apartment.
On February 17, 2012, at 11:35 a.m., Dr. Weiner called resolve and spoke with clinician Nedra Williams, asking to have involuntary commitment papers for Shick faxed to him. The clinician informed Dr. Weiner that WPIC does not fax involuntary commitment papers, and suggested that Dr. Weiner go to WPIC to fill out the forms. An hour later, one of the Shadyside Family staff members called and spoke with resolve clinician Amanda Dunmire, requesting information on the involuntary commitment process, and how a doctor would complete an involuntary commitment form – that information was provided.
On February 20, 2012, Shick was evaluated by UPP orthopedic foot and ankle surgeon Dr. Victor Prisk. Shick admitted to depression but denied any other psychiatric problems, but, curiously, wrote the word "green" on his intake sheet. Appellants’ Second Amended Complaint at ¶ 331. Upon examination and review of Shick's medical records, Dr. Prisk recognized that Shick had uncontrolled schizophrenia and needed psychiatric care. Dr. Prisk made an effort to contact personnel he referred to as "the case managers" for psychiatric help, but noted they were unable to come. Appellant's Second Amended Complaint at ¶ 333.
Later that same day, Dr. Kirby spoke with resolve clinician Valerie Krieger, seeking assistance in having Shick involuntarily committed. However, Dr. Kirby never attempted to file a commitment petition. One week later, on Tuesday, February 28, Dr. Kirby sent Shick a letter on behalf of Shadyside Family notifying him that the practice would no longer provide medical care to him, effective 30 days from that date. On March 7, 2012, Shick called for and received emergency care at his residence for shortness of breath, vomiting blood, and parasites in his intestines and eyes. Shick was taken to UPMC Presbyterian Hospital's emergency department, where he repeated that history, demanded pain medication, refused to discuss his medications with the examining physicians, and left.
The next day, March 8, 2012, Shick went to WPIC. He brought with him loaded Makarov and Beretta 9mm semiautomatic handguns and extra ammunition he had purchased a year earlier. In the WPIC lobby, he shot and injured Ms. Leight, who was seated at the receptionist's desk, and shot several other people, killing one of them, before he was shot and killed by an armed University of Pittsburgh ("Pitt") police officer stationed nearby. Ms. Leight suffered gunshot wounds, resulting in internal injuries, including a pneumothorax, and respiratory failure, as well as severe post-traumatic stress disorder.
Based on these incidents, Appellants filed a complaint in the Allegheny County Court of Common Pleas against Phillip L. Clark, Administrator of the Estate of John Shick, UPP, Pitt, UPMC, and Susan Shick. Relevant to this appeal, Appellants alleged claims against UPP and Pitt (collectively, "Appellees") for the failure of Appellees’ physicians to begin the commitment process. Notably, Appellants did not assert common law negligence; rather, they asserted only a claim under the MHPA for Appellees’ alleged gross negligence in "participat[ing] in a decision that a person be examined or treated under this act." 50 P.S. § 7114.
Thereafter, Appellees filed preliminary objections, alleging that, under the MHPA there was no duty to warn or protect Appellant Kathryn Leight and no duty owed to her. Following a hearing, Judge R. Stanton Wettick, Jr. of the Allegheny County Court of Common Pleas entered an order sustaining in part and overruling in part the preliminary objections. Significant for our purposes, the trial court dismissed Appellants’ MHPA claims, concluding, inter alia , that the MHPA does not apply to Shick, who was being treated on a voluntary outpatient basis.
UPMC, Clark, administrator of the Shick estate, and Susan Shick were ultimately dismissed from the case in prior orders. Thus, the current appeal involves only UPP and Pitt.
Specifically, before the trial court, Appellants argued that, from the observations expressed by the physicians employed by Appellees, the physicians knew or should have known that Shick was severely mentally ill and in need of immediate treatment; yet, none of them took any steps to have Shick involuntarily examined and committed. That is, Appellants alleged that the physicians breached a duty of care owed to Shick and members of the public by their failure to begin the commitment process by submitting a written application for immediate involuntary examination and treatment to the county administrator pursuant to 50 P.S. § 7302. The trial court determined that Appellants’ claims were governed by 50 P.S. § 7114, which imposes liability for willful misconduct or gross negligence in decision-making regarding, inter alia , the examination or treatment of a mentally ill individual. The trial court then turned to 50 P.S. § 7103, which pertains to the scope of the MHPA, and which establishes rights and procedures for all involuntary treatment for mentally ill persons, whether inpatient or outpatient, and voluntary inpatient treatment of mentally ill persons. The trial court concluded that the MHPA does not apply to the alleged negligence of health care workers who provide voluntary outpatient treatment, and, thus, did not apply to Shick's situation, citing, inter alia , DeJesus v. United States of America Dept. of Veterans , 479 F.3d 271 (3d Cir. 2007) (determining that the MHPA does not apply to voluntary outpatient treatment), and McKenna v. Mooney , 388 Pa.Super. 298, 565 A.2d 495 (1989) (finding, in wrongful death and survival actions, that a psychiatrist's actions fell outside the MHPA because he provided only voluntary outpatient treatment).
Additionally, the trial court found that Section 7114(a) does not apply to the physicians who never sought an emergency examination or emergency treatment because these physicians were not participating in a decision that Shick be examined or treated. According to the trial court, because the physicians never initiated the process for seeking an involuntary emergency examination, no decision was ever made as to whether Shick should have been involuntarily examined and received involuntary treatment. Based upon Sections 7103, 7114, and 7302, the trial court reasoned that, since the alleged gross negligence involved voluntary outpatient treatment , all of Shick's treatment fell outside the scope of the MHPA; thus, it sustained Appellees’ preliminary objections.
After Appellants sought clarification and certification to immediately appeal the trial court's order, the court amended its order, dismissed all claims, except for the premises liability claims against Pitt, and denied the motion for certification. The parties then engaged in discovery regarding ownership and control of security at WPIC. Thereafter, Appellants filed a motion to discontinue the remaining claims against Pitt and UPMC so that they could appeal the dismissal of the MHPA claims. The trial court granted the motion.
On appeal, a unanimous three-judge panel of the Superior Court affirmed the dismissal of all of Appellants’ MHPA claims. Leight v. University of Pittsburgh Physicians et al. , 202 A.3d 103 (Pa. Super. 2018). Writing for the court, Judge John L. Musmanno concluded that based upon a plain reading of the MHPA, the statute applies to the type of treatment set forth in Section 103, which does not include voluntary outpatient care. The court noted that Shick had received only voluntary treatment and, although various physicians had considered involuntary treatment, no application under Section 302 was filed and no decision was made as to a course of treatment. Relevantly, the court found that "the mere thought or consideration of initiating an involuntary examination during voluntary outpatient treatment" was not encompassed by the express scope of the MHPA, and did not qualify as involuntary care. Leight , 202 A.3d at 117 (citing Fogg v. Paoli Mem'l Hosp. , 455 Pa.Super. 81, 686 A.2d 1355 (1996) (providing that where patient presented himself for treatment at emergency room, but was not examined or treated by anyone in the field of mental health, and no decision regarding his treatment was made, the hospital's action did not fall within the MHPA). Accordingly, the court concluded that Appellants could not sustain a viable cause of action under the MHPA, and that the trial court properly granted Appellees’ preliminary objections.
Appellants filed a petition for allowance of appeal, which we granted. The issue to be considered, as stated by Appellants is:
Under the Mental Health Procedures Act, 50 P.S. § 7101, et seq., as interpreted by this Court in Goryeb v. Com. Dept. of Public Welfare , 525 Pa. 70, 575 A.2d 545 (1990), can physicians who recognize that their patient is severely mentally ill and a clear and present danger to others, decide that he requires emergency involuntary examination under Section
302 of the Act, take affirmative steps to cause the examination to occur, but then grossly negligently fail to complete the process, be liable for injuries caused when their dangerous, mentally ill patient then engages in a mass shooting?
Leight v. University of Pittsburgh Physicians , ––– Pa. ––––, 217 A.3d 791 (2019) (order). Our analysis involves a question of statutory interpretation, which is a pure question of law. Thus, our standard of review is de novo, and our scope of review is plenary. Buffalo Township v. Jones , 571 Pa. 637, 813 A.2d 659, 664 n.4 (2002). Moreover, as we are considering an order of the trial court sustaining preliminary objections in the nature of a demurrer, the question is whether, on the facts averred, there is no basis for recovery under the law. Dittman v. UPMC , 649 Pa. 496, 196 A.3d 1036, 1043-44 (2018). Any doubts as to whether the demurrer should be sustained should be resolved in favor of reversing the order. Finally, the Court must accept as true all material facts as set forth in the complaint, and any inferences reasonably deducible therefrom. Id .
Appellants first argue that the lower courts erred in finding that the absence of "voluntary outpatient" treatment in the MHPA's scope language in Section 103 indicated that physicians providing voluntary outpatient medical treatment were not liable for their grossly negligent involuntary examination decisions. 50 P.S. § 7103. Appellants assert that the lower courts’ interpretation of Section 103's language regarding the scope of the MHPA overrode the specific delineations of duty and liability in Sections 302 and 114. 50 P.S. §§ 7302, 7114. Specifically, Appellants observe that an "involuntary emergency mental health examination" under Section 302 gives physicians and other enumerated professionals the right to effectuate an emergency involuntary examination, for potential commitment and treatment, of severely mentally ill individuals who are a clear and present danger to themselves or others. See 50 P.S. § 7302. Thus, Appellants contend such examinations constitute involuntary treatment under the MHPA. Appellants further point to Section 114, which, as noted above, establishes limited civil immunity for physicians and others engaging in involuntary examination decisions, in the absence of willful misconduct or gross negligence. According to Appellants, this Court interpreted the interaction between these provisions in Goryeb , supra . Appellants submit that, under Goryeb , when an individual participates in a decision that a person be examined, committed, treated, or discharged pursuant to the MHPA, that individual shall be liable for injuries to third parties if they commit willful misconduct or gross negligence in making such decision. Goryeb , 575 A.2d at 548-49 ; see also Sherk , 614 A.2d at 232.
Appellants stress that, because an involuntary emergency medical health examination is, by definition, involuntary under the MHPA, a failure to act with regard to such examinations falls within the scope of Section 103, and involuntary mental health examinations cannot be transformed into voluntary outpatient treatment. This, according to Appellants, is why the trial court's reasoning that a physician providing outpatient medical treatment cannot be liable under the MHPA is flawed.
Appellants then discuss numerous decisions, asserting that none of them supports the proposition that a physician providing outpatient medical treatment cannot be liable for the consequences of their grossly negligent decisions regarding the involuntary mental health examinations of their patients. Appellants thus maintain that, consistent with the clear and unambiguous language of the MHPA, a physician should be held accountable for their determination of whether a mentally ill person should be involuntarily examined, and that such decision-making is within the scope of the Act.
Appellants also refute the lower tribunals’ reasoning that, because the physicians never initiated the process for seeking an emergency examination – that is, never signed a commitment petition document – no decision was ever made as to whether Shick should be involuntarily examined. Here, Appellants assert that the physicians were grossly negligent in initially determining that Shick should be involuntarily examined for potential commitment and treatment, but then failing to file an application for an evaluation under Section 302. Moreover, because the case was not allowed to proceed to discovery, Appellants argue that it could not be determined whether Dr. Weiner's call to "resolve" to involuntarily commit Shick would have met the certification standard under Section 302. Thus, Appellants submit that it cannot reasonably be concluded that Appellees’ physicians failed to participate in decisions to initiate the involuntary examination process — it is not the absence of paperwork, but the grossly negligent decision and resultant inaction that, according to Appellants, provided the basis for Section 114 liability.
Finally, Appellants point to over 20 "thoughts and considerations" regarding the initiation of an involuntary examination of Shick, which they believe establish that his involuntary commitment was not a mere passing thought or vague consideration, but that "necessary action was obvious and apparent," and, thus, Appellees were grossly negligent in failing to complete the process. Appellants’ Brief at 33, 60.
Appellees counter by stressing that, as voluntary outpatient treatment is excluded from the scope of the MHPA, 50 P.S. § 103, Appellants cannot assert a cause of action under the MHPA, which expressly applies to only inpatient treatment and involuntary outpatient treatment. That is, because the alleged gross negligence asserted by Appellants never involved inpatient treatment, and during the relevant times Shick was never examined under the MHPA, all treatment was voluntary outpatient treatment, and, thus, outside of the Act.
Related thereto, Appellees contend that Goryeb and Sherk , relied upon by Appellants, are inapt, as they involved decisions to discharge patients who were already receiving involuntary inpatient care at a mental health facility, and, thus, the care provided fell within the scope of the MHPA. This, according to Appellees, is distinguishable from the matter sub judice , as Shick at all times was treated on a voluntary outpatient basis, and such treatment was not provided by mental health care professionals at a mental health facility or in conjunction with mental health treatment, but for medical issues unrelated to mental health.
Appellees allege that Appellants are simply attempting to bring their action within the scope of the MHPA based upon Shick's physicians’ failure to take steps to have Shick involuntarily committed under the MHPA – that is, according to Appellants, the doctors’ discussion of initiating the procedure for involuntary commitment renders their claims within the MHPA. Appellees assert that this cannot be tantamount to participation in involuntary mental health examination decisions. Indeed, Appellees stress that voluntary outpatient care cannot become involuntary without a court order. 50 P.S. §§ 304, 305.
Appellees maintain that, with respect to an involuntary emergency examination, a decision is not made under the MHPA until an application, warrant, or certification is filed under Section 302. Appellees submit that preliminary assessment of an outpatient's potential need for involuntary commitment – which would include the failure to begin the involuntary commitment process by completing the forms necessary to commence an involuntary mental health examination – does not fall under the MHPA, and thus does not support a cause of action thereunder. Specifically, Appellees stress that Section 114 of the MHPA was intended to expand availability of mental health treatment by immunizing from criminal and civil liability medical providers who assist in and facilitate such care. While an individual or institution may be liable under Section 114 to third parties harmed by a patient when that individual or institution was grossly negligent in examining a patient, treating a patient, discharging a patient, or committing a patient, Appellees contend that, absent such acts, Section 114 liability is not triggered.
According to Appellees, liability for a "decision" that a person be examined or treated under Section 114 refers to the act of initiating the commitment process through one of the formal written procedures, as well as to subsequent inpatient treatment decisions. Appellees emphasize such decision-making is not merely a "state of mind, nor a thought or consideration," nor "an intention to take action at a later time," but requires performing the written procedures enumerated in the statute to bring about an involuntary examination. Appellees’ Brief at 30. Specifically, Appellees point out that the MHPA delineates three methods for involuntary emergency mental health examination: (1) certification by a physician; (2) warrant by a county administrator; or (3) application by a physician, peace officer, or other person authorized by the county administrator. 50 P.S. § 7302. Thus, Appellees submit that, without a completed certification, warrant, or application, the mere consideration of executing authorization under the MHPA cannot constitute an involuntary examination decision. It is only after the filing of such a document that an individual becomes a participant in the examination process, triggering potential liability under Section 114. Appellees stress that these prerequisites for examination are especially important, given the resultant forcible deprivation of the individual's liberty.
Appellees assert that Appellants’ highlighting of mere examination-related "thoughts" proves that Shick was never examined or treated under the MHPA. As no steps were taken to initiate an emergency mental health examination under Section 302(a), Appellees contend, the MHPA cannot apply. Indeed, Appellees suggest that it is only upon the deprivation of liberty that a cause of action arises under the MHPA.
Finally, Appellees urge that Appellants’ theory, if accepted, would create a new duty inconsistent with the plain language and intent of the MHPA, and that it would conflict with public policy. Specifically, Appellees argue that recognizing a duty in the instant action would have drastic consequences for medical providers. While acknowledging the shocking and tragic events that culminated in the shooting, according to Appellees, the imposition of limitless liability on all health care providers, based upon an alleged failure to institute involuntary mental health treatment proceedings, would further burden an overtaxed profession, expose health care providers who do not practice mental health care to liability, encourage the unnecessarily restrictive treatment of patients, and deter patients from receiving therapeutic treatment.
The American Medical Association, Pennsylvania Medical Society, Pennsylvania Psychiatric Society, and Pennsylvania Coalition for Civil Justice Reform jointly filed an amicus brief in support of Appellees. Amici argue that the legal framework for treating patients with mental illnesses has been developed over several decades to balance the rights of the mentally ill with the need to protect the public, and it is "the policy of the Commonwealth to seek to assure that adequate treatment is available with the least restrictions necessary to meet each client's needs." Amici Brief at 9 (quoting 55 Pa. Code § 5100.3(b) ). Amici note that, to seek voluntary inpatient care, a person has to file an application seeking an examination and must provide written consent to be admitted into a program. In this case, Shick did not cooperate or consent to a voluntary examination. Furthermore, with respect to involuntary examination and treatment, no decision was made that Shick presented a clear and present danger to himself or another person, 50 P.S. § 7301(a), and the process for involuntarily committing him to inpatient treatment was never initiated. Amici warn that one cannot judge involuntary treatment decisions through hindsight and that Appellants’ interpretation of the MHPA would reduce overall safety, incentivize involuntary commitment, and discourage working with patients who demonstrate mental ailments.
As noted, this appeal raises a question of statutory interpretation. Thus, our interpretation of the MHPA is dictated by the Statutory Construction Act, 1 Pa.C.S. §§ 1501 - 1991. Our General Assembly, unlike our federal counterpart, has expressly provided direction regarding how to discern its statutory intent. Pursuant to the Statutory Construction Act, the overriding object of all statutory interpretation "is to ascertain and effectuate the intention of the General Assembly" in enacting the statute under review. 1 Pa.C.S. § 1921(a). If statutory language is "clear and free from all ambiguity, the letter of it is not to be disregarded under the pretext of pursuing its spirit." Id . § 1921(b). Thus, when the words of a statute have a plain and unambiguous meaning, it is this meaning which is the paramount indicator of legislative intent.
However, in situations where the words of a statute "are not explicit," the legislature's intent may be determined by considering any of the factors enumerated in Section 1921(c). DEP v. Cumberland Coal , 628 Pa. 17, 102 A.3d 962, 975 (2014). These factors include the occasion and necessity for the statute; the object to be attained; and the consequences of a particular interpretation. 1 Pa.C.S. § 1921(c). Additionally, the General Assembly has cautioned that, in construing a statute, courts, inter alia , should presume that the legislature did not intend a result that is absurd, impossible of execution, or unreasonable. 1 Pa.C.S. § 1922(1).
A trio of MHPA provisions informs our analysis. Thus, we turn to consider the scope of the MHPA, the Act's immunity and cause of action provision, and the prerequisites necessary for the initiation of an involuntary emergency examination.
In determining whether Appellants have stated a cause of action under the MHPA, we begin with Section 103, which sets forth the scope of the Act. 50 P.S. § 7103. Under the plain and unambiguous language of Section 103, the MHPA applies only to inpatients and involuntary outpatients: "This act establishes rights and procedures for all involuntary treatment of mentally ill persons, whether inpatient or outpatient, and for all voluntary inpatient treatment of mentally ill persons." Id . Appellants do not allege that Appellees’ physicians were negligent in their actual examination or treatment of Shick on an involuntary basis or a voluntary inpatient basis. As there is no suggestion that Appellees’ physicians treated Shick on anything but a voluntary outpatient basis, their treatment actions clearly fall outside the coverage of the MHPA.
To avoid this result, however, Appellants maintain that the physicians began, but, albeit, did not complete, the statutory process for involuntary commitment. Because Appellees’ physicians were allegedly grossly negligent in their failure to follow through and require that Shick be involuntarily examined, according to Appellants, Appellees’ actions nonetheless fell within Section 103, and Appellees "participate[d] in a decision that a person be examined or treated" under Section 114. 50 P.S. § 7114. This, Appellants assert, supports their statutory cause of action.
As noted, Section 114 has been characterized as an immunity provision, as well as providing for a statutory cause of action, albeit by implication. It immunizes an individual who, inter alia , "participates in a decision that a person be examined or treated under [the MHPA]," except for instances of willful misconduct or gross negligence. 50 P.S. § 7114(a). Thus, Section 114 protects from civil and criminal liability those parties that examine and provide treatment to mentally ill patients under the MHPA. Furthermore, by implication, Section 114 creates a cause of action upon a showing of willful misconduct or gross negligence against an individual for, inter alia , participating in a decision that a person be examined or treated under the MHPA:
In the absence of willful misconduct or gross negligence, a county administrator, a director of a facility, a physician, a peace officer or any other authorized person who participates in a decision that a person be examined or treated under this act , or that a person be discharged, or placed under partial hospitalization, outpatient care or leave of absence, or that the restraint upon such person be otherwise reduced, or a county administrator or other authorized person who denies an application for voluntary treatment or for involuntary emergency examination and treatment, shall not be civilly or criminally liable for such decision or for any of its consequences.
50 P.S. § 7114(a) (emphasis added).
Related thereto, the decision to undertake an emergency involuntary examination of an individual for involuntary commitment is governed by Section 302 of the MHPA. 50 P.S. § 7302. Specifically, one who is severely mentally ill may be subjected to an involuntary emergency examination if one of three mandatory prerequisites is met: (1) certification of a physician; (2) warrant issued by the county administrator authorizing such examination; or (3) application by a physician or other authorized person who has personally observed actions indicating a need for an emergency application:
Section 301 provides that when a person is severely mentally disabled and in need of immediate treatment, he may be subjected to an involuntary emergency examination. A person is severely mentally disabled when:
as a result of mental illness, his capacity to exercise self-control, judgment and discretion in the conduct of his affairs and social relations or to care for his own personal needs is so lessened that he poses a clear and present danger of harm to others or to himself.
50 P.S. § 7301.
(a) Application for Examination.--Emergency examination may be undertaken at a treatment facility upon the certification of a physician stating the need for such examination; or upon a warrant issued by the county administrator authorizing such examination; or without a
warrant upon application by a physician or other authorized person who has personally observed conduct showing the need for such examination.
(1) Warrant for Emergency Examination.--Upon written application by a physician or other responsible party setting forth facts constituting reasonable grounds to believe a person is severely mentally disabled and in need of immediate treatment, the county administrator may issue a warrant requiring a person authorized by him, or any peace officer, to take such person to the facility specified in the warrant.
We hold, based upon the clear and unambiguous language contained in this constellation of statutory provisions, that "participat[ing] in a decision that a person be examined" under the MHPA is achieved for purposes of Section 114 only after one of the prerequisites set forth in Section 302 for an involuntary emergency examination is satisfied. The requirements of Section 302 are exclusive, clear, and unequivocal. Physicians who never invoke a necessary requirement for involuntary emergency examination are not, for purposes of Section 114, participating in a decision that a person be examined. It is only when a physician files the required documentation for involuntary emergency examination that he becomes a participant in the decision-making process under the Act.
In addition to the manifest requirements of Section 302, this conclusion is supported by the later phrase in Section 1114 which grants immunity to those "who den[y] an application for voluntary treatment or for involuntary emergency examination and treatment." 50 P.S. § 7114. Clearly, an application cannot be denied until it is first formally made.
Actions by a physician in an outpatient setting that fall short of satisfying these mandatory requirements do not transform voluntary outpatient treatment into involuntary treatment. 50 P.S. § 7103 ; see DeJesus , supra (determining that the MHPA does not apply to voluntary outpatient treatment); Fogg , 686 A.2d at 1358 (noting that while a patient presented himself for treatment at an emergency room, he was not examined or treated by anyone in the field of mental health, and, thus, the hospital had not been "treating" the patient for his mental illness, the hospital's actions did not fall under Section 114).
Furthermore, our holding is buttressed by the presumption that, in construing a statute, we must presume that the legislature did not intend a result that is absurd, impossible of execution, or unreasonable. 1 Pa.C.S. § 1922(1). In our view, if we interpreted the phrase "participat[ing] in a decision that a person be examined or treated" under Section 114 to include the mere thinking, consideration, or the taking of some preliminary action shy of the formal statutory steps necessary for an involuntary emergency examination, it would lead to an unreasonable result. First, and unlike a common law cause of action, such an interpretation would create a statutory gray area in which physicians would have to speculate as to the point at which their conduct might be subject to liability under the MHPA. Yet, in construing a statute, we strive to resolve, not create, ambiguity. Second, and related thereto, we are mindful that such a broad interpretation would significantly expand liability, not only for those trained as mental health professionals, but also for those, as here, who are untrained "in rendering treatment in [the] unscientific and inexact [mental health] field." Farago v. Sacred Heart General Hospital , 522 Pa. 410, 562 A.2d 300, 304 (1989). Moreover, Appellants’ interpretation of the MHPA would, if taken to its logical conclusion, render health care workers potentially liable for any thought or act, no matter how inconsequential, tangentially related to the consideration of an involuntary examination of a patient.
Additionally, a broad imposition of liability would be inconsistent with Section 114's immunization provision, and its goal of ensuring the availability of mental health treatment, and, indeed, would potentially discourage health care workers from treating patients who exhibit mental ailments. 50 P.S. § 7102 ; see also Dean , 225 A.3d at 869 ("Section 114 protects from civil and criminal liability those individuals and institutions that provide treatment to mentally ill patients, and thus promotes the statutory goal of ensuring such treatment remains available."); Farago , 562 A.2d at 304 (one purpose of MHPA "is to provide limited protection from civil and criminal liability to mental health personnel and their employers in rendering treatment"). Furthermore, expanding the duties under the MHPA giving rise to a civil action to include merely informal considerations regarding an involuntary examination would encourage the over commitment of patients to avoid potential liability. This incentive would not only be inconsistent with the goal of treating patients with the least appropriate restrictions, 50 P.S. § 7102, but would result in the unnecessary deprivation of the patient's liberty. Contrary to Appellants’ suggestion, our interpretation limits liability to discrete and clear actions on the part of health care workers, creates a bright line consistent with the plain language of the MHPA, and serves both the physician and the mental health patient.
Additionally, we find Appellants’ reliance upon Goryeb , supra , to be inapt. In Goryeb , a police officer escorted an individual to a state hospital after the individual threatened suicide with a hunting knife unless he received treatment, and told the officer that he contemplated shooting himself the prior week over the termination of his relationship with his girlfriend. He was involuntarily admitted for the statutory 120-hour period, but he was subsequently discharged after no certification for extended treatment was filed. One week later, he shot his ex-girlfriend and others, and then killed himself. The victims brought suit against the admitting hospital and treating physicians, arguing that they were grossly negligent in discharging a patient when they knew or should have known that he was a continuing danger to himself and to others. The Department of Public Welfare, the state hospital, and its physician raised sovereign immunity as a defense to the complaint. Our Court, reading the Sovereign Immunity Act, 42 Pa.C.S. § 8521 et seq ., and the MHPA in pari materia , determined that, since the immunity act contained a medical-professional liability exception, it was not inconsistent with the immunity provision contained in Section 114 of the MHPA. As a result, we concluded that an individual participating in a decision to examine, treat, or discharge a mentally ill patient under the MHPA, and who commits willful misconduct or gross negligence in doing so, may be liable for such decision, examination, or discharge; and that such individual owes a duty to third parties for the consequences of their conduct.
Goryeb is plainly distinguishable from the matter sub judice . Goryeb involved the negligent discharge of a mentally ill patient from involuntary commitment in a mental health facility. The decision to discharge is specifically set forth in Section 114, which refers to the "act" of discharge. 50 P.S. § 7114 (immunizing, in the absence of willful misconduct or gross negligence, a "person who participates in a decision that a person be examined or treated under this act, or that a person be discharged " (emphasis added)). As the patient in Goryeb was already being treated in a mental health facility, there was no question that his discharge fell within the Section 114. Goryeb , 575 A.2d at 549 ("discharging a severely mentally disabled person, especially an involuntary admittee who has been classified, by statutory definition, as a clear and present danger to himself or others, is a potential serious danger not only to the patient himself but to ‘others’ "). Here, unlike Goryeb , the physicians never initiated the formal prerequisites for the involuntary commitment process; never found Shick to be a "clear and present danger;" never involuntarily committed him; and therefore never discharged him into the community. See also Sherk , 614 A.2d at 233 (plurality) (addressing sovereign immunity in the context of treating and releasing an already committed psychiatric patient from a mental health facility).
Applying our interpretation of the MHPA's provisions to the instant case, we find that Appellees’ physicians never satisfied the prerequisites for the involuntary emergency examination process under Section 302 for Shick. That being the case, the physicians did not take part in a decision that Shick be examined or treated under Section 114, and, therefore, they were not engaged in an involuntary commitment decision. We reiterate that mere thoughts, consideration, or steps short of the mandated Section 302 prerequisites for initiating an involuntary emergency examination lie outside of a Section 114 cause of action. As Appellees and their physicians never participated in a "decision that a person be examined or treated under the [MHPA]," we are compelled to conclude that Section 114 is inapplicable and Appellants cause of action was rightfully dismissed.
Finally, we recognize that Shick's actions were horrendous, and that the injuring of Kathryn Leight, among others, and the killing of another person was a profound tragedy. However, the issue before our Court is one of statutory liability under the MHPA, and, as explained above, we find its provisions simply do not allow Appellants to pursue a cause of action under the Act in these circumstances.
For the above-stated reasons, the order of the Superior Court is affirmed.
Chief Justice Saylor and Justices Baer, Donohue, Dougherty and Wecht join the opinion.
Justices Dougherty and Wecht file concurring opinions.
Justice Mundy files a dissenting opinion.
JUSTICE DOUGHERTY, concurring
I join the majority opinion. I write separately to add that, as a general proposition, I agree with the broad strokes developed by Justice Wecht in his concurring opinion, i.e. , the MHPA does not preclude common law claims against mental health treatment providers and, had we been faced with such a claim on this record, the result might arguably be different. See generally Concurring Opinion at ––––, –––– – ––––; see also Maas v. UPMC Presbyterian Shadyside, ––– Pa. ––––, 234 A.3d 427, 439 (2020) (treatment providers had duty to warn "readily identifiable" victims). However, the statute we are charged with interpreting does not authorize recovery under the present circumstances. As the majority explains, the relevant provision grants immunity in some cases, and by implication, allows civil liability in others. See Majority Opinion at –––– – ––––. A situation where the defendant-physician "participates in a decision that a person be examined or treated" under the MHPA, and where that decision to examine or treat is made with "willful misconduct or gross negligence," may be actionable under the statute. 50 P.S. § 7114(a) ("In the absence of willful misconduct or gross negligence ... a physician ... who participates in a decision that a person be examined or treated under this act ... shall not be civilly or criminally liable for such decision or for any of its consequences."). But the statute as written is simply not susceptible to an interpretation that a provider's failure to treat is actionable, and we may not supply these missing words.
JUSTICE WECHT, concurring
On March 8, 2012, a deeply troubled man named John Shick armed himself with Makarov and Beretta 9 mm semi-automatic handguns and extra ammunition, and entered Western Psychiatric Institute and Clinic ("WPIC") in Pittsburgh. Once inside WPIC, Shick shot several people, killing one. A University of Pittsburgh police officer responded, shooting and killing Shick. Among the wounded was Kathryn Leight, a receptionist. Leight and her husband sued several defendants, including the University of Pittsburgh Physicians ("UPP"), which employed the health care providers who treated Shick, and the University of Pittsburgh Medical Center ("UPMC"). In their complaint, the Leights raised a claim only for statutory liability under the Mental Health Procedures Act ("MHPA"), 50 P.S. §§ 7101 - 7503, against these defendants. It is important to stress that the sole issue presented in this appeal is thus one of statutory interpretation.
I join the Majority's interpretation of the MHPA. Under the plain terms of that statute, physicians are not liable for merely considering (while not formalizing) the prerequisites for an involuntary emergency examination. Maj. Op. at ––––. The legislature has created a limited cause of action under the MHPA, and the Court's role is to apply the terms of that statute as written. Because the defendants have chosen nonetheless to raise arguments that invoke common-law legal principles, I write to emphasize the difference between this statutory cause of action and the common law duty to warn.
The MHPA applies to circumstances that fall within its statutory language. As the Majority recognizes, the statutory cause of action is defined by the interplay of Sections 103, 114, and 302. Based upon the plain language of these provisions, the Majority correctly perceives that the MHPA establishes a bright-line rule which allows for liability only upon satisfaction of one or more of the prerequisites for an involuntary emergency examination under Section 302. Id. at –––– – ––––. Only those physicians who invoke Section 302 are deemed to participate in a decision that a person be examined under the MHPA. Id . at ––––. Physicians who merely think about, consider, or take some preliminary action that falls short of the necessary statutory prerequisites cannot be held liable for participating in a decision subjecting a person to examination or treatment under Section 114. Id . at ––––. This result is dictated by the statute's language.
Instead of focusing upon the statutory requirements, the Leights venture twenty-one instances in which UPP and/or UPMC personnel expressed or noted "thoughts" about involuntary commitment, thereby demonstrating that it was apparent to such personnel that Shick was an archetypal candidate for involuntary commitment. Compelling as these may seem, had the General Assembly intended to allow statutory liability for physicians who simply contemplate commitment, it needed to say so. This Court would then follow that statutory directive (provided there was no preserved constitutional challenge directing otherwise). As things stand, the Leights’ argument contravenes the plain words of the MHPA.
Appellants’ Br. at 53-61.
On February 25, 2014, Appellants filed a Third Amended Complaint, which incorporated, without reproducing, the Second Amended Complaint in its entirety and modified six paragraphs. Accordingly, I cite to the incorporated averments of the Second Amended Complaint as the Third Amended Complaint.
As the Majority observes, the scope of the MHPA extends to the act of initiating the commitment process through the formal written procedures of the statute. It does not extend to thoughts, ruminations, or states of mind. To privilege the Leights’ argument while subordinating the plain statutory requirements would be to inject uncertainty and speculation into a statutory framework designed to be clear and precise in its protections of the due process rights of both mentally ill patients and the health care professionals that treat them. The Court would contravene that intent if it were to construe the plain language to allow imposition of liability solely upon a showing of ponderings, proposals, debates, or suggestions.
Under the Leights’ paradigm, countless resources would be expended in litigating whether various preliminary or partly formed thoughts, states of mind, back-and-forths, and mullings-over were encompassed within the MHPA, and health care providers would labor in uncertainty as to whether their actions exposed them to statutory liability. Suppose two physicians discuss a patient on a coffee break, comparing professional assessments of whether the patient is a danger to himself or others, and opining to each other that they really should do something about him at some point. Would statutory liability arise? What if the conversation happens during a physician's group meeting? Consider a physician who asks a nurse in passing to fill out the paperwork needed to initiate an involuntary mental health examination, but later reconsiders. Is she on the hook? What if the physician who gave such an instruction did not change her mind, but simply failed to sign the paperwork or did not ensure its delivery? What if one of the physicians has concerns about the patient, but does not voice them? What if one physician believes that the patient is a danger to himself or others, but the other physician believes that it is too soon to make that assessment? Who wins the tie?
Absent a bright-line rule, a statute designed as a shield to protect the due process rights of the mentally ill would be transformed, weaponized as a sword against health care providers. The MHPA was enacted in 1976 to move away from the indeterminate, involuntary hospitalization of the mentally ill to a community-based treatment model that vested the mentally ill with the right to reject psychiatric treatment as long as they were not a danger to themselves or others. To this end, the MHPA established the rights and responsibilities of the mentally ill and the obligations of health care providers to ensure that the dangerously mentally ill receive necessary treatment. See 50 P.S. § 7102 ("Treatment on a voluntary basis shall be preferred to involuntary treatment; and in every case, the least restrictions consistent with adequate treatment shall be employed."). The limited-immunity provision of Section 114 is consistent with the policy to afford adequate treatment to mentally ill individuals in the least restrictive environment.
See Farago v. Sacred Heart Gen. Hosp ., 522 Pa. 410, 562 A.2d 300, 302 (1989).
Third Amended Complaint, 2/25/14, at ¶¶ 147, 149, 155, 160, 172, 193, 201, 219, 221, 224, 225, 234, 235, 238, 243, 246, 250, 256, 258, 262, 264, 269, 272, 274, 278, 284, 287, 288, 292, 295, 300, 329, 351-52. As we are reviewing rulings on preliminary objections in the nature of demurrers, we take as true all material facts pled in the complaint, and any reasonable inferences we can deduce therefrom. Commonwealth by Shapiro v. Golden Gate Nat'l Senior Care LLC , 648 Pa. 604, 194 A.3d 1010, 1022 (2018).
See Allen v. Montgomery Hosp. , 548 Pa. 299, 696 A.2d 1175, 1178 (1997).
Third Amended Complaint, 2/25/14, at ¶ 162, 276 (averring Dr. Weiner, a UPP primary care physician, first noted Shick's pain complaints might be due to mental illness on October 17, 2011, and Shick was "floridly psychotic" on January 25, 2012); id. at ¶ 205 (stating on November 28, 2011, Dr. Babbar, a UPP psychiatrist at Western Psych, diagnosed Shick as schizophrenic and noncompliant with his medications); id. at ¶ 239 (alleging Dr. Southwick, a primary care physician, concluded Shick's problems were likely psychiatric on January 1, 2012); id. at ¶ 251 (stating a UPMC MedExpress UPP physician refused to treat Shick on January 9, 2012 due to psychological involvement); id. at ¶ 273 (averring Dr. Jarvis, a UPP internal medicine physician, refused to treat Shick on January 25, 2012 because his problems were psychiatric); id. at ¶ 292 (alleging Dr. Abrams, a primary care physician, sought to refer Shick to a psychiatrist on February 8, 2012); id. at ¶ 295 (stating Dr. Kirby, a primary care physician, noted Shick was acutely psychotic on February 9, 2012); id. at ¶ 332 (averring Dr. Prisk, a UPP orthopedic foot and ankle surgeon, recognized Shick displayed uncontrolled schizophrenia on February 20, 2012).
The MHPA does not preclude imposition of common law liability upon physicians who treat mentally ill individuals. The cause of action created by the MHPA applies to only a portion of the relief that may be sought for actionable conduct arising from the treatment of a mentally ill patient who harms a third party. Liability resulting from a failure to warn or, more broadly, a failure to protect a third party from a patient is available at common law. See Emerich v. Philadelphia Ctr. for Human Dev., Inc., 554 Pa. 209, 720 A.2d 1032, 1037 n.5 (1998) (observing that "a duty to warn is subsumed in this broader concept of a duty to protect"). Here, as elsewhere, the common law generally lives apart from any particular statutory language.
The judiciary's task in cases of statutory interpretation differs markedly from its role in cases brought under the common law. In the former, courts endeavor to construe and apply the plain meaning of the measures enacted by the General Assembly, see 1 Pa.C.S. §§ 1501 - 1991. Our mission in cases invoking the common law is decidedly different. Advancement and exposition of the common law is one of this Court's organic and inherent powers. The common law "develops incrementally, within the confines of the circumstances of cases as they come before the Court." "Causes of action at common law evolve through either directly applicable decisional law or by analogy and distinction."
See, e.g., Villani v. Seibert , 639 Pa. 58, 159 A.3d 478, 503 (2017) (Donohue, J., dissenting); Tincher v. Omega Flex, Inc ., 628 Pa. 296, 104 A.3d 328, 352 (2014) (noting that "its equitable powers afford the Court the authority to modify the common law forms of action to the right involved").
Third Amended Complaint, 2/25/14, at ¶ 208 (averring Shick refused Dr. Babbar's recommendation to take medication and start therapy); id. at ¶ 228 (stating Shick refused Dr. Weiner's referral to a psychiatrist and recommendation of anti-psychotic medications); id. at ¶ 296 (alleging Shick refused Dr. Kirby's suggestion of psychological evaluation or medication).
Maloney v. Valley Med. Facilities, Inc. , 603 Pa. 399, 984 A.2d 478, 489–90 (2009).
Tincher , 104 A.3d at 352.
Common-law duties are phrased broadly; they must be weighed and applied to a never-ending succession of cases. There is no general duty in the law of torts to protect third parties from harm. See Emerich , 720 A.2d at 1036. But a well-settled exception exists at common law where the defendant stands in a special relationship to the actor or the third party. Id . at 1036. Our precedents establish beyond peradventure that mental health professionals can stand in such a relationship.
See, e.g., Seebold v. Prison Health Servs., Inc. , 618 Pa. 632, 57 A.3d 1232, 1246 (2012) ; Alderwoods, Inc. v. Duquesne Light Co. , 630 Pa. 45, 106 A.3d 27, 42 n.17 (2014) (noting that expansions and contractions of legal duties are carefully considered on a developed record capable of supporting essential policy-based judgments).
The first case to hold that mental health professionals sometimes have a duty to protect third parties from harm caused by their patients was the California Supreme Court's landmark decision in Tarasoff v. Regents of Univ. of California , 17 Cal.3d 425, 131 Cal.Rptr. 14, 551 P.2d 334 (1976). Tatiana Tarasoff was killed by a psychological outpatient, Prosenjit Poddar. Id. , 131 Cal.Rptr. 14, 551 P.2d at 339. Tatiana's parents filed a lawsuit against Poddar's psychologist, asserting that Poddar had confided to his psychologist his intention to kill Tatiana. Id., 131 Cal.Rptr. 14, 551 P.2d at 340. Although Poddar did not name Tatiana, the context of the threat rendered Tatiana a readily identifiable subject. Id ., 131 Cal.Rptr. 14, 551 P.2d at 341. No one warned Tatiana. Id., 131 Cal.Rptr. 14, 551 P.2d at 340. The defendants argued that there was no duty to warn. Id . The court rejected this defense: "When a therapist determines, or pursuant to the standards of his profession should determine, that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger." Id. In Emerich , this Court adopted Tarasoff and, for the first time, imposed a duty upon Pennsylvania health care providers to convey information to at-risk third parties. 720 A.2d at 1040. This Court explained:
We believe that the Tarasoff decision and its progeny are consistent with, and supported by, Pennsylvania case law and properly recognize that pursuant to the special relationship between a mental health professional and his patient, the mental health professional has a duty to warn a third party of potential harm by his patient.
Id. at 1037. This Court held, however, that a duty to warn arises only in limited circumstances. Id . at 1040 (predicating the duty to warn upon the existence of a specific and immediate threat of serious bodily injury that has been communicated to the professional by the patient regarding a specifically identified or readily identifiable victim).
The Emerich Court did not particularize the circumstances in which an unnamed victim is readily identifiable such that the duty to warn is triggered. But the Court observed that the California Supreme Court had limited its holding in Tarasoff to identifiable victims, rejecting the argument that there was a duty to warn the public at large of threats to unidentified persons in a particular neighborhood. See Thompson v. County of Alameda , 27 Cal.3d 741, 167 Cal.Rptr. 70, 614 P.2d 728, 738 (1980).
In Maas v. UPMC Presbyterian Shadyside , ––– Pa. ––––, 234 A.3d 427, 429 (2020), this Court considered the duty of mental health treatment providers to warn individuals who might be the subjects of patients’ threats. In Maas , the patient repeatedly told his physicians and therapists that he would kill an unnamed "neighbor." The patient carried out his threat, killing an individual who lived on the same floor of his forty-unit apartment building. Id. Applying the prerequisite to the imposition of duty articulated in Emerich , this Court held that the health care providers had a duty to warn "readily identifiable" victims. Id. at 439. Because the patient had communicated threats against "a neighbor," the defendants should have realized "on a moment's reflection," see Tarasoff , 131 Cal.Rptr. 14, 551 P.2d at 345 n.11, that the patient was targeting residents of his apartment building, including the victim, who resided on the same floor. Maas , 234 A.3d at 439.
The "readily identifiable victim" prerequisite to the imposition of a common law duty may explain the absence of a common law claim in this case. In their amended complaint, the Leights premised liability upon the MHPA, asserting that UPP (acting through its various physicians) should have "take[n] [John Shick] to Western Psych for an involuntary emergency examination and immediate treatment" or completed an application for involuntary commitment. Am. Compl., ¶¶ 321, 322. Apparently misunderstanding the amended complaint to allege a duty in tort to warn or protect Leight from Shick, UPP and UPMC disputed the existence of this duty at common law.
The Leights responded by clarifying that they did not allege that UPP and UPMC breached a common law duty to warn, but that liability was premised solely upon the MHPA. Accordingly, this case presents only a statutory claim under the MHPA, not a common law claim premised upon a failure to warn.
Br. in Support of Pl.’s Prelim. Objs. to Prelim. Objs. of Def., at 3.
Nevertheless, in advocating their position here, UPP and UPMC are not content to rest upon the plain language of the MHPA. The defendants also invite the Court to consider that the Leights are attempting to create a new cause of action that contravenes the clear "public policy" of the Commonwealth. Appellees’ Br. at 41. To develop this argument, UPP and UPMC rely upon precedent pertaining to the common law duty to warn. Although it may be necessary and appropriate to consider such policy concerns in the context of a common law claim, considerations of public policy are wholly unnecessary and ill-advised for courts engaged in statutory interpretation. Wisely, the Majority ignores the defendants’ invitation to embark upon a voyage into the sea of "public policy." The "public policy" implicated in this case is solely the one prescribed by the General Assembly in the MHPA.
In contrast to statutory causes of action, courts are often called upon, in cases at common law, to mine the policy that underlies our precedents and doctrines. At common law, a legal duty exists only if the court declares it to exist, and such declarations are jurisprudential, and thus, yes, "policy." Dean Prosser saw it thus:
These are shifting sands, and no fit foundation. There is a duty if the court says there is a duty; the law, like the Constitution, is what we make it. Duty is only a word with which we state our conclusion that there is or is not to be liability; it necessarily begs the essential question. When we find a duty, breach and damage, everything has been said. The word serves a useful purpose in directing attention to the obligation to be imposed upon the defendant, rather than the causal sequence of events; beyond that it serves none. In the decision whether or not there is a duty, many factors interplay: The hand of history, our ideas of morals and justice, the convenience of administration of the rule, and our social ideas as to where the loss should fall. In the end the court will decide whether there is a duty on the basis of the mores of the community, "always keeping in mind the fact that we endeavor to make a rule in each case that will be practical and in keeping with the general understanding of mankind."
Sinn v. Burd , 486 Pa. 146, 404 A.2d 672, 681 (1979) (quoting William Prosser, Palsgraf Revisited , 52 MICH. L. REV. 1, 14-15 (1953)). As we have explained, "[i]n determining the existence of a duty of care, it must be remembered that the concept of duty amounts to no more than ‘the sum total of those considerations of policy which led the law to say that the particular plaintiff is entitled to protection’ from the harm suffered." Thus, the defendants’ invocation of common law public policy considerations is inapt in this statutory interpretation case. Such considerations are foreign to the judicial interpretation of legislative enactments.
Mazzagatti v. Everingham , 512 Pa. 266, 516 A.2d 672, 678 (1986) (quoting Leong v. Takasaki , 55 Haw. 398, 520 P.2d 758, 764 (1974) ).
See, e.g., Feleccia v. Lackawanna College , ––– Pa. ––––, 215 A.3d 3, 13–14 (2019) (examination of common law duties is not necessary in cases involving the application of existing statutory duties).
Although, for the reasons discussed by the Majority, UPP and UPMC are not liable under the MHPA, the facts of the case indicate that UPP and, more broadly, UPMC, mismanaged Shick's treatment. As the Leights allege, Shick's prior treatment records, as well as the documentation generated each time that a UPP physician provided medical services to Shick, went into his electronic medical records, which were available to all other treating UPP physicians. Every time that Shick was seen, the treating physician should have been aware of both the contents of Shick's medical records and the repeated concerns recorded therein regarding Shick's mental health and the danger he may have posed to himself and others.
Shick's prior medical record revealed that, in 2005, he was involuntarily committed due to his physicians’ belief that Shick suffered from severe mental illness which caused him to be a danger of immediate harm to himself and others. In 2008, Shick brandished a knife toward emergency personnel and police, and was again involuntarily committed. A year later, Shick attacked an airport security officer with a flashlight, and was involuntarily committed again. Shick's discharge from these commitments was premised upon the hope that Shick would voluntarily medicate and treat his mental illness, lest Shick become dangerous to himself and others.
Once Shick moved to Pittsburgh, his treating physicians observed and recorded the many instances in which they believed Shick to be: noncompliant with medications; psychotic; delusional; and even threatening. The medical record includes forty-seven calls and letters by Shick to UPMC's Shadyside Family Health Center ("Shadyside Family"), hospital emergency rooms, urologists, pain managers, and nephrologists, for nonexistent or exaggerated self-diagnosed physical symptoms that were actually psychiatric in nature.
For example, on January 10, 2012, a gastroenterologist observed Shick's threatening interactions with physicians. On January 19, Shick became verbally abusive and threatening toward a family practice physician. On February 10, 2012, Drs. Kirby and Weiner of Shadyside Family observed Shick threatening them and office staff with a baseball bat, causing the physicians to request security personnel to remove Shick from the premises and resulting in Shadyside Family declining to provide continuing care to Shick. Staff in other UPMC offices reported seeing Shick carrying a baseball bat, and UPMC Shadyside Hospital security personnel reported an altercation with Shick in which they were compelled to draw their guns. On February 25, 2012, a UCLA gastroenterologist emailed one of Shick's treating physicians about a letter that Shick had sent complaining about his UPP physicians, which caused the UCLA gastroenterologist to fear for the safety of UPP personnel.
UPP treating physicians recognized that Shick was a danger to himself and others. In February 2012, Dr. Weiner acted on this recognition by calling UPMC's Resolve Crisis Team, resulting in the dispatch of a mobile unit to Shick's apartment in order to take Shick to WPIC for a wellness check and possible commitment. When the mobile team arrived, Shick refused to open the door. Because the mobile team personnel were unsuccessful in contacting Dr. Weiner, they simply left. The Resolve Crisis Team suggested that Dr. Weiner go to WPIC directly and fill out the involuntary commitment forms. A Shadyside Family staff member called the crisis team to find out how to initiate the process of involuntary commitment, but neither Dr. Weiner, Dr. Kirby, nor anyone else took further action. A Resolve mobile unit again went to Shick's apartment, this time at the behest of Shick's mother, but Shick again declined to cooperate.
These physicians clearly believed that Shick posed a danger to himself or others, and documented their concerns in Shick's file. It should have been apparent to all of Shick's treating physicians that Shick would not cooperate with a voluntary mental health examination and that the only viable option was involuntary treatment. Although none of these professionals initiated the statutory process outlined in the MHPA to have Shick involuntarily examined, the facts as averred establish that the treating physicians of UPP and UPMC knew or should have known, based upon their own observations and their review of Shick's medical record, that Shick was severely mentally ill and posed a danger to himself or others. Although the medical record demonstrates UPP's collective concern, as well as the health care providers’ collective failure to act on this concern, the only concrete action that UPP physicians took with regard to Shick occurred when Shadyside Family informed Shick that it would no longer provide his medical care.
Unfortunately for the Leights, however, there is no liability under the MHPA where a patient clearly warrants an involuntary emergency examination but the treating physicians fail to effectuate commitment. We do not write the statutes. We interpret and apply them.
Based upon the facts alleged by the Leights, the trial court rightly dismissed the MHPA claim on preliminary objections. The plain language of the MHPA does not support liability under these facts.
JUSTICE MUNDY, dissenting
I dissent from the Majority's holding that a physician is not a participant in the decision-making process under the MHPA until the physician files the required paperwork for an involuntary examination. See Maj. Op. at ––––. Because the complaint alleges that the University of Pittsburgh Physicians (UPP) made an assessment that John Shick needed an involuntary mental health examination and then sought to have him examined, I conclude that the complaint pleads that UPP "participated in a decision that a person be examined or treated under this act" under Section 114 of the Pennsylvania Mental Health Procedure Act (MHPA), 50 P.S. § 7114, and thus pleads a cause of action under the MHPA.
Appellants’ Third Amended Complaint1 alleges that from June 22, 2011 to March 7, 2012, Shick presented to various UPP practices, approximately 33 times, seeking treatment for numerous perceived physical ailments.2 Over the course of those ten months, at least eight UPP physicians concluded that Shick was suffering primarily from mental illness.3 Additionally, Shick refused all of the UPP physicians’ attempts to voluntarily treat his mental illness.4 In early 2012, UPP physicians began to consider whether to initiate involuntary commitment for Shick, but they concluded he did not meet the involuntary commitment criteria at that time. Following two incidents in February 2012, however, they decided to pursue involuntary examination and commitment.
Id. at ¶ 276 (stating Dr. Weiner asserted Shick was "floridly psychotic" on January 25, 2012, but did not meet the criteria for an involuntary commitment); id. at ¶ 296 (alleging UPMC's Director of Behavioral Science advised Shadyside Family's director that Shick was not a candidate for involuntary mental health evaluation and commitment on February 9, 2012).
On February 10, 2012, "Shick appeared at Shadyside Family to have blood drawn for testing, and inappropriately brandished a baseball bat in a threatening manner, causing the nurse to be upset." Third Amended Complaint, 2/25/14, at ¶ 300. On the same day, Dr. Weiner, a Shadyside Family primary care physician, contacted Jeffrey McFadden at re:solve Crisis Services, which is the Western State Psychiatric Institute and Clinic (Western Psych) program that, among other things, dispatches mobile teams to evaluate and transport individuals requiring involuntary commitments. Id. at ¶¶ 209, 302-03. Dr. Weiner described Shick's behavior, stated UPMC security had removed Shick from the premises, and added "that he was afraid of the patient and did not want his name disclosed." Id. at ¶¶ 302-03. In response, Jeffrey McFadden dispatched a re:solve mobile team to pick up Shick and transport him to Western Psych for a mental health wellness check and possible commitment, but Shick refused to consent to an assessment. Id. at ¶ 304. On February 13, 2012, "the re:solve mobile team clinician spoke with Dr. Weiner, informed him that the mobile team was unable to assist with a petition commitment for Shick due to not making contact with the witnesses at Shadyside Family, and gave Dr. Weiner contact information for re:solve," which Dr. Weiner said he would pass on to Shadyside Family's medical director and staff psychiatrist. Id. at ¶¶ 313-14.
After a February 17, 2012 meeting between Dr. Gallick (Shadyside Family's medical director), Dr. Kirby (a UPP primary care physician), and Dr. Weiner, at which they discussed treatment options for Shick, Dr. Weiner called re:solve "asking to have involuntary commitment papers faxed to him to accomplish the involuntary commitment of Shick." Id. at ¶ 321. However, the re:solve clinician stated that Western Psych does not fax that paperwork and advised Dr. Weiner to go to Western Psych to fill out the forms. Id. at ¶ 322. That same day, one of Shadyside Family's staff members spoke with a re:solve clinician to determine how a doctor completes an involuntary commitment form. Id. at ¶ 323.
On February 20, 2012, "Dr. Kirby called, on an emergent basis, and spoke with re:solve clinician Valerie Krieger, seeking assistance to have Shick involuntarily committed." Id. at ¶ 335. Dr. Kirby reported that Shick had visited Shadyside Family that day with a baseball bat, intimidated staff members, and struck furniture with the bat before UPMC security officers removed him from the office. Id. at ¶ 336. Further, Dr. Kirby stated that in the prior week, UPMC Shadyside Hospital security personnel had drawn guns on Shick during an altercation due to Shick's confrontational nature. Id. at ¶ 337. "Ms. Krieger dispatched a mobile team to meet with Dr. Kirby to assist with commitment petitioning, but advised Dr. Kirby that the call was on hold due to a lack of current mobile team availability, and advised that Dr. Kirby could go to the Western Psych emergency room as needed to complete an involuntary commitment petition." Id. at ¶ 338. In two calls to re:solve later that day, Dr. Kirby stated he wanted to pick up the involuntary commitment forms instead of having a mobile team come to him, and he would fill out the commitment petition at Western Psych the next day. Id. at ¶ 340.
Ultimately, neither Dr. Weiner nor Dr. Kirby filed an involuntary commitment petition for Shick. On February 28, 2012, Dr. Kirby sent a letter to Shick stating that Shadyside Family would no longer provide care to him. On March 8, 2012, Shick carried out the mass shooting at Western Psych, killing one person and injuring several others, including Appellant Kathy Leight.
Shadyside Family was the second UPP practice that banned Shick. On February 10, 2012, Drs. Ganesh and Gulati, two UPP gastroenterologists, sent a letter to Shick dismissing him from the Center for Liver Diseases and Digestive Disease Center practice. Third Amended Complaint, 2/25/14, at ¶ 246 (alleging Shick was verbally aggressive with Dr. Gulati's staff, leading to the practice banning him); ¶ 294 (averring Shick sent Dr. Ganesh a February 8, 2012 letter telling him to be careful in February); ¶ 310.
Based on the allegations summarized above, I conclude that the complaint pleads that UPP "participated in a decision that a person be examined or treated under this act" under Section 114 of the Pennsylvania Mental Health Procedure Act (MHPA), 50 P.S. § 7114, and thus pleads a cause of action under the MHPA. Section 114(a) of the MHPA provides:
(a) In the absence of willful misconduct or gross negligence, a county administrator, a director of a facility, a physician, a peace officer or any other authorized person who participates in a decision that a person be examined or treated under this act, or that a person be discharged, or placed under partial hospitalization, outpatient care or leave of absence, or that the restraint upon such person be otherwise reduced, or a county administrator or other authorized person who denies an application for voluntary treatment or for involuntary emergency examination and treatment, shall not be civilly or criminally liable for such decision or for any of its consequences.
50 P.S. § 7114(a). This Court has interpreted Section 114 as providing that a statutorily-specified actor "participating in a decision to examine, treat or discharge a mentally ill patient within the purview of the Mental Health Procedures Act who commits willful misconduct or gross negligence can be liable for such decision." Goryeb v. Commonwealth, Dep't of Pub. Welfare , 525 Pa. 70, 575 A.2d 545, 549 (1990).
In this case, we focus on the statutory duty to abstain from willful misconduct or gross negligence when "participat[ing] in a decision that a person be examined or treated under this act[.]" I conclude that phrase encompasses the alleged conduct of the UPP physicians, who, according to the Third Amended Complaint, made an assessment that Shick needed an involuntary mental health examination and then sought to have him examined by contacting re:solve to transport him to Western Psych. Ultimately, Shick was not taken to Western Psych only because the physicians did not complete the necessary paperwork. This, in my view, does not exclude UPP from "participat[ing] in a decision that [Shick] be examined or treated under this act[.]" 50 P.S. § 7114(a).
I disagree with the Majority's holding that Section 114 applies "only when a physician files the required documentation for involuntary emergency examination[.]" Maj. Op. at ––––. Section 114(a)’s language is broad and does not contain any requirement that the physician has to file the required documentation to be considered a participant in the decision-making process. As in this case, the decision by the UPP physicians that Shick needed an involuntary mental health examination had been made, merely the paperwork was not completed. Further, the effect of the Majority's decision is to exempt from liability physicians who failed to seek, or decided against seeking, appropriate mental health treatment for a patient in need of treatment through willful misconduct or grossly negligent actions. This is not consistent with the purpose of the MHPA, which is to assure the availability of treatment "where the need is great and its absence could result in serious harm to the mentally ill person or to others." 50 P.S. § 7102. Permitting a cause of action here, where physicians decide a patient needs mental health treatment but fail to file the required paperwork is in line with the purpose of the MHPA and encourages physicians to secure mental health treatment for their patients who show signs of needing it.
For these reasons, I dissent to the Majority's holding that the MHPA statutory duty does not apply to physicians who participate in a decision that their patient be examined or treated under the MHPA but fail to file the required documentation.