In RE A.R.C. v. the State of Texas

Supreme Court of Texas
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No. 22-0987
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In re A.R.C.

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On Petition for Review from the
Court of Appeals for the Eighth District of Texas
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Argued October 25, 2023

JUSTICE YOUNG delivered the opinion of the Court.

A court may not order involuntary civil commitment unless the
State complies with a host of substantive and procedural requirements.
Only one such requirement is at issue here: that, in counties where “a
psychiatrist is available,” a psychiatrist must complete at least one of
two required “certificates of medical examination for mental illness.”
Tex. Health & Safety Code § 574.009(a). We must decide whether the
second-year psychiatry residents who signed certificates in this case
qualify as psychiatrists. We hold that they do and therefore reverse the
court of appeals’ contrary judgment.
The factual background is largely undisputed. Respondent A.R.C.,
then a 34-year-old man, exhibited psychotic symptoms and delusional
behavior during a visit to the emergency room early on Sunday, July 24,
2022. A.R.C.’s conduct led the attending physician, Dr. Morales, to file
an application for emergency detention that morning. A magistrate soon
signed a warrant that authorized A.R.C. to be detained in a medical
facility for up to forty-eight hours and required A.R.C. to undergo further
medical examination. The following morning—Monday, July 25—Dr.
Paez examined A.R.C. Dr. Paez was a second-year psychiatry resident at
the Texas Tech University Health Sciences Center El Paso Paul L. Foster
School of Medicine, practicing under a “physician-in-training” permit.
The results of Dr. Paez’s examination were troubling enough to
trigger a series of filings and actions that took place on Tuesday, July 26.
Dr. Paez prepared a certificate of medical examination based on his
evaluation of A.R.C. He also filed an application for temporary court-
ordered mental-health services. In both filings, Dr. Paez stated that
A.R.C. presented a substantial risk of serious harm to himself or others.
Around the same time, the El Paso County Attorney filed a motion for an
order of protective custody in reliance on these medical records. The
probate court soon signed the requested order. Among other things, the
order set two hearings in rapid succession: a probable-cause hearing for
the morning of Thursday, July 28, and a final hearing for the morning of
Monday, August 1.
The central role of the probable-cause hearing was to determine
whether A.R.C. “present[ed] a substantial risk of serious harm to
[himself] or others to the extent that [he could not] be at liberty pending
the [final] hearing.” Id. § 574.025(a). The judge so found, and on the
afternoon of July 28, he signed an order confirming that he had made
the finding about A.R.C. at the hearing. Accordingly, the court concluded
that there were sufficient grounds for continued detention pending the
upcoming final hearing.

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On the following morning—Friday, July 29—another physician,
Dr. Kutcher-Diaz, examined A.R.C. and then signed a second certificate
of medical examination. Dr. Kutcher-Diaz, like Dr. Paez, was a second-
year psychiatry resident. In his certificate, he determined that A.R.C.
was mentally ill and that this mental illness made it likely that A.R.C.
would cause serious harm to himself. This second certificate of medical
examination before the final hearing was necessary to comply with a
statutory requirement:
A hearing on an application for court-ordered mental health
services may not be held unless there are on file with the
court at least two certificates of medical examination for
mental illness completed by different physicians each of
whom has examined the proposed patient during the
preceding 30 days. At least one of the physicians must be a
psychiatrist if a psychiatrist is available in the county.
Tex. Health & Safety Code § 574.009(a).
On the morning of August 1, as the final hearing was about to
commence, A.R.C. filed a motion to dismiss based on the State’s alleged
noncompliance with § 574.009(a). The probate court held the hearing as
scheduled. A.R.C. attended. He was represented by counsel, who
stipulated in open court as to Dr. Kutcher-Diaz’s psychiatric expertise but
argued that neither Dr. Paez nor Dr. Kutcher-Diaz qualified as a
“psychiatrist” under the statute. Both doctors, A.R.C. emphasized, were
residents training under more senior doctors and were licensed under the
physician-in-training program. The residents’ expertise was beside the
point because, if a “psychiatrist” had signed neither certificate, the
statutory predicate would remain unsatisfied, requiring the probate court
to dismiss the case and order A.R.C.’s immediate release.

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The court rejected A.R.C.’s contention that the doctors did not
qualify as psychiatrists under the statute, finding that both “[c]ertificates
[were] in compliance with the Texas Health & Safety Code.” After
hearing the arguments of counsel and taking live evidence, including
from Dr. Kutcher-Diaz and from A.R.C. himself, the judge ultimately
ordered A.R.C. to undergo in-patient mental health services for forty-
five days and, in a separate order, to receive forced medication.
On appeal to the Eighth Court of Appeals, A.R.C. again argued
that the residents did not qualify as psychiatrists and that, even if they
did, the evidence was legally and factually insufficient to support the
probate court’s commitment order. Although the forty-five-day period
had passed and A.R.C. was no longer involuntarily committed, the court
of appeals concluded that the dispute was not moot. We agree. An
involuntary-commitment order imposes collateral consequences under
federal and state law. See, e.g., 18 U.S.C. §§ 922(g)(4), 924(a)(8); Tex.
Gov’t Code § 411.172. For this and other reasons, the jurisdiction of the
court of appeals to review the probate court’s order was secure, and so
is ours.
On the merits, a divided court of appeals agreed with A.R.C.’s
argument that the residents were not psychiatrists within the statute’s
meaning and did not reach his alternative contentions. The court vacated
the probate court’s order and dismissed the application. 657 S.W.3d 585,
595 (Tex. App.—El Paso 2022). According to the majority, this conclusion
did not require it to determine what “psychiatrist” means. Id. at 592. Its
chief rationale was that the statute defines “physician” to expressly
include physician-in-training permit holders, like the residents in this

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case, but does not define “psychiatrist” the same way. Id. at 593. Justice
Palafox dissented. She would have looked to what “psychiatrist” means
and would have held that the term, as used in the statute, includes the
psychiatry residents here. Id. at 597–98 (Palafox, J., dissenting).
We agree with Justice Palafox. The statute does not now and since
its original enactment in 1957, see Mental Health Code, 55th Leg., R.S.,
ch. 243, 1957 Tex. Gen. Laws 505, never has defined “psychiatrist.” A
nonexistent definition’s failure to reference physician-in-training permits
cannot resolve whether psychiatry residents qualify as psychiatrists.
Other statutory provisions, however, combined with the ordinary
meaning of “psychiatrist,” show that the certificates signed by Dr. Paez
and Dr. Kutcher-Diaz complied with § 574.009(a).
First, the statute makes clear that psychiatrists are a subset of
the larger class of physicians. Two physician-signed certificates are
necessary in larger counties, and “one of the physicians must be a
psychiatrist.” Tex. Health & Safety Code § 574.009(a) (emphasis added).
Moreover, § 574.009(b) allows judges to directly “appoint the necessary
physicians” if certificates are not filed with an application for court-
ordered mental health services. What the statute says about physicians,
therefore, helps inform its understanding of psychiatrists.
Second, the statute includes a detailed definition of “physician.”
That definition is directly relevant to residency status because, under
the statute, a “physician” is
(A) a person licensed to practice medicine in this state;
(B) a person employed by a federal agency who has a license
to practice medicine in any state; or
(C) a person authorized to perform medical acts under a

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physician-in-training permit at a Texas postgraduate
training program approved by the Accreditation Council for
Graduate Medical Education, the American Osteopathic
Association, or the Texas Medical Board.
Id. § 571.003(18). Dr. Paez and Dr. Kutcher-Diaz were practicing under
physician-in-training permits when they completed A.R.C.’s certificates
of medical examination, so they unquestionably qualified as “physicians”
under § 571.003(18)(C). A.R.C. does not dispute this conclusion.
So psychiatrists are physicians, and physicians include those
practicing under a physician-in-training permit. The residents’ status as
psychiatrists therefore turns on whether the word “psychiatrist” conveys
a meaning that excludes Dr. Paez and Dr. Kutcher-Diaz, despite their
status as physicians in a psychiatry-residency program. The court of
appeals was thus mistaken to conclude that § 574.009(a)’s scope can be
ascertained without examining what “psychiatrist” means.
With no statutory definition of that term, we must apply its
ordinary meaning. This Court has considered a blend of standard and
medical dictionaries when interpreting otherwise undefined medical
terms. See, e.g., Tex. State Bd. of Exam’rs of Marriage & Fam. Therapists
v. Tex. Med. Ass’n, 511 S.W.3d 28, 35–36 (Tex. 2017). Following this
approach, we have no trouble concluding that the term “psychiatrist” has
a plain and discernible meaning that reaches the two residents here.
An array of dictionaries reflects the basic point that—whether
taken from the perspective of 1957, when what is now § 574.009(a) was
first enacted, or more recently—a psychiatrist is just “a physician who
practices psychiatry.” Psychiatrist, Random House Dictionary of the
English Language (2d ed. 1987); see also Psychiatrist, Webster’s New

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International Dictionary (2d ed. 1934) (“[a] specialist in psychiatry”);
Psychiatrist, Stedman’s Medical Dictionary (5th unabridged lawyer’s ed.
1982) (“A physician who specializes in psychiatry; the medical specialist
in the diagnosis and treatment of mental diseases.”); Psychiatrist,
American Heritage Dictionary of the English Language (5th ed. 2011)
(“[a] physician who specializes in psychiatry”); Psychiatrist, Psychiatric
Dictionary (5th ed. 1981) (“A psychiatrist is a physician who has had
advanced training in the diagnosis and treatment of mental disorders.”
(emphasis added)).
Psychiatrists, in short, are physicians who specialize their practice
in psychiatry. Because everyone agrees that Dr. Paez and Dr. Kutcher-
Diaz qualify as physicians under § 571.003(18)(C), all that remains is to
determine whether they specialize their practice in psychiatry. A
specialist is “[a] physician whose practice is limited to a particular branch
of medicine or surgery, esp. one certified by a board of physicians.”
Specialist, American Heritage College Dictionary (3d ed. 1993) (emphasis
added); see also Specialist, Webster’s New International Dictionary (2d
ed. 1934) (“One who devotes himself to some special branch of
activity . . . as a doctor who devotes himself to certain diseases.”);
Specialist, Sloane-Dorland Annotated Medical-Legal Dictionary (1987)
(“[A] physician whose practice is limited to a particular branch of
medicine or surgery, especially one who, by virtue of advanced training,
is certified by a specialty board as being qualified to so limit his practice.”
(emphasis added)); Specialize, American Heritage Dictionary of the
English Language (5th ed. 2011) (“To pursue a special activity,
occupation, or field of study: a doctor who specializes in cardiology.”).

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To be a specialist under these definitions, it is sufficient but not
necessary to be board certified. Board-certified psychiatrists are
especially well credentialed specialists, not those who are minimally
qualified to be called specialists. The statute easily could impose such a
heightened standard—requiring not merely a psychiatrist, but a board-
certified one, for example—yet § 574.009(a) does not. In any event, A.R.C.
expressly abandoned at oral argument the contention that only board-
certified psychiatrists qualify under the statute. That concession was
sensible given the common usage of the relevant terms.
Thus, physicians who primarily limit their practice to psychiatry—
and certainly such physicians who have received advanced training in
psychiatry—are physicians who specialize in psychiatry. Both Dr.
Kutcher-Diaz and Dr. Paez qualify. Both had received advanced training
in psychiatry before entering the second year of their psychiatry
residencies. At the final hearing, Dr. Kutcher-Diaz testified that he had
admitted patients during his first year of residency when he worked at
the El Paso Psychiatric Center and that, as a second-year resident, his
medical practice involved “treat[ing] patients with mental illness.” The
amicus brief for Texas Tech University Health Sciences Center at El Paso
offers further context. By their second year, it observes, the residents had
completed “a six month rotation at the State of Texas Hospital-El Paso
Psychiatric Center treating exclusively mentally ill patients, a five month
rotation in internal medicine, and a one month rotation in neurology.”
We hold that a physician who can be said to specialize in psychiatry
qualifies as a psychiatrist under § 574.009(a). Common sense suggests
that physicians well into a psychiatry residency will satisfy that standard.

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The label “psychiatry residency” does not resolve the question, of course.
If a hypothetical residency delayed specialized psychiatric training or
delayed residents’ ability to primarily practice psychiatry, those residents
would not qualify as “psychiatrists” until the residency afforded them
those opportunities. Such a hypothetical residency does not affect this
case because Dr. Kutcher-Diaz and Dr. Paez had clearly passed any
dividing line between psychiatrists and non-psychiatrists by the time
they completed A.R.C.’s certificates of medical examination.
Our discussion of the minimum statutory requirement for
qualification as a “psychiatrist” should not obscure that, under Chapter
574 of the Mental Health Code, it is the court—not any physician, no
matter how credentialed—that determines whether involuntary
commitment is necessary or lawful. Only a judge can “order a proposed
patient to receive court-ordered temporary inpatient mental health
services,” and such an order is permissible “only if the judge or jury finds,
from clear and convincing evidence, that [the enumerated statutory
elements have been satisfied].” Tex. Health & Safety Code § 574.034(a).
If the court views the medical testimony provided as inadequate or
unpersuasive—even if the “physician” and “psychiatrist” requirements of
§ 574.009(a) are unquestionably satisfied—the court will presumably find
the demanding standard for civil commitment to be unmet.
We finally observe that while the parties ably address policy
grounds for one view of “psychiatrist” or another, our decision does not
embrace or reject any of them. We merely give the statute the meaning
that its text and structure require. The Texas Constitution provides that
“[n]o person shall be committed as a person of unsound mind except on

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competent medical or psychiatric testimony.” Tex. Const. art. I, § 15-a.
No party has contended that any of the proposed understandings of
“psychiatrist” in this case would transgress that basic constitutional
requirement. So long as the legislature adheres to that requirement, it
may strike whatever balance it determines best protects the rights of
individuals and of the public. The legislature can enhance the minimum
qualifications for psychiatrists and other physicians if it concludes that
the paramount need is greater experience or expertise. It could, for
example, define “psychiatrist” to exclude residents or to require board
certification. It could mandate psychiatrists in all cases, not only in
larger counties where psychiatrists are available. Or, contrariwise, the
legislature could relax the standard—for example, by requiring
psychiatrists only in certain contexts or only when a court so demands.
Protecting individual liberties and the larger public in a context of
limited resources implicates exactly the kind of policy considerations
that legislative bodies are equipped to balance and courts are not.
We hold that the residents in this case were “physicians” who
specialized their practices in psychiatry and thus qualified as
“psychiatrists” under § 574.009(a). The judgment of the court of appeals
is reversed and the case is remanded to that court for consideration of
A.R.C.’s remaining challenges.

Evan A. Young
Justice

OPINION DELIVERED: February 16, 2024

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