Alternate Health-Care Agents as Witnesses and Disability Discrimination:
Commentary on Jane Doe v. University of Maryland Medical System Corp. (4th Cir. 2025)

I. Introduction

This unpublished Fourth Circuit opinion, authored by Judge Wynn and joined by Judges Wilkinson and Rushing, addresses two intersecting domains of law:

• Maryland’s statutory regime governing health care advance directives, particularly the execution requirements and the role of alternate agents; and
• Federal disability discrimination statutes—Section 1557 of the Affordable Care Act, Title II of the ADA, and Section 504 of the Rehabilitation Act—in the context of psychiatric hospitalization and involuntary commitment.

The core holding is twofold:

1. Under Maryland’s Health Care Decisions Act, an alternate health care agent may not serve as a witness to the advance directive that appoints them; if they do, the directive is not validly executed and does not legally exist as an advance directive.
2. A patient whose directive fails these statutory formation requirements is not “otherwise qualified” for the Maryland advance directive program and therefore cannot state a disability-discrimination claim based on a provider’s refusal to honor such a document.

The court also rejects claims that the hospital’s continuation of Jane Doe’s involuntary psychiatric commitment amounted to disability discrimination—either as biased medical decision-making or as “unjustified isolation” under Olmstead v. L.C..

Although unpublished (and therefore nonbinding precedent within the Fourth Circuit), the opinion is highly instructive for:

• Maryland practitioners drafting or relying on advance directives,
• Hospitals and health systems facing ADA / Rehabilitation Act / ACA claims arising from psychiatric commitment decisions, and
• Litigants considering how to frame disability-discrimination challenges to medical decisions and civil commitments.

II. Summary of the Opinion

A. Parties and Factual Background

Jane Doe experiences episodic psychosis. Her private physician at one point diagnosed a form of non-celiac gluten sensitivity, in which ingestion of gluten allegedly triggered psychotic episodes. Between 2016 and 2022, Doe executed a written advance directive using a form downloaded from the Maryland Attorney General’s website.

Key features of the directive:

• Her father was designated as primary health care agent.
• Her mother was designated as alternate health care agent.
• Doe expressly authorized her agent to approve her admission to a psychiatric hospital.
• She chose to grant her agent immediate authority, rather than deferring that authority until two physicians declared her incompetent.
• Two witnesses signed the directive; one of them was Doe’s mother—the same person designated as alternate agent.

In November 2022, Doe voluntarily admitted herself for psychiatric treatment at Baltimore Washington Medical Center (a UMMS subsidiary). In March 2023, during another psychotic episode, police brought her to the same hospital. Dr. Thomas Cummings evaluated her, rejected the gluten-based diagnosis, and diagnosed schizophrenia, noting that Doe had recently been tapered off anti-psychotic medication.

When Doe’s father presented the advance directive, Dr. Cummings declared it invalid under Maryland law and involuntarily committed Doe instead of accepting a voluntary admission via the father’s agency authority. An administrative law judge (ALJ) subsequently certified the involuntary commitment. Outside psychiatrists later opined that Doe no longer met criteria for continued confinement.

Multiple state-court proceedings followed, along with a federal due-process suit. Ultimately, Doe was released pursuant to a state-court consent order that required dismissal of pending claims and imposed post-release treatment conditions (including continued medication).

A Maryland trial court later concluded that the ALJ erred by disregarding the advance directive without a formal challenge to its validity or factual findings about its compliance with statutory requirements. When defendants sought reconsideration and a specific ruling that the directive was invalid due to the witness rule, the court declined to reach that issue, and the subsequent state appeal was dismissed as moot after Doe’s release.

B. Federal Disability-Discrimination Suit

Doe then sued in federal district court under:

• Section 1557 of the Affordable Care Act (42 U.S.C. § 18116),
• Title II of the Americans with Disabilities Act (42 U.S.C. § 12132), and
• Section 504 of the Rehabilitation Act (29 U.S.C. § 794(a)).

Her theories, as relevant on appeal, were:

1. Defendants discriminated by refusing to honor her advance directive and thereby denying her the benefits of the “Maryland Advance Directive Program.”
2. Defendants discriminated by prolonging her involuntary confinement after it was no longer medically justified.

The district court granted defendants’ Rule 12(b)(6) motion to dismiss, holding principally that Doe was not “otherwise qualified” to participate in the advance directive program because her directive was invalid under Maryland law.

C. Holdings of the Fourth Circuit

The Fourth Circuit affirms, holding:

1. No issue preclusion (collateral estoppel) arises from the Maryland trial court’s ALJ-review decision, because that court expressly declined to decide the validity of Doe’s directive under the witness requirement.
2. Maryland advance directive law:
   • Under Md. Code, Health–Gen. § 5-602(c)(2)(ii), “[t]he health care agent of the declarant may not serve as a witness.”
   • “Health care agent” includes any appointed agent, primary or alternate; the statutory singular (“the health care agent”) is read to include the plural, and the appointment of an alternate is still an “appointment” at the time of execution.
   • The statutory optional form, § 5-603, expressly warns that “[a]nyone selected as a health care agent in Part I may not be a witness,” and Part I encompasses both primary and backup (alternate) agents.
   • Therefore, Doe’s mother, as alternate agent, could not lawfully act as a witness. Because she did, the directive failed a formation requirement and is not a valid advance directive at all.
3. Severability does not salvage the directive: Failure to satisfy statutory execution/witness requirements is a formation defect; where no valid advance directive is formed, there is nothing to sever.
4. “Otherwise qualified” requirement: Because Doe did not validly create an advance directive, she was not “otherwise qualified” for the state’s advance directive program and cannot claim disability discrimination based on exclusion from that program.
5. Prolonged confinement claims:
   • Claims that defendants continued confinement due to fear she would stop medication, or to gain leverage in pending lawsuits, do not plausibly allege discrimination “by reason of” disability. Medical decisions related to the treated disability are “benign” discrimination, and alleged litigation-motivation is unrelated to disability status.
   • Doe’s Olmstead-type unjustified-isolation theory fails because she does not allege that the hospital’s own treating professionals determined that she was appropriate for a less restrictive setting earlier than her release. Opinions of outside physicians and the later Consent Order do not reasonably imply such an earlier determination.

Accordingly, the Fourth Circuit affirms the dismissal of all federal disability-discrimination claims.

III. Detailed Analysis

A. The Preclusion Question: Why the State Ruling on the ALJ Did Not Control

Doe’s first move on appeal was to argue that a Maryland trial court already deemed her advance directive “binding,” precluding the federal court from revisiting its validity. The Fourth Circuit rejects this by applying Maryland’s issue-preclusion (collateral estoppel) test, as articulated in Washington v. Pellegrini, 125 F.4th 118 (4th Cir. 2025), which in turn relies on Nat’l Union Fire Ins. Co. of Pittsburgh v. Fund for Animals, Inc., 153 A.3d 123 (Md. 2017).

Under Maryland law, issue preclusion requires:

1. Identity of issue between the prior and current proceedings;
2. A final judgment on the merits;
3. Same party (or privy) against whom preclusion is asserted; and
4. A full and fair opportunity to litigate the issue previously.

The Fourth Circuit focuses on the first prong: identity of issue. The Maryland trial court did not decide whether the directive was invalid under the witness requirement. It merely held that the ALJ erred in ignoring the directive without a formal challenge or factual findings about its validity. When defendants later asked the court to declare the directive invalid under § 5-602(c)(2)(ii), the court expressly declined to reach that question.

Because the validity of the directive under the witness rule was never actually decided in state court, there is no “identical issue” to preclude the federal litigation. The Fourth Circuit is therefore free—indeed obligated—to interpret Maryland law on this point in the first instance.

B. Interpreting Maryland’s Health Care Advance Directive Statute

1. Statutory Framework

The relevant Maryland provisions are in the Health Care Decisions Act:

• § 5-602(b)(2) – permits a competent adult to appoint an “agent to make health care decisions.”
• § 5-602.1 – extends the advance directive framework to mental health services, including psychiatric care and hospitalization.
• § 5-601(c) – defines “agent” as “an adult appointed by the declarant under an advance directive to make health care decisions for the declarant.”
• § 5-602(c)(1) – requires that an advance directive be signed by the declarant in the presence of two witnesses.
• § 5-602(c)(2)(ii) – “The health care agent of the declarant may not serve as a witness.”
• § 5-603 – supplies an optional form advance directive, including a clear warning: “Anyone selected as a health care agent in Part I may not be a witness.”

Section 5-602.1(c)(1) further provides that a mental-health-specific directive must follow the same procedures as § 5-602, reinforcing that execution requirements (including witnessing) are mandatory formation rules.

2. Is an Alternate Agent an “Agent” for Witness-Disqualification Purposes?

The core statutory question: Does the phrase “the health care agent of the declarant” in § 5-602(c)(2)(ii) encompass an alternate (or “backup”) agent, such that the alternate agent is also barred from serving as a witness?

No Maryland appellate decision squarely addressed this issue. Therefore, following Real Time Med. Sys., Inc. v. PointClickCare Techs., Inc., 131 F.4th 205 (4th Cir. 2025), and United States v. Edwards, 128 F.4th 562 (4th Cir. 2025), the Fourth Circuit predicts how the Supreme Court of Maryland would interpret the statute, applying Maryland’s own canons of construction (as summarized in cases like Watts v. State, 179 A.3d 929 (Md. 2018) and Canton Harbor Healthcare Ctr., Inc. v. Robinson, 340 A.3d 732 (Md. 2025)).

Key interpretive steps:

1. Plain language and context:
   • “Agent” is defined by appointment (“an adult appointed … to make health care decisions”) rather than by current authority.
   • An alternate agent is expressly “selected” in the statutory form (Part I) as someone who will act if the primary cannot.
   • The Act consistently uses the singular “agent,” but Maryland’s general interpretive statute, Md. Code, Gen. Provisions § 1-202, states that the singular includes the plural absent contrary intent.
   • Thus, references to “agent” and “the health care agent” are best read as inclusive of all individuals appointed as agents in the directive, including alternates.
2. Rejection of Doe’s “authority-based” view of agency:
   • Doe argued that an alternate has no agency status until their authority actually springs into effect—i.e., only when the primary is unavailable—and hence is not yet an “agent” at the time of witnessing.
   • The court counters that the statutory definition turns on appointment, not active authority. The declarant “selects” or “chooses” the alternate at the time the directive is executed, and that selection is sufficient to make the person an “agent” for statutory purposes.
3. Statutory form as persuasive evidence of legislative intent:
   • The optional form in § 5-603 uses language in which the declarant, in the present tense, selects a backup agent (“I select…”).
   • Most importantly, the form bluntly states: “Anyone selected as a health care agent in Part I may not be a witness.” Part I includes both primary and backup agents. This is a direct indicator that the legislature intended to bar any appointed agent—primary or alternate—from witnessing the directive.
4. Purpose and policy of the witness restrictions:
   • Section 5-602(c)(2) contains several conflict-of-interest safeguards:
     • Health-care providers involved in the declarant’s care may serve as witnesses only if “acting in good faith.”
     • At least one witness must not have a known financial interest in the declarant’s death.
   • These provisions show a broad legislative concern with preventing conflicts of interest, including future, contingent conflicts.
   • Agents, whether primary or alternate, plainly hold a power-laden role with potential conflicts regarding treatment or end-of-life decisions. Prohibiting them from acting as witnesses is consistent with this policy.
5. Avoiding illogical or meaningless constructions:
   • Doe’s proposed interpretation (that only the primary agent is barred) would largely nullify the witness rule, because by default an agent’s authority does not activate until incapacity is certified by two physicians. If lack of actual authority at execution rendered the individual a non-agent, even primary agents could witness their own appointment.
   • Following Maryland precedent such as Bell v. Chance, 188 A.3d 930 (Md. 2018), the court refuses to adopt a construction that produces such illogical or self-defeating results.

Accordingly, the court holds that:

An alternate health care agent appointed in a Maryland advance directive is an “agent” within the meaning of § 5-602(c)(2)(ii) and therefore may not serve as a witness to that directive.

Because Doe’s mother was named alternate agent and simultaneously signed as a witness, the document does not satisfy the statutory execution requirements and is not a valid advance directive under Maryland law.

C. Severability and Formation: Why the Father’s Agency Cannot Be Saved

Doe’s final attempt to preserve the directive was to argue that, even if her mother’s appointment as alternate agent (or her role as witness) was invalid, the court could sever that defective portion and still give legal effect to the father’s appointment as primary agent.

The Fourth Circuit rejects this by drawing on severability principles recently restated in Johnson v. Continental Financial Co., LLC, 131 F.4th 169 (4th Cir. 2025), and on Maryland district court authority such as Trimble v. Entrata, Inc., 791 F. Supp. 3d 615 (D. Md. 2025).

The key conceptual distinction is between:

• Formation challenges – Defects that mean no valid contract (or, here, no valid directive) ever came into existence (e.g., failure to sign, lack of required witnesses, illusory consideration that prevents formation); versus
• Validity challenges to particular provisions – Even where an agreement is properly formed, particular clauses may be unenforceable (e.g., unconscionable arbitration provisions) yet separable from the rest of the instrument.

As Johnson puts it, “[f]ormation challenges render the whole contract unenforceable. There is nothing to enforce if a contract never existed.” Where no contract (or directive) is ever formed, there is no baseline agreement from which to sever offending parts.

Maryland’s statute makes compliance with § 5-602(c) a condition of formation:

• § 5-602 and § 5-602.1(c)(1) require that a written advance directive be “subscribed by two witnesses” and executed according to the enumerated formalities.
• It is these execution formalities—not merely the content of substantive choices—that effectuate the creation of a legally cognizable advance directive.

Because Doe’s document fails a core statutory execution requirement (a proper qualifying witness), the court treats this as a formation defect: the instrument never became a valid advance directive. As such, there is nothing to sever. Courts cannot blue-pencil a non-existent instrument into existence.

D. Federal Disability-Discrimination Framework Applied

1. Legal Standards Under Section 1557, ADA Title II, and the Rehabilitation Act

The opinion carefully situates the case in the framework for overlapping federal disability-discrimination statutes:

• Section 1557 of the ACA, 42 U.S.C. § 18116(a), incorporates the grounds of discrimination covered by the Rehabilitation Act for disability claims. See Lucas v. VHC Health, 128 F.4th 213, 222–23 (4th Cir. 2025).
• Section 504 of the Rehabilitation Act, 29 U.S.C. § 794(a), prohibits disability-based exclusion from, denial of benefits of, or discrimination under any program or activity receiving federal financial assistance.
• Title II of the ADA, 42 U.S.C. § 12132, similarly prohibits disability-based discrimination by public entities in the provision of services, programs, or activities.

The Fourth Circuit, consistent with Timpson ex rel. Timpson v. Anderson Cnty. Disabilities & Special Needs Bd., 31 F.4th 238 (4th Cir. 2022), treats ADA Title II and the Rehabilitation Act as imposing essentially the same elements, with one important difference in causation:

• Rehabilitation Act: exclusion or discrimination must be “solely by reason of” disability;
• ADA Title II: disability must be “a motivating cause” of the exclusion. See Halpern v. Wake Forest Univ. Health Scis., 669 F.3d 454, 461–62 (4th Cir. 2012).

Thus, to state a claim under any of the three statutes, Doe needed to allege:

1. She is a qualified individual with a disability (not disputed here);
2. She was “otherwise qualified” to participate in or benefit from the relevant program or service; and
3. She was excluded, denied benefits, or otherwise discriminated against by reason of her disability (or solely by reason, for the Rehabilitation Act).

The case thus turns on:

• Whether Doe was “otherwise qualified” for the advance directive regime, and
• Whether the continuation of her confinement was discriminatory (as opposed to purely medical or litigation-driven) in the statutory sense.

2. The “Advance Directive Program” Claim and the “Otherwise Qualified” Element

Doe framed one claim as exclusion from the “benefits of the Maryland Advance Directive Program” based on disability, when the hospital refused to honor her directive. The district court and the Fourth Circuit treat the state advance directive regime as a “program” or benefit for purposes of ADA/RA/ACA analysis, but hold that Doe fails the “otherwise qualified” prong:

• To be “otherwise qualified,” a plaintiff must meet the essential eligibility requirements of the program, with or without reasonable modification.
• Here, one essential requirement of participating in the advance directive framework is execution of a legally valid directive, including proper, conflict-free witnessing.

Because Doe’s directive did not satisfy Maryland’s formation requirements, she was not “otherwise qualified” for that program. In other words:

The hospital’s refusal to honor a legally invalid document is not a denial of a benefit to which Doe was legally entitled. Consequently, no disability discrimination arises from that refusal.

This framing is important doctrinally: the court does not decide whether ignoring a valid advance directive might, in some circumstances, constitute disability discrimination. It simply holds that where the document itself never came into legal existence under state law, there is no qualifying “benefit” of which the patient can be said to have been denied on the basis of disability.

3. Prolonged Confinement: Bias, Medical Decisions, and Olmstead

a. “Benign” vs. “Pejorative” Discrimination in Medical Decision-Making

Doe next alleged that, separate from the directive, defendants unlawfully prolonged her involuntary commitment after it ceased being medically justified. Her theory was that the continuation was driven by:

• Bias-based assumptions that she would stop taking her medication after discharge, and/or
• A desire to keep her confined as leverage to obtain favorable resolution of pending lawsuits.

The Fourth Circuit draws on two influential appellate decisions:

• Lesley v. Hee Man Chie, 250 F.3d 47 (1st Cir. 2001);
• McGugan v. Aldana-Bernier, 752 F.3d 224 (2d Cir. 2014).

Those cases articulate a distinction between:

• “Benign” discrimination – medical decisions that necessarily take account of the patient’s disability in order to treat it (e.g., prescribing psychotropic medication in response to mental illness; hospitalizing a patient judged dangerous due to psychiatric symptoms). This disability-based differential treatment is not, by itself, the kind of “discrimination” the ADA and Rehabilitation Act forbid.
• “Pejorative” discrimination – decisions driven by bias, stereotypes, or reliance on a disability that is irrelevant to the decision at hand (e.g., refusing to treat a deaf patient because of a generalized stereotype that “all deaf people are high risk”; ignoring a patient’s consent decision based on unrelated paralysis). These can be actionable discrimination.

Applying this framework, the court concludes:

• Doe’s allegation that defendants feared she would discontinue medication after discharge is directly tied to the psychiatric condition they were treating and to her prior noncompliance history. That is a paradigmatic example of “benign” discrimination, grounded in medical judgment about the very disability at issue, not a stereotype about an unrelated condition.
• Her alternative allegation—that continued confinement served as leverage regarding litigation—might, if true, be improper in a medical-ethics sense, but it is not discrimination “by reason of disability”. It is related to litigation posture, not to her status as a disabled person or to disability stereotypes.
• Doe does not allege that any disability other than the one being treated (psychosis/schizophrenia) motivated the decision, nor that defendants relied on stereotypes rather than individualized assessment.

Thus, under Lesley and McGugan, Doe’s allegations do not plausibly show that her disability was a prohibited basis for the continued commitment decision.

b. Olmstead “Unjustified Isolation” Theory

Doe also invokes Olmstead v. L.C. by Zimring, 527 U.S. 581 (1999), where the Supreme Court held that unjustified institutional isolation of persons with disabilities can be a form of discrimination. Under Olmstead, a state may violate Title II of the ADA when:

1. The state’s own professional treatment staff determines that community-based (less restrictive) treatment is appropriate;
2. The individual concurring does not oppose such treatment; and
3. The placement can be reasonably accommodated without fundamentally altering the state’s programs.

Critically, Olmstead allows the state to “generally rely on the reasonable assessments of its own professionals” in deciding when institutionalization remains justified.

The district court had dismissed Doe’s Olmstead claim because she did not allege that her treating professionals determined her continued confinement was no longer necessary prior to the Consent Order. On appeal, Doe attempted to infer such a determination from two sources:

• The fact that a Consent Order was entered in June releasing her, conditioned on post-release treatment obligations; and
• Independent evaluations by outside psychiatrists (Drs. Ratner and Messamore), who concluded in April/May that she no longer appeared psychotic and did not require inpatient care.

The Fourth Circuit rejects these inferences:

• The Consent Order shows that by June 12, the parties agreed to conditional release; it does not support an inference that Doe’s treating professionals had earlier concluded that confinement was medically unjustified and nevertheless intentionally prolonged it.
• Divergent views from non-treating, privately retained physicians do not reasonably imply that the hospital’s own professionals would (or did) reach the same conclusion at the same time. Professional disagreement is not itself evidence of discriminatory isolation.

Because Doe fails to plausibly allege that her treating professionals determined that less restrictive placement was appropriate before her actual release, she cannot satisfy Olmstead’s core “eligibility” element for a community-based setting. Without that, the unjustified-isolation claim necessarily fails.

E. Precedents Cited and Their Influence

A number of cited precedents support specific strands of the court’s reasoning:

• Pleading and procedural standards:
  • Washington v. Hous. Auth. of Columbia, 58 F.4th 170 (4th Cir. 2023) – recitation of Rule 12(b)(6) standard: accept well-pleaded facts as true.
  • Philips v. Pitt Cnty. Mem’l Hosp., 572 F.3d 176 (4th Cir. 2009) – court may consider documents integral to the complaint.
  • Colonial Penn Ins. Co. v. Coil, 887 F.2d 1236 (4th Cir. 1989) – judicial notice of other court proceedings.
• Coverage of programs and entities:
  • Basta v. Novant Health Inc., 56 F.4th 307 (4th Cir. 2022); Cummings v. Premier Rehab Keller, P.L.L.C., 596 U.S. 212 (2022) – federal-funding requirements for ACA and RA.
  • Fauconier v. Clarke, 966 F.3d 265 (4th Cir. 2020) – Title II ADA applies to public entities.
  • Hammons v. Univ. of Md. Med. Sys. Corp., 551 F. Supp. 3d 567 (D. Md. 2021) – UMMS treated as a state actor.
• Unified treatment of disability statutes:
  • Lucas v. VHC Health, 128 F.4th 213 (4th Cir. 2025) – § 1557 of the ACA incorporates Rehabilitation Act grounds for disability discrimination.
  • Timpson and Halpern – same basic test under ADA and RA; difference lies in causation stringency.
• Maryland statutory interpretation:
  • Watts v. State, Canton Harbor, Lockshin, Bell v. Chance, Motor Vehicle Admin. v. Gonce, and Md. Code, Gen. Provisions § 1-202 – emphasized to justify the plain-language, context-based reading of “agent” and to avoid illogical results.
• Contract formation and severability:
  • Johnson v. Continental Fin. Co. and Trimble v. Entrata, Inc. – applied by analogy to explain why failure to comply with execution formalities prevents the existence of a severable instrument at all.
• Preclusion and jurisdictional doctrines in related litigation:
  • Washington v. Pellegrini – Maryland’s issue-preclusion test.
  • T.M. v. Univ. of Md. Med. Sys. Corp., 139 F.4th 344 (4th Cir. 2025) – prior case involving Doe’s challenge to the state-court Consent Order, dismissed under the Rooker–Feldman doctrine (federal courts may not sit in direct appellate review of state judgments).
  • Short v. Hartman, 87 F.4th 593 (4th Cir. 2023) – argument raised first in reply brief (Doe’s attempted retaliation theory) is forfeited.
• Substantive discrimination theories:
  • Lesley and McGugan – shaped the court’s analysis of medical decisions as either benign or impermissibly biased disability-based discrimination.
  • Olmstead – established the unjustified-isolation doctrine, under which Doe’s second theory was evaluated and rejected.

F. Impact and Practical Implications

1. For Maryland Advance Directives and Mental-Health Practice

This opinion provides a clear, detailed federal-court prediction of how Maryland’s highest court would interpret the witness-disqualification rule for agents under the Health Care Decisions Act:

• Any appointed health care agent—primary or alternate—cannot serve as a witness to the advance directive that appoints them.
• A directive where such an agent signs as a witness fails statutory formation requirements and is void as an advance directive.

Practical consequences:

• Patients and families in Maryland must take care that no person designated as an agent in any capacity signs the directive as a witness.
• Hospital counsel and risk managers can treat such directives as invalid on their face; they need not assume they create enforceable agency rights.
• Providers should, however, still be mindful of process. While the Fourth Circuit has now authoritatively predicted Maryland law on this point, Maryland state courts are not formally bound by this federal construction; cautious practitioners may still prefer to seek declaratory clarity when time permits.

2. For Disability-Discrimination Claims Challenging Psychiatric Commitments

The opinion constrains how patients may frame ADA/RA/ACA challenges to involuntary psychiatric hospitalization:

• Invalid documents cannot ground discrimination claims: If the claimed “benefit” is participation in a statutory directive regime, plaintiffs must allege compliance with all essential eligibility criteria (including execution formalities). Denial of benefits not legally available is not actionable discrimination.
• Medical judgments vs. discrimination:
  • Medical decisions about a disability, even when contested or arguably erroneous, do not become ADA/RA violations merely because the patient disagrees or because the decisions are adverse.
  • To allege discrimination, plaintiffs must plead that the treatment decision was driven by stereotypes, animus, or reliance on a disability that is irrelevant to the decision, or that the stated clinical reasons are pretext for disability-based bias.
• Unjustified isolation claims require professional determinations:
  • Under Olmstead, unjustified institutionalization claims require allegations that the state’s own professionals determined that less restrictive placement was appropriate.
  • Opinions of outside physicians, without more, are insufficient to impute such a determination to state actors.
  • Consent orders that eventually result in release do not retroactively show that the state concluded confinement was unjustified earlier in time.

3. For Litigation Strategy in Medical and Psychiatric Contexts

For plaintiffs:

• Disability-discrimination claims cannot be used as a general vehicle to re-litigate alleged medical malpractice, clinical misjudgments, or procedural errors in commitment proceedings.
• To survive a motion to dismiss, pleadings must:
  • establish that the plaintiff met objective program criteria (e.g., valid directive), and
  • plausibly connect the challenged decision to disability-based stereotypes, animus, or differential treatment compared to similarly situated non-disabled persons.
• When invoking Olmstead, it is essential to allege that treating professionals themselves determined that community placement is appropriate, not merely that other doctors later disagreed or that the plaintiff believes less restrictive care would have been sufficient.

For defendants:

• Hospitals can point to objective statutory defects (like invalid directives) and to individualized clinical reasoning as powerful shields against ADA/RA/ACA liability.
• Careful documentation of decision-making rationales (including concerns about medication adherence, safety, and prior history) helps show individualized, non-stereotypical treatment decisions.

IV. Complex Concepts Simplified

1. “Otherwise Qualified”

In disability-rights statutes, a person is “otherwise qualified” if they meet the essential eligibility requirements for a program or service, with or without reasonable modifications. You cannot claim disability-based exclusion from a benefit if you never met the baseline prerequisites.

Here, the essential prerequisite to participating in Maryland’s advance directive regime is a properly executed directive (including valid witnesses). Because Doe’s directive failed that requirement, she was not “otherwise qualified” for that specific benefit, and the hospital’s refusal to honor it could not be discriminatory within the meaning of the statutes.

2. Issue Preclusion (Collateral Estoppel)

Issue preclusion prevents relitigation of factual or legal issues that were actually decided and necessary to the judgment in a prior case involving the same parties. It requires:

• The identical issue was decided previously,
• That decision was final and on the merits,
• The party against whom preclusion is asserted had a full opportunity to litigate it.

Because the Maryland court explicitly refused to decide whether Doe’s directive was invalid under the witness rule, there was no prior decision on that specific issue, hence no preclusion.

3. Contract/Directive Formation vs. Severability

Formation concerns whether a contract or directive ever came into legal existence at all, based on required formalities like signatures, witnesses, and consideration. If formation fails, the instrument is void, and no portion of it can be selectively enforced.

Severability applies when a validly formed instrument contains one or more provisions that are unenforceable, but the rest of the instrument is intact. In such a case, the court may “sever” the bad clause and enforce the rest.

In Doe’s case, improper witnessing was a formation defect: the directive never legally came into being under Maryland law. Thus, there was no directive from which to sever the mother’s role or preserve the father’s appointment.

4. Benign vs. Pejorative Discrimination in Medical Decisions

Medical professionals must treat disabilities, which inherently involves making decisions because a patient is disabled (e.g., prescribing medications for schizophrenia, committing someone during acute psychosis). This is “benign” discrimination—differential treatment justified by medical necessity.

“Pejorative” discrimination occurs when a provider:

• Relies on stereotypes (e.g., “all people with X disability are dangerous”), or
• Bases a decision on a disability that is irrelevant to the decision, or
• Uses disability as a pretext for another motive, such as dislike of disabled persons.

Only pejorative discrimination fits what the ADA and Rehabilitation Act prohibit. Courts are cautious not to turn every disputed medical judgment into a federal discrimination claim.

5. Olmstead “Unjustified Isolation”

Under Olmstead, a person with a disability may claim that unnecessary institutionalization is discriminatory when:

1. The state’s own treatment professionals conclude the person can be treated in a less restrictive setting (like community-based care),
2. The person does not oppose that setting, and
3. The state could reasonably accommodate such placement.

If those preconditions are absent—especially the treating professionals’ determination—a claim of unjustified isolation typically fails. Outside opinions or later settlements do not suffice absent allegations that the treating professionals themselves earlier found that institutional care was no longer necessary.

V. Conclusion

Jane Doe v. University of Maryland Medical System Corp. offers several important takeaways:

• Maryland Advance Directives – A person appointed as a health care agent, primary or alternate, cannot serve as a witness to the advance directive appointing them. Doing so invalidates the directive’s formation under Maryland law.
• Formation defects are fatal – Failure to satisfy statutory execution requirements means no valid directive ever came into being. Courts cannot salvage such a document via severability.
• “Otherwise qualified” is a threshold gate – To assert disability-discrimination in denial of a program’s benefits (like the advance directive regime), a plaintiff must show they met the program’s essential prerequisites.
• Medical judgment vs. discrimination – Disability-discrimination statutes do not convert contested psychiatric or medical decisions into federal civil-rights claims absent plausible allegations of bias, stereotype, or reliance on a disability irrelevant to the decision.
• Olmstead claims are demanding – Unjustified isolation claims require that the state’s own professionals determined that community-based care is appropriate; outside experts’ opinions and later consent orders are not enough by themselves.

Although unpublished, the opinion is a significant data point in the jurisprudence at the intersection of state advance directive law and federal disability discrimination, clarifying both the formal requirements for valid mental-health directives in Maryland and the limits of ADA/ACA/Rehabilitation Act claims in challenging psychiatric hospitalization and involuntary commitment decisions.