Court Sets Strict Criteria For Medicating Defendants

In a June 16 ruling, the U.S. Supreme Court limited the right of prosecutors to force mentally ill defendants charged with nonviolent crimes to take psychoactive medications. The Court stressed that such a decision must be in the defendant's best medical interest and that if such drugs are to be administered involuntarily, they must be "substantially unlikely" to cause serious side effects.

The ruling contrasts with previous decisions by the high court that granted prison officials and government prosecutors considerably more authority in ordering involuntary medication for, respectively, dangerous mentally ill inmates and defendants in criminal trials.

The majority opinion in the Court's 6-3 ruling, which was penned by Justice Stephen Breyer, emphasizes that depriving mentally ill criminal defendants of their personal liberty and autonomy by forcibly medicating them is permissible only "in limited circumstances" and only when it "will significantly further" a crucial government objective, such as punishing an accused law violator.

The case at issue, Sell v. U.S., #02-5664, involves a dentist, Charles Sell, D.D.S., who is accused of Medicaid, insurance, and mail fraud centering around the alleged submission of multiple false claims.

APA Backs Government

An amicus brief filed by APA in support of the government's position backed several of the standards the Court laid down in this decision, but APA urged it to rule in favor of making it easier for prosecutors to order involuntary medication for a defendant showing symptoms of severe mental illness than it ultimately did.

After Sell was arrested on the fraud charges, he was released on bond. The bond was revoked when the prosecutors accused him of violating the terms of the release by trying to kill an individual who formerly worked in his office and was planning to testify against him. He was then charged with that crime and with threatening the FBI agent who arrested him on the fraud charges.

Sell appeared floridly psychotic at the time of his rearrest and has been in a federal prison hospital for the last four years as a result of paranoid and other psychotic symptoms. The diagnosis resulting from his courtordered psychiatric exam indicates that he has "delusional disorder, persecutory type" and was thus incompetent to stand trial.

Neither his lawyers nor government prosecutors have disputed the fact that he is seriously mentally ill and thus unable to understand trial proceedings and participate in his defense.

Appeals Court Reversed

In March 2002, the U.S. Court of Appeals for the 8th Circuit upheld a ruling by a federal district court in Missouri that said the government had the right to medicate Sell against his will. The lower courts agreed that despite Sell's objection, medication was the only tool that would eventually allow it to fulfill its interest in adjudicating his guilt or innocence. Sell did not want to be made competent to stand trial and appealed that ruling to the high court.

The Supreme Court's June ruling sends the decision about whether Sell can be forcibly medicated back to the trial court, which must now review its decision in light of the much stricter standards.

The crux of the Supreme Court's decision was that the lower courts based their rulings solely on the government's right to medicate Sell involuntarily to make him competent to stand trial, since those courts had rejected dangerousness as grounds to justify medicating him. The lower courts, however, should have considered several other issues that must also be part of a decision on involuntarily medicating a mentally ill defendant, the Court ruled.

Last month's opinion described the considerations that courts must weigh, pointing out that it had already explicated them in its previous rulings in Riggins v. Nevada, which concerned a defendant's right to refuse medication, and Washington v. Harper, which involved involuntary medication of a prison inmate.

Lengthy Confinement Option

First, the government must show that its interest in bringing an accused to trial serves an "important government interest," the Court said, and this requires a review of "special circumstances" that may lessen the urgency of the government's interest. For example, "A defendant's refusal to take drugs may mean lengthy confinement in an institution, which would diminish the risks of freeing without punishment one who has committed a serious crime." The justices pointed out that the possibility of extended confinement is not intended "to suggest that civil commitment is a substitute for a criminal trial."

Paul Appelbaum, M.D., immediate past president of APA and director of the Law and Psychiatry Program at the University of Massachusetts Medical School, took issue with this part of the decision. "The opinion seems to suggest that keeping an incompetent defendant confined and untreated for a substantial period of time might be a reasonable alternative to involuntary treatment-neglecting the severe suffering of a person with psychosis," he told Psychiatric News.

Second, the Court ruled that the trial court "must conclude that forced medication will significantly further" the state's interest. The justices explained that this means a finding that "medication is substantially likely to render the defendant competent to stand trial and substantially unlikely to have side effects that will interfere significantly with the defendant's ability to assist counsel in conducting a defense."

APA's amicus curiae brief emphasizes, however, that the current generation of antipsychotic medications has far fewer troubling side effects than those available when the Court ruled in Riggins and Harper. Appelbaum also disagreed with the Court's interpretation of the side-effect issue. The decision indicates the belief "that it would be possible to predict in advance whether medication side effects will interfere with a particular defendant's trial competence, when that is almost always a judgment that will have to be made after the fact," he pointed out.

APA stresses that while the state should have to justify using a medication with potential side effects, it is by no means urging the Court to rule that such potential side effects should "defeat a State interest in restoring competence or that they even weigh heavily, given that side effects are broadly subject to being monitored and controlled. . . ."

In addition, the ruling said, a court must conclude that not only is forcibly medicating a defendant necessary to achieve the government's substantial interest, it must also find that "less-intrusive treatments are unlikely to achieve substantially the same result."

And finally, as the Court found in the two previous, related cases, the medications at issue must be a "medically appropriate" treatment for the mentally ill defendant.

The chair of the APA Committee on Judicial Action, Renie Binder, M.D., told Psychiatric News that psychiatrists should generally be "pleased" with the Court's decision since it in large part adopted the standards APA urged for assessing whether involuntary medication is appropriate for a mentally ill defendant.

Appelbaum agreed that psychiatrists "should be largely pleased with the decision," but added, "I think Justice Breyer gave inadequate attention to the consequences of untreated psychosis and defendants' interests in getting medically appropriate care."▪