Title: Winnebago County v. Christopher S.

State: wisconsin

Issuer: Wisconsin Supreme Court

Document:

2016 WI 1 
 
SUPREME COURT OF WISCONSIN 
 
 
 
 
 
CASE NO.: 
2014AP1048 
COMPLETE TITLE: 
In the matter of the mental commitment of 
Christopher S.: 
 
Winnebago County, 
          Petitioner-Respondent, 
     v. 
Christopher S., 
          Respondent-Appellant. 
 
 
 
 
ON CERTIFICATION FROM THE COURT OF APPEALS 
(No Cites) 
 
 
OPINION FILED: 
January 5, 2016 
SUBMITTED ON BRIEFS: 
        
ORAL ARGUMENT: 
September 18, 2015 
 
 
SOURCE OF APPEAL: 
 
 
COURT: 
Circuit 
 
COUNTY: 
Winnebago 
 
JUDGE: 
Scott C. Woldt 
 
 
 
JUSTICES: 
 
 
CONCURRED: 
      
 
CONCUR & DISSENT: 
ABRAHAMSON, A.W.BRADLEY, J.J., concur and 
dissent. (Opinion Filed) 
 
NOT PARTICIPATING: R.G. BRADLEY, did not participate.    
 
 
 
ATTORNEYS: 
 
For the respondent-appellant, there were briefs by Kaitlin 
A. Lamb, assistant state public defender and oral argument by 
Kaitlin A. Lamb. 
 
For the petitioner-respondent, there was a brief by James 
A. Kearney, assistant corporation counsel, and oral argument by 
James A. Kearney. 
 
An amicus curiae brief was filed by Maura F.J. Whelan, 
assistant attorney general, and Brad D. Schimel, attorney 
general, on behalf of the Wisconsin Department of Justice. 
 
 
 
2 
 
 
 
 
 
 
 
2016 WI 1
NOTICE 
This opinion is subject to further 
editing and modification.  The final 
version will appear in the bound 
volume of the official reports.   
No.  2014AP1048 
(L.C. No. 
2012ME5572) 
STATE OF WISCONSIN  
 
 
   : 
IN SUPREME COURT 
 
 
In the matter of the mental commitment of 
Christopher S.: 
 
 
 
Winnebago County, 
 
          Petitioner-Respondent, 
 
     v. 
 
Christopher S., 
 
          Respondent-Appellant. 
 
 
 
FILED 
 
JAN 5, 2016 
 
Diane M. Fremgen 
Clerk of Supreme Court 
 
 
 
 
APPEAL from orders issued by the Circuit Court for 
Winnebago County, Scott C. Woldt, Judge.  Affirmed. 
 
¶1 
MICHAEL J. GABLEMAN, J.   This is a review of a 
circuit court's1 order for the involuntary commitment of an 
inmate to a mental health facility, order for the involuntary 
                                                 
1 The Honorable Scott C. Woldt, Winnebago County Circuit 
Court, presided. 
No. 
2014AP1048   
 
2 
 
administration of psychotropic medication and treatment to that 
inmate, and order denying postcommitment relief. The involuntary 
commitment of an inmate of the Wisconsin state prison system for 
mental 
health 
care 
is 
governed 
by 
Wis. 
Stat. 
§ 51.20(1)(ar)(2013-14).2 
The 
involuntary 
administration 
of 
                                                 
2 All subsequent references to the Wisconsin Statutes are to 
the 2013-14 version unless otherwise indicated. 
For clarity and consistency, we will refer to Wis. Stat. 
§ 51.20(1)(ar) as either Wis. Stat. § 51.20(1)(ar) or the inmate 
commitment statute. It contains the following: 
(ar) If the individual is an inmate of a state 
prison, the petition may allege that the inmate is 
mentally ill, is a proper subject for treatment and is 
in need of treatment. The petition shall allege that 
appropriate less restrictive forms of treatment have 
been attempted with the individual and have been 
unsuccessful and it shall include a description of the 
less 
restrictive 
forms 
of 
treatment 
that 
were 
attempted. The petition shall also allege that the 
individual has been fully informed about his or her 
treatment needs, the mental health services available 
to him or her under this chapter and that the 
individual has had an opportunity to discuss his or 
her needs, the services available to him or her and 
his or her rights with a licensed physician or a 
licensed psychologist. The petition shall include the 
inmate's sentence and his or her expected date of 
release as determined under s. 302.11 or 302.113, 
whichever is applicable. The petition shall have 
attached to it a signed statement by a licensed 
physician or a licensed psychologist of a state prison 
and a signed statement by a licensed physician or a 
licensed psychologist of a state treatment facility 
attesting to either of the following: 
1. That the inmate needs inpatient treatment at a 
state treatment facility because appropriate treatment 
is not available in the prison. 
(continued) 
No. 
2014AP1048   
 
3 
 
medication or treatment3 to an individual is governed by Wis. 
Stat. § 51.61(1)(g).4 While Christopher S. ("Christopher") was 
                                                                                                                                                             
2. That the inmate's treatment needs can be met 
on an outpatient basis in the prison. 
3 Stedman's Medical Dictionary defines medication as "[t]he 
act of medicating," or "[a] medicinal substance, or medicament." 
Stedman's Medical Dictionary 1077 (27th ed. 2000). 
It defines psychotropic as "[c]apable of affecting the 
mind, emotions, and behavior; denoting drugs used in the 
treatment of mental illnesses." Id. at 1480. 
And 
it 
defines 
treatment 
as 
"[m]edical 
or 
surgical 
management of a patient." Id. at 1866. The definition refers to 
"therapy, therapeutics." Therapy means "[t]he treatment of 
disease or disorder by any method," or "[i]n psychiatry, and 
clinical psychology, a short term for psychotherapy." Id. at 
1821. Finally, psychotherapy means "[t]reatment of emotional, 
behavioral 
personality, 
and 
psychiatric 
disorders 
based 
primarily 
upon 
verbal 
or 
nonverbal 
communication 
and 
interventions with the patient, in contrast to treatments 
utilizing chemical and physical measures." Id. at 1479. 
4  For clarity and consistency, we will refer to Wis. Stat. 
§ 51.61(1)(g) 
as 
either 
Wis. 
Stat. 
§ 51.61(1)(g) 
or 
the 
involuntary medication and treatment statute. It reads as 
follows: 
Except as provided in sub. (2), each patient 
shall: 
 . . . . 
(g) 
Have 
the 
following 
rights, 
under 
the 
following 
procedures, 
to 
refuse 
medication 
and 
treatment: 
1. Have the right to refuse all medication and 
treatment except as ordered by the court under subd. 
2., or in a situation in which the medication or 
treatment is necessary to prevent serious physical 
harm to the patient or others. . . . 
 . . . . 
(continued) 
No. 
2014AP1048   
 
4 
 
serving his sentence for mayhem, Winnebago County filed a 
petition for the examination of a state prison inmate pursuant 
to Wis. Stat. § 51.20(1)(ar). The County sought commitment in 
the Wisconsin Resource Center ("WRC")5 because Christopher was 
suffering from mental illness and because the WRC could meet 
Christopher's treatment needs. In addition, the County filed a 
                                                                                                                                                             
4. For purposes of a determination under subd. 2. 
or 3., an individual is not competent to refuse 
medication or treatment if, because of mental illness, 
developmental 
disability, 
alcoholism 
or 
drug 
dependence, and after the advantages and disadvantages 
of and alternatives to accepting the particular 
medication or treatment have been explained to the 
individual, one of the following is true: 
a. The individual is incapable of expressing an 
understanding of the advantages and disadvantages of 
accepting 
medication 
or 
treatment 
and 
the 
alternatives. 
b. The individual is substantially incapable of 
applying 
an 
understanding 
of 
the 
advantages, 
disadvantages and alternatives to his or her mental 
illness, developmental disability, alcoholism or drug 
dependence in order to make an informed choice as to 
whether to accept or refuse medication or treatment. 
5 "The Wisconsin Resource Center (WRC) is administered by 
the Wisconsin Department of Health Services in partnership with 
the Wisconsin Department of Corrections. [The] WRC is a 
specialized mental health facility established as a prison under 
s. 46.056, Wisconsin Statutes." Wis. Dep't of Health Servs., 
https://www.dhs.wisconsin.gov/wrc/index.htm (last visited Nov. 
6, 2015); see also Wis. Stat. § 46.056(1) ("[T]he department 
shall have responsibility for administering the [WRC] as a 
correctional 
institution 
that 
provides 
psychological 
evaluations, 
specialized 
learning 
programs, 
training 
and 
supervision for inmates whose behavior presents a serious 
problem to themselves or others in the state prisons and whose 
mental health needs can be met at the center."). 
No. 
2014AP1048   
 
5 
 
petition for the involuntary administration of psychotropic 
medication 
and 
treatment 
pursuant 
to 
Wis. 
Stat. 
§ 51.61(1)(g)4.b. 
¶2 
The circuit court granted the County's petition for 
the involuntary commitment of Christopher for mental health care 
as 
well 
as 
the 
County's 
petition 
for 
the 
involuntary 
administration of psychotropic medication and treatment to 
Christopher. 
Christopher 
filed 
a 
postcommitment 
motion 
challenging both orders. The circuit court denied the motion, 
and Christopher appealed. The court of appeals certified the 
case to this court pursuant to Wis. Stat. § 809.61. We accepted 
certification on May 11, 2015. 
¶3 
Christopher makes three arguments on appeal. First, he 
argues that Wis. Stat. § 51.20(1)(ar) violates his substantive 
due process rights and is, therefore, facially unconstitutional. 
More 
specifically, 
Christopher 
claims 
that 
Wis. 
Stat. 
§ 51.20(1)(ar) is unconstitutional because it authorizes the 
involuntary commitment of an inmate without first finding the 
inmate dangerous. 
¶4 
Second, Christopher argues in the alternative that if 
we refuse to hear his constitutional challenge, we should 
consider whether his trial attorney performed ineffectively by 
failing to challenge the constitutionality of Wis. Stat. 
§ 51.20(1)(ar). Christopher makes clear that he raises his 
ineffective assistance of counsel argument only if we refuse to 
hear his constitutional challenge. Because we address the merits 
No. 
2014AP1048   
 
6 
 
of Christopher's constitutional claim,6 we will not address his 
claim of ineffective assistance of counsel. 
¶5 
Third, Christopher contends that the circuit court 
erred when it concluded that Christopher was incompetent to 
refuse psychotropic medication and treatment pursuant to Wis. 
Stat. § 51.61(1)(g). Christopher relies on our decision in 
Outagamie County v. Melanie L., 2013 WI 67, 349 Wis. 2d 148, 833 
N.W.2d 607, to challenge the way the circuit court applied the 
evidence presented at the involuntary medication and treatment 
hearing 
to 
the 
requirements 
contained 
in 
Wis. 
Stat. 
§ 51.61(1)(g). More specifically, Christopher argues that the 
evidence presented at the involuntary medication and treatment 
hearing did not support a finding that the County complied with 
the 
statutory 
requirements 
contained 
in 
Wis. 
Stat. 
§ 51.61(1)(g)4.b. 
¶6 
We pause briefly to point out what Christopher does 
not argue. Christopher does not make an as applied challenge 
against 
Wis. 
Stat. 
§ 51.20(1)(ar), 
the 
inmate 
commitment 
                                                 
6 Christopher did not raise his facial challenge prior to 
making 
his 
postcommitment 
motion. 
Nonetheless, 
review 
is 
appropriate because "a facial challenge is a matter of subject 
matter jurisdiction and cannot be waived." State v. Bush, 2005 
WI 103, ¶¶17, 14-19, 283 Wis. 2d 90, 699 N.W.2d 80 (citing State 
v. Cole, 2003 WI 112, ¶46, 464 Wis. 2d 520, 665 N.W.2d 328). 
No. 
2014AP1048   
 
7 
 
statute.7 Additionally, Christopher does not in any way challenge 
the constitutionality of the involuntary medication or treatment 
statute, Wis. Stat. § 51.61(1)(g). 
¶7 
We 
proceed 
to 
consider 
two 
issues 
raised 
by 
Christopher. The first is whether Wis. Stat. § 51.20(1)(ar) 
violates an inmate's substantive due process rights and is, 
therefore, facially unconstitutional. The second is whether the 
circuit court erred when it found that Winnebago County 
established by clear and convincing evidence that Christopher 
was incompetent to refuse psychotropic medication and treatment. 
¶8 
As to the first issue, we hold that Wis. Stat. 
§ 51.20(1)(ar) 
is 
facially 
constitutional 
because 
it 
is 
reasonably related to the State's legitimate interest in 
providing care and assistance to inmates suffering from mental 
illness. As to the second issue, we affirm the circuit court 
because it did not err when it found by clear and convincing 
evidence that Christopher was incompetent to refuse psychotropic 
medication and treatment. 
 
                                                 
7 Christopher has filed a motion to strike a portion of 
Winnebago County's response brief that argues, "Wis. Stat. 
§ 51.20(1)(ar) is not unconstitutional as applied to Christopher 
S." Christopher did not raise an as applied challenge in the 
court of appeals, nor did he raise an as applied challenge 
before this court. At oral argument, both parties agreed that 
the motion to strike should be granted. We grant the motion to 
strike and, therefore, will not consider an as applied challenge 
against Wis. Stat. § 51.20(1)(ar). 
No. 
2014AP1048   
 
8 
 
I. FACTUAL BACKGROUND AND PROCEDURAL HISTORY 
 
¶9 
At 
all 
times 
relevant 
to 
these 
proceedings, 
Christopher was an inmate of the Wisconsin state prison system. 
In 2005, Christopher was convicted of mayhem as a repeater, in 
violation of Wis. Stat. § 940.21 (2001-02).8 As a result of his 
conviction, Christopher was sentenced to twenty years of 
confinement, consisting of ten years of incarceration followed 
by ten years of extended supervision. 
¶10 In 2012, Fox Lake Correctional Institution received a 
complaint from Christopher that his cellmate sexually assaulted 
him. 
Subsequent 
to 
his 
complaint, 
Fox 
Lake 
Correctional 
Institution transferred Christopher to the WRC in Winnebago 
County. 
¶11 Dr. Michlowski, medical director for the WRC, spoke 
with Christopher soon after he was admitted. Dr. Michlowski 
outlined his conversation with Christopher in a letter to Mr. 
Bartow, director of the WRC. In the letter, Dr. Michlowski 
wrote, "[Christopher] understood that he was being referred to 
the WRC because he is 'being commissioned' by the 'military 
command to produce castings,' for 'engineering purposes.'" 
Subsequent interactions between Christopher and WRC personnel 
revealed that Christopher believed he was "programmed by 
                                                 
8 The mayhem statute, Wis. Stat. § 940.21 (2001-02) states, 
"Whoever, with intent to disable or disfigure another, cuts or 
mutilates the tongue, eye, ear, nose, lip, limb, or other bodily 
member of another, is guilty of a Class B felony." 
No. 
2014AP1048   
 
9 
 
'Special Operations,'" and he "insisted that there [were] chips 
in 
his 
hands 
and 
shoulder." 
Eventually, 
doctors 
x-rayed 
Christopher's hand in an effort to convince Christopher of his 
need for psychotropic medication.9 The x-ray came back normal, 
but 
Christopher 
disregarded 
it 
because 
"the 
x-ray 
can't 
penetrate Beryllium." 
¶12 In his letter, Dr. Michlowski also informed Mr. Bartow 
of an incident that occurred on September 16, 2012. On that day, 
an officer at the WRC ordered Christopher to eat in the dayroom. 
Christopher refused that order and began to "posture and loudly 
indicate that the officer giving him the order had raped 
[Christopher] while [Christopher] was in the military." Dr. 
Michlowski requested via his letter that "[the County] petition 
the court to find that [Christopher] is suffering from a major 
mental illness (presently psychotic)." In that same letter, Dr. 
Michlowski mentioned that Christopher was seeing Dr. Keshena but 
that Christopher "made it clear to [Dr. Keshena] that he does 
not believe he has any psychotic problems." Finally, Dr. 
Michlowski opined that "[Christopher] is clearly delusional at 
this time and although he did consider taking medication several 
weeks ago, his illness at this time is clearly precluding him 
from acting in his own best interest." 
                                                 
9 Christopher had previously told Dr. Michlowski that "if 
the x-ray turned out to be normal that he would be more inclined 
to accept a trial of medication." 
No. 
2014AP1048   
 
10 
 
¶13 On November 2, 2012, Dr. Maria Murgia de Moore 
conducted a two-hour clinical interview with Christopher. She 
did so at the request of the WRC. Based on this interview, a 
review of the WRC's records, and discussions with WRC staff, Dr. 
Murgia de Moore concluded that Christopher "suffers from a major 
mental illness (Psychotic Disorder, Not Otherwise Specified) 
that is characterized by disorganized speech, disorganized 
thinking, delusions, and poor judgment." Finally, Dr. Murgia de 
Moore recommended that Christopher be committed and further 
recommended that he be treated with appropriate psychotropic 
medications. 
¶14 Later that November, Winnebago County filed a petition 
for the involuntary commitment of Christopher pursuant to Wis. 
Stat. § 51.20(1)(ar) as well as a petition for the involuntary 
administration of psychotropic medication and treatment to 
Christopher pursuant to Wis. Stat. § 51.61(1)(g)4.b. Following a 
probable cause hearing, the court ordered Drs. J.R. Musunuru and 
Yogesh Pareek to examine Christopher for the purpose of 
determining his mental condition. 
¶15 Dr. Musunuru conducted a one-hour interview with 
Christopher and also reviewed his medical records from the WRC. 
In his letter to the court, Dr. Musunuru described Christopher 
as "mildly anxious," "irritable," "distractib[le]," "extremely 
paranoid," "preoccupied with persecution, mistrust, and [the 
idea that] someone is going to hurt him," and "vague about his 
hallucinations." In that same letter, Dr. Musunuru diagnosed 
Christopher with "Schizophrenia Paranoid type," which is "a 
No. 
2014AP1048   
 
11 
 
substantial disorder of thought, mood, perception, which grossly 
impairs judgment, behavior, capacity to recognize reality, or 
the ability to meet the ordinary demands of life." Based on this 
diagnosis, Dr. Musunuru recommended psychotropic medication and 
noted 
that 
"the 
advantages 
and 
disadvantages 
and 
the 
alternatives 
to 
accepting 
particular 
medications 
[were] 
explained to the subject in detail[]." However, Dr. Musunuru 
also found that "the subject holds patently false beliefs about 
the 
treatment 
recommended 
medications, 
which 
prevent 
an 
understanding of the legitimate risk and benefits. They are 
denial of illness and trust in his delusions." As a result, Dr. 
Musunuru concluded that "due to the subject's mental illness, 
the 
subject 
is 
substantially 
incapable 
of 
applying 
an 
understanding of the advantages, disadvantages, and alternatives 
to make an informed choice as to accept or refuse medications." 
¶16 Similarly to Dr. Musunuru, Dr. Pareek conducted a one-
hour interview with Christopher and also reviewed Christopher's 
medical records from the WRC. In a letter to the circuit court, 
Dr. Pareek diagnosed Christopher with "Schizophrenia chronic 
paranoid type" and noted that "[Christopher] has no insight into 
his mental illness and he does not accept that he needs to be 
treated." Finally, Dr. Pareek recommended that Christopher be 
committed and medicated. 
¶17 On December 21, 2012, a jury trial was held for the 
purpose 
of 
determining 
whether 
Christopher 
should 
be 
No. 
2014AP1048   
 
12 
 
involuntarily 
committed 
under 
Wis. 
Stat. 
§ 51.20(1)(ar).10 
Christopher was present for trial, but he did not testify. 
Winnebago 
County 
called 
two 
witnesses, 
Drs. 
Keshena 
and 
Musunuru. 
¶18 Dr. 
Keshena 
testified 
that 
she 
had 
reviewed 
Christopher's medical records, observed him, and conducted a 
mental-status evaluation on him. Based on this, she diagnosed 
Christopher with "psychosis" and noted that Christopher's 
psychosis "grossly" impairs "his capacity to recognize reality." 
Additionally, Dr. Keshena testified that she believed that 
Christopher was a proper subject for treatment and that his type 
of illness responded well to treatment. She further testified 
that she had attempted less restrictive forms of treatment with 
Christopher, but those forms were unsuccessful.11 Finally, Dr. 
Keshena testified that she had fully informed Christopher about 
his treatment needs, the availability of mental health services, 
his rights, and his ability to discuss this information with 
her. 
¶19 Dr. Musunuru testified that he reviewed Christopher's 
records and conducted an interview with Christopher. Based on 
                                                 
10 The sole issue for the jury was whether the County proved 
the requirements outlined in Wis. Stat. § 51.20(1)(ar). 
11 The petition stated, "appropriate less restrictive forms 
of treatment were attempted with the subject inmate and were 
unsuccessful, including: voluntary treatment with psychotropic 
med[ication]s and voluntary transfer to special unit within the 
institution for spec[ial] care of mental illness." 
No. 
2014AP1048   
 
13 
 
this, he concluded that Christopher "suffers from a major mental 
illness" called "schizophrenia paranoid type." Dr. Musunuru 
further 
testified 
that 
Christopher's 
illness 
substantially 
impairs his "judgment, behavior, capacity to recognize reality, 
and also, [his] ability to meet [the] ordinary demands of life." 
Like Dr. Keshena, Dr. Musunuru testified that Christopher was a 
proper subject for treatment. 
¶20 While the jury was deliberating, the circuit court 
conducted a bench trial for the purpose of determining whether 
to 
grant 
the 
County's 
petition 
for 
the 
involuntary 
administration of psychotropic medication and treatment pursuant 
to Wis. Stat. § 51.61(1)(g)4.b.12 The County called Dr. Keshena 
as a witness. Dr. Keshena testified that she had an opportunity 
to explain to Christopher the advantages, disadvantages, and 
alternatives 
to 
medication. 
Further, 
she 
testified 
that 
Christopher 
was 
substantially 
incapable 
of 
applying 
an 
understanding of the advantages, disadvantages, and alternatives 
to his mental illness in order to make an informed choice as to 
whether to refuse psychotropic medications. Finally, on cross-
examination, she explained that Christopher was previously on 
lithium and that Christopher told her he did not have side 
                                                 
12 Unlike the inmate commitment statute, the involuntary 
medication or treatment statute does not contain a right to a 
jury trial. 
Wisconsin Stat. § 51.61(1)(g)3., outlines the 
involuntary medication or treatment hearing requirements: "The 
hearing under this subdivision shall meet the requirements of 
s. 51.20(5), except for the right to a jury trial." (Emphasis 
added.) 
No. 
2014AP1048   
 
14 
 
effects from the lithium but that he also believed it was a 
placebo. 
¶21 That same day, the jury reached a verdict. The jury 
made five findings: (1) Christopher was mentally ill, (2) 
Christopher was a proper subject for treatment and in need of 
treatment, (3) Christopher was an inmate of the Wisconsin state 
prison system, (4) appropriate less restrictive forms of 
treatment were attempted with Christopher but were unsuccessful, 
and (5) Christopher was fully informed of his treatment needs, 
the mental health services available to him, his rights, and 
Christopher had an opportunity to discuss his needs, the 
services available, and his rights with a licensed physician.13 
In accordance with the jury's findings, the circuit court 
granted the County's petition for involuntary commitment for six 
months.14 The court ordered Christopher committed to the WRC. 
                                                 
13 The jury's findings tracked the requirements outlined in 
Wis. Stat. § 51.20(1)(ar). 
14 The court's role at the end of the jury trial includes 
the following: 
[A]t the conclusion of the proceedings, the court 
shall . . . [i]f the individual is an inmate of a 
state prison and the allegations under sub. (1)(a) or 
(ar) are proven, order commitment to the department 
and either authorize the transfer of the inmate to a 
state treatment facility or if inpatient care is not 
needed authorize treatment on an outpatient basis in 
the prison . . . . 
Wisconsin Stat. § 51.20(13)(a)(4) (emphasis added). 
No. 
2014AP1048   
 
15 
 
¶22 The court also granted the County's petition for the 
involuntary 
administration 
of 
psychotropic 
medication 
and 
treatment, concluding that "[Christopher] does not have an 
understanding of the advantages and disadvantages of the 
medication." The court added, "I find that the medication has a 
therapeutic 
value 
and 
would 
not 
hinder 
his 
ability 
to 
participate in future legal proceedings, and therefore, issue a 
medication order." According to the court's written order, 
Christopher was incompetent to refuse psychotropic medication 
and treatment because he "is substantially incapable of applying 
an 
understanding 
of 
the 
advantages, 
disadvantages, 
and 
alternatives to [his] condition in order to make an informed 
choice 
as 
to 
whether 
to 
accept 
or 
refuse 
psychotropic 
medications." Both the commitment order and the medication order 
were subsequently extended after the original orders expired. 
¶23 Christopher's attorney filed a postcommitment motion 
challenging the court's order for the involuntary commitment of 
Christopher and order for the involuntary administration of 
psychotropic medication and treatment to Christopher. The 
circuit court denied postcommitment relief; it concluded that 
Christopher's motion was moot because he appealed only the 
original commitment and medication orders, which had already 
expired. The circuit court did not address the merits of 
Christopher's argument that Wis. Stat. § 51.20(1)(ar) violated 
the constitution. Christopher appealed, and the court of appeals 
certified the case to this court. We accepted certification. 
 
No. 
2014AP1048   
 
16 
 
II. DISCUSSION 
 
¶24 We first discuss whether Wis. Stat. § 51.20(1)(ar) 
violates an inmate's substantive due process rights and is, 
therefore, facially unconstitutional. We hold that Wis. Stat. 
§ 51.20(1)(ar) 
is 
facially 
constitutional 
because 
it 
is 
reasonably related to the State's legitimate interest in 
providing care and assistance to inmates suffering from mental 
illness. We then consider whether the circuit court erred when 
it found that Winnebago County established by clear and 
convincing evidence that Christopher was incompetent to refuse 
psychotropic medication. We hold that the circuit court did not 
err 
because 
the 
medical 
expert's 
undisputed 
testimony 
sufficiently addressed and met the requirements outlined in Wis. 
Stat. § 51.61(1)(g)4.b. 
 
A. THE RELEVANT STATUTES 
 
¶25 Because it is important to understand the commitment 
and treatment process, we take a moment to outline the way the 
relevant statutes work. 
¶26 A county may petition for the involuntary commitment 
of an individual under Wis. Stat. § 51.20(1). Wisconsin Stat. 
§ 51.20 is titled "involuntary commitment for treatment." It 
governs how and when the State may seek the involuntary 
commitment of a person, except when that person is an inmate of 
the Wisconsin state prison system. Wisconsin Stat. § 51.20(1) 
No. 
2014AP1048   
 
17 
 
carves out a special subsection, subsection (1)(ar), which 
governs the involuntary commitment of inmates of the Wisconsin 
state prison system. To commit someone under Wis. Stat. 
§ 51.20(1), a court must conclude that the person is (1) 
mentally ill, developmentally disabled, or drug dependent; (2) a 
proper subject for treatment; and (3) dangerous.15 
¶27 In contrast, to commit an inmate under Wis. Stat. 
§ 51.20(1)(ar), a county must show that (1) the individual is an 
inmate of the Wisconsin state prison system; (2) the inmate is 
mentally ill; (3) the inmate is a proper subject for treatment 
and is in need of treatment; (4) appropriate less restrictive 
forms of treatment were attempted with the inmate, and they were 
unsuccessful; (5) the inmate was fully informed about his 
treatment needs, the mental health services available, and his 
rights; and (6) the inmate had an opportunity to discuss his 
treatment needs, the services available, and his rights with a 
                                                 
15 Wisconsin 
Stat. 
§ 51.20(1) 
contains 
the 
following 
requirements: 
(1) Petition for examination. (a) Except as provided 
in pars. (ab), (am), and (ar), every written petition 
for examination shall allege that all of the following 
apply to the subject individual to be examined: 
1. The individual is mentally ill or, except as 
provided 
under 
subd. 
2. 
e., 
drug 
dependent 
or 
developmentally disabled and is a proper subject for 
treatment. 
2. The individual is[, because he or she does any 
of the following,] dangerous . . . . 
No. 
2014AP1048   
 
18 
 
psychologist 
or 
a 
licensed 
physician.16 
Both 
Wis. 
Stat. 
§ 51.20(1) and Wis. Stat. § 51.20(1)(ar) are treatment focused; 
these statutes emphasize that a person is being committed 
because he or she has a mental illness and needs treatment to 
help that illness. 
¶28 However, Wis. Stat. § 51.61, titled "patient rights," 
states that an individual has "the right to refuse all 
medication and treatment." Wis. Stat. § 51.61(1)(g)(1). If an 
individual invokes his or her right, then the County can 
petition for the involuntary administration of medication or 
treatment to an individual pursuant to Wis. Stat. § 51.61(1)(g). 
Wisconsin Stat. § 51.61(1)(g) does not carve out a special 
subsection 
for 
inmates, 
so 
the 
requirements 
to 
prove 
incompetency to refuse medication and treatment are the same for 
everyone (inmates and non-inmates alike). To prove incompetency, 
the 
County 
must 
show 
that 
"because 
of 
mental 
illness, 
developmental disability, alcoholism or drug dependence, and 
after the advantages and disadvantages of and alternatives to 
accepting 
the 
particular 
medication 
or 
treatment 
[were] 
explained 
to 
the 
individual," 
the 
individual 
is 
either 
(1) "incapable of expressing an understanding of the advantages 
and disadvantages of accepting medication or treatment and the 
                                                 
16 Unlike Wis. Stat. § 51.20(1), which requires a finding of 
dangerousness, Wis. Stat. § 51.20(1)(ar) does not require such a 
finding. According to Christopher, it is this absence of a 
required finding of dangerousness that renders Wis. Stat. 
§ 51.20(1)(ar) facially unconstitutional. 
No. 
2014AP1048   
 
19 
 
alternatives," or (2) "substantially incapable of applying an 
understanding of the advantages, disadvantages and alternatives 
to 
his 
or 
her 
mental 
illness, 
developmental 
disability, 
alcoholism or drug dependence in order to make an informed 
choice as to whether to accept or refuse medication or 
treatment." Wis. Stat. § 51.61(1)(g)4.a., b. 
¶29 To summarize, an inmate can be involuntarily committed 
under Wis. Stat. § 51.20(1)(ar) only when the State satisfies a 
hefty set of requirements. Moreover, an inmate is committed so 
he or she can receive treatment for his or her mental illness. 
But, if the inmate invokes his or her right to refuse treatment, 
then the State will need to petition for the involuntary 
administration of medication or treatment to that inmate. 
 
B. MOOTNESS 
 
1. This Case Is Moot, But We Will Address The Issues Because 
They Are Of Great Public Importance And Are Likely To Evade 
Review. 
¶30 Before 
we 
review 
the 
merits 
of 
Christopher's 
constitutional challenge, we first address whether this case is 
moot. At the postcommitment motion hearing, Winnebago County 
argued that this case was moot because Christopher's original 
commitment order had already expired prior to the filing of his 
motion for postcommitment relief. The circuit court agreed. We 
agree with the circuit court's conclusion that this case is 
moot; however, we take up Christopher's claims because they 
No. 
2014AP1048   
 
20 
 
qualify for review under two of the four exceptions to the 
general rule barring consideration of moot claims. 
¶31 An issue is moot "when a determination is sought upon 
some matter which, when rendered, cannot have any practical 
legal effect upon a then existing controversy." In re Sheila W., 
2013 WI 63, ¶4, 348 Wis. 2d 674, 835 N.W.2d 148 (per curiam). We 
have stated that there is an "apparent lack of a live 
controversy" when an appellant appeals an order to which he or 
she is no longer subjected. In re Mental Commitment of Aaron 
J.J., 2005 WI 162, ¶3, 286 Wis. 2d 376, 706 N.W.2d 659 (per 
curiam) (noting that the case implicated a potential issue of 
mootness because Aaron was no longer subject to a commitment 
order, but dismissing the case as improvidently granted due to 
inadequate development of the legal arguments); see Sheila W., 
348 Wis. 2d 674, ¶4 ("In this case, no determination of this 
court will have any practical legal effect upon an existing 
controversy because the order being appealed has expired."). In 
Christopher's case, the issues are moot because he is no longer 
subject to the orders being appealed. 
¶32 Nevertheless, we may decide an otherwise moot issue if 
it 
(1) is of great public importance; (2) occurs so 
frequently that a definitive decision is necessary to 
guide circuit courts; (3) is likely to arise again and 
a decision of the court would alleviate uncertainty; 
or (4) will likely be repeated, but evades appellate 
review because the appellate review process cannot be 
completed or even undertaken in time to have a 
practical effect on the parties. 
No. 
2014AP1048   
 
21 
 
Melanie L., 349 Wis. 2d 148, ¶80 (citing State v. Morford, 2004 
WI 5, ¶7, 268 Wis. 2d 300, 674 N.W.2d 349). We conclude that the 
issues presented are of great public importance as they would 
affect a large number of persons in the Wisconsin State prison 
system.17 Moreover, we conclude that the issues are likely to 
evade appellate review "in many instances because the order[s] 
appealed from will have expired before an appeal is completed." 
Id. We therefore consider the issues Christopher asks us to 
review. 
 
C. WHETHER WIS. STAT. § 51.20(1)(ar) IS FACIALLY CONSTITUTIONAL. 
 
1. Standard Of Review 
¶33 "The constitutionality of a statute is a question of 
law that we review de novo." State v. Wood, 2010 WI 17, ¶15, 323 
Wis. 2d 321, 780 N.W.2d 63 (citing State v. Hansford, 219 
Wis. 2d 226, 234, 580 N.W.2d 171 (1998)). "Further, we review a 
statute under the presumption that it is constitutional." Id. 
"Every presumption must be indulged to sustain the law if at all 
possible and, wherever doubt exists as to a legislative 
enactment's constitutionality, it must be resolved in favor of 
                                                 
17 For example, in June 2008, Wisconsin housed 22,451 
inmates. Dep't of Corrs. & Dep't of Health Servs., 
An 
Evaluation: 
Inmate 
Mental 
Health 
Care 
26 
(2009), 
legis.wisconsin.gov/lab/reports/09-4Full.pdf. Of those inmates, 
6,957 were suffering from mental illness. Id. That is nearly 
one-third of the inmate population. Id. 
No. 
2014AP1048   
 
22 
 
constitutionality." In re Commitment of Dennis H., 2002 WI 104, 
¶12, 255 Wis. 2d 359, 647 N.W.2d 851 (internal quotation marks 
omitted) (quoting State v. Carpenter, 197 Wis. 2d 252, 263-64, 
541 N.W.2d 105 (1995)). "To overcome that presumption, a party 
challenging a statute's constitutionality bears a heavy burden" 
because "it is insufficient for the party challenging the 
statute to merely establish that the statute's constitutionality 
is doubtful or that the statute is probably unconstitutional"; 
rather, "the party challenging a statute's constitutionality 
must 'prove that the statute is unconstitutional beyond a 
reasonable doubt.'" State v. Smith, 2010 WI 16, ¶8, 323 
Wis. 2d 377, 780 N.W.2d 90 (quoting State v. Cole, 2003 WI 112, 
¶11, 264 Wis. 2d 520, 665 N.W.2d 328). "[I]n the context of a 
challenge to the constitutionality of a statute, the phrase 
'beyond a reasonable doubt' expresses the 'force or conviction 
with which a court must conclude, as a matter of law, that a 
statute 
is 
unconstitutional 
before 
the 
statute 
or 
its 
application can be set aside.'" League of Women Voters of 
Wisconsin Educ. Network, Inc. v. Walker, 2014 WI 97, ¶17, 357 
Wis. 2d 360, 851 N.W.2d 302 (quoting Dane Cnty. Dep't of Human 
Servs. v. Ponn P., 2005 WI 32, ¶16, 279 Wis. 2d 169, 694 
N.W.2d 344). In short, Christopher "bears a heavy burden" 
because he must prove that Wis. Stat. § 51.20(1)(ar) is 
unconstitutional beyond a reasonable doubt. 
 
 
No. 
2014AP1048   
 
23 
 
2. Facial Challenge Requirements 
¶34 A party may challenge a law or government action as 
being unconstitutional by bringing a facial challenge. Wood, 323 
Wis. 2d 321, ¶13. A facial challenge to a statute is an "uphill 
endeavor." Dennis H., 255 Wis. 2d 359 ¶5. Under a facial 
challenge, "the challenger must show that the law cannot be 
enforced 'under any circumstances.'" Wood, 323 Wis. 2d 321, ¶13 
(quoting Olson v. Town of Cottage Grove, 2008 WI 51, ¶44 n.9, 
309 Wis. 2d 365, 749 N.W.2d 211). "If a challenger succeeds in a 
facial attack on a law, the law is void 'from its beginning to 
the end.'" Id. (quoting State ex rel. Comm'rs of Pub. Lands v. 
Anderson, 56 Wis. 2d 666, 672, 203 N.W.2d 84 (1973)). Here, 
Christopher claims that Wis. Stat. § 51.20(1)(ar) is facially 
unconstitutional because it violates an inmate's substantive due 
process rights by allowing for the involuntary commitment of an 
inmate without first finding the inmate dangerous. Christopher 
faces an "uphill battle" because to succeed on his claim he must 
show that Wis. Stat. § 51.20(1)(ar) is unconstitutional under 
all circumstances. 
3. Constitutional Overview Of Substantive Due Process Rights 
¶35 "The Due Process Clauses of the United States and 
Wisconsin Constitutions protect both substantive and procedural 
due process rights." State v. Luedtke, 2015 WI 42, ¶74, 362 
Wis. 2d 1, 863 N.W.2d 592 (internal quotation marks omitted) 
(quoting State ex rel. Greer v. Wiedenhoeft, 2014 WI 19, ¶55, 
353 Wis. 2d 307, 845 N.W.2d 373, reconsideration denied sub 
nom., Greer v. Wiedenhoeft, 2014 WI 50, 354 Wis. 2d 866, 848 
No. 
2014AP1048   
 
24 
 
N.W.2d 861). Specifically, these rights are "rooted in the 
Fourteenth Amendment to the Constitution, and Article I, Section 
1 of the Wisconsin Constitution."18 Wood, 323 Wis. 2d 321, ¶17. 
Substantive due process rights "protect against state action 
that is arbitrary, wrong, or oppressive," id., by "forbid[ding] 
a government from exercising power without any reasonable 
justification in the service of a legitimate governmental 
objective," Luedtke, 362 Wis. 2d 1, ¶74 (internal quotation 
marks omitted) (quoting State v. Radke, 2003 WI 7, ¶12, 259 
Wis. 2d 13, 657 N.W.2d 66). 
4. Rational Basis Review Applies. 
¶36 We begin our analysis, as we must, by determining the 
appropriate 
level 
of 
scrutiny 
to 
apply 
to 
Wis. 
Stat. 
§ 51.20(1)(ar), 
the 
inmate 
commitment 
statute. 
"If 
the 
challenged legislation neither implicates a fundamental right 
nor discriminates against a suspect class, we apply rational 
basis review rather than strict scrutiny to the legislation." In 
re Commitment of Alger, 2015 WI 3, ¶39, 360 Wis. 2d 193, 858 
N.W.2d 346. A law subject to rational basis review will be 
upheld "unless it is patently arbitrary and bears no rational 
relationship to a legitimate government interest." Id. (internal 
                                                 
18 In general, the United States Constitution and the 
Wisconsin Constitution provide substantively similar due process 
guarantees. State v. Wood, 2010 WI 17, ¶17 n.9, 323 Wis. 2d 321, 
780 N.W.2d 63. Compare U.S. Const. Amend. XIV, with Wis. Const. 
Art. I, § 1. "Accordingly, we do not distinguish between those 
constitutional protections in this case." Id. 
No. 
2014AP1048   
 
25 
 
quotation marks omitted) (quoting Smith, 323 Wis. 2d 377, ¶12). 
Moreover, "[a] legislative classification satisfies rational 
basis review if 'any conceivable state of facts . . . could 
provide a rational basis for the classification.'" Alger, 360 
Wis. 2d 193, ¶50 (alteration in original) (emphasis added) 
(quoting State v. Mary F.-R., 2013 WI 92, ¶52, 351 Wis. 2d 273, 
839 N.W.2d 851). In contrast, "[a] law subject to strict 
scrutiny will be upheld 'only if narrowly tailored to serve a 
compelling state interest.'" Id. (quoting Mary F.-R., 351 
Wis. 2d 273, ¶35). Christopher does not argue that Wis. Stat. 
§ 51.20(1)(ar) discriminates against a suspect class; therefore, 
we 
will 
examine 
only 
whether 
Wis. 
Stat. 
§ 51.20(1)(ar) 
implicates a fundamental right.  
¶37 "[F]or the ordinary citizen, commitment to a mental 
hospital produces 'a massive curtailment of liberty,' and in 
consequence 'requires due process protection.'" Vitek v. Jones, 
445 U.S. 480, 491 (1980) (citation omitted) (first quoting 
Humphrey v. Cady, 405 U.S. 504, 509 (1972); then quoting 
Addington v. Texas, 441 U.S. 418, 425 (1979)); Foucha v. 
Louisiana, 504 U.S. 71, 80 (1992) (noting that the due process 
clause contains a substantive component that includes a right to 
freedom from restraint)). This is because "[f]reedom from 
physical restraint is a fundamental right that 'has always been 
at the core of the liberty protected by the Due Process Clause 
No. 
2014AP1048   
 
26 
 
from arbitrary governmental action.'"19 State v. Post, 197 
Wis. 2d 279, 302, 541 N.W.2d 115 (1995) (quoting Foucha, 504 
U.S. at 80). 
¶38 For example, in State v. Post, 197 Wis. 2d 279, 541 
N.W.2d 115 (1995), we applied strict scrutiny to a substantive 
due process challenge to Chapter 980, Wisconsin's sexually 
violent person commitment statute. 197 Wis. 2d at 302. We did so 
because the statute implicated a fundamental right, the right to 
be free from physical restraint. Id. But Post is distinguishable 
from Christopher's case. Chapter 980 allows the State to 
petition for the commitment of a sexually violent person.20 If 
the petition is granted, and all of the necessary procedures are 
met, a sexually violent person can be committed when his or her 
sentence expires. Thus, under Chapter 980, a person is subject 
to commitment following the expiration of his or her criminal 
sentence. In contrast, Wis. Stat. § 51.20(1)(ar) applies only 
while the individual is serving his or her sentence.  
                                                 
19 The due process "liberty" right is called many different 
things: freedom from physical restraint, freedom from bodily 
restraint, freedom from confinement, and the right to be at 
liberty.  
20 For a brief overview of Chapter 980, see In re Commitment 
of Gilbert, 2012 WI 72, ¶¶21, 23, 342 Wis. 2d 82, 816 N.W.2d 215 
("[C]h. 980 provides for the involuntary commitment of certain 
individuals who are found to be sexually violent persons. As 
such, ch. 980 prescribes a detailed procedure that the State 
must follow in order to commit a sexually violent person." 
(citation omitted)). 
No. 
2014AP1048   
 
27 
 
¶39 This 
distinction 
is 
important 
because 
"a 
valid 
criminal 
conviction 
and 
a 
prison 
sentence 
extinguish 
a 
defendant's right to freedom from confinement." Vitek, 445 U.S. 
at 493 (citing Greenholtz v. Nebraska Penal Inmates, 442 U.S. 1, 
7 
(1980) 
("But 
the 
conviction, 
with 
all 
its 
procedural 
safeguards, has extinguished that liberty right: '[G]iven a 
valid 
conviction, 
the 
criminal 
defendant 
has 
been 
constitutionally deprived of his liberty.'" (quoting Meachum v. 
Fano, 427 U.S. 215, 224 (1976) ("But given a valid conviction, 
the criminal defendant has been constitutionally deprived of his 
liberty to the extent that the State may confine him and subject 
him to the rules of its prison system . . . .")))); see also 
Johnson v. California, 543 U.S. 499, 510 (2005) ("This is 
because certain privileges and rights must necessarily be 
limited in the prison context."); In re Commitment of West, 2011 
WI 83, ¶85, 336 Wis. 2d 578, 800 N.W.2d 929 (holding that a 
liberty interest in freedom from confinement is not absolute). 
"Such a conviction and sentence sufficiently extinguish a 
defendant's liberty 'to empower the State to confine him in any 
of its prisons.'"21 Vitek, 445 U.S. at 493 (quoting Meachum, 427 
                                                 
21 Christopher cites a litany of cases to support his 
argument that a state must prove that an inmate is dangerous 
before he or she can be involuntarily committed. All are 
distinguishable. O'Connor v. Donaldson, 422 U.S. 563 (1975), and 
Addington 
v. 
Texas, 
441 
U.S. 
418 
(1979), 
addressed 
the 
involuntary commitment of individuals who were not currently 
serving sentences. The individuals committed in Addington and 
O'Connor were not inmates. Jones v. United States, 463 U.S. 354 
(1983), and Foucha v. Louisiana, 504 U.S. 71 (1992), concerned 
the involuntary commitment of individuals who were acquitted of 
(continued) 
No. 
2014AP1048   
 
28 
 
U.S. at 224). To be clear, we are not suggesting that an inmate 
loses all, or even most, of his or her constitutional rights 
while he or she is serving his or her sentence. Rather, a prison 
inmate "retains those [constitutional] rights that are not 
inconsistent with his status as a prisoner or with the 
legitimate penological objectives of the corrections system." 
Turner v. Safley, 482 U.S. 78, 95 (1987) (alteration in 
original) (internal quotation marks omitted) (quoting Pell v. 
Procunier, 417 U.S. 817, 822 (1974)). 
¶40 For example, in Washington v. Harper, 494 U.S. 210 
(1990), the Supreme Court of the United States addressed the 
constitutionality of administering antipsychotic medications to 
a prisoner against his will. 494 U.S. at 213. There, the Court 
noted that the "respondent possesses a significant liberty 
interest 
in 
avoiding 
the 
unwanted 
administration 
of 
antipsychotic drugs," id. at 221, but went on to clarify that 
"[t]he extent of a prisoner's rights under the Clause to avoid 
the unwanted administration of antipsychotic drugs must be 
defined in the context of the inmate's confinement," id. at 222 
(emphasis added). Thus, while an inmate does not lose all of his 
                                                                                                                                                             
a crime by reason of insanity. Again, the individuals committed 
in Jones and Foucha were not inmates. For that reason, these 
cases arguably require a finding of dangerousness when the State 
seeks to commit an individual who is not an inmate (just as Wis. 
Stat. § 51.20(1) requires a finding of dangerousness when the 
State seeks to commit an individual who is not an inmate). But 
these cases do not stand for the principle that a state must 
prove dangerousness when the State seeks to commit an inmate. 
No. 
2014AP1048   
 
29 
 
or her rights, his or her rights must be viewed in light of his 
or her "status as an inmate" and "the legitimate penological 
objectives of the corrections system." Turner, 482 U.S. at 95.  
¶41 As a result, the Court in Harper concluded that "[t]he 
proper standard for determining the validity of a prison 
regulation claimed to infringe on an inmate's constitutional 
rights is to ask whether the regulation is 'reasonably related 
to a legitimate penological interest.'"22 Id. at 223 (quoting 
Turner, 482 U.S. at 89 ("If [other Supreme Court cases] have not 
already resolved the question posed . . . , we resolve it now: 
when a prison regulation impinges on inmates' constitutional 
rights, the regulation is valid if it is reasonably related to a 
legitimate penological interest.")). "This is true even when the 
constitutional 
right 
claimed 
to 
have 
been 
infringed 
is 
fundamental, and the State under other circumstances would have 
                                                 
22 We realize that Washington v. Harper, 494 U.S. 210 (1990) 
and Turner v. Safley, 482 U.S. 78 (1986) dealt with prison 
regulations and we deal here with a statute. Despite this 
difference, we find both cases persuasive. The Turner Court 
stated, 
Running 
a 
prison 
is 
an 
inordinately 
difficult 
undertaking that requires expertise, planning, and 
commitment of resources, all of which are peculiarly 
within the province of the legislative and executive 
branches of government. Prison administration is, 
moreover, a task that has been committed to the 
responsibility of those branches, and separation of 
powers 
concerns 
counsel 
a 
policy 
of 
judicial 
restraint. 
482 U.S. at 84-85 (emphasis added). 
No. 
2014AP1048   
 
30 
 
been required to satisfy a more rigorous standard of review." 
Id. A reasonableness standard is appropriate because it balances 
the principle that "inmates retain at least some constitutional 
rights despite incarceration with the recognition that prison 
authorities are best equipped to make difficult decisions 
regarding prison administration." Id. at 223-24. 
¶42 Like the Supreme Court, we assess the extent of an 
inmate's rights in the context of the inmate's confinement. We 
recognize that "[c]ivil commitment for any purpose constitutes a 
significant deprivation of liberty that requires due process 
protection." Post, 197 Wis. 2d at 302 (alteration in original) 
(internal quotation marks omitted) (quoting Addington, 441 U.S. 
at 425). However, when we look at an inmate's liberty right in 
the context of his or her confinement, we conclude that his or 
her specific right to freedom from physical restraint is already 
curbed because he or she is incarcerated.23 Indeed, the very 
                                                 
23 We recognize that Christopher has an interest in avoiding 
the "adverse social consequences" associated with mental health 
commitments: "It is indisputable that commitment to a mental 
hospital 'can engender adverse social consequences to the 
individual' and that '[w]hether we label this phenomena 'stigma' 
or choose to call it something else . . . we recognize that it 
can occur and that it can have a very significant impact on the 
individual.'" Vitek, 445 U.S. at 492 (alterations in original) 
(quoting Addington, 441 U.S. at 425-26). 
(continued) 
No. 
2014AP1048   
 
31 
 
nature of incarceration encompasses physical restraint. Because 
inmates have a qualified right to freedom from physical 
restraint and because Wis. Stat. § 51.20(1)(ar) applies only to 
inmates, we hold that rational basis review applies to Wis. 
Stat. § 51.20(1)(ar).24 
5. We Determine That Wis. Stat. § 51.20(1)(ar) Is Facially 
Constitutional Because It Is Reasonably Related To A Legitimate 
State Interest. 
¶43 We turn to the task of determining whether Wis. Stat. 
§ 51.20(1)(ar) is reasonably related to a legitimate state 
interest. 
¶44 The State has more than a well-established and 
legitimate interest; it has a "compelling" interest in providing 
                                                                                                                                                             
In addition, Christopher argues that inmates have an 
interest 
in 
"avoiding 
the 
unwanted 
administration 
of 
antipsychotic drugs" against their will. While this is certainly 
true, it is not relevant to the present case. Again, Christopher 
is challenging only the constitutionality of the involuntary 
commitment statute under Wis. Stat. § 51.20(1)(ar), not the 
involuntary medication statute under Wis. Stat. § 51.61(1)(g). 
Thus, any interest that an inmate, including Christopher, has in 
avoiding unwanted medication is not relevant to the question of 
whether an inmate's involuntary commitment is unconstitutional. 
24 Christopher contends that we should adopt intermediate 
scrutiny because both an involuntary commitment order and an 
involuntary medication order are at issue in this case. However, 
Christopher is challenging only the constitutionality of the 
involuntary commitment statute under Wis. Stat. § 51.20(1)(ar); 
he is not challenging the constitutionality of the involuntary 
medication or treatment statute under Wis. Stat. § 51.61(1)(g). 
As such, this case does not provide an occasion for us to apply 
any level of scrutiny to the involuntary medication or treatment 
statute. 
No. 
2014AP1048   
 
32 
 
care and assistance to those who suffer from a mental disorder. 
Post, 197 Wis. 2d at 303 ("We find the state's dual interests 
represented 
by 
chapter 
980 
to 
be 
both 
legitimate 
and 
compelling.");25 see also Dennis H., 255 Wis. 2d at 369 ("The 
state has a well-established, legitimate interest under its 
parens patriae power in providing care to persons unable to care 
for themselves  . . . ."); Vitek, 445 U.S. at 495 ("Concededly 
the interest of the State in segregating and treating mentally 
ill patients is strong."); O'Connor v. Donaldson, 422 U.S. 563, 
575 (1975) ("That the State has a proper interest in providing 
care and assistance to the unfortunate goes without saying."). 
¶45 The State's interest in caring for and assisting 
individuals who suffer from mental illness is particularly 
strong in the context of a prison because "[a]n inmate must rely 
on prison authorities to treat his medical needs; if the 
authorities fail to do so, those needs will not be met." Estelle 
v. Gamble, 429 U.S. 97, 103 (1976). Moreover, the State's 
interest in caring for and assisting its inmates is not just an 
                                                 
25 In State v. Post, 197 Wis. 2d 279, 541 N.W.2d 115 (1995), 
the State's dual interests were (1) protecting the community 
from the dangerously mentally disordered and (2) providing care 
and treatment to those with mental disorders that predispose 
them to sexual violence. 197 Wis. 2d at 302. We went on to say, 
"The Supreme Court has recognized both of these interests as 
legitimate, the first under the state's police power and the 
latter under its parens patriae power." Id. (citing Addington, 
441 U.S. at 426). Under the parens patriae power, the state has 
a legitimate interest in "providing care to its citizens who are 
unable 
because 
of 
emotional 
disorders 
to 
care 
for 
themselves . . . ." Addington, 441 U.S. at 426. 
No. 
2014AP1048   
 
33 
 
interest; it is an obligation: "We confront here the State's 
obligations, not just its interests. The State has undertaken 
the obligation to provide prisoners with medical treatment 
consistent not only with their own medical interests, but also 
with the needs of the institution." Harper, 494 U.S. at 225 
(emphasis added). Thus, the State needs to properly care for 
inmates suffering from mental illness while they are in the 
custody of the State. 
¶46 At oral argument, Winnebago County stated that "first 
and foremost" the State has an interest in making sure its 
inmates suffering from mental illness are "taken care of." Here, 
the County has a legitimate interest in providing care and 
assistance to inmates suffering from mental illness. Further, in 
this case, caring for and assisting these inmates is more than 
an interest; it is an obligation because as a result of his or 
her incarceration, the inmate cannot obtain treatment on his or 
her own. The State needs to provide it. Wisconsin Stat. 
§51.20(1)(ar) is reasonably related to the State's interest 
because it enables the State to fulfill its interest in 
No. 
2014AP1048   
 
34 
 
providing care and assistance to those inmates who need 
treatment because they are suffering from a mental illness.26 
¶47 To 
prevail 
on 
his 
constitutional 
challenge, 
Christopher needed to prove that Wis. Stat. § 51.20(1)(ar) is 
                                                 
26 Christopher argues that Harper, requires the State to 
prove dangerousness whenever it seeks to commit an inmate. In 
Harper, the Supreme Court of the United States took up a due 
process challenge to Policy 600.30, which allowed the State of 
Washington to involuntarily administer antipsychotic medication 
to an inmate against the inmate's will only if he or she (1) 
suffered from a mental disorder and was (2) gravely disabled or 
posed a serious likelihood of harm to himself, others, or their 
property. 494 U.S. at 215 (emphasis added). To analyze the 
inmate's 
claim, 
the 
Court 
considered 
both 
the 
inmate's 
"significant interest in avoiding the unwanted administration of 
antipsychotic drugs" and the State's interest in the safety and 
security of its institution. Id. at 221, 225-26. There, the 
Court required a finding of dangerousness because it resulted in 
an "accommodation between an inmate's liberty interest in 
avoiding the forced administration of antipsychotic drugs and 
the State's interest in providing appropriate medical treatment 
to reduce the danger that an inmate suffering from a serious 
mental disorder represents to himself or others." Id. at 236 
(emphasis added). 
Christopher's reliance on Harper is misguided for two 
reasons. First, Harper is concerned with the administration of 
antipsychotic medications, not the involuntary commitment of an 
inmate. Second, Christopher ignores the fact that the legitimate 
interest in Harper was the safety and security of the prison, 
not the care and assistance of its mentally ill inmates. Harper 
may require a finding of dangerousness when the State seeks to 
involuntarily medicate an inmate and is solely relying on the 
safety and security of the prison as its legitimate reason for 
administering the antipsychotic medication. But Harper does not 
address the issue of how a state may proceed vis-à-vis the 
involuntary commitment of an inmate, nor does it address the 
issue of how a state may proceed vis-à-vis the involuntary 
administration of antipsychotic medication when the State's 
interest is unrelated to the safety and security of the 
institution. 
No. 
2014AP1048   
 
35 
 
unconstitutional under all circumstances. He also needed to 
prove that Wis. Stat. § 51.20(1)(ar) is unconstitutional beyond 
a reasonable doubt. Christopher has proved neither. Because we 
can think of at least one "conceivable set of facts" where Wis. 
Stat. § 51.20(1)(ar) is constitutional, namely where the State's 
interest is in caring for and assisting inmates who suffer from 
mental illness, Christopher has failed to prove that the statute 
is unconstitutional under all circumstances. Accordingly, we 
hold that Wis. Stat. § 51.20(1)(ar) is facially constitutional. 
 
D. WHETHER THE CIRCUIT COURT ERRED. 
 
¶48 We now turn to the issue of whether the circuit court 
erred when it concluded that Winnebago County established by 
clear and convincing evidence that Christopher was incompetent 
to refuse psychotropic medication and treatment pursuant to Wis. 
Stat. 
§ 51.61(1)(g). 
Here, 
we 
are 
not 
assessing 
the 
constitutionality of Wis. Stat. § 51.61(1)(g). Christopher does 
not 
raise 
a 
constitutional 
challenge 
against 
Wis. 
Stat. 
§ 51.61(1)(g). Rather, we examine whether the circuit court 
erred when it concluded that the County met its burden of proof. 
We turn to the merits of Christopher's argument. 
1. Standard Of Review 
¶49 Christopher argues that Winnebago County failed to 
meet its burden of proving that he was incompetent to refuse 
No. 
2014AP1048   
 
36 
 
psychotropic medication and treatment as required by Wis. Stat. 
§ 51.61(1)(g)4.b.27 Pursuant to that statute, it is the County 
that "bears the burden of proving [Christopher] incompetent to 
refuse medication by clear and convincing evidence." Melanie L., 
349 Wis. 2d 148, ¶37 (citing Wis. Stat. § 51.20(13)(e) (2009-
2010)). 
¶50 "We will not disturb a circuit court's factual 
findings unless they are clearly erroneous." Id., ¶38. Further, 
"we accept reasonable inferences from the facts available to the 
circuit court." Id. When "evaluating whether the County met its 
burden of proof, a court must apply the facts to the statutory 
standard in Wis. Stat. § 51.61(1)(g)4.b. and interpret the 
statute." Id., ¶39. Finally, "applying facts to the standard and 
interpreting the statute are questions of law that this court 
reviews independently." Id. In short, the circuit court's 
findings of fact are reviewed for clear error, but application 
of those facts to the statute and interpretation of the statute 
are reviewed independently. 
2. We Determine That The Circuit Court Did Not Err When It 
Concluded That Winnebago County Established By Clear And 
                                                 
27 In this case, the County sought to prove incompetency 
under Wis. Stat. § 51.61(1)(6)4.b., which required the County to 
prove that the "advantages and disadvantages of and alternatives 
to accepting the particular medication or treatment [were] 
explained to the [Christopher]" and that Christopher was 
"substantially incapable of applying an understanding of the 
advantages, disadvantages, and alternatives to [his] [mental 
illness] in order to make an informed choice as to whether to 
accept or refuse medication." 
No. 
2014AP1048   
 
37 
 
Convincing Evidence That Christopher Was Incompetent To Refuse 
Psychotropic Medication And Treatment. 
¶51 This case once again requires us to interpret Wis. 
Stat. § 51.61(1)(g)4. Our decision in Melanie L. is most 
instructive; thus, a brief recitation of the facts and the 
holding is appropriate. 
¶52 As is the case here, the issue in Melanie L. was 
whether the County proved by clear and convincing evidence that 
the individual was incompetent to refuse psychotropic medication 
under Wis. Stat. § 51.61(1)(g)4. There, we held that the County 
failed to meet its burden of proof: 
In particular, the medical expert's terminology and 
recitation of facts did not sufficiently address and 
meet the statutory standard. Medical experts must 
apply the standards set out in the competency statute. 
An expert's use of different language to explain his 
or her conclusions should be linked back to the 
standards in the statute. 
Melanie 
L., 
349 
Wis. 2d 148, 
¶¶8-9, 
97. 
In 
that 
case, 
Melanie L.'s doctor (Dr. Dave) diagnosed her with "Psychotic 
Disorder, 
NOS, 
a 
substantial 
disorder 
of 
thoughts 
and 
perception, which grossly impairs her judgment, capacity to 
recognize reality, [and] ability to care for herself." Id., ¶27 
(alteration in original) (internal quotation marks omitted). His 
report stated: 
Melanie, based upon her educational background, was 
able to express the benefits and risks of the 
psychotropic medication; however, she is unable to 
apply such understanding to her advantage and she is 
considered to be not competent to refuse psychotropic 
medication. . . . The patient would not comply with 
No. 
2014AP1048   
 
38 
 
psychotropic 
medication 
without 
[an] 
involuntary 
medication order from the court. 
Id. 
(alterations 
in 
original) 
(internal 
quotation 
marks 
omitted). Further, at trial the doctor testified, "I do not 
think that she's capable of applying the benefits of the 
medication to her advantage." Id., ¶30 (emphasis added). 
¶53 We summarized the testimony of Melanie L.'s doctor as 
concluding 
that 
"Melanie 
was 
incapable 
of 
applying 
an 
understanding of the medication 'to her advantage.'" See 
id., ¶91. We took issue with the doctor's testimony and 
specifically noted the following: 
The corporation counsel posed a question to Dr. Dave 
employing the statutory terms. When he did not receive 
an answer in those terms, he should have required his 
witness to expound upon his answer, so that the 
circuit court and a reviewing court did not have to 
speculate upon Dr. Dave's meaning. As the record 
stands, we cannot be certain whether Dr. Dave was 
applying the standard or changing the standard. 
Id. In short, the County needed to "more carefully articulate[] 
its case." Id., ¶95. 
¶54 The present case is distinguishable from Melanie L. 
because, here, the County carefully articulated its case by 
adhering strictly to the standards set out in the competency 
statute. In this case, Christopher's doctor's testimony closely 
tracked the language of Wis. Stat. § 51.61(1)(g)4.b.: 
Q. Dr. Keshena, in the course of your treatment of 
[Christopher] have you had an opportunity to explain 
to him the advantages, disadvantages, and alternatives 
to the medication? 
A. Yes. 
No. 
2014AP1048   
 
39 
 
Q. And after you've done that, in your opinion would 
he be substantially incapable or substantially capable 
of applying an understanding of the advantages, 
disadvantages, and alternatives to his own conditions 
in order to make an informed choice as to whether to 
accept or refuse psychotropic medication? 
A. He's not capable. 
Q. So you're saying he's substantially incapable? 
A. Yes.  
Unlike in Melanie L., we do not have to "speculate upon [Dr. 
Keshena's] meaning"; we are certain Dr. Keshena applied the 
statutory standard. 
¶55 In addition to Dr. Keshena's testimony, Dr. Musunuru's 
report also tracked the statutory language. Dr. Musunuru's 
report 
made 
six 
key 
findings: 
(1) 
"the 
advantages 
and 
disadvantages and the alternatives to accepting particular 
medication [were] explained to the subject in detail[]"; (2) 
"the subject did not appear to understand the explanation"; (3) 
"the subject holds patently false beliefs about the treatment 
recommended medications, which prevent an understanding of the 
legitimate risks and benefits"; (4) "due to the subject's mental 
illness, the subject is substantially incapable of applying an 
understanding of the advantages, disadvantages, and alternatives 
to make an informed choice as to accept or refuse medications"; 
(5) "the subject has no insight into his illness due to his 
mental illness"; and (6) "the subject is not competent to refuse 
psychotropic medications." 
¶56 Finally, Dr. Keshena's testimony was not disputed at 
trial. In fact, cross-examination of Dr. Keshena, which brought 
No. 
2014AP1048   
 
40 
 
about the discussion of Christopher's prior experience with 
lithium, 
provided 
further 
evidence 
that 
Christopher 
was 
"substantially incapable of applying an understanding of the 
advantages, disadvantages and alternatives to [his] mental 
illness . . . in order to make an informed choice as to whether 
to 
accept 
or 
refuse 
medication 
or 
treatment."28 
These 
uncontroverted 
statements 
establish 
that 
Christopher 
was 
incompetent to refuse psychotropic medication and treatment, so 
it was not necessary for Dr. Keshena to engage in a lengthier 
discussion of her explanation of the advantages, disadvantages, 
and alternatives. See Melanie L., 349 Wis. 2d 148, ¶67 ("Medical 
professionals and other professionals should document the timing 
and frequency of their explanations so that, if necessary, they 
have documentary evidence to help establish this element in 
court." (emphasis added)). Because these statements mirrored the 
statutory standard, they met the statutory standard. Thus, the 
circuit court did not err when it concluded that the County 
proved by clear and convincing evidence that Christopher was 
incompetent to refuse psychotropic medication and treatment as 
required by Wis. Stat. § 51.61(1)(g)4.b. 
 
                                                 
28 During cross-examination, Dr. Keshena testified that 
Christopher "was previously on lithium" and that Christopher 
told her "he didn't have any side effects from that medication, 
but he thought it was a placebo."  
No. 
2014AP1048   
 
41 
 
IV. CONCLUSION 
 
¶57 First, we hold that Wis. Stat. § 51.20(1)(ar) is 
facially constitutional because it is reasonably related to the 
State's legitimate interest in providing care and assistance to 
inmates suffering from mental illness. Second, we affirm the 
circuit court because it did not err when it found by clear and 
convincing evidence that Christopher was incompetent to refuse 
psychotropic medication and treatment. We therefore uphold the 
circuit court's order for involuntary commitment, order for 
involuntary 
medication 
and 
treatment, 
and 
order 
denying 
postcommitment relief. 
By the Court.—The circuit court's orders are affirmed. 
¶58 REBECCA G. BRADLEY, J., did not participate. 
 
No.  2014AP1048.ssa 
 
1 
 
 
¶59 SHIRLEY 
S. 
ABRAHAMSON, 
J.   (concurring 
in 
part, 
dissenting in part).  At issue in this case are (1) whether Wis. 
Stat. § 51.20(1)(ar), which permits the involuntary commitment 
of mentally ill prisoners, is facially unconstitutional because 
it does not require a finding of dangerousness to involuntarily 
commit a prisoner; and (2) whether Winnebago County met its 
burden of proof by clear and convincing evidence that the 
defendant, 
Christopher 
S., 
was 
incompetent 
to 
refuse 
psychotropic medication.   
¶60 The 
majority 
opinion 
holds 
that 
Wis. 
Stat. 
§ 51.20(1)(ar) is facially constitutional1 even though the 
statute 
does 
not 
require 
a 
finding 
of 
dangerousness 
to 
involuntarily commit a prisoner to a mental institution.2  
Applying the rational basis test, the majority opinion concludes 
that the involuntary commitment statute does not violate 
substantive due process because it is reasonably related to a 
legitimate state interest, namely "providing care and assistance 
to [prisoners] suffering from mental illness."3   
¶61 I write separately to make two points:  
(1) 
Although several Wisconsin and United States Supreme 
Court cases are informative, none clearly describes 
the standard to be applied to a substantive due 
                                                 
1 Majority op., ¶8.   
2 Majority op., ¶46 n.26.   
3 Majority op., ¶8.   
No.  2014AP1048.ssa 
 
2 
 
process 
challenge 
to 
a 
prisoner's 
involuntary 
commitment to a mental institution.  I conclude that 
the State must show an "essential" or "overriding" 
state interest——for example, ensuring prison safety or 
security, or providing treatment to a gravely disabled 
prisoner——to 
overcome 
a 
prisoner's 
 
significant, 
constitutionally 
protected 
liberty 
interests 
in 
avoiding 
involuntary 
commitment 
to 
a 
mental 
institution and the stigma attached thereto.  The 
majority 
opinion 
does 
not 
interpret 
Wis. 
Stat. 
§ 51.20(1)(ar) 
as 
requiring 
an 
"essential" 
or 
"overriding" state interest to involuntarily commit a 
prisoner to a mental institution.  Unless it is so 
interpreted, 
I 
conclude 
that 
the 
statute 
is 
unconstitutional as a matter of substantive due 
process. 
(2) 
I concur in the majority opinion's conclusion that 
Winnebago County met its burden of proving by clear 
and convincing evidence that Christopher S. was 
incompetent 
to 
refuse 
psychotropic 
medication 
as 
required for involuntary medication under Wis. Stat. 
§ 51.61(g).4  Nevertheless, in recognition of the 
significant, 
constitutionally 
protected 
liberty 
interests 
at 
play 
in 
involuntary 
medication 
proceedings, the County and the circuit court should 
take the time to make a record pursuant to Outagamie 
                                                 
4 Majority op., ¶57.   
No.  2014AP1048.ssa 
 
3 
 
County 
v. 
Melanie 
L., 
2013 
WI 
67, 
¶67, 
349 
Wis. 2d 148, 833 N.W.2d 607.   
¶62 For the reasons set forth, I dissent in part and write 
separately.   
I 
¶63 Applying the rational basis test, the majority opinion 
determines 
that 
Wis. 
Stat. 
§ 51.20(1)(ar) 
is 
facially 
constitutional 
because 
commitment 
under 
Wis. 
Stat. 
§ 51.20(1)(ar) is reasonably related to the State's interest "in 
providing care and assistance to [prisoners] suffering from 
mental illness."5  The majority opinion also concludes that 
substantive 
due 
process 
does 
not 
require 
a 
finding 
of 
dangerousness in order to involuntarily commit a prisoner to a 
mental institution.6 
¶64 Despite 
acknowledging 
prisoners' 
constitutionally 
protected liberty interests in being free from involuntary 
commitment to a mental institution and the associated stigma, 
the majority opinion gives the prisoner's liberty interest 
little or no weight.   
¶65 In a substantive due process challenge, a court must 
first define the individual's protected constitutional interest 
before identifying when, if at all, a competing state interest 
might outweigh it.  State v. Wood, 2010 WI 17, ¶18, 323 
                                                 
5 Majority op., ¶8.   
6 Majority op., ¶¶42, 46 & n.26.   
No.  2014AP1048.ssa 
 
4 
 
Wis. 2d 321, 780 N.W.2d 63 (quoting Washington v. Harper, 494 
U.S. 210, 220 (1990)).   
¶66 All persons, including prisoners, have a significant, 
constitutionally 
protected 
liberty 
interest 
in 
avoiding 
involuntary commitment to a mental institution and the stigma 
often associated with such a commitment.7   
¶67 The United States Supreme Court has not ruled on what 
level of scrutiny applies when a court reviews a statute 
implicating 
a 
prisoner's 
liberty 
interest 
in 
not 
being 
involuntarily committed to a mental institution and experiencing 
the associated stigma.  Nonetheless, some guidance can be 
derived from relevant case law.   
¶68 In Vitek v. Jones, 445 U.S. 480 (1980), the United 
States Supreme Court addressed the procedural due process 
                                                 
7 See, e.g., Sandin v. Conner, 515 U.S. 472, 479 n.4, 484 
(1995) 
(describing 
a 
prisoner's 
interest 
in 
not 
being 
transferred to a mental institution as a constitutionally 
protected 
liberty 
interest 
and 
stating 
that 
involuntary 
commitment to a mental institution is "'qualitatively different' 
from the punishment characteristically suffered by a person 
convicted of crime, and ha[ving] 'stigmatizing consequences.'") 
(referencing Vitek v. Jones, 445 U.S. 480, 493-94 (1980) and 
Washington v. Harper, 494 U.S. 210, 221-22 (1990)); Foucha v. 
Louisiana, 504 U.S. 71, 79-80 (1992) (holding that given an 
individual's liberty interests, an individual found not guilty 
by reason of insanity could not continue to be confined after he 
was no longer mentally ill and did not pose a danger to himself 
or others); Vitek v. Jones, 445 U.S. 480, 493 (1980) (holding 
that the involuntary transfer of a prisoner to a mental hospital 
implicated a liberty interest protected by the due process 
clause); Addington v. Texas, 441 U.S. 418, 425 (1979) (stating 
that involuntary commitment "for any purpose constitutes a 
significant deprivation of liberty that requires due process 
protection" and may subject a committed individual to stigma 
even after the commitment and criminal sentence have ended)). 
No.  2014AP1048.ssa 
 
5 
 
protections required for involuntarily transferring a prisoner 
to a mental institution.  The Court determined that a prisoner 
facing involuntary transfer to a mental institution has a 
constitutionally protected liberty interest in avoiding the 
deprivation of liberty and the stigma associated with such a 
transfer.8  Prisoners have such liberty interests even though 
they are imprisoned because a criminal sentence "do[es] not 
authorize the State to classify [a prisoner] as mentally ill and 
to subject him to involuntary psychiatric treatment without 
affording 
him 
additional 
due 
process 
protections."9  
Nevertheless, the Vitek Court did not state what level of 
scrutiny applies when gauging the constitutionality of a statute 
authorizing the involuntary commitment of a prisoner to a mental 
institution.   
¶69 In Washington v. Harper, 494 U.S. 210 (1990), the 
United States Supreme Court applied rational basis scrutiny to a 
prison regulation authorizing the involuntary medication of 
dangerous or gravely disabled prisoners.10  The Court stated that 
the rational basis test applied in light of the State's 
interests in prison safety and security, even though prisoners 
have 
a 
liberty 
interest 
in 
avoiding 
the 
involuntary 
administration of antipsychotic medication.11  In applying the 
                                                 
8 Vitek, 445 U.S. at 494.   
9 Vitek, 445 U.S. at 494.   
10 Harper, 494 U.S. at 224, 226.   
11 Harper, 494 U.S. at 223.   
No.  2014AP1048.ssa 
 
6 
 
rational basis test to the challenged prison regulation, the 
Harper Court described the state's interest——the safety of 
prisoners and staff——as legitimate, important, and "necessarily 
encompass[ing] an interest in providing [the mentally ill 
prisoner] with medical treatment for his illness."12   
¶70 Although Harper stated it was applying rational basis 
scrutiny, the United States Supreme Court has subsequently 
described Harper and other involuntary medication cases as 
holding 
that 
involuntary 
medication 
of 
a 
prisoner 
is 
impermissible absent an "essential" or "overriding" state 
interest.13  See Sell v. United States, 539 U.S. 166, 179 (2003) 
("[A]n individual has a constitutionally protected liberty 
interest in avoiding involuntary administration of antipsychotic 
drugs——an interest that only an 'essential' or 'overriding' 
state interest might overcome.") (internal quotation marks 
omitted); Riggins v. Nevada, 504 U.S. 127, 135 (1992) ("Under 
Harper, forcing antipsychotic drugs on a convicted prisoner is 
impermissible absent a finding of overriding justification and a 
determination of medical appropriateness.").  
¶71 Thus, Sell and Riggins (as well as State v. Wood, 2010 
WI 17, ¶25, 323 Wis. 2d 321, 780 N.W.2d 63) incorporate the need 
for an "essential" or "overriding" state interest, at least in 
involuntary medication cases. 
                                                 
12 Harper, 494 U.S. at 225-26.  
13 So has this court.  See State v. Wood, 2010 WI 17, ¶¶19-
20, 22-25, 323 Wis. 2d 321, 780 N.W.2d 63 (discussing Harper, 
Riggins, and Sell). 
No.  2014AP1048.ssa 
 
7 
 
¶72 An "essential" or "overriding" state interest is not 
required in applying rational basis scrutiny.  In an ordinary 
rational basis analysis, like the majority opinion conducts, a 
court decides whether the challenged statute is rationally 
related to a legitimate state interest.14  Thus, the United 
States 
Supreme 
Court's 
requirement 
of 
an 
"essential" 
or 
"overriding" state interest indicates that a more searching 
analysis is required, at least when the State seeks to 
involuntarily medicate a prisoner.   
¶73 Involuntary medication and involuntary commitment to a 
mental 
institution 
impose 
similar 
burdens 
on 
prisoners' 
constitutionally protected liberty interests.  As a result, the 
two should be treated similarly in conducting a substantive due 
process analysis.   
¶74 Both involuntary medication and involuntary commitment 
to a mental institution "exceed[] [a criminal] sentence in such 
an unexpected manner as to give rise to protection by the Due 
Process Clause of its own force . . . ."15   
¶75 Both involuntary medication and involuntary commitment 
to a mental institution are "'qualitatively different' from the 
punishment characteristically suffered by a person convicted of 
crime, and ha[ve] 'stigmatizing consequences.'"16  As a result, 
                                                 
14 See State v. Alger, 2015 WI 3, ¶39, 360 Wis. 2d 193, 858 
N.W.2d 346.  
15 Sandin, 515 U.S. at 484 (citing Harper, 494 U.S. at 221-
22; Vitek, 445 U.S. at 493).   
16 Sandin, 515 U.S. at 479 n.4 (quoting Vitek, 445 U.S. at 
493-94).   
No.  2014AP1048.ssa 
 
8 
 
the mere fact that a prisoner is serving a criminal sentence 
does not authorize the State to designate the prisoner as 
mentally ill, involuntarily commit him or her to a mental 
institution, or involuntarily medicate him or her without 
significant due process protections.17 
¶76 Furthermore, 
involuntary 
commitment 
to 
a 
mental 
institution under Wis. Stat. § 51.20(1)(ar) and involuntary 
medication under Wis. Stat. § 51.61(1)(g) are significantly 
intertwined, more than the majority opinion lets on.  
¶77 The 
close 
relationship 
between 
Wis. 
Stat. 
§ 51.20(1)(ar) and Wis. Stat. § 51.61(1)(g) (as demonstrated by 
the facts of this case) further illustrates why requiring, as a 
matter 
of 
substantive 
due 
process, 
an 
"essential" 
or 
"overriding" state interest in both involuntary commitment and 
involuntary medication cases is appropriate.   
¶78 In the instant case, Christopher S. was ordered 
involuntarily committed and involuntarily medicated in the same 
proceeding, before the same judge, in the same court, on the 
same day.  A temporary involuntary medication order was also 
entered during the pendency of Christopher S.'s involuntary 
commitment proceedings.   
¶79 While the jury was deliberating whether Christopher S. 
should be involuntarily committed, the trial judge conducted a 
bench trial to determine whether Christopher S. could be 
involuntarily medicated.  Based on the jury verdict, the trial 
                                                 
17 See Sandin, 515 U.S. at 484.    
No.  2014AP1048.ssa 
 
9 
 
judge granted the petition for involuntary commitment for a six-
month period.  The trial judge also issued an involuntary 
medication order.   
¶80 One of the requirements for involuntary commitment of 
a 
prisoner 
to 
a 
mental 
institution 
under 
Wis. 
Stat. 
§ 51.20(1)(ar) is that the prisoner be "a proper subject for 
treatment and [be] in need of treatment."   
¶81 For 
what 
treatment 
did 
the 
County 
seek 
to 
involuntarily 
commit 
Christopher 
S.? 
 
The 
involuntary 
administration of psychotropic medication.   
¶82 Simply put, the County sought to involuntarily commit 
Christopher S. for the purpose of treating him by involuntarily 
administering psychotropic medication.  Despite the majority 
opinion's efforts to distinguish between the two statutes for 
the purpose of its constitutional analysis, the two statutes 
are, in fact, intimately intertwined. 
¶83 Upon 
consideration 
of 
the 
case 
law 
and 
the 
relationship between involuntary medication and involuntary 
commitment, 
I 
conclude 
that 
when 
the 
State 
seeks 
to 
involuntarily commit or involuntarily medicate a prisoner, an 
"essential" or "overriding" state interest is required to 
outweigh the prisoner's significant, constitutionally protected 
liberty 
interests 
in 
avoiding 
involuntary 
medication 
or 
involuntary commitment and the associated stigma.   
¶84 Although I agree with the majority opinion that a 
finding 
of 
dangerousness 
is 
not 
required 
to 
outweigh 
a 
prisoner's 
constitutionally 
protected 
liberty 
interests, 
I 
No.  2014AP1048.ssa 
 
10 
 
conclude that when the State seeks to involuntarily commit a 
prisoner, 
the 
State 
must 
demonstrate 
an 
"essential" 
or 
"overriding" 
state 
interest 
to 
outweigh 
the 
prisoner's 
significant, constitutionally protected liberty interests in 
avoiding involuntary commitment and the associated stigma.  Such 
an "essential" or "overriding" state interest may be, for 
example, safeguarding the prison, prisoners, and staff against a 
mentally ill prisoner who is dangerous to him or herself or 
others, or providing treatment to a gravely disabled prisoner.   
¶85 The majority opinion concludes the state's interest 
"in providing care and assistance to [prisoners] suffering from 
mental illness"18 is sufficient.  
Although the majority opinion 
describes this state interest as "compelling,"19 providing 
involuntary care and assistance to prisoners suffering from 
mental illness, standing alone, is not an "essential" or 
"overriding" state interest as these terms are used in the case 
law.  Providing involuntary care and assistance to prisoners 
suffering 
from 
mental 
illness 
is 
not 
an 
"essential" 
or 
"overriding" state interest unless the prisoner poses a danger 
to self or others, is gravely disabled, or another "essential" 
or "overriding" state interest exists.  
¶86 The state's interest in providing care and assistance 
to mentally ill prisoners (or others within the State's care) is 
present in all involuntary commitment and involuntary medication 
                                                 
18 Majority op., ¶8.   
19 Majority op., ¶44.   
No.  2014AP1048.ssa 
 
11 
 
cases.  The United States Supreme Court's involuntary medication 
and involuntary commitment cases have, however, all focused on 
state interests above and beyond providing care and assistance 
to the mentally ill person.  The Court has addressed, for 
instance, "essential" or "overriding" interests such as ensuring 
the safety and security of the prison, treating a gravely 
disabled prisoner,20 restoring trial competency,21 or protecting 
society and providing treatment to individuals found not guilty 
by reason of insanity.22 
¶87 If 
the 
state's 
interest 
in 
providing 
care 
and 
assistance to mentally ill prisoners were sufficient to overcome 
a prisoner's countervailing liberty interests, then a statute 
permitting involuntary commitment or involuntary medication 
based 
solely 
on 
a 
finding 
of 
mental 
illness 
would 
be 
constitutionally permissible.  However, a finding of mental 
illness alone is not enough to support involuntary commitment.23  
¶88 Unlike providing care and assistance to mentally ill 
prisoners, ensuring the safety and security of prisons, prison 
staff, and prisoners by removing dangerous (to self or others) 
mentally ill prisoners, or providing care and treatment to 
                                                 
20 See Harper, 494 U.S. at 222-24.   
21 See Sell, 539 U.S. at 178-80.   
22 See Jones v. United States, 463 U.S. 354, 365-66 (1983).   
23 See, e.g., O'Connor v. Donaldson, 422 U.S. 563, 575 
(1975) 
(implying 
that 
a 
State's 
legitimate 
interests 
in 
providing care and treatment could not overcome a person's 
liberty interests). 
No.  2014AP1048.ssa 
 
12 
 
gravely disabled prisoners, are "essential" and "overriding" 
state interests.  Wisconsin Stat. § 51.20(1)(ar) is not, 
however, limited to circumstances in which "essential" and 
"overriding" state interests are present.  
¶89 On the contrary, Wis. Stat. § 51.20(1)(ar) does not 
require the State or County to have any interest above and 
beyond providing care and assistance to mentally ill prisoners.  
The statute provides:  
If the individual is an inmate of a state prison, the 
petition may allege that the inmate is mentally ill, 
is a proper subject for treatment and is in need of 
treatment.  The petition shall allege that appropriate 
less 
restrictive 
forms 
of 
treatment 
have 
been 
attempted 
with 
the 
individual 
and 
have 
been 
unsuccessful and it shall include a description of the 
less 
restrictive 
forms 
of 
treatment 
that 
were 
attempted.  The petition shall also allege that the 
individual has been fully informed about his or her 
treatment needs, the mental health services available 
to him or her and his or her rights under this chapter 
and that the individual has had an opportunity to 
discuss his or her needs, the services available to 
him or her and his or her rights with a licensed 
physician or a licensed psychologist.  The petition 
shall include the inmate's sentence and his or her 
expected date of release as determined under s. 302.11 
or 302.113, whichever is applicable.  The petition 
shall have attached to it a signed statement by a 
licensed physician or a licensed psychologist of a 
state prison and a signed statement by a licensed 
physician or a licensed psychologist of a state 
treatment facility attesting either of the following: 
1. That the inmate needs inpatient treatment at a 
state 
treatment 
facility 
because 
appropriate 
treatment is not available in the prison. 
2. That the inmate's treatment needs can be met 
on an outpatient basis in the prison. 
No.  2014AP1048.ssa 
 
13 
 
¶90 As a result, the text of Wis. Stat. § 51.20(1)(ar) is 
not rationally related to an "essential" or "overriding" state 
interest.  Pursuant to Wis. Stat. § 51.20(1)(ar), the State or 
County 
may 
commit 
a 
mentally 
ill 
prisoner 
without 
any 
"essential" or "overriding" state interest. 
¶91 Because 
Wisconsin 
Stat. 
§ 51.20(1)(ar) 
is 
not 
reasonably related to an "essential" or "overriding" state 
interest, 
I 
conclude 
Wis. 
Stat. 
§ 51.20(1)(ar) 
is 
unconstitutional as a matter of substantive due process.   
II 
¶92 Finally, I wish to offer a brief comment about 
Christopher S.'s claim that the County did not show by clear and 
convincing 
evidence 
that 
he 
was 
incompetent 
to 
refuse 
psychotropic medication.   
 
¶93 As I explained above, the jury trial regarding 
Christopher's involuntary commitment took place the same day as 
the bench trial regarding his involuntary medication.  Only one 
witness, Dr. Keshena, testified.   
 
¶94 The direct examination of Dr. Keshena largely parroted 
the language of Wis. Stat. § 51.61(1)(g)4.b., stating, in 
relevant part:  
Q. 
Dr. Keshena, in the course of your treatment of 
[Christopher], have you had an opportunity to 
explain to him the advantages, disadvantages, and 
alternatives to the medication?   
A. 
Yes.  
Q. 
And after you've done that, in your opinion would 
he be substantially incapable or substantially 
capable of applying an understanding of the 
advantages, disadvantages, and alternatives to 
No.  2014AP1048.ssa 
 
14 
 
his own condition in order to make an informed 
choice 
as 
to 
whether 
to 
accept 
or 
refuse 
psychotropic medication?   
A. 
He's not capable. 
Q. 
So you're saying he's substantially incapable? 
A. 
Yes.   
¶95 Elsewhere in the record there is ample evidence that 
the doctors who treated Christopher S. explained the advantages, 
disadvantages, and alternatives to medication to him.  The trial 
judge was familiar with this evidence.  As a result, I concur in 
the majority opinion's conclusion that the County met its burden 
of proving by clear and convincing evidence that Christopher S. 
was incompetent to refuse psychotropic medication and treatment.   
¶96 Nevertheless, I write separately to point out that the 
majority opinion explains that Dr. Keshena's testimony was "not 
disputed at trial," so it was "not necessary for Dr. Keshena to 
engage in a lengthier discussion of her explanation of the 
advantages, disadvantages, and alternatives" under Outagamie 
County v. Melanie L., 2013 WI 67, ¶67, 349 Wis. 2d 148, 833 
N.W.2d 607.24  Although lengthier discussion may not have been 
necessary because of the record in this case, given the 
significant constitutional rights at stake, the County should 
develop a sufficient record to show that, for instance, the 
person was advised of the advantages, disadvantages, and 
alternatives to treatment in order to enable appellate review.  
See Melanie L., 349 Wis. 2d 148, ¶67.   
                                                 
24 Majority op., ¶56. 
No.  2014AP1048.ssa 
 
15 
 
¶97 For the reasons set forth, I dissent in part and write 
separately. 
¶98 I am authorized to state that Justice ANN WALSH 
BRADLEY joins this opinion. 
 
 
No.  2014AP1048.ssa 
 
 
 
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