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United States Court of Appeals

FOR THE DISTRICT OF COLUMBIA CIRCUIT

Argued September 6, 2019 Decided October 4, 2019 

No. 18-3082

UNITED STATES OF AMERICA,

APPELLEE

v.

JEAN-PAUL GAMARRA,

APPELLANT

Appeal from the United States District Court

for the District of Columbia

(No. 1:17-cr-00065-1)

Lisa B. Wright, Assistant Federal Public Defender, argued

the cause for appellant. With her on the briefs was A.J. Kramer,

Federal Public Defender. Tony Axam Jr. and David W. Bos, 

Assistant Federal Public Defenders, entered appearances.

Nicholas P. Coleman, Assistant U.S. Attorney, argued the

cause for appellee. With him on the brief were Jessie K. Liu,

U.S. Attorney, and Elizabeth Trosman, and Chrisellen R. Kolb,

Assistant U.S. Attorneys.
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Before: ROGERS and PILLARD, Circuit Judges, and

RANDOLPH, Senior Circuit Judge.

Opinion for the Court filed by Senior Circuit Judge

RANDOLPH.

Concurring opinion filed by Circuit Judge PILLARD.

1

RANDOLPH, Senior Circuit Judge: This is a criminal case. 

The defendant, Jean-Paul Gamarra, appeals from an order of the

district court. The order authorized the government to medicate

him without his consent for the purpose of rendering him

competent to stand trial.

 

Questions about Gamarra’s soundness of mind arose from

these largely undisputed circumstances of his arrest on March

28, 2017. Gamarra approached a Secret Service Agent stationed

near the Treasury Department Building, adjacent to the White

House. Gamarra told the Agent that he had a package

containing a “nuclear bomb detonator or defuser.” The Agent

ordered Gamarra to place his package on the ground. On the

package were messages: “Warning this is a tre threat on the

President and Senator life Secure Keyboard to be Reversed

Engineered,” and “Warning 100% threat Brand New Electronic

Detonator Device president Secrete Servisce Explosive

technology Department.” On the package’s label was this:

“Blue tooth Bomb Explosion Component.”

In response, the Agent arrested Gamarra while other law

enforcement officers closed the surrounding areas to pedestrian

and vehicular traffic for an hour and a half. When officers

NOTE: Portions of the concurring opinion contain Sealed

1

Information, which has been redacted.
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examined Gamarra’s package they found only an ordinary

Bluetooth keyboard.

A grand jury indicted Gamarra for threatening bodily harm

to the President (18 U.S.C. § 871) and for conveying false

information concerning the use of an explosive (18 U.S.C.

§ 844(e)). 

Gamarra’s actions raised doubts about whether he was

competent to stand trial. On the government’s motion, the

magistrate judge ordered Gamarra committed to custody for the

purpose of evaluating his competency. A forensic psychologist

examined Gamarra and concluded that he suffered from a

‘schizoaffective disorder’ and that he was not competent to

stand trial. After a hearing, the Magistrate Judge agreed and

issued an order under 18 U.S.C. § 4241(d) committing Gamarra

to continuing custody for the purpose of determining whether he

could become competent. This subsection provides, in part:

The Attorney General shall hospitalize the defendant

for treatment in a suitable facility . . . for such a

reasonable period of time, not to exceed four months,

as is necessary to determine whether there is a

substantial probability that in the foreseeable future he

will attain the capacity to permit the proceedings to go

forward[.]

After some delay, Gamarra was transferred to the Federal

Medical Center, Butner, North Carolina. A psychology intern

at Butner and her supervisor, a forensic psychologist, attended

to Gamarra and signed a report. From multiple clinical

evaluations, interviews and observations, they concluded that

Gamarra suffered from delusional thinking and disorganized

speech. His medical history and the accounts of his family
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members indicated that he could not become competent without

anti-psychotic medicine. At Butner, Gamarra started taking the

prescribed medication, but within a short time became

noncompliant.

The government therefore moved for an order authorizing

involuntary medication. After a three-day evidentiary hearing,

the Magistrate Judge recommended denying the motion on the

ground that the government failed to provide treatment to

Gamarra within the four month period specified in 18 U.S.C. §

4241(d)(2). The district court rejected the recommendation and

granted the government’s motion, concluding that under Sell v.

United States, 539 U.S. 166 (2003), “the government had met its

burden of proof with respect to each of the four Sell factors.” 

United States v. Gamarra, 2018 WL 5257846, *9 (D.D.C.

2018).

Gamarra’s appeal is limited to the district court’s rulings on

two of the four Sell factors – the second and the fourth. The

second Sell factor requires the government to establish that “the

administration of the drugs 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 trial

defense, thereby rendering the trial unfair.” Sell, 539 U.S. at

181. The fourth Sell factor requires the government to establish

that “administration of the drugs is medically appropriate, i.e.,

in the patient’s best medical interest in light of his medical

condition.” Id. 

The district court’s conclusions in favor of the government

must rest on “clear and convincing evidence.” United States v.

Dillon, 738 F.3d 284, 291 (D.C. Cir. 2013). Our review of those

conclusions is for “clear error.” Id. Under this standard, we
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may reverse only “if (1) the findings are ‘without substantial

evidentiary support or ... induced by an erroneous application

of the law’; or if (2) ‘on the entire evidence [we are] left with the

definite and firm conviction that a mistake has been committed.” 

Id. at 297 (quoting Cuddy v. Carmen, 762 F.2d 119, 124 (D.C.

Cir. 1985)).

Gamarra’s objections to the district court’s assessment of

the second Sell factor are that the court should not have relied on

the opinion of Butner’s head psychiatrist – Logan Graddy, M.D.

– because Dr. Graddy did not personally examine Gamarra, and

because he ignored Gamarra’s recollection and his medical

records regarding the side effects he experienced when he took

anti-psychotic medications in the past.

Although Dr. Graddy acknowledged that it was “unusual”

and “unfortunate” that he was offering an opinion without a

personal examination, Gamarra has failed to identify how the

lack of a personal examination compromised Dr. Graddy’s

conclusion that the second Sell factor was satisfied. Moreover,

courts have relied on experts who reached their opinions based

on a review of a patient’s medical records and other information

without personally conducting an examination. See Jones v.

Sec’y, Fla. Dep’t Of Corr., 834 F.3d 1299, 1315–16 (11th Cir.

2016) (collecting cases in which courts relied on a medical

expert who had not personally examined the patient). As the

district court noted, an opinion of the American Psychiatric

Association’s Ethics Committee then in effect concluded that it

was both ethical and common for a “‘forensic expert to offer

opinions’ based on review of records and without examining the

defendant in person.” Gamarra, 2018 WL 5257846 at *10

(quoting American Psychiatric Ass’n, Opinions of the Ethics

Committee on The Principles of Medical Ethics 35 (2017),

available at https://www.psychiatry.org/psychiatrists/practice/
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ethics). The government’s burden here was higher than under

the common preponderance of evidence standard. But Gamarra

has identified no countervailing authority connecting the lack of

personal examination with a failure to meet that burden. 

The district court also did not clearly err in concluding that

the prescribed medication was substantially unlikely to cause

side effects impairing Gamarra’s ability to assist his counsel. 

Dr. Graddy reviewed Gamarra’s medical history, including

medical records of Gamarra’s previous experiences taking antipsychotic medication. Dr. Graddy based his judgment on those

records, on his clinical experience, and on his review of the

medical literature regarding the effects of anti-psychotic

medication. Gamarra argues that Dr. Graddy’s conclusion

affords insufficient weight to Gamarra’s experiences in taking

anti-psychotic medication. Dr. Graddy acknowledged the side

effects and explained how they would be managed if they

recurred. The District Court did not clearly err in crediting Dr.

Graddy’s opinion. We assume that Gamarra will be returned to 

FMC Butner and that, as Dr. Graddy testified, the medical

personnel at that facility will adjust Gamarra’s medication to

minimize side effects. Were side effects to require attention

while Gamarra is in the District of Columbia awaiting trial or

during trial, the district court should ensure appropriate medical

personnel will promptly respond.

Accordingly, the district court did not commit any clear

error regarding the second Sell factor.

Gamarra’s arguments regarding the fourth Sell factor

overlap with his arguments regarding the second Sell factor. We

are again told that the district court should not have credited Dr.

Graddy’s opinion on medical appropriateness because he did not

interview Gamarra. Once again, Gamarra has failed to identify
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how the district court clearly erred in relying on Dr. Graddy’s

testimony to determine that the government satisfied the fourth

Sell factor. The fact that Dr. Graddy did not personally examine

Gamarra does not detract from his finding that Gamarra’s

symptoms would be ameliorated through medication. Dr.

Graddy understood Gamarra’s condition from his review of the

medical records and reports of forensic psychologists who

interacted with Gamarra. We therefore believe Gamarra has

presented no basis for concluding that the district court clearly

erred in relying on Dr. Graddy to conclude that involuntary

medication would be in Gamarra’s best medical interests.

For the reasons stated above, the district court’s order

authorizing involuntary medication is

Affirmed.
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PILLARD, Circuit Judge, concurring:1

 A district court 

order authorizing the forcible medication of an incompetent 

defendant has serious consequences, implicating the 

defendant’s “significant constitutionally protected liberty 

interest in avoiding the unwanted administration of antipsychotic drugs.” Sell v. United States, 539 U.S. 166, 178

(2003) (internal quotation marks omitted) (quoting Washington 

v. Harper, 494 U.S. 210, 221 (1990)). Medication “changes 

one’s mental state—one’s very thought processes—and in a 

way that can’t be resisted by any effort.” Elyn R. Saks, 

Refusing Care: Forced Treatment and the Rights of the 

Mentally Ill 87 (2002). State-imposed medication raises the 

stakes even further, conjuring up plots of dystopian science 

fiction. 

The Supreme Court has held that forced medication to 

render a defendant competent for trial is intended to be “rare,”

appropriate only when the four specified “Sell” factors are

satisfied. Sell, 539 U.S. at 180. These factors permit forcible 

medication only where (1) “important governmental interests 

are at stake”; (2) “involuntary medication will significantly 

further those concomitant state interests” by administration of 

drugs “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 trial defense”; (3) “involuntary 

medication is necessary to further [state] interests”; and (4) 

“administration of the drugs is medically appropriate, i.e., in 

the patient’s best medical interest in light of his medical 

condition.” Sell, 539 U.S. at 180-81. In the aftermath of Sell, 

lower courts have further acknowledged the gravity of this step 

by requiring the government to demonstrate that the Sell factors 

1 NOTE: Portions of this opinion contain Sealed

Information.
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are met by clear and convincing evidence. See, e.g., United 

States v. Dillon, 738 F.3d 284, 291-92 (D.C. Cir. 2013) 

(collecting cases).

The government must exercise exacting diligence to meet 

its burden. The grave risks involuntary psychotropic 

medication pose to a person’s liberty and autonomy—his say 

over what is done to his own brain—call for heightened 

attention. This is especially so given the broader context in 

which forcible medication may occur. Not only does the 

government control whether to initiate prosecution against

incompetent defendants, it oversees the medical personnel in 

federal facilities who observe such defendants and, where 

warranted, treats them, and it determines in the first instance 

whether such defendants have been rendered competent for 

trial. As a result, the government almost always has superior 

expertise and access to information than does defense counsel 

or the courts. Defense counsel, for their part, face extra 

challenges posed by the imperative to mount the most powerful 

and comprehensive defense while guided by the wishes of a 

client who, even though not competent for trial, retains legal 

authority to direct his representation. These unusual 

background conditions strain our adversary system. 

This case illustrates these complexities and raises

questions about whether the government has met its burden 

under the demanding Sell standard. The government seeks to 

medicate Gamarra against his will based almost exclusively on 

the report and testimony of a single psychiatrist, Dr. Graddy, 

without requiring or outlining any specifics regarding the 

dosage and timeframe of the envisioned course of treatment, in 

a context where Gamarra has already spent longer in detention 

than he will for any sentence he is likely to receive. By the 

time of the Sell hearing, Gamarra had been detained for seven
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months, but Dr. Graddy had not met with him, and it does not 

appear that any psychiatrist or other health care provider sought 

to establish a consistent therapeutic relationship with him. The 

record is thin—quite frankly, thinner than it should be—as to 

the current importance of the government’s interest in this 

prosecution, the details and rationales of the planned treatment, 

the extent to which voluntary compliance was meaningfully 

sought as a less restrictive means, and whether the specific drug 

chosen is the best one. 

Most of the questions these circumstances evoke were not 

raised on appeal. And our review is for clear error. The

standard of review reflects the institutional advantage of 

district courts’ first-hand evaluation of factual circumstances—

an advantage especially significant in the context of highly 

contextual decisions regarding psychiatric intervention. I 

therefore join the panel opinion. Nonetheless, because 

approving the forcible administration of medication here 

without additional comment threatens “the sensitive balancing 

required by Sell in light of the significant liberty interests 

implicated by forcible medication,” id. at 296, I write 

separately to highlight benchmarks we expect the government 

to meet when requesting approval for forcible medication 

going forward, with the hope that these benchmarks provide 

useful guidance to district courts evaluating such motions in 

future cases.

I.

The government must show by clear and convincing 

evidence that it has a continuing, important interest in forcibly 

medicating an incompetent defendant. Sell, 539 U.S. at 180. 

Satisfying that first Sell factor requires the government to 

provide affirmative answers to “two distinct questions”: First, 
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“whether the charged crime is ‘serious,’ because the 

Government’s interest in a prosecution generally qualifies as 

‘important’ when the defendant is charged with a serious 

crime”; and, second, whether no ‘“[s]pecial circumstances . . . 

lessen the importance of that interest.’” Dillon, 738 F.3d at 292

(quoting Sell, 539 U.S. at 180). The government’s ordinarily 

strong interest in prosecuting serious crimes may be offset 

where there are countervailing considerations, such as “the 

prospect of lengthy civil commitment” or “an extended period 

of pretrial detention.” Id.; see also Sell, 539 U.S. at 180. 

Subjecting a defendant to an extended period of pretrial 

detention may lessen the government’s penal interest to the 

point that it no longer justifies forcibly medicating the 

defendant. Gamarra has been in detention on these charges 

since March 28, 2017. See Gamarra Rule 28(j) Letter (filed 

9/6/19). The government calculated Gamarra’s likely 

Guidelines range, in the event that he is convicted of the 

charges against him, to be from 21 to 27 months in prison. J.A. 

100. We have yet to decide this issue, but other circuits, faced 

with charged crimes they treat as “serious,” compare the 

recommended Guidelines range that the defendant is likely to

face if convicted to the amount of time the defendant has 

already spent in custody. See, e.g., United States v. Berry, 911 

F.3d 354, 362-63 (6th Cir. 2018); United States v. Grigsby, 712 

F.3d 964, 973-74 (6th Cir. 2013); United States v. RuizGaxiola, 623 F.3d 684, 694 (9th Cir. 2010); United States v. 

White, 620 F.3d 401, 413-19 (4th Cir. 2010). They do so

because the Bureau of Prisons is required to credit pre-trial 

detention toward any term of imprisonment imposed, see 18

U.S.C. § 3585(b)(1), and because “[w]here a defendant has 

already served sufficient time that a guilty verdict will result 

only in a sentence of time served, the deterrent effect of 

imprisonment has evaporated,” Berry, 911 F.3d at 363. The 
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government has already detained Gamarra for longer than the 

recommended Guidelines range. It will need to detain him for 

several more weeks to medicate him and bring him to trial. 

Whatever specific deterrent effect a post-conviction term of 

imprisonment is supposed to have on the defendant, section 

3585(b)(1) tells us, will be effectively achieved by that time.

Governmental interests in criminal prosecution extend 

beyond incapacitation and deterrence of the particular 

defendant. Sell, 539 U.S. at 186; Dillon, 738 F.3d at 296. They 

include the “significance for society” of a prosecution,

including achieving general deterrence. United States v. 

Onuoha, 820 F.3d 1049, 1056 (9th Cir. 2016); see also United 

States v. Gutierrez, 704 F.3d 442, 451 (5th Cir. 2013). The 

government may also pursue a prosecution to secure a term of 

supervised release with specified conditions that follow

incarceration. See Onuoha, 820 F.3d at 1056; United States v. 

Mackey, 717 F.3d 569, 575 (8th Cir. 2013); Gutierrez, 704 F.3d 

at 451. The law places a burden on the government up to the 

time of forcible administration of psychotropic medication to 

have a current, important interest in prosecuting the defendant 

that suffices to justify that grave intrusion. The government 

has not explained in any but the most general terms how these 

interests are promoted by the prosecution of Gamarra. We do 

not, however, resolve the issue here because Gamarra has 

failed to appeal the district court’s conclusion that the first Sell 

factor has been satisfied. 

II.

The government may forcibly medicate a defendant only 

where no treatment short of forced medication would render 

the defendant competent to stand trial, such that “involuntary 

medication is necessary to further” the government’s interest 
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in prosecution. Sell, 539 U.S. at 181. In other words, a court 

cannot approve involuntary administration of psychotropic 

medication unless the government produces clear and 

convincing evidence that any “alternative, less intrusive 

treatments are unlikely to achieve substantially the same 

results.” Id. Of particular import is whether medical staff have 

adequately attempted to encourage the patient’s voluntary 

compliance with a medication regimen before they resort to 

administering medication by force.

Here, too, Gamarra fails to make any argument on appeal. 

Indeed, with the government focused on obtaining 

authorization to administer medication even over Gamarra’s 

objections, and Gamarra insisting that no medication is 

necessary to render him competent, neither party fully explored 

what would appear to be critical terrain: Which treatment 

regimen is most likely to achieve the best results in pursuit of 

the public interest with the least intrusion on the defendant’s 

fundamental rights. The record convincingly supports the 

conclusion that medication is an essential ingredient to 

restoration of Gamarra’s competence. But that is hardly the 

end of the medical or legal story. 

The record does not paint a clear picture as to how or 

whether the government considered medically informed

measures to enhance the prospect of voluntary compliance. 

Nor does it explain in any detail any measures to minimize 

Gamarra’s risk of side effects—let alone any measure that 

might limit or ameliorate the trauma associated with 

involuntary administration. Any psychiatrist, Dr. Graddy 

included, would agree that the prospects for voluntary 

compliance with a course of psychotropic medication depends

on establishing a consistent therapeutic relationship. Indeed, 

Dr. Graddy testified that he believed “therapy plus medications 
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is the best treatment for pretty much any psychiatric problem.” 

See 4/13/18 Hr’g Tr. at 119. Yet, remarkably, it appears from 

the record that no psychiatrist had seen Gamarra in person, and 

that no therapist of any sort had established a therapeutic 

relationship with Gamarra or treated him on a regular basis 

during the time from September 2017 to April 2018 that he had 

been detained pursuant to a court order to “hospitalize the 

defendant for treatment in a suitable facility.” 18 U.S.C. 

§ 4241(d).

2

The magistrate judge’s order authorizing commitment at

Butner stated, in accordance with 18 U.S.C. § 4241(d)(1), that 

the purpose of confinement was “to determine whether there is 

a substantial probability that in the foreseeable future 

[Gamarra] will attain the capacity to permit the proceedings to 

go forward.” J.A. 31. Gamarra arrived at Butner in September 

2017 and was confined there for seven months prior to his Sell 

hearing. During that period, Dr. Graddy could not recall a 

single in-person meeting with Gamarra, stating only that “I 

may have seen him around. I don’t know. I looked at his 

picture. I’m not sure honestly.” 4/13/18 Hr’g Tr. at 135. Dr. 

Graddy points to the fact that he “received updates” from Dr. 

Laura Enman, a clinical pharmacist, id. at 112, but she appears 

only to have dispensed medication when Gamarra asked for it, 

and was not in a position to support compliance even with that 

limited treatment regimen. A staff psychologist, Dr. DuBois,

saw Gamarra 5-7 times, and a graduate student intern, Ms. 

2 Whatever the situation when Dr. Graddy testified, it appears 

that current ethical guidelines would not support testimony by a 

psychiatrist who did not make reasonable efforts to examine the 

patient in person. See American Psychiatric Ass’n, Opinions of the 

Ethics Committee on The Principles of Medical Ethics 25 (2019), 

available at https://www.psychiatry.org/psychiatrists/practice/ethics.
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Laxton, saw Gamarra 13-15 times before completing their 

report in January 2018. But it appears that their primary 

purpose was to observe him for purposes of writing their report, 

in which context they occasionally challenged some of his 

delusional beliefs; the record does not cast them in a 

therapeutic role. Dr. Graddy confirmed at the Sell hearing that 

“no one who was supervising Mr. Gamarra from a psychiatric 

standpoint” between October 2017 and April 2018 “had a 

medical degree.” 4/13/18 Hr’g Tr. at 138. Apart from 

recounting those contacts, the record says nothing about what 

individual therapeutic attention, if any, Gamarra received at 

Butner.

Under these circumstances, I am skeptical that the record 

contains clear and convincing evidence that no treatment short 

of forcible medication could have rendered Gamarra competent 

for trial. Indeed, the magistrate judge in this case 

recommended that the government’s Sell motion be denied 

precisely because she was uncertain whether Gamarra had 

received treatment at all. J.A. 153-57. Although she framed 

this question as preliminary to the Sell inquiry as a whole, her

concern also goes to whether the government has met its 

burden under the third Sell factor. Of course, none of this is to 

question the basic premise on which all treating personnel 

agreed, namely, that some form of medication would be 

required to render Gamarra competent. The only issue here is

whether the government met its burden of showing that 

garnering voluntary compliance, most likely in the context of 

an in-person therapeutic relationship, could not succeed. 

Revealingly, Dr. Graddy testified that only with a Sell order in 

hand would he embark on “hav[ing] a conversation with 

[Gamarra] about what medication he wanted to start,” and that 

“with [Gamarra’s] input, he could voluntarily decide at that 

point to take medication in conjunction with the court order.” 
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4/13/18 Hr’g Tr. at 123. To decide in favor of involuntary 

medication in these circumstances puts the cart before the 

horse. 

As noted above, Gamarra did not press this issue. In 

general, however, a court should approve a Sell order only 

where the government can demonstrate by clear and 

convincing evidence not only that psychotropic medication is 

needed, but also that medically appropriate efforts at voluntary 

compliance have been made and were not successful.

III.

Finally, in evaluating whether forcible medication is 

warranted, district courts must also look beyond the immediate 

goal of gaining competency for trial to determine whether the 

particular treatment proposed to that end is in the defendant’s 

best interest. Under the fourth Sell factor, courts must therefore 

“conclude that administration of the drugs is medically 

appropriate, i.e., in the patient’s best medical interest in light 

of his medical condition.” Sell, 539 U.S. at 181. The “specific 

kinds of drugs at issue may matter here as elsewhere” because 

“[d]ifferent kinds of antipsychotic drugs may produce different 

side effects and enjoy different levels of success.” Id. This 

factor raises a series of issues that district courts should grapple 

with in resolving Sell motions.

First, the government’s medical personnel should provide 

a specific treatment plan to serve as the basis of their analysis 

of the benefits and side effects of medication, and the court’s 

review of that analysis. As the Tenth Circuit persuasively 

observes, “without knowing which drugs the government 

might administer and at what range of doses, a court cannot 

properly conclude that such a vague treatment plan is 
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‘medically appropriate.’” United States v. Chavez, 734 F.3d 

1247, 1253 (10th Cir. 2013) (quoting Sell, 539 U.S. at 181). 

Here, it is unclear what the Butner staff have in mind as 

Gamarra’s treatment plan. Other than stating that 

Dr. Graddy provides no details about his plans for 

Gamarra. He identifies no specific starting 

dose, nor does he commit to a maximum dosage that Gamarra 

will receive. All we have to go on is the generic statement in 

the appendix that Butner provides in every Sell case, noting that 

 Dr. Graddy testified that he would monitor 

Gamarra and adjust his medication “immediately” in response 

to any side effects. 4/20/18 Hr’g Tr. at 41. He also claimed 

that he would “immediately” act to mitigate any side effects, 

perhaps by using beta blockers. Id. at 42, 46. 

Faced with plans sketched at that level of generality, it is 

difficult to see how a court could make the medically informed 

determinations that the second and fourth Sell factors demand. 

How, for example, would Dr. Graddy modulate his treatment 

“immediately” if he has administered a long-acting form of 

risperidone that lasts several weeks? Indeed, other courts have 

been able to reach those conclusions only by reviewing 

detailed, recommended treatment plans medical personnel

proffer for specific patients, and probing them with the aid of 

academic studies and medical testimony. See, e.g., Onuoha, 

820 F.3d at 1057-60; United States v. Watson, 793 F.3d 416, 

424-27 (4th Cir. 2015); Grigsby, 712 F.3d at 975-76; United 

States v. Evans, 404 F.3d 227, 241 (4th Cir. 2005). It is unclear 

why the government did not provide a specific treatment plan

here and how, without one, a district court can be expected to 
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engage in the “sensitive balancing” that Sell contemplates. 

Dillon, 738 F.3d at 296. 

Second, the government must demonstrate by clear and 

convincing evidence that the particular drug recommended is

medically appropriate. As noted, Sell itself provides that the 

“specific kinds of drugs at issue” are a relevant consideration 

under this factor. Sell, 539 U.S. at 181. In this case, Dr. Graddy 

said that he would pursue a course of risperidone because 

Gamarra has responded well to it in the past. But Gamarra’s 

medical records reveal an incident where he blacked out and 

was hospitalized after ingesting risperidone, with treating staff 

recording an unhealthily low blood pressure level. And 

Gamarra has consistently articulated an aversion to that

particular drug. To be sure, his aversion was irrationally 

expressed. He said that

asserted that 

 But even an aversion

entangled in delusional beliefs would seem to bear on a 

patient’s level of compliance with the proposed medication 

regimen, as well as the likelihood that its administration will be 

unnecessarily traumatic for him. 

Indeed, Dr. Graddy’s own report suggests no reason to 

administer risperidone rather than another antipsychotic, 

especially one such as Seroquel that Gamarra actually favored. 

 

 Gamarra 

requested Seroquel when he arrived at FMC Butner, and he did 

at the outset demonstrate some compliance on it. The Sell 

Appendix asserts that
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 And, 

as applied to Gamarra himself, Dr. Graddy’s report stated that 

 Perhaps there are good medical reasons for Dr. 

Graddy’s choice of risperidone, but those reasons are not 

apparent from the record. 

Third, a court order granting a Sell motion should state

meaningful limitations on what drugs and dosages a defendant 

may receive, and for how long attempts to restore a defendant’s 

competence may continue. Other circuits have required that 

the “order to involuntarily medicate a non-dangerous defendant 

solely in order to render him competent to stand trial must 

specify which medications might be administered and their 

maximum dosages.” Chavez, 734 F.3d at 1253; see also United 

States v. Breedlove, 756 F.3d 1036, 1043-44 (7th Cir. 2014);

United States v. Hernandez-Vasquez, 513 F.3d 908, 916-17 

(9th Cir. 2008); United States v. Bush, 585 F.3d 806, 817-18 

(4th Cir. 2009); Evans, 404 F.3d at 240-42. By statute, once it 

has been determined that “there is a substantial probability that 

in the foreseeable future” a defendant may be rendered 

competent, the defendant may be detained only for “the time 

period specified.” 18 U.S.C. § 4241(d)(1), (d)(2). Here, the 

district court order granting forcible medication required only 

that the “medical staff at FMC Butner submit a report detailing 

Gamarra’s treatment (including the assessment and 

management of any side effects), and any further 

recommendations concerning future treatment within thirty 

(30) days of the commencement of Gamarra’s involuntary 

medication, and then every thirty (30) days thereafter.” J.A. 

207. An open-ended order of this kind impermissibly grants 

the Butner staff “carte blanche” to treat Gamarra as they see fit. 
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Breedlove, 756 F.3d at 1044 (quoting Evans, 404 F.3d at 241). 

This is especially so since Dr. Graddy’s “proposed 

individualized treatment plan” broadly authorizes him to 

 It is thus worth stressing that our 

judgment here does not prevent the district court from seeking 

any further information it may need as Gamarra’s treatment 

proceeds to ensure that the treatment is carried out in a manner 

that is medically appropriate under Sell, and time-limited as 

required by section 4241(d)(2). 

Courts cannot and need not micromanage the medication 

decisions of medical professionals. Cf. Onuoha, 820 F.3d at 

1059; Hernandez-Vasquez, 513 F.3d at 917. The medical 

decisions can be made only by experts. But where the 

government seeks to medicate a defendant in order to prosecute 

him, it must persuade the court that the medical decisions are 

appropriate. In this context, it is not too much to ask that 

doctors propose, and district courts set, basic boundaries on 

permissible treatment, including the drug(s) to be administered, 

the maximum dosage, and the contemplated timeframe for 

treatment. Although Gamarra does not raise these 

considerations, other circuits have required such specificity for

Sell orders within their jurisdiction, and I see no reason why we 

would not follow suit.

* * * 

In light of the serious liberty interest at stake in the forcible 

administration of psychotropic medication, the government 

must demonstrate, in each case by clear and convincing 

evidence, that it retains an important interest in the prosecution, 
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that adequate efforts at voluntary compliance were attempted, 

and that medical staff have provided the court with a treatment 

plan with enough specificity to guide the court’s Sell analysis. 

In turn, the court must guarantee that an appropriate drug has 

been prescribed and specify limits on what treatment the 

patient may receive and for how long. Because Gamarra does 

not raise these considerations on appeal, and in respect for the 

district court’s superior vantage point, I join the opinion of the 

court. But I do so uneasily. I would not in future be inclined 

to rest on a trial-incompetent defendant’s forfeiture of 

arguments to relieve the government of its burden to establish 

each of the Sell factors by clear and convincing evidence.