In th e S u p re m e Co u rt o f Ge o rg ia

De c id e d: Oc to b e r 1 9 , 2 01 5

S 1 5 A0 79 5 . WARREN v . THE S TATE.

NAHMIAS , Ju stic e

.

Je sse Ja m e s Wa rre n h a s b e e n in d ic te d on fo u r c o u n ts o f m u rd e r a n d m a n y

a d d itio n a l c h a rg e s in c o n ne c tio n with a m a ss sh o o t i n g a t a P e n sk e Tru c k in g

Co m p a n y lo c a tio n in Co b b Co u nty on Ja n u a ry 1 2

, 2 0 1 0

, in wh ic h fo u r v ic tim s

we re k ille d a n d a

fifth v ic tim

wa s p a ra ly z e d

. Th e Sta te h a s g iv e n n o tic e o f its

in te nt to se e k th e d e a th p e na lty

. On M arc h 4

, 2 01 3

, Wa rre n file d a sp e c ia l p le a

o f m e n ta l in c o m

p e te n c e to sta n d tria l. S e e O C GA § 1 7-7 -1 3 0 (b ) (2 ). Th a t

sa m e d a y

, th e tria l c o u rt issu e d a n o rd e r fo r Wa r r e n t o b e ev a lu a te d b y th e

Ge o rg ia De p a rtm e n t o f Be h a vio ra l He a lth a n d De v e lo p m e n ta l Disa bilitie s. S e e

OCGA § § 1 7 -7 -1 2 9

, 17 -7 -1 3 0 (b ) (1 ). On Ma y 9, 2 0 1 3

, a fte r re c e iv in g a re p ort

o n th a t e v a lu a tio n fro m Dr. Bria n S c h ie f a n d Dr. Do n Hu g h e y

, wh ic h in d ic a te d

th a t Wa rre n wa s in c om

p e te n t to sta n d tria l b u t m ig h t b e ne fit fro m tre a tm e n t, th e

tria l c o u rt issu e d a n o rd e r fo r Wa rre n t o b e p la c e d in th e c u sto d y o f th e

De p a rtm e n t in o rd e r to re c e iv e fu rth e r p sy c ho lo g ic a l o b se rv a tio n

, e v a lu a t io n

,a n d tre a tm e n t. S e e OCGA § 1 7 -7 -1 3 0 (c ). Wa rre n h a s re m a in e d c o n fin e d in a

sta te p sy c h ia tric ho sp ita l sin c e th a t tim e

. O n N o v e m b e r 1 8

, 2 0 1 3

, t

h e S t a t e f i l e d

a m o tio n re q u e stin g th e a

u th o rity to m e d ic a te Wa rre n in vo lu n ta rily in a n a tte m p t

to m a k e him m e n ta lly c o m p e te n t to sta n d tria l. On Ju n e 2 5, 2 0 1 4

, th e tria l c o urt

h e ld an e v id e n tia ry h e a rin g, a n d o n Ju ly 9

, 2 0 1 4

, th e c o urt file d a sh o rt o rd e r

g ra n tin g th e S ta te ’s m o tio n

. 1 Wa rre n file d a n o tic e o f a p p e a l to th is Co u rt. 2 F o r

th e re a so n s se t fo rth b e lo w, we v a c a te th e tria l c o u rt’s o rd e r a n d re m a n d th e c a se

fo r fu rth e r p ro c e e din g s.

1 On Aug u st 7

, 2014, the trial court filed a related order directing the Department to conduct

further evaluation and r e p orting in conjunction with the involuntary medication. See OCGA § 17-7-

130 (c) - (f). W arren has not appealed from this order.

2 The criminal c a se ag ainst W arren is still pendin g in the trial court, and he did not follow

the procedures required f or an interlocutory appeal, see OCGA § 5-6-34 (b), b u t w e hold that an

immediate appeal of the trial court’s order is authoriz ed under the collateral order doctrine. Under

that doctrine, an order that does not resolve the entire case in the trial c o u r t m a y b e a ppealed

immediately if it “(1) resolves an issue that is ‘substantial l y s e p a ra t e ’ f rom the basic issues to be

decided at trial, (2) would r esult in the loss of an important rig ht if r ev i ew h a d t o await final

judg ment, and (3) completely and conclusively decides the issue on a ppeal such that nothing in the

underly ing action can affect it.” F ulton County v. State, 282 Ga. 570, 5 71 ( 651 SE2d 679) (2007)

(citations omitted). The U.S. Supreme Court has held that a pretrial o rder to involuntarily medicate

a cri m i nal defendant in an effort to r ender him competent to stand trial is immediately appealable

under the federal collateral order doctrine. See Sell v

. U nited States, 539 U. S. 166, 175-177 (123

SCt 2174, 1 56 L E 2d 197) (2003). W e follow that Court’s lead, as w e have in most of our previous

decisions on Georg ia’s version of the doctrine. See Patterson v. State, 248 Ga. 875, 875-877 (287

SE2d 7) (1982) (looking to f ederal collateral order case law in developing the doctrine under Georg ia

law); Scrog g ins v. E dmondson, 250 Ga. 430, 432 (297 SE2d 469) (1982) (same). See also Sosniak

v. State, 292 Ga. 35, 40 (734 SE2d 362) (2012) (overruling Georg ia collateral order doctrine cases

that had “stray ed” from the analog o us U.S. Supreme Court precedents). B ut see Turner v. Giles, 264

Ga. 8 12, 813-814 (450 SE2d 421) (1994) (declining to follow the federal case l a w t h a t allows

immediate appeals of pretrial ruling s deny ing qualified immunity defenses in § 1983 actions).

21

. In tro d uc tio n

In S e ll v

. Un ite d S ta te s, 5 3 9 U. S. 1 6 6 (1 2 3 S Ct 21 74

, 1 5 6 L E2 d 1 9 7 )

(2 0 0 3 ), th e S up re m e Co urt o f th e Un ite d S ta te s e sta b lish e d a fo u r-p a rt te st fo r

d e te rm in in g th e “ ra re ” in sta n c e s w h e n it is c o n stitu tio n a lly p e rm issib le to

in v o lu n ta rily m e d ic a te a m e n ta lly ill c rim in a l d e fe n d a nt fo r th e so le p u rp o se o f

m a k in g him c om

p e te n t to sta n d tria l. Id

. a t 1 8 0

. Un d e r th a t te st, th e Sta te m u st

d e m o n stra te th e fo llo win g: (1 ) im p o rta n t g o v e rn m e n ta l in te re sts are a t sta k e ;

(2 ) in v olu n ta ry m e d ic a tio n w i l l sig n ific a n tly fu rth e r th o se g o v e rn m e n ta l

in te re sts; (3 ) in vo lu n ta ry m e d ic a tio n is n e c e ssa ry to fu rth e r th o se g o v e rn m e n ta l

in te r e s t s ; a n d (4 ) th e a d m in istra tio n o f th e d ru g s to b e u se d is m e d ic a lly

a p p ro p ria te fo r th e d e fe n d a n t. S e e id . a t 1 80 -1 8 1

.

Th is Co u rt ha s n o t p re v io usly a p p l i e d t h e S e ll te st. 3 We n o w h o ld

, in

3 Sell was decided under the United States Co n s t i t u t i o n

, a n d we follow it a s a matter of

federal law. O n appeal, W arren summarily cites three provisions o f the G eorg ia Constitution, only

one of which he raised, also in summary fashion, in the trial court. B ecause the trial court did not

distinctly rule on the application of any of the provisions of the Georg ia Constitution W a rren cites

o n appeal, we ex press no o pinion on them. See Smith v. B aptiste, 287 Ga. 23, 30 ( 6 9 4 S E 2 d 8 3 )

(2010) ( “B ecause Appellees did not raise this constitutional issu e i n t h e trial court and obtain a

distinct ruling on it from that court, the issue cannot be considered for the f irst time in this Court.”).

See also Miller v. Deal, 2 95 Ga. 504, 511 (761 SE2d 274) (2014) (addressing the inadequacy

of a

state constitutional arg ument made in summary fashion on appeal); Hall v

. Terrell, 285 Ga. 448, 457

(679 SE2d 17) (2009) (holding under Supreme Court Rule 22 that c laims raised on appeal without

“sufficient arg ument and citation to a l l o w t h e m to be meaning fully addressed” should be deemed

abandoned).

3a g re e m e n t with th e m a jo rity o f o th e r c o u rts th a t h a v e a d d re sse d th e issu e , th a t

th e first p a rt o f th e te st g e n e ra ll y p r e s e n t s a le g a l q u e stio n a n d th us sh o u ld b e

re v ie we d d e n o v o o n a

p p e a l, wh ile th e re m a in in g th re e p a rts pre se n t p rim a rily

fa c tu a l q u e stio n s a n d th us sh o u l d b e re v ie we d o n ly fo r c le a r e rro r b y th e tria l

c o u rt. Se e

, e .g

., Un ite d S ta te s v

. D illo n

, 7 3 8 F 3 d 2 8 4

, 2 9 1 (D.C. Ci r. 2 0 1 3 )

(c o lle c tin g c a se s); U n ite d S ta te s v

. Dia z

, 63 0 F3 d 1 31 4

, 1 3 3 0 -1 3 3 1 (1 1 th C ir.

2 0 1 1) (sa m e ). 4 We a lso jo in th e p re v a ilin g v ie w a n d h o ld th a t th e S ta te sh o u ld

b e a r th e b u rd e n o f p ro o f o n th e fa c tu a l q ue stio ns in v olv e d u nd e r th e c le a r a n d

c o n v in c in g e v id e n c e sta nd a rd

. Se e

, e

. g

., Dillo n

, 7 3 8 F 3 d a t 2 9 1 -2 9 2 (c o lle c tin g

c a se s); Dia z

, 63 0 F 3 d a t 1 3 3 1 (sa m e ). S e e a lso Ad d in g to n v

. Te x a s, 4 4 1 U. S

.

4 1 8

, 4 3 2 -4 3 3 (9 9 S Ct 18 0 4

, 6 0 LE2 d 3 2 3 ) (1 97 9) (h o ld in g th a t th e c le a r a n d

c o n v in c in g e v id e n c e sta n d a rd is th e lo we st sta n d a rd th a t d u e p ro c e ss p e rm its fo r

c a se s in v o lv in g c iv il c o m m itm e n t).

4 The points to be considered under the first part of the Sell test are often based on undisputed

facts, such as the max imum leng th o f the d efendant’s potential sentence, so the first part is g enerally

suitable for de novo review. However, to the ex tent that any circumstances in the case relevant to

the first part of the test necessitate finding s of f act, those finding s wi l l b e reviewed only for clear

error. See Dillon, 7 38 F 3d at 291 (“To the ex tent that the District Court’s determination under the

fir s t p r o n g o f Sell depends on finding s of fact, we r eview those finding s under a clear-error

standard.” (citation omitted)); United States v. Evans, 404 F 3d 2 27, 2 36 (4th Cir. 2005) (“ The

district c ourt’s determination that the g overnment’s interest is ‘important’ is a leg al conclusion that

we review de novo, althoug h we review any factual finding s relevant to this leg al determination f or

clear error.” (citation omitted)). See also Sell, 539 U.S. at 180 ( “Courts

. . . must consider the facts

of the individual case in evaluating the Government’s interest in prosecution.”).

4In th e d iv isio n s th a t fo llo w, we first re v ie w th e e v id e n c e p re se n te d to th e

tria l c o urt a n d th e n a d d re ss e a c h o f th e fo u r p arts o f th e S e ll te st in d e t a il.

F in d in g c le a r e rro rs in th e t r i a l c o u rt’s ru lin g s, we c o nc lu d e with a d isc u ssio n

o f th e a p p ro p ria te re m e d y in th is c a se

.

2

. Th e Ev id e n c e P re se nte d to th e Tria l Co u rt

Th e e v id e n c e pre se n te d b y th e S ta te in su p p o rt o f its m otio n to h a v e

Wa rre n i n v o l u n ta rily m e dic a te d wa s c om p rise d o f te stim o ny fro m th e

p s yc h i a trist a

n d psy c h o lo g ist w h o h a d c o n d u c te d h is o rig in a l c om p e te n c y

e v a lu a tio n

, Dr. Bry a

n S c h ie f a n d Dr. Do n Hu g h e y

. Th e e vid e n c e pre se n te d b y

Wa rr e n in c lu d e d his m e d ic a l re c o rd s fro m b e fo re a nd a fte r th e sh o o tin g a n d

te stim o n y fro m h is tre a tin g p sy c h ia trist a n d psy c h o lo g ist, Dr. F ra n c is J. Ka n e

,

Jr., a nd Dr. N o rris Cu rre nc e

, a n d fro m a c o n su ltin g p h a rm a c o lo g ist, D r.

Ale x a nd e r Mo rto n

. Ac c o rd in g to th e m e d ic a l re c o rd s an d a ll fiv e e x p e rts,

Wa rre n wa s m e n ta lly in c o m p e te n t to sta n d tria l b e c a

u se o f a d e lu sio n a l d iso rd e r

a n d wa s n o t c u rre n tly ta k in g a n y p sy c h o a c tiv e m e d ic a tio n s. Th e e v id e n c e wa s

o th e rwise in c o n flic t o n im p o rta n t p o in ts, a n d d iso rg a niz e d a n d in c om p le te o n

o th e r sig n ific a n t p o in ts. Ou r re v ie w of th is e v id e n c e i s r a t h e r le n g th y

, b u t

n e c e ssa ry fo r th e le g a l a n a ly sis th a t fo llo ws in Div isio n 3

.

5(a ) Th e S ta te ’s Two Ex p e rt Witn e sse s

(1 ) Dr. S c h ie f

Th e S ta te ’s p rin c ip a l witn e ss wa s Dr. S c h ie f, a psy c h ia trist wh o wo rk s a t

Ge o rg ia Re g io na l Ho sp ita l a n d wh o h a d e va lu a te d Wa rre n m u ltip le tim e s a n d

h a d re v ie w e d h is m e d ic a l re c o rd s. Dr. Sc h ie f te stifie d g e n e ra lly th a t

a n tip sy c h o tic me d i ca t io n s will m a k e d e lu sio n s go a wa y c o m p le te ly in so m e

p e o p le

, th a t o th e r p e o p le will h a v e a p artia l re sp o nse

, th a t o th e rs “ d o n’t

im p ro v e ,” a n d th a t th e re is n o wa y to de te rm in e h o w a g iv e n pe rso n will re sp o n d

to th e m e d ic a tio n s o th e r th a n to a d m in iste r th e m a n d o b se rv e th e re sp o n se

. D r.

S c h i e f sa id

, h o we v e r, “ Ce rta in ly m o st [p e o p le ] ge t b e tte r e n ou g h to b e c om e

c o m p e te n t to sta n d tria l,” a d d in g

, “ Mo st o f th e tim e fo lk s d o v e ry we ll with

th e se m e d ic a tio n s a nd y o u d o n ’t h a v e m a jo r sid e e ffe c ts.”

Tu rn in g to Wa rre n ’s c a se

, Dr. Sc h ie f te stifie d th a t h is d e lu sio ns, in c lu d in g

h is b e lie f th a t h e is a n “e m p e ro r,” wo u ld re n d e r h im in c om p e te n t to sta n d tria l

b e c a u se h e wo u ld q ue stio n th e v a lid ity o f h is c rim in a l p ro c e e d in gs a n d wo u ld

b e “ irra tio n a l a

b o u t h is a p p ro a c h to h is de fe n se a n d wo u ld [b e ] un a b le to a ssist

h is a tto rn e y e ffe c tiv e ly .” Wh e n a sk e d if W a rre n wa s re fu sin g to b e m e d ic a te d

,

Dr. S c h ie f sa id th a t m e d ic a tio n s “ h a ve n ’t b e e n o ffe re d in q u ite so m e tim e , b u t

6wh e n t h e y w e r e la st offe re d h e re fu se d to ta k e th e m

. ” Wh e n a sk e d if Wa rre n

wo u ld b e a

b le to a ssist his d e fe ns e co u n se l if m e d ic a te d

, Dr. S c h ie f re p lie d

,

“ [I] t’s h a rd to pre d ic t h o w [ e a c h in d iv id u a l is] go in g to re sp o n d

, b u t th e re ’s a

su b sta n tia l p ro b a

b ility h e wo u l d b e ab le to a ssist his a tto rn e y with m e d ic in e ,”

a d d in g th a t th e m e d ic a tio n s “ a re u n lik e ly to in te rfe re w i t h a bility to a ssist in

c o u rt.” Re g a rd in g tre a tm e nts o th e r th an m e d ic a tio n

, D r

. S c h ie f sa id

, “ Th e y

m i g h t h a v e b e n e fitte d h im a little b it in te rm s o f o rg a niz in g h is th o u g h ts a n d

c o n firm in g so m e o f th e th in gs h e n e e d e d to k n o w a b o u t c o urt, b ut th e y d id n o t

c o m e v e ry c lo se to g e ttin g h im c o m p e te n t to sta n d tria l.” Ask e d if a d m in iste rin g

m e d ic a tio n to Wa rre n wo u ld b e m e d ic a lly a p p ro pria te

, Dr. S c h ie f a nswe re d

,

“ Ye s,” b u t o ffe re d n o fu rth e r e x p la n a tio n. Dr. S c h ie f a g re e d with Wa rre n ’s

tre a tin g ph y sic ia n

, Dr. Ka n e

, th a t Wa rre n su ffe rs fro m a d e lu sio n a l d iso rd e r b u t

d isa g re e d a

b o u t “ A, w h e th e r th e m e d ic in e is lik e ly to h e lp h im g e t a lo t b e tte r

a n d g e t h im c o m

p e te nt to sta n d tria l, a n d

, B, w h e th e r th e m e d ic in e is lik e ly to

h a v e p ro b le m a tic sid e e ffe c ts fo r h im .”

Dr. S c h ie f th e n d isc u sse d o n e stu d y c o n d u c te d fro m 1 9 6 5 to 1 9 8 5

, wh ic h

sh o we d th a t, wh e n m e d i c a t e d

, “ m o re th a n h a lf o f th e p a tie n ts re c o v e re d

,

me a n i n g w e re so m

uc h b e tte r th a t th e y we re e ith e r sy m p to m fre e or la rg e ly

7sy m

p to m fre e

, ” th a t “ 2 8 p e rc e n t a c h ie ve d p artia l re c o v e ry ,” a n d th a t “ 1 9 p e rc e n t

d id n o t im

p ro v e .” He n o te d th a t a n o th e r stu d y p ub lish e d in 2 0 0 6 sh o we d th a t

“ 5 0 p e r ce n t re c o v e re d

, ju st a b o u t, a n d th e n an o th e r 4 0 pe rc e n t sh o we d

sig nific a n t im

p ro v e m e n t.”

Dr. S c h ie f n e x t e x p la in e d th a t th e re a re th re e “ g e n er a tio n [s] ” o f

a n tip sy c h o tic me d i ca tio n s. Th e first c a rrie s “a h ig he r ra te o f m o v e m e n t

d iso rd e rs o v e r tim e ” ; th e se c o n d c a rrie s a s ma lle r risk o f m o ve m e n t d iso rd e rs

b u t “ a little b it o f a h ig h e r risk o f in c re a sin g p e o p le ’s we ig h t, b lo o d su g a r a n d

c h o le ste ro l” ; a nd th e th ird is “ v e ry lo w in te rm s o f lik e lih o o d o f a d d in g to th e

risk o f in c re a se d blo o d su g a r, c h o le ste ro l a n d we ig h t.” He te stifie d th a t Wa rre n

h a d ta k e n a se c o n d ge n e ra tio n d ru g

, G e o d o n, fo r o n e d ay

, bu t a f t e r Wa rre n

su ffe re d a d e c re a se in b lo o d p re ssu re

, Dr. Ka n e c h a n g e d th e m e d ic a tio n to a first

g e n e ra tio n d ru g

, Ha ld o l. 5 Re g a rd in g th e tre a tm e n t with Ha ld o l, Dr. S c h i e f

te stifie d :

[W a r re n] wa s p re sc rib e d th a t fo r, I th in k 2 0

– 1 9 d a y s a t fo u r

m illig ra m s. He c o m

p la in e d o f so m e tire dn e ss, a n d t h e n it wa s

5 According to his medical records, W a rren took Geodon on May 21 and 22, 2013, and he

took Haldol for a

bout six weeks beg inning on May 29

, 2 0 1 3

. The records indicate that W arren

“refused” to take the Haldol on three occasions, which were o n J une 17, J uly 9, and J uly 10, 2013.

The records do not show any other refusal to take prescribed medication.

8re d u c e d to two m illig ra m s. He to o k th a t fo r a b o u t 2 5 d a y s a n d h e

still c o m p l a i n e d o f tire d n e ss so th e d o c to r sto p p e d a n d d id n ’t try

a n y o th e r m e d ic in e un til a fte r o u r se c o nd e v a lu a tio n in la te Au g u st

[2 0 1 3 ]

, a n d

. . . we su gg e ste d th a t a n o th e r m e d ic in e b e trie d

. Mr.

Wa rre n a g re e d to u s th a t h e wo uld try it, b u t th e n wh e n th e d o c to r

trie d to p re sc rib e it h e re fu se d

. S o re a lly a fte r th a t tim e

, th e 2 5 -d a y

tria l, h e d id n ’t ta k e a ny th in g m o re

.

Wh e n a sk e d h o w lo n g it g e n e ra lly ta ke s fo r an tip sy c h o tic m e dic a tio n s to h a v e

a n e ffe c t o n d e lu sio n s, Dr. S c h ie f sa id :

An a d e q u a te tria l re a lly d e p e n d s o n wh o y o u a sk

, b u t a m in im u m

p ro b a b ly o f fo u r to six we e k s a t a n ad e q u a t e d o se

. Bu t p ro b a b ly

m o re re a listic a lly fo r so m e o n e th a t h a s h a d sy m pto m s fo r a s lo n g a s

Mr. W a r r e n h a s a

n d a re a s se v e re a s Mr. W a rre n ’s a re wo u ld ta k e

. . . a m in im u m o f e ig h t to twe lv e we e k s fo r a tria l.

As fo r sid e e ffe c ts, D r. Sc h ie f te stifie d th a t “y o u c a n ’t e ve r sa y I’m g o in g

to e n su re y o u r sa fe ty ,” b u t in Wa rre n ’s h o sp ita l se ttin g, th e sta ff wo u ld

“ m a x im iz e [h is] sa fe ty a n d m a k e it so th a t a n y sig n ific a n tly b a d o u tc o m e is

u n lik e ly

, o r v e ry un lik e ly .” Dr. S c h ie f in dic a te d th a t th e y wo u ld “ m o n ito r

[Wa rre n ’s] blo o d p re ssu re a t le a st d a ily a n d m o n ito r his b lo o d su g ar re g u la rly

,

m o n ito r h is we ig h t re g u la rly

, a sk h im a b o u t sid e e ffe c ts, o b se rv e h im

, lo o k a t

h is m e n ta l sta tu s.” At th e c o n c lu sio n of h is dire c t e x a m in a tio n by th e S ta te

, D r.

S c h ie f sa id :

9If [Wa rre n ] wa s my pa tie n t a nd I wa s pre s c r i b in g m e d ic in e I

wo u ld n ’t h a ve a p ro b le m in th e rig h t c irc u m sta nc e s, e ith e r a c o u rt

o rd e r o r he a g re e d w i t h p re sc rib in g h im m e d ic in e

. Ev e n h a d h e

–

e v e n if – I d id k n o w th a t h e h a d so m e sid e e ffe c ts to o th e r – to th e

o th e r two m e d ic in e s, it d o e sn ’t m e a n th a t h e ’s g o in g to h a v e sid e

e ffe c ts to a

d iffe re n t m e d ic a tio n

.

O n cr o ss-e x a m in a tio n

, Dr. S c hie f liste d a n u m b e r of first, se c o n d

, a n d

th ird ge n e ra tio n a n tip sy c h o tic m e dic a tio n s. He sta te d th a t Risp e rd a l w a s th e la st

m e d ic a tio n re c o m m e n d e d to Wa rre n b u t th a t “ h e re fu se d to try it.” Dr. S c h ie f

sa id th a t Wa rre n ’s d ro p in b lo o d p re ssu re w h e n g iv e n Ge o d o n wa s n o t

“ d ra m a tic ” b u t th a t h e wo u ld n o t c ritic iz e Dr. Ka n e ’s d e c isio n to d isc o n tin u e

th a t m e d ic a tio n. Re g a rd in g th e two stu die s h e h a d c ite d

, D r. S c h ie f

a c k n o wle d g e d th a t h e wa s u n c e rta in a b ou t wh a t d ru g s h a d b e e n in v o lv e d

,

in c lu din g wh e th e r th e stu d ie s in c lu d e d a d ru g c a lle d P im o z id e

, wh ic h h e

a d m itte d m ig h t n o t b e a v a ilab le in th e Un ite d S ta te s.

Wh e n a sk e d dire c tly if h e wa s p ro po sin g a n y sp e c ific m e dic a tio n fo r

W a r r e n

, D r

. S c h ie f a n swe re d

, “ No .” Dr. S c h ie f te stifie d th a t Wa rre n wa s 6 4

y e a rs o ld a

n d h a d a h isto ry o f d ia

b e te s th a t wa s c u rre n tly “ die t c o n tro lle d ” b u t

h a d p re v io u sly b e e n c o n tro lle d with m e d ic a tio n

. A sk e d wh e th e r a n “ a ty p ic a l”

(th ird g e n e ra tio n) a n tip sy c h o tic d ru g c o u ld wo rse n Wa rre n ’s d ia be te s by ra isin g

10h is b lo od su ga r le ve ls, Dr. S c h ie f re p lie d :

I d o n ’t a g re e with th a t. I th in k th e re ’s a fe w th a t

– I d o n ’t e v e n

k n o w if I wo u ld c a ll it su b sta n tia l, b u t th e re is so m e risk o f th a t w ith

m a yb e th e wo rst c o u p le [ o f d ru g s]

. Oth e r th an th a t, m o st o f th e m

I wo u ld n ’t c a ll it su b sta n tia l risk o f m a k in g it sig n ific antly wo rse

. Th e re ’s so m e risk

.

He c o u l d n o t q u a

n tify th e risk

, b u t h e e x p la in e d th a t h e h a s “ tre a te d p le n ty o f

p e o p le w ith d i a b et e s ” a n d “ th e re a re so m e [m e d ic a tio n s] th a t a re kn own to b e

n e u tra l in th is re g a rd ,” in c lu d in g “ La tu d a

, S a ph ris, F a n a

p t, Ge o d o n

, a nd Ab ilify

is o n th e b o rd e r.”

Dr. S c h ie f a c kn o wle d g e d th a t Wa rre n a lso h a d a h isto ry of h y pe rte n sio n

(h ig h b lo o d pre ssu re ), a d d in g :

Yo u h a v e to b e c a

u tio u s. If th e y ’re n o t c o ntra in d ic a te d

, a n d a ga in

, th e re a re so m e [d ru g s] th a t a re fa irly

– a re th ou gh t to b e n e u tra l in

th is in te rm s o f b lo o d su g a r, wh ic h c a n p u t p e o p le a t hig h e r risk o f

h e a rt d ise a se , h ig he r c h o le ste ro l, wh ic h c a n in c re a se th a t risk , an d

in te rm s o f we ig h t. S o m e o f th e se m e dic in e s a re n e u tra l in th is

re g a rd

. Ag a in

, fo r h im I wo u ld p ro ba b ly wa n t to a v oid so m e of th e

wo rst o ffe nd e rs, a t le a st a t first, in o rd e r to c ho o se th e on e s th a t a re

le ss lik e ly to c a

u se th a t p ro b le m

. B u t th e h o sp ita l c a n m on ito r v e ry

c lo se ly th in gs lik e h is c h o le ste ro l, b lo o d su g ar, b lo o d p re ssu re a n d

we ig h t, c ha n g e th e m e dic in e

, c h a ng e th e do se if so m e th in g we re to

h a p p e n

. Bu t e v e n fo r p e o p le with h e a r t d i se a se a n d a h isto ry o f

d ia b e te s – o r a h isto ry o f h e a rt d ise a se

, a h isto ry o f d ia b e te s, a

h isto ry o f h y

p e r t e n sio n, th e se m e d ic in e s a re n ’t c o n tra in d ic a te d o r

th o u g h t to b e d a ng e ro us. T h e y ’re u s e d a ll th e tim e in th is se ttin g

with fo lk s lik e th a t.

11With ou t sp e c ify in g w h ic h d ru g s h e wa s re fe re nc in g

, Dr. S c h ie f sta te d th a t so m e

m e d ic a tio n s a re “wo rse o ffe n d e rs” th a t he wo u ld av o i d b u t th a t “ a s a g e n e ra l

c la ss, n o , th e re isn ’t a c o n tra in d ic a tio n with th ose

. ”

Dr. S c h ie f a lso a g re e d th a t so m e o n e lik e Wa rre n wh o h a s su ffe re d fro m

d e lu sio n s fo r a lo n g tim e is le ss lik e ly to re sp o n d to m e d ic a tio n , b u t h e a d d e d

,

“ I d on ’t h a v e sta tistic s, b u t in my e x p e rie n c e a p re tty h ig h p er c e n t a g e

. . . g e t

b e tte r.” He c on tin u e d :

[Y] o u c a n im

p ro ve [Wa rre n’s] be h a v io r in th e se n se o f w o rk in g o n

th in gs h e ’s no t wo rk in g o n lik e le a rn in g a b o u t his illn e ss, e n g a g in g

in a re la p se p re v e n tio n p la n so th a t h e c a n th i n k a b o u t h o w th is

illn e ss h a s a ffe c te d his life a n d h o w he c o u ld so m e da y re in te g ra te

in to th e c o m m

u n ity p e rh a

p s, o r e v e n in to th e sm a lle r c o m m u n ity o f

th e h o sp ita l in a wa y with a lit t l e m o r e f

re e d o m

, fig urin g o ut h o w

h e c a n re la te a little b e tte r to o th e rs th a t m a y b e in sid e a nd o u tsid e

th e h o sp ita l if h e d o e sn ’t h a v e th is b e lie f a n d th e se so rts o f th in g s.

S o in th a t se n se

, in a b ro a d e r life fu nc tio n in g se n se I th in k h e c o u ld

d o b e tte r. Bu t in te rm s o f h i s d a y -to -d a y in te ra c tio ns, y o u k no w

,

we ’v e he a

rd h e isn ’t pre se n tin g a n y k in d o f p ro ble m s, s o t h a t ’s

–

th e re ’s re a lly n o t m

uc h ro o m f

o r im p ro ve m e n t in te rm s o f

p re se n tin g a

p ro b le m , to th e h o sp ita l sta ff.

Re g a rd in g h o w m e dic a tio n wo u ld a ffe c t th e risk th a t Wa rre n pre se n ts to th e

h o sp ita l sta ff, Dr. S c h ie f te stifie d :

He wo u ld g o f

r o m a sm a ll

– a lo w risk

, wh ic h h e is n ow, to I

b e lie v e a n e ve n lo we r risk

, b e c a u se th e re wo u ld b e le ss lik e ly so m e

12c h a n c e th a t h e c o u ld in c o rp o ra te o th e r p e o p le in th e h o sp ita l in to h is

d e lu sio n a l sy ste m

, wh ic h h e ’s o bv io u sly d o n e in o th e r p la c e s in h is

life

.

Dr. S c h ie f sa id th a t he wa s u n c e rta in wh e th e r m e d ic a tin g Wa rre n wo u ld a llo w

h im to re in te g ra te in to so c ie ty

, b u t it wo u ld lik e ly a t le a st im p ro v e h is a

b ility to

c o m m u nic a te with a n d re la te to o th e rs.

(2 ) Dr. Hu g h e y

Th e S ta t e n e x t p re se n te d te stim o ny fro m Dr. Hu g he y

, a p sy c h o lo g ist a t

Ge o rg ia Re gio na l H o sp ita l wh o h a d e v a lu a te d Wa rre n m u ltip le tim e s a n d a lso

h a d re v ie we d his m e d ic a l re c o rd s. Dr. Hu gh e y a g re e d wi t h D r

. S c h ie f th a t

Wa rr e n h a s a d e lu sio n a l d iso rd e r a n d th a t h e is in c o m p e te n t to sta n d tria l

b e c a u se

, a lth o u g h h e u n d e rsto o d th e n a tu re o f th e p ro c e e d in g s, “ h e h a d c e rta in

b e lie fs re la te d to th o se c h a rg e s th a t wo u ld in te rfe re with h is ra tio n a lly a sse ssin g

h is c a se ” a nd wo u ld c a

u se h im d iffic u lty in wo rk in g with h is c o un se l a n d

m a k in g d e c isio n s in h is own b e st in te re st. Dr. Hu g h e y te stifie d th a t d e lu sio n s

a re u su a lly tre a te d with a c o m b in a tio n o f m e d ic a tio n a n d “ ta lk th e ra p y ” a n d th a t,

“ [b ] a se d o n th e p u b lish e d lite ra tu re

, b e twe e n 50 a n d 7 7 p e rc e n t [o f p a tie n ts] c a n

h a v e a re d u c tio n in th e ir sy m p to m s with tre a tm e n t.” Dr. Hu g h e y n o t e d t h a t

tre a tin g Wa rre n a t th e h o sp ita l wo uld a llo w fo r “ f re q ue n t la

b wo rk a n d

13m o n it o rin g d a ily by n u rsin g sta ff.” Dr. H u g he y o p in e d th a t “ w ith tre a tm e n t

[Wa rre n ] c o u ld b e re sto re d to c o m p e te n c y ,” b u t sa id “[h ]e i s r e f u sin g

m e d ic a tio n s.” Re g a rd in g wh e th e r m e dic a tio n w o u l d in te rfe re with Wa rre n ’s

a b ility to a ssist his c ou nse l, Dr. Hu g h e y a n swe re d g e n e ric a lly

, “ Ma n y p e o p le a re

o n m e d ic a tio n a n d still p ro c e e d e d to th e ir tria ls.” H e c o n c lu d e d h is d ire c t

te stim o n y b y sta tin g

, “ F o r th e p a st y e a r a t Ce n tra l S ta te [Ho sp ita l, Wa rre n ] ha s

re c e iv e d e d u c a tio n o n le g a l issu e s, h e ’s re c e iv e d in d iv id u a l a n d gro u p th e ra p ie s.

Th e se h a v e no t a ffe c te d h is fix e d b e lie fs. Th e y a re in ta c t a s th e y we re wh e n we

first sa w h im .”

On c ro ss-e x a m in a tio n

, Dr. Hu g h e y a d m itte d th a t th e 5 0 to 7 7 p e rc e n t

im p ro v e m e n t ra te th a t h e h a d re fe re n c e d wa s fro m a ge n e ra l re v ie w o f lite ra tu re

re g a rd in g stu d ie s th a t in c lu de d p a tie n ts with p ro ble m s o th e r th a n d e lu sio n s, th a t

lo n g sta n d in g de lu sio ns a

re m o re d iffic u lt to tre a t, a n d th a t W a rre n h a s su ffe re d

d e l u sio n s fo r a t le a st 10 y e a rs. Wh e n a sk e d if h e wa s p ro p o sin g a sp e c ific

tre a tm e nt p la n

, Dr. Hu g h e y re p lie d

, “ [A] s a p sy c h olo g ist I d o n o t p re sc r i b e

m e d ic a tio n s. Th a t wo u ld b e u p to th e tre a tin g p hy sic ia n a t Ce n tr a l S t a te .”

Re g a rd in g th e d e c isio n b y Wa rre n ’s tre a tin g p h y sic ia n, Dr. Ka n e

, to lo we r th e

d o sa g e o f Ha ld o l a n d th e n to d i s c o n tin u e th e m e d ic a tio n c o m p le te ly

, D r.

14Hu g he y sa id

, “ We ll, [Wa rre n ] wa s c o m p la i n in g o f sid e e ffe c ts. Ma ny tim e s

p e o p le c o m

p la in of s i d e e ffe c ts wh e n th e y a c tu a lly d o n o t w a n t to ta k e th e

m e d ic a tio n .” Dr. H u g he y a c k n owle d g e d

, h o we v e r, th a t Dr. Ka n e h a d m a d e a

m e d ic a l de c isio n to d isc o n tin u e th e H a ld o l. Dr. Hu g h e y a lso a c kn o wle d g e d th a t

th e e a rlie r tr e a tm e n t w ith Ge o d o n ha d c a u se d a “ d ra m a tic ” dro p in Wa rre n ’s

b lo o d p re ssu re

.

Dr. Hu g h e y c ite d wh a t a

p p e a re d to b e o n e pa rtic u la r stu d y in wh ic h 1 7 o f

e ith e r 2 2 o r 3 2 pa tie n ts with a d e lu sio n a l d iso rd e r “ we re re sto re d to c om p e te n c y

with tre a tm e n t ” w i t h a first g e n e ra tio n a n tip sy c h otic m e d ic a tio n

. Dr. Hu g h e y

a g re e d th a t th e re a re “se v e r a l sid e e ffe c ts th a t c a n c om e with m e d ic a tio n s.

Mo v e m e n t diso rd e rs, c a lle d e x tra p y ra m id a l sy m

p to m s wo uld b e o ne

, th e y c a n

a ffe c t m e ta

b o lic p ro c e sse s su c h a s d ia b e te s, we ig h t, a n d c a n a ffe c t b lo o d

p re ssu re

, a tte ntio n, c o n c e n tra tio n

, g a it.” He a lso n o te d th a t a g e c a n be a risk

fa c to r, d e p e n d in g on a p a tie n t’s h e a lth

. Re g a rd in g th e sp e c ific risk s to Wa rre n

b a se d o n h is d ia

b e te s, h y p e rte n sio n , an d p o ssib le h isto ry o f a h e a rt a tta c k

, D r.

Hu g he y sa id

, “ Th e se wo u ld b e risk fa c to rs. Y o u wo u ld n e e d to a sk a p h y sic ia n

fo r sp e c i f

i c d e ta ils o f th o se

, sin c e a s a p sy c ho lo gist I d o n’t p re sc rib e

m e d ic a tio n .”

15(b ) Wa rre n ’s Th re e Ex p e rt Witn e sse s

(1 ) Dr. Ka

n e

Afte r th e S ta te re ste d its c a s e

, th e d e fe n se p re se n te d te stim o ny fro m D r.

Ka n e

, th e p sy c h ia trist wh o h a d se rv e d a s Wa rre n ’s tre a tin g p h y sic ia n a t Ce n tra l

S ta te Ho sp ita l sin c e Wa rre n wa s tra n sfe rre d th e re sh o rtly a fte r th e tria l c o u rt’s

Ma y 9

, 2 0 1 3 o rd e r. Dr. Ka n e c o n firm e d th a t Wa rre n h a d b e e n d ia g n o se d a s

h a v in g a d e lu sio n a l d iso rd e r fro m wh ic h he h a d su ffe re d sin c e a t le a st 2 0 0 5 ; th e

d e lu sio n s in vo lv e h is b e lie fs a b o u t h a v in g m a d e d isc o ve rie s wo rth m illio n s o f

d o lla rs th a t we re ta k e n fro m h im o r a tte m pte d to b e ta k e n fro m him by v a rio u s

p e o p le

. Dr. Ka n e te stifie d th a t su c h lo n g sta n d in g d e lu sio n s a re m o re d iffic u lt

to tre a t; th a t d e lu sio n s fro m a d e lu sio n a l d iso rd e r a re m o re d iffic u lt to tre a t th a n

d e lu sio n s fro m sc h iz o p h re n ia o r b ip o la r d iso rd e r; th a t p a tie n ts with a d e lu sio n a l

d iso rd e r se ld o m o b ta in c o m p le te re lie f fro m th e ir de lu sio n s; a n d th a t he k n e w

o f n o o n e with a fix e d d e lu sio n w h o h a d be e n c u re d

, a lth o ug h so m e p e rso n s

with d e lu sio n a l d iso r d er s h a v e im p ro v e d to th e p o in t o f b e in g c o m p e te n t to

sta n d tria l. Dr. Ka n e sa id t h a t d e l u sio n a l p a tie n ts m a y b e n e fit fro m tre a tm e n t

with m e dic a tio n e v e n if th e y m a y n o t lo se th e ir p sy c h o tic s y mp t o m s, b e c a use

“ th e y w ill b e c o m e m

uc h le ss a n x io u s a n d n e rv ou s” a nd “ th e y m a y e ve n b e a b le

16to wo rk a n d liv e with th e ir fa m ily a n d e n jo y a m e n i t i e s o f so c ia l life with o u t

b e in g u nd u ly distu rb e d .”

Dr. Ka ne th e n d isc u s s e d th e “m a n y risk s” a sso c ia te d with a n tip sy c h o tic

m e d ic a tio n s, in c lu d in g “ ta rd iv e d y sk in e sia w h e re [p a tie n ts] re c e iv e p e rm a n e n t

n e u ro lo g ic a l sy m

p to m s” su c h a s c o n to rte d lip s a n d bo d ie s. Wh e n a sk e d

wh e th e r tre a tin g Wa rre n with a n tip sy c h o tic m e d ic a tio n wo u ld b e m e d ic a lly

a p p ro p ria te

, Dr. Ka

n e sa id :

We ll, we trie d m e d ic in e o n two o c c a sio n s with h im

, a n d h e

– o n o n e

o c c a sio n [with Ge o d o n ] h e

– h is b lo o d p re ssu re d ro p p e d, a nd o f

c o u rse h e h a s a h isto ry o f

– h is EKG sh o ws so m e su gg e stio n h e

m a y h a ve h a d a p re v io u s h e a rt a tta c k

, so we c o u ld n ’t c o n tin u e th a t

m e d ic in e a nd ha v e h is b lo o d p re ssu re d ro p

. We tri e d h i m o n

a n o th e r m e d ic in e [Ha ld o l,] wh ic h wa s n o t risk y fo r h is dia b e te s, b u t

h e b e c a m e se d a te d o n th a t. A n d of c o u rse w e d id n’t wa n t h im

fa llin g d o wn b e c a

u se h e wa s dro wsy

, wh ic h so m e tim e s h a p pe n s.

S o a fte r I trie d th o se t w o a n d s in c e h e wa s no c lin ic a l p ro ble m o n

my u n it, h e wa s v e ry w e ll b e h a v e d

, n e v e r m e n tio ne d h is d e lu sio n a l

id e a s to o th e r p e o p le

, u n le ss we a sk e d h im

, h e wa s no t a b e h a v i o r

p ro b le m a t a ll. Ve ry c o o p e ra tiv e

, p le a sa n t. I sa w n o u rg e n c y in

tre a tin g h im fo r th a t re a so n

.

Dr. Ka n e a d d e d th a t Wa rre n h a d ne v e r b e e n d i s r u ptiv e o r in ju rio u s to a n y o n e

e lse in th e h osp ita l an d h a d a lwa y s b e e n c o m p lia n t.

Ask e d a g a in a

b o u t Wa rre n ’s p re v io u s tre a tm e n t with me d ic a tio n s, D r.

Ka n e e x p la in e d th a t Wa rre n h a d b e e n g iv e n two d ru gs:

17Ge o d on is le ss lik e ly to c o m p lic a te th e d ia

b e te s, bu t w h e n h e g o t

lo w b lo o d p re ssu re we c o u ld n ’t go th e re

. An d Ha ld o l a lso d o e s n o t

g e t in th e wa y o f h is d ia b e te s, b u t h e b e c a m e se d a te d a n d w e

b e c a m e c on c e rn e d a

b o u t h im fa llin g, so we sto p p e d th a t.

Dr. Ka n e re ite ra te d th a t th e H a l d o l wa s d isc o ntin u e d b a se d on a m e d ic a l

d e c isio n , e x p la in in g :

It b e c a m e c le a r to m e th a t [Wa rre n ] wa s n o t to le ra tin g tre a tm e n t

with p h a rm a c [o lo g ic a l] th e ra p y v e ry we ll, a nd sin c e h e wa s n o t a

b i g tim e be h a v io r p ro b le m I fe lt

– y o u k n o w, I trie d a c o u p le o f

tim e s a n d , y o u k no w , it ju st – it wa s risk y , an d so I – th a t d e te rre d

m e fro m fu rth e r e xp e rim e n ta tio n

.

Dr. Ka n e te stifie d th a t he wa s “ v e ry d o u b t f u l ” th a t a n tip sy c h o tic

m e d ic a tio n wo u ld h a v e a p o sit i v e e f f e c t on Wa rre n b e c a

use “th e tra c k re c o rd

a n d th e sc ie ntific lite ra tu re is su c h th a t it isn ’t

– th e y [p a tie n ts with a d e lu sio n a l

d iso rd e r] a re v e ry d iffic u lt to tre a t.” Wh e n a sk e d if h e b e lie v e d th a t Wa rre n ’s

c o m p e te n c e to sta n d tria l c o u ld b e re sto re d

, D r. Ka n e an swe re d, “ [T] h a t

c e rta in ly h a sn ’t h a

p p e n e d

– o c c u rre d up till n o w.” As fo r th e risk s Wa rre n fa c e s

fro m m e d ic a tio n du e to h is d ia b e te s, Dr. Ka

n e sa id :

Th e re ’s a c e rta in p e rc e n ta ge o f p a tie n ts wh o su ffe r fo r

– th e lo ng e r

th e p a t i e n t is o n m e d ic in e th e m o re lik e ly it is th a t h e will su ffe r

u n d e s ira b le sid e e ffe c ts. Ho w se rio u s th o se a re

, y o u k n o w, w e

se e m to b e g e ttin g b e tte r d ru g s in so m e re g a rd fo r c e rta in p ro ble m s

th a n o th e rs, a nd so w e k e e p h o p in g fo r th a t.

18Dr. Ka

ne n o te d th a t o n e d ru g , P im o z id e , “ wo rk e d pre tty we ll [with fe w e r sid e

e ffe c ts] b u t i s u n a v a ilab le in th is c o u n try a n d th e F DA wo u ld n o t a pp ro v e it.”

He a d d e d th a t o ld e r p e o p l e f a c e a g re a te r risk of su ffe rin g n e u ro lo g ic a l sid e

e ffe c ts fro m a n tip sy c h o tic m e d ic a tio n s, an d re g ard in g W a rre n

, “ we t r i e d a n d

h e ’s se n sitiv e

, a n d so th a t m a k e s h im n o t e a sy to tre a t.” Wh e n a sk e d if Wa rre n

h a d e ve r re fu se d to ta k e a n y m e d ic a tio n

, Dr. Ka n e re p lie d

, “ He to ld m e h e d id n’t

lik e th e m

, h e to ld m e th e sid e e ffe c ts h e wa s h a v in g

, so m e o f w h ic h

– h is b lo o d

p re ssu re d ro p p e d . No

, h e h a s n e v e r re fu se d .”

On c ro ss-e xa m in a tio n

, h o w e v e r

, D r

. Ka n e sa id th a t Wa rre n h a d re fu se d

m e d ic a tio n be c a

u se h e wa s su ffe rin g sid e e ffe c ts a nd b e c a u se he d id n ot b e lie v e

th a t h e wa s p sy c h o tic

. W h e n a sk e d a b o u t th e u se o f th e a lte rn a tiv e m e d ic a tio n s

S a p hris, La tu d a

, a n d Fa n a

p t, D r. Ka n e sta te d th a t th e y we re “ m e -to o ” d ru g s th a t

we re “ n o t sig n ific a n tly diffe re n t th a n

, sa y

, Ge o d o n .” He a g re e d th a t d i ffe re n t

d ru g s c o u ld c re a te d iffe re nt sid e e ffe c ts, th a t it wa s im p ossib le to k n o w wh e th e r

t h e y wo u ld im

pro v e Wa rre n ’s sy m

p to m s with o u t a c tu a lly try in g th e m

, th a t

Wa rre n m ig h t “p o ssib ly ” b e re sto re d to c om p e te n c e if giv e n m e d ic a t i o n

, a n d

th a t it c o u ld b e “wo rth a try .” Wh e n a sk e d if he wa s c a te g o ric a lly a g a in st g iv in g

Wa rre n m e d ic a tio n

, Dr. Ka n e a n s w e r e d

, “No ,” b ut h e a d d e d

, “ I a m wo rrie d

19a

b o u t it, b ut I

– I d o n ’t wa n t to g o to ja il,” a p pa re n tly re fe rrin g to th e p o te n tia l

fo r be in g ja ile d if h e re fu se d to c o m p ly with a c o u rt o rd e r to m e d ic a te Wa rre n

.

Dr. Ka ne re ite ra te d th a t h is c o n c e rn s in c lu d e d th e fa c t th a t Wa rre n h a d p ro v e n

“ se n sitiv e ” to two d ru g s th a t a re k n o wn to h a v e a m in im a l e ffe c t o n d ia b e te s, b u t

h e a g re e d th a t o th e r d ru g s c o u ld b e trie d. He a lso a g re e d th a t tre a tin g p a tie n ts

in Wa rre n ’s c o n d itio n with dru g s wa s “c o m m o n ” a n d th a t su c h tre a tm e n t c o u ld

b e n e fit Wa rre n b y m a k in g h im c o m p e te n t. Dr. Ka n e n o te d t h a t so m e

m e d ic a tio n s c o u ld b e u se d to tre a t Wa rre n o n ly if h e we re willin g to c oo p e ra te

,

b e c a u se th e d ru g s a re ta ke n o ra lly

.

On re dire c t e x a m in a tio n

, D r. Ka ne wa s a sk e d a ga in wh e th e r W a rre n h a d

e v e r re fu se d m e d ic a tio n

, a n d e x p la in e d :

[I] t wa s a lwa y s a p e rsu a sio n fo r Mr. Wa rre n to ta k e m e d ic in e . He

d id no t th in k h e n e e d e d it, a n d I to ld h im

, y o u k n ow, wh a t I te ll a ll

p a tie n ts, th a t th e ju d g e h a s se n t th e m th e re fo r e v a lu a tio n a n d

tre a tm e n t a n d I’m ob lig a te d to tre a t h im

. An d h e trie d th e m e d ic in e

a n d he

– y o u k n o w, h e n e v e r lik e d it an d h e d id n ’t th in k h e n e e d e d

it. A n d t h a t w a s a lwa y s

– y o u k no w

, I d id n ’t write a b ou t th a t [in

Wa rre n ’s m e d ic a l re c o rd ] b e c a u se th a t wa s u n de rsto o d b e twe e n h e

a n d I. S o

– b u t h e d i d t ak e th e m e d ic in e

, a nd wh e n h e sta rte d

c o m p la in in g of se d a tio n a n d my sta ff b e c a m e c o n c e rn e d a b ou t th is

th e n we d e c id e d t h a t w a s a n o th e r strik e o u t a n d th a t’s w h e n I

d e c id e d to so rt o f sit o n th in g s.

Wh e n a sk e d if th ird g e n e ra tio n a n tip sy c h o tic m e d ic a ti o n s we re sig n ific a n tly

20d iffe re n t th a n th e p re v io u s g e n e ra tio n s

, D r

. Ka n e a n swe re d

, “ T he d ru g

c o m p a nie s wo u ld lik e y o u to th in k so , b u t th e y a re n ’t.”

(2 ) Dr. Cu rre nc e

Wa rre n n e x t pre se n te d th e te stim o n y o f Dr. Cu rre n c e

, a p sy c h o l o g i s t a t

Ce n tra l S ta te Ho sp ita l wh o h a d tre a te d Wa rre n th e re

. Dr. Cu rre n c e te stifie d th a t

Wa rre n ’s b e h a v io r a t th e h o sp ita l “ h a s b e e n c o m p lia n t a n d a

p p ro pria te ” a n d th a t

h e ha s n ot re q uire d “ in te n siv e c li n i c a l tre a tm e n t” b e c a u se h e h a s b e e n

“ b e h a vio r a l l y sta b le a nd e m o tio na lly sta b le .” D r. Cu rre nc e c o n firm e d th a t

Wa rre n h a d b e e n d ia gn o se d a s h a v in g a de lu sio n a l d iso rd e r, e xp la in in g th a t h e

“ c u rre n tly h a s a fix e d d e lu sio n in v o lv in g h is b e lie f th a t h e h a s b e e n th e v ic tim

o f a ro b b e ry , m illio n s o f d o lla rs h a v e b e e n sto le n fro m h im

, a n d [it] is k in d o f

a gra n d io se a n d p a ra n o id ty pe o f d e lu sio n a l be lie f sy ste m

. ” Dr. Cu rre n c e n o te d

th a t Wa rre n ’s “fix e d d e lu sio n s” h a v e e x iste d fo r a lo n g tim e

, th a t d e lu sio n a l

d iso rd e r is m o re diffic u lt to tr e a t t h a n d e lu sio n s re la te d to sc h iz o p hre n ia o r

b ip o la r d iso rd e r, a n d th a t Wa rre n ’s d e lu sio n s w e re n o t re d uc e d w h e n h e wa s

ta k in g m e d ic a tio n s. Dr. Cu rre n c e te stifie d th a t Wa rre n ’s d e lu sio n s c o u ld a ffe c t

h is a bility to a ssist h is c o u n se l a n d to u n d e rsta n d th e im p lic a tio n s o f te stify in g

.

Dr. C u rre n c e a c k n o w le d g e d th a t h e h a d n o sp e c ific e d u c a tio n o r tra in in g o n th e

21e ffe c t o f m e d ic a tio n s a n d wa s n o t a u th o riz e d to p re sc rib e m e dic a tio n s. Wh e n

a sk e d if m e dic a tio n c o u ld im pro v e fix e d d e lu sio n s, h e re p lie d

, “ On c e a g a in

, I’d

ra th e r no t be sp e c ific re g a rd in g Mr. Wa rre n

. I c a n sa y th a t I h a v e wo rk e d with

in d iv id u a ls wh o h a d fix e d d e lu sio n s in th e p a st a nd

. . . t h o s e d e l u sio n s we re

h ig h ly re sista n t to m e d ic a l in te rv e n tio n s.”

On c ro ss-e x a m in a tio n, Dr. Cu rre n c e a d m itte d th a t h e a lso k n e w p e rso n s

with fix e d d e lu sio n s wh o sh o we d im pro v e m e n t to th e e x te n t th a t th e y wo u ld b e

a b le to a ssist th e ir c ou n se l in th e ir o wn de fe nse

. Dr. Cu rre n c e a lso te stifie d th a t

“ if [Wa rre n ] wa s a

bso lu te ly fre e with o ut a n y ty pe o f su p er v isio n

, I wo u ld

d e fin ite ly h a v e so m e c o n c e rn s a b o u t h is a b ility to c a re fo r h im se lf o r his risk to

th e p u b lic .”

On re d ire c t e x a m in a tio n, Dr. Cu rre n c e n o te d th a t W a r r e n “ h a s n e v e r g iv e n

u s a n y re a so n to b e lie v e th a t h e wo uld b e o p p o sitio n a l o r n o n c o m p lia n t with a n y

re a so na b le d e m a n d of th e h o sp ita l.” Dr. Cu rre nc e a d d e d th a t W a rre n h a d

in d ic a te d th a t h e b e lie v e d th a t “ re ta lia tin g in a v e ry v io le n t wa y ” wo u ld b e

a p p ro p ria te if so m e o n e w e re th e v ic tim o f a th e ft, wh ic h o c c u rs o f t e n a t th e

h o sp ita l, b u t th a t “h e h a sn ’t d e m o n stra te d a n y ty p e o f ph y s i c a l in d ic a to rs th a t

h e w o u ld be a g g re ssiv e to wa rd s a n yb o d y ” th e re

. Dr. Cu rre n c e e x p la in e d

, “ He

22h a s a v e ry h ig h le v e l of c o p in g sk ills. S o h e ’s d e m o n stra te d be h a v io ra l c o n tro l

d e sp ite th e de lu sio n a l b e lie f.” Ne v e rth e le ss, Dr. C u rre n c e sa id th a t Wa rre n ’s

a b ility to a ssist h is c o u n se l “ wo u ld b e fu n n e le d th ro u g h th a t filte r o f d e lu sio n .”

Dr. Cu rre n c e e xp la in e d th a t h e h a d s e e n “ t a lk th e ra p y ” o ffe r so m e su c c e ss in

c h a n g in g th e b e h a v io r o f d e lu sio n a l p e rso ns, b u t h e ha d s e e n l i ttle su c c e ss

th ro u g h tre a tm e n t with m e d ic a tio n

.

(3 ) Dr. Mo rto n

F in a lly

, Wa rre n pre se n te d th e te stim o n y of Dr. Mo rto n

, a ph arm a c o lo g ist

with a c o n su ltin g b u sin e ss wh o h a d ne v e r tre a te d Wa rre n b u t h a d re v ie we d h is

m e d ic a l re c o rd s. Dr. Mo rto n e x p la in e d th a t o ld e r a n tip sy c h o tic d ru g s we re le ss

e f f ec t i v e a n d “ h a d a n u m b e r o f sid e e ffe c ts” ; th a t n e we r “ a ty p ic a l ”

a n tip sy c h o tic s h a v e b e e n to u te d a s b e in g m o re e ffe c tiv e a n d a s h a v in g fe we r

sid e e ffe c ts, b u t “th e c lin ic a l tria ls h a v e qu e stio n e d th a t” ; a n d th a t “b o th ty p ic a l

a n d a ty p ic a l [d ru g s] h a v e b e e n re la tiv e ly in e ffe c tiv e in tre a tin g fix e d de lu sio n s,”

p a r tic u la rly p e rse c u to ria l d e lu sio n s a nd lo n gsta nd in g d e lu sio n s. Dr. Mo rto n

a d v ise d th a t th e sid e e ffe c ts c a n in c lu d e tire d n e ss a n d a p a th y th a t c a n ma s k

ra th e r th a n c u re sy m

p to m s, m e ta

bo lic a nd e n d o c rin e p ro b l e m s

, a b n o r m a l m u s c l e

to n e a nd re stle ssn e ss, sy m p to ms sim ila r to P a rk in so n ’s d ise a se

, ta rd iv e

23d y sk in e sia p ro d u c in g in v olu n ta ry m u sc le m o v e m e nt in th e f a c e

, ch a n g e s to

b lo o d p re ssu re a n d h e a rt ra te

, d iz z i n es s, g a stro in te stin a l p ro b le m s, a ffe c te d

v isio n, p ro b le m s w ith u rin a tio n

, p ro b le m s w ith c o n c e n tra tio n

, a nd n e u ro le p tic

m a lig n a n t sy n d ro m e w h e re b o d y te m p e ra tu re rise s o u t o f c o n tro l. D r. Mo rto n

a d d e d th a t sid e e ffe c ts c a n n o t b e sto p p e d q u ic k ly

, b e c a use a d o se o f m e d ic a tio n

we a rs off slo wly

, th a t n e u ro le p tic m a lig n a n t sy n d r o m e o cc u rs in “o n e in a

th o u sa n d to o n e in a h u n d re d” c a se s, a n d th a t ta rd iv e d y sk in e sia o c c u rs in 2 0 to

4 0 p e rc e n t o f c a se s b u t a t a lo we r ra te with a ty p ic a l a n tip sy c h o tic m e d ic a tio n s.

Dr. M o rto n te stifie d th a t Wa rre n ’s p a st re a c tio n s to m e d ic a tio n s in d ic a te d

th a t h is p h y sic ia n sh o u ld “ sta y a wa y fro m ” Zy pre xa a n d Ge o d o n ; th a t a 6 4 -y e aro ld wo uld b e a t g re a te r risk o f sid e e ffe c ts a n d a d ia b e tic c ou ld

h a v e h is b lo o d

su g a r g e t o u t o f c o n tro l, e sp e c ia lly with c e rta in d ru g s su c h a s Ola n z a p in e a n d

Zy p re xa ; a n d th a t oth e r d ru g s, su c h a s Ase n a p in e an d La tu d a

, m ig ht a ffe c t b lo o d

su g a r le ss b ut ha d n o t b e e n stu die d in th a t re g a rd

. Ask e d a b ou t th e u se o f

a n tip sy c h o tic m e dic a tio n s fo r so m e o n e with a h isto ry o f d ia b e te s, h y p e rte n sio n

,

a n d a p o ssib le p a st h e a

rt a tta c k

, Dr. Mo rto n re p lie d

, “It wo u ld d e p e n d o n t h e

b e n e fits ov e r th e risk s. I d o n ’t th in k th e y are c on tra in d ic a te d

. Th e y wo uld h a v e

to b e u se d with a lo t o f c a u tio n

, b e ca u se

. . . y o u wo u ld h a v e to d e c id e is th e

24d ia

b e te s c o ntro l o f th a t go in g to o u twe ig h th e p o te n tia l risk o f p s y c h ia tric

sy m p to m s.” H e e x p la in e d th a t th e tre a tin g ph y sic ia n u su a lly m a k e s th is

d e c isio n

. He a d d e d t h a t ty pic a l a n tip sy c h otic m e d ic a tio n s will a lm o st a lwa y s

ra ise th e b lo o d su ga r o f p a tie n ts with d ia b e te s a n d th a t a d ia

b e tic

, lik e Wa rre n

,

wh o p re v io u sly h a d his d ise a se m a na g e d th r o u g h d ie t m ig h t n e e d to g o o n

m e d ic a tio n fo r h ig h b lo o d su g a r.

Dr. Mo rt o n sa id th a t a d y sto n ic re a c tio n with sy m p to m s lik e a se iz u re

o c c u rs in 1 0 to 1 5 p e rc e nt o f p e rso n s m e d ic a te d ; th a t th e in c id e n c e o f o th e r sid e

e ffe c ts su c h a s P a rk in so nism

, a ka th isia

, a nd a k in e sia v ary a mo n g t h e v a rio u s

a n tip sy c h o tic m e d ic a tio n s; a n d th a t sid e e ffe c ts a ffe c tin g m u sc le c o n tro l wo u ld

b e m o re d a n g e ro u s fo r Wa rre n b e c a u se h is d e n tu re s a n d d iffic u lty swa llo win g

wo u ld p u t h im a t risk o f c h o k in g

. Dr. Mo rto n n ote d th a t Ma lla ril a n d Th o ra z in e

h a v e lo we r ra te s o f d y sto n ic re a c tio n s b u t a re m o re lik e ly to in d uc e sle e p in e ss

a n d lo w e re d b lo o d p re ssu re

. He sta te d th a t Ge o d o n h a d lo w e re d W a rre n ’s b lo o d

p re ssu re so d ra m a tic a lly th a t h e wa s d iz z y a n d no t a ble to sta n d , an d th is d ro p

in b lo o d p re ssu re wo u ld h a v e c re a te d a n in c re a se d h e a rt ra te a n d a r e su ltin g

in c re a se d risk fo r a h e a rt a tta c k

. Dr. Mo rto n a lso n o te d t h a t W a r re n h a d a

h isto ry o f fa llin g

, p a rtly d ue to v isio n p ro b le m s, a n d th a t Wa rre n h a d e le v a te d

25c h o le ste ro l a n d e x c e ss b o d y we ig ht th a t p ut h im a t an in c re a se d risk fo r stro ke s

a n d h e a rt a tta c k s.

Dr. Mo rto n e x p la in e d t h a t a d d itio n a l sid e e ffe c ts o f a n tip sy c h o tic

m e d ic a tio n s c a n in c lu d e e n la rg e d b re a sts a n d /o r th e e xp re ssio n o f m ilk in m a le

p a tie n ts, a d r y m ou th

, so m e se d a tio n th a t c a n so m e tim e s le a d to c on fu sio n

,

d iffic u lty fo c u s i n g th e e y e s, a n d d e c re a se d b o we l a n d bla d d e r fu n c tio n

. D r.

Mo rto n sa id th a t Ha ld ol ha d n o t c a u se d a d e c re a se in blo o d pre ssu re in Wa rre n

a n d th e re fo re “ wo uld b e so m e th in g to c o n sid e r” fo r a n y fu tu re tre a tm e n t,

a d d in g

, “ Ha ld o l, y o u k n o w h e ’s to le ra te d it, a n d th a t m ig h t b e s o me t h i n g y o u

wo u ld wa n t to try a t a h ig h e r d o se fo r 12 we e k s, b e c a u se h e ’s o n ly be e n o n it fo r

six we e k s.” Dr. Mo rto n n o te d

, h o we v e r, t h a t H a ld o l h a d a se d a tin g e ffe c t o n

Wa rre n th a t m a d e h im sle e p y

. F in a lly

, Dr. Mo rto n a sse rte d th a t n e we r d ru g s

su c h a s F a n a p t, S a

p h ris, a nd La tu d a h a v e no t “d ra m a tic a lly b e e n b e tte r th a n

a n y th in g e lse th a t we u se

, ” a lth o u g h th e y c o st m o re

.

On c ro ss-e x a m in a tio n, D r. Mo rto n a c k no w le d g e d th a t “ [t] h e re is a b e n e fit

o f [a n tip sy c h o tic ] d ru g s,” bu t n o te d th a t th e b e n e fit m u st b e b a la n c e d a g a i n s t

o th e r c o n c e rn s. He in siste d th a t Wa rre n ’s situ a tio n “ is lo a d e d w ith m a n y m o re

c o m p lic a tio n s th a

n o th e r p e op le ” a n d th a t “ [i]f h e ha s n e u ro le p tic m a lig n a n t

26sy n d r o m e h e ’ll p ro ba b ly d ie .” Dr. M o rto n a lso te stifie d th a t h e c o n sid e re d

Wa rre n ’s risk o f fa llin g o r c h o k in g to b e u n a c c e p ta b le

. Dr. M o rto n sta te d

,

“ Ma y b e h is d o c to r n e e d e d to g iv e h im Ha ld o l lo n g e r

, ” b u t “ [i] f we g iv e

h im

. . . a n y o f th e se m e d ic i n e s o n th is list we ’re p uttin g h im a t g ra v e risk .”

Wh e n a sk e d if Wa rre n c ou ld b e m a d e c o m p e te n t to sta nd tria l, Dr. Mo rto n

a n swe re d

, “ I d o n ’t th in k so

. I th in k th e re is a p o ssib ility

. T h e re ’s a p o ssib ility

.

I c a n ’t sa y th a t th o se m e d ic in e s will a b so lu te ly n o t w o rk

, b u t th e re ’s a v e ry lo w

lik e lih o o d th a t th e y will wo rk .”

On re d ire c t e x a m in a tio n

, Dr. Mo rto n e x p la in e d th a t “ [a ] tre a tm e n t p la n is

u su a lly d e v e lo p e d b y a p sy c h ia trist

. . . in c o n ju n c tio n with o th e r tre a tm e n t

p ro fe ssio n a ls th e re

, lo o kin g a t th e b e n e fits a nd risk s,” a n d su c h a p la n is

c o m m itte d to writin g

. He n o te d th a t Wa rre n h a d no w ritte n tre a tm e n t p la n a n d

a d d e d th a t if th e re we re o n e

, in c lu d in g o n e th a t m ig h t in c lu d e a re n e we d u se o f

Ha ld o l, h e wo u ld b e a

b le to re v ie w it a n d c om m e nt o n it. F in a lly , Dr. Mo rto n

o p in e d th a t, b e c a

u se Wa rre n h a s sp e c ia l m e d ic a l risk s a n d d o e s n o t a pp e a r to

p re se nt a d a n g e r to th e h o sp ita l sta ff, th e on ly p o ssib le b e n e fit to Wa rre n fro m

a n an tip sy c ho tic m e d ic a tio n wo u ld b e a re d uc tio n in de lu s io na l th o u gh ts th a t

m ig h t a llo w h im to wo rk with h is d e fe n se c o un se l.

27(c ) Th e Tria l Co u rt’s Ru lin g s

In c lo sin g a rg um e n t a t th e e v id e ntia ry he a rin g

, Wa rre n ’s c o u n se l a sse rte d

th a t th e a b se n c e o f a sp e c ific tre a tm e n t p la n fo r Wa rre n m a d e it im p o ssib le fo r

th e S ta te to sa tisfy th e Se ll te st. Co u n se l n ote d th a t h e h a d a sk e d th e S ta te

m o n th s e a rlie r to pro v id e a t r e atm e n t p la n so th a t th e de fe n se c o u ld h a v e it

re v ie we d b y th e ir e x p e rts, b u t wa s to ld th a t th e S ta te w a s g oin g t o re ly o n th e

tre a tin g p h y sic ia n to d e te rm in e h o w to e ffe c tu a te a n y c o u rt o rd e r fo r in v o lu n ta ry

m e d ic a tio n

. In th e S ta te ’s c l o s i n g a rg u m e n t, th e p ro se c u to r a sse rte d

, “ Qu ite

fra n k ly we c a n ’t fa sh io n a tre a tm e n t p la n u ntil th is Co u rt first giv e s u s th e

a b ility to fo rc e tre a tm e n t o n th e d e fe n d a nt so th a t w e c a n g e t to th e re sto ra tio n

p ro c e ss.” Th e p ro se c u to r a dd e d

,

B y r e q u irin g so m e so rt o f tre a tm e n t p la n in a d va n c e o f fo rc e d

m e d ic a tio n s i n th is c a se y o u ’re e sse n tia lly ty in g th e h a nd s o f th e

S ta te a n d y o u’re ty in g th e h a n d s o f h is c lin ic ia n s, h is do c to rs, fro m

b e in g a d e q u a te ly a

b le to tre a t th e m e n ta l d iso rd e r su c h th a t w e c a n

re sto re c o m

p e te n c y a n d a lso a c c o u n t fo r his u n iq u e m e d ic a l

c o n d itio n

.

Th e tria l c o u rt th e n a n n o u n c e d :

I fin d by c le a

r a n d c on v in c in g e v id e n c e th e r e i s a n im p o rta n t

g o v e rn m e n ta l in te re st to b rin g th is c a se to tria l, th a t i n v o lu nta ry

a d m in istra t i o n of m e d ic a tio n will su b sta ntia lly fu rth e r su c h

g o v e rn m e n ta l in te re st. I fin d th a t it is n e c e ssa r y b y c l ea r a n d

28c o n v in c in g e vid e n c e

. A n d th e te stim o ny of th e witn e sse s su p p o rts

a fin d in g b y th is C o u rt, a n d I d o so fin d th a t le ss in tru siv e m e a n s a re

u n lik e ly to a c hie v e su b sta n tia lly th e sa m e re su lt. I fu rth e r fin d th a t

th e a d m in istra tio n o f th e d ru g

– o f d ru g s is m e dic a lly a p p ro p ria te

in th e c a se

. I a m n o t g o i n g t o g ra n t th e [d e fe n se ] re q u e st fo r a

t r ea tm e nt pro g ra m in a d v a n c e o r fu rth e r p ro c e e d in g s, a n d [ t h e

p ro se c u to r] c a

n [d ra ft] a n o rd e r to th a t e ffe c t. . . .

Eig h t d a y s la te r, o n Ju ly 3

, 2 0 1 4

, th e tria l c o urt sig ne d a n o rd e r p re se n te d

b y th e S ta te g ra n tin g th e S ta te ’s m o tio n to m e d ic a te Wa rre n in v o lu n ta rily

. Th e

o rd e r wa s file d o n Ju ly 9

. Th e su b sta n c e o f th e o rd e r wa s le ss th a n a p a g e lo n g

.

3

. Ap plic a tio n o f th e S e ll Te st

We tu rn n o w to re vie win g th e tria l c o u rt’s a p p lic a tio n of th e fo u r-p a rt te st

e n u n c ia te d in S e ll v

. Un ite d S ta te s, 5 3 9 U. S

. 1 6 6

, 1 8 0 -1 81 (1 2 3 S Ct 2 1 7 4

, 1 5 6

LE2 d 1 9 7 ) (2 0 0 3 ), fo r id e n tify in g th e “ra re ” in sta n c e s in w h ic h th e C o n stitu tio n

p e rm its in vo lu nta ry a d m in istra tio n of a n tip sy c h o tic d ru g s to b e o rd e re d so le ly

fo r tria l c o m

p e te nc e p u rp o se s.

(a ) Go ve rn m e n ta l In te re st

S e ll first d ire c ts c o u rts c o n sid e rin g a m o tio n fo r a n o rd e r a u th oriz in g th e

in v o lu n ta ry m e d ic a tio n of a c rim in a l d e fe n d a n t fo r th e p u rp o se of m a kin g h im

c o m p e t e n t to d e te rm in e wh e th e r “ imp o rta n t g o ve rn m e nta l in te r e s t s a r e at s t a k e

. ”

Id

. a t 1 80 (e m

ph a sis in o rig in a l). He re

, th e tria l c o urt’s writte n o rd e r sa y s o nly

,

29“ [t] h e S ta te h a s im p o rta nt g o v e r n m e n ta l in te re sts in p ro se c u tin g th is c rim in a l

De fe n d a n t,” wi th o u t id e n tify in g wh a t th o se in te re sts a re

, a n d th e c o u rt’s o ra l

p ro n o u n c e m e n t sa id o n ly

, “ th e re is a n im p o rta n t go v e rn m e n ta l in te re st to b rin g

th is c a se to tria l.” Ho we v e r, b e c a u se a n a p p e lla te c ou rt re v ie ws th is p art o f th e

S e ll te st de n o v o, a s we e x p la in e d in Div isio n 1 a b o v e

, we c an re v ie w th e re c o rd

a n d d e te rm in e fo r o urse lv e s if th is p a rt o f th e te st is sa tisfie d

.

Th e S e ll C o u rt e x p la in e d th a t “ [t] h e G o v e rn m e n t’s in te re st in b rin g in g to

tria l a n in d iv id u a l a c c u se d o f a se rio u s c rim e is im

p o rta n t. Th a t is so wh e th e r

th e o ffe nse is a se rio u s c rim e a g a in st th e p e rso n o r a se rio u s c rim e a g a in st

p ro p e rty .” 53 9 U. S

. a t 1 8 0

. I n ad d i tio n “[t] he Go v e rn m e n t h a s a su b sta n tia l

in te re st in tim e ly p ro se c u tio n ” a n d “ a c o n c o m ita n t, c o n stitu tio na lly e sse n tia l

in te re st in a s s u rin g th a t th e d e fe n d a n t’s tria l is a fa ir o ne .” Id

. Wa rre n is

a c c u se d, a m o n g o th e r c rim e s, o f sh o o tin g fiv e p e op le

, k illin g fo u r o f th e m a n d

p a r a l y z in g th e fifth

. Th e se a re c rim e s a g a in st pe rso n s o f th e m o st se rio u s

m a g n itu d e

. Mo re o v e r, ne a rly six y e a rs h a v e a lre a d y p a sse d sin c e th e a lle g e d

c rim e s, an d e v e n if th e a d m in istra tio n o f m e dic a tio n u ltim a te ly su c c e e d e d in

m a k in g Wa rre n c o m

p e te n t to sta n d tria l, his tria l wo u ld n o t b e g in fo r q uite so m e

tim e

, pa rtic u la rly g iv e n th e e x te n siv e p r e tria l p ro c e e d in g s a sso c ia te d with a

30d e a th p e na lty p ro c e e d in g

. Th u s, if th is e x c e p tio n a lly se rio u s c a se is to b e trie d

,

a n d trie d fa irly

, th e Sta te h a s c om p e llin g in te re sts in d o in g so with a s l i t t l e

fu rth e r d e la y a s p o ssib le

.

Th e se im po rta n t go ve rn m e n ta l in te re sts are n o t sig n ific a n tly un de rm in e d

b y a n y “ [s] p e c ia l c irc u m sta nc e s” p re se n t in th is c a se

. Id

. Sp e c ia l c irc um sta n c e s

m a y i n c l u d e th e a m o u n t o f tim e th a t a d e fe n d a n t wh o re fu se s to ta k e

p s yc h o a c tiv e d ru g s v olu n ta rily is lik e ly to re m a in c o n fin e d in a m e n ta l h e a lth

in stitu tio n if h e is n o t trie d

, b e c a u se a “le n g th y c on fin e m e n t in a n in stitu tio n fo r

th e m e n ta lly ill

. . . w o u ld d im in ish th e risk s th a t o rd in a rily a tta c h to fre e in g

with ou t p u n ish m e nt o n e wh o h a s c o m m itte d a se rio u s c rim e .” Id

. G e o rg ia la w

a llo w s fo r c iv il c on fin e m e n t w h e re a p e rso n a c c u se d o f a vio le n t c rim e is fo u n d

m e n ta lly in c o m

p e te n t to sta n d tria l, wh ic h m a y c o n tin ue in a n nu a l in c re m e n ts

fo r u p to “ th e m a x im

u m p e rio d fo r w h ic h th e a c c u se d c o u l d h av e b e e n

se n te nc e d o n th e m o st se rio u s v io le n t o ffe nse c h a rg e d .” O CGA § 1 7 -7 -1 3 0 (e )

(2 ) (B) (iv ).

Ho we v e r, c iv il c o m m itm e n t is n o t “ a su b stitu te fo r a c rim in a l tria l,”

p a rtic u la rly wh e re “ it m a y b e d iffic u lt o r im p o ssib le to try a d e fe nd an t wh o

re g a in s c o m

p e te nc e a fte r y e a rs o f c o m m itm e n t d urin g w h i c h m e m o r i e s m a y f a d e

31a n d e v id e n c e m a y b e l o s t .” S e ll, 5 3 9 U

. S

. a t 1 8 0

. Th u s, “ [t] h e p o te n tia l fo r

fu tu re c o n fin e m e n t a ffe c ts, b u t d o e s n o t to ta lly u n d e rm in e

, th e stre n g th o f t h e

n e e d fo r p ro se c utio n .” Id

. He re

, th e S ta te is pro se c utin g c ha rg e s th a t, if p ro v e d

a t tria l, w o u ld a t a m in im

um re su lt in Wa rre n’s re c e iv in g m ultip le life se n te n c e s

a n d se rv in g a m in im

u m o f 3 0 y e a rs in priso n

. S e e OCGA §§ 16 -5 -1 (e ) (1 ), 1 7

-

1 0 -6 .1 (c ) (1 ). S e e a lso Un ite d S ta te s v. B re e d lo v e

, 7 5 6 F 3 d 1 0 3 6

, 1 0 4 1 (7 th

Cir. 2 0 1 4 ).

An o th e r “ sp e c ia l c irc u m sta n c e ” id e n tifie d in S e ll is w h e th e r th e d e fe n d a n t

h a s “ a lre a d y b e e n c o n fin e d fo r a sig n ific an t a m o u nt o f tim e ” fo r wh ic h h e wo u ld

re c e iv e c re d it to wa rd a ny se n te n c e u ltim a te ly im p o se d

. 5 3 9 U. S

. a t 1 8 0

.

Alth ou g h Wa rre n h a s b e e n d e ta in e d a lm o st six y e a rs a lre a d y

, th a t tim e a g a in

p a le s in c o m

p a riso n to th e life se n t en c e s he fa c e s if c o n v ic te d. Th is c a se a lso

in v o lv e s a c irc u m sta n c e

, b e y o n d a n y p e rio d o f c o n fin e m e n t, th a t we ig h s i n fa v o r

o f th e S ta te ’s in te re st in b rin g in g Wa r r e n t o t ria l

– th e S ta te ’s va lid in te re st in

se e k in g Wa rre n ’s e x e c utio n u p o n p ro of th a t h e c o m m itte d m u ltip le c a p ita l

c rim e s.

Th u s, a lth o u g h th e tria l c o u rt’s fin d in g s a s to th e first ste p o f th e S e ll te st

we re in c o m

p le te

, th e c o u rt d id n o t e r r in its c o n c lu sio n th a t th e S ta te

32d e m o n stra te d im po rta n t g o v e rn m e n ta l in te re sts in re n d e rin g Wa rre n c o m p e te n t

to sta n d tria l, a

n d th o se in te re sts a re n o t o ffse t b y a n y sp e c ia l c irc u m sta n c e s o f

th e c a se

. 6

(b ) F u rth e ra n c e o f Go v e rn m e n ta l In te re st

Th e se c o n d p a rt o f th e S e ll te st re q uire s th e tria l c o u rt to d e te rm in e th a t

“ in vo lu n ta ry m e dic a tio n will sig n ific a n tly fu rth e r ” th e g o v e rn m e n ta l in te re sts

in b rin g in g th e d e fe nd a n t to tria l. 5 3 9 U. S

. a t 18 1 (e m p h a sis in o rig in a l). Th is

in q u iry h a s two c o m

p o n e n ts. Th e c o u rt m

u st fin d th a t “ a d m in istra tio n o f th e

d r u g s is su b sta n tia lly lik e ly to re n d e r th e de fe nd a n t c om p e te n t to sta n d tria l ”

a n d

, a t th e sa m e tim e

, th a t “ a d m in istra tio n of th e d ru g s is su bsta n tia lly un lik e ly

to h a ve sid e e ffe c ts th a t will in te rfe re sig n ific an tly with th e d e fe n d a n t’s a b ility

to a ssist c o u n se l in c o n d u c tin g a tria l d e fe n se

, th e re by re n de rin g th e tria l u n fa ir.”

Id

.

On th e se p o in ts, th e tria l c o u rt’s o rd e r in th is c a se sa id o n ly th e fo llo win g :

I n vo lu n ta ry m e d ic a tio n will su bsta n tia lly fu rth e r th o se im p o rta n t

g o v e rn m e n ta l in te re sts. Th e a d m in istra tio n o f d r u g s is su b sta n tia lly

6 Given the charg e s and potential sentences involved in this c ase, we need n ot delve into the

nuances that have divided other courts in apply ing the first part of the Sell test. See, e

. g.

, U n ited

States v

. Hernandez -Vasquez

, 5 13 F 3d 908, 918-919 (9th Cir. 2007) (amended opinion) (discussing

the federal circuit split as to w hether the statutory max imum sentence or the recommended federal

sentencing g uidelines should be used as the basis for comparisons).

33lik e ly to re nd e r D e fe n d a n t c om pe te n t to sta nd tria l an d is

su b sta n tia lly u n lik e ly to h a v e sid e e ffe c ts th a t will in te rfe re

sig n ific a ntly with De fe n d a n t’s a bility to a ss i st c o un se l in

c o n d u c tin g a

tria l d e fe n se

.

Alth ou g h th is p a ssa g e re c ite s th e re le v a nt la n g u a ge fro m S e ll, th e tria l c o u rt’s

writte n fin d in g s, wh ic h we re n o t su p p le m e n te d b y a n y a d d itio n a l o ra l fin d in g s,

a re in su ffic ie nt to w ith sta n d re v ie w.

Th e fu n d a m e n ta l p ro b le m with th e tria l c o u rt’s ru lin g o n th is p a rt o f th e

S e l l te st

– a n d with its ru lin g s o n th e th ird a n d fo u rth p a rts o f th e t e s t

, a s

d isc u sse d b e lo w

– is th a t th e co u rt h a s n ot sp e c ifie d wh a t a n tip sy c h o tic

m e d ic a tio n o r m e d ic a tio n s m a y b e fo rc ib ly a dm in iste re d t o W a r r e n

, in wh a t

d o sa g e o r ra n ge o f d o sa g e s, fo r wh a t pe rio d o f tim e

, an d with wh a t o v e rsig h t b y

th e c o u rt. Th is is a pro b le m c re a te d b y th e S ta te

– wh ic h d ra fte d th e o rd e r th e

tria l c o u rt sig n e d

– b e c a

u se th e Sta te h a s n o t p re se n te d a sp e c ific tre a tm e n t p la n

fo r Wa rre n su pp orte d b y e xp e rt te stim on y

, n o r c a n a n y p a rtic u la r tre a tm e n t p la n

b e re a d ily d isc e rn e d fro m th e e v id e n c e o f f e r e d a t th e h e a rin g

. An d th is is n o t

a p ro b le m th a t h a s b e e n id e n tifie d fo r th e first tim e o n a p pe a l. At th e h e a rin g

,

Wa rre n ’s c o u n se l a sk e d th e tria l c o u rt to re q u ire th e S ta te to p ro v id e a sp e c ific

tre a tm e nt p la n , b u t th e S ta te o b je c te d , an d th e c o u rt d e n ie d th e re qu e st.

34As re c o u n te d in D iv isio n 2 a b o v e

– a t c o n sid e ra

b le le ng th

, to g iv e a se nse

o f th e d iso rg a n iz e d a

n d in c o m p le te wa y th e e v id e n c e wa s p re se nte d

– th e re wa s

a g re e m e n t a m o n g th e Sta te ’s two e x p e rts a n d Wa rre n’s th re e e x p e rts th a t

a n tip sy c h o tic m e d ic a tio n s o ffe r so m e lik e lih o o d o f m a k in g a d e lu sio n a l p e rso n

c o m p e te n t to sta n d tria l. B u t th e re wa s n o c o n se n su s, an d th e c e rta in ty o f th e

o p in io n s o ffe re d b y th e Sta te ’s e x p e rts d issip a te d

, wh e n th e q u e stio n s fo c u se d

o n th e lik e lih o o d o f su c c e ss u sin g th e va rio u s “ g e n e ra tio n s” a n d p a rtic u la r

n a m e s o f dru g s a n d wh e n th e d i s c u ssio n m o v e d fro m d e lu sio n a l p a tie n ts in

g e n e ra l to p e rso n s lik e Wa rre n wh o su ffe r fro m a lo ng -te rm d e lu sio n a l d iso rd e r

a n d fix e d d e lu sio n s. Fo r e x a m p le

, th e S ta te ’s p rin c ip a l e x p e rt, Dr. S c h ie f, c ite d

o n ly two sc ie n tific stu d ie s, a n d h e d id n o t k n o w wh a t dru g s we re u se d in th e

stu die s an d d id n o t sa y wh e th e r th e stu d ie s in v olv e d p a tie n ts with a d e lu sio n a l

d iso rd e r lik e Wa rre n ’s. Lik e wise

, th e S ta te ’s oth e r e xp er t

, D r

. Hu g h e y

,

m e n tio n e d h is g e n e ra l re v ie w o f sc ie n tific stu d ie s, bu t h e a d m itte d th a t th e y

i n c l u d e d p a

t i e n t s w i t h d iffe re nt a n d e a sie r-to -tre a t c o n d itio n s th a n W a r r e n ’ s

, a n d

h e d id n o t sa y wh a t d ru g o r d ru g s h a d b e e n u se d

. D r. Hu gh e y a lso re fe rre d to

wh a t wa s a

p p a re n tly o n e p a rtic u la r stu d y u sin g a first-g en e r a t io n d ru g

, b u t h e

wa s n o t su re if th e su c c e ss ra te wa s 7 7 p e rc e n t of p a tie n ts (1 7 o f 2 2) o r ju st 5 3

35p e rc e nt (1 7 o f 3 2 )

– a sig n ific an t d isc re pa n c y

. N o w ritte n re p o r t s o n th e se

stu die s we re o ffe re d in to e v id e n c e

.

S im ila rly

, th e re wa s a g re e m e n t a m o n g th e e x pe rts th a t a n tip s y c h o tic

m e d ic a tio n s, a n d c e rta in d ru g s in p a rtic u la r, h a v e n u m e ro u s sid e e ffe c ts th a t c a n

b e se v e re

, e sp e c ia lly fo r a n o ld e r p e rso n l i k e Wa rre n wh o ha s d ia b e te s,

h y p e rte n sio n

, a n d a p o ssib le h i s t o r y o f a h e a rt a tta c k

. Bu t th e e x p e rts o ffe re d

d iffe re n t p re d ic tio n s a

b o u t wh e th e r diffe re nt m e d ic a tio n s wo u ld h a v e p a rtic u la r

sid e e ffe c ts fo r Wa rre n

– a n d th e y d id so with little fo c u s o n s i d e effe c ts th a t

wo u ld in te rfe re with his a bility to a ssist h is c o u n se l a t tria l, ra th e r th a n a ffe c t h is

we ll-b e in g in o th e r wa y s (wh ic h is a c o n sid e ra tio n in th e fo urth p a rt o f th e S e ll

te st). S e e S e ll, 5 3 9 U

. S

. a t 1 8 5 (n o tin g th e a b se n c e o f e x p e rt te stim o n y “ a b o u t

tria l-re la te d sid e e ffe c ts a nd risk s” o f th e pro p o se d m e dic a tio n s). F or e x a m p le

,

Dr. S c h ie f te stifie d th a t th e th re e ge n e ra tio n s of an tip sy c h o tic m e d ic a tio n s c a rry

d i f f e re nt risk s o f va rio u s sid e e ffe c ts, a c k n o wle d ge d th a t Wa rre n h a d sh o wn

sig nific a n t sid e e ffe c ts w h e n g iv e n Ge o d on (a se c o n d g e n e ra tio n d ru g ) a n d

Ha l do l (a first g e n e ra tio n d ru g ), a n d sa id th a t h e d id no t c ritic iz e Dr. Ka n e ’s

d e c isio n to d isc o n tin ue th e Ge o d o n a fte r on ly o n e d a y wh e n Wa rre n ’s b lo o d

p re ssu re d ro p p e d

. Ho w e ve r, wh i l e o p in in g th a t th e re wa s a “ su b sta n tia l

36p ro b a

b ility ” th a t Wa rre n w o u ld b e re n de re d c o m p e te n t if m e dic a te d

, Dr. S c h ie f

n e v e r sa id wh a t d ru g s sh o u ld a n d wo u ld b e u se d to d o th a t; to th e c o ntra ry

, D r.

S c h ie f m a de it c le a r th a t h e wa s no t p ro p o si n g a n y s p e c ific m e d ic a tio n

. His

te stim o n y

, a n d th e c o u rt’s o rd e r, wo uld n o t p re c lu d e giv in g Ge o d o n to Wa rre n

a g a in

– th is tim e fo rc ib ly

.

As th e fa c tfin d e r in th is c a se

, th e tria l c ou rt w a s e n title d to sift th ro u g h th e

e v id e n c e a n d g iv e wh a t c re d it a n d we ig ht it d e e m e d a p p ro p ria te to wh a t wa s

o fte n q u a lifie d

, u n c e rta in

, a n d c o n flic tin g te stim o n y (a lth o u g h th e c o u rt m a d e

n o sp e c ific o ra l o r writte n fin din g s in th is re g ard ). An d th e tria l c o u rt in d ic a te d

(o ra lly ) th a t it wa s p ro pe rly c on sid e r i n g th e re c o rd u sin g th e c le a r a n d

c o n v in c in g sta n d a rd o f p ro o f a n d p la c in g th e b u rd e n o f p ro o f o n th e S ta te

. S e e

Div isio n 1 a

b o v e

. Vie we d in th is wa y

, th e re c o r d mig h t su p po rt fin d in g s th a t

o n e o r se v e ra l ty pe s of a n tip sy c h o tic m e d ic a tio n wo u ld b e su b sta n tia lly lik e ly

to re n d e r Wa rre n c om

p e te n t to sta n d tria l wh ile a lso b e in g su b sta n tia lly un lik e ly

to h a v e sid e e ffe c ts th a t wo u ld in te rfe re sig n ific an tly with h is a b ility to a ssist h is

c o u n se l. Ho we v e r, th e re c ord d o e s n o t su p po rt a fin d in g th a t th e in v o l u n t a r y

a d m in istra tio n o f an

y o f th e m a n y m e d ic a tio n s d isc u s s ed in th e e x p e rt

te stim o n y

, in an

y do sa ge s a n d fo r a n

y p e rio d s o f tim e

, m e e ts th is sta n da rd

, a n d

37y e t th a t wa s th e sc o p e of th e fin d in g m a d e in th e tria l c o u rt’s o rd e r. Se e Un ite d

S ta te s v

. Ch a v e z

, 7 3 4 F 3 d 1 2 4 7

, 1 2 5 2 (1 0 th C ir. 2 0 1 3 ) (“ Be c a u se d iffe re n t ty pe s

o f a ntip sy c h o tic d ru g s c a n pro d u c e d iffe re nt sid e e ffe c ts a n d re su lt in d iffe re n t

d e g re e s o f su c c e ss, g ra n tin g th e g o v e rn m e n t s u c h u n fe tte re d d isc re tio n in

d e te rm in in g wh ic h d ru gs w ill b e a d m in iste re d to a d e fe n da n t d o e s n o t c o n fo rm

with th e fin d in gs re q u ire d b y S e ll.” ). S e e a lso Se ll, 5 3 9 U. S a t 18 5 (e x p la in in g

th a t “ [w] h e th e r a p a rtic u la r d ru g will te n d to se d a te a d e fe nd a n t, in te rfe re with

c o m m u nic a tio n with c o u n se l, p re ve n t ra pid re a c tio n to tria l d e v e lo p m e n t s

, o r

d im in ish th e a

bility to e x p re ss e m o tio n s a re m a tte rs im p orta n t in d e t e r

m in in g th e

p e rm issib ility o f m e d ic a tio n to re sto re c o m p e te n c e ” (e m

p ha sis a dd e d )).

“ [A] n in d i v i d

u a l h a s a s i g n i f

i c a n t c o n s t i t u t i o n a l l y p ro te c te d lib e rty in te re st

in a v o id in g th e un wa n te d a d m in istra tio n of an tip sy c h o tic d ru g s.” S e ll, 5 3 9 U. S

.

a t 1 7 8 (c ita tio n a n d q uo ta tio n m ark s o m itte d).

Th e i n te rfe re n c e is “p a rtic u la rly se v e re ” wh e n

, a s in th is c a se

, th e

m e d ic a t i o n i n q ue stio n is a n a n tip sy c h o tic

, fo r th e u se o f su c h

m e d ic a tio n s th re a te n s a n in d iv id u a l’s “ m e n ta l, a s we ll a s ph y sic a l,

in te g rity .” On th e p h y sic a l sid e

, th e re is th e “ v i o le n c e in h e re n t in

fo rc ib le m e d ic a tio n,” c om p o u n de d w h e n it c om e s to a n tip sy c h otic s

b y th e p o ssib ility o f “se rio u s, e v e n fa ta l, sid e e ffe c ts.” B u t it is th e

in v a sio n in to a p e rso n ’ s m e nta l sta te th a t tru ly d istin g u ish e s

a n tip sy c h o tic s, a c la ss o f m e d ic a tio n s e x p re ssly in te n d e d “ to a lte r

th e will a nd th e m in d o f th e su b je c t.”

38Un ite d S ta te s v

. W a tso n

, 79 3 F 3 d 4 1 6

, 41 9 (4 th C ir. 2 0 1 5 ) (c ita tio n s o m itte d ).

Giv e n “ th e se v e rity o f th e in tru sio n a n d c o rre sp o n d in g im p o rta n c e o f th e

c o n stitu tio n a l issu e ,” S e ll, 5 3 9 U. S

. a t 17 7, th e ju d ic ia l fin d in g s re qu ire d to

a u th oriz e su c h a

n i n t r u sio n b y th e S ta te m u st b e m a de with c a re a n d

th o ro u g h n e ss, a n d with su ffic ie n t d e ta il to a llo w m e a n in g fu l re v ie w o n a p p e a l.

S e e Ch a v e z

, 7 3 4 F 3 d a t 1 2 5 2 (“ Wh ile Se ll d o e s n o t e xp lic itly id e n tify wh a t

le v e l o f sp e c ific ity is re q uire d in a c o u rt’s ord e r fo r in v o lu n ta ry m e dic a tio n

. . . ,

th e n e e d fo r a h ig h le v e l o f d e ta il is p la in ly c o nte m p la te d b y th e c o m

p re h e n siv e

fin d in g s S e ll re q u ire s.” ). 7

Th e S t a t e c o n te n d s th a t it is im p o ssib le to e sta blish a sp e c ific tre a tm e n t

p la n fo r Wa rre n

, b e c a

use th e o n ly wa y to k no w h o w a n y g iv e n p a tie n t will

re sp o n d to a n tip sy c ho tic m e d ic a tio n is to a d m in iste r va rio u s d ru g s a n d se e wh a t

h a p p e n s th ro ug h “tria l a n d e rro r.” B u t Se ll d oe s n o t re qu ire c e rta in ty a s to

7 Cf. Hig g enbottom v. State, 288 Ga. 429, 430-431 ( 704 SE2d 786) (2011) (ex plaining that

to a llow adequate appellate review in cases implicating a defendant’s constitutional r ig ht to a speedy

trial, it is imperative that the trial court enter finding s of fact and conclusions of law c onsistent with

the four-part test set f

orth in B arker v. W ing o, 4 07 U. S. 514 (92 SCt 2 182, 33 L E2d 1 01) (1972));

W a ng v

. L iu, 292 Ga. 5 68, 570-571 ( 7 4 0 SE2d 136) (2013) (ex p laining

, in the non-constitutional

contex t of the forum non conveniens doctrine, that “ [ w] hat is r e q u i r e d t o permit meaning ful

appellate review is that the trial c ourt set out upon the record the essential reasoning that forms the

basis for its ex e rcise of discretion.

. . . W i t h o u t s u c h a statement of the essential reasoning of the

trial court, we frequently cannot ascertain whether the decision of the trial court was a r e asoned and

reasonable one in the lig

ht of the standard set out.”).

39wh e th e r m e dic a tio n will m a k e a d e fe n da n t c om pe te n t to sta n d tria l o r a s to th e

sid e e ffe c ts, o n ly fa c tu a lly su p p o rte d p r e d i c tio ns a s to w h a t re su lts a re

“ su b sta n tia lly lik e ly ” fro m th e tre a tm e n t re g im e p ro p o se d b y th e S ta te

. An d S e ll

d id no t c o n do n e

– n o r will th is Co u rt a llo w

– tria l c ou rts to c e d e o v e rsig h t o f

su c h a sig n ific a n t c o n stitu tio n a l m a tte r to th e S ta te

, a llo win g its d o c to rs to fo rc e

a m e n ta lly ill c rim in a l d e fe n d a n t to ta k e wh a te ve r m e d ic a tio ns in w h a te v e r

d o sa g e s a n d fo r wh a te v e r p e rio d o f tim e th e y c o n sid e r a pp ro p ria te

.

W e w o u ld h o p e th a t th e S ta te ’s p h y sic ia ns, a s h e a lth c a re p ro fe ssio n a ls,

wo u ld n o t m isu se su c h u n fe tte re d a u th o rity

, b u t h isto ry te a c h e s th a t in v o lu n ta ry

m e d ic al tre a tm e n t, e sp e c ia lly o f th e po or, th e o utc a st, a nd th e in c a rc e ra te d

, is

wo rth y of c lo se a n d i n d ep e n d e n t o v e rsig h t. S e e Wa tso n

, 79 3 F 3d a t 4 1 9

(e m p h a siz in g th a t “fo rc ib le m e d ic a tio n u n d e r S e l l is ‘a to o l th a t m u st n o t b e

c a su a lly d e p lo y e d ,’ a nd c o u rts m u st b e v ig ila n t to e n su re th a t su c h ord e rs, wh ic h

‘c a rry a n u n sa v o ry p e d ig re e ,’ d o n o t b e c o m e ‘ro u tin e ’” (c ita tio n o m itte d )).

To a p p ro v e o f a tre a tm e n t p l a n with o u t k no w in g th e p ro p o se d

m e d ic a tio n a

n d do se ra n ge wo uld g iv e p riso n m e d ic a l sta ff c a rte

b la n c he to e xp e rim e n t with w h a t m ig h t e v e n b e d a n g e ro u s d ru g s o r

d a n ge ro u sly h ig h d o sa g e s o f o th e rwise sa fe dru g s a n d wo u ld no t

g iv e d e fe n se c o u n se l a nd e x pe rts a m e a n in g fu l a b ility to c h a lle n g e

th e p ro prie ty o f th e p ro p o se d tre a tm e n t.

40Un ite d S ta te s v

. Ev a n s, 4 0 4 F 3 d 2 2 7, 2 41 (4 th Cir. 2 0 0 5 ).

S e l l in d ic a te s th a t its te st sh o u ld b e a p p lie d in th e c o nte x t o f a sp e c ifi c

p ro p o se d tre a tm e n t p la n fo r a sp e c ific d e fe n d a n t. S e e 5 3 9 U. S

. a t 18 3 (sta tin g

th a t th e u ltim a te qu e stio n fo r th e tria l c o u rt is, “ Ha s th e Go v e rn m e n t, in lig h t o f

th e e ffic a c y

, t h e sid e e ffe c ts, th e p o ssib le a lte rn a tiv e s, a n d th e m e d ic a l

a p p ro p ria te ne ss o f a p a rtic u la r c o u rse o f a ntip sy c h o tic d

ru g tre a tme nt

, sh o wn

a ne e d fo r th a t tre a tm e n t su ffic ie n tly imp o rta n t to o v e rc om e th e in d iv id u a l’s

p ro te c te d in te re st in re fu sin g it? ” (e m p ha sis a d d e d ; c ita tio n s o m itte d )).

Ac c o rd in g ly

, a s m a n y o th e r c o u rts h a v e h e ld

, we n o w ho ld th a t th e S e ll te st c a n

b e p ro p e rly a

p p lie d o n ly in re la tio n to a n in d iv id u a liz e d tre a tm e n t pla n th a t

sp ec ifie s, a t a m in im

u m

, (1 ) th e d ru g o r dru g s th e tre a tin g ph y sic ia n s a re

p e rm itte d to u se o n th e de fe n d a nt, ( 2 ) t h e m a x im um do sa g e s th a t m a y b e

a d m in iste re d

, a n d (3 ) th e d u ra tio n th e d ru g s m a y b e u se d b e fo re th e p h y sic ia n s

re p o rt b a c k

to th e c o u rt. 8

8 See, e.g

., B reedlove, 7 5 6 F 3d at 1 043-1044 (“To satisfy its d uty [ to approve an

individua l i z ed treatment plan]

, the district court must indicate the medication or rang e of

medications to b e administered, the dose rang e and the leng th of treatment,” which may be done by

“reference to the g overnment’s detailed treatment plan”); Chavez

, 7 34 F 3d at 1253 (“[ W] e hold that

an order to involuntarily medicate a non-dang e rous d efendant sole l y i n order to render him

competent to stand trial must specify which medications mig ht b e administered and their max imum

dosag es. W ithout this information, a court cannot ensure that the ‘a dministration of the drug s is

substantially unlikely to have side effects that will interfere sig nificantly with the defendant’s ability

41Th e p re se nta tio n a n d a p p ro v a l o f su c h sp e c ifi c an d in d iv id u a liz e d

tre a tm e nt p la n s in n u m e ro u s o th e r c a se s d e m o n stra te s th a t wh a t t h e S ta te

c o n te n d s is im

p o ssib le is, in fa c t, n o t e v e n im p ra c tic a l. 9 Th is is p a rtic u la rly so

b e c a u se

, lik e th e c ou rts wh ose h o ld in g s we a re jo in in g

,

we a re m in d fu l of th e b a la n c e we mu s t strik e b e twe e n th e ju d ic ia l

o v e rsig h t n e c e ssa ry to p ro te c t d e fe n d a n ts’ c o n stitu tio n a l rig h ts a n d

th e n e e d o f p riso n m e d ic a l sta ff to re ta in a d e g re e o f fle x ib ility in

o rd e r to p ro vid e e ffe c tiv e tre a tm e n t. Th e re fo re

, so lo n g a s a ll d ru g s

to assist counsel in conducting a trial defense,’ a s required by the second p rong of Sell. Similarly

, without knowing which drug s the g overnment mig ht administer and at what rang e of doses, a court

cannot p roperly conclude that su c h a v a gu e treatment plan is ‘medically a ppropriate, i.e., in the

patient’s best medical interest’ as the fourth part of Sell demands” (citations omitted)); Hernandez

Vasquez

, 5 13 F 3d at 916-917 (“[ W ] e hold that a Sell order must provide at least some limitations

on the medications that may be administered and the max imum dosag e s and duration of treatment.

A t a minimum, to pass muster under Sell, the district court’s order must identify : (1) the specifi c

medication or r ang e of medications that the treating p hy sicians are p ermitted to u se in their treatment

of the defendant, (2) the max imum dosag es that may be administered, a nd (3) the duration of time

that involuntary treatment of the defendant may continue before the treating p hy sicians are required

to report back to the c ourt on the defendant’s mental condition and prog ress.”); Evans, 404 F 3d at

241 (“[ F ] or the district court even to assess whether involuntary medicat i o n i s co nstitutionally

p e r m issible under Sell’s second and fourth factors, the g overnment must set forth the particula r

medication, including the dose r ang e, it proposes to administer to [ t h e defendant] to r estore his

competency .”). See also United States v. Green, 532 F 3d 538, 556-557 (6th Cir. 2008) (approving

an order directing involuntary medication that did not itself specify a treatment plan for the defendant

but referenced the plan proposed by the State’s ex p ert during the Sell hearing ).

9 See, e

. g ., United States v. Ruark, 611 F ed. A ppx

. 5 91, 599 (11th Cir. 2015) (per curiam)

(“Here, the g overnment has presented an individualiz ed treatment plan that details the drug s to be

used and the relevant dosag e rang es. . .

. Dr. Sarraz in, further, proposed a detailed treatment plan

describing the procedure t o be followed if a c ourt orders Ruark to be involuntarily medicated.”);

Diaz

, 630 F 3d at 1 324-1325, 1326-1327, 1330 (affirming a detailed trial court order that approved

the g o vernment’s very detailed treatment plan for Diaz

, which was in turn supported by detailed and

specific ex pert testimony ); G r ee n

, 532 F 3d a t 555-557 (affirming the trial c ourt’s a pproval of the

g overnment’s proposed treatment plan, individualiz ed to the defendant, which “ s e t [ ] f o rth the

specific medications, alternative means o f i n j ecting it, the specific d osag e, and the potential side

effects [ the defendant] could face”).

42th a t m ig h t b e a d m in iste re d to a d e fe n d a n t a n d t h e i r ma x im u m

d o sa g e s a re sp e c ifie d

, c o u rts m a y p ro p e rly a p p ro v e tre a tm e n t p la n s

id e n tify in g a ra n g e o f m e d i c a t i o n s th a t c o uld be use d if th e first

d ru g o r dru g s a d m in iste re d p ro v e u nsa tisfa c to ry

. We a lso n o te th a t

e ith e r th e g o v e rn m e nt o r th e de fe n d a n t m a y m o ve to re v ise th e

c o u rt’s S e ll ord e r if c irc u m sta nc e s c h a n g e d u rin g a d e fe nd a n t’s

tre a tm e n t.

Ch a v e z , 7 3 4 F 3 d a t 1 2 5 4 (c ita tio n s o m itte d ). 1 0

F o r th e se re a so n s, th e tria l c o u rt’s ru lin g w ith r e sp e c t to th e se c o n d p a rt

o f th e S e ll te st wa s p la in ly in su ffic ie nt. Th a t a lo n e is e n o u g h to v a c a te th e tria l

c o u rt’s ord e r, b u t b e c a

u se th e c o u rt m a y b e c a lle d o n to a p p ly th e S e ll te st a g a in

o n re m a n d , we will p ro c e e d to d isc u ss th e re m a in in g two p a rts o f th e te st.

(c ) Ne c e ssity

Th e th ird p a rt o f th e S e ll te st re qu ire s th e tria l c ou rt to c o n c lu d e th a t

“ in vo lu n ta ry m e d ic a tio n is n e c e ssa ryto fu rth e r” th e g o v e rn m e n ta l in te re sts in

p ro c e e d in g with th e d e fe n d a n t’s p ro se c u tio n

. S e ll, 5 3 9 U

. S

. a t 1 8 1 (e m p h a sis

in o rig in a l). To re a c h th is c o n c lu sio n

, “ [t] h e c o u rt m u st fin d t h a t a n y

a lte rn a tiv e

, le ss in tru siv e tre a tme n t s a re u nlik e ly to a c h ie ve su b sta n tia lly th e

1 0 See a l s o Green, 532 F 3d at 557 (“The fact that [ the p h y sician] offered alternatives

depending on Green’s reaction to forced medication only su p p o rts the individualiz ed and

appropriately tailored nature o f her treatment plan.”); Hernandez- V asquez

, 513 F 3d at 917 (“[ W ] hile

the court may not simply d eleg ate unrestricted authority to p h y sicians, the restrictions it does impose

should be b r o a d e n o ug h to g ive phy sicians a reasonable deg r ee of flex ibility in responding to

chang es in the defendant’s condition.”).

43sa m e re su lts,” a n d th e c o u rt a lso “ m u st c o n sid e r le ss in tru siv e m e a n s fo r

a d m i n iste rin g th e d ru g s, e .g

., a c ou rt o rd e r to th e d e fe n d a n t b a c k e d b y th e

c o n te m pt po we r, b e f

o re c o n sid e rin g m o re in tru siv e m e th o d s.” Id

. (e m p h a sis

a d d e d ). As w ith its o th e r ru l i n g s, th e tria l c o urt’s o rd e r in th is c a se sim p ly

re c ite s a p o rtio n o f th e re le v a nt la n g u a g e fro m Se ll: “ In v o lu n ta ry m e d ic a tio n is

n e c e ssa ry to fu rth e r th o se in te re sts a n d a n y a lte rn a tiv e le ss in tru siv e tre a tm e n ts

h a v e b e e n a nd a re u n lik e ly to a c h ie v e su b s t a n t i a lly th e sa m e re su lts.” Th e se

fin d in g s a re a g a in in su ffic ie n t to a llo w p ro p e r a pp e lla te re v ie w, a n d th e c o urt

a lso fa ile d to fu lly a d d re ss th is p a rt o f th e S e ll te st.

To b e g in with

, th e a

b se n c e o f a sp e c ific t r e at me n t p la n fo r Wa rre n

,

id e n tify in g wh a t d ru g o r d ru g s wo u ld b e g iv e n to h im in wh a t d o se s, le a v e s u s

u n a b le to e v a lu a te wh e th e r th e re c o rd su p p o rts a fin d in g th a t c o m p e llin g Wa rre n

to ta k e th e u n id e n tifie d “ m e d ic a ti o n ” i s l i k e ly to b e e ffe c tiv e in m a k in g h im

c o m p e te n t to sta nd tria l o r to c o m p a re th a t lik e lih o o d to th e p o te n tia l

e f fe c tiv e n e ss o f th e a lte rn a tiv e

, n o n -d ru g th e ra p y d isc u sse d by th e e x p e r t

witn e sse s. M o re o v e r, e v e n if m e dic a tio n of so m e so rt is m o re lik e ly to b e

e ffe c tiv e th a n le ss in tru siv e tre a tme n ts , th e tria l c o u rt’s writte n o rd e r d o e s n o t

a d v e rt to c o n sid e ra tio n o f a n y le ss in tru siv e m e a ns fo r a d m in iste rin g th e d ru g s,

44d e s p i t e th e c o n flic tin g e vid e n c e in th e re c o rd o n th is issu e

, a n d th e c o u rt sa id

o n ly c o n c lu so rily a t th e h e a rin g

– w i t h o ut id e ntify in g wh a t m e d ic a tio n (s) th e

c o u rt wa s re fe re n c in g – th a t “ th e te stim o n y o f th e witn e sse s su p p o rts a fin d in g

b y th is C o u rt, a n d I d o so fin d th a t le ss in tru siv e m e a ns a re u n lik e ly to a c h ie v e

su b sta n tia lly th e sa m e re su lt.”

Th u s, a lth o u gh th e e v id e n c e in th e re c o rd wa s m ix e d a s to wh e th e r Wa rre n

h a d lite ra lly re fu se d to ta k e e ith e r or b o t h o f th e a n tip sy c h o tic m e d ic a tio n s

p re v io u sly p re sc rib e d fo r him

, o r ra th e r w h e th e r th e d isc o n tin u a tio n o f h is

m e d ic a tio n s wa s in ste a d ba se d o n th e m e d ic a l ju d g m e nt of his tre a tin g p h y sic ia n

Dr. Ka ne (in fo rm e d b y Wa rre n ’s c o m p la in ts a b o u t sid e e ffe c ts), th e tria l c o urt

m a d e n o c le a r fin d in g a s to wh e th e r W a rre n w o u l d r e fu se to ta k e w h a te v e r

m e d ic a tio n m ig h t n o w b e p re sc rib e d fo r h i m. W h e n a c o u rt c o nsid e rs th e

c o n stitu tio n a lity o f in vo lu n ta rily m e d ic a tin g a d e f e nd an t, th e re le v a n t

in v o lu n ta rin e ss is th a t o f th e d e fe nd an t

, n o t his tre a tin g ph y s i c i a n

. 1 1

Ac c o rd in g ly

, a n o rd e r fo r in v o lu n ta ry m e dic a tio n m u st a dd re ss th e d e fe n d a n t’s

1 1 F or this r eason, we disag ree with W arren’s arg ument that ordering h im to take medication

would b e leg ally improper unless h is current treating phy sician concurs with the tr i a l c o u rt’s

judg ment reg a r d i ng the a ppropriateness of the proposed treatment, a lthoug h we recog niz e that a

phy sician faced with a court’s medication order that is contrary to his own medical o pinion may have

difficult professional and ethical issues to resolve.

45re fu sa l to v o lu n ta rily ta k e th e m e d ic a tio n b e in g c o n sid e re d

, a lth o u g h th e o rd e r

m a y do so in a

m a nn e r th a t c o n te m

p l a te s a lte rn a tiv e a

p p ro a c h e s fo r situ a tio n s

th a t m a y u n fo ld d u rin g th e d e fe n d a n t’s tre a tm e nt, su c h a s his su bse q u e n t o r

in te rm itte n t re fu sa l to ta k e th e m e dic a tio n

. As th is c a se n ow sta n d s, it wo u ld b e

h a rd to ma k e a fin d in g o n th is p o in t (o r to e va lu a te su c h a fin d in g on a p p e a l),

with ou t k no win g w h a t s p e c ific d ru g o r d ru g s th e S ta te ’s d oc to rs a c tu a lly

p ro p o se to p re se n t to Wa rre n (e .g

., a d ru g lik e Ge od on

, to wh ic h h e p re v io u sly

h a d a se rio u s n e g a tiv e re a c tio n

, o r a th ird ge n e ra tio n a n tip sy c h o tic h e h a s n e v e r

b e e n g iv e n). Th e re is little if a n y e v id e n c e in th e re c ord th a t Wa rre n ha s

in d ic a te d h is re fu sa l to ta ke a n y m e d ic a tio n u n d e r a n

y c irc u m sta n c e s.

S i m i l a r l y

, th e re c o rd sh o ws th a t so m e of th e d ru g s th a t th e e x p e rt s

d isc u sse d m

u st be a d m in iste re d b y in je c tio n

, w h i l e o th e rs a re ta k e n o ra lly

, a

c o n sid e ra tio n th a t be a rs on h o w in tru siv e th e fo rc ib le a d m in istra tio n o f d iffe re n t

d r ug s m a y be

, wh ic h a g a in c o u ld n o t b e p ro p e rly e v a lu a te d with o u t k n o w i n g

wh ic h sp e c ific d ru g s a re p ro po se d fo r use

. S e e S e ll, 5 3 9 U

. S. a t 18 1 (h o ld in g

th a t th e c o u rt “ m

ust c o n sid e r le ss in tru siv e m e a n s fo r a d min iste rin g th e d ru gs”

(e m p h a sis a d d e d)). F u rth e rm o re

, th e tria l c o u rt’s o rd e r sa y s no th in g a b o u t

wh e th e r Wa rre n wo u ld a g re e to ta k e m e d ic a tio n

, e v e n th o u g h h e wo u ld p re fe r

46n o t to

, if h e we re o rd e re d b y th e c o u rt to d o so on p e n a lty o f c o nte m p t. S e ll

in d ic a te s th a t th is is a n a lte rn a ti v e t h a t th e tria l c o u rt sh o u ld c o n sid e r b e fo re

issu in g a n o rd e r a

u th oriz in g th e S ta te to p h y sic a lly fo rc e a d e fe n d a n t to ta k e a n

a n tip sy c h o tic m e d ic a tio n

. S e e i d

. ( g iv in g

, a s th e on ly sp e c ific e x a m p le o f th e

le ss in tru siv e m e a n s fo r a dm in iste rin g th e d ru g s th a t th e c ou rt m u st c o nsid e r, “ a

c o u rt o rd e r to th e d e fe n d a n t b a c k e d b y th e c o nte m p t p o we r” ). 1 2

F in a lly

, th e tria l c o u rt’s o rd e r wa s in a d e q u a te b e c a u se it fa ile d to a d d re ss

wh e th e r o rd e rin g in v o lu n ta ry m e d ic a tio n so le ly fo r th e p u rp o se o f m a k in g

Wa rre n c om

p e t e n t t o sta nd tria l wa s n e c e ssa ry in lig h t o f th e p o te n tia l

1 2 I n the absence of clear evidence that W a rren would refuse all antipsy chotic medication,

it is worth comparing the u nfettered discretion that t h e t r i a l court’s o rder would g ive the State to

force drug s on h im with the ty pe o f careful and stepwis e treatment p lans that have been approved

in other cases. See, e.g

. , Ruark, 611 F ed. Appx

. a t 596 ( “Dr. Sarraz in’s written report d e t a i l s the

treatment plan that will be implemented should a court order that Ruark be involuntarily medicated.

The staff at [ the hospital] will first present Ruark with a copy of the order and will try to convince

him to take an oral antipsy c hotic medicatio n a t the lowest effective dose. I f Ruark is willing to

cooperate, he will be g iven Abilify

, G eodon, Risperdal, or Haldol. I f he suffers from any side effects

that are not relieved b y adjunctive medications, he will be switched to another ant i p s y c h o t i c

. I f

Ruark is unwilling to cooperate and must b e forcibly medicated, D r

. Sarraz in w i l l b eg in by

administering a test d ose of 5 millig rams of H aldol. I f Ruark develops neuromuscular side effects

during h is treatment, he will b e g iven other m ed ications to treat those adverse effects. I f Ruark

becomes ag itated or combative during th e involuntary medication process, he w ill be g iven an

injection o f L oraz epam, a sedative.”); B reedlove, 756 F 3d at 1042 (“[ T ]he district court found that

the treatment method w ould follow the least intrusive course possible, only using forced injections

if B reedlove refused to take the medication orally .”); Diaz

, 6 30 F 3d a t 1326-1327, 1330 (outlining

the detailed treatment plan and approving the district court’s o rder direct i n g t he g overnment to

medicate Diaz forcibly in accordance with the plan, but only after “first seeking to obtain Mr. Diaz ’s

voluntary participation with any

treatment.”).

47a lte rn a tiv e o f o rd e rin g in v o lu n ta ry m e d ic a tio n “ fo r a d iffe re n t p u rp o se

, su c h a s

th e p u rp o se s se t o u t in Ha rp e r re la te d to th e in div id u a l’s d a ng e ro usn e ss, o r

p u rp o se s re la te d to th e in d iv id u a l’s o w n in te re sts wh e re th e re fu sa l to ta k e d ru g s

p u t s h is h e a lth g ra v e ly a t risk .” S e ll, 5 3 9 U. S

. a t 1 8 2 (e m p h a sis in o rig in a l)

(re fe rrin g to Wa sh in gto n v

. Ha rp e r, 4 9 4 U. S

. 2 1 0 ( 1 10 S Ct 1 0 2 8

, 1 0 8 LE2 d

1 7 8 ) (1 9 9 0 )). Th e S e ll Co u rt e x p la in e d th a t “th e in q u iry in to wh e th e r

m e d ic a tio n is p e rm issib le

, sa y

, to re nd e r an in d iv id ua l n o n d a n ge ro u s is u su a lly

m o re ‘o b je c tiv e a nd m a na g e a

b le ’ th a n t h e i n q u iry in to wh e th e r m e dic a tio n is

p e rm issib le to re n d e r a

d e fe n d a n t c om

p e te n t,” a n d

[t] h e m e dic a l e x p e rt s m a y fin d it e a sie r to p ro v id e a n in fo rm e d

o p in io n a b o u t w h e t h e r

, g iv e n th e risk o f sid e e ffe c ts, p a rtic ula r

d ru g s a re m e d ic a lly a

p p ro p ria te a nd n e c e ssa ry to c o n tro l a p a tie n t’s

p o te n t i al l y d a n g e ro u s b e h a v io r (o r to a v oid se rio u s h a rm to th e

p a tie n t h im se lf) th a

n to try to ba la n c e h arm s a n d b e n e fits re la te d to

th e m o re q u in te sse n tia lly le g a l q ue stio ns o f tr i a l fa irn e ss a n d

c o m p e te n c e

.

Id . a t 1 8 2 (c ita tio n o m itte d).

T h e S u p r e m e Co u rt n o te d th a t th e se o th e r g ro u nd s fo r in v o lu n ta ry m e d i c a l

tre a tm e nt a re ty pic a lly a d d re sse d b y c o u rts a s a c iv il m a tte r, wi t h v a r io u s

p ro c e d u ra l p ro te c tio n s fo r th e p a tie n t, a n d a d d e d :

48Ev e n if a c ou rt d e c id e s m e d ic a tio n c a n n o t b e a u th o riz e d o n th e

a lte rn a tiv e g ro u n d s, th e fin d in gs u nd er l y i n g su c h a d e c isio n w ill

h e lp to in fo rm e x p e rt o p in io n an d ju d ic ia l d e c isio nm a k in g in

re sp e c t t o a re q u e st to a d m in iste r d ru g s fo r tria l c o m p e te n c e

p u rp o se s. At th e le a st, th e y will fa c ilita te d ire c t m e d ic a l a n d le g a l

fo c u s u p o n su c h q u e st i o n s a s: Wh y is it m e d ic a lly a p p ro p ria te

fo rc ib ly to a d m in iste r a n tip sy c h o tic d ru g s to a n in d iv id ua l wh o (1 )

is n o t d a n g e ro u s a n d (2 ) is c o m p e te nt to m a k e u p h i s o wn m in d

a b o u t t r e a t m e n t? Ca n b rin g in g su c h a n in d iv id u a l to tria l a lo n e

ju stify in wh o le (o r a t le a st in s i g n i f i c a n t p a rt) a d m in istra tio n o f a

d ru g th a t m a y h a v e a d v e rse sid e e ffe c ts, in c lu d in g sid e e ffe c ts th a t

m a y to so m e e x te n t im

p a ir a d e fe n se a t tria l?

Id

. a t 1 8 3 (e m

p h a sis in o r i g i n a l ). F o r th e se re a so n s, th e S u p re m e Co urt

c o n c lu d e d th a t a

tria l c o u rt a sk e d to a

p p ro v e fo rc e d a dm in istra tio n o f d ru g s to

re n d e r a d e fe n d a

n t c o m pe te n t to sta n d tria l “ sh o u ld o rd in a rily d e te rm in e

wh e th e r th e Go ve rn m e n t se e k s, o r ha s firs t s o u g h t, p e rm issio n fo r fo rc e d

a d m in istra tio n o f dru g s o n th e se o t h e r Ha rp e r-ty p e g ro u n d s; a n d

, if no t, w h y

n o t.” Id

. S e e a lso Un ite d S ta te s v

. He rn a n d e z -Va sq u e z

, 5 1 3 F3 d 9 0 8

, 9 1 5 (9 th

Cir. 2 0 0 7 ) (a m e n d e d op in io n ) (sta tin g th a t th e “ [tria l] c ou rt m a y wish to in q u ire

fu rth e r a s to th e Go ve rn m e n t’s re a so n s fo r n o t se e k in g in v o lu n ta ry m e d ic a tio n

o n th e b a sis of d a n g e ro u sn e ss, a n d sh ou ld no te fo r th e re c o rd its re a so n s fo r n o t

p ro c e e d in g u n d e r Ha rp e r, be fo re u nd e rta k in g th e S e ll in q u iry ,” b e c a u se “ [a ]

d e fe n d a n t’s lib e rty in te re st in a v o id in g u n n e c e ssa ry in v olu n ta ry m e dic a tio n is

49to o im

p o rta n t to a llo w fo r situ a tio n s in wh ic h th e c o u rt is a sk e d to un d e rta k e th e

m o re e rro r-p ro ne [S e ll] a n a ly sis fo r wh a t m a y b e a rb itra ry o r ta c tic a l re a so n s” ).

In th is c a se

, n o th in g i n t h e r e c o rd in d ic a te s th a t th e Sta te h a s so u g h t

p e rm issio n to in v o l u n t a rily m e d ic a te Wa rre n fo r th e a lte rn a tiv e p u rp o se o f

p re v e n tin g h im

fro m b e in g a d a n g e r to h im se lf o r o th e rs, o r th a t th e tria l c o urt

a sk e d wh y th e S ta te h a d n o t d o n e so

. Th is is e sp e c i a lly c on c e rn in g b e c a use

th e re w a s e x p e r t t e s tim o n y th a t Wa rre n w o u ld lik e ly p re se nt a “ risk to th e

p u b lic ” if re le a se d, th a t h e b e lie v e d th a t “ re ta lia tin g in a v e r y v io le n t wa y ”

wo u ld b e a n a

p p ro p ria te re sp o n se to th e th e fts th a t a re c o m mo n in th e m e n ta l

h o sp ita l, a n d th a t a n tip sy c h o tic m e d ic a tio n wo u ld c a u se h im to g o fro m a “ lo w

risk ” to h o sp ita l sta ff to “a n e v e n lo w e r risk

, b e c a use th e re wo uld be le ss lik e ly

so m e c h a n c e th a t h e co u l d in c o rp o ra te o th e r p e op le in th e h o sp ita l in to h is

d e lu sio n a l sy ste m .” In lig h t o f th is e v id e n c e

, a n d in th e a b se n c e of a c o g e n t

e x p la n a tio n fro m th e S ta te a s to wh y it h a s n o t so u gh t to m e d ic a te W a rre n u n d e r

Ha rp e r, it wa s e rro r fo r th e tria l c o u rt to ju m p d ire c tly to th e fo r c i b le

a d m in istra tio n o f m e d ic a tio n fo r t h e s o le p urp ose o f re n d e rin g Wa rre n

c o m p e te n t to sta nd tria l.

50(d ) Me d ic a l Ap p ro p ria te n e ss

Th e fo u rth a nd fin a l p a rt of th e S e l l t e s t re qu ire s th e tria l c o u rt to

“ c o n c lu d e th a t a dm in istra tio n o f th e d ru g s is m e d ic a lly a p p ro pria te

, i.e

., in th e

p a tie n t’s b e st m e dic a l in te re st in lig h t o f h is m e d ic a l c o nd itio n .” S e ll, 5 3 9 U. S

.

a t 1 8 1 ( e mp h a s i s i n o rig in a l). Th is p art o f th e te st is c lo se ly re la te d to th e

se c o nd p a rt, a nd th e tria l c o u rt’s ru lin g o n it su ffe rs th e sa m e i n f i r mi tie s a s

id e n tifie d a

b o v e a s to th e ru lin g o n th e s e c o nd p art. A g a in

, th e c ou rt’s o rd e r

sim p ly su m m a rily re c ite s th a t “ [t] h e a dm in istra tio n o f m e d ic a tio n s is m e d ic a lly

a p p ro p ria te a n d in v o lu n ta ry m e d ic a tio n is in De fe n d a n t’s b e st in te re st in lig h t

o f h is m e d ic a l c o n d itio n ,” with o u t id e n tify in g wh a t m e d i c at i o n s in wh a t d o sa ge s

fo r wh a t d u ra tio n s th e c o u rt wa s b le ssin g

.

Th e S e ll C o u rt’s e x p la na tio n im m e d ia te ly fo llo win g th e la ng u a g e th a t th e

tria l c o u rt’s o rd e r tra c k e d m a k e s t h e i n a d e q u a c y o f th e o rd e r a p p a re n t: “ T

h e

sp e c ific k in d s o f d ru g s a t issu e ma

y ma tte r h e re a s e lse wh e re . Diffe re n t k in d s

o f a n t i p s y c h o tic d ru g s m a y p ro d u c e d iffe re n t sid

e e ffe c ts a n d e n

jo y d iffe re n t

le v e ls o f su c c e ss. ” Id

. (e m

p h a sis a dd e d ). As d isc u sse d a bo ve

, th e e x p e rt

te stim o n y p re se n te d in th is c a se re fe rre d to a v a rie ty o f a n tip sy c ho tic dru g s a n d

g e n e ra tio n s o f d ru g s, wh ic h th e e x p e rts in d ic a te d c o u ld p ro du c e d iffe re n t sid e

51e ffe c ts, in ge n e ra l a n d fo r Wa rre n in p a rtic u la r, a n d c ou ld h a ve d iffe re n t c h a n c e s

fo r su c c e ss, in g e n e ra l a n d fo r Wa rre n in p a rtic u la r, a lth o u g h th e e x p e rts we re

f a r fro m u n ifo rm in th e ir o p in io n s a n d th e te stim o n y wa s o fte n im p re c i s e i n

lin k in g sp e c ific p re d ic tio n s o f su c c e ss a n d sp e c ific po ssib le sid e e ffe c ts to

sp e c ific m e d ic a tio n s. Th e t r i a l c o urt’s o rd e r d oe s n o th in g to so rt o u t th is

e v id e n c e , an d th u s th is a sp e c t o f th e o rd e r is a lso fla we d

. S e e Ev an s, 4 0 4 F 3 d

a t 2 42 (h o ld in g th a t th e g o v e rn m e nt m u st n o t o n ly p re se n t a sp e c ific tre a tm e n t

p la n

, b u t m

u st a lso “ re la te th e pro p o se d tre a tm e n t pl an to th e in d iv id u a l

d e fe n d a n t’s p a rtic u la r m e d ic a l c o n d itio n” in o rd e r to sa tisf y th e se c o n d a n d

fo u rth p a rts o f th e S e ll te st).

4

. Co nc lu sio n

F o r th e re a so ns d isc u sse d a b o v e

, w e c o n c lu d e th a t th e tria l c o u rt’s o rd e r

wa s in su ffic ie n t in n u m e ro u s re sp e c ts to ju stif y Wa rre n ’s in v o lu n ta ry

m e d ic a tio n fo r th e so le p u rp o se o f m a k in g h im m e n ta lly c o m p e te n t to sta n d tria l

fo r th e v e r y s e r i o u s c rim e s h e is a c c u se d o f c o m m ittin g

. Ac c o rd in g ly

, a s th e

U.S

. Su p re m e Co u rt d id in Se ll, we v a c a te th e tria l c o u rt’s o rd e r a n d re m a n d th e

c a se fo r f

u r t h er p ro c e e d in g s in lig h t o f th is op in io n

. We no te th a t th e

e v id e n tia ry h e a

rin g wa s h e ld m o re th a n a y e a r a g o

, a n d it is p o ssib le th a t

52Wa rre n ’s m e n ta l a n d p h y sic a l c o n d itio n h a s m a te ria lly c h a ng e d in th e m e a n tim e

a n d a lso p o ssib le th a t n e w sc ie n tific in fo rm a tio n is a v a ila b le r e g a rd in g

a n tip sy c h o tic d ru g s a n d th e ir lik e ly e ffe c tiv e n e ss a n d sid e e ffe c ts.

Co n se q u e n tly

, if th e S ta te e le c ts to p u rsu e its m o tio n fo r in v o lu nta ry m e d ic a tio n

o n re m a nd

, th e tria l c o u rt sh o u ld a llo w th e pa rtie s to p re se nt a dd itio n a l e v id e n c e

to e n su re th a t th e c o u rt’s fin d in g s a re b a se d o n c u rre n t c irc u m sta n c e s. S e e S e ll,

5 3 9 U. S

. a t 18 6. S e e a lso Ev a n s, 4 0 4 F 3 d a t 2 4 2 -2 4 3 (v a c a tin g a n d re m a n d in g

“ with in stru c tio n s to th e d istric t c o u rt to re a sse ss th e m o tio n a fte r a ffo rd in g th e

p a rtie s th e o p p o rtu n ity to su p p le m e n t th e re c o rd in a m a n ne r c o n siste n t with [th e

Circ u it Co u rt’s] o p in io n ” ); He rn a n d e z -Va sq u e z

, 5 1 3 F 3 d a t 91 9 (v a c a tin g a n d

re m a n d in g with sim ila r in stru c tio n s).

Ju d g m e n t v a c a te d a n d c a se r e m a nd e d with d ire c tio n. All th e Ju stic e s

c o n c u r, e x c e p t Me lto n , J., wh o c o n c u rs in th e ju dg m e n t o n ly

.

53