Compulsory medical treatment: the limits of bodily integrity.

Liberals celebrated the Supreme Court's 2003 term for its support of affirmative action and its condemnation of criminal penalties for same sex intercourse. At first glance, the Court's opinion in Sell v. United States, appears equally liberal. The Court held that the government may forcibly administer anti-psychotic drugs to a mentally ill defendant only under strict conditions. Yet discerning liberals will notice not simply the Court's reiteration of a constitutionally protected interest in avoiding compulsory treatment, but the palpable limits of bodily integrity. Forcible Medication Charles Sell, a dentist, was indicted for Medicaid fraud and other offenses. He had a long history of mental illness, was found incompetent to stand trial, and was confined in a federal prison system medical center for more than four years while he refused medication. The lower courts determined that he was not a danger to himself or others, and the Supreme Court was obliged to accept that conclusion. His long incarceration and the nonviolent nature of the charges made Sell "a symbol of clinging to personal autonomy in the face of overweening government power." (1) The case also divided the mental health profession, with the American Psychiatric Association supporting compulsory medication and the American Psychological Association opposing it. The question presented was whether the Constitution permits the government to forcibly administer antipsychotic drugs solely to render a mentally ill defendant competent to stand trial for serious but nonviolent crimes. The Supreme Court's starting premise was that individuals have a basic, constitutionally protected "liberty interest" in avoiding unwanted medical treatment. (2) That interest, however, may be trumped by the state's countervailing interest in bringing a defendant to trial. The Court made clear that involuntary medication for competency purposes is permissible but closely limited: the treatment must be medically appropriate, unlikely to have side effects that undermine the fairness of the trial, and (taking account of less intrusive alternatives), necessary to significantly further important governmental trial-related interests. (3) Justice Breyer, writing for the Court, cautioned that cases in which drugs may be forcibly administered solely for trial competence purposes "may be rare" because a court must first make several important findings. First, the government must have an important interest at stake. Although the state's interest in bringing to trial a person accused of a serious crime is significant, courts must weigh "special circumstances." A finding of incompetence to stand trial may result in a lengthy confinement in a mental institution. Ironically, Sell's decision to refuse medication resulted in a pretrial confinement that exceeded the sentence he would have received if convicted. This diminishes the state's interest in prosecution because a defendant ordinarily receives credit toward a sentence for time served, and pretrial confinement reduces the likelihood of the defendant committing future crimes. Second, involuntary medication must "significantly further" the state's interests, including its interest in assuring that the defendant receives a fair trial. The medication must not interfere significantly with the defendant's ability to assist in his own defense. While antipsychotic medication can relieve psychotic symptoms such as hallucinations and delusions, it can also interfere with the defendant's ability to exercise trial rights. A heavily medicated defendant may be unable to communicate meaningfully with counsel or decide whether to testify. Additionally, a defendant's "affect, demeanor, and responsiveness" may be so compromised as to affect his or her credibility and presumption of innocence at trial. (4) Third, the trial court must find that alternative, less intrusive treatments (such as psychotherapy) are unlikely to achieve substantially the same results. …