Opinion ID: 624293
Heading Depth: 4
Heading Rank: 2

Heading: Specificity of Proposed Treatment

Text: Harper instructed that a decision to medicate involuntarily must be medically appropriate. See Harper, 494 U.S. at 227, 110 S.Ct. 1028. Sell, which incorporated Harper's medical appropriateness requirement, observed that [d]ifferent kinds of antipsychotic drugs may produce different side effects and enjoy different levels of success. Sell, 539 U.S. at 181, 123 S.Ct. 2174. Interpreting the medical appropriateness requirement in United States v. Hernandez-Vasquez , we observed that  Sell 's discussion of specificity would have little meaning if a district court were required to consider specific drugs at a Sell hearing but then could grant the Bureau of Prisons unfettered discretion in its medication of a defendant. 513 F.3d at 916. We therefore held that, to satisfy the medical appropriateness requirement, the district court's order must identify: (1) the specific medication or range of medications that the treating physicians are permitted to use in their treatment of the defendant, (2) the maximum dosages that may be administered, and (3) the duration of time that involuntary treatment of the defendant may continue before the treating physicians are required to report back to the court on the defendant's mental condition and progress. Id. at 916-17. We have never identified the government's purpose in seeking involuntary medication, whether dangerousness or trial competency, as a relevant factor in applying the medical appropriateness requirement. Instead, we have assumed that the same requirement for a specific treatment plan applies in both contexts. In United States v. Williams, 356 F.3d 1045 (9th Cir.2004), for example, we applied the medical appropriateness requirement, under the Harper standard, to a supervised release condition that required the convict to take antipsychotic medication under threat of reincarceration. Id. at 1056-57. And in Rivera-Guerrero, we held that Williams's interpretation of the medical appropriateness requirement applies to the medical appropriateness inquiry under Sell. See 426 F.3d at 1137 (citing Williams, 356 F.3d at 1056). Hernandez-Vasquez should therefore apply with equal force in all involuntary medication contexts. Moreover, the reasons supporting a specification requirement in the Sell context apply with equal force where medication is justified on dangerousness grounds. Sell proceeded from that premise, stating that [t]he specific kinds of drugs at issue may matter here as elsewhere. Sell, 539 U.S. at 181, 123 S.Ct. 2174 (emphasis added). With no specific limitsor at least prescribed ranges or categoriescovering the types, dosages, and duration of a patient's involuntary medication. Dr. Tomelleri could not meaningfully evaluate the medication proposal, as compared to alternatives (including an alternative medication regime). This particularized focus, for reasons already noted, is of special importance with regard to pretrial medication for dangerousness. In this context, the governmental interest in long-term correction evaporates: Drugs with serious side effects, though appropriate where ultimate cure is the goal, may not be medically indicated (or may be indicated in lower doses) for elimination of symptoms alone. The majority maintains that cabining the discretion of Loughner's treating physicians in this way would prevent them from adjusting his medication regimen to changing circumstances. This concern was addressed by Hernandez-Vasquez. In that case, we held that the specifications in the involuntary medication order should be broad enough to give physicians a reasonable degree of flexibility in responding to changes in the defendant's condition, and noted that the government or the defendant may move to alter the court's order as the circumstances change and more becomes known about the defendant's response to the medication. 513 F.3d at 917. [14] I would therefore hold that an involuntary medication order premised on dangerousness to self or others, like an order premised on restoration to competency, must identify the types, maximum dosages, and estimated duration of an inmate's involuntary medication. In the procedural regime I favor for this case, in which the involuntary medication decision would be made as part of the proceedings concerning commitment for restoration of competency, the order could provide substantial medical flexibility; in the administrative regime the majority presupposes, the order can be more focused, as adjustments can be accomplished on site and through the facility's independent hearing officer(s). The policy approved in Harper operated in just this way, providing regular review by the administrative hearing committee as to both the type and dosage of the drugs to be administered. See Harper, 494 U.S. at 216, 232-33, 110 S.Ct. 1028. Because Dr. Tomelleri did not tailor his analysis to the temporary, nonconviction, pretrial context, and did not provide specific directions to Loughner's treating physicians regarding the types of drugs, the maximum dosages to be administered, or the estimated duration of involuntary medication, I would hold that FMC-Springfield did not properly determine whether involuntary medication was medically appropriate, even for the period of Loughner's prior commitment.