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

Heading: The Commitment Decision

Text: The majority first labors to determine whether this case is governed by Harper or by Sell, and settles on the former with regard to the pretrial-medication-for-dangerousness question. The majority then proceeds to treat that prior medication decision as a background event that the district court did not need to revisit itself when deciding whether to commit Loughner to FMC-Springfield for restoration of competency. But the majority's analysis goes off course proceeding in this fashion, in two ways: The majority addresses the questions before us in the wrong order, as the commitment decision is the currently operative one. And it seeks to sort the issues we face into a preexisting box that is, either Harper or Sell when, in fact, this case presents us with somewhat novel questions. Specifically, we must decide whether a district court may rely on a prior administrative authorization to medicate involuntarily a pretrial detainee based on dangerousness to self, issued while the detainee was under an earlier commitment order, to justify a new commitment for the express purpose of restoration of competency pursuant to 18 U.S.C. § 4241(d)(2)(A). The question is a difficult one, for it requires us to weigh the interests and values at stake in two separate, but related, proceedings, conducted for different reasons. Reviewing those interests, together with the principles gleaned from Sell and our post- Sell cases, I conclude that a court may not commit a pretrial detainee for the purpose of restoring his trial competency through involuntary medication without itself deciding that involuntary medication is both justified on some properly applicable ground and unlikely to infringe the detainee's fair trial rights. Because of the way it structures its opinion, however, the majority does not squarely confront the now-dispositive question. Instead, the majority cleaves the issue of Loughner's involuntary medication from the question of his commitment for restoration, even though the commitment decision was entirely dependent on continuing the involuntary medication during the entirety of Loughner's treatment for restoration of competency at FMC-Springfield. In other words, the majority holds that it was proper to commit Loughner to FMC-Springfield for restoration of competency because, if so committed, the earlier administrative decision to medicate him for dangerousness to himself could be relied upon, and if thus medicated, Loughner would likely become competent to stand trial. The logical flaw here is obvious: One cannot decide whether Loughner should be committed to restore competency by assuming an administrative medication decision that rested on the premise that he is already an inmate of the institution and needs to be medicated while there. [5] Further, to justify its analysis, the majority holds that whenever dangerousness is the ground for involuntary medication whether pre- or post-trial, and whether with the ultimate aim is restoration to competency or not Harper governs entirely as to both the substantive and procedural safeguards. Why that should be so, we are not told. In particular, we are not told why the question of the propriety of involuntary medication on dangerousness grounds can be relegated to an administrative proceeding when: (1) it is the court that must decide whether Loughner is to be medically treated so as to be restored to competency; and (2) its decision in that regard depends on the availability of involuntary medication.
To my mind, Sell goes almost all of the way toward establishing that where, as here, the involuntary medication decision is embedded in a pretrial judicial decision concerning restoration of competency, the court must decide whether the defendant is to be involuntarily medicated. Sell does not address the precise situation here, in which there was a previous mid-commitment administrative involuntary medication decision. [6] But it does establish the proposition that a court must itself address the involuntary medication issue when, as here, the government's ultimate aim is restoration of competency, and the court is deciding the propriety of treatment toward that end. Because the relevant passage from Sell is singularly important to the correct disposition of this case, and is brushed aside by the majority, I quote it at length: We emphasize that the court applying these standards is seeking to determine whether involuntary administration of drugs is necessary significantly to further a particular governmental interest, namely, the interest in rendering the defendant competent to stand trial. A court need not consider whether to allow forced medication for that kind of purpose, if forced medication is warranted for a different purpose, such as the purposes set out in Harper related to the individual's dangerousness, or purposes related to the individual's own interests where refusal to take drugs puts his health gravely at risk. There are often strong reasons for a court to determine whether forced administration of drugs can be justified on these alternative grounds before turning to the trial competence question. . . . [C]ourts typically address involuntary medical treatment as a civil matter, and justify it on these alternative, Harper -type grounds. Every State provides avenues through which, for example, a doctor or institution can seek appointment of a guardian with the power to make a decision authorizing medication when in the best interests of a patient who lacks the mental competence to make such a decision. And courts, in civil proceedings, may authorize involuntary medication where the patient's failure to accept treatment threatens injury to the patient or others. If a court authorizes medication on these alternative grounds, the need to consider authorization on trial competence grounds will likely disappear. Even if a court decides medication cannot be authorized on the alternative grounds, the findings underlying such a decision will help to inform expert opinion and judicial decisionmaking in respect to a request to administer drugs for trial competence purposes. Sell, 539 U.S. at 181-83, 123 S.Ct. 2174 (emphases added) (citations omitted). The rhythmically insistent pulse of Sell 's refrainA court need not consider. . . . There are often strong reasons for a court to determine. . . . [C]ourts typically address. . . . If a court authorizes. . . . Even if a court decides. . . .repeatedly reinforces the command that a court, asked to approve forced administration of drugs for purposes of rendering a defendant competent to stand trial, should itself begin by determining whether the drugs may be justified on alternative, Harper -type substantive grounds. See id. at 183, 123 S.Ct. 2174. In other words, Sell recognized that the substantive reasons for an involuntary medication order and the applicable procedural protections are not necessarily tied together in discrete packages. Instead, where an ultimate judicial decision concerning medical treatment toward restoration of competency turns on involuntary medication, the court can vary the substantive ground for ordering involuntary medication, but must itself determine whether involuntary medication is appropriate on some proper basis. Sell does not stand alone in this regard. Its predecessor, Riggins v. Nevada, 504 U.S. 127, 112 S.Ct. 1810, 118 L.Ed.2d 479 (1992), stated that the government certainly would have satisfied due process if the prosecution had demonstrated, and the District Court had found, that treatment with antipsychotic medication was medically appropriate and, considering less intrusive alternatives, essential for the sake of Riggins' own safety or the safety of others. Id. at 135, 112 S.Ct. 1810 (emphasis added) (citations omitted). Although this sentence from Riggins does not, as Loughner maintains, adopt as a holding the requirement of a no-less-intrusive-alternative finding, it does presage Sell's insistence that, whatever the substantive standard is, the pertinent finding, even as to medication for dangerousness, be made by a court, where that finding is an alternative to medication for trial competency purposes and restoration is the likely result. Justice Kennedy's concurrence in Riggins reinforces this point, explicitly rejecting the analytical bifurcation of involuntary medication and trial-related proceedings. I cannot accept the premise . . . that the involuntary medication order comprises some separate procedure, unrelated to the trial and foreclosed from inquiry or review in the criminal proceeding itself, Justice Kennedy wrote, To the contrary, the allegations pertain to the State's interference with the trial. Riggins, 504 U.S. at 139, 112 S.Ct. 1810 (Kennedy, J., concurring in the judgment). Similarly, I cannot, especially in light of Sell, accept the proposition that the involuntary medication order can be a separate, administrative procedure, even though the judicial commitment proceeding is part of the overall criminal prosecution and concerns whether Loughner can be restored to competency to stand trial through involuntary medication. Our own cases similarly suggest that a court, asked to authorize restoration of a pretrial detainee to trial competency through mandatory administration of drugs, must itself determine whether medication can be justified on dangerousness grounds. In United States v. Hernandez-Vasquez, 513 F.3d 908 (9th Cir.2008), we stated that the district court, in an ordinary case, should refrain from proceeding with the Sell inquiry before examining dangerousness and other bases to administer medication forcibly, and added that the court should state its reasons for not proceeding under Harper if it chose to advance directly to the Sell analysis. Id. at 914 (emphasis added). Moreover, we cautioned that, [o]n remand, the district court. . . . should take care to separate the Sell inquiry from the Harper dangerousness inquiry and not allow the inquiries to collapse into each otheran instruction that would have made little sense if we had expected the prison to conduct the Harper hearing. Id. at 919; see also United States v. Rivera-Guerrero, 426 F.3d 1130, 1138 n. 4 (9th Cir.2005) (stating that  the district court should have conducted a Harper dangerousness hearing instead of proceeding under Sell ) (emphasis added). [7] Thus, where the government has asked the district court to authorize the detainee's restoration through involuntary medication, Sell and its progeny require the court to determine whether a pretrial detainee may be involuntarily drugged on dangerousness grounds, if that appears to be a feasible alternative to involuntary medication on restoration grounds alone. That is, of course, precisely what has happened here.
Apart from brushing aside Sell and our related cases with regard to the need for a judicial decision whenever the ultimate aim is restoration of competency, the majority attempts to distinguish this case from Sell by separating the involuntary medication decision from the decision that Loughner could be restored to competency within a reasonable period of time if committed for treatment at FMC-Springfield. But the two issues cannot be disentangled in this manner. 18 U.S.C. § 4241(d)(2)(A) focuses the commitment for treatment inquiry on the likelihood of the detainee's restoration after the treatment. Obviously, a judge cannot meaningfully decide whether restoration to trial competency as a result of treatment is likely without knowing what treatment is contemplated. And equally obviously, where the treatment contemplated is the administration of involuntary psychotropic medication, the detainee's prospects for restoration depend on the propriety of an order authorizing involuntary medication. Thus, as the majority acknowledges, the involuntary medication decision is important to the overall outcome of the § 4241(d)(2) proceeding because it `likely affect[s] both the scope and term of a § 4241(d)(2) order.' Majority Op. at 767 (quoting United States v. Magassouba, 544 F.3d 387, 418 n. 27 (2d Cir.2008)). What the majority does not acknowledge, however, is that the involuntary medication order itself depends on the detainee's commitment. Certainly, a defendant would not be subject to involuntary medication were he released from government custody. Were he instead simply transferred from a mental health treatment facility to an ordinary pretrial detention center, changes to the circumstances of his confinement would necessitate a new involuntary medication proceeding to determine whether the inmate poses a danger to himself or others in the context of his new confinement. [8] Thus, the district court's decision to extend Loughner's commitment for the purpose of effecting his restoration both required and enabled the administration of involuntary medication. Under these circumstances, the prior administrative involuntary medication decision, made while Loughner was already committed to FMC-Springfield for a limited period and for a different purpose than is now at issue, cannot simply be assumed valid and treated as a background condition of the commitment decision.
I would therefore view the § 4241(d)(2)(A) commitment proceeding as functionally indistinguishable from the involuntary medication decision in Sell. And, as I have shown, Sell and our later cases could not be more clear in directing that, where restoration of trial competency is the ultimate goal, any decision to medicate involuntarily a pretrial detainee, even on dangerousness grounds, must be made in a judicial proceeding. As Sell does not elaborate on why that is so in any detail, I do so now, with particular attention to the circumstances we face. I conclude that, at the point at which a decision must be made concerning the detainee's commitment for restoration of competency to stand trial, the relative advantages of judicial involvement in the involuntary medication decision and concern for the impact psychotropic medication may have on the detainee's fair trial rights both counsel in favor of requiring the district court itself to resolve the involuntary medication issue, whether on dangerousness or other grounds. I review each of these considerations in turn.
In deciding that a convicted, incarcerated prisoner is not entitled to a judicial hearing regarding the involuntary medication decision, Harper expressed significant concern over the fact that requiring judicial hearings will divert scarce prison resources, both money and the staff's time, from the care and treatment of mentally ill inmates. Harper, 494 U.S. at 232, 110 S.Ct. 1028. The Court also reasoned that these additional costs were not justified, given the specifically medical nature of the inquiry and the absence of any reason to doubt the administrative decisionmaker's impartiality. See id. at 233-35 & n. 13, 110 S.Ct. 1028. In the quite different context of a judicial decision concerning pretrial treatment for restoration of competency, focused on the detainee's prospects for restoration of capacity to stand trial, there are several important purposes served by, and few reasons for avoiding, judicial resolution of the involuntary medication for dangerousness issue. First, unlike the Harper context, in which the inmate has been convicted and is incarcerated for the term of his sentence, the marginal costs of judicial inquiry into the involuntary medication issue are minimal. A judicial hearing is required anyway for purposes of determining the propriety of treatment for restoration of competency. Here, for example, the district judge, counsel for both parties, Loughner's treating psychologist (Dr. Pietz), a government expert witness with a background in clinical psychiatry (Dr. Ballenger), and Loughner himself were all present in the courtroom for the district court's September 28 commitment hearing. Concomitantly, the issues pertaining to Loughner's commitment for restoration (e.g., his likely reaction to psychotropic drugs, the need to continue medication throughout the extended commitment period, and so on) are closely related to the issues pertaining to whether he may be medicated involuntarily for dangerousness to self or others. If Loughner's attorneys had been permitted to inquire at the September 28 hearing into the propriety of forced medication on dangerousness grounds, they could conceivably have established that such medication was not justified, and so treatment on that ground would not be the basis for any conclusion that Loughner could, if committed, be restored to competency in a reasonable period of time. The marginal difficulty of requiring the court to explore whether Loughner's involuntary medication is justified on dangerousness grounds, in addition to determining whether that medication, if administered, will likely restore his trial competency, would be immeasurably less than for a convicted prisoner, as to whom no legal proceedings at all are ongoing, much less proceedings focused on matters closely related to, and dependent upon, the involuntary medication determination. Nor would requiring judicial determination in the present context encroach on the prerogative of the prison's medical staff. Like the criminal defendant in Riggins and the pretrial detainee in Sell, Loughner was already in the midst of government-initiated judicial proceedings that dealt explicitly with legal issues relating to his involuntary medication (i.e., whether the medication is likely to restore him to the capacity to permit the proceedings to go forward). See Sell, 539 U.S. at 175, 123 S.Ct. 2174; Riggins, 504 U.S. at 139, 112 S.Ct. 1810 (Kennedy, J., concurring in the judgment). Because the government has itself opened the door to judicial proceedings relating to involuntary medication, its professed concerns about judicial encroachment on matters of prison administration carry significantly less weight. Moreover, where, as for the commitment decision, the question of the propriety of medication for dangerousness is embedded in an inquiry into the likelihood of restoration of competency, the district court is no worse placed, and in some respects better placed, than the prison's medical staff to render an objective and impartial decision. For one thing, FMC-Springfield's physicians are, like most physicians, professionally disposed to favor medical treatment. The district court recognized as much when it acknowledged that Loughner's physicians may be overly optimistic in forecasting his prospects for restoration through involuntary medication. They're doctors, the court observed, They want to help and heal people. Doctor Tomelleri's involuntary medication orders bear out the district court's observation. The Harper I, Harper II, and Harper III orders repeatedly rejected less-intrusive measures, such as seclusion and physical restraints, because they have no direct effect on mental illness, and justified the use of psychotropic medication on the grounds that only the psychotropic drugs address the fundamental problem. Doctor Tomelleri's preoccupation with treating Loughner's underlying mental illness, although professionally appropriate, could have significantly clouded his judgment as to whether the drastic measure of involuntary psychotropic medication was justified under the temporary detention circumstances. This skew may well have influenced the original involuntary medication decision, which was premised on dangerousness to others. At that point, Loughner's manifestations of dangerousness consisted of throwing some plastic chairs against a metal grill and a wall, throwing some toilet paper at a camera, and spitting and lunging at his attorneys (a characterization the attorneys dispute, but as to which there has been no evidentiary hearing). Although very likely manifestations of serious mental illness, these incidents do not appear to have endangered anyone and would be most unlikely, I would think, to have triggered involuntary psychotropic medicationas opposed to physical security measuresin most incarceration contexts. See Weston, 206 F.3d at 13. Further, Loughner's FMC-Springfield physicians in particular are, unlike physicians in other jail and prison settings, charged with additional duties that could color their medication for dangerousness decision. FMC-Springfield was previously charged with treating Loughner as necessary to determine whether there is a substantial probability that he can be restored to competency, 18 U.S.C. § 4241(d)(1), and is now charged with treating Loughner for the express purpose of restoring him to competency. See 18 U.S.C. § 4241(d)(2)(A). Where, as here, the detention facility's medical staff perceive involuntary medication as the only option for restoring [the detainee] to competency, the institutional responsibility to restore competency if possible is likely to color the medical staff's deliberations regarding involuntary medication on any grounds. Indeed, there is some indication that this confusion of roles occurred with respect to FMC-Springfield's involuntary medication decisions in this case. For example, Loughner's Notice of Medication Hearing and Advisement of Rights form, filled out by Dr. Pietz, stated: Reason for Treatment: Mr. Loughner suffers from a mental illness and refused to take the medication prescribed to him. He was referred to this facility to restore competency. Contrary to the district court's observation that Loughner's prison physicians remain free to find that he cannot be, or has not been restored, the language of Loughner's notice form suggests Dr. Pietz believed that Loughner was sent to FMC-Springfield to restore competency (which was not true; the commitment was for evaluation, see 18 U.S.C. § 4241(d)(1)) and that the purpose of involuntary medication was to restore Loughner's competency for trial, not to treat dangerousness. [9] Such instances support the conclusion that the district court may be better placed than the prison's administrative decisionmakers to render an objective decision on the involuntary medication of a pretrial detainee for purposes of dangerousness to self. Although the majority suggests otherwise, Majority Op. at 755-56 (citing Harper, 494 U.S. at 233-34, 110 S.Ct. 1028), this particular structural conflict theory did not come into play in Harper. In the postconviction context, the prison's administrative decisionmakers did not confront any statutory restoration obligations that could potentially interfere with the necessary independence to provide an inmate with a full and fair hearing. See Harper, 494 U.S. at 233, 110 S.Ct. 1028. The majority also suggests that the courts are ill-suited for making medical judgments about a detainee's medication treatment and should avoid doing so wherever possible. Majority Op. at 755. Courts are not institutionally disabled from deciding such questions. As Sell recognized, they typically address involuntary medical treatment as a civil matter, and justify it on these alternative, Harper -type grounds. Sell, 539 U.S. at 182, 123 S.Ct. 2174; see also, e.g., Kulas v. Valdez, 159 F.3d 453, 455-56 (9th Cir. 1998). For example, the criteria courts must apply in determining whether a federal criminal defendant may be civilly committed strongly resemble the criteria applied by the Bureau of Prisons' administrative decisionmakers in Harper proceedings. Compare 18 U.S.C. § 4246(d) with 28 C.F.R. 549.46(a)(7). Indeed, the district court's decision to extend Loughner's commitment itself involved a medical judgment as to the likelihood that Loughner's current regimen of psychotropic medication will successfully induce his restoration within the authorized period. If we can trust the court's acumen to determine, after an evidentiary hearing at which experts appear, that a certain medication regimen is likely to restore Loughner's capacity to stand trial, there is no reason simultaneously to distrust that same court's ability to ascertain whether that same medication is needed to make him less dangerous to himself or others.
Central to the holding in Sell was the understanding that the side-effects associated with psychotropic medication may severely prejudice a defendant's right to receive a fair trial. Here, for example, Dr. Pietz testified that Loughner has developed a flat, emotionless aspect since resuming psychotropic medication. The district court further observed that Loughner did appear to be tired at the commitment proceeding and did appear to close his eyes from time to time today and maybe a little sleepy or nod off. This sedation-like effect may result in serious prejudice during trial proceedings if medication inhibits [Loughner's] capacity to react and respond to the proceedings and to demonstrate remorse or compassion. Riggins, 504 U.S. at 143-44, 112 S.Ct. 1810 (Kennedy, J., concurring in the judgment). The tendency of psychotropic medication to flatten or deaden emotional responses could prove particularly damaging if the government seeks the death penalty, as it very well might in this case, because the jury would then be especially sensitive to [Loughner's] character and any demonstrations of remorse (or lack thereof). Weston, 206 F.3d at 20 (Tatel, J., concurring). Even the intended effects of psychotropic drugs may infringe Loughner's fair trial rights. Assuming Loughner will put on an insanity defense, manifestations in court of how his mind works may well be his own best evidence. Because psychotropic medication chemically alters the brain, it deprives the jury of the opportunity to observe the defendant in the delusional state he was in at the time of the crime. Id. at 21 (Tatel, J., concurring). The government's decision to restore Loughner's trial competency may therefore prevent him from putting on his chosen defense, by altering the material evidence for that defense. See Riggins, 504 U.S. at 139, 142, 112 S.Ct. 1810 (Kennedy, J., concurring in the judgment). [10] Thus, both the intended and unintended effects of psychotropic medication can conceivably deprive a criminal defendant of his right to a fair trial. There is no point in restoring a defendant's trial competency, through commitment to a medical facility and involuntary administration of psychotropic medication, if the means necessary to effect restoration will so infringe the defendant's fair trial rights as to render the trial itself unconstitutional. That is why Sell requires a court to find, before ordering involuntary medication on trial competency grounds, that the involuntary medication to be administered is both substantially likely to render the defendant competent to stand trial and substantially unlikely to create side-effects that would render his trial unfair. See Sell, 539 U.S. at 181, 123 S.Ct. 2174 (citing Riggins, 504 U.S. at 142-45, 112 S.Ct. 1810 (Kennedy, J., concurring in the judgment)). Only then, the Court observed, will the medication sufficiently advance the trial-related interests put forward to justify depriving the defendant of his liberty to reject medical treatment. See id. And, although the Court did not expressly so state, the possible impact of involuntary medication on the ultimate trial explains Sell's repeated insistence on the need for a court to determine the need for involuntary medication on grounds of dangerousness where restoration of trial competency is the government's ultimate goal. See id. at 181-83, 123 S.Ct. 2174. Given the particular circumstances of this casenamely, a commitment proceeding governed by 18 U.S.C. § 4241(d)(2)(A)there is the same need for a judicial determination as to how the psychotropic drugs will likely impact Loughner's fair trial rights, even though dangerousness to self is the immediate reason for his involuntary medication. To commit Loughner for the purpose of restoration, the court must conclude that there is a substantial probability that he will attain the capacity to permit the proceedings to go forward during the commitment period. See 18 U.S.C. § 4241(d)(2)(A). Thus, § 4241 requires the court to focus on whether Loughner's commitment is likely to advance the prosecution's trial-related interests. Pretrial commitment for restoration of competency will likely not permit the [trial] proceedings to go forward if Loughner can only be restored through means likely to render any resulting trial unfair. So the district court may only commit Loughner for restoration of trial competency if it concludes that the psychotropic means through which his restoration is to be accomplished are substantially unlikely to infringe his fair trial rights. [11] Of course, at the time of the § 4241(d)(2)(A) commitment hearing, there may not be sufficient evidence to support the conclusion that involuntary psychotropic medication will render the trial unfair. But that should not excuse the district court from its responsibility to evaluate the evidence that is available according to its own best lights, providing both the defendant, whose right to present a defense may be infringed by involuntary medication, and the government, whose eventual prosecution of the defendant may be foreclosed because of the infringement, with the best available pre-medication resolution of the Sixth Amendment issue. Weston, 206 F.3d at 14. If the district court concludes that there is insufficient evidence to reach a final conclusion on the impact involuntary medication will have on the defendant's fair trial rights, it could simply defer the issue until some later, pre-trial date. See id. at 21 (Tatel, J., concurring). The government would then, however, bear the risk that the court might bar criminal prosecution if it subsequently concludes that the drugs have infringed the defendant's fair trial rights. Regardless of whether the court had sufficient evidence to resolve Loughner's fair trial rights concerns at the time of the commitment hearing, however, the inquiry is not, as the majority asserts, premature and irrelevant at this stage. Majority Op. at 769.
In short, I would hold that a district court asked to commit a pretrial detainee for the purpose of restoring his trial competency through involuntary medication must itself determine whether involuntary medication is justified. In doing so, it should first consider, as in Sell, whether the medication is justified on grounds of dangerousness to self or others. If the court concludes that involuntary medication is justified, it may then proceed to determine whether involuntary medication is likely to restore the detainee's capacity to such a point that trial may proceed. But I would require the court to determine, as part of that inquiry, whether the contemplated treatment is substantially unlikely to infringe the detainee's fair trial rights. I cannot agree with the majority's conclusion that the district court could authorize Loughner's commitment under § 4241(d)(2)(A) on the bare determination that the medication he is currently receiving is likely to restore his purely cognitive trial competency, meaning the ability to appreciate the course of the proceedings and confer with counsel, with no consideration of either the medication's propriety or its potential effect on his fair trial rights.