Opinion ID: 776793
Heading Depth: 2
Heading Rank: 3

Heading: The Standard of Review for Forcible Administration of Antipsychotic Drugs.

Text: 23 We now consider Sell's claim that the district court employed the wrong standard of review to determine whether forced administration of medication is appropriate in this case. Sell encourages us to adopt strict scrutiny, but the Supreme Court declined to adopt such a standard in Riggins. See Riggins, 504 U.S. at 136, 112 S.Ct. 1810. 6 Based on the Supreme Court's decision in Riggins and Harper, and the decisions of our sister courts, 7 we hold that the government must meet the following test in order for the government to forcibly medicate an individual. First, the government must present an essential state interest that outweighs the individual's interest in remaining free from medication. See Riggins, 504 U.S. at 135, 112 S.Ct. 1810 (noting that the government must prove an overriding state interest). Second, the government must prove that there is no less intrusive way of fulfilling its essential interest. See id. Third, the government must prove by clear and convincing evidence that the medication is medically appropriate. See id. Medication is medically appropriate if: (1) it is likely to render the patient competent, see Weston, 255 F.3d at 876; (2) the likelihood and gravity of side effects do not overwhelm its benefits, see id.; and (3) it is in the best medical interests of the patient. See Harper, 494 U.S. at 227, 110 S.Ct. 1028 (noting that the court should consider the petitioner's medical interest). The district court did not explicitly apply this test, so we review the district court in light of the standards we have set forth. 24 The first question, therefore, is whether the district court erred by holding that the government's interest in bringing Sell to trial is sufficient to outweigh Sell's interest in refusing medication. This is a mixed question of law and fact, so we review the district court's finding de novo. See Boysiewick v. Schriro, 179 F.3d 616, 619 (8th Cir.1999). To make this determination, we must weigh the government's interest in rendering Sell competent against Sell's interest in refusing unwanted medication. 25 The government has an essential interest in bringing a defendant to trial. See Illinois v. Allen, 397 U.S. 337, 347, 90 S.Ct. 1057, 25 L.Ed.2d 353 (1970) (Brennan, J., concurring) (Constitutional power to bring an accused to trial is fundamental to a scheme of `ordered liberty' and a prerequisite to social justice and peace.). Not all charges, however, are sufficient to justify forcible medication of a defendant; rather, the charges must be serious. See United States v. Brandon, 158 F.3d 947, 961 (6th Cir.1998). Here, the sixty-two charges of fraud and the single charge of money-laundering are serious, a fact not denied by the defendant. 8 Despite Sell's significant liberty interest in refusing antipsychotic medication, in view of the seriousness of the charges, we believe that the government's interest in restoring his competency so that he may be brought to trial is paramount. 9 26 The second part of our analysis is whether the district court erred in finding that there were no less intrusive means by which the government may achieve its essential interest. See Riggins, 504 U.S. at 135, 112 S.Ct. 1810 (noting that the government must prove that there is no less intrusive means). The government may not constitutionally bring an incompetent defendant to trial, see Pate v. Robinson, 383 U.S. 375, 86 S.Ct. 836, 15 L.Ed.2d 815 (1966), so the only way the government may try Sell is by restoring his competency. Both Dr. Wolfson and Dr. DeMier testified that antipsychotic medication is the most effective treatment for delusional disorder and that it is the only way Sell could be restored to competency. See Transcript of Evidentiary Hr'g, Sept. 29, 1999 at 21, 75-78. Even Dr. Cloninger, who submitted an affidavit on behalf of Sell and stated that antipsychotic drugs are not a proven treatment, did not suggest any alternative means of restoring competency. See generally Cloninger Aff. Based on this evidence, we believe that the district court correctly concluded that there were no less intrusive means. 27 Third, we must determine whether the evidence supports the district court's conclusion that antipsychotic medication is medically appropriate for Sell's treatment. We review the district court's findings of fact under the clearly erroneous standard. See Love v. M.D. Reed, 216 F.3d 682, 687 (8th Cir.2000). Whether a proposed action is medically appropriate depends on the judgment of medical professionals. See Harper, 494 U.S. at 231, 233-34, 110 S.Ct. 1028. At the hearing before the Magistrate Judge, the government presented testimony from Dr. DeMier and Dr. Wolfson. Dr. DeMier, Sell's treating psychologist, testified that antipsychotic medication is the only treatment that has been shown to be effective in treating delusional disorder and it is the only treatment that could restore Sell to competency. He also stated that he has treated two patients suffering from delusional disorder with antipsychotic medication. Of the two, one was restored to clinical competency; the other patient improved, but did not regain competency. 10 Dr. DeMier also stated that antipsychotic medications have potentially significant side effects, but there's also potentially, very significant recovery from symptoms. 28 Dr. Wolfson, the staff psychiatrist who works as a consultant on Sell's case, also recommended that Sell be treated with antipsychotic drugs. Dr. Wolfson has treated seven patients with delusional disorder but only four for the purpose of restoring competency. 11 Dr. Wolfson reported that all seven benefitted clinically from antipsychotic medication and of the four who were treated for restoration of competency, three regained competency. Dr. Wolfson testified that the medical literature indicated that patients with delusional disorder respond less to medication than patients with other illnesses, but he stated that he doubts the accuracy of that conclusion and noted that the literature shows favorable results in many cases. 12 Dr. Wolfson admitted that there are both harmful and unpleasant side effects to antipsychotic drugs; these include sedation, neuroleptic malignant syndrome, which is rare but fatal, 13 and tardive dyskinesia and/or dystonic reaction, which causes a person to have involuntary movements of various parts of the body. Dr. Wolfson also stated, however, that the existence and/or degree of side effects could be controlled by changes in the doses and type of medication being used. He testified that the new generation of atypical antipsychotic drugs, such as Pimozide, have more benign side effects than the older typical antipsychotic drugs, such as Haldol. Dr. Wolfson admitted, however, that the atypical drugs can only be administered orally, and therefore cannot be used to forcibly drug uncooperative patients. 29 To combat this testimony, Sell presented the affidavit of Dr. Cloninger. Dr. Cloninger stated that there is no evidence that [antipsychotic medications] are beneficial for patients with Delusional Disorder. Cloninger Aff. at 8. Dr. Cloninger admitted that antipsychotic drugs are often beneficial in treating schizophrenia but maintained that they do not provide the same benefit in the treatment of delusional disorder. Dr. Cloninger attached to his affidavit an excerpt from the American Psychiatric Press Textbook of Psychiatry. That text notes that there is a disagreement between experts on the effectiveness of treating delusional disorders with antipsychotic medication, but it also states that the medication may be useful, particularly for accompanying anxiety, agitation, and psychosis. Donald W. Black et al., Schizophrenia, Schizophreniform Disorder, and Delusional (Paranoid) Disorders, in Textbook of Psychiatry (John A. Talbott et al. eds.) 1988. Dr. Cloninger was not able to recommend a less intrusive alternative to restore Sell to competency; rather, he suggested that treatment be limited to basic support and voluntary symptomatic treatment, and that such treatment also include access to exercise and reading material. See Cloninger Aff. ¶¶ 18-19. 30 In addition, Sell also presented the court with a report from the Federal Bureau of Prisons Institutional Metropolitan Correctional Center (MCC) in which Dr. Daniel Greenstein, the forensic psychologist at MCC, stated that delusional disorders do not typically respond to medication or psychotherapy. 31 Based on the totality of this evidence, Sell argues that the district court was clearly erroneous in finding that antipsychotic medication was medically appropriate. He contends that the district court erred by basing its finding, in part, on testimony that atypical antipsychotic medications have more benign side effects, because atypical drugs can only be administered orally, thus they cannot be given involuntarily. Sell also argues that the government did not prove that the medication has a reasonable probability of restoring competency. Finally, Sell argues that the court erred in finding medical appropriateness when the government failed to disclose which medication it would use. 14 Sell posits that without knowing which drugs would be administered, he was incapable of making anything more than a generalized argument. See United States v. Sell, No. 4: 98CR177 at 7 (April 4, 2001) (upholding Magistrate's order allowing the involuntarily medication of Sell and stating that Sell's arguments against medication were generalized). 32 We disagree with these assertions. We acknowledge that there is a difference of opinion on the efficacy of using antipsychotic drugs to treat delusional disorder, but we do not believe that the district court committed clear error in finding that the government proved medical appropriateness by clear and convincing evidence. First, the government presented evidence that the medication can reasonably be expected to minimize Sell's delusions and render him competent for trial. Dr. DeMier has a 50% success rate and Dr. Wolfson has a 75% success rate in restoring competency to patients with delusional disorders. Moreover, the medication improved the condition of all the patients they treated, whether or not they were restored to competency. Dr. Wolfson testified about how the medication works, stating that the medication should reduce the impact of the delusion on Sell's thought process. Although we cannot say with 100% certainty whether Sell will regain competency with his treatment, the district court did not clearly err in finding a sufficient likelihood that antipsychotic medication will restore Sell's competence. 33 Second, the government proved that the side-effects produced by the medication could be minimized through careful treatment and changing medications and dosages. Although Dr. Wolfson did not name a specific medication, he did name the two he would most likely use. Therefore, we reject Sell's contention that he was not given the opportunity to make specific objections to specific drugs. Furthermore, we reject Sell's argument that the court erred in basing its opinion in part on the availability of atypical antipsychotic drugs which can only be administered orally. The availability of the atypical medications was not determinative to the district court's findings, and the evidence supports the conclusion that the doctors treating Sell will be able to reduce the incidence of unpleasant and harmful side-effects produced by typical antipsychotic medication as well. 34 Finally, the district court appropriately considered Sell's medical interest. The court noted that Sell's delusions interfere with his ability to make sound judgments about his life and his treatment, and that his disorder currently impairs and misleads his interpretation of reality and his reasoning. The government presented evidence that antipsychotic medication is commonly used to help reduce delusions and their impact on an individual's life, and the court found that these benefits outweighed the risks associated with antipsychotic drugs. 35 The district court did not err in applying the wrong standard of review. As required, the court found that the government has an essential interest in adjudicating the serious charges against Sell. The court found that involuntary medication is the only way for the government to achieve its interest in fairly trying Sell and found that the medication is medically appropriate for him. The government proved these elements by clear and convincing evidence. Therefore, we find no reversible error in the standard of review employed by the district court. 36 We note, however, that this is a limited holding. We do not believe this standard will be met in all circumstances in which the government wishes to restore competence. Furthermore, we note that an entirely different case is presented when the government wishes to medicate a prisoner in order to render him competent for execution. See, e.g., Singleton v. Norris, 267 F.3d 859 (8th Cir.2001), vacated and reh'g en banc granted (Dec. 5, 2001). Therefore, our holding must be read narrowly.