Opinion ID: 624293
Heading Depth: 4
Heading Rank: 3

Heading: Loughner's As-applied Challenges to His Harper III Hearing

Text: We next address whether the Harper III hearing, under which Loughner is currently being forcibly medicated, complied with the procedural protections of 28 C.F.R. § 549.46. Loughner argues that even if Harper applies, his rights were violated, for four reasons: First, the decision maker failed to demonstrate that he was dangerous; second, FMC-Springfield failed to specify the course of treatment, that is, the types or dosages of drugs that may be administered to him; third, the BOP decision makers were not actually independent; and, finally, Loughner was not provided meaningful representation at the hearings. Although no statute affirmatively grants an inmate the right to obtain judicial review of a Harper -dangerousness hearing, the court that authorized commitment in the first place pursuant to 18 U.S.C. § 4241(d) has jurisdiction over the involuntary medication order, and we have appellate jurisdiction under the collateral order doctrine. In reviewing the order, we recognize that deference . . . is owed to medical professionals who have the full-time responsibility of caring for mentally ill inmates. . . and who possess, as courts do not, the requisite knowledge and expertise to determine whether the drugs should be used in an individual case. Harper, 494 U.S. at 230 n. 12, 110 S.Ct. 1028. Giving such deference, we review Loughner's involuntary medication order to ensure the decision is not arbitrary. See Morgan, 193 F.3d at 263 ([S]uch a determination is subject to judicial review for arbitrariness.).
Loughner maintains that FMC-Springfield never determined that medication was necessary to mitigate any danger that he posed to himself. In the Justification section of the Involuntary Medication Report that followed the Harper III hearing on September 15, Dr. Tomelleri cited Loughner's deterioration after the discontinuation of antipsychotics authorized by Harper I. Loughner expressed feelings of depression and hopelessness, complained of a radio talking to him inserting thoughts into his mind, . . . engaged in yelling, crying, [and] rocking back and forth for prolonged periods of time, made statements such as that he wanted to die,[and] requested to be given an injection to be killed. His sleep schedule became erratic, including a 50-hour period without sleep. His food intake was poor and he lost weight, and he would pace or spin in circles for hours without interruption. Since involuntary medication resumed, Loughner's agitation has decreased, his sleep has improved, and his communication with staff is progressing, but he is still restless and paces and cries frequently. Dr. Tomelleri concluded that [p]sychotropic medication is the treatment of choice for conditions such as Mr. Loughner is experiencing, and rejected the alternatives. Psychotherapy, he wrote, would not address the fundamental problem; minor tranquilizers are useful to reduce anxiety and agitation and were being used for that purpose; and seclusion and restraints are merely protective temporary measures with no direct effect on the core manifestations of the mental illness. Rejecting the argument that Loughner is no longer a danger to himself, Dr. Tomelleri stated that [d]iscontinuation of current medications is virtually certain to result in an exacerbation of Mr. Loughner's illness as it did when medication was discontinued in July. [14] Loughner attempts to recharacterize his current danger to himself as being caused by his depression, which he attributes to the effects of the antipsychotic drugs because they are making him more lucid. Loughner thus alleges that the antipsychotics are not in his medical interest, but offers no medical opinion or other evidence to counter Dr. Tomelleri's determination. By contrast, Dr. Ballenger testified before the district court that Loughner's depression, borne of his remorse of what happened, is logical and his self-realization [was] an indication that the medication is helping and a very strong indication that his psychosis is better. We must leave such medical judgments to medical staff and professionals. See Harper, 494 U.S. at 230 n. 12, 110 S.Ct. 1028. Based on the substantial evidence in the record, we conclude that FMC-Springfield did not act arbitrarily in finding Loughner to be a danger to himself and that antipsychotic medication was in his best interest.
Loughner next contends that the Harper III hearing violated the Due Process Clause because no specific, future course of treatment was identified and no limitations were placed upon the types or dosages of drugs that could be administered to him. He further faults FMC-Springfield staff for modifying his medication without first seeking `due process' authorization, and the hearing psychiatrist for relying on the current medication regimen rather than a proposed future plan. Loughner's complaints may be contrary to his own medical interests. Loughner relies on three cases for the proposition that the government must specify his drug regimen in advance: Hernandez-Vasquez, 513 F.3d 908; Evans, 404 F.3d 227; and United States v. Williams, 356 F.3d 1045 (9th Cir.2004). All involved persons who were ordered involuntarily medicated, either to render them competent to stand trial, see Hernandez-Vasquez, 513 F.3d at 912; Evans, 404 F.3d at 236, or as a condition of supervised release, see Williams, 356 F.3d at 1047. In each of these cases, the defendant or probationer had not been found to be a danger to himself or others. See Hernandez-Vasquez, 513 F.3d at 915; Evans, 404 F.3d at 235 n. 3; Williams, 356 F.3d at 1057. The difference between Harper and Sell is critical here. When an inmate is involuntarily medicated because he is a danger to himself or others, he is being treated for reasons that are in his and the institution's best interests; the concern is primarily penological and medical, and only secondarily legal. But when the government seeks to medicate an inmate involuntarily to render him competent to stand trial, the inmate is being treated because of the government's trial interests, not the prison's interests or the inmate's medical interests; the concern is primarily a legal one and only secondarily penological or medical. Hence, the Supreme Court has emphasized that resorting to a Sell hearing is appropriate only if there is no other legitimate reason for treating the inmate. See Sell, 539 U.S. at 181-82, 123 S.Ct. 2174. Loughner's treating psychiatrist is addressing Loughner's serious and immediate medical needs and, accordingly, must be able to titrate his existing dosages to meet his needs, and to change medications as necessary, as other treatments become medically indicated. No one who is being treated for a serious medical condition would benefit from a court order that restricted the drugs and the dosages permissible; mental illness cannot always be treated with such specificity. [15] We are not the dispensary and should let the doctors conduct their business. The Washington policy approved in Harper required that the treatment plan be proposed by the treating psychiatrist and then approved by a reviewing psychiatrist. The purpose of this scheme, however, was not to limit the prison personnel's future course of treatment; it was to ensure that treatment will be ordered only if it is in the prisoner's medical interests. Harper, 494 U.S. at 222, 110 S.Ct. 1028. Harper did not envision a process in which medical professionals were limited to a treatment plan set out in the original hearing. Rather, the Court recognized that treatment of a mental illness is a dynamic process. See id. at 232-33, 110 S.Ct. 1028 (Under the Policy, the hearing committee reviews on a regular basis the staff's choice of both the type and dosage of drug to be administered, and can order appropriate changes.). Loughner's suggestion that FMC-Springfield abused its authority by increasing the dosages and changing the types of prescribed medication ignores the realities of psychiatric medicine and overlooks the fact that BOP's doctors have an ethical duty to do what is in the best interest of the patient. See id. at 222 n. 8, 110 S.Ct. 1028 ([W]e will not assume that physicians will prescribe these drugs for reasons unrelated to the medical needs of the patients; indeed, the ethics of the medical profession are to the contrary.). Finally, even if specificity of the treatment were required, the Involuntary Medication Report from the Harper III hearing lists Loughner's then-current medication regimen as 3 mg of risperidone, twice a day; 300 mg of buproprion XL, daily; 1 mg of benztropine, twice a day; 1 mg of clonazepam, twice a day, and 2 mg at bedtime. The report also states: There is a documented treatment plan on patient's chart, and the box is checked indicating that Dr. Tomelleri considered and/or reviewed a treatment proposal and justification. Additionally, Dr. Pietz's August 22, 2011, progress report describes Loughner's psychiatric treatment as of that day, and we note that it is substantially the same as the treatment plan on September 15 3 mg of risperidone, twice a day; 300 mg of buproprion XL, daily; 1 mg benztropine, twice a day; 1 mg lorazepam (anti-anxiety), three times a day, at bedtime, and as needed. Both his treating psychiatrist, Dr. Sarrazin, and the hearing officer, Dr. Tomelleri, have opined that Loughner requires medication. The district court heard additional testimony from Dr. Ballenger that Loughner's medication regimen was a standard approach to his schizophrenia and other medical conditions. Loughner has offered no evidence to the contrary, and we hold that there was no due process violation relating to the medication regimen.
Loughner argues that FMC-Springfield doctors were charged with competing responsibilities and that the decision makers were not independent. Independence of the decision maker is required by 28 C.F.R. § 549.46(a)(4), however, and the hearing in this case was conducted by Dr. Tomelleri, a psychiatrist who is not currently involved in the diagnosis or treatment of Loughner. The decision to medicate Loughner was upheld by the Associate Warden, who agreed with Dr. Tomelleri's findings, conclusions, and diagnosis. The bare fact that the involuntary medication decision was made at FMC-Springfield, by BOP-employed doctors, is insufficient to demonstrate a conflict without proof of actual bias. See Harper, 494 U.S. at 233-34, 110 S.Ct. 1028. BOP is charged with caring for those who have been committed to a detention facility; it is not a prosecuting arm of the government and has no particular interest in the continued incarceration of those inmates. The district court found no evidence that the FMC[-Springfield] staff is in any way an ally of the Government prosecution team, Order on Def's Mot. to Enjoin Medication 5, and elaborated this point during the hearing: I just don't see any evidence whatsoever that the findingsthe determination made by FMC[-Springfield] to take this action was colored in any way by considerations of how it's going to affect the pending charges. . . . [The] professional staff, including the professional psychologists and psychiatrists, are calling things as they see them and they're acting on the basis of observation and judgment and experience and training. Hr'g on Mot. to Enjoin Tr. 50, June 29, 2011. We are also not persuaded that FMC-Springfield is in league with the prosecution team. It was, after all, FMC-Springfield doctors who found Loughner incompetent to stand trial in the first place, a conclusion instinctively contrary to a prosecutor's interests. Moreover, we can take notice of the fact that the same doctors involved in Loughner's treatment have had to make these judgments in other cases, and the judgments do not always favor the prosecution. For example, in Grape, Dr. Pietz and Dr. Sarrazin opined that Grape was not competent to stand trial. 549 F.3d at 594-95. At a Harper hearing, Dr. Tomelleri found that, although Grape was a potential danger to others, he could be managed without resort to involuntary medication. See id. at 595. That finding forced the prosecution to ask for a Sell hearing, which has a much more demanding burden of proof, to medicate Grape in order to restore him to trial competency. Id. at 594-95. We can find no evidence that FMC-Springfield staff was biased or lacked independence. The dissent argues that a conflict of interest may have existed because whereas the currently operative commitment order charges the medical staff with restoring Loughner to competency, the initial order charged FMC-Springfield only with determining whether restoration was possible. Dissenting Op. at 787-88. The dissent cites language from Loughner's Notice of Medication Hearing and Advisement of Rights form as evidence that there may have been a confusion of roles . . . with respect to FMC-Springfield's involuntary medication decision in this case. Id. at 788. This form was filled out prior to the first involuntary medication decision by Loughner's treating psychologist, Dr. Pietz, who participated in the Harper hearings, and stated that Loughner was referred to this facility to restore competency. Therefore, the argument proceeds, in making the initial decision to medicate involuntarily Loughner on dangerousness grounds, the medical staff may have been clouded by their interest in actually restoring him to competency. Dr. Pietz, however, was not a key decision maker in the involuntary medication determination. 28 C.F.R. § 549.46(a)(6) requires the treating psychiatrist to attend the hearing and present data and background information demonstrating the patient's need for antipsychotic medication; § 549.46(a)(7) vests the presiding psychiatrist, who must not be currently involved in the detainee's treatment or diagnosis, with the authority to determine whether treatment with antipsychotic medication is necessary because of an inmate's dangerousness; § 549.46(a)(9) vests the institution's mental health division administrator with authority to resolve any appeal from the presiding psychiatrist's decision. There is no evidence that these decision makers shared Dr. Pietz's possibly mistaken understanding of the reasons for Loughner's commitment and their concomitant statutory obligations. Therefore, the district court did not clearly err in finding that FMC-Springfield did not operate under a conflict of interest.
Loughner argues that his appointed staff representative, John Getchell, did not adequately represent his interests at the Harper III hearing. He claims that in all three of the hearings, Getchell failed to seek out or present any witnesses, cross-examine or challenge the prison's witnesses, or advocate in any other meaningful way against forced medication. Instead, Loughner contends, Getchell's sole efforts were to relay to the administrative hearing officer Loughner's witness request and continued objection to involuntary medication. Loughner further contends that the inadequacy of his staff representative deprived him of his substantive and procedural due process, and that he should have been afforded [a] proper adversarial hearing, before a judge, and with representation of counsel. The government does not dispute Loughner's factual assertions, but argues that Getchell's representation satisfied due process. Due process does not require that a pretrial detainee be represented by counsel. The Supreme Court has held that providing a lay adviser who understands the psychiatric issues involved provides sufficient procedural protection. The Court has not defined further the required qualifications of the personal representative, except to hold that it need not be an attorney. See Harper, 494 U.S. at 236, 110 S.Ct. 1028. Following the procedures outlined in Harper, 28 C.F.R. § 549.46 requires that the facility provide the inmate with a staff representative for the hearing. If the inmate does not request a staff representative, or requests one with insufficient experience or education, FMC-Springfield must appoint a qualified staff representative. 28 C.F.R. § 549.46(a)(3) (emphasis added). Although the Supreme Court has only held that it is sufficient that the representative understand[ ] the psychiatric issues involved, Harper, 494 U.S. at 236, 110 S.Ct. 1028, we have some concerns with the adequacy of Loughner's representation. Loughner's representative, Getchell, is an LCSW. We do not doubt the ability of an LCSW to understand psychological issues in general, particularly those related to counseling and psychotherapy. What is less clear is whether an LCSW has the background necessary to challenge either the diagnosis or the medical regimen prescribed by a psychiatrist. Our concerns may stem from some confusion over the nature of Harper hearings. Although the Court characterized Washington's policy in Harper as an adversary hearing, 494 U.S. at 235, 110 S.Ct. 1028, BOP's regulations create something of a hybrid between an adversarial hearing and an inquisitorial hearing. The expectations of advocates participating in those respective hearings are quite different. The adversarial mode is party driven, as each side has the opportunity to present its best case, and the judge or hearing officer makes a decision based on the evidence the parties have mustered. Advocates take an active role, whereas the judge remains a passive participant. By contrast, in the inquisitorial model more familiar to continental systems, the judge takes a far more active role in directing the case and developing the evidence, whereas the advocate takes a passive role. See McNeil v. Wisconsin, 501 U.S. 171, 181 n. 2, 111 S.Ct. 2204, 115 L.Ed.2d 158 (1991) (What makes a system adversarial rather than inquisitorial is not the presence of counsel. . . but rather, the presence of a judge who does not (as an inquisitor does) conduct the factual and legal investigation himself, but instead decides on the basis of facts and arguments pro and con adduced by the parties.); see also Stephan Landsman, A Brief Survey of the Development of the Adversary System, 44 Ohio St. L.J. 713, 714-15, 724 (1983); Jeffrey S. Wolfe & Lisa B. Proszek, Interaction Dynamics in Federal Administrative Decision Making: The Role of the Inquisitorial Judge and the Adversarial Lawyer, 33 Tulsa L.J. 293, 313-15 (1997). Although the adversarial model is more familiar, we have examples of inquisitorial proceedings, particularly in agencies charged with administering benefits programs, such as social security or veterans' benefits. See Sims v. Apfel, 530 U.S. 103, 110-11, 120 S.Ct. 2080, 147 L.Ed.2d 80 (2000) (Social Security proceedings are inquisitorial rather than adversarial.); Nat'l Ass'n of Radiation Survivors, 473 U.S. at 309-11, 105 S.Ct. 3180 (explaining that the Veterans' Administration benefits system is not an adversary mode). The Harper hearing bears some characteristics of both systems. At first glance, the Harper hearing is decidedly adversarial because the purpose is to determine if the inmate can be medicated against his will. Unlike agency hearings to determine an applicant's eligibility for federal largesse, the Harper hearing pits the inmate against his prison doctor in a clash over his best interests. Beyond this obvious difference, however, it is less clear that the hearing has been structured in either a plainly adversarial or plainly inquisitorial fashion. The hearing officer is not a judge but a doctor charged with confirming or rejecting the medical judgment of a colleague. That makes the hearing officer not just a neutral decision maker, but a decision maker who has been selected precisely because of his own expertise in the field. As in an inquisitorial system, the hearing officer conducts the proceeding and directs the development of the evidence. See 28 C.F.R. § 549.46(a)(4), (7). In a Harper hearing, the government is not represented by counsel, but by the inmate's own treating psychiatrist or psychologist who is there to testify as to why, in her judgment, the inmate's own interests, as well as BOP's institutional interests, require that the inmate be involuntarily medicated. The treating psychiatrist has no interest in the outcome of the hearing other than to present and defend her own diagnosis and recommendation. Importantly, she is not directing the case in the sense that we would expect from the government's advocate in a purely adversarial proceeding. For his part, the inmate may present evidence, request his own witnesses, and ask that any witnesses be questioned. BOP's regulations provide, somewhat ambiguously, that witnesses may be questioned either by the staff representative or by the person conducting the hearing. Id. § 549.46(a)(3). The staff representative also assist[s] the inmate in preparing and submitting the appeal. Id. § 549.46(a)(8). The acts required of the staff representative do not necessarily speak in terms of advocacy, but require that the staff representative facilitate the inmate's presentation at the hearing and any appeal. The role of the inmate's staff representative changesand perhaps dramaticallyas we characterize the Harper hearing as adversarial or inquisitorial. If it is adversarial, then we would expect the staff representative to assist the inmate to present any evidence or request witnesses who would challenge his treating psychiatrist's assessment that he is a danger to himself or others and the recommendation that the inmate be medicated against his will. Indeed, in some circumstances, we might assume that the staff representative should vigorously represent the inmate's desire not to be medicated. On the other hand, if the Harper hearing is largely inquisitorial in nature, then the hearing officer has the primary duty to develop the evidence to his own satisfaction, and the staff representative is there to facilitate the presenting of evidence or witnesses for the inmate. On balance, although the question is a curious one, the Harper hearing is about countermanding the desires of the inmate in an area in which he possesses a significant liberty interest in avoiding the unwanted administration of antipsychotic drugs. Harper, 494 U.S. at 221, 110 S.Ct. 1028. Within our traditions, and in the absence of clearer direction in the regulations, we consider the Harper hearing to be adversarial. Based on that premise, we question whether any representative appointed by BOP who is not qualified to make medical diagnoses or prescribe medicationor, at the least, qualified by training to know what medications are typically called for to treat serious mental illnessescan meet the inmate's treating psychiatrist on a level playing field. We thus question whether Getchell, as Loughner's representative, was placed in a situation where his training did not qualify him to challenge Loughner's treating psychiatrist. In other words, in the American adversarial tradition, we wonder whether, in a contest to be decided by a hearing officer who is a psychiatrist, the hearing really pits adversaries and advocates prepared to challenge each other fairly. We do not mean to suggest that a Harper hearing requires that counsel be present, lest [t]he role of the hearing [officer] itself . . . may become more akin to that of a judge at a trial, and less attuned to the [medical] needs of the individual. Gagnon v. Scarpelli, 411 U.S. 778, 787-88, 93 S.Ct. 1756, 36 L.Ed.2d 656 (1973). But it may suggest a more demanding role for the staff representative. Here, Getchell's failure to present any affirmative evidence or question any of the evidence in support of involuntary medication may indicate that his representation was unqualified or procedurally defective. [16] See Morgan, 193 F.3d at 265-66 (noting that the staff representative's lack of meaningful participation during the administrative hearing supported the inference that the staff representative lacked sufficient education and experience as required by the regulations); United States v. Humphreys, 148 F.Supp.2d 949, 953 (D.S.D.2001) (finding that the staff representative did not meet the requirements of due process because she presented no evidence; testified against the defendant, stating that she believed he had a mental illness; and may have filed a disciplinary report against the defendant when he first arrived at FMC-Rochester). Or, it may simply indicate that Getchell had nothing to say because the evidence was overwhelming that Loughner required medication and that his prescriptions were standard protocol. We cannot determine the answers to these questions from this record. If we were deciding this matter based on the Harper III hearing alone, we might well send the case back for further proceedings or a new Harper hearing. The record in this case, however, is far more complete because the district court held an extensive hearing following Harper III. See Order Den. Stay 2, Oct. 3, 2011 (referring to the lengthy and, at times, tedious hearing). Thus, we think that any error that may have resulted from the staff representative's lack of advocacy in the Harper III hearing was harmless. Three Harper hearings all reached the same conclusion: Loughner is a danger and needs to be medicated. The Harper III hearing was followed by a district court hearing where each party had the opportunity to call witnesses. The government called Dr. Pietz, Loughner's treating psychologist, and Dr. Ballenger, a clinical psychiatrist and independent expert. At the hearing before the district court in late September 2011, Dr. Pietz testified to her daily contact with Loughner, beginning in March 2011. She testified concerning Loughner's behavior, her conversations with him, and his contacts with other FMC-Springfield staff. Dr. Ballenger provided a written statement and testified before the district court. Dr. Ballenger has more than forty years experience, having served as a professor at the University of Virginia Medical Center and Chairman of the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina. He has authored or co-authored almost 400 peer-reviewed articles and 16 books, most of which deal with psychopharmacology. Dr. Ballenger did not examine Loughner or perform a comprehensive review of his treatment records, but he had reviewed Loughner's progress notes and had spoken to Loughner's treating psychiatrist, Dr. Sarrazin. He provided general background on first- and second-generation antipsychotic medications and their effectiveness and side-effects. Dr. Ballenger testified regarding the drugs and dosages prescribed for Loughner, and he affirmed that the regimen was the logical routine and the dosages were highly appropriate. He confirmed that the combination of drugs Loughner's psychiatrist had prescribed presented no problems of using them together. Although the district court attempted to keep both sides focus[ed] on the issue of the dayi.e., the extension of commitment under 18 U.S.C. § 4241(d)(2)the district court also addressed the adequacy of the Harper III hearing. Thus, at the hearing, Loughner had the opportunity to challenge the assessments of his doctors, and to present evidence that the dangerousness finding at his Harper hearings was arbitrary. Loughner's counsel cross-examined both Dr. Pietz and Dr. Ballenger. His counsel called no witnesses, but produced graphs and charts compiled from Loughner's own FMC-Springfield medical records. Ultimately, the government's presentation was nearly unchallenged by Loughner's counsel. Indeed, over the course of months, and numerous hearings before the district court, Loughner has never presented any witnesses or other evidence that calls into question his diagnosis or treatment. The evidence before the district court thus fully supported the judgment reached at the Harper hearings. Additionally, in making the finding that there was a substantial probability that within a reasonable period of time . . . Mr. Loughner can be restored to competency, see 18 U.S.C. § 4241(d)(2), the district court relied on Loughner's ongoing treatment at FMC-Springfield. Because his ongoing treatment necessarily encompassed the involuntary medication of Loughner, a current, valid involuntary medication order must exist. Thus, Loughner effectively had two chances to attack the existing Harper order during the hearing regarding the extension of his commitment: by either attacking the Harper order directly or as a challenge to the § 4241 determination. But Loughner called no witnesses, introduced no new evidence, and did not allege that the doctors chose a course that was medically inappropriate. Any deficiency in Getchell's representation in Loughner's case was cured in the district court's subsequent hearing.