Opinion ID: 624293
Heading Depth: 2
Heading Rank: 3

Heading: The Involuntary Medication Order

Text: Because I conclude that the district court was obligated itself to decide anew the involuntary medication issue in conjunction with its § 4241(d)(2)(A) commitment determination, I consider the propriety of the prison's Harper III involuntary medication order moot in all relevant respects. I nevertheless proceed to review the deficiencies I see in those proceedings, for two reasons. First, in reviewing the administrative involuntary medication order, I wish to clarify the substantive standards and associated requirements I believe must be applied by the district court in deciding whether involuntary medication is justified on dangerousness grounds. Second, I disagree with the majority's conclusion that the Harper III involuntary medication order otherwise satisfies the demands of substantive and procedural due process. Setting aside my conviction that the procedural posture of this case requires a court to adjudicate the merits of Loughner's involuntary medication, I agree that a mid-commitment medication decision on dangerousness grounds need not be made by a judge. Where an otherwise proper judicial commitment decision has already been made, either for a certain period or indefinitely, it is appropriate to regard direct judicial intervention, even pretrial, as both unnecessary and burdensome. Moreover, in that circumstance, the penological and liberty interests are similar, in many respects, to those that pertain post-conviction. But despite that basic procedural agreement, I would hold that the Harper III involuntary medication order cannot stand, given its substantive and procedural shortcomings.

I agree with the majority's conclusion that involuntary medication may be justified even if it is not necessarily the least restrictive alternative. The so-called  Riggins standard, put forth by Loughner to justify the least restrictive alternative requirement, simply does not exist; Riggins rejected the opportunity to finally prescribe such substantive standards. 504 U.S. at 136, 112 S.Ct. 1810. In light of Sell's command to determine whether medication is justified on Harper -type grounds prior to deciding whether medication is justified to restore competency, 539 U.S. at 183, 123 S.Ct. 2174, I do not dispute the application of Harper's substantive standard, broadly construed, to the decision to medicate a pretrial detainee for dangerousness to self or others. Harper's substantive due process standard was, however, expressly predicated on the particular circumstances of a convicted prisoner's confinement. See Harper, 494 U.S. at 222, 110 S.Ct. 1028. It must therefore be modified to accommodate the pretrial context of Loughner's confinement. Harper identified three general factors as particularly important to assessing the constitutional validity of a prison regulation authorizing the use of involuntary medication: (1) the existence of a valid, rational connection between the prison regulation and the legitimate governmental interest put forward to justify it; (2) the impact accommodation of the asserted constitutional right would have on guards and other inmates, and on the allocation of prison resources generally; and (3) the availability of ready alternatives. 494 U.S. at 224-25, 110 S.Ct. 1028. The pretrial context of Loughner's confinement significantly affects our application of these factors, in at least two respects. First, Loughner's status as a pretrial detainee narrows the scope of the government's legitimate interests in restricting his constitutional rights. Where the government seeks to medicate involuntarily a convicted prisoner, its legitimate longterm correctional interests countervail, to a degree, the prisoner's liberty interest in avoiding the intended, mind-altering effects of psychotropic medication. The federal sentencing standards, for example, recognize that correctional treatment, including appropriate medical care, can be legitimately imposed on a convicted defendant. See 18 U.S.C. § 3553(a)(2)(D); 18 U.S.C. § 3563(b)(9). When the government seeks to medicate a convicted prisoner on dangerousness grounds, these treatment interests provide a modicum of justification for preferring long-term, systemic correction, through involuntary psychotropic medication, of the mental illness causing the convict's dangerousness, over temporary interventions that will not alleviate the condition causing the dangerousness. See Harper, 494 U.S. at 225, 110 S.Ct. 1028. The government may not, however, assert such correctional interests as a justification for restricting the constitutional rights of a pretrial detainee. We have recognized that [a]ll legitimate intrusive prison practices have basically three purposes: the preservation of internal order and discipline, the maintenance of institutional security against escape or unauthorized entry, and the rehabilitation of the prisoners. United States v. Hearst, 563 F.2d 1331, 1345 n. 11 (9th Cir.1977) (per curiam) (internal quotation marks omitted). The first two interests, which are regulatory in nature, may be asserted as legitimate justifications for restricting the constitutional rights of pretrial detainees, but the government's correctional interest in punishment or rehabilitation may not. Id.; see, e.g., Bell v. Wolfish, 441 U.S. 520, 537, 99 S.Ct. 1861, 60 L.Ed.2d 447 (1979); Mauro v. Arpaio, 188 F.3d 1054, 1065 (9th Cir.1999). Instead, the Due Process Clause requires conditions of pretrial confinement to be analyzed according to whether they are appropriate to ensure the detainees' presence at trial and to maintain the security and order of the detention facility. Halvorsen v. Baird, 146 F.3d 680, 689 (9th Cir.1998). As Halvorsen observed, these principles are of ancient vintage. See id. Blackstone, for example, wrote that pretrial detention is only for safe custody, and not for punishment: therefore, in this dubious interval between the commitment and trial, a prisoner ought to be used with the utmost humanity; and neither be loaded with needless fetters, or subjected to other hardships than such as are absolutely requisite for the purpose of confinement only. IV William Blackstone, Commentaries on the Laws of England 297 (1769) (quoted by Halvorsen, 146 F.3d at 689). Second, the temporary context of Loughner's pretrial confinement means that inquiry into the effectiveness and cost-efficiency of involuntary medication as compared to alternatives must be limited to the relative short-term. Some alternatives may be more appropriate than involuntary psychotropic medication if they are equally effective and cost-efficient over that short-term, even if they will not affect the detainee's long-term dangerousness. So, while Harper rejected physical restraints as an acceptable substitute for involuntary medication in part because [p]hysical restraints are effective only in the short term, 494 U.S. at 226, 110 S.Ct. 1028, that rejection might not carry over in some pretrial contexts. Involuntary medication may therefore be appropriate as a long-term solution for a dangerous, mentally-ill convicted prisoner and yet inappropriate as a short-term solution for a dangerous, mentally-ill pretrial detainee. In light of these adjustments of perspective appropriate to the pretrial context, I am skeptical that the prison's asserted justification for involuntary medication could carry the day on the present record. [12] Doctor Tomelleri concluded that psychotropic medication is justified because it is the treatment of choice for conditions such as Mr. Loughner is experiencing, and rejected various alternatives because they are merely protective temporary measures with no direct effect on the core manifestations of the mental illness. But, in the pretrial context, protective temporary measures may be precisely what is called for, and there may therefore be no cognizable governmental interest in addressing the core manifestations of the mental illness. Doctor Tomelleri's justifications thus demonstrate a misapprehension of the appropriate inquiry in the pretrial context. [13] This criticism is not meant to presage that the outcome of the medication for dangerousness-to-self inquiry in the pretrial context is foreordained. Instead, it is to say that attention to the particular circumstances of a specific pretrial detainee is essential in determining whether there are ready alternatives to medication. In Loughner's case, those circumstances might include the likely significant length of the pretrial period, as well as the needs and capabilities of the mental health facility to which he is committed.
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.

Both the predecessor to the currently operative regulation and the state policy at issue in Harper contained provisions requiring periodic administrative review of an inmate's involuntary medication. See 57 Fed.Reg. 53820-01, 1992 WL 329581 (Nov. 12, 1992); Harper, 494 U.S. at 216, 232-33, 110 S.Ct. 1028. The present regulation, 28 C.F.R. § 549.46, does not include such a periodic review requirement. The majority, concluding that periodic review is not constitutionally required, holds that its absence does not render 28 C.F.R. § 549.46 constitutionally infirm. Majority Op. at 753-54. I disagree. Harper concluded that a judicial hearing might not be as effective, as continuous, or as probing as administrative review using [the prison's] medical decisionmakers, in part because the state policy at issue required the administrative hearing committee to review[ ] on a regular basis the staff's choice of both the type and dosage of drug to be administered. See id. at 232-33, 110 S.Ct. 1028 (emphasis added). Such continuity is especially important because involuntary medication is, as the majority notes, a fluid process that must be adjusted depending on how the patient reacts and why [sic], if any, side effects are experienced. Majority Op. at 767. Under such circumstances, periodic review is necessary to ensure the continued accountability of the inmate's treating physicians. The majority maintains that the short-term context of a pretrial detainee's confinement alleviates the need for periodic review. Majority Op. at 753. Not so, or at least, not necessarily. Pretrial confinement, although inherently temporary, is not inherently brief. In Rivera-Guerrero, for example, we observed that the defendant had been committed at FMC-Springfield for nearly two years and had been involuntarily treated with antipsychotic medication for approximately one year. 426 F.3d at 1143. In United States v. Weston, 326 F.Supp.2d 64 (D.D.C.2004), the district court authorized an additional six-month commitment, even though defendant had already been committed for roughly five years and had been treated with involuntary medication for two and one half years. See id. at 67. I cannot reconcile the concept of due process with the conclusion that a pretrial detainee may be involuntarily treated with psychotropic medication for several years on the basis of a single administrative hearing. [15] In this case, I am concerned that Loughner's deterioration after the discontinuation of medication in July will be used to justify involuntary medication for years on end. I find this possibility deeply troubling both because the absence of periodic review deprives Loughner of the opportunity to demonstrate that he no longer needs medication, or as much medication, and because the true causes of Loughner's psychological deterioration remain murky. The particular symptoms provoking particular concern for Loughner's own safety were not observed before his medication was suddenly withdrawn. On the record made available to us, it is impossible to ascertain whether the rapid deterioration Loughner experienced in July was caused by the emergence of his underlying mental illness, by the jarring manner in which his medication was discontinued, or, perhaps, by the imposition of the rigors of a suicide watch. Periodic administrative review could perhaps (although not necessarily) mitigate some of these causation concerns by providing for routine reevaluation of the need for involuntary psychotropic medication, as well as the type and amount of medication prescribed.
On my preferred approach, the involuntary medication determination in this case would have been made in court, and Loughner's ordinary right to full representation by counsel would pertain. But even for mid-commitment dangerousness determinations made pretrial, I disagree with the majority's conclusion that Loughner is not entitled to the assistance of counsel, to a limited extent, in connection with the administrative involuntary medication hearing. Majority Op. at 756. As the majority points out, Harper held (in the post-conviction context) that lawyers are not necessary participants is an administrative involuntary medication determination, because their legal expertise bears no relation to the relevant medical judgment. See Harper, 494 U.S. at 236, 110 S.Ct. 1028. In the pretrial context, however, there is, as pointed out earlier, heightened potential for legal confusion among the detention facility's physicians as to both their statutory responsibilities and the proper purpose of an administrative involuntary medication order. Here, for example, Loughner's treating psychologist initially viewed competency restoration as the primary purpose of Loughner's involuntary medication, and the involuntary medication decisions seem focused on long-term cure rather than short-term safety. See supra Section II(C)(i). Staff representatives are insufficient protection against such confusion. They lack the requisite legal expertise and, as here, often do not assert themselves in the medication hearing. See Morgan, 193 F.3d at 266; United States v. Humphreys, 148 F.Supp.2d 949, 953 (D.S.D.2001); United States v. Weston, 55 F.Supp.2d 23, 26-27 (D.D.C.1999). Moreover, and critically, lawyers for pretrial detainees are in the process of preparing and implementing an overall defense strategy. As that strategy will often be influenced by the events during, and results of, a medication hearing, excluding lawyers from any involvement in that hearing constitutes an impediment to the right to counsel with regard to the impending prosecution. A misstep at the administrative medication hearing could well impact the ultimate likelihood of conviction in a manner that could be foreseen by the defendant's lawyer but not by the defendanta lay person who is, by definition, incompetentor the lay staff representative. Thus, pretrial detainees have a significantly greater interest in the right to counsel than convicted prisoners. Conversely, the government's interest in excluding counsel from the administrative hearing is weaker with regard to a pretrial detainee than with respect to a convicted prisoner. In the pretrial context, there is no punitive or rehabilitative interest in isolating the inmate from society generally. That is why, in the pretrial context, part of the process due to a person if his liberty is taken is the opportunity to communicate with someone outside the institution where he is held, at a time and in a manner consistent with practical management of booking and confinement procedures and institutional security and order. Halvorsen, 146 F.3d at 689. Given the different balance of interests in the context of pretrial confinement for restoration, I would hold that a pretrial detainee has a limited right to the participation of counsel in connection with the administrative involuntary medication hearing. Briefly sketching the contours of this right, I would hold that the prison must: (1) notify the pretrial detainee's counsel of its intention to conduct an involuntary medication hearing, as well as the types, maximum dosages, and expected duration of the proposed involuntary medication; (2) provide the detainee's counsel an opportunity to confer with the staff representative prior to the involuntary medication hearing; and (3) allow the detainee's counsel to observe the involuntary medication hearing or, if there is a good reason to exclude the attorney from the proceedings, provide an audiovisual recording of the hearing. Providing the detainee's counsel with notice of the involuntary medication hearing and an opportunity to confer with the staff representative would allow counsel to apprise the staff representative of relevant legal issues, including: the importance of identifying a valid purpose for an administrative medication decision and of establishing the requisite specificity in the medical record; proper consideration of available alternatives; and the detainee's various procedural rights in connection with the administrative hearing. Recognizing these benefits, courts have often ordered detention facilities to inform counsel of any proposed involuntary medication hearings and to provide an opportunity for counsel to engage in pre-hearing conference with the detainee's staff representative. See Humphreys, 148 F.Supp.2d at 953; Weston, 55 F.Supp.2d at 26. Furthermore, just as a public trial remind[s] the prosecutor and judge of their responsibility to the accused and the importance of their functions, United States v. Waters, 627 F.3d 345, 360 (9th Cir.2010), allowing counsel to witness the administrative hearing would remind the hearing's participants of the important legal rights affected by an involuntary medication determination. And counsel's observation of the administrative hearing would expedite judicial review of any resulting involuntary medication order, because counsel would not need to resort to discovery to familiarize itself with the administrative proceedings. These benefits more than justify the limited right to counsel sketched above. As to whether the lawyer must be permitted to participate in the hearing, I would leave that question to be decided on a case-by-case basis. With notice, the attorney will have the opportunity to seek full representation rights from the court on a showing that, in the particular circumstances, there is a need for direct representation so as to preserve the defendant's rights as to ultimate conviction.
Quite aside from the exclusion of counsel, the staff representation in this case was a charade, and violated even the majority's lax due process standards. [16] Throughout the successive administrative involuntary medication hearings, Loughner's staff representative consistently 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. What he did was sit in the room and, after the hearing concluded, see that Loughner's appeal form was filed. No more. Such anemic representation falls well below the standard demanded by due process and 28 C.F.R. § 549.46(a)(3). See Morgan, 193 F.3d at 266; Humphreys, 148 F.Supp.2d at 953; Weston, 55 F.Supp.2d at 26-27. Judge Bybee (but not Judge Wallace) recognizes the troubling deficiencies in the representation afforded by Loughner's staff representative. But he regards them as effectively harmless because, he insists, the district court's September 28 commitment hearing provided Loughner sufficient opportunity to challenge the prison's involuntary medication decision. Majority Op. at 764-65. Not so, as review of the district court's orders and statements surrounding the September 28 hearing demonstrates. The district court reiterated, in its September 30 order, the position it had taken consistently theretoforethat its only role with respect to the institution's medication for dangerousness decisions was to review for adequacy of procedures, not to entertain evidence or arguments substantively challenging the determination. The evidentiary aspect of the September 28 hearing was therefore restricted to the specific question whether Loughner's prior treatment that is, involuntary medicationwould, if continued, likely result in his timely restoration to competency, not whether that treatment was needed to mitigate Loughner's dangerousness to himself or medically appropriate for that purpose. Judge Bybee's suggestion to the contrary has no basis in the sequence of events leading up to the September 28 hearing or in the record of that hearing. First, in its July 1 order reviewing the prison's Harper I determination, the district court held that Loughner was not entitled to an evidentiary hearing to contest the administrative determination of dangerousness. Instead, the court adopted the holding of Morgan, 193 F.3d at 262-63, and reviewed the prison's Harper I determination for arbitrariness and compliance with 28 C.F.R. § 549.46. The district court then consistently reaffirmed this holding, stating in its August 30 order that [t]he defense's motion for a post-deprivation [judicial] hearing is denied. Consistent with the district court's settled view of its extremely limited role as to the involuntary medication decision, its September 1 order scheduling Loughner's § 4241(d)(2)(A) commitment hearing gave no indication that the court intended to reverse its prior practice and hold an evidentiary hearing on the involuntary medication issue. Instead, the court stated quite clearly that the scope of the [commitment] hearing will be limited to the question of whether an additional period of time should be granted to actually restore the defendant to competency. Although the court also suggested that the parties should be prepared to state their positions regarding the necessity of scheduling a Sell involuntary medication hearing at some later point, the court never suggested allowing an evidentiary hearing on the prison's involuntary medication for dangerousness determination as part of its commitment hearing. During the pre-hearing telephonic conference, the district court further explicated its concern that a Sell hearing may be required where a court orders a pretrial detainee recommitted for restoration through the involuntary administration of psychotropic medication. I think it is a game changer and a significant event that Iif I do extend him, the purpose for the extension is for restoration, the court stated, Knowing that he is being involuntarily medicated, I think it is incumbent upon the court at that point to conduct a Sell hearing. The court, however, reiterated its decision to focus on the commitment decision and leave the involuntary medication issue for another day, stating: As I forecast, I think [the necessity of a Sell hearing is] an issue that is timely now and that we have to get to. But the immediate issue is whether there is enough evidence to support an extension on the substantial probability that [Loughner] can be restored. How they restore him and what due process rights he has during that period is a secondary issue. It's one I intend to get to ultimately. But the immediate issue is just this question of whether an extension is warranted. At the September 28 hearing, the district court repeatedly declared its intention to restrict the evidentiary hearing to the commitment issue. Doctor Pietz provided detailed testimony concerning Loughner's condition and his prospects for restoration. When defense counsel attempted to cross-examine Dr. Pietz regarding Dr. Sarrazin's diagnosis and its relation to the prescribed antibiotics, however, the government objected on relevance grounds and the court sustained the objection, reminding the defense that the limited focus here is whether an extension is likelysubstantially probable to restore [Loughner]. The court further stated: I'm well familiar with all of the background reports. I've read them myself. You'll have the opportunity, obviously, at some point when that's relevant to go over those. But the questions should focus on going forward. Doctor Ballenger provided generalized testimony about the likelihood and duration of psychiatric restoration through involuntary medication, gave an opinion as to Loughner's prospects for restoration based on his medical history and medication regimen, and passed on the propriety of Loughner's current medication. But when defense counsel attempted to cross-examine Dr. Ballenger regarding the medical appropriateness of Loughner's involuntary medication regimen, the court chided the digression. [T]he appropriateness of the treatment is a matter for a Sell hearing or some later hearing, the court said, It's not the subject of this hearing. Defense counsel responded that [t]he restoration depends upon the treatment that's going to be given. The court, however, persisted in its refusal to expand the scope of the evidentiary hearing, stating that [t]he question here is whether he's likely to be restored with an extended commitment to Springfield. I'd like both sides to keep focused on that. . . . I want to focus on the issue of the day, which is whether he's to be extended and whether the standard of proof is met by the evidence. Then, in response to defense counsel's request for a ruling on its motion to stay Loughner's involuntary medication, the court responded that its view continues to be . . . that because [the involuntary medication order is] predicated on the ground of dangerousness and really has nothing to do with [Loughner's] competency to stand trial, that that's an issue with the Bureau of Prisons and the physicians there, and for good reason. Following the approach adopted in its July 1 order, the court applied Morgan's arbitrariness standard and concluded that there's no arbitrariness in the third Harper hearing and that the medication going forward, at least of today, is authorized pursuant to the Harper case. The Court reaffirmed this holding in its written order, which appropriately characterized its review of the administrative Harper III determination as minimal. In short, the district court's pre-hearing orders, the statements it made during the September 28 hearing itself, and its written post-hearing order, all demonstrate, without doubt, that the evidentiary aspect of the hearing was restricted to a specific questionwhether Loughner's current treatment will likely result in his timely restoration, assuming the continuation of involuntary medication. No evidentiary challenge to that treatment was permitted. Instead, following the approach outlined in its July 1 Order, the court conducted a minimal review of the prison's Harper III determination and concluded that the decision was not arbitrary. Nowhere did the court contemplate or suggest a reversal of its previous holdings that Loughner is not entitled to an evidentiary hearing on the issue of his involuntary medication for dangerousness. Indeed, when defense counsel argued that the district court had simply deferred to the Bureau of Prisons on the Harper determination, the district court responded: What I've said is that there is another basis for him being medicated that has nothing to do with me. It has to do with dangerousness. In light of the district court's strict limitations on the scope of its evidentiary hearing and the extraordinary deference it accorded the prison's involuntary medication decisions, the majority's conclusion that the September 28 hearing provided Loughner an adequate opportunity to challenge his involuntary medication rests on air, nothing more.