Opinion ID: 4524141
Heading Depth: 2
Heading Rank: 1

Heading: The Constitutional and Statutory Framework

Text: Washington v. Harper has been called “the seminal involuntary medication case.” 7 Mr. Harper was medicated against his will with antipsychotic drugs while he was imprisoned in a state correctional facility for convicted felons with serious mental disorders. 8 The facility had established an administrative hearing process for approving such medication to treat inmates whose mental disorders rendered them 6 D.C. Code § 24-531.09(a). 7 United States v. Loughner, 672 F.3d 731, 744 (9th Cir. 2012). 8 Harper, 494 U.S. at 214. 6 gravely disabled or seriously dangerous to themselves or others. This process afforded inmates like Harper an evidentiary hearing before an independent medical review committee and other procedural protections, with judicial review ultimately available in state court. 9 Harper brought a civil rights action in which he challenged the administrative process as violative of due process. The Washington Supreme Court agreed with him, holding that the Due Process Clause entitled Harper to a judicial hearing with the “full panoply of adversarial procedural protections,” at which the State would have to prove not only that Harper was mentally ill and dangerous, but also that his involuntary medication was “necessary and effective for furthering a compelling state interest.” 10 The United States Supreme Court reversed. Acknowledging the “significant liberty interest in avoiding the unwanted administration of antipsychotic drugs,” 11 9 Id. at 215-16. 10 Id. at 218. 11 Id. at 221-22; see also id. at 229 (“The forcible injection of medication into a nonconsenting person’s body represents a substantial interference with that person’s liberty. The purpose of the [antipsychotic] drugs is to alter the chemical balance in a patient’s brain, leading to changes intended to be beneficial, in his or her cognitive processes. While the therapeutic benefits of antipsychotic drugs are 7 the Court held that the state facility’s non-judicial procedures satisfied both the substantive and the procedural requirements of due process. On the substantive question, the Court explained that, in light of the state’s important interests in prison safety and security, the constitutionality of prison regulations must be “judged under a ‘reasonableness’ test less restrictive than that ordinarily applied to alleged infringements of fundamental constitutional rights.” 12 The Court concluded that the state policy was “a rational means of furthering the State’s legitimate objectives.” 13 “[G]iven the requirements of the prison well documented, it is also true that the drugs can have serious, even fatal, side effects.” (Internal citations omitted.)). 12 Id. at 224 (quoting O’Lone v. Estate of Shabazz, 482 U.S. 342, 349 (1987)). “[T]he proper standard for determining the validity of a prison regulation claimed to infringe on an inmate’s constitutional rights is to ask whether the regulation is reasonably related to legitimate penological interests.” Id. at 223 (internal quotation marks omitted). 13 Id. at 226. In affirming the reasonableness of the policy at issue, the Court cited (1) the state’s important prison safety concerns; (2) the policy’s “exclusive application . . . to inmates who are mentally ill and who, as a result of their illness, are gravely disabled or represent a significant danger to themselves or others”; (3) the fact that “[t]he drugs may be administered for no purpose other than treatment and only under the direction of a licensed psychiatrist”; and (4) the wide agreement “in the psychiatric profession that proper use of the drugs is one of the most effective means of treating and controlling a mental illness likely to cause violent behavior.” Id. at 225-26. 8 environment,” the Court held, “the Due Process Clause permits the State to treat a prison inmate who has a serious mental illness with antipsychotic drugs against his will, if the inmate is dangerous to himself or others and the treatment is in the inmate’s medical interest.” 14 The Court went on to hold that the administrative hearing procedures comported with procedural due process. 15 Because the decision was essentially a medical one, the Court concluded, “an inmate’s interests are adequately protected, and perhaps better served, by allowing the decision to medicate to be made by medical professionals rather than a judge.” 16 Under the state’s policy, the Court explained, the decisionmaker is asked to review a medical treatment decision made by a medical professional. That review requires two medical inquiries: first, whether the inmate suffers from a “mental disorder”; and second, whether, as a result of that disorder, he is dangerous to himself, others, or their property. . . . The risks associated with antipsychotic drugs are for the most part medical ones, best assessed by medical professionals. A State may conclude with good reason that a judicial hearing will not 14 Id. at 227. 15 Id. at 228. 16 Id. at 231. 9 be as effective, as continuous, or as probing as administrative review using medical decisionmakers.[17] The Court further held that the procedures adopted to implement the policy – which included notice, the right to be present at an adversary hearing before an independent decisionmaking body, the assistance of a lay advocate, and the right to present and cross-examine witnesses – sufficed to meet the requirements of due process “in all other respects.” 18 Thirteen years later, in Sell v. United States, 19 the Court considered the involuntary antipsychotic medication of a mentally ill pretrial detainee who was held for competency restoration at the United States Medical Center for Federal Prisoners. Following an administrative process like that approved in Harper, the Medical Center concluded that medication would be appropriate both to alleviate Mr. Sell’s dangerousness and to help him attain competency. However, when Sell appealed this decision, the federal district court and the court of appeals upheld it 17 Id. at 232-33. 18 Id. at 235. The Court rejected Harper’s contentions that due process required a right to representation by legal counsel, a hearing conducted in accordance with the rules of evidence, and proof by clear and convincing evidence. Id. at 235-36. 19 539 U.S. 166 (2003). 10 only on the latter, competency restoration ground. The Supreme Court granted certiorari to consider Sell’s argument that “allowing the government to administer antipsychotic medication against his will solely to render him competent to stand trial for non-violent offenses” violated his due process rights.20 In its decision, the Sell Court reiterated Harper’s holding that the requirements of due process are satisfied where the government demonstrates antipsychotic medication is “medically appropriate and, considering less intrusive alternatives, essential for the sake of [the pretrial defendant’s] own safety or the safety of others.” 21 But where the only asserted governmental interest is to bring a defendant to trial, the Court held, the Constitution requires other conditions to be met before the government may override the defendant’s liberty interest in refusing psychotropic medication. 22 Specifically, the Court stated, the Constitution permits the Government involuntarily to administer antipsychotic drugs to a mentally ill defendant facing serious criminal charges in order to render that defendant competent to stand trial, but only if the treatment is medically appropriate, is substantially 20 Id. at 175. 21 539 U.S. at 179 (quoting Riggins v. Nevada, 504 U.S. 127, 135 (1992); emphasis added in Sell; internal quotation marks omitted). 22 Id. at 169. 11 unlikely to have side effects that may undermine the fairness of the trial, and, taking account of less intrusive alternatives, is necessary significantly to further important governmental trial-related interests.[23] The Court strongly implied, if it did not explicitly hold, that such “trial-related” determinations must be made by a court. 24
D.C. Code § 24-531.09 governs the involuntary medication of defendants in the District of Columbia who have been ordered held for competency restoration treatment. Following Sell and Harper, the statute provides for different standards and procedures to be followed depending on the purpose for which the involuntary medication is sought. Subsection (a) provides that if “the sole purpose” is to render the defendant competent, the involuntary administration of medication is prohibited “[e]xcept as set forth in subsection (b),” which requires a court to make specific findings that the governmental interest in bringing the defendant to competency 23 Id. at 179. 24 See id. at 180-81. 12 outweighs the defendant’s interest in refusing the medication. 25 The Judiciary Committee report on the statute explains that, “[t]his requirement is based on the Supreme Court’s decision in Sell. . . . Subsection (b) lists the factors enumerated in Sell that the court should find in weighing the two interests.” 26 Subsection (a) of § 24-531.09 goes on to state that “[f]or any other purpose, the defendant may be administered medication without his or her consent consistent with [D.C. Code] § 7-1231.08, and the regulations promulgated thereunder.” 27 25 Specifically, subsection (b) states that the court may order the involuntary administration of medication for the sole purpose of rendering the defendant competent only if it “determines that the government’s interest in bringing the defendant to trial or proceeding with sentencing, probation revocation, or transfer outweighs the defendant’s interest in refusing medication to render him or her competent.” § 24-531.09(b)(1)(B). In order to make that determination, the court “must find” that (1) the defendant has been charged with a dangerous crime or a crime of violence as defined elsewhere in the Code; (2) the medication is substantially likely to render the defendant competent; (3) the medication is substantially unlikely to have side effects that will significantly interfere with the defendant’s ability to assist counsel in conducting a defense; (4) involuntary medication is necessary to further the government’s interest because any less intrusive treatment alternatives are unlikely to render the defendant competent; and (5) the medication is medically appropriate. § 24-531.09(b)(2). 26 District of Columbia Council, Committee on the Judiciary, Report on Bill 15-967, the “Incompetent Defendants Criminal Commitment Act of 2004” (“Judiciary Committee Report”) at 9 (November 17, 2004). 27 The regulations implementing § 7-1231.08 are codified at 22A DCMR § 104 (2020). 13 Section 7-1231.08 governs the administration of medication to all “consumers,” i.e., persons who seek or receive mental health services or supports in the District of Columbia under Chapter 5 of Title 21 (“Hospitalization of Persons with Mental Illness”), “without regard to [their] voluntary, non-protesting, or involuntary status.” 28 The Judiciary Committee Report explains that, by its incorporation of § 7-1231.08, subsection (a) of § 24-531.09 “authorizes the involuntary administration of medication for any other purposes [i.e., other than restoration of competency] as long as the same procedures are followed for defendants as would be followed for any other consumer of mental health services.” 29 Those procedures do not require judicial authorization. Rather, § 7- 1231.08(c) states that a provider of mental health services may administer medication involuntarily to an incapacitated consumer “only after receiving approval for such action through an administrative procedure established by” the Department of Behavioral Health (DBH). The administrative procedure must include, among other things, 28 See D.C. Code § 7-1231.02(4) (2018 Repl.) (defining the term “consumers” for purposes of § 7-1231.08 and other sections of the Mental Health Consumers’ Rights Protection Act of 2001). 29 Judiciary Committee Report at 8. 14 notice to the consumer of available advocacy services; . . . [t]he right to a meeting convened by a neutral party . . . for the purpose of reviewing the necessity for involuntary administration of medication; . . . [t]he right of the consumer to be present and have representation during any such meeting; . . . [t]he opportunity, at the meeting, for the consumer . . . to present information and discuss the necessity of medication with the physician seeking to administer it; [and] [t]he right to appeal the decision of the neutral party to an independent panel[.][30] A decision to medicate without consent is valid for “no more than 30 days.” 31 The parties before us agree that such a decision is subject to judicial review in an appropriate equitable action in Superior Court. 32 30 D.C. Code § 7-1231.08(c); see also 22A DCMR § 104.9 et seq. A formal policy adopted by Saint Elizabeths and DBH implements this process for pretrial detainees. It requires a detainee’s treating psychiatrist to document (1) that due to a diagnosed mental illness, the detainee is “gravely disabled or poses a likelihood of serious harm or dangerousness to self, others, or property without the medication,” and (2) “after considering less restrictive intervention, that psychotropic medication is appropriate.” The request for medication must be approved, after a hearing (at which the detainee has a right to representation), by a neutral Medication Review Officer, and the detainee may appeal to a three-member Medication Review Panel. 31 D.C. Code § 7-1231.08(c)(6); 22A DCMR § 104.11. The Saint Elizabeths policy specifies that “[i]f the prescribing physician seeks to continue the involuntary administration of medication for an additional 30 days, the procedures set forth herein shall be repeated.” 32 See District of Columbia v. Sierra Club, 670 A.2d 354, 358 (D.C. 1996); Capitol Hill Restoration Soc’y Inc. v. Moore, 410 A.2d 184, 188 (D.C. 1979). We refrain from attempting to delineate the precise scope of such review in this opinion, beyond noting that the parties before us agree it is not de novo, because that question is not directly presented in these appeals. Cf. United States v. Morgan, 193 F.3d 15 The administrative process envisioned by § 7-1231.08(c) is not materially different from the administrative process upheld in Harper. 33 Thus, § 24-531.09(a) provides that defendants undergoing competency restoration may be approved for non-emergency involuntary medication through a Harper-compliant administrative process rather than by a court as long as the sole purpose of the medication is not to make the defendants competent. This non-judicial process is commonly referred to as a “Harper hearing.”