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

Heading: The Reasons for Requiring Judicial Authorization of Involuntary Medication

Text: 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.