Opinion ID: 185465
Heading Depth: 2
Heading Rank: 2

Heading: Restoring Competence to Stand Trial

Text: 18 In Riggins, the Court prescribed the conditions sufficient for a dangerousness justification, but explicitly declined to prescribe ... substantive standards for determining when other government interests override a pretrial detainee's liberty interest in refusing antipsychotic medication. See Riggins, 504 U.S. at 136; see also Weston, 206 F.3d at 12-13 (also declining to prescribe substantive standards). The Court did, however, suggest that the governmental interest in restoring a pretrial detainee's competence to stand trial could override his liberty interest: the State might have been able to justify medically appropriate, involuntary treatment with [antipsychotic medication] by establishing that it could not obtain an adjudication of [the pretrial detainee's] guilt or innocence by using less intrusive means. Riggins, 504 U.S. at 135. 19 The substantive issue involves a definition of the protected constitutional interest, as well as identification of the conditions under which competing state interests might outweigh it. Harper, 494 U.S. at 220 (quoting Mills v. Rogers, 457 U.S. 291, 299 (1982)) (internal brackets omitted); see also Foucha v. Louisiana, 504 U.S. 71, 116 (1992) (Thomas, J., dissenting) (The standard of review determines when the Due Process Clause ... will override a State's substantive policy choices, as reflected in its laws.). Weston argues that the appropriate substantive standard is strict scrutiny and that involuntary medication must be narrowly tailored to achieve a compelling government interest. See Brief for Appellant at 36-37; accord United States v. Brandon, 158 F.3d 947, 957 (6th Cir. 1998) (strict scrutiny applies to determination whether governmental interest in medicating nondangerous pretrial detainee to make him competent for trial outweighs liberty interest); Bee v. Greaves, 744 F.2d 1387, 1396 (10th Cir. 1984) (requiring use of less restrictive alternatives); see also Kulas v. Valdez, 159 F.3d 453, 455 (9th Cir. 1998) (using heightened scrutiny under Riggins); United States v. Sanchez-Hurtado, 90 F. Supp. 2d 1049, 1055 (S.D. Cal. 1999) (same); Khiem v. United States, 612 A.2d 160, 165-66 (D.C. 1992) (as amended on rehearing) (applying Riggins and requiring a showing of overriding justification and medical appropriateness). The government argues for an arbitrary and capricious standard like that employed to review administrative agency action. See Brief for Appellee at 22-27; accord Harper, 494 U.S. at 223 (applying reasonableness standard to forcible medication of prisoners to mitigate dangerousness); Weston, 206 F.3d at 14-15 (Henderson, J., concurring); United States v. Charters, 863 F.2d 302, 306 (4th Cir. 1988) (en banc) (liberty interest is protected against arbitrary and capricious actions by government officials); United States v. Morgan, 193 F.3d 252, 262 (4th Cir. 1999) (under Charters, the determination of whether to forcibly medicate a pretrial detainee ... rests upon the professional judgment of institutional medical personnel, subject only to judicial review for arbitrariness); United States v. Keeven, 115 F. Supp. 2d 1132, 1137 (E.D. Mo. 2000) (following Morgan); cf. Jurasek v. Utah State Hosp., 158 F.3d 506, 511 (10th Cir. 1998) (applying Harper's reasonableness standard to civilly committed patient); see also Charters, 863 F.2d at 31213 (professional judgment standard from Youngberg v. Romeo); Morgan v. Rabun, 128 F.3d 694, 697 (8th Cir. 1997) (same). 20 The Supreme Court denied that it had adopted a strict scrutiny standard in Riggins. See Riggins, 504 U.S. at 136. It also appeared not to apply a reasonableness test or its various analogues: arbitrary and capricious, rational basis, or exercise of professional judgment. Rather, the opinion's language suggests some form of heightened scrutiny: the emphasis on the severity of infringement antipsychotic drugs impose on an individual's liberty interest, see id. at 134; the reasoning that forcing antipsychotic drugs on a convicted prisoner is impermissible absent a finding of overriding justification, id. at 135 (emphasis added); the statement that medicating to mitigate dangerousness must be essential and that the trial court must consider less intrusive alternatives, id.; and the criticism of the district court's failure to find that safety considerations or other compelling concerns outweighed Riggins' [liberty] interest, id. at 136. 21 We think the appropriate standard is the one the Court set forth in the penultimate paragraph where it noted the lack of a finding that might support a conclusion that administration of antipsychotic medication was necessary to accomplish an essential state policy.... Id. at 138. Although that paragraph addressed trial prejudice, it outlines the standard the state failed to meet in ascertaining whether a governmental interest outweighs a right to avoid antipsychotic medication. Accordingly, to medicate Weston, the government must prove that restoring his competence to stand trial is necessary to accomplish an essential state policy. 5 22
23 Preventing and punishing criminality are essential governmental policies. The Supreme Court has recognized that preventing crime is a compelling governmental interest. See Schall v. Martin, 467 U.S. 253, 264 (1984); United States v. Salerno, 481 U.S. 739, 749-50 (1987). This interest lies not just in incapacitating dangerous criminals, but also in demonstrating that transgressions of society's prohibitions will be met with an appropriate response by punishing offenders. See Kansas v. Hendricks, 521 U.S. 346, 361-62 (1997); Foucha v. Louisiana, 504 U.S. 71, 80 (1992). The Court has repeatedly adverted to the government's compelling interest in finding, convicting, and punishing those who violate the law. Moran v. Burbine, 475 U.S. 412, 426 (1986); accord Texas v. Cobb, 121 S. Ct. 1335, 1343 (2001); Gray v. Mary land, 523 U.S. 185, 202 (1998) (Scalia, J., dissenting); McNeil v. Wisconsin, 501 U.S. 171, 181 (1991); Richardson v. Marsh, 481 U.S. 200, 210 (1987); Garrett v. United States, 471 U.S. 773, 796 (1985) (O'Connor, J., concurring). 24 The Court in Riggins recognized the strength of the government's policy in adjudicating criminality when it stated that the government might be able to involuntarily medicate a defendant if it could not obtain an adjudication of guilt or innocence by using less intrusive means, 504 U.S. at 135, and when it cited Justice Brennan's statement that Constitutional power to bring an accused to trial is fundamental to a scheme of 'ordered liberty' and prerequisite to social justice and peace, id. at 135-36 (quoting Illinois v. Allen, 397 U.S. 337, 347 (1970) (Brennan, J., concurring)). We do not believe the Court's use of might reflects any tentativeness about whether the government could ever justify medicating to restore competence to stand trial. If that were what the Court had in mind we doubt that it would have included the statement. We read might, rather, as indicating that the interest in adjudicating criminality is not necessarily an essential state policy under all circumstances. Cf. Brandon, 158 F.3d at 960-61 (no compelling interest in trying man accused of sending a threatening letter; factors relevant to this determination include seriousness of the offense, whether the pretrial detainee is dangerous, and whether the detainee will be released if not tried); Khiem, 612 A.2d at 176 & n.1 (Ferren, J., dissenting from denial of rehearing en banc) (Whereas the District may have a compelling state interest in force-medicating Khiem [to try him for murder], the District will not necessarily have such an interest in forcemedicating pretrial detainees charged with lesser crimes.). 25 We need not decide under what circumstances trying and punishing offenders is not essential. The government's interest in finding, convicting, and punishing criminals reaches its zenith when the crime is the murder of federal police officers in a place crowded with bystanders where a branch of government conducts its business. The Court made the point in Salerno: While the Government's general interest in preventing crime is compelling, even this interest is heightened when the Government musters convincing proof that the arrestee, already indicted or held to answer for a serious crime, presents a demonstrable danger to the community. Under these narrow circumstances, society's interest in crime prevention is at its greatest. 481 U.S. at 750; see also Khiem, 612 A.2d at 167; but see Bee v. Greaves, 744 F.2d 1387, 1395 (10th Cir. 1984). The statutory sentences for the crimes Weston is accused of committing--life in prison and death--reflect the intensity of the government's interest in bringing those suspected of such crimes to trial. See 18 U.S.C. §§ 1111, 1114. 26 Weston concedes that in the ordinary case, the strength of the government's interest in trying a defendant accused of first degree murder is undisputed, but argues that when the government seeks to forcibly medicate a defendant in order to try him, however, the case is no longer ordinary, because presumptions against forced medication have deep roots in the law. Brief for Appellant at 43. This argument is a reprise of the medical ethics point we considered and rejected in determining whether antipsychotic medication is medically appropriate. It has no more purchase here. The presumption against forced medication goes to the importance of Weston's constitutional right to refuse antipsychotic drugs (which we agree is substantial), not to the nature of the government's countervailing interest. 27 We also do not believe that the governmental interest in medicating a defendant in order to try him is diminished ... by the option of civil commitment. Note, Riggins v. Nevada: Toward a Standard for Medicating the Incompetent Defendant to Competence, 71 N.C. L. Rev. 1206, 1223 (1993). The civil commitment argument assumes that the government's essential penological interests lie only in incapacitating dangerous offenders. It ignores the retributive, deterrent, communicative, and investigative functions of the criminal justice system, which serve to ensure that offenders receive their just deserts, to make clear that offenses entail consequences, and to discover what happened through the public mechanism of trial. Civil commitment addresses none of these interests. In Weston's case, civil commitment would be based on his present mental condition, not on his culpability for the crimes charged: criminal responsibility at the time of the alleged offenses ... is a distinct issue from his competency to stand trial. Jackson v. Indiana, 406 U.S. 715, 739 (1972); see also 18 U.S.C. 4241(f) (A finding by the court that the defendant is mentally competent to stand trial shall not prejudice the defendant in raising the issue of his insanity as a defense to the offense charged, and shall not be admissible as evidence in a trial for the offense charged.). 28
29 The sole constitutional mechanism for the government to accomplish its essential policy is to take Weston to trial. See U.S. Const. amend. V (no deprivation of life, liberty, or property without due process). Antipsychotic medication is necessary because, as the district court found, antipsychotic medication is the only therapeutic intervention available that could possibly improve Weston's symptom picture, lessen his delusions, and make him competent to stand trial. Weston, 134 F. Supp. 2d at 132. The government cannot obtain an adjudication of [Weston's] guilt or innocence by using less intrusive means. Riggins, 504 U.S. at 135. 30 Although Weston does not propose any alternative means, he claims that the fit between involuntary medication and the government's interest is not sufficiently tight in two respects. First, he argues that the medication will not restore his competence to stand trial because he is not likely to respond to it. Second, he contends that the medication's mindaltering properties and likely side effects will prejudice his right to a fair trial such that the government could not lawfully try him even if his competence were restored. Either way, the argument goes, there is an insufficient probability that forcible medication will satisfy the government's interest. 31 We will treat what Weston styles the narrow tailoring requirement of strict scrutiny as an attack on the necessity of antipsychotic medication. In determining whether a governmental interest overrides a constitutional right, courts examine not only the nature of the right and the strength of the countervailing interest, but also the fit between the interest and the means chosen to accomplish it. This inquiry entails a predictive judgment about the probable efficacy of the means to satisfy the interest. In the terms of this case, antipsychotic medication may not be necessary if its use will not permit the government to try Weston. 32 That antipsychotic medication must be necessary to restore Weston's competence to stand trial does not mean there must be a 100% probability that it will produce this result. As the Court has recognized, necessity may mean absolute physical necessity or inevitability or that which is only convenient, useful, appropriate, suitable, proper, or conducive to the end sought. Webster v. Reproductive Health Servs., 492 U.S. 490, 515 n.13 (1989) (plurality opinion) (quoting Black's Law Dictionary); see also Board of Trustees v. Fox, 492 U.S. 469, 476-77 (1989). Even narrow tailoring in strict scrutiny analysis does not contemplate a perfect correspondence between the means chosen to accomplish a compelling governmental interest. See Burson v. Freeman, 504 U.S. 191, 20610 (1992) (plurality opinion). 33 The government has established a sufficient likelihood that antipsychotic medication will restore Weston's competence while preserving his right to a fair trial. See Brandon, 158 F.3d at 960. The district court acknowledged that it is not certain that the medication will restore Weston's competency, but credit[ed] the ... testimony of the mental health experts that this outcome is likely. Weston, 134 F. Supp. 2d at 132. The government presented evidence that antipsychotic medication mitigated symptoms for at least 70 percent of patients. See 7/24/00 p.m. Tr. at 108-09; 8/20/99 a.m. Tr. at 56; 11/15/00 a.m. Tr. at 57. Dr. Johnson testified that the response rate is probably higher with the atypicals. See 7/24/00 p.m. Tr. at 108-09. The government also provided reason to believe that the probability of restoring competence might be higher in Weston's case because of Weston's relatively little exposure to antipsychotic medication and his generally positive response to the limited medication he received in 1996. See Weston, 134 F. Supp. 2d at 122; see also 8/20/99 a.m. Tr. at 56; 7/27/00 a.m. Tr. at 120-21; 4 Joint Appendix 105 (Report of Dr. Daniel). 34 The small possibility that antipsychotic medication will not make Weston competent for trial is certainly tolerable considering that antipsychotic medication is the sole means for the government to satisfy its essential policy in adjudicating the murder of federal officers. See Burson, 504 U.S. at 207-08 (emphasizing that the means chosen is the only way to satisfy the state's compelling interest). The district court made the most precise predictive judgment it could in this context. See 8/20/99 a.m. Tr. at 56 (Dr. Johnson's testimony that you are unable to predict in the individual case whether that individual will actually respond). 35 Weston points out that there is also a possibility that antipsychotic medication could prejudice his right to a fair trial by, for instance, altering his courtroom demeanor, interfering with his recollection and ability to testify, and obstructing his right to present an insanity defense. We agree with the district court that [t]here is no reason to conclude, at this time, that involuntary medication would preclude Weston from receiving a fair trial. Weston, 134 F. Supp. 2d at 137. 36 The general right to a fair trial includes several specific rights such as the right to be tried only while competent, that is, while able to understand the proceedings, consult with counsel, and assist in the defense. See Drope v. Missouri, 420 U.S. 162, 171-72 (1975). As we determined, there is a sufficiently high probability that antipsychotic medication will restore Weston's competence to stand trial. The district court found and the evidence indicates that a strong likelihood exists that medication will enhance some of Weston's trial rights, particularly his right to consult with counsel and to assist in his defense. Weston, 134 F. Supp. 2d at 133. 6 37 Another aspect of the right to a fair trial is Weston's right to testify and to present his own version of events in his own words. Rock v. Arkansas, 483 U.S. 44, 49, 52 (1987). The defense is concerned that the medication might affect Weston's memory and his capacity to relate his delusions and other aspects of his mental state at the time of the crime, which in turn may impair his ability to mount an effective insanity defense. Weston, 206 F.3d at 21 (Tatel, J., concurring); see also 18 U.S.C. 17 (affirmative defense of insanity). But the record contains no basis to suppose that antipsychotic drugs will prevent Weston from testifying in a meaningful way. Rather, it indicates that medication will more likely improve Weston's ability to relate his belief system to the jury. See 7/24/00 p.m. Tr. at 49-51. The benefits of antipsychotic medication in terms of Weston's ability to understand the proceedings and communicate with his attorneys presumably will also translate into an improved capacity to communicate from the witness stand. And although memory loss is a potential side effect, Dr. Johnson testified that she thought he'd be able to remember his belief system. 7/24/00 p.m. Tr. at 50 (also stating that I don't think the treatment would impact his memory); see also 7/25/00 a.m. Tr. at 4-5 (Dr. Johnson's testimony that I don't expect him to lose the memory of his delusional beliefs as a result of treatment). 38 There is a possibility that the medication could affect Weston's behavior and demeanor on the witness stand such that the jury might regard his synthetically sane testimony as inconsistent with a claim of insanity. As Justice Kennedy put it in Riggins, [i]f the defendant takes the stand ... his demeanor can have a great bearing on his credibility and persuasiveness, and on the degree to which he evokes sympathy. Riggins, 504 U.S. at 142 (Kennedy, J., concurring). We recognize this small risk, but we see little basis to suppose that the jury will take Weston's testimony (if he decides to testify) as an indication that he must have been sane at the time of the crime, or that he is making it up, or that he deserves no sympathy. There is ample evidence of Weston's history of mental illness and bizarre behavior; the jury's overall impression of Weston will depend as much on this evidence as his testimony. 39 The district court also correctly held that a defendant does not have an absolute right to replicate on the witness stand his mental state at the time of the crime. See Weston, 134 F. Supp. 2d at 134. A defendant asserting a heat-of-passion defense to a charge of first degree murder does not have the right to whip up a frenzy in court to show his capacity for rage, nor does a defendant claiming intoxication have the right to testify under the influence. See Weston, 206 F.3d at 15 (Henderson, J., concurring). There is little meaningful distinction between these cases and medication-induced competence to stand trial. Either way, the defendant's mental state on the stand is different from the mental state he claims to have operated under at the time of the crime. The tolerable level of difference no doubt increases in a case like this where there is substantial evidence of mental state other than the defendant's present appearance. 40 Weston will not have to rely solely on his own testimony to show his state of mind on July 24, 1998. Involuntary medication therefore stands little chance of impairing his right to present an insanity defense. There is extensive documentation and testimony concerning Weston's delusional system, his history of mental illness, and his behavior, appearance, speech, actions, and extraordinary or bizarre acts ... over a significant period. Weston, 134 F. Supp. 2d at 135-36. Multiple experts have examined Weston and presumably may testify. Many of these examinations no doubt related to his trial competence, but [t]he tapes and psychiatric reports ... document Weston's delusional state over several years. Id. at 135. There is also a taped interview in which Weston discussed his delusional beliefs with the Central Intelligence Agency. See id. at 135 n.22. Given the wealth of expert and lay testimony and other documentation the district court described, see id. at 135-36, Weston's insanity defense does not stand or fall on his testimony alone. 41 A third trial right that could be implicated by antipsychotic medication is Weston's right to be present at trial in a state that does not prejudice the factfinder against him. See Estelle v. Williams, 425 U.S. 501, 503-04 (1976); Illinois v. Allen, 397 U.S. 337, 338, 344 (1970). To the extent the medication alters Weston's demeanor, courtroom behavior, or reactions to events in the courtroom, it may cause the jury to see Weston in a state that might seem inconsistent with a claim of insanity. It could also produce a flattened emotional affect that could convey to the jury a lack of remorse, a critical consideration if this case proceeded to sentencing. 42 Here again the record indicates that medication will likely enhance rather than impair Weston's right to a fair trial. Dr. Johnson stated that medication will alter [Weston's demeanor] to the extent that it will be more a return to his baseline non-psychotic state. I would anticipate he would have less blunting or flattening of his affect. He would be able to respond more appropriately from an emotional standpoint with his facial expression than he is now. 7/24/00 p.m. Tr. at 8; see also 7/25/00 a.m. Tr. at 22-24 (Dr. Johnson agreeing with the proposition that, with medication, Weston's expressions potentially could be more appropriate to the context of what's occurring in the courtroom; also, her testimony that [i]t is the patient who is over-medicated or whose side effects are not managed who would demonstrate an increased lack of responsiveness). 43 The possibility of side effects from antipsychotic medication is undeniable, but the ability of Weston's treating physicians and the district court to respond to them substantially reduces the risk they pose to trial fairness. The district court found that Weston's doctors can manage side effects in a number of ways: the Court credits the testimony of the government experts and Dr. Daniel, the independent expert, that the side effects of medication are manageable through adjustments in the timing and amount of the doses, and through supplementary medications. Weston, 134 F. Supp. 2d at 137; see also 11/15/00 a.m. Tr. at 125 (Dr. Daniel's testimony that antipsychotic medications have side effects but [g]enerally they can be treated or an adjustment made in the medication, or the medication replaced with a different one. There's generally a way to deal with the side effects.); 4 Joint Appendix 102 (Statement in Dr. Daniel's report to the district court that the side effects can most often be managed or an alternative course of treatment provided to the benefit of the patient. General experience with antipsychotics, particularly the newer medications, indicates that given their benefits they are reasonably safe and well-tolerated.). As the Court wrote in Harper, the risks associated with antipsychotic drugs are for the most part medical ones, best assessed by medical professionals. 494 U.S. at 233. 7 44 The district court also has measures at its disposal: If Weston is medicated and his competency is restored, the Court is willing to take whatever reasonable measures are necessary to ensure that his rights are protected. This may include informing the jurors that Weston is being administered mind-altering medication, that his behavior in their presence is conditioned on drugs being administered to him at the request of the government, and allowing experts and others to testify regarding Weston's unmedicated condition, the effects of the medication on Weston, and the necessity of medication to render Weston competent to stand trial. Weston, 134 F. Supp. 2d at 137. Weston is free to propose other options. 45 There is a very high probability that involuntary medication will serve the government's essential interest in rendering Weston competent to stand trial in a proceeding that is fair to both parties. Brandon, 158 F.3d at 954. 8 Given the lack of alternative means for the government to satisfy its essential policy, we cannot demand more.