Opinion ID: 624293
Heading Depth: 2
Heading Rank: 5

Heading: commitment to restore competency

Text: We next turn to Loughner's appeal of the district court's extension of his commitment. This is a separate inquiry and, although the issues are related, we must keep the issues distinct. The dissent, however, argues that the involuntary medication and commitment decisions are one and the same. See Dissenting Op. at 784-85. Because the court . . . must decide whether Loughner is to be medically treated so as to be restored to competency and because that decision depends on the availability of involuntary medication, the dissent argues that the district court may not rely on a previous involuntary medication order, but instead must make an independent decision as to whether the medication is justified and unlikely to infringe on Loughner's fair trial rights. Id. at 781-82. But these determinations must be kept separate. 18 U.S.C. § 4241(d)(2) requires a court to decide whether there is a substantial probability that . . . [the detainee] will attain the capacity to permit the proceedings to go forward. Although the court will necessarily have to consider the preexisting treatment that will lead to such attainment, the basis for that treatment, when it is involuntary medication, is 28 C.F.R. § 549.46. This is a completely separate authorization, and one that the Supreme Court has indicated may be made in an administrative hearing. We therefore address whether, given the currently operative involuntary medication order, the district court properly extended Loughner's commitment pursuant to § 4241(d)(2). Under 18 U.S.C. § 4241(d), if a court finds that a defendant's mental disease renders him mentally incompetent to the extent that he is unable to understand the nature and consequences of the proceedings against him or to assist properly in his defense, the court shall commit the defendant for up to four months to determine if there is a substantial probability that he will be restored to competency. 18 U.S.C. § 4241(d)(1). After such time, the court shall commit the defendant for an additional reasonable period of time until he is fit to proceed to trial, if the court finds that there is a substantial probability that within such additional period of time he will attain the capacity to permit the proceedings to go forward. Id. § 4241(d)(2); see also Jackson v. Indiana, 406 U.S. 715, 738, 92 S.Ct. 1845, 32 L.Ed.2d 435 (1972). In challenging the extension of his commitment, Loughner raises three claims. First, he contends that the district court's order extending his commitment is flawed because the court failed to demand a particularized course of treatment from FMC-Springfield. Second, he argues that the district court did not consider whether the antipsychotic medications would render his trial unfair. Third, he maintains that the district court clearly erred in finding that there is a substantial probability that Loughner will regain competency. We will consider each in turn. [17] A. Particularized Course of Treatment Loughner argues that the district court failed to consider the medical appropriateness of his treatment regimen and, without considering that regimen, could not assess the likelihood of Loughner being restored to competency. We think Loughner has failed to distinguish between the reasons for which he may be medicated pursuant to Harper  reasons that predominantly have to do with the prison's and his own medical interestsand the reasons for which he may be medicated pursuant to Sell which involve the government's interests. Loughner is being medicated for his serious mental illness irrespective of whether he can concomitantly be restored to competency in order to stand trial. The purpose of the district court's hearing was to determine whether, in light of his existing treatment, there is a substantial probability that within [the] additional period of time he will attain the capacity to permit the proceedings to go forward. 18 U.S.C. § 4241(d)(2). If his current regimen is sufficient to determine that there is a substantial probability that he can be rendered competent, then he can be hospitalize[d]. . . in a suitable facility. Id. § 4241(d). If, however, the treatment for his dangerousness will not concomitantly render him trial-competent, then additional medication could be forced upon him only if it is in the government's (rather than his own) interests, and in such case the government would have to proceed under Sell. As the Court explained in Sell, [a] court need not consider whether to allow forced medication for [trial competency purposes], if forced medication is warranted for a different purpose. . . . If a court authorizes medication on these alternative grounds, the need to consider authorization on trial competence grounds will likely disappear. 539 U.S. at 181, 183, 123 S.Ct. 2174. We agree with Loughner that the existing involuntary medication decision is important to the overall outcome of the § 4241(d)(2) proceeding because it likely affect[s] both the scope and term of a § 4241(d)(2) order. United States v. Magassouba, 544 F.3d 387, 418 n. 27 (2d Cir.2008). Section 4241(d), however, is a commitment statute, not an involuntary medication statute, and a § 4241(d)(2) extension of commitment for purposes of competency restoration does not alter the legitimacy of the decision to medicate involuntarily Loughner under Harper. The court must therefore consider only whether his ongoing treatment is likely to restore competency, not whether it is medically appropriate. The medical appropriateness of Loughner's treatment was addressed in his Harper hearing, and we have approved that treatment. See supra Part III. In any event, the district court heard what medications the defendant is receiving, what dosages of those medications he is receiving, and when during the day he is receiving those dosages. Order Den. Stay 4-5. Although the district court assumed that the present medication regimen will continue with only minor modifications, id. at 5, the district court heard testimony that Loughner's medication regimen has changed in the months that he has been committed to FMC-Springfield, and his treating psychologist. Dr. Pietz, testified that his medication might continue to change. Dr. Ballenger testified that the medication currently administered to Loughner was highly appropriate but that if Loughner does not fully respond to the medication, it would be a very appropriate strategy to increase the dosages, even doubling some. But the administration of antipsychotic drugs is a fluid process and must be adjusted depending on how the patient reacts and why, if any, side effects are experienced. See APA Br. at 26 ([T]he choice whether and how to medicate an inmate is not a one-time decision; it involves a process of monitoring and, for many patients, adjustments in medication and dosage.); see also Indiana v. Edwards, 554 U.S. 164, 176, 128 S.Ct. 2379, 171 L.Ed.2d 345 (2008) (Mental illness itself is not a unitary concept. It varies in degree. It can vary over time. It interferes with an individual's functioning at different times in different ways.). Requiring FMC-Springfield to submit with particularity the exact course of treatment over several months is impractical and unnecessary, and would ignore the concerns expressed in Harper that medical decisions should not be made by judges. See Harper, 494 U.S. at 232, 110 S.Ct. 1028 (`The mode and procedure of medical diagnostic procedures is not the business of judges. . . .' (quoting Parham, 442 U.S. at 607, 99 S.Ct. 2493)); id. at 231 n. 12, 110 S.Ct. 1028 (stating that deference should be given to medical professionals in making medication decisions because courts do not have the necessary knowledge or expertise). [18] The district court found that Loughner was being lawfully medicated pursuant to Harper and that there was a substantial probability that his existing treatment will restore him to competency to stand trial. In the process, the court considered Loughner's existing regimen but did not undertake to micromanage his treatment or otherwise limit his course of treatment. See Harper, 494 U.S. at 231 n. 12, 110 S.Ct. 1028; Hernandez-Vasquez, 513 F.3d at 916-17. The Due Process Clause does not demand more. B. Side Effects and Fair Trial Rights Loughner argues that when forced medication is the means employed by BOP to seek restoration of competency, the district court must engage in a predictive analysis of whether side effects are substantially unlikely to render a trial unfair before the defendant can be committed under § 4241(d)(2). Specifically, Loughner argues that the district court must predict whether the antipsychotic medication is substantially unlikely to alter his demeanor in a manner that will prejudice his reactions and presentation in the courtroom, and render him unable or unwilling to assist counsel. Loughner's concerns are well-taken, but premature. As the district court recognized, Loughner will have a full and fair opportunity to raise his concerns before he goes to trial. See Order on Sell Hr'g 8. To demand that the district court answer such questions at this juncture blurs the distinction between a defendant who is being medicated under Harper and one the government seeks to medicate under Sell. Before a defendant can be committed for evaluation of his competence, the district court must find that the defendant is unable to understand the nature and consequences of the proceedings against him or to assist properly in his defense. 18 U.S.C. § 4241(d). The premise for granting the government's motion for a competency examination of Loughner at FMC-Springfield in March 2011 was reasonable cause to believe that he was not competent to understand trial procedures or to assist in his defense. Id. § 4241(a). That belief was confirmed shortly after Loughner was committed. Before granting an extension of commitment for the purpose of restoration, the district court must find that there is a substantial probability that the pretrial detainee will attain the capacity to permit the proceedings to go forward. Id. § 4241(d)(2). Once these findings are made, the court must then commit the defendant for a reasonable period of time until trial may proceed. Id. The statute itself therefore contemplates that the capacity that the district court is required to predict is the ability to understand the nature and consequences of the proceedings and to assist in his defense in other words, competency. See United States v. Marks, 530 F.3d 799, 814 (9th Cir.2008) (The substantive standard for determining competence to stand trial is whether the defendant had sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding, and a rational as well as factual understanding of the proceedings against him. (internal quotation marks omitted)); see also Edwards, 554 U.S. at 174, 128 S.Ct. 2379 (explaining that the Supreme Court's mental competency cases have defined competency in terms of the capacity to understand the nature and object of the proceedings against him, to consult with counsel, and to assist in preparing his defense) (emphasis omitted) (quoting Drope v. Missouri, 420 U.S. 162, 171, 95 S.Ct. 896, 43 L.Ed.2d 103 (1975)); Order Extending Restoration Commitment 2 n. 1 (finding that competency and capacity are equivalent). Sell requires, among other things, that the government demonstrate not only that involuntary medication is likely to render the defendant competent to stand trial, but that administration of the drugs is substantially unlikely to have side effects that will interfere significantly with the defendant's ability to assist counsel in conducting a trial defense. Sell, 539 U.S. at 181, 123 S.Ct. 2174; see also id. at 185, 123 S.Ct. 2174 (Whether a particular drug will tend to sedate a defendant, interfere with communication with counsel, prevent rapid reaction to trial developments, or diminish the ability to express emotions are matters important in determining the permissibility of medication to restore competence. . . .). That predictive judgment is required where the government seeks to medicate the defendant for no reason other than to render him competent. As we have pointed out, Loughner is being medicated involuntarily because he is a danger to himself or others, irrespective of whether the medications may cause side effects that interfere with his ability to assist counsel in his defense. A district court's judgement on side effects is both premature and irrelevant at this stage. See Order Den. Stay 3 (It was obviously premature at this stage of the competency restoration process for the Court to determine whether there are side effects of the defendant's medication that will prevent the Court from making a finding of competency in the future.). Because Loughner remains under medical treatment for his mental illness, the district court properly focused on whether his treatment might also restore him to competency. The district court acknowledged that Loughner's concerns will be fully addressed if there is a future competency hearing. Order on Sell Hr'g 8. We agree that such concerns are important and that Loughner should have an opportunity to raise these issues. We also agree that the district court need not address Loughner's concerns before deciding to extend his commitment to determine whether he can be restored to competency. C. Substantial Probability of Restoration of Competency Loughner contends that the district court applied the wrong legal standard in granting the extension of commitment, arguing that the substantial probability of restoration must be proven by clear and convincing evidence. First, we agree with the district court that a second layer of proof is not required and that the statute itself provides the requisite burden of proofthe government must prove there is a substantial probability that Loughner will regain competency. See 18 U.S.C. § 4241(d)(2)(A). Next, in defining that standard, the district court noted that a `substantial' probability is any probability worth taking seriously. Order Extending Restoration Commitment 3. To demonstrate this proposition, the court used an analogy: For example, a 40 percent chance of rain is enough of a reason to leave the house with a raincoat, or cancel plans to spend a day outside; it wouldn't be unreasonable to label that chance `a substantial probability, ' even if rain is not substantially probable. Id. The district court then looked to Ninth Circuit precedent, finding that `courts have generally construed § 4241(d)(2) to allow extensions for a reasonable period of time only when the individual is likely to attain competency within a reasonable time.' Id. at 4 (emphasis added) (quoting Rivera-Guerrero, 426 F.3d at 1143) (some internal quotation marks omitted). The district court's determination that substantial probability means likely (and not necessarily more likely than not) was based on both a fair reading of the statute and the guidance of our precedent and, therefore, we agree. Loughner further challenges the district court's finding that there was a substantial probability that Loughner can be restored to competency as clear error. He raises three objections to the district court's § 4241(d)(2) finding: (1) that his past improvement does not support an inference that his condition will continue to improve to the point of competency, (2) that expert opinion regarding the amount of time required for restoration was unsupported by any specific data and impermissibly relied on generalities, and (3) that the district court improperly relied on Dr. Ballenger's testimony because it equated functional competency with trial competency. After reviewing the evidence, we are not left with the definite and firm conviction that a mistake has been committed. Ruiz-Gaxiola, 623 F.3d at 693 (citations omitted) (internal quotation marks omitted). 1. Past Improvement Loughner argues that because a response to medication will eventually plateau, some additional indication beyond past improvement is required to establish a probability that his condition will continue to improve to the point of competency. In concluding that Loughner was likely to continue improving, however, the district court did not rely solely on Loughner's past improvement. The court based its finding on Loughner's positive response to the antipsychotic drugs, including the lack of significant side effects; Dr. Pietz's testimony regarding Loughner's progress and potential for further progress; the experience of Dr. Ballenger, corroborating the optimistic viewpoint and prognosis of Dr. Pietz; and his own observations of Loughner's improvement. Regardless, past experience is often the best predication of future performance, and the district court did not clearly err in basing its determination of the likelihood of competency restoration on readily available evidence of Loughner's reaction to antipsychotic medication already administered, and the views of the medical experts who testified. 2. Time Required for Restoration to Competency Loughner next disputes the district court's finding that restoration would be accomplished in four months, and the basis for Dr. Pietz's opinion that Loughner could be restored to competency within eight months. In her progress report on September 7, 2011, Dr. Pietz opined that Loughner remained incompetent to stand trial. She requested an extension of his commitment because she believed that Loughner would improve and reach competency to stand trial. Dr. Pietz could not predict how much additional time was required, but she noted that [h]istorically, most defendants reach competency within 8 months of their commitment, and recommended that Loughner's commitment be extended for four months. At the extension hearing, Dr. Pietz clarified that the eight months goes to when we start to medicate [him]. In coming to the eight-month figure, Dr. Pietz relied on her experience restoring defendants to competency over twenty-one years, her colleagues' experience, a book, and several articles that were presented to the district court. She did not have, however, any formal data from which she based her figure of eight months. Dr. Pietz further explained that she recommended an extension of commitment for four months because, based on her understanding of the statute and her experience, extensions are granted in four-month increments, with the possibility of a second extension if necessary. See 18 U.S.C. § 4241(d). Based on the testimony that he heard from Dr. Pietz, a review of the records in this case, and his own experience, Dr. Ballenger confirmed that it is highly likely that Loughner will get clinically better in two to six, eight more months. The district court found that Dr. Pietz is credible, experienced, and qualified to make the judgments required of her during the commitment hearing. The court further credited Dr. Pietz's day-to-day personal contact with Loughner, as well as her barometer on whether he's made progress [and] whether he'll continue to make marked progress. Status Hr'g Tr. 275. Additionally, Dr. Pietz's opinion was supported by the testimony of Dr. Ballenger, an experienced and well-credentialed psychiatrist. The district court did not rely exclusively on the experts. At the hearing, the district judge found that measurable progress toward restoration has been made, id., and offered his own observation of Loughner's progress: I watched Mr. Loughner today as I have in the other proceedings. His demeanor, while all the characterizations are correct about flat affect and all, has been distinctly different than in other proceedings. . . . The smirk, what we referred to as affect, is gone. He's appeared to pay attention to the proceedings today. In earlier proceedings, the court notes that he wasn't particularly paying attention. He was looking down, looking away, didn't seem connected at all. Today, in my lay view, he does appear to be more connected to the proceedings, appears to be paying attention to what's going on. Id. at 276-77. After admitting that he is not a physician, the district court judge concluded that everything I observe about [Loughner] seems to connect with the expert testimony that I've heard; that there is reason to be optimistic, that he will recover and be able to assist his lawyers in defending him against this case. Id. at 277. Next, the district court determined the appropriate length of the commitment extension. The court considered Dr. Pietz's request for an additional eight months, as modified from her original request for four months, based on her prior understanding of the statute and case law. Recognizing that [i]t's for me to determine what is a reasonable period of time, the district judge explained that he could not at this point [predict] that it would be four months or eight months. Id. at 278. The court also noted that it was established that if Dr. Pietz or the physicians at FMC-Springfield determined that Loughner was restored to competency before the end of the four-month extension, the court would be notified. Thus, following another district court decision, the district court set a four-month period, with the possibility of granting another extension if necessary. See United States v. Rodriguez-Lopez, No. CR 08-2447, 2010 WL 4339282, at  (D.N.M. Sept. 22, 2010) (Section 4241 provides insight into the measure of a reasonable `additional period of time' by establishing that an initial reasonable period is `not to exceed four months.' The statute appears to contemplate one four-month term followed by another four-month term. (citation omitted)). The district court based its § 4241(d)(2) determination on the credible testimony of both Dr. Pietz and Dr. Ballenger; a reading of all the evidence in the record, including contrary evidence presented by Loughner; and the district judge's own observations. Loughner did not offer any evidence that he could not be restored to competency within four months. We find that the district court considered proper evidence before it and did not clearly err in determining that there was a substantial probability that Loughner would be restored to competency within four months. 3. Trial Competency and Clinical Competency Loughner finally argues that the district court erred in accepting Dr. Ballenger's testimony as a proxy for competency restoration. See Riggins, 504 U.S. at 141, 112 S.Ct. 1810 (Kennedy, J., concurring) (The avowed purpose of the [involuntary] medication is not functional competence, but competence to stand trial.). In the oral ruling on September 28, the district court acknowledged that clinical competence is a proxy, that is a parallel of what's going on here. Restoration in the case of someone in a clinical setting, for all intents and purposes, is the same goal that we have in this case, which is to get somebody functioning again as a human being who understands, appreciates, and assists in the context of the criminal case with the defense of his case. Status Hr'g Tr. 276. Although restoration in the clinical setting may not be the same goal as restoration for trial competency, Dr. Ballenger's testimony was certainly relevant for determining the likelihood of restoration, generally, of signs of an improvement in mental disease (and thus whether Loughner's condition has improved thus far), and the likelihood of restoration given Loughner's current treatment regimen. Thus, the district court did not clearly err in relying on Dr. Ballenger's testimony to support a finding that there was a substantial probability that Loughner would attain the capacity to permit the proceedings to go forward.