U.S. Supreme Court Ruling Affirms Strict Criteria for Involuntary Medication of Defendants to Gain Competency

A decision in June by the U.S. Supreme Court will limit prosecutors' efforts to forcibly medicate most psychotic criminal defendants in order to render them competent to stand trial. In a 6 to 3 ruling, the justices said that antipsychotic drugs can be used only in "limited circumstances," and they set specific criteria that lower courts must follow in determining whether defendants can be medicated against their will.

The case involves Thomas Sell, a dentist who was accused in 1997 of Medicaid fraud and money laundering and was further charged in 1998 for conspiring while free on bond to kill a witness and the FBI agent who arrested him. Sell, who had a history of mental illness, was subsequently diagnosed as having a delusional disorder of the persecutory type and deemed incompetent to stand trial. The lower court ordered that, although Sell may not be a danger to himself or others, he should be treated with antipsychotic medication to help him gain the capacity to stand trial. Sell challenged this ruling, asserting that he has the constitutional right to refuse medication. An appeals court upheld the ruling, and Sell has spent the past five years in jail, including 20 months in solitary confinement, and in prison hospitals while the case worked its way through the legal system.

The Supreme Court was asked to clarify the circumstances in which a criminal defendant who is legally incompetent to stand trial but who is competent to make personal medical decisions, including the decision to refuse antipsychotic medication, and who is not dangerous to himself or others can be involuntarily medicated. Justice Stephen Breyer, writing for the majority, stated that the lower courts were wrong in approving forced medication solely to render Sell competent to stand trial and that other criteria must be met, which the Court noted that it had already explicated in previous rulings. Breyer wrote that the government had not met its burden of showing a "compelling interest" in trying the defendant or "a need for treatment sufficiently important to overcome the individual's protected interest in refusing it."

The Supreme Court's ruling means that the trial court must now reconsider its decision in light of the other criteria. First, "special circumstances" must be considered when the government seeks to show that it has an "important interest" in bringing a defendant to trial. In Sell's case, his already lengthy confinement could constitute such a circumstance. Second, the government must show that "medication is substantially likely to render the defendant competent to stand trial and substantially unlikely to have side effects that will interfere significantly with the defendant's ability to assist counsel in conducting a defense." Third, a court must conclude that "less-intrusive treatments are unlikely to achieve substantially the same result." Finally, the medication at issue must be "medically appropriate" treatment for the defendant's mental illness.

The American Psychiatric Association filed a brief for the government, arguing that medications that restore a defendant to competency are often the most medically appropriate way of treating the mental illness. "The court should not ignore the real costs of leaving a defendant untreated," the brief noted.

In the wake of the ruling, the Justice Department released figures showing that every year hundreds of defendants facing federal charges are medicated—most of them willingly—and that a majority become competent to stand trial. In a recent one-year period, about 80 percent of 285 defendants voluntarily accepted medication. Of the 59 people who were treated against their will, about three-quarters were rendered competent.

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