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7/23/2003

Supreme Court Limits Use of Forced Medications for Criminal Defendants

Donna Young

In a June 16 ruling, the Supreme Court held that the Constitution permits the government to forcibly administer antipsychotic drugs to a mentally ill criminal defendant, but restricted the circumstances in which those drugs could be used against a defendant’s will.

The ruling vacated decisions by three lower federal courts in the case of Charles T. Sell, a St. Louis, Missouri, dentist who was judged incompetent to stand trial for charges of Medicaid and mail fraud. Sell had refused to take antipsychotic drugs as ordered by a federal magistrate in 2000.

In a 6 to 3 ruling, the Supreme Court set guidelines to ensure that there is a balance between the government’s interest in bringing to trial an individual accused of a serious crime and the interests of a defendant in receiving proper medical and psychological care.

A court must find that the use of antipsychotic drugs is “substantially likely to render the defendant competent to stand trial” and that the administration of those 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, thereby rendering the trial unfair,” the court said in an opinion written by Justice Stephen G. Breyer.

Before a court can order the administration of antipsychotic drugs to a defendant against his or her will, it must find that “any alternative, less intrusive treatments are unlikely to achieve substantially the same results,” the court ruled.

Courts must also consider less intrusive means for administering the drugs before considering more intrusive methods.

Administration of drugs must also be in “the patient’s best medical interest in light of his medical condition,” the court held.

The Supreme Court’s decision forces courts to rely on their ability to know the expected benefit and expected adverse effects of a particular antipsychotic drug, said David Brushwood, an attorney and pharmacy health care administration professor at the University of Florida’s College of Pharmacy at Gainesville.

“This is where law and science interface,” he said.

“Certainly what the court says is that the ability to predict how a medication will work for an individual patient is the crux of the issue,” he said.

Before a court can decide whether to forcibly medicate a defendant, he explained, it must first know the identity of the drug, the effect the drug is expected to have on the patient, and the likely adverse effects on the patient. “So what is required is that someone do an assessment of how medications have been used in patients previously,” Brushwood said.

Evidence needs to show, he added, that there is a reasonable probability that an antipsychotic drug will be effective for the defendant and that adverse effects will not interfere with the defendant’s ability to stand trial.

“The answer isn’t to forcibly medicate the patient so that it incapacitates him,” Brushwood said. “He can’t be so sedated that he is not able to participate. The whole idea is that he has the right to participate in his own defense and understand the charges. The government’s goal is to enable the defendant to participate and to remove behaviors and other factors that make it impossible for the defendant to stand trial without creating new factors.”

Only with good pharmacotherapeutic advice, Brushwood said, can a court make a good legal decision about the forced use of medications.

Pharmacists, he added, could be potential sources to provide that advice.

Pharmacist Joseph L. Fink III, a professor at the University of Kentucky and an attorney, said the court’s ruling “came down on the side of the individual” by vacating the lower courts’ rulings.

“This is one more reflection of the general principle that we have with us in the United States, since the founding of the country, that individual freedoms are exalted above governmental interference with those freedoms,” he said. “This case is consistent with a long flow of court decisions in a variety of areas that emphasize the rights of the individual vis-a-vis the rights of the government.”

Sell’s attorney, Fink said, made a “preemptive strike” by appealing the federal magistrate’s order authorizing the involuntary administration of antipsychotic drugs to Sell.

“The lawyer took the bull by the horns and raised the issue,” he said. “And it worked, and individual rights prevailed.”

Idaho attorney Samuel A. Hoagland, adjunct professor of pharmacy law at Idaho State University School of Pharmacy in Pocatello, said the Supreme Court’s ruling in the Sell case “didn’t advance the ball very far down the field.”

The case to watch, he said, is a pending appeal to the high court of a February 10 ruling from the U.S. Court of Appeals for the 8th Circuit that approved the forcible administration of medication for a death row inmate, Charles Laverne Singleton, to make him competent to be executed.

“Singleton argued that it was not in his best medical interest to be competent to be executed,” Hoagland said. “But he also argued that dying was not in his best medical interest.”