Involuntary Medication to Restore Competence to Stand Trial: Sell Applied

Facts of the Case

On October 1, 2003, Dawna Cantrell was arrested and charged with the murder of her husband and two counts of tampering with evidence. Ms. Cantrell's competency was questioned after evaluation by the defense expert, Dr. Eric Westfried. After subsequent evaluation by the state's expert, Dr. Edward Siegel, both experts found that Ms. Cantrell had a “persecutory delusional disorder” and that her mental illness precluded her from assisting her attorney in her defense. The trial court found her incompetent to stand trial and ordered a dangerousness evaluation. Dr. Siegel conducted another evaluation, after Ms. Cantrell had been treated with antidepressant medication, and opined that she was not dangerous and could probably assist her attorney during trial if she were also treated with antipsychotic medication.

In response to Dr. Siegel's report, the court ordered a re-evaluation of competency to be performed by a new forensic evaluator, Dr. Gerald Fredman. He concurred with the previous competency evaluations that Ms. Cantrell was unable to assist her attorney and therefore not competent, but would become competent if treated with antipsychotic medications. The state filed a motion asking for the court to order Ms. Cantrell to submit to a psychiatric examination for the purpose of prescribing antipsychotic medication and restoring her competency. At the hearing on that motion, the court heard contrary testimony from two experts, Dr. Fredman, characterized by the court as an experienced clinical and forensic psychiatrist, and Dr. Westfried, characterized as an experienced research and forensic psychologist.

Dr. Fredman relied on clinical experience and testified that it was “more likely” than not that antipsychotic medication would restore Ms. Cantrell's competency to stand trial and that disabling side effects from said medication would not occur. Dr. Westfried relied on the lack of literature support for antipsychotic medication in treating delusional disorder and testified that, in his opinion, antipsychotic drugs would not help, because they “diminish the frequency and severity of the looseness of associations,” a symptom he did not believe Ms. Cantrell displayed.

The trial court applied the due process guidelines from Sell and found clear and convincing evidence that the state had met the burden for each leg of the Sell test. Ms. Cantrell was ordered to submit to a medication evaluation and take said medication, if medically appropriate. The trial court certified the decision for an interlocutory appeal, sending the matter to the New Mexico Supreme Court.

Ruling and Reasoning

Relying primarily on Washington v. Harper, 494 U.S. 210 (1990), and Sell, the court ruled that the trial court appropriately determined that there was no question of dangerousness that would allow involuntary medication on “Harper-type grounds.” In this case, when involuntary administration of medications would be solely for restoration of competence, the Sell standard was appropriate.

The court then clarified the standards of review for each of the four legs of the Sell test, acknowledging that legal conclusions are reviewed de novo and factual findings are reviewed only for sufficiency of evidence. The first Sell factor is a legal consideration that important governmental interests must be at stake to warrant consideration of involuntary medication.

The second Sell factor directs, “the court must conclude that involuntary medication will significantly further concomitant state interests” and be “substantially likely” to restore competency and “substantially unlikely” to cause side effects that would prevent the defendant from assisting counsel (Sell, pp 180–1). Here, the court acknowledged that the Second and Fourth Federal Circuit Courts of Appeals have interpreted this factor as a factual issue (in United States v. Gomes, 387 F.3d 157 (2d. Cir. 2004) and United States v. Evans, 404 F.3d 227 (4th Cir. 2005)), while the Tenth Circuit interpreted it as a legal issue (in United States v. Bradley, 417 F.3d 1107 (10th Cir. 2005) and United States v. Valenzuela-Puentes, 479 F.3d 1220 (10th Cir. 2007)). The court clarified that the second Sell factor is therefore a mixed question of law and fact. This interpretation requires the appellate court to review the trial court's factual finding for sufficiency of evidence and then to determine, de novo, whether the facts meet the legal standards.

The third Sell factor requires the court to find that involuntary medications are necessary to further the state's interest, and the fourth factor requires that proposed treatment be in the defendant's best medical interest. Both these factors are questions of fact, the court explained, and are best determined by the trial court. The court also supported precedent that Sell factors must be satisfied by clear and convincing evidence.

In light of these clarifications, the court found that the first and third factors were not in dispute. On the second Sell factor, the court found that Dr. Fredman's testimony that adding antipsychotic medication to Ms. Cantrell's treatment would “more likely than not” render her competent did satisfy the state's burden, as the trial court had found this testimony factual. On the fourth factor, the court also ruled that there was significant evidence, based on Dr. Fredman's testimony, that the antipsychotic treatment was medically appropriate. The trial court's order was therefore affirmed.

Discussion

An individual's “significant liberty interest in avoiding the unwanted administration of antipsychotic drugs under the Due Process Clause of the Fourteenth Amendment” was established in Washington v. Harper, 494 U.S. at 221–2. The Due Process Clause prohibits deprivation of that liberty interest unless certain conditions are met. While Harper sets out minimum due process requirements for dangerousness to be an avenue through which the government can medicate an individual over his or her objection, there are certain other compelling state interests in which involuntary antipsychotic medication may be warranted.

In Sell v. United States, the United States Supreme Court delineated due process requirements for the instances in which involuntary medication was necessary to render an otherwise nondangerous defendant competent to stand trial. Justice Breyer's opinion in Sell left little doubt that the Court hoped these instances would be “rare” (Sell, p 180) and could be avoided if “forced medication is warranted for a different purpose” (Sell, p 182). As such, the Court was cautious in providing much guidance in applying what have become known as the Sell criteria.

New Mexico v. Cantrell is noteworthy for the New Mexico Supreme Court's having settled an inconsistency in prior Sell cases as to how appeals of the second Sell criterion should be reviewed (although it remains to be seen if other courts, particularly Federal courts, will agree with their solution). Here, the court concluded that the second Sell criterion is a “mixed question of law and fact,” that is: …[Q]uestions in which the historical facts are admitted or established, the rule of law is undisputed, and the issue is whether the facts satisfy the statutory standard, or to put it another way, whether the rule of law as applied to the established facts is or is not violated [Pullman-Standard v. Swint, 456 U.S. 273, 289 (1982)].

Essentially, if the second Sell criterion is a “mixed question of law and fact,” then the appellate court will determine if the trial court erred in determining that the expert testimony was factual and then determine if that factual testimony meets the evidentiary burden that the involuntary medication is “substantially likely” to make the defendant competent to stand trial and “substantially unlikely” to have side effects that would hinder the defendant in assisting counsel.

What is left unclear for forensic psychiatrists, despite the court's agreeing with precedent that the evidentiary standard in all factors of Sell cases is clear and convincing evidence and the interpretation of the second criterion as above, is what “substantially likely” or “substantially unlikely” mean on a psychiatric level. The court did acknowledge that setting a number or percentage level of confidence to “substantial” risks inviting experts to tailor their testimonies to the desired result. The court seemed satisfied with the trial court's interpretation that, “whether the percentages are twenty percent or thirty percent or ten percent, is not for me to decide, there's just whether there's substantial unlikely [sic] to have side affects [sic]: (Cantrell, p 1222). It remains to be seen whether courts outside of New Mexico will also be satisfied with these interpretations of Sell.