Let’s review the facts of the case. Dr. Sell is a 52-year-old, twice-married, white, male dentist charged with 56 counts of mail fraud, six counts of Medicaid fraud, one count of money laundering and two counts of conspiracy to commit murder and witness tampering. He was initially arrested in 1997 on the fraud charges and released on bond. In 1998 bond was revoked because of the new charges, and since then he has been incarcerated primarily in the Medical Center for Federal Prisoners at Springfield, MO.

The clinical history revealed that Dr. Sell has a 21-year history of intermittent contact with mental health professionals, most often related to pronounced paranoid delusions, some olfactory, auditory and visual hallucinations, and bizarre behavior related to these psychotic experiences.

While in custody, Dr. Sell had two competency evaluations by the government and two by a psychiatrist hired by the defense. He was found incompetent in the last three of the four evaluations, with diagnoses as follows:

Axis I: Delusional disorder, persecutory type (plus major depressive disorder, recurrent, by private psychiatrist)
Axis II: Personality disorder (paranoid, or borderline with prominent paranoid features)

The mental health professionals opined that mental illness has rendered Dr. Sell unable to assist his attorney in his own defense and that he does not have a rational and factual understanding of the crime with which he is charged.

The court found that Dr. Sell is incompetent to stand trial and ordered him into the custody of the attorney general for the purpose of hospitalization and treatment to restore him to competence.

The attending psychiatrist determined that antipsychotic medication is the only treatment by which the defendant is likely to be restored to competence. However, Dr. Sell appealed that clinical finding and has refused voluntary treatment.

An administrative due process hearing was held and involuntary medication was determined to be medically appropriate and necessary for restoration of competence.

Before the defendant was involuntary medicated, he filed an appeal that over four years made its way through the lower courts, all of them finding in favor of the government. On March 3, 2003, the case was argued before the Supreme Court.

Legal Guidance
This case involves multiple legal, medical and ethical dilemmas. Some guidance may be found in federal statutes that govern the evaluation, treatment and confinement of defendants with possible mental illness (see Title 18, US Code, §4241-4247). Bottom line: All individuals committed to the custody of the attorney general for mental health evaluation or treatment are still accorded due process prior to the administration of involuntary medication.

In addition, the legal background in which any particular case is viewed is based on preceding cases, regardless of the time that has passed since those cases were settled and regardless of how science, society or any other factors may have changed.

Over the last 30 years, case law (see Washington v. Harper, Riggins v. Nevada, US v. Brandon and US v. Weston) has established that for the government to involuntary medicate an individual, it must show three things:

1. There is an essential government interest that outweighs the individual’s liberty interest in remaining free of unwanted intrusions (medication).
2. There is no less restrictive or intrusive means to achieve the government’s interest.
3. Medication is medically appropriate for the individual’s condition.

The Defendant’s Argument
The defendant contends that administration of “medication against his will solely to render him competent to stand trial for nonviolent offenses would violate his rights under the First, Fifth and Sixth Amendments.”

Six amicus briefs were filed on behalf of the defendant. Some excerpts:
“...the rights to liberty, bodily integrity, freedom of thought and privacy are fundamental rights....”
“Dr. Sell has fundamental trial rights...not to be medicated into drug-induced, synthetic sanity.... In a case where diminished capacity is raised as a defense, the jury must assess their belief about the defendant’s mental state at the time the crime occurred.... The accused, sitting in the courtroom drugged and listless, becomes an instrument of his own conviction....”

The defendant’s side also argued that “[a]ntipsychotic medications are potent, mind-altering drugs with the potential for severe, irreversible, and even deadly side effects.... They] do not cure illnesses; they simply suppress symptoms....” He further argues that the government wants to medicate Dr. Sell only so that it can bring him to trial.

An amicus brief from the American Psychological Association repeats the defendant’s constitutional arguments, but also provides a more balanced look at the issue of antipsychotic medication. It mentions that antipsychotics are very effective, and even while espousing the benefits of nondrug therapies it notes that they are not likely to be effective in Dr. Sell’s case.

The Government’s Argument
To summarize the government’s argument, it said that it has a compelling interest in adjudicating serious criminal charges, but since an incompetent defendant cannot be brought to trial, the government has an essential interest in making efforts to restore competence.

The government emphasized the devastating effects of untreated psychosis and noted the ability to manage side effects of antipsychotics through dosage changes, medication changes or the addition of other medications to treat side effects.

The government also argued that the impact of medication on the defendant’s right to a fair trial can be determined only after the treatment, not before. Further, the defendant does not have a right to appear before the court in the same state of mind that he was in before commission of the crime.

An amicus brief from the American Psychiatric Association aimed in part to “ensure that the court has well-grounded facts about antipsychotic medications...and appreciates the adverse consequences...of not giving ...the medically appropriate treatment for psychotic illnesses....”

The Court’s Decision
An argument before the Supreme Court is a relatively civilized (though adversarial), much rehearsed and painfully abbreviated presentation of exceedingly complex social, legal and moral issues. And the decision has the potential to have profound, far-reaching, long-term ramifications.

In Sell v. USA, the Supreme Court’s holding is as follows: The government may involuntary medicate a nondangerous pretrial detainee solely for the purpose of restoring to competency to stand trial when...

1. The treatment is medically appropriate (that is, in the patient’s best medical interest).
2. It is proven that the treatment is substantially likely to restore competency, and that it is substantially unlikely to have side effects that would undermine the fairness of the criminal trial.
3. Compared to less intrusive means, the treatment furthers an important government interest, considering factors such as the seriousness of the alleged crime and any special circumstances that lessen the importance of the government interest.

The dissenting opinion of three justices strongly stated that since this case involved an interlocutory order (an interim order that decides only a part of the case without necessarily deciding the entire litigation),  the Court of Appeals and the Supreme Court do not have jurisdiction until after adjudication of the criminal case by the lower court.

In light of the Supreme Court decision, the government will have to again bring the issue of involuntary medication before the lower court. If it is eventually determined that one or more of the above conditions are not met, then the government has several options:

• It can pursue its responsibility under §4246 to evaluate Dr. Sell for dangerousness, which is likely to result in his indefinite commitment to the Bureau of Prisons. It can later pursue adjudication of the fraud charges if he ever recovers to the extent that he becomes competent to stand trial.

• It can pursue the conspiracy to commit murder charges. Under these charges, it is likely that the government would meet the compelling interest necessary to involuntarily medicate Dr. Sell and bring him to trial.

While the outcome of the trial cannot be predicted, typically the presence of a delusional disorder does not preclude an individual from having the capacity to understand the wrongfulness of his actions or the ability to conform his actions. If that were to be found in ths case, he could be found guilty. Upon expiration of his sentence he would likely still be mentally ill and may satisfy the criteria for commitment under §4246.