By Eric Jones

On July 17, 2015, the Fourth Circuit issued a published opinion in the criminal case United States v. Watson.  John Watson, Jr. appealed to the Circuit asking that an order to forcibly medicate him with antipsychotics in order to render him competent to stand trial be reversed.  Because the government failed to establish by clear and convincing evidence that the involuntary medication was substantially likely to restore Watson’s competency, the Fourth Circuit reversed without remand.

The Attempted Destruction of an Aircraft and Medical Opinions

On September 28, 2012, Watson fired a handgun at a Coast Guard helicopter as it flew overhead.  The helicopter was undamaged, and none of the crew members were injured.  After his arrest, Watson was interviewed by a clinical psychologist and informed her that he was a covert operative for the British Special Forces, and had been since he was seven years old.  Watson believed that as a covert operative for the United Kingdom, he was entitled to diplomatic immunity.  It was concluded that Watson was incompetent to stand trial, and he was later diagnosed with Delusional Disorder, Persecutory Type, which is a rare mental illness characterized by the presence of one or more delusions that persist for at least a month.

Watson had never been medicated before, but an expert for the government nevertheless believed that antipsychotic medicine had a good chance of rendering him competent.  This opinion was based on the expert’s prior experience with psychotic patients, and the existing literature on the efficacy of antipsychotics.  Defense expert Dr. James H. Hilkey argued that there was very little existing literature involving double-blind studies on the efficacy of pharmacological treatment of Delusional Disorders.  Hilkey further argued that the Persecutory Type of the disorder was the most resistant to treatment, and opined that the chronic nature of Watson’s illness made treatment less likely to succeed.  Both experts agreed that Watson was not likely to be a threat to himself or to others, given the nature of his delusions.

The Standard for Forcible Medication

If a defendant is not a threat to himself or others, four factors laid out in the Supreme Court case Sell v. United States, 539 U.S. 166 (2003) must be met before he can be forcibly medicated for the sole purpose of rendering him competent to stand trial.  It is important to note that this is an exceptional and rare solution, and is granted only with significant vigilance because of the inherent deprivation of liberty that accompanies the administration of medication which alters the will and mind of the subject.  Each element must be shown by clear and convincing evidence.  First, the government must show that important governmental interests are at stake, and that special circumstances do not mitigate those interests.  Second, the government must show that involuntary medication significantly furthers those interests, which requires proof that the medication is substantially likely to render the defendant competent as well as that it is substantially unlikely to have side effects that will interfere with the defendant’s ability to assist counsel.  Third, the medication must be necessary to further the government’s interests, and less intrusive means must be unlikely to achieve the same results.  Fourth, the court must find that the administration of the drugs is medically appropriate and is in the defendant’s best medical interests.

A magistrate judge recommended that Watson be forcibly medicated, relying on the government’s expert and disregarding Hilkey’s testimony.  The District Court for the Eastern District of Virginia issued a brief order adopting the magistrate’s recommendations, and granting the government’s motion for involuntary medication.  This appeal followed.

The Likelihood of Forcible Medication to Render Watson Competent

The result in this appeal turned on the second prong of the Sell test—whether forcible medication was substantially likely to render Watson competent to stand trial.  In order to support this finding, the Fourth Circuit noted that the proposed treatment plan must be effective for this particular patient, and not simply that it is a generally effective treatment for the medical condition at issue.  In this case, the government’s expert opined that the treatment was likely to be successful based only on his own previous patients and on medical literature. Notably absent was any consideration of Watson’s particular circumstances or condition.  The Fourth Circuit explained that the extraordinary nature of forcible medication requires such particular and specific consideration, and thus held that the District Court had erred.

The Government Could Not Meet Their Burden on the Existing Record

Generally, an appellate court will remand for further consideration in cases similar to this.  Here, the Fourth Circuit took the rare position that a remand would be inappropriate because the burden could not be met by the government.  As explained above, the Circuit examined the evidence offered by the government and found it to be severely lacking.  Upon consideration of Hilkey’s testimony, the Fourth Circuit further held that the clear and convincing standard could not possibly be met.  Hilkey’s arguments focused extensively on Watson’s particular circumstances, and largely discredited the government’s evidence.  For instance, many of the studies cited dealt with psychotic disorders in general, and not delusional disorders in particular.  Furthermore, these studies showed questionable success rates at best with antipsychotic medication, especially in patients with Watson’s illness.  Additionally, based on Watson’s persecutory and paranoid delusions, Hilkey concluded that forcible medication was likely to increase Watson’s fears of persecution.  Given the concerns raised by Hilkey, the total lack of support offered by the government, and the fact that the standard had been established over a decade ago, the Fourth Circuit held that a remand would be ineffective and inappropriate.

The Fourth Circuit Reversed without Remand

One judge dissented, arguing that the standard was met, and that even if it was not, the case should be remanded rather than simply reversed outright.  However, because forcible medication was not substantially likely to render Watson competent, the Fourth Circuit reversed the District Court.  Furthermore, because the Circuit held that the standard could not be met given the facts in this case, the Court refused to remand.