certiorari to the supreme court of nevada Argued January 15, 1992—Decided May 18, 1992 When petitioner Riggins, while awaiting a Nevada trial on murder and robbery charges, complained of hearing voices and having sleep prob-lems, a psychiatrist prescribed the antipsychotic drug Mellaril.
he was found competent to stand trial, Riggins made a motion to sus-pend the Mellaril’s administration until after his trial, arguing that itsuse infringed upon his freedom, that its effect on his demeanor andmental state during trial would deny him due process, and that he hadthe right to show jurors his true mental state when he offered an insan-ity defense.
After hearing the testimony of doctors who had examined Riggins, the trial court denied the motion with a one-page order givingno indication of its rationale.
At Riggins’ trial, he presented his insan- ity defense and testified, was convicted, and was sentenced to death.
In affirming, the State Supreme Court held, inter alia, that expert testi-mony presented at trial was sufficient to inform the jury of the Mellaril’seffect on Riggins’ demeanor and testimony.
Held: The forced administration of antipsychotic medication during Rig- gins’ trial violated rights guaranteed by the Sixth and FourteenthAmendments.
(a) The record narrowly defines the issues in this case.
tion of Mellaril was involuntary once Riggins’ motion to terminate itsuse was denied, but its administration was medically appropriate.
addition, Riggins’ Eighth Amendment argument that the drug’s ad-ministration denied him the opportunity to show jurors his true men-tal condition at the sentencing hearing was not raised below or in thepetition for certiorari and, thus, will not be considered by this Court.
P. 133.
(b) A pretrial detainee has an interest in avoiding involuntary admin- istration of antipsychotic drugs that is protected under the Due ProcessClause.
Cf. Washington v. Harper, 494 U. S. 210; Bell v. Wolfish, 441 Once Riggins moved to terminate his treatment, the State became obligated to establish both the need for Mellaril and itsmedical appropriateness.
tainly would have been satisfied had the State shown that the treatmentwas medically appropriate and, considering less intrusive alternatives,essential for Riggins’ own safety or the safety of others.
also might have been able to justify the treatment, if medically appro- priate, by showing that an adjudication of guilt or innocence could notbe obtained by using less intrusive means.
allowed the drug’s administration to continue without making any de-termination of the need for this course or any findings about reasonablealternatives, and it failed to acknowledge Riggins’ liberty interest infreedom from antipsychotic drugs.
(c) There is a strong possibility that the trial court’s error impaired Riggins’ constitutionally protected trial rights.
disprove actual prejudice from the record before this Court would befutile, and guesses as to the trial’s outcome had Riggins’ motion beengranted would be speculative.
ing Mellaril upon him cannot be shown from a trial transcript, the tes-timony of doctors who examined Riggins establishes the strong possi-bility that his defense was impaired.
impacted not only his outward appearance, but also his testimony’s con-tent, his ability to follow the proceedings, or the substance of his com-munication with counsel.
Thus, even if the expert testimony presented at trial allowed jurors to assess Riggins’ demeanor fairly, an unaccept-able risk remained that forced medication compromised his trial rights.
Pp. 137–138.
(d) While trial prejudice can sometimes be justified by an essential state interest, the record here contains no finding to support a conclu-sion that administration of antipsychotic medication was necessary toaccomplish an essential state policy.
107 Nev. 178, 808 P. 2d 535, reversed and remanded.
O’Connor, J., delivered the opinion of the Court, in which Rehnquist, C. J., and White, Blackmun, Stevens, and Souter, JJ., joined.
filed an opinion concurring in the judgment, post, p. 138.
Thomas, J., filed a dissenting opinion, in which Scalia, J., joined exceptas to Part II–A, post, p. 146.
Mace J. Yampolsky argued the cause for petitioner.
him on the briefs were Jay Topkis, Neal H. Klausner, andSteven C. Herzog. James Tufteland argued the cause for respondent.
*Briefs of amici curiae urging reversal were filed for the Coalition for Fundamental Rights of Equality of Ex-patients by Peter Margulies, Her-bert Semmel, and Patrick Reilly; for the National Association of Criminal Justice O’Connor delivered the opinion of the Court.
Petitioner David Riggins challenges his murder and rob- bery convictions on the ground that the State of Nevada un-constitutionally forced an antipsychotic drug upon him dur-ing trial.
Because the Nevada courts failed to make findings sufficient to support forced administration of the drug, wereverse.
During the early hours of November 20, 1987, Paul Wade was found dead in his Las Vegas apartment.
revealed that Wade died from multiple stab wounds, includ-ing wounds to the head, chest, and back.
arrested for the killing 45 hours later.
A few days after being taken into custody, Riggins told Dr. R. Edward Quass, a private psychiatrist who treated pa-tients at the Clark County Jail, about hearing voices in hishead and having trouble sleeping.
Quass that he had been successfully treated with Mellarilin the past.
Mellaril is the trade name for thioridazine, an scribed Mellaril at a level of 100 milligrams per day.
cause Riggins continued to complain of voices and sleep prob-lems in the following months, Dr. Quass gradually increasedthe Mellaril prescription to 800 milligrams per day.
also received a prescription for Dilantin, an antiepilepticdrug.
In January 1988, Riggins successfully moved for a deter- mination of his competence to stand trial.
Defense Lawyers by David M. Eldridge; and for Nevada Attorneys forCriminal Justice by Kevin M. Kelly. Briefs of amici curiae were filed for the State of Louisiana et al. by William J. Guste, Jr., Attorney General of Louisiana, and M. PatriciaJones and Kathleen E. Petersen, Assistant Attorneys General, and by theAttorneys General for their respective States as follows: Charles M. Ob-erly III of Delaware and Michael E. Carpenter of Maine; and for theAmerican Psychiatric Association by Richard G. Taranto and Joel I. Klein. court-appointed psychiatrists performed examinations dur-ing February and March, while Riggins was taking 450 milli-grams of Mellaril daily.
trist who had treated Riggins for anxiety in 1982, and Dr.
Franklin Master concluded that Riggins was competent tostand trial.
The third psychiatrist, Dr. Jack Jurasky, found Court determined that Riggins was legally sane and compe-tent to stand trial, id., at 13, so preparations for trial wentforward.
In early June, the defense moved the District Court for an order suspending administration of Mellaril and Dilantinuntil the end of Riggins’ trial.
the Fourteenth Amendment and the Nevada Constitution,Riggins argued that continued administration of these drugsinfringed upon his freedom and that the drugs’ effect on hisdemeanor and mental state during trial would deny him dueprocess.
Riggins also asserted that, because he would offer an insanity defense at trial, he had a right to show jurors his“true mental state.” noted that Nevada law prohibits the trial of incompetentpersons, see Nev. Rev. Stat. § 178.400 (1989), and arguedthat the court therefore had authority to compel Riggins totake medication necessary to ensure his competence.
On July 14, 1988, the District Court held an evidentiary “guess[ed]” that taking Riggins off medication would not no-ticeably alter his behavior or render him incompetent tostand trial.
opinion, Riggins would be competent to stand trial evenwithout the administration of Mellaril, but that the effectsof Mellaril would not be noticeable to jurors if medicationcontinued.
court that Mellaril made the defendant calmer and more re- laxed but that an excessive dose would cause drowsiness.
Id., at 464–466.
Riggins might behave if taken off antipsychotic medication,yet he questioned the need to give Riggins the high dose hewas receiving.
it a written report in which Dr. Jurasky held to his earlierview that Riggins was incompetent to stand trial and pre-dicted that if taken off Mellaril the defendant “would mostlikely regress to a manifest psychosis and become extremelydifficult to manage.” The District Court denied Riggins’ motion to terminate medication with a one-page order that gave no indication ofthe court’s rationale.
ceive 800 milligrams of Mellaril each day through the comple-tion of his trial the following November.
At trial, Riggins presented an insanity defense and testi- Wade’s death he used cocaine before going to Wade’s apart-ment.
Riggins admitted fighting with Wade, but claimed that Wade was trying to kill him and that voices in his headsaid that killing Wade would be justifiable homicide.
found Riggins guilty of murder with use of a deadly weaponand robbery with use of a deadly weapon.
hearing, the same jury set the murder sentence at death.
Riggins presented several claims to the Nevada Supreme Court, among them that forced administration of Mellaril de-nied him the ability to assist in his own defense and prejudi-cially affected his attitude, appearance, and demeanor attrial.
This prejudice was not justified, Riggins said in his opening brief, because the State neither demonstrated aneed to administer Mellaril nor explored alternatives to giv-ing him 800 milligrams of the drug each day.
Riggins amplified this claim in his reply brief, objecting thatthe State intruded upon his constitutionally protected lib- erty interest in freedom from antipsychotic drugs withoutconsidering less intrusive options.
“In United States v. Bryant, 670 F. Supp. 840, 843 (Minn. 1987)[,] the court, in reference to medicating pris-oners against their will, stated that ‘courts have recog-nized a protectable liberty interest . . . in the freedomto avoid unwanted medication with such drugs.’ court in so stating cited Bee v. Greaves, 744 F. 2d 1387(10th Cir. 1984)[,] which addressed the issue of medicat-ing pre-trial detainees and stated that ‘less restrictivealternatives, such as segregation or the use of less con-troversial drugs like tranquilizers or sedatives, shouldbe ruled out before resorting to antipsychotic drugs.’In the case at bar, no less restrictive alternatives wereutilized, considered or even proposed.” The Nevada Supreme Court affirmed Riggins’ convictions With respect to administration of Mellaril, the court heldthat expert testimony presented at trial “was sufficient toinform the jury of the effect of the Mellaril on Riggins’ de-meanor and testimony.” Id., at 181, 808 P. 2d, at 538.
although Riggins’ demeanor was relevant to his insanity de-fense, the court held that denial of the defense’s motion toterminate medication was neither an abuse of discretion nora violation of Riggins’ trial rights.
Justice Rose suggested that the District Court should havedetermined whether administration of Mellaril during trialwas “absolutely necessary” by ordering a pretrial suspensionof medication.
Id., at 185, 808 P. 2d, at 540 (concurring opin- Justice Springer dissented, arguing that antipsychotic drugs may never be forced on a criminal defendant solely toallow prosecution.
Id., at 186, 808 P. 2d, at 541.
We granted certiorari, 502 U. S. 807 (1991), to decide whether forced administration of antipsychotic medication during trial violated rights guaranteed by the Sixth andFourteenth Amendments.
The record in this case narrowly defines the issues before The parties have indicated that once the District Court denied Riggins’ motion to terminate use of Mellaril, subse-quent administration of the drug was involuntary.
Brief for Petitioner 6 (medication was “forced”); Brief forRespondent 14, 22, 28 (describing medication as “unwanted,”“over objection,” and “compelled”).
cords with the determination of the Nevada Supreme Court.
See 107 Nev., at 181; 808 P. 2d, at 537 (describing medicationas “involuntary” and “forced”).
on this point and the absence of any record evidence to thecontrary, we adhere to the understanding of the State Su-preme Court.
We also presume that administration of Mellaril was medi- Riggins received a very high dose of the drug, at no pointdid he suggest to the Nevada courts that administration ofMellaril was medically improper treatment for his client.
Finally, the record is dispositive with respect to Riggins’ Eighth Amendment claim that administration of Mellaril de-nied him an opportunity to show jurors his true mental con-dition at the sentencing hearing.
was presented neither to the Nevada Supreme Court norin Riggins’ petition for certiorari, we do not address it here.
With these considerations in mind, we turn to Riggins’ core contention that involuntary administration of Mellarildenied him “a full and fair trial.” discussion in Washington v. Harper, 494 U. S. 210 (1990),provides useful background for evaluating this claim.
Harper, a prison inmate alleged that the State of Washingtonand various individuals violated his right to due process bygiving him Mellaril and other antipsychotic drugs against hiswill.
Although the inmate did not prevail, we agreed that his interest in avoiding involuntary administration of anti-psychotic drugs was protected under the Fourteenth Amend-ment’s Due Process Clause.
medication into a nonconsenting person’s body,” we said,“represents a substantial interference with that person’s lib-erty.” Mellaril, that interference is particularly severe: “The purpose of the drugs is to alter the chemical bal-ance in a patient’s brain, leading to changes, intended tobe beneficial, in his or her cognitive processes.
the therapeutic benefits of antipsychotic drugs are welldocumented, it is also true that the drugs can have seri-ous, even fatal, side effects.
fied by the trial court is acute dystonia, a severe involun-tary spasm of the upper body, tongue, throat, or eyes.
The trial court found that it may be treated and re-versed within a few minutes through use of the medi-cation Cogentin.
(motor restlessness, often characterized by an inabilityto sit still); neuroleptic malignant syndrome (a relativelyrare condition which can lead to death from cardiac dys-function); and tardive dyskinesia, perhaps the most dis-cussed side effect of antipsychotic drugs.
kinesia is a neurological disorder, irreversible in somecases, that is characterized by involuntary, uncontrolla-ble movements of various muscles, especially around theface. . . . [T]he proportion of patients treated with anti-psychotic drugs who exhibit the symptoms of tardivedyskinesia ranges from 10% to 25%.
American Psychiatric Association, studies of the condi-tion indicate that 60% of tardive dyskinesia is mild orminimal in effect, and about 10% may be characterizedas severe.” Id., at 229–230 (citations omitted).
Taking account of the unique circumstances of penal con-finement, however, we determined that due process allows a mentally ill inmate to be treated involuntarily with antipsy-chotic drugs where there is a determination that “the inmateis dangerous to himself or others and the treatment is in theinmate’s medical interest.” Under Harper, forcing antipsychotic drugs on a convicted prisoner is impermissible absent a finding of overridingjustification and a determination of medical appropriateness.
The Fourteenth Amendment affords at least as much pro-tection to persons the State detains for trial.
Wolfish, 441 U. S. 520, 545 (1979) (“[P]retrial detainees, whohave not been convicted of any crimes, retain at least thoseconstitutional rights that we have held are enjoyed by con-victed prisoners”); O’Lone v. Estate of Shabazz, 482 U. S. 342,349 (1987) (“[P]rison regulations . . . are judged under a‘reasonableness’ test less restrictive than that ordinarily ap-plied to alleged infringements of fundamental constitutionalrights”).
Thus, once Riggins moved to terminate adminis- tration of antipsychotic medication, the State became obli-gated to establish the need for Mellaril and the medicalappropriateness of the drug.
Although we have not had occasion to develop substantive standards for judging forced administration of such drugs inthe trial or pretrial settings, Nevada certainly would havesatisfied due process if the prosecution had demonstrated,and the District Court had found, that treatment with anti-psychotic medication was medically appropriate and, consid-ering less intrusive alternatives, essential for the sake ofRiggins’ own safety or the safety of others.
supra, at 225–226; cf. Addington v. Texas, 441 U. S. 418(1979) (Due Process Clause allows civil commitment of indi-viduals shown by clear and convincing evidence to be men-tally ill and dangerous).
been able to justify medically appropriate, involuntary treat-ment with the drug by establishing that it could not obtainan adjudication of Riggins’ guilt or innocence by using lessintrusive means.
See Illinois v. Allen, 397 U. S. 337, 347 (1970) (Brennan, J., concurring) (“Constitutional power tobring an accused to trial is fundamental to a scheme of ‘or-dered liberty’ and prerequisite to social justice and peace”).
We note that during the July 14 hearing Riggins did notcontend that he had the right to be tried without Mellaril ifits discontinuation rendered him incompetent.
nal defendant may refuse antipsychotic medication if cessa-tion of medication would render him incompetent at trial isnot before us.
Contrary to the dissent’s understanding, we do not “adopt occasion to finally prescribe such substantive standards asmentioned above, since the District Court allowed admin-istration of Mellaril to continue without making any deter-mination of the need for this course or any findings aboutreasonable alternatives.
Riggins’ motion did not adopt the State’s view, which wasthat continued administration of Mellaril was required to en-sure that the defendant could be tried; in fact, the hearingtestimony casts considerable doubt on that argument.
Nor did the order indicate a finding that safety considerations or other compelling concerns out-weighed Riggins’ interest in freedom from unwanted anti-psychotic drugs.
Were we to divine the District Court’s logic from the hear- ing transcript, we would have to conclude that the court sim-ply weighed the risk that the defense would be prejudicedby changes in Riggins’ outward appearance against thechance that Riggins would become incompetent if taken offMellaril, and struck the balance in favor of involuntary medi-cation.
See Record 502 (“[T]hat he was nervous and so forth . . . can all be brought out [through expert testimony].
And when you start weighing the consequences of takinghim off his medication and possibly have him revert into anincompetent situation, I don’t think that that is a good exper- The court did not acknowledge the defendant’s lib- erty interest in freedom from unwanted antipsychotic drugs.
This error may well have impaired the constitutionally protected trial rights Riggins invokes.
consider terminating medication, Dr. O’Gorman suggestedthat the dosage administered to Riggins was within the toxicrange, id., at 483, and could make him “uptight,” id., at 484.
Dr. Master testified that a patient taking 800 milligrams ofMellaril each day might suffer from drowsiness or confusion.
Id., at 416.
Cf. Brief for American Psychiatric Association as Amicus Curiae 10–11 (“[I]n extreme cases, the sedation-like effect [of antipsychotic medication] may be severeenough (akinesia) to affect thought processes”).
possible that such side effects had an impact upon not justRiggins’ outward appearance, but also the content of histestimony on direct or cross examination, his ability to fol-low the proceedings, or the substance of his communicationwith counsel.
Efforts to prove or disprove actual prejudice from the rec- ord before us would be futile, and guesses whether the out-come of the trial might have been different if Riggins’ motionhad been granted would be purely speculative.
ingly reject the dissent’s suggestion that Riggins should berequired to demonstrate how the trial would have proceededdifferently if he had not been given Mellaril.
Like the consequences of compelling a defendant to wear prison clothing, see Estelle v. Williams, 425 U. S.
501, 504–505 (1976), or of binding and gagging an accusedduring trial, see Allen, supra, at 344, the precise conse-quences of forcing antipsychotic medication upon Rigginscannot be shown from a trial transcript.
mony of doctors who examined Riggins establishes, and whatwe will not ignore, is a strong possibility that Riggins’ de-fense was impaired due to the administration of Mellaril.
We also are persuaded that allowing Riggins to present expert testimony about the effect of Mellaril on his de- meanor did nothing to cure the possibility that the substanceof his own testimony, his interaction with counsel, or his com-prehension at trial were compromised by forced administra-tion of Mellaril.
Even if (as the dissent argues, post, at 147–149) the Nevada Supreme Court was right that experttestimony allowed jurors to assess Riggins’ demeanor fairly,an unacceptable risk of prejudice remained.
To be sure, trial prejudice can sometimes be justified by See Holbrook v. Flynn, 475 U. S.
560, 568–569 (1986); Allen, supra, at 344 (binding and gag-ging the accused permissible only in extreme situationswhere it is the “fairest and most reasonable way” to controla disruptive defendant); see also Williams, supra, at 505(compelling defendants to wear prison clothing at trial fur-thers no essential state policy).
no finding that might support a conclusion that administra-tion of antipsychotic medication was necessary to accomplishan essential state policy, however, we have no basis for say-ing that the substantial probability of trial prejudice in thiscase was justified.
The judgment of the Nevada Supreme Court is reversed, and the case is remanded for further proceedings not incon-sistent with this opinion.
Justice Kennedy, concurring in the judgment.
The medical and pharmacological data in the amicus briefs and other sources indicate that involuntary medication withantipsychotic drugs poses a serious threat to a defendant’sright to a fair trial.
hearing or well-developed record on the point, and the wholesubject of treating incompetence to stand trial by drug medi-cation is somewhat new to the law, if not to medicine.
the sparse record before us, we cannot give full considerationto the issue.
I file this separate opinion, however, to express my view that absent an extraordinary showing by the State,the Due Process Clause prohibits prosecuting officials fromadministering involuntary doses of antipsychotic medicinesfor purposes of rendering the accused competent for trial,and to express doubt that the showing can be made in mostcases, given our present understanding of the properties ofthese drugs.
At the outset, I express full agreement with the Court’s conclusion that one who was medicated against his will inorder to stand trial may challenge his conviction.
State commands medication during the pretrial and trialphases of the case for the avowed purpose of changing thedefendant’s behavior, the concerns are much the same as if itwere alleged that the prosecution had manipulated materialevidence.
See Brady v. Maryland, 373 U. S. 83, 87 (1963) (suppression by the prosecution of material evidence favor-able to the accused violates due process); Arizona v. Young-blood, 488 U. S. 51, 58 (1988) (bad-faith failure to preservepotentially useful evidence constitutes a due process viola-tion).
I cannot accept the premise of Justice Thomas’ dis- sent that the involuntary medication order comprises someseparate procedure, unrelated to the trial and foreclosedfrom inquiry or review in the criminal proceeding itself.
the contrary, the allegations pertain to the State’s interfer-ence with the trial.
I also agree with the majority that the State has a legiti- mate interest in attempting to restore the competence of oth-erwise incompetent defendants.
the State’s right to bring an accused to trial and from ourholding in Pate v. Robinson, 383 U. S. 375, 378 (1966), thatconviction of an incompetent defendant violates due process.
Unless a defendant is competent, the State cannot put himon trial.
Competence to stand trial is rudimentary, for upon it depends the main part of those rights deemed essential toa fair trial, including the right to effective assistance of coun- sel, the rights to summon, to confront, and to cross-examinewitnesses, and the right to testify on one’s own behalf or toremain silent without penalty for doing so.
souri, 420 U. S. 162, 171–172 (1975).
is correct that this case does not require us to address thequestion whether a defendant may waive his right to be triedwhile competent, in my view a general rule permittingwaiver would not withstand scrutiny under the Due ProcessClause, given our holdings in Pate and Drope. ant’s waiver of the right to be tried while competent wouldcast doubt on his exercise or waiver of all subsequent rightsand privileges through the whole course of the trial.
The question is whether the State’s interest in conducting the trial allows it to ensure the defendant’s competence byinvoluntary medication, assuming of course there is a soundmedical basis for the treatment.
require further proceedings on remand, but there seems tobe little discussion about what is to be considered.
Court’s failure to address these issues is understandable insome respects, for it was not the subject of briefing or argu-ment; but to underscore my reservations about the proprietyof involuntary medication for the purpose of rendering thedefendant competent, and to explain what I think ought tobe express qualifications of the Court’s opinion, some discus-sion of the point is required.
This is not a case like Washington v. Harper, 494 U. S. 210 (1990), in which the purpose of the involuntary medicationwas to ensure that the incarcerated person ceased to be aphysical danger to himself or others.
context is both objective and manageable.
of the medication is not merely to treat a person with gravepsychiatric disorders and enable that person to function andbehave in a way not dangerous to himself or others, butrather to render the person competent to stand trial.
the last part of the State’s objective, medicating the personfor the purpose of bringing him to trial, that causes most bare level of functional competence can be induced, thatwould be a grave matter in itself, but here there are evenmore far reaching concerns.
medication is not functional competence, but competence tostand trial.
In my view elementary protections against state intrusion require the State in every case to make ashowing that there is no significant risk that the medicationwill impair or alter in any material way the defendant’s ca-pacity or willingness to react to the testimony at trial or toassist his counsel.
cal literature, I have substantial reservations that the Statecan make that showing.
for it assumes some baseline of normality that experts mayhave some difficulty in establishing for a particular defend-ant, if they can establish it at all.
to underscore the difficult terrain the State must traversewhen it enters this domain.
To make these concerns concrete, the effects of antipsy- 1950’s, antipsychotic drugs such as Mellaril have wide accept-ance in the psychiatric community as an effective treatmentfor psychotic thought disorders.
Press Textbook of Psychiatry 770–774 (J. Talbott, R. Hales, &S. Yodofsky eds. 1988) (Textbook of Psychiatry); Brief forAmerican Psychiatric Association as Amicus Curiae 6–7.
The medications restore normal thought processes by clear-ing hallucinations and delusions.
See also Brief for American Psychiatric Association as Amicus Curiae 9 (“The mental health produced by antipsy-chotic medication is no different from, no more inauthenticor alien to the patient than, the physical health produced byother medications, such as penicillin for pneumonia”).
many patients, no effective alternative exists for treatmentof their illnesses.
Although these drugs have changed the lives of psychiatric patients, they can have unwanted side effects.
mented some of the more serious side effects in Washingtonv. Harper, supra, at 229–230, and they are mentioned againin the majority opinion.
effects that, it appears, can compromise the right of a medi-cated criminal defendant to receive a fair trial.
can prejudice the accused in two principal ways: (1) by alter-ing his demeanor in a manner that will prejudice his reac-tions and presentation in the courtroom, and (2) by renderinghim unable or unwilling to assist counsel.
It is a fundamental assumption of the adversary system that the trier of fact observes the accused throughout thetrial, while the accused is either on the stand or sitting atthe defense table.
to be present at trial, which in turn derives from the rightto testify and rights under the Confrontation Clause.
lor v. United States, 414 U. S. 17, 19 (1973) (per curiam).
At all stages of the proceedings, the defendant’s behavior,manner, facial expressions, and emotional responses, or theirabsence, combine to make an overall impression on the trierof fact, an impression that can have a powerful influence onthe outcome of the trial.
as Riggins did, his demeanor can have a great bearing on hiscredibility and persuasiveness, and on the degree to whichhe evokes sympathy.
be relevant to his confrontation rights.
487 U. S. 1012, 1016–1020 (1988) (emphasizing the importanceof the face-to-face encounter between the accused and theaccuser).
The side effects of antipsychotic drugs may alter demeanor in a way that will prejudice all facets of the defense.
ous due process concerns are implicated when the State ma-nipulates the evidence in this way.
ric Association as Amicus Curiae 10.
a condition called parkinsonism, which, like Parkinson’s dis-ease, is characterized by tremor of the limbs, diminishedrange of facial expression, or slowed functions, such asspeech.
Some of the side effects are more subtle.
Antipsychotic drugs such as Mellaril can have a “sedation-like effect” that in severe cases may affect thought processes.
Ibid. At trial, Dr. Jurasky testified that Mellaril has “a are dealing with someone very sick then you may prescribeup to 800 milligrams which is the dose he had been takingwhich is very, very high.
following side effects of large doses of Mellaril: “Drowsi-ness, constipation, perhaps lack of alertness, changes in bloodpressure. . . . Depression of the psychomotor functions.
you take a lot of it you become stoned for all practicalpurposes and can barely function.” These potential side effects would be disturbing for any patient; but when the patient is a criminal defendant who isgoing to stand trial, the documented probability of side ef-fects seems to me to render involuntary administration ofthe drugs by prosecuting officials unacceptable absent ashowing by the State that the side effects will not alter thedefendant’s reactions or diminish his capacity to assist coun-sel.
As the American Psychiatric Association points out: “By administering medication, the State may be creat- ing a prejudicial negative demeanor in the defendant—making him look nervous and restless, for example, orso calm or sedated as to appear bored, cold, unfeeling,and unresponsive. . . . That such effects may be subtledoes not make them any less real or potentially influen-tial.” Brief for American Psychiatric Association as As any trial attorney will attest, serious prejudice could result if medication inhibits the defendant’s capacity to react and respond to the proceedings and to demonstrate remorseor compassion.
The prejudice can be acute during the sen- tencing phase of the proceedings, when the sentencer mustattempt to know the heart and mind of the offender andjudge his character, his contrition or its absence, and his fu-ture dangerousness.
sessments of character and remorse may carry great weightand, perhaps, be determinative of whether the offender livesor dies.
See Geimer & Amsterdam, Why Jurors Vote Life or Death: Operative Factors in Ten Florida Death PenaltyCases, 15 Am. J. Crim. L. 1, 51–53 (1987–1988).
Concerns about medication extend also to the issue of right to the effective assistance of counsel is impaired whenhe cannot cooperate in an active manner with his lawyer.
Massiah v. United States, 377 U. S. 201 (1964); Geders v.
United States, 425 U. S. 80 (1976) (trial court order directingdefendant not to consult with his lawyer during an overnightrecess held to deprive him of the effective assistance of coun-sel).
The defendant must be able to provide needed infor- mation to his lawyer and to participate in the making of deci-sions on his own behalf.
drugs can hamper the attorney-client relation, preventing ef-fective communication and rendering the defendant less ableor willing to take part in his defense.
with this relation when it administers a drug to dull cog-nition.
See Brief for National Association of Criminal Defense Lawyers as Amicus Curiae 42 (“[T]he chemicalflattening of a person’s will can also lead to the defendant’sloss of self-determination undermining the desire for self-preservation which is necessary to engage the defendant inhis own defense in preparation for his trial”).
It is well established that the defendant has the right to testify on his own behalf, a right we have found essential toour adversary system.
We have found the right implicit as well in the Com- pulsory Process Clause of the Sixth Amendment.
Arkansas, 483 U. S. 44 (1987).
rule excluding all testimony aided or refreshed by hypnosisviolated the defendant’s constitutional right to take the standin her own defense.
mony would contradict not only the right of the accused toconduct her own defense, but also her right to make thisdefense in person: “ ‘It is the accused, not counsel, who mustbe “informed of the nature and cause of the accusation,” whomust be “confronted with the witnesses against him,” andwho must be accorded “compulsory process for obtainingwitnesses in his favor.” ’ ” Id., at 52, quoting Faretta v. Cal- ifornia, 422 U. S. 806, 819 (1975).
tion to the right of the accused to testify in his or her ownwords, and noted that this in turn was related to the FifthAmendment choice to speak “in the unfettered exercise ofhis own will.” of the type here prescribed may be for the very purpose ofimposing constraints on the defendant’s own will, and forthat reason its legitimacy is put in grave doubt.
If the State cannot render the defendant competent with- out involuntary medication, then it must resort to civil com-mitment, if appropriate, unless the defendant becomes com-petent through other means.
tried without his behavior and demeanor being affected inthis substantial way by involuntary treatment, in my viewthe Constitution requires that society bear this cost in orderto preserve the integrity of the trial process.
our knowledge of antipsychotic drugs and their side effectsis evolving and may one day produce effective drugs thathave only minimal side effects.
can permit their use only when the State can show that invol-untary treatment does not cause alterations raising the con-cerns enumerated in this separate opinion.
With these observations, I concur in the judgment revers- Justice Thomas, with whom Justice Scalia joins ex- Petitioner David Edward Riggins killed Paul William Wade by stabbing him 32 times with a knife.
cash, drugs, and other items from Wade’s home.
jury convicted Riggins of first-degree murder and robberywith a deadly weapon and sentenced him to death.
This Court reverses the conviction, holding that Ne- vada unconstitutionally deprived Riggins of his liberty inter-est in avoiding unwanted medication by compelling him totake an antipsychotic drug.
The Court’s opinion, in my view, conflates two distinct questions: whether Riggins had a full and fair criminal trialand whether Nevada improperly forced Riggins to take med-ication.
In this criminal case, Riggins is asking, and may ask, only for the reversal of his conviction and sentence.
is not seeking, and may not seek, an injunction to terminatehis medical treatment or damages for an infringement of hispersonal rights.
I agree with the positions of the majority and concurring opinions in the Nevada Supreme Court: Evenif the State truly forced Riggins to take medication, and evenif this medication deprived Riggins of a protected libertyinterest in a manner actionable in a different legal proceed-ing, Riggins nonetheless had the fundamentally fair criminaltrial required by the Constitution.
Riggins contended in the Nevada Supreme Court that he did not have a “ ‘full and fair’ trial” for two reasons, the firstrelating to exclusion of evidence of his mental condition andthe second concerning his ability to assist in his defense.
Record 1018.
To the extent that Riggins’ arguments below involved federal constitutional issues, I believe that theNevada Supreme Court correctly rejected them.
Riggins first argued that the trial court improperly pre- vented him from presenting relevant evidence of his de-meanor.
As the Court notes, Riggins suffers from a mental illness and raised insanity as a defense at trial.
gins killed Wade, he was not using any antipsychotic medica-tion.
During his trial, however, Riggins was taking large doses of the antipsychotic drug Mellaril.
that this drug would make his appearance at trial differentfrom his appearance when he attacked Wade and that thisdifference might cause the jury to misjudge his sanity.
show his mental condition as it existed at the time of thecrime, Riggins requested permission to appear before thejury in an unmedicated state.
court denied the request, and the Nevada Supreme Courtaffirmed.
This Court has no power to decide questions concerning the admissibility of evidence under Nevada law.
McGuire, 502 U. S. 62, 67–68 (1991).
duct only a limited review of a Nevada court’s decision toexclude a particular form of demeanor evidence.
cases involving a violation of a specific constitutional provi-sion such as the Confrontation Clause, see, e. g., Ohio v. Rob-erts, 448 U. S. 56 (1980), this Court may not reverse a state“trial judge’s action in the admission of evidence” unless theevidentiary ruling “so infuse[s] the trial with unfairness asto deny due process of law.” See also Marshall v. Lonberger, 459 U. S. 422, 438, n. 6 (1983); Burgett v. Texas, 389 U. S. 109,113–114 (1967).
In this case, I see no basis for concluding that Riggins had less than a full and fair trial.
The Court declines to decide whether Mellaril actually af- psychiatric testimony it speculates only that Riggins mighthave looked less uptight, drowsy, or confused if he had nottaken the drug.
At least one psychiatrist believed that a jury would not “be able to notice whether or not [Riggins]was on Mellaril as compared to the period of the time whenhe was not medicated by that drug.” even if Mellaril noticeably affected Riggins’ demeanor, theCourt fails to explain why the medication’s effects renderedRiggins’ trial fundamentally unfair.
The trial court offered Riggins the opportunity to prove his mental condition as it existed at the time of the crimethrough testimony instead of his appearance in court in anunmedicated condition.
by explaining to the jury the history of his mental health,his usage of Mellaril, and the possible effects of Mellaril onhis demeanor.
A. Jurasky, a psychiatrist, who testified about Riggins’ condi-tion after his arrest and his likely mental state at the timeof the crime.
Riggins’ use of Mellaril and how it might be affecting him.
Id., at 752–753, 760–761.
The Nevada Supreme Court concluded that this “testi- mony was sufficient to inform the jury of the effect of theMellaril on Riggins’ demeanor and testimony.” other state courts that also have held that expert testimonymay suffice to clarify the effects of an antipsychotic drug ona defendant’s apparent demeanor.
S. C. 664, 673, 244 S. E. 2d 302, 306 (1978); State v. Jojola, 89N. M. 489, 493, 553 P. 2d 1296, 1300 (1976).
133 Vt. 253, 257–258, 336 A. 2d 174, 177 (1975) (reversing aconviction because no expert testimony explained how anti-psychotic medicine affected the defendant’s appearance).
Having reviewed the record as a whole, I see no reasonto disturb the conclusion of the Nevada Supreme Court.
On the facts of this case, Riggins’ inability to introduce evi-dence of his mental condition as he desired did not renderhis trial fundamentally unfair.
U. S. 44, 55, n. 11 (1987); id., at 64–65 (Rehnquist, C. J.,dissenting).
Riggins also argued in the Nevada Supreme Court, al- though not in his briefs to this Court, that he did not have a“ ‘full and fair’ trial” because Mellaril had side effects thatinterfered with his ability to participate in his defense.
He alleged, in particular, that the drug tended contention, stating: “It is clearly possible that such side ef-fects had an impact upon . . . the content of his testimony ondirect or cross examination, his ability to follow the proceed-ings, or the substance of his communication with counsel.”Ante, at 137 (emphasis added).
clude that Riggins had less than a full and fair trial merelybecause of the possibility that Mellaril had side effects.
All criminal defendants have a right to a full and fair trial, and a violation of this right may occur if a State tries a de-fendant who lacks a certain ability to comprehend or partici-pate in the proceedings.
ess Clause guarantees the fundamental elements of fairnessin a criminal trial,” Spencer v. Texas, 385 U. S. 554, 563–564(1967), and have made clear that “conviction of an accusedperson while he is legally incompetent violates due process,”Pate v. Robinson, 383 U. S. 375, 378 (1966).
Riggins has no claim of legal incompetence in this case.
The trial court specifically found him competent while hewas taking Mellaril under a statute requiring him to have“sufficient mentality to be able to understand the nature ofthe criminal charges against him, and . . . to aid and assisthis counsel in the defense interposed upon the trial.” due process imposes a higher standard.
The record does not reveal any other form of unfairness relating to the purported side effects of Mellaril.
has failed to allege specific facts to support his claim that he could not participate effectively in his defense.
stated how he would have directed his counsel to examine orcross-examine witnesses differently.
any testimony or instructions that he did not understand.
The record, moreover, does not even support his assertionthat Mellaril made him worse off.
his concurring opinion below: “Two psychiatrists who hadprescribed Mellaril for Riggins, Dr. Quass and Dr. O’Gorman,testified that they believed it was helpful to him.
psychiatric testimony established that Mellaril may have in-creased Riggins’ cognitive ability . . . .” See also State v. Hayes, 118 N. H. 458, 461, 389 A. 2d 1379, 1381 (1978) (holding a defendant’s perceptionadequate because “[a]ll the expert evidence support[ed] theconclusion that the medication ha[d] a beneficial effect onthe defendant’s ability to function”).1 moreover, tends to confirm that he had a fair trial.
State v. Jojola, supra, at 492, 553 P. 2d, at 1299 (presuming,absent other evidence, that the side effects of an antipsy-chotic drug did not render a competent defendant unable toparticipate fully in his trial).
Riggins also argues for reversal on the basis of our holding in Washington v. Harper, 494 U. S. 210, 221 (1990), that theDue Process Clause protects a substantive “liberty interest”in avoiding unwanted medication.
vada unconstitutionally deprived him of this liberty interestby forcing him to take Mellaril.
1 We previously have noted that “ ‘[p]sychotropic medication is widely accepted within the psychiatric community as an extraordinarily effectivetreatment for both acute and chronic psychoses, particularly schizophre-nia.’ ” Washington v. Harper, 494 U. S. 210, 226, n. 9 (1990) (quoting Brief for American Psychiatric Association et al. as Amici Curiae, O. T. 1989,No. 88–599, pp. 10–11).
that “the Nevada courts failed to make findings sufficient tosupport forced administration of the drug” in this case.
Ante, at 129.
I consider reversal on this basis improper.
Riggins may not complain about a deprivation of the lib- erty interest that we recognized in Harper because the rec-ord does not support his version of the facts.
his arrest, as the Court notes, Riggins told a psychiatrist athis jail that he was hearing voices and could not sleep.
not eliminate the problem, Riggins sought further treatmentand the psychiatrist increased the dosage.
The Court concludes that the medication became involun- tary when the trial court denied Riggins’ motion for permis-sion not to take the drug during the trial.
Although the court denied Riggins’ motion, it did though Riggins alleges that the state physicians forced himto take the medication after the court’s order, the recordcontains no finding of fact with respect to this allegation.
The Court admits that it merely assumes that the physiciansdrugged him, and attempts to justify its assumption by ob-serving that the Nevada Supreme Court also assumed thatinvoluntary medication occurred.
preme Court, however, may have made its assumption forthe purpose of argument; the assumption, in its view, did 2 Riggins’ counsel confirmed this interpretation of the order at oral “QUESTION: . . . [D]id the court ever go further than saying I will not order the State to stop administering the medication? . . . It simply said. . . I won’t intervene and enjoin the administration of this medication[.] “MR. YAMPOLSKY: Yes . . . .
“QUESTION: So if [Riggins] had then said, well, I’m not going to take it, he wouldn’t be in violation of the court order? . . .
the same assumption if it requires reversal of Riggins’conviction.
Riggins also cannot complain about a violation of Harper because he did not argue below for reversal of his convictionon the ground that Nevada had deprived him of a libertyinterest.
Riggins consistently maintained in the Nevada courts that he did not have a “full and fair trial” because themedication deprived him of the opportunity to present hisdemeanor to the jury and to participate in his defense.
20–24 (trial court motion); id., at 42–47 (trial court reply);Record 1018–1021 (appellate brief); id., at 1068–1071 (appel-late reply brief).
As counsel for Nevada put it at oral argu- ment: “The way this issue was initially presented to the trialcourt was really a question of trial strategy.
never an indication in this case that Mr. Riggins was aHarper-type defendant who did not want to be medicated.”Tr. of Oral Arg. 23.3 Because the claims that Riggins raised below have no merit, Riggins has altered his theory of the case.
Court, therefore, should not condemn the Nevada courtsbecause they “did not acknowledge the defendant’s libertyinterest in freedom from unwanted antipsychotic drugs.”Ante, at 137.
The Nevada courts had no reason to consider an argument that Riggins did not make.
recently that “[i]n reviewing the judgments of state courtsunder the jurisdictional grant of 28 U. S. C. § 1257, the Courthas, with very rare exceptions, refused to consider petition- 3 Riggins noted in his reply brief before the Nevada Supreme Court that the courts in United States v. Bryant, 670 F. Supp. 840, 843 (Minn. 1987),and Bee v. Greaves, 744 F. 2d 1387 (CA10 1984), had recognized a personalliberty interest in avoiding unwanted medication.
Yet, Riggins never asked for reversal because of a deprivation of thisinterest.
He argued for reversal in that brief only on grounds that the medication “violated [his] right to a ‘full and fair’ trial because it deniedhim the ability to assist in his defense, and prejudiced his demeanor, atti-tude, and appearance to the jury.” ers’ claims that were not raised or addressed below.” Escondido, 503 U. S. 519, 533 (1992).
expressed inconsistent views as to whether this rule is juris-dictional or prudential in cases arising from state courts,”ibid., the Court does not attempt to justify its departurehere.
Finally, we did not grant certiorari to determine whether the Nevada courts had made the findings required by Harperto support forced administration of a drug.
case to decide “[w]hether forced medication during trial vio-lates a defendant’s constitutional right to a full and fairtrial.” question one way or the other, stating only that a violationof Harper “may well have impaired the constitutionally pro-tected trial rights Riggins invokes.” have stated, “we ordinarily do not consider questions outsidethose presented in the petition for certiorari.” consider Riggins’ Harper argument.
The Harper issue, in any event, does not warrant rever- Riggins, as a detainee awaiting trial, had at least the sameliberty interest in avoiding unwanted medication that theinmate had in Harper. Harper in a very significant respect.
Harper complained that physicians were drugging himagainst his will, he sought damages and an injunction againstfuture medication in a civil action under 42 U. S. C. § 1983.
See 494 U. S., at 217.
forced medication, he is seeking a reversal of his criminalconviction.
I would not expand Harper to include this We have held that plaintiffs may receive civil remedies for all manner of constitutional violations under § 1983.
Dennis v. Higgins, 498 U. S. 439, 443–451 (1991).
Court, however, has reversed criminal convictions only onthe basis of two kinds of constitutional deprivations: those“which occu[r] during the presentation of the case” to thetrier of fact, and those which cause a “structural defect af-fecting the framework” of the trial.
nante, 499 U. S. 279, 307, 310 (1991).
reveal why it considers a deprivation of a liberty interest inavoiding unwanted medication to fall into either category ofreversible error.
Even if Nevada failed to make the findings necessary to support forced administration of Mellaril, thisfailure, without more, would not constitute a trial error or aflaw in the trial mechanism.
entitled to other remedies, he has no right to have his convic-tion reversed.4 4 A State, however, might violate a defendant’s due process right to a fundamentally fair trial if its administration of medication were to dimin-ish substantially the defendant’s mental faculties during the trial, even ifhe were not thereby rendered incompetent.
(1797) (“If felons come in judgement to answer, . . . they shall be out ofirons, and all manner of bonds, so that their pain shall not take away anymanner of reason, nor them constrain to answer, but at their free will”);Resolutions of the Judges upon the Case of the Regicides, Kelyng’s Reportof Divers Cases in Pleas of the Crown 10 (1708) (Old Bailey 1660) (“It wasresolved that when Prisoners come to the Bar to be tryed, their Ironsought to be taken off, so that they be not in any Torture while they maketheir defense, be their Crime never so great”), reprinted in 5 How. St. Tr.
971, 979–980 (1816); Trial of Christopher Layer, 16 How. St. Tr. 94, 100(1812) [K. B. 1722] (“[T]he authority is that [the defendant] is not to be ‘invinculis’ during his trial, but should be so far free, that he should have theuse of his reason, and all advantages to clear his innocence”); see also Statev. Williams, 18 Wash. 47, 49–51, 50 P. 580, 581 (1897) (“ ‘[T]he condition ofthe prisoner in shackles may, to some extent, deprive him of the free andcalm use of all his faculties’ ”) (quoting State v. Kring, 64 Mo. 591 (1877)).
Riggins has not made (much less proved) any such allegation in this Court;indeed, the record indicates that Riggins’ mental capacity was enhancedby his administration of Mellaril.
We applied a similar analysis in Estelle v. Williams, 425 In that case, a prisoner challenged his con- viction on grounds that the State had required him to wearprison garb before the jury.
did not ask whether the State had violated some personalright of the defendant to select his attire.
sidered only whether the prison clothing had denied him a“fair trial” by making his appearance less favorable to thejury.
the merits because the prisoner had waived the issue at trial,id., at 512, we observed that lower courts had held that “ashowing of actual prejudice must be made by a defendantseeking to have his conviction overturned on this ground,”id., at 504, n. 1.
In my view, just as the validity of the con- viction in Estelle v. Williams would depend on whether theprisoner had a fair trial, so does the validity of Riggins’conviction.
The need for requiring actual unfairness in this case (either in the form of a structural defect or an error in thepresentation of evidence) becomes apparent when one con-siders how the Court might apply its decision to other cases.
A State could violate Harper by forcibly administering anykind of medication to a criminal defendant.
surely would not reverse a criminal conviction for a Harperviolation involving medications such as penicillin or aspirin.
Perhaps Mellaril, in general, has a greater likelihood of af-fecting a person’s appearance and powers of perceptions thanthese substances.
dication in this case, considering the record as a whole, thatMellaril unfairly prejudiced Riggins.
I do not mean in any way to undervalue the importance of a person’s liberty interest in avoiding forced medication orto suggest that States may drug detainees at their whim.
Under Harper, detainees have an interest in avoiding un-wanted medication that the States must respect.
priate instances, detainees may seek damages or injunctions against further medication in civil actions either under§ 1983, as in Harper, or under state law.
Court reviews a state-court criminal conviction of a defend-ant who has taken medication, it cannot undo any violationthat already has occurred or punish those responsible.
may determine only whether the defendant received aproper trial, free of the kinds of reversible errors that wehave recognized.
Because Riggins had a full and fair trial in this case, I would affirm the Nevada Supreme Court.
For the foregoing reasons, I find it unnecessary to address the precise standards governing the forced administration ofdrugs to persons such as Riggins.
violated these standards, I would affirm Riggins’ conviction.
I note, however, that the Court’s discussion of these stand-ards poses troubling questions.
ports to rely on Washington v. Harper, the standards that itapplies in this case differ in several respects.
The Court today, for instance, appears to adopt a standard It specifically faults the trial court for failing to find either that the “continued administration ofMellaril was required to ensure that the defendant could betried,” ante, at 136 (emphasis added), or that “other compel-ling concerns outweighed Riggins’ interest in freedom fromunwanted antipsychotic drugs,” ibid. (emphasis added).
We specifically rejected this high standard of review inHarper. In that case, the Washington Supreme Court had held that state physicians could not administer medicationto a prisoner without showing that it “was both necessaryand effective for furthering a compelling state interest.”494 U. S., at 218.
We reversed, holding that the state court “erred in refusing to apply the standard of reasonableness.”Id., at 223.
The Court today also departs from Harper when it says that the Nevada Supreme Court erred by not “considering sumably believes that Nevada could have treated Rigginswith smaller doses of Mellaril or with other kinds of thera-pies.
In Harper, however, we imposed no such requirement.
In fact, we specifically ruled that “[t]he alternative meansproffered by [the prisoner] for accommodating his interest inrejecting the forced administration of antipsychotic drugs donot demonstrate the invalidity of the State’s policy.” This case differs from Harper because it involves a pretrial detainee and not a convicted prisoner.
forcibly medicating inmates well may differ from those forpersons awaiting trial.
on this distinction in departing from Harper; instead, it pur-ports to be applying Harper to detainees.
Either the Court is seeking to change the Harper standardsor it is adopting different standards for detainees withoutstating its reasons.


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