The Case of the Delusional Dentist

Policies affecting psychiatry are made in many venues, among them legislatures, administrative agencies, and the courts. Much of the work that APA does on behalf of our members takes place in these varied forums. Since many members are not aware of these efforts, I thought it would be worth highlighting them in this and subsequent columns. Here I want to focus on our work in the courts, in particular, the activities of the Committee on Judicial Action. To illustrate, I will use “The Case of the Delusional Dentist.”

The dentist in question is Dr. Charles Sell, who in 1997 was charged with submitting fraudulent billings to Medicaid and private insurers and with money laundering. Dr. Sell has a history of psychiatric hospitalizations for psychosis, and although initially considered competent to stand trial, his condition appeared to deteriorate over time. After yelling and spitting at a magistrate at a bail revocation hearing, and facing additional charges of conspiring to kill a witness and an FBI agent, Dr. Sell was sent for another evaluation and was found incompetent to stand trial. His diagnosis was delusional disorder, persecutory type.

As is common in such cases, Sell was sent to a federal medical facility for a determination of whether his competence could be restored. The judgment of the evaluating psychiatrist was that it could, but only if he were treated with antipsychotic medication, a finding upheld at a subsequent hearing. Dr. Sell, however, refused to accept treatment, leaving him in a state of psychotic limbo. He has remained confined in the federal prison hospital ever since, while litigation about the government’s power to treat him over his objections has wound its way through the courts and is now under consideration by the U.S. Supreme Court.

Why is this an issue of concern for psychiatrists? At the broadest level, whenever the courts deal with cases involving psychiatry—whatever the underlying legal issues—it is important that they get the facts right. Since judges share in the general ignorance of, and prejudices about, mental disorders and their treatment, that cannot be taken for granted. In the past, unfortunate mischaracterizations by influential courts of the validity of psychiatric diagnoses, the impact of civil commitment, and the effects of antipsychotic medications, among other issues, have caused considerable damage. Beyond their impact on the case at hand, these misconceptions have been picked up by the media, undercutting our efforts to educate the public about the real nature of mental diseases and their treatment. Moreover, they have been relied upon by subsequent courts as if they constituted proven fact, sometimes echoing through the case law for decades.

In particular, APA has been very concerned about how the courts have characterized the effects of antipsychotic medications. Decisions in the 1970s and 1980s on the rights of civilly committed patients to refuse medication often painted antipsychotic medications in lurid colors, describing them as “mind altering” and emphasizing their most severe side effects, while downplaying the positive impact they can have on psychotic symptoms. Ironically, many courts drew their depictions from articles published in law reviews by attorneys with antipsychiatry agendas, rather than referencing more reliable data from the medical literature. With a new generation of antipsychotic medications now available, having a more favorable side-effect profile and perhaps greater efficacy, this may be an opportunity to re-educate the courts—and through them the public—about these important modalities of treatment.

Of course, American psychiatry has an interest in the legal issue at stake in Sell v. U.S. as well. Allowing psychotic defendants who are incompetent to stand trial to refuse treatment with medications transforms the psychiatric units in which they are housed into nontherapeutic detention facilities. While these people suffer helplessly from the consequences of their psychosis, their psychiatrists are reduced to noting their deterioration in their medical records. They may represent a risk to themselves, to other patients, and to staff in an unmedicated state, and their presence undercuts the therapeutic milieu. From a societal perspective, by refusing medication, they effectively stymie the efforts of the state or federal government to adjudicate responsibility for the criminal act with which they are charged. In effect, alone among criminal defendants, they are being allowed to say, “Thanks, but I’d really rather not stand trial.” (Note that the issues in Sell are very different from those that arise when a condemned prisoner refuses treatment with medication, such as occurred in the Singleton case, which Psychiatric News will be cover in the next issue.) Hence, APA’s Committee on Judicial Action, now chaired by Renée Binder, M.D., has been tracking cases related to the treatment of incompetent defendants for more than a decade. APA wrote an amicus curiae (or “friend of the court”) brief in Riggins v. Nevada, a 1992 decision on this issue by the U.S. Supreme Court, and more recently was invited by the U.S. 2nd Circuit Court of Appeals to submit a brief in a similar case.

When Dr. Sell’s case was accepted for consideration by the U.S. Supreme Court, the Committee on Judicial Action went to work. After reviewing the lower court decisions upholding the government’s power to treat Sell, the committee held a conference call to discuss whether APA should submit an amicus brief in the case and, if so, how the brief should be framed. They were aided in their deliberations by Richard Taranto, J.D., an excellent Washington-based appellate attorney who has served as counsel to the committee for many years.

A decision was made to support APA involvement, and Mr. Taranto set to work outlining the brief. In essence, the argument made was that treatment should be permitted in cases of sufficient seriousness if it is medically appropriate, has a reasonable prospect of restoring competence, and is necessary to achieve that goal. Meanwhile, the committee’s recommendation was reviewed and approved by the Council on Psychiatry and Law, to which the committee reports; the Joint Reference Committee, which reviews all items coming to the attention of the Board; and the Executive Committee of the Board of Trustees in one of its biweekly conference calls. By the time the question reached the Board, an advanced draft of the brief was ready for its review. Given the acknowledged importance of the issues at stake, the Executive Committee authorized filing of the brief on behalf of APA. Oral arguments in Sell v. U.S. will take place soon, and a decision is expected before the end of the Court’s term in June.

In the last decade, APA has participated as amicus in a wide range of cases impacting psychiatry, offering support for states’ obligations to provide adequate funding for community-based treatment and for the imposition of liability on HMOs for negligence in utilization review, and opposing the unreasonable attribution of responsibility to psychiatrists for patients’ violence and the extension of laws allowing sex offenders to be committed to psychiatric facilities after serving their terms in prison—to offer just a few examples.

Added to the cases at the U.S. Supreme Court and circuit court levels in which APA participates directly are cases making their way through the state courts, which can have considerable impact on our members in those jurisdictions. At the request of an APA district branch, advice and partial funding are available to support amicus briefs at those levels as well.

We owe thanks to the members of the Committee on Judicial Action for the expertise they bring to this process and the time they spend on it. It is one more example of how APA members work together for the benefit of our patients and our field. ▪