Insanity Goes Back on Trial

The New York Times, March 3, 2003

By Sally Satel

Sally Satel, a psychiatrist and a fellow at the American Enterprise Institute, is co-author of the forthcoming “One Nation Under Therapy.”

Charles T. Sell, a St. Louis dentist, was indicted in 1997 on counts of mail fraud, Medicaid fraud and money laundering. As the trial approached, he became agitated and paranoid. When he became too delusional to understand the charges against him or to participate in his own defense—the threshold used for determining competence to stand trial—prosecutors asked him to take anti-psychotic medication. Mr. Sell refused.

Today the question of whether he has that right comes before the Supreme Court.

The issue of forced medication is by no means new. Lawyers for Russell Weston Jr., the schizophrenic man who killed two Capitol Hill police officers in 1998, unsuccessfully tried to block him from receiving medication, presumably to shield him from the risk of a death penalty.

The difference here is that Mr. Sell did not kill anyone, and his lawyers claim that the government’s interest in prosecuting him for a lesser, nonviolent offense does not outweigh his right to refuse medication. Rather, the defense holds, imposing “mind altering” anti-psychotic medications to induce “synthetic sanity” breaches his liberty interest and exposes him to potentially permanent side effects.

Mr. Sell has supporters. The Association of American Physicians and Surgeons, in an amicus brief, warns of “mind control” and draws an analogy between Mr. Sell and Winston Smith, the hero of Orwell’s “1984.” The Center for Cognitive Liberty and Ethics contends that administering the medications would be “cognitive censorship” and that Mr. Sell is under “no obligation to think the way the government wants him to think.” The American Civil Liberties Union and the National Association of Criminal Defense Lawyers lodged similar protests.

Although well-intended, these depictions of serious mental illness as a free expression of thought, and of pharmacotherapy as censorship, are grievously naive.

The freedom to remain straitjacketed by psychosis is no freedom. Psychiatrists say Mr. Sell has delusional disorder. He thinks he is under siege and, likely as a result of paranoia, he conspired to kill a witness and a Federal Bureau of Investigation agent, prosecutors say. He stayed awake for days terrified that the F.B.I. would burst into his cell. His mental function is hostage to an illness that compels him to view the world through a persecutory lens.

Relieving such torment is not only humane, it would permit him to be coherent enough to participate in his own defense. One alternative is that Mr. Sell remain indefinitely in a hospital, effectively imprisoned both mentally and physically.

Nor is it true that these are “mind-altering drugs.” They are mind-ordering drugs. When given properly, they enhance autonomy by increasing capacity for concentration, learning and communication. They do not erode personality, they allow its full expression. They are the standard of care for people in Mr. Sell’s condition.

It is true that some older medications like Haldol pose a significant risk of lethargy, restlessness and mental dullness. But these side effects can be managed by careful monitoring, switching to newer drugs, lowering the dosage or adding benign counteracting agents. Tardive dyskinesia, a side effect involving uncontrollable body movements that Mr. Sell’s lawyers have specifically cited, almost never develops early in treatment. Its onset is generally mild and usually improves or disappears if medication is stopped early.

The more general question is whether Mr. Sell really has a “right” to refuse. To say that he has that right presumes that he has the rational ability to weigh the pros and cons of being medicated. Not only do his actions call this assumption into question, but the fact is that half the people with illnesses like schizophrenia or mania do not even recognize that they are ill.

Should the court side with Mr. Sell, the case will be applauded as a victory for patients’ rights and civil liberties. But this simplistic view ignores the bigger question: is there not a duty to treat a person who is obviously suffering?

A decision in Mr. Sell’s favor that appears to give credence to the clinical arguments made by his lawyers could have widespread implications. It could hurt efforts to help the homeless who are mentally ill and the high numbers of psychotics languishing in jail cells for minor offenses. These people are the intended beneficiaries of civil laws in many states that require the medication of certain people who would otherwise deteriorate to the point of helplessness or becoming a danger to others. But these state laws are regularly challenged by civil libertarians and patients’ rights groups arguing just what Mr. Sell’s lawyers insist: that psychotic people can make rational decisions about their care and that medication is too risky.

The lower courts that hear such appeals look to the Supreme Court for guidelines. In considering today’s case, the justices must understand that the freedom to be delusional is no freedom at all.