Coercing Fitness for Trial: Mandating Efficacious Pharmacotherapy: Sell v United States 539 U.S. 166 (2003); 123 S. Ct. 2174; 156 L. Ed. 2d 197 (2003)

On rare occasions when the criteria for civil commitment are not established, there may be a clinical view that a patient is too psychiatrically unwell to be able to stand trial. The United States Supreme Court decision in Sell v United States, 539 U.S. 166 (2003), imposes four requirements for when a court can mandate provision of medication, contrary to a patient's wishes, for the purpose of seeking to render the patient fit to stand trial. While the clarity in the requirements provides a measure of predictability to this difficult legal question, the new law leaves a significant amount of uncertainty in the practical application of the clinician and judicial balancing processes. This is not inappropriate in principle but some of the expectations of the Court in terms of predicting the efficacy of pharmacotherapy and its side-effects may be unrealistic. Insofar as the requirements prescribe that it be established that no measure less intrusive than coerced medication be available to address the patient's symptomatolology, and that the medication be in the patient's best interests, the decision is consonant with international legal standards and with orthodox clinical practice. However, it remains to be seen how effectually the Supreme Court's ruling is applied in first instance decision-making.