Competency, Restoration of

Legal and Ethical Context

All U.S. jurisdictions provide for treatment of individuals found IST. Traditionally, this was presumed to involve commitment to a government-run facility for inpatient care. In Jackson v. Indiana (1972), the Supreme Court clarified that such commitment must be reasonably related, in duration and circumstances, to the purpose of restoring the individual to competency. Those found not restorable within the reasonably foreseeable future may be subjected to civil commitment. Surveys suggest that nearly half the defendants referred for restoration are placed in state hospitals and receive services typical for a civil patient population. Most of the remainder are confined in high-security facilities. In view of the significant deprivation of liberty entailed in inpatient restoration, a small number of jurisdictions have created provisions for outpatient competency [Page 109]restoration treatment. This innovation is also politically attractive, as the services are much less costly.

The majority of IST defendants appear to accept restoration treatment voluntarily, but significant legal and ethical conflicts arise regarding those who refuse court-mandated treatment. In Sell v. United States (2003), the Supreme Court considered the circumstances under which psychiatric medication could be administered against defendants' objections, for the purpose of restoring competency. The court emphasized that alternative bases for involuntary treatment should be considered first, including treatment justified by danger to self or others or treatment through guardianship procedures. In the absence of these alternative justifications, the government could seek involuntary treatment solely to restore competency in limited circumstances—namely, if the proposed treatment was medically appropriate, substantially unlikely to have competency-impairing side effects, and necessary vis-à-vis less intrusive alternatives to accomplish an important governmental interest in bringing the defendant to trial. Nonmedication treatments have been viewed as less intrusive or objectionable and have not been a source of significant litigation.

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