Can a North Carolina court order a criminal defendant to take psychotropic medication against his will, when the medication is needed to make him competent to stand trial and he is refusing it?

Plain-English summary

A NC superior court judge in the Fourth Judicial District faced a hard case. A criminal defendant had been committed to Dorothea Dix Hospital for a competency evaluation. The psychiatrist's testimony at the hearing was that the defendant currently might not be competent to stand trial, but would likely become competent if he took psychotropic medication. The defendant was refusing the medication. The judge asked AG Edmisten whether he could order the defendant to take the medication anyway.

Assistant AGs Ben Irons and James Peeler Smith, for AG Edmisten, said yes, with conditions. The AG framework had two parts. First, there had to be direct psychiatric testimony that the medication was likely to render the defendant competent. Speculation or general expert literature was not enough; the judge needed a treating-physician opinion specific to the defendant. Second, the psychiatrist also had to testify that the medication did not create a substantial risk of serious or long-term side effects to that defendant. Given both findings, the court could order the defendant committed for the purpose of administering the medication and could order the medication administered without the defendant's consent.

The AG anchored that conclusion in the balance between two competing interests. The defendant had a bodily-integrity interest in refusing unwanted medication, recognized by federal civil-rights cases like Rennie v. Klein (3d Cir.) and Rogers v. Okin (1st Cir.). The state had a compelling interest in bringing the accused to trial, articulated by Justice Brennan in Illinois v. Allen: "The safeguards that the Constitution affords a criminal defendant presuppose that the government has a sovereign prerogative to put on trial those accused in good faith of violating valid laws. Constitutional power to bring an accused to trial is fundamental to a scheme of 'ordered liberty' and prerequisite to social justice and peace."

When weighing those interests, the AG followed the South Carolina Supreme Court's analysis in State v. Law and the New Hampshire Supreme Court's in State v. Hayes. Both courts had held that medication could be ordered without consent under compelling circumstances, of which restoring competence to stand trial was one. The AG noted no published decisions reaching a contrary conclusion. The Court was further supported by two NC Supreme Court cases, State v. Buie and State v. Potter, which had observed that defendants otherwise incompetent could become legally competent on psychotropic drugs (though neither case had involved forced administration).

The opinion acknowledged that the General Assembly's competency framework (G.S. § 15A-1001 et seq.) did not address involuntary medication. The legislative gap did not relieve the court of its duty to handle the situation. The AG's reading was that the court's inherent authority, combined with the constitutional balance, supplied the necessary power, subject to the dual psychiatric-testimony conditions.

Currency note

This opinion was issued in 1981. Subsequent statutory amendments, court decisions, or later AG opinions may have changed the analysis. Treat this page as historical context, not current legal advice. Verify current law before relying on any specific rule, deadline, or remedy mentioned here. The most important later development is Sell v. United States, 539 U.S. 166 (2003), in which the U.S. Supreme Court set out a four-factor federal constitutional test for involuntary medication to restore trial competence: (1) important governmental interests, (2) the medication will significantly further those interests, (3) the medication is necessary to further those interests, and (4) the administration is medically appropriate. Sell is now the controlling federal standard. NC courts apply Sell when handling these motions today. Anyone working a current involuntary-medication question must read Sell and the post-Sell NC appellate cases, not this 1981 AG opinion.

Background and statutory framework

NC's framework for handling defendants who may lack competence to stand trial is set out at G.S. § 15A-1001 et seq. The framework requires the court to determine, on motion or sua sponte, whether the defendant lacks capacity to proceed (a standard that tracks the federal Dusky v. United States, 362 U.S. 402 (1960) test: rational and factual understanding of the proceedings plus ability to consult with counsel). If the court finds the defendant lacks capacity, the proceedings are suspended. The defendant is typically committed to a state psychiatric facility for evaluation and treatment.

What happens when the defendant, committed to the hospital, refuses the treatment that might restore competence? The 1981 statutes were silent on this point. The General Assembly had built the front end of the framework (assessment, commitment) but had not addressed the back end (involuntary treatment to restore competence). That gap forced the AG and the courts to construct an answer from constitutional principle and from out-of-state precedent.

Federal civil-rights litigation in the late 1970s and early 1980s recognized that psychiatric patients had a limited right to refuse psychotropic medication. Rennie v. Klein (3d Cir.) and Rogers v. Okin (1st Cir.) developed competing standards (Rennie's professional-judgment standard versus Rogers' judicial-hearing standard), with the U.S. Supreme Court granting cert in Mills v. Rogers (which it ultimately decided on Massachusetts state-law grounds in 1982). The shared baseline was that the right was real but defeasible. State interests could override the right in the right circumstances, with the right procedural safeguards.

The compelling state interest in restoring competence to stand trial sits at the high end of the spectrum. Without competence, the defendant cannot be tried, and the prosecution cannot proceed. A defendant who is permanently medication-refusing would be permanently untriable. The state's interest in bringing serious criminal charges to a verdict (favorable or not) is fundamental, as Justice Brennan emphasized in Allen.

The AG's dual condition (likely to work, no substantial long-term harm) was a reasonable threshold for the override. It required the prosecution to come forward with specific psychiatric proof, not just general willingness to medicate. It also kept the door closed to medication regimens that, even if effective, carried real risks of tardive dyskinesia or similar permanent injury. The AG was unwilling to authorize medication that traded competence for permanent neurological harm.

Common questions

Does this opinion authorize indefinite medication?

The opinion contemplates medication for a defined purpose: restoring competence to stand trial. It does not authorize indefinite medication for general treatment purposes; that question is governed by civil commitment law, not the criminal competence framework. The medication ordered under this authority was meant to bridge the defendant to a state where trial could proceed, not to replace ongoing civil-commitment review.

What if the defendant has been committed and won't take the medication?

Under the AG's framework, the court could order the medication administered without consent. As a practical matter, hospital staff at Dorothea Dix or another state facility would administer the medication under medical supervision, typically by injection if oral administration was refused. The court order provided legal authority for the medical staff to proceed.

What if a defendant later argued his trial was unfair because he had been medicated against his will?

That question was not directly addressed in the AG opinion. Defendants medicated to restore competence have, at various times, raised concerns about due process (could a medicated defendant adequately assist in his own defense?) and Sixth Amendment fair trial rights. The federal Sell framework now addresses many of these concerns by requiring the medication to be medically appropriate and the trial benefits to outweigh the medication burdens.

Did this opinion apply to civil commitment cases?

No. Civil commitment proceedings have their own framework for forced medication, governed by NC's civil commitment statutes and by the federal civil-rights cases like Rennie and Rogers. This opinion addressed only the criminal-trial-competence context, where the state's interest is bringing the defendant to trial.

Source

• Landing page: https://ncdoj.gov/opinions/administration-of-psychotropic-drugs-to-a-non-consenting-defendant/

Citations

• N.C. Gen. Stat. § 15A-1001 et seq.
• N.C. Gen. Stat. § 15A-1002
• State v. Buie, 297 N.C. 159, 254 S.E.2d 26 (1979)
• State v. Potter, 289 N.C. 238, 204 S.E.2d 649 (1974)
• State v. Law, 270 S.C. 664, 244 S.E.2d 302 (1978)
• State v. Hayes, 118 N.H. 458, 389 A.2d 1379 (1978)
• Rennie v. Klein, 653 F.2d 836 (3d Cir. 1981) (en banc)
• Rogers v. Okin, 634 F.2d 650 (1st Cir. 1980)
• Illinois v. Allen, 397 U.S. 337 (1970)

Original opinion text

Requested By: Honorable Henry L. Stevens, III Judge of Superior Court Fourth Judicial District

Question: When administration of psychotropic medications to a criminal defendant who may be incompetent to stand trial is likely to make the defendant competent, can the medication be administered without the patient's consent?

Conclusion: Yes, if there is direct psychiatric testimony that the medications are likely to make the defendant competent and that the medications do not create a substantial risk of serious or long term side effects to the defendant.

The question presented involves facts that should be set out in some detail. The defendant had been committed to Dorothea Dix Hospital where he was to be examined by psychiatrists to determine whether he was capable of proceeding. See G.S. 15A-1002. A hearing was held on the matter after the commitment. At the hearing, a psychiatrist at Dix testified that at present, the defendant may not be competent to stand trial but that he was likely to become competent if he would take psychotropic medications which he had been refusing. The question is whether the defendant can be required to take the necessary medications.

It is our conclusion that under some circumstances a psychiatrist may administer psychotropic drugs to a criminal defendant for the purpose of making him competent. There is ample authority to support this conclusion. In State v. Law, 270 S.C. 664, 244 S.E.2d 302 (1978), the Supreme Court of South Carolina addressed the matter as follows:

"Counsel for the appellee apparently take the position that under no circumstances can medication be administered a defendant without his consent. They contend that such would be violative of his bodily integrity. We do not feel that such an absolute right exists. It is our view that medication may be administered without the consent of a defendant under compelling circumstances, including those where the medication is necessary to render a defendant competent to stand trial. We are of the opinion that such necessity would constitute a compelling state interest justifying infringement upon the right to bodily integrity. However, such a practice should be sparingly used with prior notice to defense counsel." Id. at 307.

The Supreme Court of New Hampshire dealt with the same argument and reached the same result. See State v. Hayes, 118 N.H. 458, 389 A. 2d 1379 (1978). There the court specifically authorized the trial court to compel the defendant to be under the influence of medications at least four weeks prior to his trial. Id.

We have researched the point and we find no published decisions which indicate a contrary conclusion.

When the General Assembly drafted the statutes providing for determination of incapacity to proceed (G.S. 15A-1001, et seq.), it did not address this issue. Thus, there are no statutes which specifically authorize the court to order that treatment be administered to make a defendant competent in any given case. Still, the fact that the General Assembly did not contemplate the problem does not relieve the court of its duty to deal with it.

Several cases decided by our Supreme Court are helpful. Our Court has twice observed that defendant otherwise incompetent may become legally competent when psychotropic drugs are administered. State v. Buie, 297 N.C. 159, 254 S.E.2d 26 (1979), State v. Potter, 289 N.C. 238, 204 S.E.2d 649 (1974). The opinions in these cases do not indicate that the defendants were forced to accept drugs. They do show, however, that our Supreme Court has recognized the usefulness of these drugs in helping defendants to arrange their thought processes to that they will be competent to stand trial.

It is important that the Court recognize the state's interest in bringing the criminal defendant to trial. The individual defendant also has an interest, but the civil rights cases recognizing a limited right to refuse psychotropic medications focus on the possible harmful side effects such as tardive dyskenisia that might or might not result from long term use of these drugs. See Rennie v. Klein, 653 F.2d 836 (3rd. Cir. 1981) (en banc); Rogers v. Okin, 634 F.2d 650 (1st Cir.), cert. granted, U.S. , 101 S.Ct. 1972, 68 L.Ed.2d 293 (1981). A criminal defendant compelled to accept medication for a short period of time would not be subjected to a substantial risk of serious or long term side effects. The importance of the state's interest is reflected in the words of Justice Brennan in his concurring opinion in Illinois v. Allen, 397 U.S. 337 (1970) which is quoted in State v. Law, supra, 244 S.E.2d at 307.

"The safeguards that the Constitution affords a criminal defendant presuppose that the government has a sovereign prerogative to put on trial those accused in good faith of violating valid laws. Constitutional power to bring an accused to trial is fundamental to a scheme of 'ordered liberty' and prerequisite to social justice and peace."

If this defendant has a constitutional interest in maintaining his bodily integrity, the state's interest in bringing the individual to trial clearly outweighs it.

We emphasize that there should be direct psychiatric testimony to show that the medications are likely to produce competence and that the medications do not create a substantial risk of serious or long term side effects. Given these circumstances, the Court may order the commitment of a defendant who has been found to be incompetent or possibly incomplete to a state hospital for the purpose of administration of medication and other treatments that will enable him to assist in preparation of his defense and his trial. If the defendant refuses to accept the medications, the Court may order that the medications be administered without the defendant's consent.

Rufus L. Edmisten
Attorney General

Ben G. Irons, II
Assistant Attorney General

James Peeler Smith
Assistant Attorney General