United States v. Jesse Gutierrez , 704 F.3d 442 ( 2013 )


Menu:
  •      Case: 12-50028   Document: 00512110222     Page: 1   Date Filed: 01/11/2013
    IN THE UNITED STATES COURT OF APPEALS
    FOR THE FIFTH CIRCUIT  United States Court of Appeals
    Fifth Circuit
    FILED
    January 11, 2013
    No. 12-50028                      Lyle W. Cayce
    Clerk
    UNITED STATES OF AMERICA
    Plaintiff - Appellee
    v.
    JESSE JOE GUTIERREZ
    Defendant - Appellant
    Appeal from the United States District Court
    for the Western District of Texas
    Before JOLLY, JONES, and GRAVES, Circuit Judges.
    JAMES E. GRAVES, JR., Circuit Judge:
    Defendant - Appellant Jesse Joe Gutierrez (“Gutierrez”) appeals an order
    of the district court directing the Bureau of Prisons (“BOP”) to involuntarily
    administer psychiatric medicine to him for the purpose of restoring his
    competency to stand trial. For the following reasons, we AFFIRM the order of
    the district court.
    BACKGROUND
    I.    Offense and Initial Commitment
    In November and December of 2008, Gutierrez made over one hundred
    telephone calls to a television station in Austin, Texas, threatening to harm or
    kill former President George W. Bush, Texas Governor Rick Perry, and both of
    Case: 12-50028   Document: 00512110222      Page: 2   Date Filed: 01/11/2013
    No. 12-50028
    their wives. This prompted an investigation by the Secret Service and a visit to
    Gutierrez by a Secret Service Agent, Nguyen Vu. On August 27, 2009, Gutierrez
    called Agent Vu and left a message on his voice mail. Gutierrez claimed to be
    delivering a message from God, and threatened to kill President Obama, former
    Presidents George W. Bush and George H.W. Bush, Agent Vu, and “all lawyers.”
    Gutierrez was arrested and charged with threatening to kill the President,
    a former President, and a federal law enforcement officer. On the government’s
    motion, the district court ordered that Gutierrez be given a mental examination
    to determine his competency to stand trial as well as his sanity at the time of the
    alleged offenses. Dr. Dwyer, a BOP forensic psychologist, diagnosed paranoid
    schizophrenia and opined that Gutierrez could not understand the nature and
    consequences of the proceedings against him or assist in his defense. Dr. Dwyer
    offered no opinion as to Gutierrez’s sanity at the time of his alleged offenses.
    Based on Dr. Dwyer’s report, the district court found that Gutierrez was
    incompetent to stand trial and committed him to the BOP to be hospitalized for
    treatment and determination of whether he was likely to regain competency in
    the foreseeable future.
    II.    Forensic Evaluation and First Administrative Hearing
    In July 2010, Dr. Pyant, a BOP psychologist, and Dr. Williamson, a BOP
    psychiatrist, completed a forensic evaluation of Gutierrez. In the evaluation, Dr.
    Pyant and Dr. Williamson diagnosed Gutierrez with Schizophrenia,
    Undifferentiated Type. Dr. Pyant and Dr. Williamson found a substantial
    probability that Gutierrez’s competency could be restored by treatment with
    psychiatric medicine, but opined that he was unlikely to regain competency
    without such medicine.      Dr. Pyant and Dr. Williamson also stated that
    administration of psychiatric medicine would be “medically appropriate” and
    described a proposed course of treatment.         However, Dr. Pyant and Dr.
    2
    Case: 12-50028   Document: 00512110222      Page: 3   Date Filed: 01/11/2013
    No. 12-50028
    Williamson noted that Gutierrez refused to take any medicine because he did not
    believe that he was mentally ill.
    On July 21, 2012, the BOP held a hearing to determine whether Gutierrez
    could be involuntarily medicated on the grounds that he was gravely disabled or
    a danger to himself or others at the institution. The hearing officer, Dr.
    Newman, determined that involuntary medication was not justified on these
    grounds. Nonetheless, Dr. Pyant and Dr. Williamson “highly recommended”
    that Gutierrez be involuntarily medicated in order to restore his competency.
    III.    First Sell Hearing in the District Court
    On December 17, 2010, the government moved for a hearing pursuant to
    Sell v. United States, 
    539 U.S. 166
     (2003), to determine whether Gutierrez could
    be involuntarily medicated to restore his competency to stand trial.            On
    February 3, 2011, after conducting a hearing, the district court issued an opinion
    analyzing the four factors set forth in Sell and ordering that Gutierrez be
    involuntarily medicated for this purpose. See United States v. Gutierrez, No.
    1:09-CR-453, 
    2011 WL 386784
     (S.D. Tex. Feb. 3, 2011). Gutierrez’s counsel
    appealed this order, arguing that before the district court could order
    involuntary psychiatric medication for the purpose of restoring competency to
    stand trial, the BOP must hold a hearing in which a neutral hearing officer
    determines that medication is necessary for this purpose. Gutierrez’s counsel
    also argued, based on the first Sell factor, that important government interests
    did not justify involuntary medication.
    IV.     Reversal of Involuntary Medication Order on Appeal
    A panel of this court reversed the district court’s order. See United States
    v. Gutierrez, 443 F. App’x 898 (5th Cir. 2011). The panel relied upon United
    States v. White, 
    431 F.3d 431
    , 433 (5th Cir. 2005), in which this court noted that
    the BOP had adopted by regulation mandatory procedures dealing with
    involuntary medication, and held that “when an inmate refuses medication, he
    3
    Case: 12-50028    Document: 00512110222      Page: 4    Date Filed: 01/11/2013
    No. 12-50028
    is entitled to an administrative hearing at the facility to determine whether he
    may be medicated against his will.” Although White did not squarely address
    whether the BOP must determine in the first instance whether involuntary
    medication is necessary to restore a defendant’s competency to stand trial, the
    panel held that such a determination is required.
    The government pointed out on appeal that at the time of Gutierrez’s
    administrative hearing, the BOP had proposed new regulations that would not
    require the BOP to determine whether involuntary medication is necessary to
    restore a defendant’s competency. By the time the panel issued its opinion,
    these regulations had been adopted. The new regulations authorize the BOP to
    administer psychiatric medicine involuntarily only on the grounds that an
    inmate “is dangerous to self or others, poses a serious threat of damage to
    property affecting the security or orderly running of the institution, or is gravely
    disabled (manifested by extreme deterioration in personal functioning).” 
    28 C.F.R. § 549.46
    (a)(7). The regulations further state that “[o]nly a Federal court
    of competent jurisdiction may order the involuntary administration of
    psychiatric medication for the sole purpose of restoring a person’s competency
    to stand trial.” 
    28 C.F.R. § 549.46
    (b)(2). However, the panel held that the BOP
    was required to follow the regulations in place at the time of the hearing.
    Furthermore, the panel held that the BOP must apply the earlier 1992
    regulations on remand in order to avoid the “improper retroactive effect” that
    would be caused by applying the new regulations.
    V.    Second Administrative Hearing
    On remand, the district court requested that the BOP hold a new
    administrative hearing in accordance with the panel’s directions. Dr. Pyant and
    Dr. Williamson submitted a new evaluation to the hearing officer recommending
    once again that Gutierrez be involuntarily medicated to restore his competency
    and opining that “no other less intrusive means are available to treat his mental
    4
    Case: 12-50028   Document: 00512110222      Page: 5   Date Filed: 01/11/2013
    No. 12-50028
    illness and achieve competency restoration.” The hearing officer, Dr. Zula,
    concluded that involuntary medication was “in [Gutierrez’s] best medical
    interest” and was likely to restore his competency. However, Dr. Zula noted that
    “[s]econdary to the Supreme Court Sell decision, we are unable to treat Mr.
    Gutierrez involuntarily for the purpose of restoring him to competency to stand
    trial; that authority is restricted to the Court.” Gutierrez appealed the hearing
    officer’s decision, stating: “I don’t need medicine. Your government is broken
    and corrupt.” Gutierrez also complained about his mail, discrimination, and
    delay by the courts. The warden rejected Gutierrez’s appeal and referred the
    matter back to the district court.
    VI.    Second Sell Hearing in the District Court
    On January 4, 2012, the district court held a second hearing to determine
    whether Gutierrez could be involuntarily medicated. In a subsequent order
    addressing the four Sell factors, the district court first held that “[t]wo equally
    important government interests weigh heavily in favor of involuntary
    treatment”: the government’s interest in “bringing to trial an individual accused
    of a serious crime,” and the government’s interest in “avoiding the alternatives
    to forced medication and trial.” The district court stated that “[o]nly one
    alternative exists if Gutierrez does not become competent and cannot be
    prosecuted: he will spend the rest of his life in a hospital.” Gutierrez’s counsel
    argued that there is no important government interest in prosecuting a
    defendant who almost certainly would not be convicted due to the significant,
    uncontested evidence of his insanity at the time of the offense. The district court
    responded that “[t]he rule announced in Sell would be a dead letter if courts
    accepted Gutierrez’s argument, which begs the question of whether, on the
    merits, Gutierrez will prove he was insane when the offense occurred.” The
    district court further stated that although there was “little doubt that Gutierrez
    5
    Case: 12-50028     Document: 00512110222      Page: 6   Date Filed: 01/11/2013
    No. 12-50028
    will ultimately be found insane, Gutierrez nevertheless bears the burden of
    proving this affirmative defense.”
    Addressing the second Sell factor, the district court found that medication
    is substantially likely to render Gutierrez competent to stand trial. The district
    court noted that, as part of this analysis, it must determine whether the
    medication will produce side effects that will interfere significantly with
    Gutierrez’s ability to assist counsel in conducting a trial defense. However, the
    district court did not discuss this issue other than to note that the 2010 forensic
    evaluation had concluded that treatment was “substantially unlikely” to have
    such side effects.
    Addressing the third Sell factor, the district court found that no
    alternative, less intrusive treatments are likely to achieve substantially the
    same results. The district court noted that no one, including Gutierrez, had ever
    argued that any less intrusive treatments would achieve the same results. The
    district court further noted that “every expert appears to agree . . . that only
    medication can help Gutierrez regain competence, because the nature of his
    psychosis is such that he has no idea he is ill, and so is unable and unwilling to
    accept other forms of therapy.” Although Gutierrez argued that the hearing
    officer’s report failed to make a finding that less intrusive methods were unlikely
    to succeed, the district court rejected this argument. The district court noted
    that the hearing officer’s report had indicated that alternative treatments were
    considered, and suggested that the report’s subsequent silence on the matter
    implied that these alternatives had been rejected. The district court also noted
    that the hearing officer, Dr. Zula, had testified at the second Sell hearing that
    no alternative treatments were likely to succeed. Finally, addressing the fourth
    Sell factor, the district court found that medication was medically appropriate
    and in Gutierrez’s best interests.
    6
    Case: 12-50028     Document: 00512110222     Page: 7   Date Filed: 01/11/2013
    No. 12-50028
    The district court also rejected Gutierrez’s argument that he was being
    denied due process because the administrative hearing did not fully comply with
    the 1992 regulations. The district court explained that “[t]he most important
    issue, and the one that appears to have motivated the Fifth Circuit’s holding in
    this case, appears to be . . . the requirement of having the hearing before an
    independent, nontreating psychiatrist.” The district court found that “[a]lthough
    the October 21, 2011 Hearing may not have perfectly complied with the 1992
    regulations, it did meet the substantive due process concerns raised by the Court
    of Appeals.” The district court also found that “any further effort by the
    Government to obtain administrative relief would be futile” because BOP
    officials believed, based on the advice of Department of Justice lawyers, that
    “they have no authority under Sell to actually order and carry out forced
    medication solely for the purpose of making a defendant competent for trial.”
    Accordingly, the district court held that the government had properly exhausted
    administrative remedies and complied with due process requirements. The
    district court concluded that it was appropriate to order forced medication under
    the Sell analysis. See United States v. Gutierrez, No. 1:09-CR-453 (S.D. Tex. Jan.
    10, 2012) (ECF No. 69).
    STANDARD OF REVIEW
    In reviewing a district court’s order to medicate a defendant involuntarily,
    we review findings of fact for clear error and conclusions of law de novo. United
    States v. White, 
    431 F.3d 431
    , 433 (5th Cir. 2005). “[W]hether the government’s
    asserted interests are sufficiently important is a legal issue subject to de novo
    review.” United States v. Palmer, 
    507 F.3d 300
    , 303 (5th Cir. 2007).
    DISCUSSION
    An individual “possesses a significant liberty interest in avoiding the
    unwanted administration of antipsychotic drugs.” Washington v. Harper, 
    494 U.S. 210
    , 221 (1990). However, “in certain instances” which “may be rare,” the
    7
    Case: 12-50028    Document: 00512110222       Page: 8   Date Filed: 01/11/2013
    No. 12-50028
    Constitution permits the government “involuntarily to administer antipsychotic
    drugs to a mentally ill defendant facing serious criminal charges in order to
    render that defendant competent to stand trial.” Sell v. United States, 
    539 U.S. 166
    , 179-80 (2003). First, a court must determine that “important governmental
    interests are at stake.” 
    Id. at 180
    . Second, the court must determine that
    involuntary medication “will significantly further” those interests – that is, that
    “administration of the drugs is substantially likely to render the defendant
    competent to stand trial” and is “substantially unlikely to have side effects that
    will interfere significantly with the defendant’s ability to assist counsel in
    conducting a trial defense.” 
    Id. at 181
    . Third, the court must determine that
    involuntary medication “is necessary to further those interests” – that is, that
    “any alternative, less intrusive treatments are unlikely to achieve substantially
    the same results.” 
    Id.
     Fourth, the court must determine that “administration
    of the drugs is medically appropriate” – that is, “in the patient’s best medical
    interest in light of his medical condition.” 
    Id.
    I.    Compliance with Regulatory Procedure
    The prior 1992 version of CFR § 549.43(a)(5) required that a psychiatrist
    hearing officer “determine whether treatment or psychotropic medication is
    necessary in order to attempt to make the inmate competent for trial.”
    Gutierrez’s counsel argues that the government still has not complied with this
    procedure because the hearing officer did not make a specific finding that
    medication was “necessary” for this purpose. It appears that the BOP declined
    to use the word “necessary” because it viewed such a finding as tantamount to
    an approval of involuntary medication. As the BOP correctly noted, only a
    district court can make the quintessentially legal determination of whether the
    government’s interest in prosecution overrides a defendant’s liberty interest in
    avoiding forced medication.
    8
    Case: 12-50028     Document: 00512110222     Page: 9   Date Filed: 01/11/2013
    No. 12-50028
    In Gutierrez’s prior appeal, this court described the procedure under the
    1992 regulations as a “bifurcated process” under which “[t]he BOP made medical
    findings: whether medication was necessary and effective to render a defendant
    competent” and “[t]he district court . . . made a legal determination: whether the
    person could, consistent with the Constitution and substantive due process, be
    forced to receive medication.” Gutierrez, 443 F. App’x at 903. We emphasized
    that requiring the government to “satisfy a psychiatrist not involved in [an
    inmate’s] treatment that medication [is] justified as a medical determination”
    served to “protect the inmate’s substantive right to be free from forced
    medication.” Id. at 903 & 906. Accordingly, the question is whether the BOP
    adequately made the medical findings required by Sell: whether medication is
    substantially likely to render a defendant competent to stand trial, whether less
    intrusive treatments are likely to achieve substantially the same results, and
    whether medication is “medically appropriate.”
    In this case, Dr. Zula, a neutral hearing officer, concluded after a proper
    hearing that involuntarily medicating Gutierrez would be in his best medical
    interests, would likely restore his competency, and was the only treatment that
    had any chance of success. Although Dr. Zula could have been more explicit on
    the last point in her report, it is clearly implied by the report and confirmed in
    her testimony before the district court. Moreover, none of these conclusions is
    actually in dispute. No person involved with this case has ever suggested that
    medication is unlikely to render Gutierrez competent to stand trial or that any
    alternative treatment is likely to achieve the same results. And although
    Gutierrez personally believes that he is not mentally ill and does not need
    medication, no one else has seriously suggested that medication would not be in
    his best medical interest. We find that the BOP satisfactorily complied with the
    1992 regulations.
    9
    Case: 12-50028     Document: 00512110222      Page: 10   Date Filed: 01/11/2013
    No. 12-50028
    II.     Important Government Interests
    In Sell, the Supreme Court provided the following guidance on
    determining whether important government interests are at stake:
    The Government’s interest in bringing to trial an individual accused
    of a serious crime is important. That is so whether the offense is a
    serious crime against the person or a serious crime against property.
    In both instances the Government seeks to protect through
    application of the criminal law the basic human need for security.
    ...
    Courts, however, must consider the facts of the individual case in
    evaluating the Government’s interest in prosecution. Special
    circumstances may lessen the importance of that interest. The
    defendant’s failure to take drugs voluntarily, for example, may
    mean lengthy confinement in an institution for the mentally
    ill—and that would diminish the risks that ordinarily attach to
    freeing without punishment one who has committed a serious crime.
    We do not mean to suggest that civil commitment is a substitute for
    a criminal trial. The government has a substantial interest in
    timely prosecution. And it may be difficult or impossible to try a
    defendant who regains competence after years of commitment
    during which memories may fade and evidence may be lost. The
    potential for future confinement affects, but does not totally
    undermine, the strength of the need for prosecution. The same is
    true of the possibility that the defendant has already been confined
    for a significant amount of time (for which he would receive credit
    toward any sentence ultimately imposed, see 
    18 U.S.C. § 3585
    (b)).
    Moreover, the Government has a concomitant, constitutionally
    essential interest in assuring that the defendant’s trial is a fair one.
    Sell, 
    539 U.S. at 180
    .
    Gutierrez’s counsel does not contest that Gutierrez is charged with a
    “serious crime.” Rather, counsel argues that special circumstances lessen the
    government’s interest in prosecution.          Counsel first points to the “strong
    likelihood that [Gutierrez] will continue to be institutionalized,” apparently
    referring to the possibility of civil commitment. Second, counsel argues that the
    time Gutierrez has already spent in custody, thirty-one months, is longer than
    10
    Case: 12-50028    Document: 00512110222       Page: 11   Date Filed: 01/11/2013
    No. 12-50028
    the likely sentence he would receive upon conviction. Third, counsel argues that
    forcibly medicating Gutierrez may undermine his right to a fair trial. Finally,
    counsel argues that there is no significant government interest in prosecuting
    Gutierrez because it is virtually certain that he would be found not guilty by
    reason of insanity.
    A.    Possibility of Civil Commitment
    This court and other circuits have held that the government’s interest in
    prosecution is not diminished if the likelihood of civil commitment is uncertain.
    See, e.g., United States v. Nicklas, 
    623 F.3d 1175
    , 1178-79 (8th Cir. 2010);
    Palmer, 
    507 F.3d at 304
    ; United States v. Bradley, 
    417 F.3d 1107
    , 1116-17 (10th
    Cir. 2005); United States v. Evans, 
    404 F.3d 227
    , 239 (4th Cir. 2005); United
    States v. Gomes, 
    387 F.3d 157
    , 161 (2d Cir. 2004). Under 
    18 U.S.C. § 4246
    ,
    Gutierrez could be civilly committed only if a court finds “by clear and convincing
    evidence that [he] is presently suffering from a mental disease or defect as a
    result of which his release would create a substantial risk of bodily injury to
    another person or serious damage to the property of another.” Similarly, under
    Texas law, Gutierrez could be civilly committed only if a judge or jury finds by
    clear and convincing evidence that he is likely to cause serious harm to himself
    or others, or is “suffering severe and abnormal mental, emotional, or physical
    distress” that causes “substantial mental or physical deterioration of [his] ability
    to function independently” and is “unable to make a rational and informed
    decision as to whether or not to submit to treatment.” Tex. Health & Safety
    Code § 574.035(a)(2) (West 2010). To be “clear and convincing,” the evidence
    “must include expert testimony and evidence of a recent overt act or a continuing
    pattern of behavior that tends to confirm: (1) the likelihood of serious harm to
    [himself] or others; or (2) [his] distress and the deterioration of [his] ability to
    function.” Id. § 574.035(e).
    11
    Case: 12-50028    Document: 00512110222      Page: 12    Date Filed: 01/11/2013
    No. 12-50028
    It is not clear that Gutierrez would be eligible for civil commitment under
    either federal or Texas law. Notably, the BOP concluded that involuntary
    medication was not justified because Gutierrez did not present a danger to
    himself or others and was not severely disabled by his mental illness. This
    finding, of course, was made in the context of his commitment at a mental
    hospital and did not directly address his expected dangerousness or his ability
    to function upon release. Nonetheless, it does suggest that it is far from certain
    that Gutierrez would be eligible for civil commitment. Other than making
    threats over the telephone, the record contains no evidence of any past violence
    on his part.
    Gutierrez’s counsel argues that the district court’s statement in its
    involuntary medication order that Gutierrez “will spend the rest of his life in a
    hospital” if he “does not become competent and cannot be prosecuted” was a
    factual finding that he would almost certainly be eligible for civil commitment.
    We do not believe that the district court intended this remark as a factual
    finding, and we do not interpret it as such. The district court did not even set
    forth the elements required for civil commitment, much less discuss how or why
    Gutierrez would satisfy them for the remainder of his life. In any event, if we
    viewed this statement as a factual finding, we would find it to be clearly
    erroneous based on the evidence in the record.
    B.       Time Already Spent in Custody
    Gutierrez is charged with threatening to kill the President and
    threatening to kill a former President, each of which carries a five-year statutory
    maximum, as well as threatening to kill a federal law enforcement officer with
    intent to interfere with the performance of official duties, which carries a ten-
    year statutory maximum. 
    18 U.S.C. §§ 115
    (b)(4), 871(a) & 879(a). Accordingly,
    assuming conviction on all counts and consecutive sentencing, Gutierrez could
    receive a maximum of twenty years imprisonment. Gutierrez’s counsel argues
    12
    Case: 12-50028    Document: 00512110222      Page: 13    Date Filed: 01/11/2013
    No. 12-50028
    that the “likely” advisory guidelines range upon conviction would be fifteen to
    twenty-one months imprisonment, whereas the government suggests that the
    range appears to be at least seventy-eight to ninety-seven months and “possibly”
    as high as 235 to 293 months.
    This disagreement between the parties illustrates the difficulty of trying
    to estimate the applicable guidelines range without the benefit of a presentence
    report. Gutierrez’s counsel suggests that the district court could have directed
    the U.S. Probation Office to prepare a report calculating the likely guidelines
    sentence in advance of the Sell hearing. This is not an acceptable solution. A
    presentence report involves an often lengthy investigation by a probation officer,
    after which both parties have an opportunity to object.          An incompetent
    defendant is, by definition, unable to meaningfully participate in this process.
    More importantly, even if it were possible to produce an accurate
    presentence report in advance of a Sell hearing, this would not take into account
    the broad discretion of the district judge to impose a sentence outside the
    advisory guidelines range. It is not appropriate either to require a district court
    to conduct a mock sentencing hearing and select a provisional sentence at a
    Sell hearing, or to prematurely speculate about a defendant’s possible sentence
    in an interlocutory appeal. Accordingly, we follow the approach of several other
    circuits in comparing the time already served by Gutierrez with the statutory
    maximum authorized for his indicted offenses. See, e.g., Bradley, 
    417 F.3d at 1117
    ; Evans, 
    404 F.3d at 239
    ; Gomes, 
    387 F.3d at 160
    ; but see United States v.
    Ruiz-Gaxiola, 
    623 F.3d 684
    , 694 (9th Cir. 2010) (using expected guidelines range
    rather than statutory maximum to determine “seriousness” of crime, as well as
    additional incarceration that the defendant would face upon conviction). Under
    this standard, the government’s interest in prosecution is clearly not diminished.
    Furthermore, even assuming Gutierrez would serve little or no prison time
    if tried and convicted, the government’s interest in prosecution is not
    13
    Case: 12-50028    Document: 00512110222       Page: 14   Date Filed: 01/11/2013
    No. 12-50028
    extinguished.   In Palmer, we noted that “the government interest, as the
    [Supreme C]ourt explained in Sell, is not in seeing [a defendant] convicted, but
    rather in ensuring that he is brought to trial.” Palmer, 
    507 F.3d at 304
    . Aside
    from exacting retribution against and incapacitating Gutierrez himself,
    prosecution of the instant offenses expresses society’s disapproval of such
    conduct and potentially deters others from engaging in it.            Additionally,
    conviction would authorize the district court to impose a term of supervised
    release, which would facilitate monitoring of Gutierrez to ensure that he does
    not pose a threat to others.
    C.    Right to a Fair Trial
    In discussing the government’s interest in bringing a defendant to trial,
    the Supreme Court in Sell stated also that “the Government has a concomitant,
    constitutionally essential interest in assuring that the defendant’s trial is a fair
    one.” Sell, 
    539 U.S. at 180
    . The Court has also suggested that psychiatric
    medication may impinge upon a defendant’s right to a fair trial by adversely
    affecting his “outward appearance, . . . the content of his testimony on direct or
    cross examination, his ability to follow the proceedings, or the substance of his
    communication with counsel.” Riggins v. Nevada, 
    504 U.S. 127
    , 137 (1992). As
    explained further in Justice Kennedy’s concurrence, the concerns with a
    defendant’s “outward appearance” arise from the possibility that medication will
    “alter[] his demeanor in a manner that will prejudice his reactions and
    presentation in the courtroom.” 
    Id. at 142
     (Kennedy, J., concurring). If a
    defendant testifies, his “demeanor can have a great bearing on his credibility,
    persuasiveness, and on the degree to which he evokes sympathy.” 
    Id.
     “[S]erious
    prejudice could result if medication inhibits the defendant’s capacity to react and
    respond to the proceedings and to demonstrate remorse or compassion.” 
    Id. at 143-44
    . Antipsychotic drugs may cause the defendant to be “restless and unable
    to sit still”; may cause “tremor of the limbs, diminished range of facial
    14
    Case: 12-50028    Document: 00512110222      Page: 15    Date Filed: 01/11/2013
    No. 12-50028
    expression, or slowed movements and speech”; and may cause extreme
    drowsiness. 
    Id. at 142-43
    .
    The concern expressed by Gutierrez’s counsel is not comparable to the
    concerns recognized by the Supreme Court as legitimate.           In essence, his
    argument is that medication will undermine Gutierrez’s insanity defense by
    making him appear to be more sane.            As other circuits have noted, an
    incompetent defendant simply cannot be tried, regardless of the defense he
    wishes to present. See Gomes, 
    387 F.3d at 162
    . If an insanity defense could not
    be successfully advanced by a competent defendant, it would not exist. At trial,
    Gutierrez could present evidence of his insanity at the time of his alleged offense
    and could of course point out that his demeanor had been altered by involuntary
    medication. Furthermore, “a defendant does not have an absolute right to
    replicate on the witness stand his mental state at the time of the crime.” United
    States v. Weston, 
    255 F.3d 873
    , 884 (D.C. Cir. 2001). We find that involuntary
    medication would not interfere with Gutierrez’s right to a fair trial.
    D.    Likelihood of Successful Insanity Defense
    Although Gutierrez’s counsel argues that a verdict of not guilty by reason
    of insanity is virtually certain if Gutierrez is restored to competency and
    prosecution is resumed, this is not necessarily so. As the government points out,
    Gutierrez could decide to dispute his guilt by arguing that he did not have the
    requisite mens rea at the time he made the alleged threats. Gutierrez could
    alternately decide that pleading guilty and accepting a possibly short sentence
    is preferable to risking indeterminate civil commitment with an insanity plea.
    Or, as Gutierrez’s counsel predicts, he could choose to plead not guilty by reason
    of insanity. Because Gutierrez himself is currently incompetent to stand trial
    due to mental illness, he cannot explain what he would do if restored to
    competency. Given this uncertainty and the variety of possible outcomes, it does
    not follow that prosecution is unnecessary.
    15
    Case: 12-50028     Document: 00512110222     Page: 16   Date Filed: 01/11/2013
    No. 12-50028
    Furthermore, even if it were certain that Gutierrez would successfully
    plead not guilty by reason of insanity, the government would continue to have
    an interest in prosecution due to the shifted burden of proof for insanity
    acquitees in civil commitment proceedings. Under the Insanity Defense Reform
    Act, a defendant found not guilty by reason of insanity is automatically
    committed unless he can prove “that his release would not create a substantial
    risk of bodily injury to another person or serious damage of property of another
    due to a present mental disease or defect.” 
    18 U.S.C. § 4243
    . If the charged
    offense involved “bodily injury to, or serious damage to the property of, another
    person, or . . . a substantial risk of such injury or damage,” the defendant must
    prove his lack of dangerousness by clear and convincing evidence; otherwise it
    must be proven by a preponderance of the evidence. 
    Id.
     The Tenth Circuit,
    apparently the only circuit to address the question in a published opinion, has
    held that “the crime of making a threat against the President of the United
    States in violation of 
    18 U.S.C. § 871
     necessarily involves a substantial risk of
    bodily injury to another person or damage to another person’s property.” United
    States v. Gilgert, 
    314 F.3d 506
    , 515 (10th Cir. 2002).
    Under normal civil commitment procedures, the government must prove
    by clear and convincing evidence that Gutierrez’s release would create a
    substantial risk to others. Making Gutierrez prove by clear and convincing
    evidence that his release would not create substantial risk to others is a very
    different standard. In a case such as this, where it is not clear whether
    Gutierrez has the inclination to act on his threats, the difference in burdens
    could well determine the outcome of a civil commitment proceeding. Moreover,
    it is worth noting that this difference in burdens is not merely a procedural
    anomaly or accident – the Insanity Defense Reform Act represents a clear
    legislative judgment that persons who have in fact committed crimes but have
    16
    Case: 12-50028     Document: 00512110222      Page: 17   Date Filed: 01/11/2013
    No. 12-50028
    not been held legally responsible due to insanity should be presumed dangerous
    rather than not dangerous.
    CONCLUSION
    The district court’s order approving involuntary medication for the purpose
    of restoring Gutierrez to competency is AFFIRMED. The case is remanded to
    the district court for further proceedings.
    17