Slip opinion
 

NOTE: Where it is feasible, a syllabus
(headnote) will be released, as is being
done in connection with this case, at
the time the opinion is issued.  The
syllabus constitutes no part of the
opinion of the Court but has been pre-
pared by the Reporter of Decisions for
the convenience of the reader.  See
United States v. Detroit Lumber Co., 200
U. S. 321, 337.

SUPREME COURT OF THE UNITED STATES

              Syllabus

          RIGGINS v. NEVADA
   certiorari to the supreme court of nevada
No. 908466.   Argued January 15, 1992"Decided
            May 18, 1992

When petitioner Riggins, while awaiting a Nevada
trial on murder and robbery charges, complained
of hearing voices and having sleep problems, a
psychiatrist prescribed the antipsychotic drug
Mellaril.  After he was found competent to stand
trial, Riggins made a motion to suspend the
Mellaril's administration until after his trial,
arguing that its use infringed upon his freedom,
that its effect on his demeanor and mental
state during trial would deny him due process,
and that he had the right to show jurors his
true mental state when he offered an insanity
defense.  After hearing the testimony of doc-
tors who had examined Riggins, the trial court
denied the motion with a one-page order giving
no indication of its rationale.  At Riggins' trial,
he presented his insanity defense and testi-
fied, was convicted, and was sentenced to death.
In affirming, the State Supreme Court held,
inter alia, that expert testimony presented at
trial was sufficient to inform the jury of the
Mellaril's effect on Riggins' demeanor and testi-
mony.
Held:The forced administration of antipsychotic
medication during Riggins' trial violated rights
guaranteed by the Sixth and Fourteenth Amend-
ments.  Pp.510.
(a)The record narrowly defines the issues in
this case.  Administration of Mellaril was invol-
untary once Riggins' motion to terminate its use
was denied, but its administration was medically
appropriate.  In addition, Riggins' Eighth Amend-
ment argument that the drug's administration
denied him the opportunity to show jurors his
true mental condition at the sentencing hearing
was not raised below or in the petition for
certiorari and, thus, will not be considered by
this Court.  P.5.
(b)A pretrial detainee has an interest in
avoiding involuntary administration of antipsy-
chotic drugs that is protected under the Due
Process Clause.  Cf. Washington v. Harper, 494 U.S.
210; Bell v. Wolfish, 441 U.S. 520, 545.  Once
Riggins moved to terminate his treatment, the
State became obligated to establish both the
need for Mellaril and its medical appropriate-
ness.  Cf. Harper, supra, at 227.  Due process
certainly would have been satisfied had the
State shown that the treatment was medically
appropriate and, considering less intrusive
alternatives, essential for Riggins' own safety
or the safety of others.  The State also might
have been able to justify the treatment, if
medically appropriate, by showing that an adju-
dication of guilt or innocence could not be
obtained by using less intrusive means.  Howev-
er, the trial court allowed the drug's adminis-
tration to continue without making any determi-
nation of the need for this course or any find-
ings about reasonable alternatives, and it
failed to acknowledge Riggins' liberty interest
in freedom from antipsychotic drugs.  Pp.59.
(c)There is a strong possibility that the trial
court's error impaired Riggins' constitutionally
protected trial rights.  Efforts to prove or
disprove actual prejudice from the record be-
fore this Court would be futile, and guesses as
to the trial's outcome had Riggins' motion been
granted would be speculative.  While the precise
consequences of forcing Mellaril upon him can-
not be shown from a trial transcript, the testi-
mony of doctors who examined Riggins establish-
es the strong possibility that his defense was
impaired.  Mellaril's side effects may have im-
pacted not only his outward appearance, but
also his testimony's content, his ability to
follow the proceedings, or the substance of his
communication with counsel.  Thus, even if the
expert testimony presented at trial allowed
jurors to assess Riggins' demeanor fairly, an
unacceptable risk remained that forced medica-
tion compromised his trial rights.  Pp.910.
(d)While trial prejudice can sometimes be
justified by an essential state interest, the
record here contains no finding to support a
conclusion that administration of antipsychotic
medication was necessary to accomplish an es-
sential state policy.  P.10.
107 Nev. ___, 808 P.2d 535, reversed and remand-
ed.

O'Connor, J., delivered the opinion of the Court,
in which Rehnquist, C. J., and White, Blackmun,
Stevens, and Souter, JJ., joined.  Kennedy, J.,
filed an opinion concurring in the judgment.  Tho-
mas, J., filed a dissenting opinion, in which Scali-
a, J., joined except as to Part IIA.
Opinion
NOTICE: This opinion is subject to formal
revision before publication in the pre-
liminary print of the United States
Reports.  Readers are requested to
notify the Reporter of Decisions, Su-
preme Court of the United States, Wash-
ington, D.C. 20543, of any typographical
or other formal errors, in order that
corrections may be made before the
preliminary print goes to press.

SUPREME COURT OF THE UNITED STATES
             No. 90-8466
 
 DAVID RIGGINS, PETITIONER v. NEVADA
 on writ of certiorari to the supreme court of
                    nevada
                [May 18, 1992]

  Justice O'Connor delivered the opinion of the
Court.
  Petitioner David Riggins challenges his murder
and robbery convictions on the ground that the
State of Nevada unconstitutionally forced an
antipsychotic drug upon him during trial.  Because
the Nevada courts failed to make findings suffi-
cient to support forced administration of the
drug, we reverse.
                       I
  During the early hours of November 20, 1987,
Paul Wade was found dead in his Las Vegas apart-
ment.  An autopsy revealed that Wade died from
multiple stab wounds, including wounds to the
head, chest, and back.  David Riggins was arrested
for the killing 45 hours later.
  A few days after being taken into custody,
Riggins told Dr. R. Edward Quass, a private psychi-
atrist who treated patients at the Clark County
Jail, about hearing voices in his head and having
trouble sleeping.  Riggins informed Dr. Quass that
he had been successfully treated with Mellaril in
the past.  Mellaril is the trade name for thiorida-
zine, an antipsychotic drug.  After this consulta-
tion, Dr. Quass prescribed Mellaril at a level of
100 milligrams per day.  Because Riggins continued
to complain of voices and sleep problems in the
following months, Dr. Quass gradually increased
the Mellaril prescription to 800 milligrams per
day.  Riggins also received a prescription for
Dilantin, an antiepileptic drug.
  In January 1988, Riggins successfully moved for
a determination of his competence to stand trial.
App. 6.  Three court-appointed psychiatrists
performed examinations during February and
March, while Riggins was taking 450 milligrams of
Mellaril daily.  Dr. William O'Gorman, a psychiatrist
who had treated Riggins for anxiety in 1982, and
Dr. Franklin Master concluded that Riggins was
competent to stand trial.  The third psychiatrist,
Dr. Jack Jurasky, found that Riggins was incompe-
tent.  The Clark County District Court determined
that Riggins was legally sane and competent to
stand trial, id., at 13, so preparations for trial
went forward.
  In early June, the defense moved the District
Court for an order suspending administration of
Mellaril and Dilantin until the end of Riggins'
trial.  Id., at 20.  Relying on both the Fourteenth
Amendment and the Nevada Constitution, Riggins
argued that continued administration of these
drugs infringed upon his freedom and that the
drugs' effect on his demeanor and mental state
during trial would deny him due process.  Riggins
also asserted that, because he would offer an
insanity defense at trial, he had a right to show
jurors his ``true mental state.''  Id., at 22.  In re-
sponse, the State noted that Nevada law prohibits
the trial of incompetent persons, see Nev. Rev.
Stat. 178.400 (1989), and argued that the court
therefore had authority to compel Riggins to take
medication necessary to ensure his competence.
App. 3132.
      On July 14, 1988, the District Court held an
evidentiary hearing on Riggins' motion.  At the
hearing, Dr. Master ``guess[ed]'' that taking Riggi-
ns off medication would not noticeably alter his
behavior or render him incompetent to stand trial.
Record 412.  Dr. Quass testified that, in his
opinion, Riggins would be competent to stand trial
even without the administration of Mellaril, but
that the effects of Mellaril would not be notice-
able to jurors if medication continued.  Id., at
443445.  Finally, Dr. O'Gorman told the court that
Mellaril made the defendant calmer and more
relaxed but that an excessive dose would cause
drowsiness.  Id., at 464466.  Dr. O'Gorman was
unable to predict how Riggins might behave if
taken off antipsychotic medication, yet he ques-
tioned the need to give Riggins the high dose he
was receiving.  Id., at 474476.  The court also
had before it a written report in which Dr. Jurasky
held to his earlier view that Riggins was incompe-
tent to stand trial and predicted that if taken off
Mellaril the defendant ``would most likely regress
to a manifest psychosis and become extremely
difficult to manage.''  App. 19.
  The District Court denied Riggins' motion to
terminate medication with a one-page order that
gave no indication of the court's rationale.  Id.,
at 49.  Riggins continued to receive 800 milligrams
of Mellaril each day through the completion of his
trial the following November.
  At trial, Riggins presented an insanity defense
and testified on his own behalf.  He indicated that
on the night of Wade's death he used cocaine
before going to Wade's apartment.  Riggins admit-
ted fighting with Wade, but claimed that Wade was
trying to kill him and that voices in his head said
that killing Wade would be justifiable homicide.  A
jury found Riggins guilty of murder with use of a
deadly weapon and robbery with use of a deadly
weapon.  After a penalty hearing, the same jury
set the murder sentence at death.
  Riggins presented several claims to the Nevada
Supreme Court, among them that forced adminis-
tration of Mellaril denied him the ability to
assist in his own defense and prejudicially af-
fected his attitude, appearance, and demeanor at
trial.  This prejudice was not justified, Riggins
said in his opening brief, because the State
neither demonstrated a need to administer Mellar-
il nor explored alternatives to giving him 800
milligrams of the drug each day.  Record 1020.
Riggins amplified this claim in his reply brief,
objecting that the State intruded upon his con-
stitutionally protected liberty interest in
freedom from antipsychotic drugs without consid-
ering less intrusive options.  Riggins argued:

       In United States v. Bryant, 670 F. Supp. 840,
   843 (Minn. 1987)[,] the court, in reference to
   medicating prisoners against their will, stat-
ed that `courts have recognized a protectable
   liberty interest . . . in the freedom to avoid
   unwanted medication with such drugs.'  The
   court in so stating cited Bee v. Greaves, 744
   F.2d 1387 (10th Cir. 1984)[,] which addressed the
   issue of medicating pre-trial detainees and
   stated that `less restrictive alternatives,
   such as segregation or the use of less con-
troversial drugs like tranquilizers or seda-
tives, should be ruled out before resorting to
   antipsychotic drugs.'  In the case at bar, no
   less restrictive alternatives were utilized,
   considered or even proposed.  Record 10701-
071 (emphasis in original).

     The Nevada Supreme Court affirmed Riggins'
convictions and death sentence.  107 Nev. ___, 808
P. 2d 535 (1991).  With respect to administration of
Mellaril, the court held that expert testimony
presented at trial ``was sufficient to inform the
jury of the effect of the Mellaril on Riggins'
demeanor and testimony.''  Id., at ___, 808 P. 2d,
at 538.  Thus, although Riggins' demeanor was
relevant to his insanity defense, the court held
that denial of the defense's motion to terminate
medication was neither an abuse of discretion nor
a violation of Riggins' trial rights.  In a concur-
ring opinion, Justice Rose suggested that the
District Court should have determined whether
administration of Mellaril during trial was ``abso-
lutely necessary'' by ordering a pretrial suspen-
sion of medication.  Id., at ___, 808 P. 2d, at 540
(concurring opinion).  Justice Springer dissented,
arguing that antipsychotic drugs may never be
forced on a criminal defendant solely to allow
prosecution.  Id., at ___, 808 P. 2d, at 541 (dis-
senting opinion).
  We granted certiorari, 502 U. S. ___ (1991), to
decide whether forced administration of antipsy-
chotic medication during trial violated rights
guaranteed by the Sixth and Fourteenth Amend-
ments.
                      II
  The record in this case narrowly defines the
issues before us.  The parties have indicated that
once the District Court denied Riggins' motion to
terminate use of Mellaril, subsequent administra-
tion of the drug was involuntary.  See, e. g., Brief
for Petitioner 6 (medication was  forced); Brief
for Respondent 14, 22, 28 (describing medication
as  unwanted,  over objection, and  compelled).
This understanding accords with the determination
of the Nevada Supreme Court.  See 107 Nev., at
___; 808 P. 2d, at 537 (describing medication as
 involuntary and  forced).  Given the parties'
positions on this point and the absence of any
record evidence to the contrary, we adhere to the
understanding of the state Supreme Court.
  We also presume that administration of Mellaril
was medically appropriate.  Although defense
counsel stressed that Riggins received a very
high dose of the drug, at no point did he suggest
to the Nevada courts that administration of
Mellaril was medically improper treatment for his
client.
  Finally, the record is dispositive with respect
to Riggins' Eighth Amendment claim that adminis-
tration of Mellaril denied him an opportunity to
show jurors his true mental condition at the
sentencing hearing.  Because this argument was
presented neither to the Nevada Supreme Court
nor in Riggins' petition for certiorari, we do not
address it here.
  With these considerations in mind, we turn to
Riggins' core contention that involuntary adminis-
tration of Mellaril denied him ``a full and fair
trial.''  Pet. for Cert. i.  Our discussion in Wash-
ington v. Harper, 494 U. S. 210 (1990), provides
useful background for evaluating this claim.  In
Harper, a prison inmate alleged that the State of
Washington and various individuals violated his
right to due process by giving him Mellaril and
other antipsychotic drugs against his will.
Although the inmate did not prevail, we agreed
that his interest in avoiding involuntary adminis-
tration of antipsychotic drugs was protected
under the Fourteenth Amendment's Due Process
Clause.  ``The forcible injection of medication into
a nonconsenting person's body,'' we said, ``repre-
sents a substantial interference with that perso-
n's liberty.''  Id., at 229.  In the case of antipsy-
chotic drugs like Mellaril, that interference is
particularly severe:

   ``The purpose of the drugs is to alter the
   chemical balance in a patient's brain, leading
   to changes, intended to be beneficial, in his or
   her cognitive processes.  While the therapeu-
tic benefits of antipsychotic drugs are well
   documented, it is also true that the drugs can
   have serious, even fatal, side effects.  One
   such side effect identified by the trial court
   is acute dystonia, a severe involuntary spasm
   of the upper body, tongue, throat, or eyes.
   The trial court found that it may be treated
   and reversed within a few minutes through use
   of the medication Cogentin.  Other side ef-
fects include akathesia (motor restlessness,
   often characterized by an inability to sit
   still); neuroleptic malignant syndrome (a
   relatively rare condition which can lead to
   death from cardiac dysfunction); and tardive
   dyskinesia, perhaps the most discussed side
   effect of antipsychotic drugs.  Tardive dyski-
nesia is a neurological disorder, irreversible
   in some cases, that is characterized by invol-
untary, uncontrollable movements of various
   muscles, especially around the face. . . .  [T]he
   proportion of patients treated with antipsy-
chotic drugs who exhibit the symptoms of
   tardive dyskinesia ranges from 10% to 25%.
   According to the American Psychiatric Associ-
ation, studies of the condition indicate that
   60% of tardive dyskinesia is mild or minimal in
   effect, and about 10% may be characterized as
   severe.''  Id., at 229230 (citations omitted).

Taking account of the unique circumstances of
penal confinement, however, we determined that
due process allows a mentally ill inmate to be
treated involuntarily with antipsychotic drugs
where there is a determination that ``the inmate is
dangerous to himself or others and the treatment
is in the inmate's medical interest.''  Id., at 227.
  Under Harper, forcing antipsychotic drugs on a
convicted prisoner is impermissible absent a
finding of overriding justification and a determi-
nation of medical appropriateness.  The Four-
teenth Amendment affords at least as much pro-
tection to persons the State detains for trial.
See Bell v. Wolfish, 441 U. S. 520, 545 (1979) (``[P]r-
etrial detainees, who have not been convicted of
any crimes, retain at least those constitutional
rights that we have held are enjoyed by convicted
prisoners''); O'Lone v. Estate of Shabazz, 482 U. S.
342, 349 (1987) (``[P]rison regulations . . . are
judged under a `reasonableness' test less re-
strictive than that ordinarily applied to alleged
infringements of fundamental constitutional
rights'').  Thus, once Riggins moved to terminate
administration of antipsychotic medication, the
State became obligated to establish the need for
Mellaril and the medical appropriateness of the
drug.
  Although we have not had occasion to develop
substantive standards for judging forced adminis-
tration of such drugs in the trial or pretrial
settings, Nevada certainly would have satisfied
due process if the prosecution had demonstrated
and the District Court had found that treatment
with antipsychotic medication was medically
appropriate and, considering less intrusive
alternatives, essential for the sake of Riggins'
own safety or the safety of others.  See Harper,
supra, at 225226; cf. Addington v. Texas, 441 U. S.
418 (1979) (Due Process Clause allows civil commit-
ment of individuals shown by clear and convincing
evidence to be mentally ill and dangerous).  Simi-
larly, the State might have been able to justify
medically appropriate, involuntary treatment with
the drug by establishing that it could not obtain
an adjudication of Riggins' guilt or innocence by
using less intrusive means.  See Illinois v. Allen,
397 U. S. 337, 347 (1970) (Brennan, J., concurring)
(``Constitutional power to bring an accused to
trial is fundamental to a scheme of `ordered
liberty' and prerequisite to social justice and
peace'').  We note that during the July 14 hearing
Riggins did not contend that he had the right to be
tried without Mellaril if its discontinuation
rendered him incompetent.  See Record 424425,
496, 500.  The question whether a competent
criminal defendant may refuse antipsychotic
medication if cessation of medication would
render him incompetent at trial is not before us.
  Contrary to the dissent's understanding, we do
not  adopt a standard of strict scrutiny.  Post,
at 12.  We have no occasion to finally prescribe
such substantive standards as mentioned above,
since the District Court allowed administration of
Mellaril to continue without making any determina-
tion of the need for this course or any findings
about reasonable alternatives.  The court's
laconic order denying Riggins' motion did not adopt
the State's view, which was that continued admin-
istration of Mellaril was required to ensure that
the defendant could be tried; in fact, the hearing
testimony casts considerable doubt on that argu-
ment.  See supra, at 23.  Nor did the order indi-
cate a finding that safety considerations or
other compelling concerns outweighed Riggins'
interest in freedom from unwanted antipsychotic
drugs.
  Were we to divine the District Court's logic from
the hearing transcript, we would have to conclude
that the court simply weighed the risk that the
defense would be prejudiced by changes in Riggins'
outward appearance against the chance that
Riggins would become incompetent if taken off
Mellaril, and struck the balance in favor of
involuntary medication.  See Record 502 (``[T]hat
he was nervous and so forth . . . can all be brought
out [through expert testimony].  And when you
start weighing the consequences of taking him off
his medication and possibly have him revert into
an incompetent situation, I don't think that that
is a good experiment'').  The court did not ac-
knowledge the defendant's liberty interest in
freedom from unwanted antipsychotic drugs.
  This error may well have impaired the constitu-
tionally protected trial rights Riggins invokes.
At the hearing to consider terminating medication,
Dr. O'Gorman suggested that the dosage adminis-
tered to Riggins was within the toxic range, id., at
483, and could make him ``uptight,'' id., at 484.  Dr.
Master testified that a patient taking 800 milli-
grams of Mellaril each day might suffer from
drowsiness or confusion.  Id., at 416.  Cf. Brief for
American Psychiatric Association as Amicus Curiae
1011 (``[I]n extreme cases, the sedation-like
effect [of antipsychotic medication] may be
severe enough (akinesia) to affect thought proce-
sses'').  It is clearly possible that such side
effects impacted not just Riggins' outward ap-
pearance, but also the content of his testimony
on direct or cross examination, his ability to
follow the proceedings, or the substance of his
communication with counsel.
  Efforts to prove or disprove actual prejudice
from the record before us would be futile, and
guesses whether the outcome of the trial might
have been different if Riggins' motion had been
granted would be purely speculative.  We accord-
ingly reject the dissent's suggestion that Riggins
should be required to demonstrate how the trial
would have proceeded differently if he had not
been given Mellaril.  See post, at 5.  Like the
consequences of compelling a defendant to wear
prison clothing, see Estelle v. Williams, 425 U. S.
501, 504505 (1976), or of binding and gagging an
accused during trial, see Allen, supra, at 344, the
precise consequences of forcing antipsychotic
medication upon Riggins cannot be shown from a
trial transcript.  What the testimony of doctors
who examined Riggins establishes, and what we will
not ignore, is a strong possibility that Riggins'
defense was impaired due to the administration of
Mellaril.
  We also are persuaded that allowing Riggins to
present expert testimony about the effect of
Mellaril on his demeanor did nothing to cure the
possibility that the substance of his own testi-
mony, his interaction with counsel, or his compre-
hension at trial were compromised by forced
administration of Mellaril.  Even if (as the dissent
argues, post, at 24) the Nevada Supreme Court
was right that expert testimony allowed jurors to
assess Riggins' demeanor fairly, an unacceptable
risk of prejudice remained.  See 107 Nev., at ___-
___, 808 P. 2d, at 537538.
  To be sure, trial prejudice can sometimes be
justified by an essential state interest.  See
Holbrook v. Flynn, 475 U. S. 560, 568569 (1986);
Allen, supra, at 344 (binding and gagging the
accused permissible only in extreme situations
where it is the ``fairest and most reasonable way''
to control a disruptive defendant); see also
Williams, supra, at 505 (compelling defendants to
wear prison clothing at trial furthers no essen-
tial state policy).  Because the record contains
no finding that might support a conclusion that
administration of antipsychotic medication was
necessary to accomplish an essential state
policy, however, we have no basis for saying that
the substantial probability of trial prejudice in
this case was justified.
     The judgment of the Nevada Supreme Court is
reversed, and the case is remanded for further
proceedings not inconsistent with this opinion.
                             It is so ordered.

Concur
      SUPREME COURT OF THE UNITED STATES
             No. 90-8466
 
 DAVID RIGGINS, PETITIONER v. NEVADA
 on writ of certiorari to the supreme court of
                    nevada
                [May 18, 1992]

  Justice Kennedy, concurring in the judgment.
  The medical and pharmacological data in the
amicus briefs and other sources indicate that
involuntary medication with antipsychotic drugs
poses a serious threat to a defendant's right to
a fair trial.  In the case before us, there was no
hearing or well-developed record on the point, and
the whole subject of treating incompetence to
stand trial by drug medication is somewhat new to
the law, if not to medicine.  On the sparse record
before us, we cannot give full consideration to
the issue.  I file this separate opinion, however,
to express my view that the Due Process Clause
prohibits prosecuting officials from administering
involuntary doses of antipsychotic medicines for
purposes of rendering the accused competent for
trial absent an extraordinary showing, and to
express doubt that the showing can be made, given
our present understanding of the properties of
these drugs.
  At the outset, I express full agreement with the
Court's conclusion that one who was medicated
against his will in order to stand trial may chal-
lenge his conviction.  When the State commands
medication during the pretrial and trial phases of
the case for the avowed purpose of changing the
defendant's behavior, the concerns are much the
same as if it were alleged that the prosecution
had manipulated material evidence.  See Brady v.
Maryland, 373 U. S. 83, 87 (1963) (suppression by
the prosecution of material evidence favorable to
the accused violates due process); Arizona v.
Youngblood, 488 U.S. 51, 58 (1988) (bad faith failure
to preserve potentially useful evidence consti-
tutes a due process violation).  I cannot accept
the premise of Justice Thomas' dissent that the
involuntary medication order comprises some
separate procedure, unrelated to the trial and
foreclosed from inquiry or review in the criminal
proceeding itself.  To the contrary, the allega-
tions pertain to the State's interference with the
trial and review in the criminal proceeding is
appropriate.
  I also agree with the majority that the State
has a legitimate interest in attempting to re-
store the competence of otherwise incompetent
defendants.  Its interest derives from the State's
right to bring an accused to trial and from our
holding in Pate v. Robinson, 383 U. S. 375, 378
(1966), that conviction of an incompetent defen-
dant violates due process.  Unless a defendant is
competent, the State cannot put him on trial.
Competence to stand trial is rudimentary, for
upon it depends the main part of those rights
deemed essential to a fair trial, including the
right to effective assistance of counsel, the
rights to summon, to confront, and to cross
examine witnesses, and the right to testify on
one's own behalf or to remain silent without
penalty for doing so.  Drope v. Missouri, 420 U.S.
162, 171172 (1975).  Although the majority is
correct that this case does not require us to
address the question whether a defendant may
waive his right to be tried while competent, in my
view a general rule permitting waiver would not
withstand scrutiny under the Due Process Clause,
given our holdings in Pate and Drope.  A defendant-
's waiver of the right to be tried while competent
would cast doubt on his exercise or waiver of all
subsequent rights and privileges through the
whole course of the trial.
  The question is whether the State's interest in
conducting the trial allows it to insure the
defendant's competence by involuntary medication,
assuming of course there is a sound medical basis
for the treatment.  The Court's opinion will re-
quire further proceedings on remand, but there
seems to be little discussion as to what must be
considered in these further proceedings.  The
Court's failure to address these issues is under-
standable in some respects, for it was not the
subject of briefing or argument; but to under-
score my reservations about the propriety of
involuntary medication for the purpose of render-
ing the defendant competent, and to explain what
I think ought to be express qualifications of the
Court's opinion, some discussion of the point is
required.
  This is not a case like Washington v. Harper, 494
U.S. 210 (1990), in which the purpose of the invol-
untary medication was to insure that the incar-
cerated person ceased to be a physical danger to
himself or others.  The inquiry in that context is
both objective and manageable.  Here the purpose
of the medication is not merely to treat a person
with grave psychiatric disorders and enable that
person to function and behave in a way not dan-
gerous to himself or others, but rather to render
the person competent to stand trial.  It is the
last part of the State's objective, medicating the
person for the purpose of bringing him to trial,
that causes most serious concern.  If the only
question were whether some bare level of func-
tional competence can be induced, that would be a
grave matter in itself, but here there are even
more far reaching concerns.  The avowed purpose
of the medication is not functional competence,
but competence to stand trial.  In my view elemen-
tary protections against state intrusion require
the State in every case to make a showing that
there is no significant risk that the medication
will impair or alter in any material way the defen-
dant's capacity or willingness to react to the
testimony at trial or to assist his counsel.
Based on my understanding of the medical litera-
ture, I have substantial reservations that the
State can make that showing.  Indeed, the inquiry
itself is elusive, for it assumes some baseline of
normality that experts may have some difficulty in
establishing for a particular defendant, if they
can establish it at all.  These uncertainties
serve to underscore the difficult terrain the
State must traverse when it enters this domain.
  To make these concerns concrete, the effects of
antipsychotic drugs must be addressed.  First
introduced in the 1950's, antipsychotic drugs such
as Mellaril have wide acceptance in the psychiat-
ric community as an effective treatment for
psychotic thought disorders.  See American Psy-
chiatric Press Textbook of Psychiatry 770774 (J.
Talbott, R. Hales & S. Yodofsky eds. 1988) (Text-
book of Psychiatry); Brief for American Psychiat-
ric Association as Amicus Curiae 67.  The medica-
tions restore normal thought processes by clear-
ing hallucinations and delusions.  Textbook of
Psychiatry, at 774.  See also Brief for American
Psychiatric Association, at 9 ( The mental health
produced by antipsychotic medication is no dif-
ferent from, no more inauthentic or alien to the
patient than, the physical health produced by
other medications, such as penicillin for pneumo-
nia).  For many patients, no effective alternative
exists for treatment of their illnesses.  Id., at 7,
and n.3.
  Although these drugs have changed the lives of
psychiatric patients, they can have unwanted side
effects.  We documented some of the more serious
side effects in Washington v. Harper, supra, at
229230, and they are mentioned again in the
majority opinion.  More relevant to this case are
side effects that, it appears, can compromise the
right of a medicated criminal defendant to receive
a fair trial.  The drugs can prejudice the accused
in two principal ways:  1) by altering his demeanor
in a manner that will prejudice his reactions and
presentation in the courtroom, and 2) by rendering
him unable or unwilling to assist counsel.
  It is a fundamental assumption of the adversary
system that the trier of fact observes the
accused throughout the trial, either while the
accused is on the stand or sitting at the defense
table.  This assumption derives from the right to
be present at trial, which in turn derives from the
right to testify and rights under the Confronta-
tion Clause.  Taylor v. United States, 414 U. S. 17,
19 (1973) (per curiam).  At all stages of the pro-
ceedings, the defendant's behavior, manner, facial
expressions, and emotional responses, or their
absence, combine to make an overall impression on
the trier of fact, an impression that can have a
powerful influence on the outcome of the trial.  If
the defendant takes the stand, as Riggins did, his
demeanor can have a great bearing on his credibil-
ity, persuasiveness, and on the degree to which he
evokes sympathy.  The defendant's demeanor may
also be relevant to his confrontation rights.  See
Coy v. Iowa, 487 U. S. 1012, 10161020 (1988) (empha-
sizing the importance of the face-to-face encoun-
ter between the accused and the accuser).
  The side effects of antipsychotic drugs may
alter demeanor in a way that will prejudice all
facets of the defense.  Serious due process
concerns are implicated when the State manipu-
lates the evidence in this way.  The defendant may
be restless and unable to sit still.  Brief for
American Psychiatric Association, at 10.  The
drugs can induce a condition called parkinsonism,
which, like Parkinson's disease, is characterized
by tremor of the limbs, diminished range of facial
expression, or slowed movements and speech.  Ibid.
Some of the side effects are more subtle.  Anti-
psychotic drugs such as Mellaril can have a
 sedation-like effect that in severe cases may
affect thought processes.  Ibid.  At trial, Dr.
Jurasky testified that Mellaril has  a tranquiliz-
er effect.  Record 752.  See also ibid. ( If you
are dealing with someone very sick then you may
prescribe up to 800 milligrams which is the dose
he had been taking which is very, very high.  I mean
you can tranquilize an elephant with 800 milli-
grams).  Dr. Jurasky listed the following side
effects of large doses of Mellaril:   Drowsiness,
constipation, perhaps lack of alertness, changes
in blood pressure. . . .  Depression of the psycho-
motor functions.  If you take a lot of it you
become stoned for all practical purposes and can
barely function.  Id., at 753.
  These potential side effects would be disturbing
for any patient; but when the patient is a criminal
defendant who is going to stand trial, the docu-
mented probability of side effects seems to me to
render involuntary administration of the drugs by
prosecuting officials unacceptable absent a
showing by the State that the side effects will
not alter the defendant's reactions or diminish
his capacity to assist counsel.  As the American
Psychiatric Association points out:
    By administering medication, the State may be
   creating a prejudicial negative demeanor in
   the defendant"-making him look nervous or
   restless, for example, or so calm or sedated
   as to appear bored, cold, unfeeling, and unre-
sponsive. . . .  That such effects may be subtle
   does not make them any less real or potential-
ly influential.Brief for American Psychiatric
   Association, at 13.  As any trial attorney will
   attest, serious prejudice could result if
   medication inhibits the defendant's capacity
   to react and respond to the proceedings and
   to demonstrate remorse or compassion.  The
   prejudice can be acute during the sentencing
   phase of the proceedings, when the sentencer
   must attempt to know the heart and mind of the
   offender and judge his character, his contri-
tion or its absence, and his future dangerous-
ness.  In a capital sentencing proceeding,
   assessments of character and remorse may
   carry great weight and, perhaps, be determi-
native of whether the offender lives or dies.
   See Geimer & Amsterdam, Why Jurors Vote Life
   or Death:  Operative Factors in Ten Florida
   Death Penalty Cases, 15 Am. J. Crim. L. 1, 5153
   (19871988).
  Concerns about medication extend also to the
issue of cooperation with counsel.  We have held
that a defendant's right to the effective assis-
tance of counsel is impaired when he cannot
cooperate in an active manner with his lawyer.
Massiah v. United States, 377 U.S. 201 (1964); Geders
v. United States, 425 U. S. 80 (1976) (trial court
order directing defendant not to consult with his
lawyer during an overnight recess held to deprive
him of the effective assistance of counsel).  The
defendant must be able to provide needed informa-
tion to his lawyer, and to participate in the
making of decisions on his own behalf.  The side
effects of antipsychotic drugs can hamper the
attorney-client relation, preventing effective
communication and rendering the defendant less
able or willing to take part in his defense.  The
State interferes with this relation when it admin-
isters a drug to dull cognition.  See Brief for
National Association of Criminal Defense Lawyers
as Amicus Curiae 42 ( [T]he chemical flattening of
a person's will can also lead to the defendant's
loss of self-determination undermining the desire
for self-preservation which is necessary to
engage the defendant in his own defense in prepa-
ration for his trial).
  It is well established that the defendant has
the right to testify on his own behalf, a right we
have found essential to our adversary system, In
re Oliver, 333 U.S. 257, 273 (1948).  We have found
the right implicit as well in the Compulsory Pro-
cess Clause of the Sixth Amendment.  Rock v.
Arkansas, 483 U.S. 44 (1987).  In Rock, we held that
a state rule excluding all testimony aided or
refreshed by hypnosis violated the defendant's
constitutional right to take the stand in her own
defense.  We observed that barring the testimony
would contradict not only the right of the accused
to conduct her own defense, but also her right to
make this defense in person:   `It is the accused,
not counsel, who must be  informed of the nature
and cause of the accusation, who must be  con-
fronted with the witnesses against him, and who
must be accorded  compulsory process for obtain-
ing witnesses in his favor.'  Id., at 52, quoting
Faretta v. California, 422 U.S. 806, 819 (1975).  We
gave further recognition to the right of the
accused to testify in his or her own words, and
noted that this in turn was related to the Fifth
Amendment choice to speak  in the unfettered
exercise of his own will.  Rock, supra, at 53.  In my
view medication of the type here prescribed may
be for the very purpose of imposing constraints
on the defendant's own will, and for that reason
its legitimacy is put in grave doubt.
  If the State cannot render the defendant compe-
tent without involuntary medication, then it must
resort to civil commitment, if appropriate, unless
the defendant becomes competent through other
means.  If the defendant cannot be tried without
his behavior and demeanor being affected in this
substantial way by involuntary treatment, in my
view the Constitution requires that society bear
this cost in order to preserve the integrity of
the trial process.  The state of our knowledge of
antipsychotic drugs and their side effects is
evolving and may one day produce effective drugs
that have only minimal side effects.  Until that
day comes, we can permit their use only when the
State can show that involuntary treatment does
not cause alterations raising the concerns
enumerated in this separate opinion.
  With these observations, I concur in the judg-
ment reversing the conviction.


Dissent
      SUPREME COURT OF THE UNITED STATES
             No. 90-8466
 
       DAVID RIGGINS, PETITIONER v. NEVADA
  on writ of certiorari to the supreme court
                   of nevada
                [May 18, 1992]

  Justice Thomas, with whom Justice Scalia joins
except as to Part IIA, dissenting.
  Petitioner David Edward Riggins killed Paul
William Wade by stabbing him 32 times with a knife.
He then took cash, drugs, and other items from
Wade's home.  A Nevada jury convicted Riggins of
first-degree murder and robbery with a deadly
weapon and sentenced him to death.  The Nevada
Supreme Court affirmed.  107 Nev. 178, 808 P. 2d
535 (1991).  This Court reverses the conviction,
holding that Nevada unconstitutionally deprived
Riggins of his liberty interest in avoiding unwant-
ed medication by compelling him to take an anti-
psychotic drug.  I respectfully dissent.
  The Court's opinion, in my view, conflates two
distinct questions:  whether Riggins had a full and
fair criminal trial and whether Nevada improperly
forced Riggins to take medication.  In this criminal
case, Riggins is asking, and may ask, only for the
reversal of his conviction and sentence.  He is
not seeking, and may not seek, an injunction to
terminate his medical treatment or damages for an
infringement of his personal rights.  I agree with
the positions of the majority and concurring
opinions in the Nevada Supreme Court:  Even if the
State truly forced Riggins to take medication, and
even if this medication deprived Riggins of a
protected liberty interest in a manner actionable
in a different legal proceeding, Riggins nonethe-
less had the fundamentally fair criminal trial
required by the Constitution.  I therefore would
affirm his conviction.

                       I
  Riggins contended in the Nevada Supreme Court
that he did not have a ```full and fair' trial'' for
two reasons, the first relating to exclusion of
evidence of his mental condition and the second
concerning his ability to assist in his defense.
Record 1018.  To the extent that Riggins' argu-
ments below involved federal constitutional
issues, I believe that the Nevada Supreme Court
correctly rejected them.

                       A
  Riggins first argued that the trial court im-
properly prevented him from presenting relevant
evidence of his demeanor.  As the Court notes,
Riggins suffers from a mental illness and raised
insanity as a defense at trial.  When Riggins killed
Wade, he was not using any antipsychotic medica-
tion.  During his trial, however, Riggins was taking
large doses of the antipsychotic drug Mellaril.
Riggins believed that this drug would make his
appearance at trial different from his appearance
when he attacked Wade and that this difference
might cause the jury to misjudge his sanity.  To
show his mental condition as it existed at the time
of the crime, Riggins requested permission to
appear before the jury in an unmedicated state.
App. 2024, 4247.  The trial court denied the
request and the Nevada Supreme Court affirmed.
  This Court has no power to decide questions
concerning the admissibility of evidence under
Nevada law.  Estelle v. McGuire, 502 U. S. "", ""
(1991).  We therefore may conduct only a limited
review of a Nevada court's decision to exclude a
particular form of demeanor evidence.  Except in
cases involving a violation of a specific consti-
tutional provision such as the Confrontation
Clause, see, e.g., Ohio v. Roberts, 448 U. S. 56
(1980), this Court may not reverse a state  trial
judge's action in the admission of evidence
unless the evidentiary ruling  so infuse[s] the
trial with unfairness as to deny due process of
law.  Lisenba v. California, 314 U. S. 219, 228
(1941).  See also Marshall v. Lonberger, 459 U. S.
422, 438, n. 6 (1983); Burgett v. Texas, 389 U. S. 109,
113114 (1967).  In this case, I see no basis for
concluding that Riggins had less than a full and
fair trial.
  The Court declines to decide whether Mellaril
actually affected Riggins' appearance.  On the
basis of some pretrial psychiatric testimony it
speculates only that Riggins might have looked
less uptight, drowsy, or confused if he had not
taken the drug.  Ante, at 9.  Other evidence casts
doubt on this possibility.  At least one psychia-
trist believed that a jury would not  be able to
notice whether or not [Riggins] was on Mellaril as
compared to the period of the time when he was not
medicated by that drug.  Record 445.  Yet, even if
Mellaril noticeably affected Riggins' demeanor,
the Court fails to explain why the medication's
effects rendered Riggins' trial fundamentally
unfair.
  The trial court offered Riggins the opportunity
to prove his mental condition as it existed at the
time of the crime through testimony instead of his
appearance in court in an unmedicated condition.
Riggins took advantage of this offer by explaining
to the jury the history of his mental health, his
usage of Mellaril, and the possible effects of
Mellaril on his demeanor.  Id., at 739740.  Riggins
also called Dr. Jack A. Jurasky, a psychiatrist,
who testified about Riggins' condition after his
arrest and his likely mental state at the time of
the crime.  Id., at 747748.  Dr. Jurasky also ex-
plained Riggins' use of Mellaril and how it might be
affecting him.  Id., at 752753, 760761.
  The Nevada Supreme Court concluded that this
 testimony was sufficient to inform the jury of
the effect of the Mellaril on Riggins' demeanor and
testimony.  107 Nev., at "", 808 P. 2d, at 538.  Its
analysis comports with that of other state courts
that also have held that expert testimony may
suffice to clarify the effects of an antipsychotic
drug on a defendant's apparent demeanor.  See
State v. Law, 270 S.C. 664, 673, 244 S. E. 2d 302,
306 (1978); State v. Jojola, 89 N. M. 489, 493, 553
P. 2d 1296, 1300 (1976).  Cf. In re Pray, 133 Vt. 253,
257258, 336 A. 2d 174, 177 (1975) (reversing a
conviction because no expert testimony explained
how antipsychotic medicine affected the defen-
dant's appearance).  Having reviewed the record as
a whole, I see no reason to disturb the conclusion
of the Nevada Supreme Court.  On the facts of this
case, Riggins' inability to introduce evidence of
his mental condition as he desired did not render
his trial fundamentally unfair.  See Rock v. Arkan-
sas, 483 U. S. 44, 55, n. 11 (1987); id., at 6465
(Rehnquist, C. J., dissenting).

                       B
  Riggins also argued in the Nevada Supreme
Court, although not in his briefs to this Court,
that he did not have a  `full and fair' trial
because Mellaril had side effects that interfered
with his ability to participate in his defense.
Record 1018.  He alleged, in particular, that the
drug tended to limit his powers of perception.  The
Court accepts this contention, stating:   It is
clearly possible that such side effects impacted
. . . the content of his testimony on direct exami-
nation or cross-examination, his ability to follow
the proceedings, or the substance of his communi-
cation with counsel.  Ante, at 9 (emphasis added).
I disagree.  We cannot conclude that Riggins had
less than a full and fair trial merely because of
the possibility that Mellaril had side effects.
  All criminal defendants have a right to a full and
fair trial and a violation of this right may occur
if a State tries a defendant who lacks a certain
ability to comprehend or participate in the pro-
ceedings.  We have said that  the Due Process
Clause guarantees the fundamental elements of
fairness in a criminal trial, Spencer v. Texas, 385
U. S. 554, 563564 (1967), and have made clear that
 conviction of an accused person while he is
legally incompetent violates due process, Pate v.
Robinson, 383 U. S. 375, 378 (1966).
  Riggins has no claim of legal incompetence in
this case.  The trial court specifically found him
competent while he was taking Mellaril under a
statute requiring him to have  sufficient mentali-
ty to be able to understand the nature of the
criminal charges against him, and . . . to aid and
assist his counsel in the defense interposed upon
the trial.  Nev. Rev. Stat. 178.400(2) (1989).
Riggins does not assert that due process imposes
a higher standard.
  The record does not reveal any other form of
unfairness relating to the purported side effects
of Mellaril.  Riggins has failed to allege specific
facts to support his claim that he could not
participate effectively in his defense.  He has not
stated how he would have directed his counsel to
examine or cross-examine witnesses differently.
He has not identified any testimony or instruc-
tions that he did not understand.  The record,
moreover, does not even support his assertion
that Mellaril made him worse off.  As Justice Rose
noted in his concurring opinion below:   Two
psychiatrists who had prescribed Mellaril for
Riggins, Dr. Quass and Dr. O'Gorman, testified that
they believed it was helpful to him.  Additional
psychiatric testimony established that Mellaril
may have increased Riggins' cognitive ability
. . . .  107 Nev., at "", 808 P. 2d, at 540.  See also
State v. Hayes, 118 N. H. 458, 461, 389 A. 2d 1379,
1381 (1978) (holding a defendant's perception
adequate because  [a]ll the expert evidence
support[ed] the conclusion that the medication
ha[d] a beneficial effect on the defendant's
ability to function).  Riggins' competence,
moreover, tends to confirm that he had a fair
trial.  See State v. Jojola, supra, at 492, 553
P. 2d, at 1299 (presuming, absent other evidence,
that the side effects of an antipsychotic drug did
not render a competent defendant unable to
participate fully in his trial).  I thus see no basis
for reversing the Nevada Supreme Court.
                        II

  Riggins also argues for reversal on the basis of
our holding in Washington v. Harper, 494 U. S. 210,
221 (1990), that the Due Process Clause protects
a substantive  liberty interest in avoiding
unwanted medication.  Riggins asserts that Nevada
unconstitutionally deprived him of this liberty
interest by forcing him to take Mellaril.  The
Court agrees, ruling that  the Nevada courts
failed to make findings sufficient to support
forced administration of the drug in this case.
Ante, at 1.  I consider reversal on this basis
improper.
                       A
  Riggins may not complain about a deprivation of
the liberty interest that we recognized in Harper
because the record does not support his version
of the facts.  Shortly after his arrest, as the
Court notes, Riggins told a psychiatrist at his
jail that he was hearing voices and could not
sleep.  The psychiatrist prescribed Mellaril.  When
the prescription did not eliminate the problem,
Riggins sought further treatment and the psychi-
atrist increased the dosage.  Riggins thus began
taking the drug voluntarily.  Ante, at 12.
  The Court concludes that the medication became
involuntary when the trial court denied Riggins'
motion for permission not to take the drug during
the trial.  Ante, at 5.  I disagree.  Although the
court denied Riggins' motion, it did not order him
to take any medication.  Moreover, even though
Riggins alleges that the state physicians forced
him to take the medication after the court's
order, the record contains no finding of fact with
respect to this allegation.  The Court admits that
it merely assumes that the physicians drugged
him, and attempts to justify its assumption by
observing that the Nevada Supreme Court also
assumed that involuntary medication occurred.
Ibid.  The Nevada Supreme Court, however, may
have made its assumption for the purpose of
argument; the assumption, in its view, did not
change the result of the case.  The Court cannot
make the same assumption if it requires reversal
of Riggins' conviction.
  Riggins also cannot complain about a violation
of Harper because he did not argue below for
reversal of his conviction on the ground that
Nevada had deprived him of a liberty interest.
Riggins consistently maintained in the Nevada
courts that he did not have a  full and fair trial
because the medication deprived him of the oppor-
tunity to present his demeanor to the jury and to
participate in his defense.  App. 2024 (trial
court motion); Id., at 4247 (trial court reply);
Record 10181021 (appellate brief); Id., at
10681071 (appellate reply brief).  As counsel for
Nevada put it at oral argument:   The way this
issue was initially presented to the trial court
was really a question of trial strategy.  There
was never an indication in this case that Mr.
Riggins was a Harper-type defendant who did not
want to be medicated.  Tr. of Oral Arg. 23.
    Because the claims that Riggins raised below
have no merit, Riggins has altered his theory of
the case.  The Court, therefore, should not
condemn the Nevada courts because they  did not
acknowledge the defendant's liberty interest in
freedom from unwanted antipsychotic drugs.
Ante, at 9.  The Nevada courts had no reason to
consider an argument that Riggins did not make.
We have said quite recently that  [i]n reviewing
the judgments of state courts under the jurisdic-
tional grant of 28 U. S. C. 1257, the Court has,
with very rare exceptions, refused to consider
petitioners' claims that were not raised or ad-
dressed below.  Yee v. Escondido, 503 U. S. "", ""
(1992) (slip op., at 12).  Although  we have ex-
pressed inconsistent views as to whether this
rule is jurisdictional or prudential in cases
arising from state courts, ibid., the Court does
not attempt to justify its departure here.
  Finally, we did not grant certiorari to determine
whether the Nevada courts had made the findings
required by Harper to support forced administra-
tion of a drug.  We took this case to decide  [w]h-
ether forced medication during trial violates a
defendant's constitutional right to a full and fair
trial.  Pet. for Cert.  The Court declines to
answer this question one way or the other, stat-
ing only that a violation of Harper  may well have
impaired the constitutionally protected trial
rights Riggins invokes.  Ante, at 9.  As we have
stated,  we ordinarily do not consider questions
outside those presented in the petition for
certiorari.  Yee v. Escondido, supra, at "" (slip
op., at 14).  I believe that we should refuse to
consider Riggins' Harper argument.
             B
  The Harper issue, in any event, does not warrant
reversal of Riggins' conviction.  The Court cor-
rectly states that Riggins, as a detainee awaiting
trial, had at least the same liberty interest in
avoiding unwanted medication that the inmate had
in Harper.  This case, however, differs from Harper
in a very significant respect.  When the inmate in
Harper complained that physicians were drugging
him against his will, he sought damages and an
injunction against future medication in a civil
action under 42 U. S. C. 1983.  See 494 U. S., at
217.  Although Riggins also complains of forced
medication, he is seeking a reversal of his crimi-
nal conviction.  I would not expand Harper to
include this remedy.
  We have held that plaintiffs may receive civil
remedies for all manner of constitutional viola-
tions under 1983.  See Dennis v. Higgins, 498 U. S.
"", "" (1991).  This Court, however, has reversed
criminal convictions only on the basis of two kinds
of constitutional deprivations:  those  which
occu[r] during the presentation of the case to
the trier of fact, and those which cause a  struc-
tural defect affecting the framework of the
trial.  Arizona v. Fulminante, 499 U. S. "", "", ""
(1991).  The Court does not reveal why it considers
a deprivation of a liberty interest in avoiding
unwanted medication to fall into either category
of reversible error.  Even if Nevada failed to
make the findings necessary to support forced
administration of Mellaril, this failure, without
more, would not constitute a trial error or a flaw
in the trial mechanism.  See 107 Nev., at "", 808
P. 2d, at 540 (Rose, J., concurring).  Although
Riggins might be entitled to other remedies, he
has no right to have his conviction reversed.
  We applied a similar analysis in Estelle v. Wil-
liams, 425 U. S. 501 (1976).  In that case, a prisoner
challenged his conviction on grounds that the
State had required him to wear prison garb before
the jury.  In reviewing the challenge, we did not
ask whether the State had violated some personal
right of the defendant to select his attire.
Instead, we considered only whether the prison
clothing had denied him a  fair trial by making his
appearance less favorable to the jury.  Id., at
503.  Although we ultimately declined to reach the
merits because the prisoner had waived the issue
at trial, id., at 512, we observed that lower
courts had held that  a showing of actual preju-
dice must be made by a defendant seeking to have
his conviction overturned on this ground.  Id., at
504, n. 1.  In my view, just as the validity of the
conviction in Estelle v. Williams would depend on
whether the prisoner had a fair trial, so does the
validity of Riggins' conviction.
  The need for requiring actual unfairness in this
case (either in the form of a structural defect or
an error in the presentation of evidence) becomes
apparent when one considers how the Court might
apply its decision to other cases.  A State could
violate Harper by forcibly administering any kind
of medication to a criminal defendant.  Yet, the
Court surely would not reverse a criminal convic-
tion for a Harper violation involving medications
such as penicillin or aspirin.  Perhaps Mellaril, in
general, has a greater likelihood of affecting a
person's appearance and powers of perceptions
than these substances.  As noted above, however,
we have no indication in this case, considering the
record as a whole, that Mellaril unfairly preju-
diced Riggins.
  I do not mean in any way to undervalue the
importance of a person's liberty interest in
avoiding forced medication or to suggest that
States may drug detainees at their whim.  Under
Harper, detainees have an interest in avoiding
unwanted medication that the States must re-
spect.  In appropriate instances, detainees may
seek damages or injunctions against further
medication in civil actions either under 1983, as
in Harper, or under state law.  Yet, when this
Court reviews a state court criminal conviction
of a defendant who has taken medication, it cannot
undo any violation that already has occurred or
punish those responsible.  It may determine only
whether the defendant received a proper trial,
free of the kinds of reversible errors that we
have recognized.  Because Riggins had a full and
fair trial in this case, I would affirm the Nevada
Supreme Court.
                       C
  For the foregoing reasons, I find it unnecessary
to address the precise standards governing the
forced administration of drugs to persons such as
Riggins.  Whether or not Nevada violated these
standards, I would affirm Riggins' conviction.  I
note, however, that the Court's discussion of
these standards poses troubling questions.  Al-
though the Court purports to rely on Washington v.
Harper, the standards that it applies in this case
differ in several respects.
  The Court today, for instance, appears to adopt
a standard of strict scrutiny.  It specifically
faults the trial court for failing to find either
that the  continued administration of Mellaril was
required to ensure that the defendant could be
tried, ante, at 8 (emphasis added), or that  other
compelling concerns outweighed Riggins' interest
in freedom from unwanted antipsychotic drugs,
ibid., (emphasis added).  We specifically rejected
this high standard of review in Harper.  In that
case, the Washington Supreme Court had held that
state physicians could not administer medication
to a prisoner without showing that it  was both
necessary and effective for furthering a compel-
ling state interest.  494 U. S., at 218.  We re-
versed, holding that the state court  erred in
refusing to apply the standard of reasonable-
ness.  Id., at 223.
  The Court today also departs from Harper when
it says that the Nevada Supreme Court erred by
not  considering less intrusive alternatives.
Ante, at 7.  The Court presumably believes that
Nevada could have treated Riggins with smaller
doses of Mellaril or with other kinds therapies.
In Harper, however, we imposed no such require-
ment.  In fact, we specifically ruled that  [t]he
alternative means proferred by [the prisoner] for
accommodating his interest in rejecting the
forced administration of antipsychotic drugs do
not demonstrate the invalidity of the State's
policy.  494 U. S., at 226.
  This case differs from Harper because it in-
volves a pretrial detainee and not a convicted
prisoner.  The standards for forcibly medicating
inmates well may differ from those for persons
awaiting trial.  The Court, however, does not rely
on this distinction in departing from Harper;
instead, it purports to be applying Harper to
detainees.  Ante, at 6.  Either the Court is seeking
to change the Harper standards or it is adopting
different standards for detainees without stating
its reasons.  I cannot accept either interpreta-
tion of the Court's opinion.  For all of these
reasons, I respectfully dissent.
