State ex rel. Urban v. Hardy: West Virginia Adopts the Sell Test and a Clear-and-Convincing Standard for Involuntary Medication to Restore Competency

State ex rel. Urban v. Hardy: West Virginia Adopts the Sell Test and a Clear-and-Convincing Standard for Involuntary Medication to Restore Competency

I. Introduction

In State of West Virginia ex rel. Aaron Jimmie Urban v. The Honorable David Hardy, No. 24-547 (Nov. 12, 2025), the Supreme Court of Appeals of West Virginia addressed for the first time the constitutional and statutory framework governing the involuntary administration of psychotropic medication to restore a criminal defendant’s competency to stand trial.

The petitioner, Aaron Jimmie Urban, had been found incompetent to stand trial on serious felony charges, including first-degree robbery with a firearm, fleeing with reckless indifference, child neglect creating substantial risk of serious bodily injury or death, grand larceny, and related offenses. After he refused antipsychotic medication at the state hospital where he had been committed for competency restoration, the hospital sought court approval to medicate him over his objection. The circuit court granted that request, applying the four-part test from the United States Supreme Court’s decision in Sell v. United States, 539 U.S. 166 (2003).

Mr. Urban petitioned for a writ of prohibition to block enforcement of the order, arguing principally that:

  • West Virginia statutory law did not authorize circuit courts to order involuntary medication for competency restoration; and
  • The West Virginia Constitution provides broader protections for bodily integrity and medical decision-making than the federal Constitution, rendering the Sell framework inadequate as a matter of state law.

The West Virginia Supreme Court denied the writ. In doing so, it:

  • Confirmed statutory authority for circuit courts to order involuntary medication in competency restoration cases under West Virginia Code §§ 27‑6A‑3 and 27‑6A‑10;
  • Formally adopted the Sell four-part test as the governing constitutional standard in West Virginia for involuntary medication to restore competency;
  • Held that the State bears the burden of proving the Sell factors by clear and convincing evidence; and
  • Applied those principles to uphold the circuit court’s order, concluding that the State’s evidence would satisfy the more demanding clear-and-convincing standard even though the circuit court had used a preponderance standard.

This decision is a leading West Virginia precedent on the interplay between criminal procedure, mental health treatment, and constitutional due process in the context of competency restoration.

II. Summary of the Opinion

A. Procedural Posture and Relief Sought

The case came to the Supreme Court on a petition for a writ of prohibition, an extraordinary remedy used to prevent a lower court from acting without jurisdiction or in excess of its legitimate powers. Mr. Urban sought to prohibit enforcement of the circuit court’s order authorizing Sharpe Hospital to administer antipsychotic medication (paliperidone) to him involuntarily for the sole purpose of restoring his competency to stand trial.

The Court first noted the standard for issuing writs of prohibition as articulated in State ex rel. Peacher v. Sencindiver and State ex rel. Hoover v. Berger, emphasizing that prohibition is not a vehicle to correct mere abuse of discretion; it is appropriate only where a court either lacks jurisdiction or exceeds its lawful powers. Because there was no jurisdictional defect alleged, the Court applied the discretionary, five-factor Hoover test, giving substantial weight to whether the circuit court’s order was “clearly erroneous as a matter of law.”

B. Factual Background

Key facts included:

  • Charges: During the January 2023 term, a Kanawha County grand jury indicted Mr. Urban on:
    • First-degree robbery;
    • Use or presentment of a firearm during the commission of a felony;
    • Fleeing with reckless indifference;
    • Child neglect creating substantial risk of serious bodily injury or death;
    • Grand larceny; and
    • Misdemeanor prohibited person in possession of a firearm.
  • Competency concerns: At his arraignment, statements made by Mr. Urban prompted the circuit court to question his competency. Defense counsel moved for a competency evaluation.
  • Psychological evaluations: Psychologist Dr. Steven Cody performed an evaluation and then a supplemental evaluation. The circuit court, relying on his reports, found Mr. Urban not competent to stand trial under West Virginia Code § 27‑6A‑1, but also found a substantial likelihood that he would attain competency within three months.
  • Commitment for restoration: On January 19, 2024, the court committed Mr. Urban to William R. Sharpe Jr. Hospital for competency restoration services (not to exceed 90 days), later extended by another 90 days after the hospital reported that more time was needed.
  • Refusal of treatment: Initially, Mr. Urban attended competency group sessions and took medication briefly, but by May 16, 2024, he:
    • Stopped attending competency restoration groups;
    • Refused to participate in a competency evaluation; and
    • Refused to continue taking paliperidone, complaining it made him very tired and unwilling to engage in normal activities like working out.
  • Diagnosis and treatment plan: The Statewide Forensic Clinical Director forwarded a request from attending psychiatrist, Dr. Aynampudi, to involuntarily medicate Mr. Urban. Mr. Urban had been diagnosed with delusional disorder. The treatment plan proposed:
    • Offering oral paliperidone;
    • If refused, administering long-acting injectable paliperidone on a structured schedule; and
    • Using a maximum of three injections initially, with no known comorbidities that would contraindicate medication, while acknowledging possible side effects (e.g., nausea, vomiting, headache, constipation, and weight gain).

At a hearing on September 19, 2024, both Dr. Aynampudi and Mr. Urban testified. The psychiatrist testified, to a reasonable degree of medical certainty, that:

  • Mr. Urban could not regain competency without antipsychotic medication; and
  • With appropriate medication, there was a substantial likelihood his competency could be restored within the remaining statutory restoration period.

Mr. Urban maintained he had been misdiagnosed and insisted on refusing medication because of adverse side effects.

On September 20, 2024, the circuit court granted the hospital’s request for involuntary medication, explicitly applying the Sell test. Mr. Urban then filed the present petition for prohibition. The Supreme Court issued a rule to show cause and heard argument.

C. Holdings in Brief

The Court’s core holdings can be summarized as follows:
  1. Statutory authority: West Virginia’s competency restoration statutes – particularly West Virginia Code §§ 27‑6A‑3 and 27‑6A‑10 – authorize circuit courts to order involuntary administration of medication to incompetent criminal defendants for competency restoration, under specified conditions.
  2. Adoption of the Sell test: As a matter of West Virginia law, a circuit court’s ruling authorizing involuntary medication to restore competency must conform to the four-part test from Sell v. United States.
  3. State constitutional baseline: The Court acknowledged that Article III, § 1 of the West Virginia Constitution (“pursuing and obtaining happiness and safety”) can in some contexts provide broader protection than the federal Constitution, but held that the protections embedded in the Sell test satisfy West Virginia’s due process requirements in this context. No additional state-constitutional safeguards beyond Sell were imposed.
  4. Burden and standard of proof: The Court held that the State bears the burden to prove the four Sell factors by clear and convincing evidence when it seeks to medicate a defendant solely to render the defendant competent to stand trial.
  5. Application to Urban: Although the circuit court had used a preponderance of the evidence standard, the Supreme Court concluded that the record was so one-sided that the State’s showing would satisfy even the clear-and-convincing standard. Accordingly, there was no clear error of law, and the Court denied the writ of prohibition.

III. Precedents Cited and Their Role

A. Writ of Prohibition Framework

  • State ex rel. Peacher v. Sencindiver, 160 W. Va. 314, 233 S.E.2d 425 (1977), as reaffirmed in State ex rel. Healthport Technologies, LLC v. Stucky, 239 W. Va. 239, 800 S.E.2d 506 (2017):
    • Syllabus point (quoted as Syl. Pt. 1 here) states that a writ of prohibition is not available to correct a “simple abuse of discretion.” It lies only when the trial court:
      • lacks jurisdiction, or
      • having jurisdiction, exceeds its legitimate powers.
    • This sets the high threshold for interference with ongoing trial court proceedings.
  • State ex rel. Hoover v. Berger, 199 W. Va. 12, 483 S.E.2d 12 (1996):
    • Provides the five-factor test to guide discretionary issuance of prohibition where there is no jurisdictional defect but an alleged “excess of legitimate powers.”
    • The factors include availability of alternative remedies, irreparable harm, clear error of law, repetition or persistent disregard of law, and whether the order raises new and important issues of first impression.
    • The Court reiterates that the third factor, clear error of law, is given substantial weight.

These cases frame the standard of review: unless the circuit court’s order reflects clear legal error (or other strong Hoover factors), prohibition is inappropriate. Having ultimately concluded that the circuit court properly applied the Sell test and that the State’s proof met the appropriate standard, the Supreme Court found no basis for relief under Hoover.

B. State Constitutional Law and the Potential for Higher Protection

  • Pauley v. Kelly, 162 W. Va. 672, 255 S.E.2d 859 (1979); restated in State v. Bonham, 173 W. Va. 416, 317 S.E.2d 501 (1984):
    • Syllabus point 2 of Pauley, adopted as Syl. Pt. 1 in Bonham, states: “The provisions of the Constitution of the State of West Virginia may, in certain instances, require higher standards of protection than afforded by the Federal Constitution.”
    • These cases are cited to acknowledge that West Virginia may, but need not always, interpret its own Bill of Rights to offer more protection than the U.S. Constitution.
  • Baughman v. Wal-Mart Stores, Inc., 215 W. Va. 45, 592 S.E.2d 824 (2003):
    • The Court quotes this case to reinforce the importance of personal autonomy and privacy, including in medical decisions: “The principle and right of personal autonomy and privacy is just as important as the more traditional civil rights of freedom of assembly, speech, and religion.”
    • This underscores that any regime allowing involuntary medication must be tightly constrained.

These precedents provide the doctrinal foundation for considering whether Article III, § 1 (the right of “pursuing and obtaining happiness and safety”) requires additional procedural or substantive protections beyond those recognized by the U.S. Supreme Court in Sell. The Court ultimately holds that the robust, multi-factor Sell test itself satisfies West Virginia’s constitutional demands; it declines to impose further state-specific enhancements.

C. Competency and the State’s Interest in Restoration

  • State ex rel. Walker v. Jenkins, 157 W. Va. 683, 203 S.E.2d 353 (1974):
    • Recognizes that the State has a legitimate interest in both:
      • determining a defendant’s competency to stand trial, and
      • attempting to restore an incompetent defendant to competency so that he may be tried.
    • This case underpins the Court’s conclusion, consistent with Sell, that the State’s interest in bringing Mr. Urban – charged with serious violent offenses – to trial is an “important governmental interest.”

D. Federal Due Process and Involuntary Medication

  • Washington v. Harper, 494 U.S. 210 (1990):
    • Upheld a state policy permitting prison officials to medicate an inmate with antipsychotics against his will if he:
      • has a serious mental illness,
      • is dangerous to himself or others, and
      • the treatment is in his medical interest.
    • Establishes that the right to refuse antipsychotic drugs is not absolute; it can yield to safety and medical considerations under proper procedural safeguards.
  • Riggins v. Nevada, 504 U.S. 127 (1992):
    • Recognized that a pretrial detainee has a constitutionally protected liberty interest in avoiding involuntary antipsychotic medication, but that this interest may be overridden upon a showing of an essential or overriding state interest and medical appropriateness.
    • Characterized forced medication as a “substantial interference” with liberty, reinforcing the need for a rigorous standard.
  • Sell v. United States, 539 U.S. 166 (2003):
    • The key federal precedent: a non-dangerous, mentally ill defendant charged with fraud was subjected to a court order authorizing involuntary medication solely to render him competent for trial.
    • The Supreme Court vacated the order but articulated a four-part test for when such involuntary medication may be constitutionally permissible, emphasizing that such cases are likely “rare.”
    • Urban imports this test wholesale into West Virginia law for competency restoration cases.

E. Federal Appellate Guidance on Burden of Proof

  • United States v. Watson, 793 F.3d 416 (4th Cir. 2015):
    • Interprets Sell and sets a clear-and-convincing standard for the government to satisfy before forcibly medicating a defendant solely for competency restoration.
    • Describes the government’s burden as “deliberately high” to minimize the risk of error in this “important context,” and explains clear and convincing evidence as evidence producing a “firm belief or conviction” or making the facts “highly probable.”
    • Urban tracks this reasoning closely in selecting the clear-and-convincing standard.
  • United States v. Bush, 585 F.3d 806 (4th Cir. 2009):
    • Reiterates that government’s ability to enforce the criminal law is foundational, and that by committing a crime an individual forfeits some liberty interests to the extent necessary to bring him to trial.
    • Supports Urban’s conclusion that restoration of competency to try serious offenses is a compelling state interest.

F. Other Supporting Cases

  • People In Interest of Joergensen, 524 P.3d 293 (Colo. 2022); Cotner v. Liwski, 403 P.3d 600 (Ariz. 2017); State v. Holden, 110 A.3d 1237 (Conn. Super. Ct. 2014):
    • These out-of-state authorities are cited to show that other jurisdictions have adopted the Sell framework and generally require clear and convincing proof of the Sell factors.
    • They reinforce both the national significance of the issue and the trend toward heightened evidentiary standards.
  • State ex rel. Allstate v. Gaughan, 203 W. Va. 358, 508 S.E.2d 75 (1998):
    • Holds that in the context of petitions for extraordinary writs directed at non-appealable interlocutory orders, counsel must request specific findings of fact and conclusions of law from the trial court if they intend to challenge those rulings in the Supreme Court.
    • The Court invokes this to reject late-developed arguments that the circuit court’s order lacked adequate specificity about the medication regimen: the petitioner had not requested detailed findings below.
  • Argus Energy, LLC v. Marenko, 248 W. Va. 98, 887 S.E.2d 223 (2023):
    • Reiterates that appellate courts generally limit themselves to issues and arguments “clearly set forth in a party’s brief,” and are reluctant to entertain new theories raised for the first time at oral argument.
    • This provides the backdrop for the Court’s refusal to entertain many of Mr. Urban’s late-breaking suggestions about how Sell should be applied.
  • Wright v. Lassiter, 921 F.3d 413 (4th Cir. 2019); Raleigh Wake Citizens Ass’n v. Wake Cnty. Bd. of Elections, 827 F.3d 333 (4th Cir. 2016); Pullman-Standard v. Swint, 456 U.S. 273 (1982):
    • These cases support the proposition that when a trial court uses the wrong legal standard, an appellate court will usually remand, but may affirm without remand where “the record permits only one resolution of the factual issue.”
    • Urban uses this limited exception to affirm despite the circuit court’s use of a preponderance standard rather than clear and convincing.

IV. The Court’s Legal Reasoning

A. Statutory Authority for Involuntary Medication

Mr. Urban argued that circuit courts lack statutory authority to order involuntary medication for competency restoration, because no statute explicitly authorizes such orders. The Court rejected this, focusing on the structure and language of West Virginia Code § 27‑6A‑1 et seq., which governs competency determinations and restoration.

1. Definition of “Competency Restoration” – § 27‑6A‑1

Section 27‑6A‑1 defines “competency restoration” as:

“the treatment or education process for attempting to restore a criminal defendant’s ability to consult with his or her attorney with a reasonable degree of rational understanding, including a rational and factual understanding of the court proceedings and charges against the person.”

Competency restoration services may occur in jail, outpatient, or inpatient (hospital) settings as ordered by the court. Thus, “treatment” in this context includes clinical interventions aimed at restoring the defendant’s capacity to participate in the defense.

2. Court’s Role in Choosing Restoration Modality – § 27‑6A‑3(d)

Under § 27‑6A‑3(d):

“If at any point in the proceedings the defendant is found not competent to stand trial and substantially likely to attain competency, the court of record shall in the same order, upon the evidence, make further findings as to whether the defendant, in order to attain competency, should receive outpatient competency restoration services or if the attainment of competency requires inpatient management in a mental health facility or state hospital.”

The circuit court complied with this provision by committing Mr. Urban to Sharpe Hospital for inpatient restoration upon finding him incompetent but restorable.

3. Authority to Override Refusal of Medication – § 27‑6A‑10

The crucial statute is § 27‑6A‑10, which governs “medications and medical management” for individuals in competency-related custody. It provides (in relevant part) that:

“An individual with health care decision-making capacity may refuse medications or other management unless court-ordered to be treated, or unless a treating clinician determines that medication or other management is necessary in emergencies or to prevent danger to the individual or others: Provided, That medication management intended to treat an individual’s condition that causes or contributes to incompetency shall constitute treatment.”

The Court reads this as follows:

  • An individual may ordinarily refuse medication if competent to make health-care decisions; but
  • That right of refusal yields when:
    • a court has “ordered [the individual] to be treated,” or
    • a clinician determines that emergency or danger-prevention requires medication.
  • Medication intended to treat the condition causing incompetency is explicitly characterized as “treatment.”

Because Mr. Urban had been “court-ordered to be treated” for competency restoration, and the treatment plan included medication intended to address the condition (delusional disorder) contributing to his incompetency, the Court held that § 27‑6A‑10 implicitly authorizes involuntary medication in this context, even though the phrase “involuntary medication” does not appear in the statute.

This is a critical interpretive move: the Court uses plain language analysis – invoking cases such as Appalachian Power Co. v. State Tax Dep’t, Crockett v. Andrews, and State v. Epperly – to conclude that when a defendant is subject to a court-ordered treatment plan for competency restoration, the statute contemplates that medication may be administered over objection.

Thus, the circuit court did not exceed its legitimate powers in approving Sharpe Hospital’s request to medicate Mr. Urban involuntarily.

B. Adoption and Application of the Sell Test

Turning to the constitutional question, the Court evaluated whether West Virginia should adopt the Sell test and, if so, whether it needed to enhance it under the West Virginia Constitution.

1. The Four-Part Sell Test

Under Sell, a court may authorize involuntary administration of antipsychotic drugs to render a defendant competent to stand trial only if it finds:

  1. Important governmental interests are at stake;
    • Typically, the State’s interest in bringing to trial a defendant charged with a serious crime.
  2. Involuntary medication will significantly further those interests;
    • The medication must be substantially likely to render the defendant competent, and substantially unlikely to produce side effects that will significantly interfere with the defendant’s ability to assist counsel.
  3. Involuntary medication is necessary to further those interests;
    • Less intrusive alternatives (e.g., talk therapy, education, voluntary meds) are unlikely to achieve substantially the same results.
  4. Administration of the medication is medically appropriate;
    • That is, in the defendant’s best medical interest in light of his or her condition.

The West Virginia Supreme Court holds, in explicit syllabus form, that these four elements are now mandatory findings whenever a circuit court considers involuntary medication for competency restoration.

2. Application to Mr. Urban’s Case

The Court methodically ties each Sell factor to the record:

  • Factor 1 – Important governmental interest:
    • The State’s interest in bringing to trial a person accused of a serious crime is important.
    • Mr. Urban was charged with first-degree robbery involving a firearm and related violent and serious offenses. This clearly qualifies as “serious” under Sell.
    • Citing Walker and Bush, the Court emphasizes that the State must be afforded an opportunity both to determine and, where possible, to restore competency so that serious criminal charges can be adjudicated.
  • Factor 2 – Medication will significantly further the interest:
    • Dr. Aynampudi testified that, without antipsychotic medication, Mr. Urban could not regain competency, but with appropriate medication there was a substantial likelihood he would become competent within the statutory restoration window.
    • This expert testimony, uncontradicted by any defense expert, provided the required nexus between the medication and the State’s interest in trial.
  • Factor 3 – Necessity and lack of effective alternatives:
    • Less intrusive measures (competency groups, evaluations) had been attempted, but Mr. Urban stopped attending sessions and refused further participation.
    • Given these refusals, the Court found that non-pharmacological interventions were unlikely to restore competency.
    • Thus, the circuit court reasonably concluded that involuntary medication was “necessary” under Sell.
  • Factor 4 – Medical appropriateness:
    • Paliperidone is an antipsychotic appropriate for treating delusional disorder and similar psychotic conditions.
    • There were no comorbidities that would contraindicate its use, although side effects were acknowledged.
    • On the basis of the detailed treatment plan and expert testimony, the circuit court found the proposed medication medically appropriate and in Mr. Urban’s best medical interest.

Significantly, Mr. Urban did not argue in the Supreme Court that these factual findings were unsupported or that the Sell factors were misapplied; he instead attacked the adequacy of Sell itself under the West Virginia Constitution. The Court therefore focused its analysis on whether additional state-law protections were required.

C. State Constitutional Argument: “Happiness and Safety” and Bodily Integrity

Mr. Urban relied on Article III, § 1 of the West Virginia Constitution, which guarantees, among other things, the right of all persons to “pursuing and obtaining happiness and safety.” He argued that:

  • this provision applies to personal medical decisions; and
  • it creates a broad right of individuals to decline medications based on their own assessment of the impact on their happiness and safety.

The Court acknowledged:

  • its prior recognition, in Pauley and Bonham, that West Virginia’s Constitution may impose higher standards than the federal Constitution in some contexts; and
  • the serious liberty interest implicated by forced medication, as recognized in Riggins and Harper.

However, it emphasized that:

  • the right to refuse antipsychotic drugs is not absolute under federal doctrine; it can be overridden by an essential or overriding state interest, as long as treatment is medically appropriate and procedural safeguards are robust; and
  • Sell itself contemplates involuntary medication of a non-dangerous defendant but only in tightly controlled and “rare” circumstances.

Critically, Mr. Urban did not propose any concrete additional procedures or substantive standards that should be required by the West Virginia Constitution beyond what Sell already demands. He essentially urged a freestanding, nearly absolute right to refuse medication grounded in “happiness and safety” but did not articulate a workable doctrinal framework.

The Court concluded that the “rigorous” and individualized Sell test appropriately balances:

  • the individual’s liberty and bodily integrity;
  • the State’s interest in adjudicating serious criminal charges; and
  • the medical realities of treating serious mental illness.

It therefore held that:

“the rigorous Sell test satisfies the due process standards articulated in the West Virginia Constitution.”

The Court also emphasized that forcible medication is not automatically justified whenever an incompetent defendant refuses treatment; rather, quoting Sell and Watson, it cautioned that such cases “may be rare.” This “rarity” caveat itself serves as a substantive limitation on the use of involuntary medication.

D. Standard of Proof: Clear and Convincing Evidence

Although the parties did not squarely litigate the applicable standard of proof below, the Supreme Court chose to address this directly as an issue of law of general importance.

The Court’s reasoning proceeded in several steps:

  1. Nature of the right at stake:
    • Forced antipsychotic medication implicates a “highly prized” right of personal autonomy and bodily integrity.
    • Given its seriousness, the risk of error must be minimized.
  2. Trend in other jurisdictions:
    • “Most” other courts applying Sell require proof by clear and convincing evidence, not merely a preponderance.
    • The Fourth Circuit in Watson explicitly applied the clear-and-convincing standard and described the government’s burden as “deliberately high.”
  3. Adoption of the clear-and-convincing standard:
    • The Court held that, in West Virginia, the State bears the burden of proving, by clear and convincing evidence, that all four Sell factors are satisfied when it seeks to medicate a defendant solely to restore competency.
    • Clear and convincing evidence is described, consistently with Watson, as evidence that:
      • produces in the fact-finder a “firm belief or conviction” as to the truth of the allegations, or
      • makes the facts at issue “highly probable.”

This ruling materially raises the evidentiary bar in West Virginia above a simple preponderance (more likely than not) standard. It aligns competency-restoration medication with other contexts where important liberty interests (such as termination of parental rights or certain civil commitments) often require clear and convincing proof.

E. Handling the Trial Court’s Use of the Wrong Standard

Because the circuit court had in fact used a preponderance standard, the usual course would be to remand for reconsideration under the correct standard. The Court, however, invoked the narrow exception recognized in Wright, Raleigh Wake Citizens, and Pullman-Standard: when the evidence “permits only one resolution” under the correct legal standard, an appellate court may affirm without remand.

Here, the Court considered the evidence:

  • Serious charges with significant societal interest in adjudication;
  • A detailed written treatment plan from Sharpe Hospital;
  • Uncontroverted expert testimony from Dr. Aynampudi:
    • that medication was necessary and substantially likely to restore competency within the statutory timeframe;
    • that alternative treatments had been tried and effectively rejected by Mr. Urban; and
    • that the chosen medication was medically appropriate for his diagnosed condition.
  • Absence of any defense expert or contrary medical evidence.

On this record, the Court found that even under the clear-and-convincing standard, the State’s proof compelled only one conclusion: the Sell criteria were met. Therefore, remand would have been a purely formal exercise, and the Court instead affirmed the circuit court’s order as substantively correct.

F. Application of the Hoover Factors

Having concluded there was no clear legal error, the Court indicated that there was no need to analyze the remaining Hoover factors in depth. Without clear error, the extraordinary remedy of prohibition could not be justified, particularly where any putative error could be addressed in a direct appeal after conviction.

V. Complex Concepts Simplified

A. Writ of Prohibition

A writ of prohibition is an extraordinary judicial order, issued by a higher court to a lower court, directing the lower court to stop doing something. It is not a routine appeal. It is used when:

  • a lower court has no jurisdiction to act at all, or
  • the court has jurisdiction but is acting beyond its lawful powers in a way that cannot be adequately corrected later through normal appeals.

Think of it as a “preventive” or “emergency” measure to stop an unlawful action by a court before it causes irreparable harm.

B. Competency to Stand Trial and Competency Restoration

  • Competency to stand trial:
    • A defendant is competent if he:
      • understands the nature of the charges and the court process, and
      • can consult with his lawyer and assist in his own defense with a reasonable degree of rational understanding.
    • If a defendant lacks this capacity because of mental illness or defect, he cannot constitutionally be tried until competency is restored.
  • Competency restoration:
    • Refers to the medical, psychological, and educational interventions intended to restore an incompetent defendant’s ability to understand and participate in the proceedings.
    • In West Virginia, restoration can be:
      • jail-based,
      • outpatient, or
      • inpatient (hospital-based),
      as ordered by the court.

C. Involuntary Medication

“Involuntary medication” means administering drugs – especially psychiatric medications – to a patient without the patient’s consent. It is a serious invasion of bodily autonomy and therefore triggers constitutional scrutiny. Courts allow it only under limited circumstances, such as:

  • Emergency situations where there is immediate danger; or
  • Carefully controlled non-emergency situations, like competency restoration under the Sell framework.

D. Standards of Proof

A standard of proof tells us how convincing the evidence must be for a party to win on an issue. Common standards include:

  • Preponderance of the evidence:
    • Used in most civil cases.
    • Means “more likely than not” – even a 51% likelihood can suffice.
  • Clear and convincing evidence:
    • A higher standard, often used when important rights (e.g., parental rights, bodily autonomy) are at stake.
    • Requires evidence that leads to a “firm belief or conviction” of the truth of the allegations, or makes them “highly probable.”
  • Beyond a reasonable doubt:
    • The highest standard, used in criminal trials to prove guilt.
    • Requires near-certainty, leaving no reasonable doubt in the fact-finder’s mind.

In Urban, the Court decided that because involuntary medication so deeply affects personal autonomy, the State must meet the clear-and-convincing standard to justify it.

E. The Sell Test in Plain Terms

To authorize forced medication solely to make a defendant competent for trial, the court must be convinced of all of the following:

  1. The case is serious enough:
    • The charges are sufficiently serious that society has a strong interest in bringing the defendant to trial (e.g., violent crimes or major felonies).
  2. The drugs will probably help:
    • Medication is substantially likely to restore the defendant’s ability to understand the trial and help his lawyer.
    • Side effects will probably not interfere with his ability to participate in the defense.
  3. There is no effective, less intrusive alternative:
    • Other options (like therapy, education, or voluntary medication) have been tried, or are clearly unlikely to work, and thus cannot reasonably achieve the same result.
  4. The treatment is medically sound:
    • According to competent medical judgment, the proposed medication regimen is appropriate for the defendant’s diagnosis and is in his overall best medical interest.

VI. Impact and Future Significance

A. Clarified Power of West Virginia Courts in Competency Cases

Urban removes ambiguity about whether West Virginia courts can order involuntary medication to restore competency. By reading § 27‑6A‑10 in conjunction with §§ 27‑6A‑1 and 27‑6A‑3, the Court confirms that:

  • When a defendant is ordered into competency restoration treatment, that order can include, where justified, involuntary administration of psychiatric medications;
  • This authority is bounded by both statutory language and constitutional limits (the Sell test and the clear-and-convincing standard).

This has practical consequences for:

  • Circuit courts, which now have a clear roadmap for handling hospital requests to medicate over objection;
  • State hospitals, which must provide detailed treatment plans and expert testimony tailored to the Sell factors; and
  • Counsel on both sides, who must frame their evidence and arguments around this structure.

B. Integration of Federal Constitutional Doctrine into State Law

By adopting Sell explicitly and holding that it satisfies West Virginia’s due process guarantees, the Court aligns state practice with federal constitutional standards, while adding a state-law requirement of clear and convincing proof.

Future implications include:

  • Defense attorneys challenging involuntary medication orders must:
    • focus on disputing whether the Sell factors are factually satisfied (through their own expert testimony), and
    • show that the State has not met the clear-and-convincing evidentiary threshold.
  • Prosecutors and state hospitals must:
    • ensure robust, patient-specific expert evidence addressing each Sell factor,
    • document prior attempts at less intrusive methods, and
    • demonstrate the medical appropriateness of the exact medications proposed (including dose, duration, and monitoring).

C. Protection of Bodily Integrity and Personal Autonomy

Although the outcome allows involuntary medication in this case, the decision’s long-term effect is to strengthen procedural and evidentiary safeguards in all such cases. In particular:

  • The clear-and-convincing standard reduces the risk that a borderline or weak case for medication will be approved;
  • The explicit adoption of Sell requires individualized attention to:
    • seriousness of the crime,
    • likely benefits and side effects,
    • availability and history of alternatives, and
    • medical appropriateness for this person, not just generalized assumptions about a diagnosis.
  • The Court’s reminder that such cases should be “rare” serves as a normative restraint on overuse of involuntary medication.

D. Guidance on Appellate Review of Competency-Restoration Orders

The Court’s willingness to affirm despite the trial court’s use of the wrong standard of proof – based on the “only one possible outcome” exception – sends two messages:

  • Trial courts must use the clear-and-convincing standard going forward, as that is now clearly established; but
  • In cases where the evidence is overwhelming and uncontested, appellate courts may treat certain legal errors as harmless rather than reflexively remanding.

That said, in closer cases involving contested expert evidence or less serious offenses, misapplication of the standard could very well require reversal or remand.

E. Strategic Considerations for Practitioners

  • Defense counsel:
    • Should be prepared to:
      • request detailed findings of fact and conclusions of law under Allstate v. Gaughan when an involuntary medication order is contemplated;
      • present their own psychiatric/psychological experts where feasible;
      • challenge whether less intrusive alternatives have truly been exhausted;
      • argue that side effects could impair the defendant’s ability to meaningfully assist in his defense.
    • Must recognize that competency restoration is constrained by a statutory time cap (240 days under § 27‑6A‑3(g)(1)), which may bear on the necessity and proportionality of forced medication.
  • Prosecution and State hospitals:
    • Must treat Sell as a strict checklist: failure to present evidence on any factor could be fatal under the clear-and-convincing standard.
    • Should anticipate litigation around:
      • whether the charged offense is sufficiently “serious”; and
      • whether lengthy pretrial detention might diminish the State’s interest (a factor noted in Sell though not elaborated in Urban).

VII. Conclusion

State ex rel. Urban v. Hardy is a foundational decision in West Virginia criminal and mental health law. It does three major things:

  1. Clarifies statutory authority: West Virginia Code §§ 27‑6A‑3 and 27‑6A‑10, read together, empower circuit courts to authorize involuntary administration of medication to incompetent defendants when such treatment is part of court-ordered competency restoration.
  2. Constitutionalizes the Sell framework: The Court adopts the U.S. Supreme Court’s four-part Sell test as the governing due process standard for involuntary medication to restore competency in West Virginia, holding that it adequately satisfies both federal and state constitutional requirements, including Article III, § 1.
  3. Elevates the evidentiary threshold: The State must prove each Sell factor by clear and convincing evidence, reflecting the gravity of forcibly medicating a person and the imperative to minimize erroneous deprivations of bodily autonomy.

While the Court ultimately denies the writ of prohibition and permits the forced medication of Mr. Urban, it sets a demanding and structured legal framework that will govern future attempts to medicate incompetent defendants. Going forward, any such order will require:

  • serious charges implicating important governmental interests;
  • strong, individualized medical evidence showing medication is substantially likely to restore competency and unlikely to undermine trial fairness;
  • a demonstrable lack of effective, less intrusive alternatives; and
  • a clear showing, supported by expert testimony, that the proposed regimen is medically appropriate for the particular defendant.

In short, Urban both enables and tightly cabins the State’s power to medicate an unwilling defendant for trial competency, ensuring that such extraordinary measures occur, if at all, only under rigorous judicial supervision and in circumstances where the constitutional balance clearly favors intervention.

Note: This commentary is for informational and analytical purposes and does not constitute legal advice.

Case Details

Comments