                                           PRECEDENTIAL

         UNITED STATES COURT OF APPEALS
              FOR THE THIRD CIRCUIT
                  _______________

                       No. 13-4378
                     _______________

             UNITED STATES OF AMERICA

                              v.

                    ABRAHAM CRUZ,
                               Appellant
                     _______________

      On Appeal from the United States District Court
          for the Middle District of Pennsylvania
          (D.C. Criminal No. 1-11-cr-00242-001)
        District Judge: Hon. Christopher C. Conner
                     _______________

                    Argued June 10, 2014

     BEFORE: FISHER, COWEN AND TASHIMA*,
                  Circuit Judges
_______________

*Hon. A. Wallace Tashima, Senior United States Circuit
Judge, United States Court of Appeals for the Ninth Circuit,
sitting by designation.
                    (Filed: July 10, 2014)


Frederick W. Ulrich, Esq. (Argued)
Office of the Federal Public Defender
100 Chestnut Street, Suite 306
Harrisburg, PA 17101

      Counsel for Appellant

Stephen R. Cerutti, II, Esq. (Argued)
Kim D. Daniel, Esq.
Office of the United States Attorney
228 Walnut Street, P.O. Box 11754
220 Federal Building and Courthouse
Harrisburg, PA 17108

      Counsel for Appellee
                    _______________

                        OPINION
                     _______________


COWEN, Circuit Judge.

       We here confront an issue of first impression: whether
the Government, pursuant to the Supreme Court’s decision in
United States v. Sell, 539 U.S. 166 (2003), can have a
sufficiently important interest in forcibly medicating a
defendant to restore his mental competency and render him fit


                              2
to proceed with sentencing. Under the facts presented in this
case, we answer that question in the affirmative and we will
affirm.

                              I.

                              A.

       Cruz was arrested in August of 2011 and indicted on
one count of assaulting, resisting, or impeding Social Security
Administration (“SSA”) employees, a violation of 18 U.S.C.
§ 111 (“Count I”), and two counts of threatening a federal law
enforcement officer, violations of 18 U.S.C. § 115
(respectively, “Count II” and “Count III”). The District Court
granted Cruz a judgment of acquittal on Count I, and a jury
returned guilty verdicts on Count II and Count III.

       In August of 2012, after the District Court received but
before Cruz could raise objections to the pre-sentence
investigation report (“PSR”), the Government raised concern
about and moved for a determination of Cruz’s competency. 1
Its motion was granted, and Cruz was evaluated by Dr.
William J. Ryan, a forensic psychologist working for the
Federal Bureau of Prisons (“BOP”). Dr. Ryan, as reflected in
a report submitted to the District Court, concluded that Cruz
was mentally incompetent because he suffered from

      1
          The Government sought a competency determination
at this stage of the proceedings because “Franklin County
prison officials [had] complained about Cruz’s behavior.”
(App. 69.)

                              3
schizophrenic disorder, bipolar type. Upon receipt of Dr.
Ryan’s report, the District Court scheduled a competency
hearing. Following that hearing, it concluded that Cruz was
mentally incompetent and found that he could not proceed
with sentencing.

        The District Court received a second competency
evaluation and report from the BOP in May of 2013, which
was co-authored by forensic psychologist Angela Weaver and
BOP staff psychologist Robert Lucking. Drs. Weaver and
Lucking concurred with Dr. Ryan’s diagnosis, noted Cruz’s
ongoing refusal to take anti-psychotic medication
recommended by BOP personnel, and concluded that without
such medication Cruz would remain mentally incompetent.
They also concluded that “there is a substantial probability
that [his] competency can be restored with a period of” forced
medication. (App. 70.) The Weaver/Lucking report included
a proposed treatment plan and a request that the Government
seek a court order under Sell, authorizing the BOP to
medicate Cruz involuntarily.

                              B.

       The Government filed a motion on May 29, 2013,
seeking an order authorizing the BOP to medicate Cruz
against his will. (See App. 68-142.) The papers filed by the
Government included, inter alia, its “Omnibus Motion and
Brief,” related exhibits, and, pursuant to the District Court’s
local rules, a certificate indicating that Cruz’s lawyer was
contacted and expressed Cruz’s non-concurrence in the
motion. The Omnibus Motion and Brief made clear that the


                              4
Government sought two forms of relief: first, a hearing
pursuant to Sell; and second, following the hearing, a court
order authorizing forced medication.

       The District Court promptly scheduled an evidentiary
hearing, which was continued three times (twice at Cruz’s
request) and ultimately held on October 22, 2013. In the
intervening five months—i.e., the period following the May
29, 2013 filing of the motion and preceding the October 22,
2013 hearing—Cruz failed to file a petition, motion, brief, or
other document indicating that he opposed the Government’s
ultimate request for relief.

       The District Court began the October 22, 2013 hearing
by informing the parties that it was “held pursuant to the
Supreme Court decision in Sell v. United States” and
providing “the Sell criteria sort of as a backdrop to the
testimony” that would be presented. (App. 145, 147.) It
reminded the parties that “involuntary medication of
nondangerous individuals should only occur when four
conditions are satisfied” and recited those factors for their
benefit:

              First, the court must find that important
      governmental interests are at stake. Second, the
      court must conclude that involuntary
      medication will significantly further those
      interests, and this second factor includes
      determining that medication is substantially
      likely to render the defendant competent and
      that the treatment is unlikely to have side effects


                              5
      that impair the defendant’s ability to assist
      counsel.
              Third, the court must determine that
      involuntary medication is necessary to further
      those interests because alternative[,] less
      intrusive treatments are unlikely to achieve the
      same results. And fourth, the court must find
      that involuntary medication is medically
      appropriate, or, in other words, in the patient’s
      medical interests in light of his medical
      condition.
              The first factor, whether the government
      has advanced sufficiently important interests to
      justify forcible medication, is a question of law,
      and the remaining three factors are factual
      questions which the government must prove
      with clear and convincing evidence . . . .
              So in light of those factors and that
      background, . . . I’ll turn to the government and
      ask . . . if [it] would like to present testimonial
      evidence in support of [its] motion.

(App. 147-49.)

      Drs. Weaver and Lucking testified for the
Government, which introduced, among other documents, both
the PSR and the May 2013 Weaver/Lucking report. Cruz,
who was represented by the Federal Public Defender, did not
object to the introduction of either of those documents.
However, he noted through counsel that he “didn’t
necessarily agree with that guideline range.” (App. 229.)


                              6
Shortly thereafter, again acting through counsel, he declined
the opportunity to present evidence at the hearing and stated
that he “[did not] have any argument at [that] juncture.”
(App. 230.)

        The District Court took the matter under advisement
and two days later entered the order that is at issue on appeal.
As there illustrated, the District Court considered the
circumstances of Cruz’s case and concluded that all four of
the Sell criteria were satisfied. Its analysis of the first
criterion, which is central to this appeal, rested on two legs.

       First, the District Court concluded that a sufficiently
important government interest was at stake because
“[r]endering a defendant competent for sentencing enables
not only the government, but also the court and the defendant
himself, to ensure that the defendant receives a sentence that
accurately reflects the nature of his offense and his individual
circumstances.” (App. 7 (citing United States v. Wood, 459
F. Supp. 2d 451, 457-60 (E.D. Va. 2006)).) It further
explained:

              Neither the Supreme Court nor the Third
       Circuit ha[s] promulgated a test to determine
       the seriousness of a crime, but other circuits
       have looked to the statutory maximum
       mandated for the offense or the applicable
       guidelines range. The Third Circuit in [United
       States v. ]Grape[, 549 F.3d 591, 600 (3d Cir.
       2008),] determined that under either rubric, the
       defendant was accused of “serious” crimes


                               7
       because the crimes had statutory mandatory
       minimums of 10 and 15 years and the defendant
       had a guidelines range of 87 to 108 months[’]
       imprisonment.
               In the case sub judice, the draft pre-
       sentence investigation report provisionally
       identifies a 10-year statutory maximum for each
       count and a guidelines range of 100 to 125
       months[’] imprisonment. Certainly, pursuant to
       the criteria set forth in Grape, Cruz was
       convicted of “serious” crimes and the
       government possesses a strong interest in
       rendering him competent for sentencing.

(App. 7-8 (citations omitted).) 2

       Second, the District Court found that no special
circumstances lessened the importance of the Government’s
interest. It noted that Sell identified two examples of such
special circumstances: “(1) when the defendant has already
been incarcerated for a significant period of time; or (2)
whether there is a possibility of future civil commitment.”
(App. 8.) But it concluded that neither of those circumstances
were present here.


       2
          The District Court was “mindful . . . that neither
party . . . had the opportunity to lodge objections to the pre-
sentence investigation report’s findings” and noted that it had
not “yet . . . consider[ed] the many circumstances that may
contribute to Cruz’s ultimate sentence.” (App. 5 n.1.)

                                8
        With respect to the length of Cruz’s incarceration, the
court concluded that he had not been incarcerated for a
significant amount of time. It cited and discussed Grape,
where this Court noted that the defendant had been
incarcerated for approximately three and half years but
“reasoned that in light of [his] potential sentence, he would
still need to serve a majority of his sentence if convicted.”
(Id. (citing Grape, 549 F.3d at 602).) The Grape court
concluded as a matter of law that that defendant had not been
incarcerated for a significant amount of time. By analogy, the
District Court reached the same conclusion here. It reasoned
that Cruz, who had been incarcerated for only two years,
might still need to serve the majority of his sentence. When
reaching that conclusion, the District Court relied principally
upon the PSR, which “provisionally identifie[d] a 10-year
statutory maximum for each count and a guidelines range of
100 to 125 months[’] imprisonment.” (Id.)

       With respect to the possibility of future civil
confinement, the District Court examined the statutes that
might authorize such confinement, 18 U.S.C. § 4246 and 50
Pa.C.S. § 7301, and noted each statute’s prerequisites to civil
confinement. Importantly, 18 U.S.C. § 4246 required “a
substantial risk of bodily injury to another person or serious
damage to property of another” while 50 Pa.C.S. § 7301
required a showing of “clear and present danger or harm to
others or to himself.” In light of those prerequisites, the
District Court made note of record evidence that called into
question the likelihood that Cruz could be civilly committed.
Although “the [PSR] indicate[d] that Cruz has a lengthy
criminal history involving numerous acts of violence and


                              9
threats of violence,” and although “[e]ntries from the [BOP]’s
Psychology Data System . . . indicat[ed] that Cruz ha[d]
continued to threaten violence against others,” “[t]he May
2013 evaluation explicitly state[d] that Cruz ha[d] not posed a
threat to himself or others . . . and does not pose a risk of
committing serious harm to others.” (App. 9-10.) The
District Court characterized the conflict in the record as
“[u]ncertainty surrounding the” likelihood that “Cruz [could]
be civilly committed” in the future and concluded that such
uncertainty did “not materially diminish” and “clearly [did]
not undermine” the Government’s interest in restoring Cruz’s
mental competency to render him fit to proceed with
sentencing. (App. 10.)

                              C.

       Cruz moved for a stay of the District Court’s order on
October 29, 2013. In the brief filed in support of that motion
(“Stay Brief”), he conceded that “the government has an
interest in sentencing a convicted defendant.” (Supplemental
App. 9.) However, he argued that the District Court erred in
finding that special circumstances did not lessen the
importance of the Government’s interest.

       Cruz first argued that the District Court erred when it
concluded that he had not been incarcerated for a significant
amount of time. He disagreed with the District Court’s
reliance on the PSR, and he argued that such reliance was
inappropriate because he had not yet had an opportunity to
object to the Guidelines, argue for relevant departures, or
raise other considerations under 18 U.S.C. § 3553(a).


                              10
Specifically, he argued that it was unclear whether he needed
to serve a majority of his sentence. (Supplemental App. 6.)

       He also argued, with specific reference to both 18
U.S.C. § 4246 and 50 Pa.C.S. § 7301, that “it is quite possible
that [he] could be civilly committed in the future.” (Id.) He
failed, however, to flesh out that argument by either
developing it further or citing relevant legal sources.

       The Government did not oppose Cruz’s stay motion,
which the District Court granted. Thereafter, Cruz filed this
appeal.

                              II.

       We pause here to restate the arguments that Cruz
presents on appeal and to draw a roadmap for our analysis.
Cruz argues that the District Court erred when it authorized
the BOP to forcibly administer antipsychotic medication
because the first Sell criterion, which concerns the importance
of the Government’s interest in restoring his competency, was
not adequately established. He raises five arguments that
bear on that issue.

       First, he argues that the Government’s interest in
restoring his competency is less than that shown in other
cases (e.g., Grape and Sell) because, here, the Government
merely seeks to restore his mental competency for sentencing.
He thus seeks to distinguish his case from the vast majority of
cases under Sell, where the Government seeks to restore a
defendant’s competency before trial has begun. He then


                              11
argues that the Government lacks an important interest here
because the crimes at issue, violations of 18 U.S.C. § 115, are
less serious than the crimes that were at issue in Grape and
Sell.

       Cruz next raises arguments that concern the District
Court’s reference to and, in some sense, reliance on the PSR.
He contends that such reliance was misplaced because he had
not yet had an opportunity to object to the Guidelines range
calculated in the PSR, which was based on a career-offender
enhancement. He also finds fault with the District Court for
relying on the PSR because it does not take into account his
mental health status, which could serve as a basis for either a
downward departure or variance.

        Finally, he states that it is very likely that he will be
civilly committed to a suitable facility for care and treatment
and that such likelihood constitutes a special circumstance
that undermines the Government’s interest.

        The Government responds that Cruz failed to raise
these issues before the District Court and urges us to review
those issues only for plain error. Cf. FED. R. CRIM . P. 52(b).
It also asserts that no error was committed, plain or otherwise,
in the Sell proceedings before the District Court.

       Our discussion will begin with the threshold inquiry
raised by the Government: the appropriateness of plain error
review. We thereafter turn our attention to the Sell-specific
standard of review, which we have not had cause to examine



                               12
since our 2008 decision in Grape. Finally, we will examine
the merits of each of Cruz’s arguments. 3

                              III.

       The District Court had jurisdiction under 18 U.S.C. §
3231 because Cruz was charged with violations of federal
law. It is well-settled that we have jurisdiction under the
collateral order exception to 28 U.S.C. § 1291. See, e.g.,
Grape, 549 F.3d at 597.

                              IV.

       Cruz disputes the Government’s invocation of plain
error review on three grounds. First, he argues that plain
error review cannot rise here under Federal Rule of Criminal
Procedure 52(b) because the appeal does not concern a purely
“criminal” issue. Second, he argues that the Government’s
invocation of plan error review “overlooks significant factual

       3
         Ordinarily, we would determine as a threshold matter
whether our analysis is better couched under Sell or,
alternatively, Washington v. Harper, 494 U.S. 210 (1990).
See, e.g., United States v. Dillon, 738 F.3d 284, 290 (D.C.
Cir. 2013). Here, the District Court received psychological
evaluations that rendered Harper inapplicable because they
demonstrated that Cruz was not a danger to himself or others.
Those evaluations accorded with the Government’s position
before the District Court and similarly accord with its position
on appeal. Thus, we will proceed under Sell without further
discussion.

                              13
and procedural aspects of this case that belie the application
of such a standard.” (Reply Br. at 3.) Finally, he contends
that the arguments at issue raised on appeal were preserved in
the Stay Brief.

       Upon full consideration of Cruz’s arguments, we have
concluded that they have little merit. For the reasons that
follow, we will review this appeal only for plain error.

                              A.

        Cruz first argues against the Government’s invocation
of plain error review because the Federal Rules of Criminal
Procedure neither explicitly recognize nor provide a
framework for objections in Sell proceedings. He thus
distinguishes the instant appeal from an appeal from, for
example, denial of traditional post-trial motions. He also
argues that the absence of such framework precludes the
forfeiture of arguments that he could have raised but did not
raise in the District Court’s Sell proceedings.

       Cruz’s arguments invite consideration of traditional
notions of issue preservation, forfeiture, and waiver.
Forfeiture, of course, is not exactly the same as waiver; rights
may be forfeited without being waived. See Freytag v.
Comm’r, 501 U.S. 868, 895 (1991) (Scalia, J., concurring in
part and dissenting in part). The distinction between those
terms is particularly important in criminal appeals. We will
review issues and arguments that were forfeited before the
District Court but, as a general rule, we will not examine
those that were knowingly and intelligently waived. See, e.g.,


                              14
Gov’t of the V.I. v. Rosa, 399 F.3d 283, 290-91 (3d Cir. 2005)
(“‘[W]here there was forfeiture, we apply a plain error
analysis; where there was waiver, we do not.’” (citation
omitted)).

        The Supreme Court considered the differences
between forfeiture and waiver in United States v. Olano.
There, in the context of a criminal appeal, the Court rejected
the bright-line application of waiver doctrines to an issue that
was merely forfeited during trial and presented for the first
time on appeal. See United States v. Olano, 507 U.S. 725,
732-34 (1993). It noted that “[a] rigid and undeviating
judicially declared practice under which courts of review
would invariably and under all circumstances decline to
consider all questions” that were forfeited “would be out of
harmony with . . . the rules of fundamental justice.” Id. at
732 (citation and internal quotation marks omitted).
“Although in theory it could be argued that ‘[i]f the question
was not presented to the trial court no error was committed by
the trial court [and] hence there is nothing to review,’” the
Court rejected that theory, noting that it was “not the theory
that Rule 52(b) adopts.” Id. at 733 (first alteration in original;
citation omitted).

       The Supreme Court further explained in Olano that
plain error includes any “[d]eviation from a legal rule” that is
not explicitly, knowingly, and intelligently waived (e.g.,
through a guilty plea made pursuant to Rule 11). See 507
U.S. at 732-33. The parties do not assert and the record does
not support a finding of such waiver here. Thus, the plain
language of Rule 52(b) appears to belie Cruz’s argument, as


                               15
that rule applies to any “plain error that affects substantial
rights.” FED. R. C RIM. P. 52(b). 4

       Finally, it is noteworthy that this Court’s review for
plain error would comport with other courts’ application of

       4
         We are sensitive to the fact that this appeal concerns
Cruz’s “substantial rights,” in the colloquial sense. Indeed,
we are sensitive to the significant liberty interest at stake:
Cruz’s interest “in avoiding the unwanted administration of
antipsychotropic drugs.” Harper, 494 U.S. at 221. There are
“several dimensions” to that liberty, which “are both physical
and intellectual. Every violation of a person’s bodily
integrity is an invasion of his or her liberty. . . . And when
the purpose or effect of forced drugging is to alter the will
and the mind of the subject, it constitutes a deprivation of
liberty in the most literal and fundamental sense.” Id. at 237-
38 (Stevens, J., concurring in part and dissenting in part); see
also id. (“The liberty of citizens to resist the administration of
mind altering drugs arises from our Nation’s most basic
values.”).
        We note, however, that the appeal also concerns
“substantial rights” in the sense contemplated by Rule 52(b)
and characterized in Olano as rights that affect the outcome
of a proceeding. The order authorizing the BOP to forcibly
medicate Cruz plainly meets that test. See, e.g., Sell, 539 U.S.
at 176-77 (“By the time of trial [the defendant] will have
undergone forced medication—the very harm that he seeks to
avoid. He cannot undo that harm even if he is acquitted.
Indeed, if he is acquitted, there will be no appeal through
which he might obtain review.”).

                               16
that standard to similar appeals. See Dillon, 738 F.3d at 287
(recognizing forfeiture of argument on the first Sell criterion
and related “special circumstances,” and reviewing appeal for
plain error); United States v. Baldovinos, 434 F.3d 233, 239
(4th Cir. 2006).

                               B.

        Cruz next argues that any assertion of forfeiture
“overlooks significant factual and procedural aspects of this
case that belie the application of” plain error review. (Reply
Br. at 3.) Specifically, he argues that his appellate arguments
warrant de novo review because he lacked an opportunity to
oppose the Government’s motion. Essentially, his argument
tracks Rule 51(b) of the Federal Rules of Criminal Procedure,
which provides in pertinent part: “If a party does not have an
opportunity to object to a ruling or order, the absence of an
objection does not later prejudice that party.” FED . R. C RIM.
P. 51(b).

       We see little merit in this argument. Review of the
District Court proceedings plainly demonstrates that Cruz
enjoyed but failed to avail himself of several opportunities to
oppose the Government’s motion.

        Cruz initially faults the Government for asserting that
he failed to respond to its motion. This aspect of his
argument has two parts. First, he cites the Government’s
certificate of non-concurrence (i.e., the certificate included in
its motion papers) as evidence of his opposition. Second, and
of purportedly “[g]reater significance,” he notes that the


                               17
District Court scheduled an evidentiary hearing only six days
after the Government filed its motion. Because the District
Court granted the Government some of the relief that it
sought, he posits that there existed no basis for a response.

       We find no merit in the argument that relies on the
Government’s certificate of non-concurrence. That certificate
was filed pursuant to the District Court’s Local Rules, which
require the movant to certify that it “sought concurrence in
the motion from each party, and that it ha[d] been either given
or denied.” M.D. P A. L. R. 7.1. By filing the certificate, the
Government met its burden. But the Government’s filing
cannot be construed as meeting Cruz’s burden of filing
meaningful opposition. This conclusion rests on both the
District Court’s adoption and interpretation of its Local Rules.
The District Court has made clear that a party opposing a
motion must file an opposition brief. See Nat’l Med. Care,
Inc. v. Am. Renal Assocs., Inc., No. 1-702, 2002 WL
31107534, at *5 n.5 (M.D. Pa. Sept. 17, 2002); GGIS Ins.
Servs., Inc. v. Lincoln Gen. Ins. Co., Inc., No. 10-932, 2011
WL 484180, at *2 n.3 (M.D. Pa. Feb. 7, 2011). Indeed,
Middle District Local Rule 7.6 provides the framework for
timely-filed opposition and states that “[a]ny party who fails
to comply with this rule shall be deemed not to oppose such
motion.” M.D. P A. L. R. 7.6 (emphasis added).

       We similarly find no merit in Cruz’s argument that the
District Court’s calendaring of an evidentiary hearing
obviated the need for opposition papers. Although the
District Court quickly granted the Government’s scheduling
request, the Government’s ultimate goal was clear: it sought


                              18
an order authorizing the BOP to forcibly medicate Cruz.
Cruz was on notice of the Government’s ultimate request for
relief, and he thus was or should have been aware of his
obligation to oppose (or be deemed to support) it.

       Cruz also argues that he was not obliged to present
either evidence or argument at the Sell hearing. In some
sense, he is correct. The Government bore the ultimate
burden of proof under Sell, and Cruz was free to leave the
Government to its proofs. But insofar as Cruz ignored the
local rules and chose not to present argument at the
conclusion of the Sell hearing, he made that choice at his
peril. E.g. Cabán Hernández v. Philip Morris USA, Inc., 486
F.3d 1, 7 (1st Cir. 2007).

                              C.

        Notwithstanding his earlier arguments, Cruz argues
that the Stay Brief preserved the same arguments that he now
raises on appeal. We disagree. The Stay Brief was incapable
of preserving the arguments that Cruz could have raised
earlier but did not raise. See Mick Haig Prods. E.K. v. Does
1-670, 687 F.3d 649, 652 (5th Cir. 2012). That conclusion
would hold true even if the Stay Brief was treated as favoring
both a stay and reconsideration on the merits. See United
States v. Dupree, 617 F.3d 724, 732-33 (3d Cir. 2010). And
it “applies with added force” here, “where the timely raising
of the issue would have permitted the parties to develop a
factual record.” Gass v. V.I. Tel. Corp., 311 F.3d 237, 246
(3d Cir. 2002) (citation and internal quotation marks omitted).



                              19
                               V.

       We now address the Sell-specific standard of review
and the substantive arguments that Cruz advances on appeal.

                               A.

       As noted above, the first Sell criterion concerns the
Government’s interest in forcibly medicating a defendant to
restore his mental competency. To justify such action, “a
court must find that important governmental interests are at
stake.” Sell, 539 U.S. at 180. A court’s conclusions
regarding the importance of the government’s interest
necessarily involve balancing the seriousness of the crimes at
issue with case-specific “[s]pecial circumstances” that “may
lessen the importance of that interest.” Id. Examples of
special circumstances include “the possibility that the
defendant has already been confined for a significant amount
of time (for which he would receive credit toward any
sentence ultimately imposed[)]” and the likelihood, given
“[t]he defendant’s failure to take drugs voluntarily,” that he
will face “lengthy confinement in an institution for the
mentally ill . . . that would diminish the risks that ordinarily
attach to freeing without punishment one who has committed
a serious crime.” Id.

        The Sell Court did not allocate burdens of proof or
establish standards for appellate review for any of the four
Sell criteria. Thus, we addressed those issues for the first
time in Grape, and we concluded that: (1) the first Sell
criterion is a question of law subject to plenary review; (2) the


                               20
second, third, and fourth Sell criteria are questions of fact that
are subject to clear error review; and (3) “the Government
bears the burden of proof on factual questions by clear and
convincing evidence.” 549 F.3d at 598-99.5 Our discussion
of case-specific special circumstances in that case was limited
both by and to the arguments raised by the parties.

       Since Grape was issued, at least two other federal
appellate courts have further refined the burdens of proof and
standard of review that apply to the first Sell criterion. First,
the Court of Appeals for the Sixth Circuit announced a
burden-shifting standard that recognizes the defendant’s
interest in bringing special circumstances to light. See United
States v. Mikulich, 732 F.3d 692, 699 (6th Cir. 2013) (“While
the ultimate burden of proving an important interest . . .
remains with the Government, . . . the defendant [must]
demonstrate that the special circumstances of his case
undermine the Government’s interest . . . .”). Shortly
thereafter, the Court of Appeals for the D.C. Circuit clarified
the related standard of review, ruling that it would “review de
novo the District Court’s conclusion that the Government has
an important interest” but qualifying that “[t]o the extent that
the District Court’s determination under the first prong of Sell
depends on findings of fact,” it would “review those findings

       5
          Those conclusions followed the trends set by the
majority of federal appellate courts. When Grape was
decided, the federal appellate courts that had reviewed the
first Sell criterion agreed that it was a question of law subject
to plenary review. See Grape, 549 F.3d at 598 & n.7
(surveying cases).

                               21
under a clear-error standard.”       Dillon, 738 F.3d at 291
(citations omitted).

        Insofar as the Grape court discussed the first Sell
criterion, it had little reason to consider it as a mixed question
of both law and fact, expound upon the related standards of
review, or address a shifting allocation of the burdens of
proof. There was no dispute in that case that the defendant
had been incarcerated for three-and-a-half years and faced
mandatory minimum sentences of ten and fifteen years.
Further, the facts of that case led the Court to “decline to
reach whether [the defendant’s] potential for indefinite civil
confinement on the facts prior to his Harper medication
would have sufficed under the first Sell factor to overcome
the Government’s stated interest.” Grape, 549 F.3d at 603
n.10. 6

       We will thus adopt both the Mikulich burden-shifting
standard and the mixed standard of review set forth in Dillon.
Such adoption builds on the standard set forth by the Grape
court and clarifies the extent to which defendants bear
responsibility for proving the existence of special
circumstances—circumstances recognized by the Supreme
Court as inherently fact-specific. See Sell, 539 U.S. at 180
(“Courts . . . must consider the facts of the individual case in
evaluating the Government’s interest . . . .”).

       6
          Admittedly, the Grape court discussed the likelihood
of civil confinement. But given the clear statement that it
would not reach that issue, its related commentary is best
characterized as obiter dicta.

                               22
                               B.

         Cruz earlier conceded, in the Stay Brief, that “the
government has an interest in sentencing a convicted
defendant.” (Supplemental App. 9.) Similarly, he recognizes
on appeal that “there is a punishment interest that has some
import.” (Appellant Br. at 8.) But he now raises four related
arguments that we must address. First, he argues that the
Government does not and cannot have an important interest in
restoring a defendant’s mental competency to proceed with
sentencing. In that sense, he distinguishes his case from
Grape, Sell, and others where the Government’s interest arose
pre-trial. He next argues that the offenses for which he was
convicted—i.e., Count II and Count III, which were each a
violation of 18 U.S.C. § 115—are not “serious” offenses that
might justify the Government’s interest. Finally, he argues
that the District Court erred when it considered the
importance of the Government’s interest by reference to the
Guidelines range in the PSR and, more generally, to the PSR
itself.7

1.     The Government Can Have an Important Interest
       in Restoring a Defendant’s Mental Competency
       and Rendering Him Fit to Proceed with Sentencing

       In 2006, the Court of Appeals for the Sixth Circuit
stated that it “appear[ed] yet unresolved whether the Sell

       7
         Certain other arguments that Cruz raises for the first
time in the Reply Brief will not be addressed. See, e.g.,
United States v. Pelullo, 399 F.3d 197, 222 (3d Cir. 2005).

                              23
principles permit the Government to involuntarily medicate a
defendant for the purpose of rendering him competent to be
sentenced,” noting that the Sell principles had to that point
only been applied “where the Government’s purpose in
medicating a defendant is to render him ‘competent to stand
trial.’” Baldovinos, 434 F.3d at 241 n.7 (quoting Sell, 539
U.S. at 181). On that basis, Cruz argues on appeal that the
Government lacks an important interest in restoring his
mental competency to render him fit to proceed with
sentencing. He seeks to distinguish this case from Grape,
Sell, and others like it, where the Sell proceedings took place
pre-trial.

       Since Baldovinos was decided, only one court has
considered whether the Government may have such an
interest.8 In 2006, in United States v. Wood, the District
Court for the Eastern District of Virginia affirmatively
answered that question. See Wood, 459 F. Supp. 2d at 456-
60. In effect, the Wood court reached the same conclusion

      8
         At oral argument, Cruz directed our attention to a
second case, United States v. Perez-Rubalcava, No. 03-
20018, 2008 WL 4601024, at *2 (N.D. Cal. Oct. 15, 2008).
However, because the parties in that case agreed that the
defendant “ha[d] already been in custody for a period of time
nearly as long as the time for which he would likely have
been sentenced if competent,” that court did not have
occasion to reach the questions presented here. See id.
(noting that the Government “ha[d] in large part obtained the
deterrence and other goals of a criminal conviction and
sentence”).

                              24
that the Government urges here: it held that the Government
has an important interest in restoring a defendant’s mental
competency for sentencing because it has a legitimate interest
in punishing those who have committed crimes. See id. at
458 (“[T]he sentence a defendant receives should accurately
reflect the real nature of his offense, and should be tailored to
the defendant’s circumstances.”); id. at 459 (“[T]here is a
very important, legislatively articulated, governmental
interest in achieving fair, reasonable and non-disparate
sentences for similarly situated defendants who have engaged
in similar conduct.”).

       The Wood court’s holding rests on its analysis of the
Sentencing Reform Act of 1984 (“the Sentencing Act”), the
Sentencing Guidelines, and United States v. Booker, 543 U.S.
220 (2005), where the Supreme Court discussed
governmental sentencing interests. See id. at 458-59. It
found in pertinent part that Booker “made clear that the
Government has an important interest in enforcing” both the
Sentencing Act and Sentencing Guidelines. Id. It thus
concluded that the Government has an important interest in
“[r]easonable, constitutionally acceptable measures that help
achieve that interest,” including, importantly, “[t]he forcible
administration of medication to restore competence for
sentencing.” Id. at 459.

      Although the Wood court’s decision does not bind this
Court, its reasoning is highly persuasive. As that court
recognized, in Booker the Supreme Court highlighted
governmental interests that are inherent in sentencing
proceedings. It repeatedly emphasized that the sentencing


                               25
scheme put in place by the Sentencing Act and Sentencing
Guidelines “diminishes sentencing disparity” and “move[s]
the sentencing system in the direction of increased
uniformity.” Booker, 543 U.S. at 250, 253. It also repeatedly
emphasized that sentencing uniformity depends in critical part
on the relationship between punishment and “the real conduct
that underlies the crime of conviction.” Id. at 250; see id. at
251 (“Judges have long looked to real conduct when
sentencing,” and often rely on “a presentence report, prepared
by a probation officer, for information (often unavailable until
after the trial) relevant to the manner in which the convicted
offender committed the crime of conviction.”); id. at 253-54
(“[I]ncreased uniformity . . . does not consist simply of
similar sentences for those convicted of violations of the same
statute . . . . It consists, more importantly, of similar
relationships between sentences and real conduct,
relationships that Congress’ [sic] sentencing statues helped to
advance[.]”).

       The Government cannot achieve the sort of uniformity
contemplated in Booker without formal sentencing
proceedings. A criminal defendant enjoys the right to
allocute at sentencing, and he also enjoys the right to object to
the PSR, to argue for favorable sentencing variances and
downward departures from the Sentencing Guidelines, and to
oppose any arguments favoring upward variances or
departures from the Guidelines. Those rights, which to a
great degree reflect the defendant’s “real conduct,” id. at 250,
necessarily require the defendant to both actively participate
in sentencing proceedings and inform his attorney’s actions.
Because an incompetent defendant is presumed unable to take


                               26
those actions, the Government maintains an important interest
in restoring his mental competency and enabling him to do so.

        Cruz here raises two arguments that the Wood court
appears not to have had occasion to address. First, he argues
that the Government’s interest in forcibly medicating him to
restore his competency for sentencing is undercut by its
ability to seek a provisional sentence under 18 U.S.C. § 4244,
whereby “in lieu of being sentenced to imprisonment” he
would “be committed to a suitable facility for care and
treatment” until he either “recovered from his mental disease
or defect” or had been confined for “the maximum term
authorized by law for the offense for which [he] was found
guilty.” 18 U.S.C. § 4244(d), (e). He also argues that the
Government’s interest in restoring his competency for
sentencing is less than the interest recognized in Sell,
contending that the Supreme Court placed particular emphasis
on the pre-trial nature of the proceedings when it announced
that “it may be difficult or impossible to try a defendant who
regains competence after years of commitment during which
memories may fade or evidence may be lost.” Sell, 539 U.S.
at 180. But neither argument carries significant weight. Cruz
would have this Court parse sentencing proceedings from the
substantive trial proceedings to which they are inexorably
linked. This Court, like the Wood court, will reject that
invitation. “If the sentencing phase of a federal criminal
prosecution is not quite a ‘tail which wags the dog of the
substantive offense,’ McMillan v. Pennsylvania, 477 U.S. 79,
88[] (1986), it is nonetheless a critical step in the criminal
justice process that Congress designed.” Wood, 459 F. Supp.
2d at 459.


                             27
        Insofar as Cruz argues that provisional sentencing
under § 4244 undermines the Government’s important
interest in restoring his competency for sentencing, he
appears to ignore important language from the Supreme
Court’s opinion in Sell. There, the Supreme Court noted that
the possibility of civil confinement “affects, but does not
totally undermine, the strength of the need for prosecution.”
539 U.S. at 180 (emphasis added). And it appears axiomatic
that sentencing is an integral part of prosecution:

              When people speak of prosecutions, they
      usually mean a proceeding that is under way in
      which guilt is to be determined. In ordinary
      usage, sentencing is not part of the prosecution,
      but occurs after the prosecution has concluded. .
      . [However, r]ather than using terms in their
      everyday sense, (t)he law uses familiar legal
      terms in their familiar legal sense. The term
      ‘prosecution’ clearly imports a beginning and
      an end.
              . . . Final judgment in a criminal case
      means sentence. The sentence is the judgment.
      In the legal sense, a prosecution terminates only
      when sentence is imposed.

Bradley v. United States, 410 U.S. 605, 608 (1973) (defining
“prosecution” within meaning ascribed by savings clause of
Section 1103(a) of the Comprehensive Drug Abuse




                             28
Prevention and Control Act of 1970). 9 Indeed, it is hard to
imagine prosecution without sentencing. Such a scheme
would turn criminal convictions into little more than paper
tigers. See United States v. Petty, 982 F.2d 1365, 1371 (9th
Cir. 1993) (Noonan, J., dissenting on other grounds) (“To
deny that the sentencing process is part of a criminal
prosecution is to cut out the guts of criminal prosecution as it
is conducted in our courts.”).

       Furthermore, insofar as Cruz argues that the Supreme
Court’s holding in Sell should be limited to the proceedings in

       9
          Several cases support this conclusion. See Gardner
v. Florida, 430 U.S. 349, 358 (1977) (concluding in context
of Sixth Amendment that “sentencing is a critical stage of the
criminal proceedings at which [a defendant] is entitled to the
effective assistance of counsel”); Bradley, 410 U.S. at 611
(“As we have said, sentencing is part of the prosecution.”);
United States v. Thompson, 713 F.3d 388, 394 (8th Cir. 2013)
(holding in First Amendment context that “[s]entencing may .
. . be viewed as within the scope of the criminal trial itself”
(citation omitted)); United States v. Smith, 354 F.3d 171, 175
(2d Cir. 2003) (“[S]entencing is an integral part of
‘prosecution’ of the accused, as that term is used in” the
General Saving Statute, 1 U.S.C. § 109”); United States v.
Wells, 154 F.3d 412, 414 (7th Cir. 1998) (in affirming
conviction for obstruction of justice, stating unequivocally
that “sentencing is part of the prosecution”); United States v.
Green, 680 F.2d 183, 191 (D.C. Cir. 1982) (Bazelon, J.,
dissenting on other grounds) (“Sentencing is the most
important part of the typical criminal trial.”).

                              29
which a defendant’s guilt may be determined, he ignores
important procedural aspects of the sentencing phase of trial.
As noted above, the Supreme Court stated its concern in Sell
that “memories may fade or evidence may be lost.” 539 U.S.
at 180. That concern applies with equal force to both the
jury’s determination of a defendant’s guilt and the court’s
sentencing determinations. Whereas the Court announced in
Sell that “it may be difficult or impossible to try a defendant
who regains competence after years of commitment during
which memories may fade and evidence may be lost,” id.
(emphasis added), we recognize that it may be difficult or
impossible to sentence a defendant who regains competence
after years of commitment for substantially the same reasons.
Cf. Booker, 543 U.S. at 251 (noting that “judges have long
relied upon a presentence report . . . for information (often
unavailable until after the trial)” for sentencing purposes).

2.     The Offenses at Issue Were “Serious” and They
       Thus Justified the Government’s Interest

       Cruz next argues that the crimes for which he was
convicted—Count II and Count III, violations of 18 U.S.C. §
115—were not as serious as the crimes at issue in Sell and
Grape, and he appears to contend that the seriousness of his
crimes undermines the Government’s interest in restoring his
competency for sentencing. The seriousness of a defendant’s
crimes is, of course, the yardstick against which the court will
measure the governmental interests that are at stake. And
serious crimes may be committed against either persons or
property because “[i]n both instances the Government seeks



                              30
to protect through application of the criminal law the basic
need for human security.” 539 U.S. at 180.

       Because this Court has not yet promulgated a test to
determine the seriousness of a crime, the District Court
gauged the seriousness of Cruz’s crimes by reference to both
the statutory maximum sentence associated with those
offenses and the likely Guidelines range that was set forth in
the PSR. It concluded that, under either rubric, his crimes
were serious. We agree, and, as in Grape, need not decide
here whether the seriousness of an offense should be
measured against either the statutory maximum associated
with an offense or the likely Guidelines range.

       Cruz has not argued by reference to the applicable
statutory maximum that his crimes are not serious. Indeed, it
appears that he cannot. At least two other federal appellate
courts have determined that the offense at issue here, a
violation of 18 U.S.C. § 115, is a serious crime because it
carries a maximum sentence of ten years. See United States
v. Palmer, 507 F.3d 300, 301, 303-04 (5th Cir. 2007); United
States v. Evans, 404 F.3d 227, 238 (4th Cir. 2005)
(concluding that violation of 18 U.S.C. § 115 is a serious
crime “under any reasonable standard”).

       His argument on the seriousness of his crimes as
gauged by the Guidelines range in the PSR is similarly
unavailing. In United States v. Gillenwater, the defendant
was charged with violations of 18 U.S.C. §§ 875 (transmitting
threatening interstate communications) and 876 (transmitting
threatening communications by mail), and the “likely


                             31
Guidelines range [w]as 33 to 41 months.” 749 F.3d 1094,
1101 (9th Cir. 2014). That Guidelines range is less than that
at issue here. 10 Retired Supreme Court Justice Sandra Day
O’Connor, writing for the Ninth Circuit Court of Appeals,
considered the likely Guidelines range and concluded that the
charged offenses were “serious enough to establish an
important governmental interest in [the defendant’s]
prosecution.” Id. She noted that the defendant stood
“accused of making lurid and distressing threats against a
bevy of government officials and employees” and she thus
reasoned that through prosecution the Government sought
“‘to protect through application of the criminal law the basic
human need for security’ . . . [and] the very integrity of our
system of government.” Id. (quoting Sell, 539 U.S. at 180).


      10
           Cruz takes issue with the likely Guidelines range
that was presented in the PSR, which was premised on a
career offender enhancement. It appears, however, that the
legal arguments relating to that issue are foreclosed by our
recent decision in United States v. Marrero, 743 F.3d 389
(2014).
        In any event, the Guidelines range urged by Cruz—
i.e., 51 to 63 months—is still greater than that at issue in
Gillenwater. It is thus a difference without distinction. Even
if we accepted the Guidelines range urged by Cruz, then we
would conclude that the crimes at issue are serious. See
Gillenwater, 749 F.3d at 1101 (concluding that threats of
violence, directed against federal officials, were serious
where likely Guidelines range called for only thirty three to
forty-one months’ imprisonment).

                              32
        The crimes at issue here are no less “lurid and
distressing” than those at issue in Gillenwater. There, the
defendant was charged with sending violent and graphically
descriptive threats to officials from the Occupational Safety
and Health Administration and the Department of Labor. See
id. at 1097-98. Here, Cruz repeatedly threatened officials
from the SSA and Federal Protective Service (“FPS”). He
yelled at several SSA officials that they were “going to need
toe tags” and told an FPS official that he would “take [his]
ticket book, take [his] gun, take [his] doughnut and beat [his]
ass.” In another, particularly graphic encounter with an FPS
official, he stated that “[t]here [sic] gonna be a war about
this,” explaining that you should be concerned about yourself.
. . . If I’m gonna tell you I’m gonna kill you, I ain’t gonna
tell you I’m gonna kill you, I’m gonna swing at you, all I
gotta do is hit you one time,” and inviting the official to
“come see me in person so we can talk and see whatever, so I
can see what I’m talking to. Give me a target, you have one.”
United States v. Cruz, No. 11-242, 2012 WL 3027809, at *1
(M.D. Pa. July 24, 2012) (citations and quotation marks
omitted).

      Those statements demonstrate the reasonableness of
concluding that the Government’s interest in preserving
“human security” is as great here as it was in both Sell and
Gillenwater. See Sell, 539 U.S. at 180 (recognizing the
Government’s need “to protect through application of the
criminal law the basic human need for security”);
Gillenwater, 749 F.3d at 1101 (recognizing the Government’s




                              33
need “to protect the very integrity of our system of
government”). 11

3.     As a General Matter, the District Court Did Not
       Commit Reversible Plain Error When it
       Considered and Relied on the PSR

      Cruz next argues that the District Court erred when it
considered the Guidelines range appearing in the PSR

       11
          In any event, the District Court’s consideration of
the seriousness of Cruz’s offenses by reference to the likely
Guidelines range cannot constitute plain error. As noted
above, we have yet to decide whether the seriousness of an
offense should be measured against mandatory minimum
sentences or likely Guidelines ranges. Other circuit courts are
split on that issue. See Grape, 549 F.3d at 600; see also
Dillon, 738 F.3d at 292 (recognizing the circuit split as
recently as December of 2013). Under those circumstances,
there could be no plain error. See, e.g., United States v.
Keller, 666 F.3d 103, 109 & n.7 (3d Cir. 2011).
        Furthermore, the error that Cruz would have us assign
could not have affected his substantial rights. Although the
District Court concluded that Cruz’s crimes were serious by
reference to the likely Guidelines range, it reached the same
conclusion upon its separate and alternative analysis of the
mandatory maximum sentence associated with his crimes.
Because it consideration of the likely Guidelines range
ultimately did not affect the outcome of his Sell proceeding,
Cruz was not and could not be prejudiced by it. See United
States v. Stevens, 223 F.3d 239, 242 (3d Cir. 2000).

                              34
because that range did not account for Cruz’s mental health
status, which could potentially serve as a basis for a
downward departure or variance. However, because Cruz
raises this argument for the first time in the Reply Brief, we
will not consider it. Instead, we will deem it, like the other
arguments that were raised for the first time in the Reply
Brief, to be waived. See Pelullo, 399 F.3d at 222.

                              C.

       Lastly, Cruz argues that the District Court erred when
it concluded that the Government’s interest was not
undermined by the likelihood that Cruz will be civilly
committed in the future.         As discussed above, that
circumstance involves a fact-specific inquiry, and ,
accordingly, this Court should review the District Court’s
related legal conclusions de novo and its factfinding for clear
error. See Dillon, 738 F.3d at 291.
       The District Court considered the likelihood that Cruz
would be civilly committed in the future under both federal
and state civil commitment statutes and concluded that it was,
at best, unclear. (See App. 9-10.) In pertinent part, it
explained:

       Under 18 U.S.C. § 4246(d), the court would
       need to find that Cruz is suffering from a mental
       disease or defect that would create “a
       substantial risk of bodily injury to another
       person or serious damage to property of
       another” if released. Similarly, the state civil
       commitment statute, 50 [Pa.C.S.] § 7301,


                              35
provides       for     involuntary     emergency
examination and treatment of people who are
“severely mentally disabled and in need of
immediate treatment.” Under the statute, a
person is severely mentally disabled when, as a
result of mental illness, “he poses a clear and
present danger of harm to others or to himself.”
50 [Pa.C.S.] § 7301(a). A “clear and present
danger of harm” to others may be
“demonstrated by proof that the person has
made threats of harm and has committed acts in
furtherance of the threat to commit harm.” 50
[Pa.C.S.] § 7301(b).
        The May 2013 evaluation explicitly
states that Cruz has not posed a threat to himself
or others while housed at FMC-Butner and does
not pose a risk of committing serious harm to
others. Cruz was convicted of two counts of
threatening federal law enforcement officers,
but there is no indication that he committed
explicit acts in furtherance of those threats. On
the other hand, the pre-sentence investigation
report     indicates that Cruz has a lengthy
criminal history involving numerous acts of
violence and threats of violence and an
extensive history of mental health treatment,
including involuntary commitments. Entries
from the [BOP’s] Psychology Data System,
dated June 20, 2013 to October 10, 2013,
indicate that Cruz has continued to threaten
violence against others. Several entries indicate


                       36
      that the potential for Cruz to cause harm to
      others is moderate or high.

(Id.)   On those facts, it concluded that “[u]ncertainty
surrounding the issue of whether Cruz is likely to be civilly
committed does not materially diminish, and it clearly does
not undermine, the government’s interest in sentencing Cruz.”
(App. 10.)

       Following close review of the record, we will not
disturb the District Court’s factfinding because it is not
clearly erroneous. Its recitation of the facts, including those
related to the May 2013 evaluation, Cruz’s history of mental
health issues, and his history of violence and threats of
violence, is well-supported by the record. Thus, we find no
error in the District Court’s conclusion that it was uncertain
whether Cruz would in the future meet the factual
prerequisites for civil commitment under either 18 U.S.C. §
4246 or 50 Pa.C.S. § 4244. The stark contrast between the
May 2013 evaluation and Cruz’s history of both threats of
violence and actual violence fairly led the District Court to
reach that conclusion. Further, we find no plain error in the
District Court’s conclusion that such uncertainty neither
materially diminished or undermined the Government’s
interest in restoring his competency for sentencing. Cf.
Mikulich, 732 F.3d at 697.

       Furthermore, under plain error review, Cruz has failed
to demonstrate that he was prejudiced by any alleged error in
either the District Court’s factfinding or ultimate conclusion
that uncertainty surrounded the likelihood of future civil


                              37
commitment. Although eligibility for civil commitment may
“diminish[] the risks that ordinarily attach to freeing without
punishment one who has committed a serious crime,” Sell,
539 U.S. at 180, and thereby lessen the Government’s interest
in restoring Cruz’s competency, see Gillenwater, 749 F.3d at
1101, the uncertainty found by the District Court here would
undoubtedly reduce the amount by which this circumstance
would lessen the Government’s interest.

                              VI.

       For the forgoing reasons, we will affirm the order
entered by the District Court pursuant to Sell v. United States,
539 U.S. 166 (2003) on October 24, 2013.




                              38
