Medicating Death Row: Executing the Mentally Ill

Introduction: The Moral Dilemma of Executing the Mentally Ill

"An eye for an eye, a tooth for a tooth" is the philosophy many people adhere to when it comes to the punishment of criminals. The death penalty has been debated for many years as it has come into and then fallen out of favor with the American public. The issue is especially volatile when it comes to the mentally ill. When a mentally ill person commits a crime that carries the death penalty, the state and those involved with the case often face a profound moral and ethical dilemma.

If the person is not capable of understanding why they are being executed, or what the death penalty means to them, a legal, ethical, and moral question arises about the fairness of that execution. The states' answer has been to medicate the mentally ill prisoner with antipsychotic drugs so that they become mentally capable of understanding that they will be executed. The question then becomes: how humane is it to bring someone out of mental illness, restore them to a state of comprehension, and then kill them precisely because they can now understand what is happening?

In 1986, the United States Supreme Court decided Ford v. Wainwright, holding that the execution of a mentally incompetent prisoner violates the Eighth Amendment's prohibition against cruel and unusual punishment. A prisoner cannot be executed unless sufficiently competent to understand the nature and reasons for their punishment. Making death row inmates sane enough to execute is therefore a legal, moral, and ethical debate that warrants serious investigation.

Singleton v. Norris and the Question of Forced Medication

In a six-to-five decision — the first ruling of its kind — the closely divided United States Court of Appeals for the Eighth Circuit held, in Singleton v. Norris, that a mentally ill prisoner may be involuntarily medicated with antipsychotic drugs to restore his competency for execution. The decision raised acute ethical dilemmas for criminal law and for medical and mental health professionals who provide treatment to the condemned. Should medical professionals provide necessary mental health treatment to a condemned prisoner when restoration of competency will likely result in his execution? Does doing so shift their role from that of "healer" to accomplice in the administration of the death penalty?

In that particular case, the death row inmate was a man who had murdered and committed aggravated robbery. While in prison, his mental health began to deteriorate, and he was diagnosed with schizophrenia. His illness caused paranoia, delusions, and other symptoms common to that disorder. Singleton believed, for example, that his thoughts were being stolen and that demons filled his cell. In his hallucinations, his food turned to worms and his cigarettes to bones. He lost considerable weight, spoke in unfamiliar languages, and sometimes refused to wear clothing. There were times when he believed he had already been executed.

In 1997, the prison began involuntarily medicating Singleton with antipsychotics, after a medication review panel found that he posed a danger to himself and others and that forcibly administered medication was appropriate. Under current constitutional jurisprudence, people have a substantial liberty interest in refusing mind-altering medication. A prisoner may be forcibly medicated only when the treatment is medically appropriate and the prisoner poses a danger to himself, herself, or others when unmedicated.

The medication caused Singleton's psychotic symptoms to subside, and in 2000 a date of execution was set. His lawyers argued, however, that once the execution date was set, the forced medication became unconstitutional because it was no longer in his long-term medical interest. Rather than allowing Singleton to face the choice of being involuntarily medicated and later executed, or left to suffer painful psychotic symptoms, his attorneys suggested that his execution should be stayed unless and until involuntary medication was no longer required to maintain his competence. The Eighth Circuit disagreed.

The court held that forcibly medicating Singleton — regardless of the ultimate consequence of execution — was the medically appropriate way to restore his competence while satisfying his best medical interests, which the court defined in terms of his immediate need for treatment to alleviate psychotic symptoms. Without apparent irony, the court noted that "[e]ligibility for execution [would be] the only unwanted consequence of medication."

The question remained: Was the state's decision to medicate Singleton intended to alleviate his symptoms and protect him from harm, or simply to render him competent for execution? Judge Gerald Haney's vigorous dissent, joined by three other judges, argued that the state's true motivation for forcibly administering medication is called into question once an execution date is set, at which point the justification for medicating Singleton in his best medical interests "evaporate[s]."

Medical Ethics and the 'Do No Harm' Principle

The ruling also highlighted the ethical dilemmas forced upon medical and mental health professionals. Under the ethics guidelines of both the American Medical Association and the American Psychiatric Association, health professionals are prohibited from assisting in the execution of a condemned prisoner. The Hippocratic Oath directs physicians to "First, do no harm." Those treating an incompetent, psychotic prisoner are often left in an untenable position: provide needed psychiatric treatment that may enable an ultimate execution, or refuse to provide treatment that would alleviate painful and potentially dangerous psychotic symptoms.

The clinician's role becomes particularly fraught because it is the clinician who administers the drugs that make the inmate mentally capable of being executed. The "do no harm" vow becomes caught in a catch-22: the clinician is ethically obligated to treat the mental illness, but by doing so, facilitates the execution.

Some professionals endorsing treatment argue that providing care is not an endorsement of the death penalty, but rather a permissible way to separate one's duty as a clinician from the legal system's administration of punishment. The "sometimes treat" position — most readily accepted by mental health professionals — advocates treatment for the incompetent prisoner facing execution on a case-by-case basis, and only when the individual wants to receive it. The immediate benefits of treatment, such as the restoration of dignity and the alleviation of symptoms, are weighed against the risks of treatment and the possible facilitation of an ultimate execution. Those who are incompetent for execution may, however, be unable to provide valid consent, or will refuse treatment — as Singleton did.

Those who oppose any form of forced treatment argue that treating the illness assists in a greater harm — providing the means to execute — and that health care workers therefore should not agree to administer such medications. Condemning the death penalty as "both cruel and unnecessary," Pope John Paul II stated that "the dignity of human life must never be taken away." In the encyclical Evangelium vitae, the pope urged professionals not to participate in medical procedures that endanger human life. Yet the dignity of the condemned is also threatened when he or she is allowed to suffer painful psychotic symptoms without receiving the efficacious treatments that modern medicine offers. As the psychiatrist Sally Satel notes, "the freedom to be delusional is no freedom at all."

Singleton's lawyers considered an appeal of the Eighth Circuit decision to the U.S. Supreme Court. At the same time, the Court was already preparing to decide the constitutionality of forcibly medicating defendants to make them competent to stand trial in Sell v. United States. During oral arguments in that case, Justice Antonin Scalia captured the difficulty well: "We can't try him because his mind is not working properly, but [counsel argues] he's entitled to refuse the drugs that would make his mind work properly — it's just a crazy situation." Many observers expected the Court to hold that the government's interest in adjudicating defendants would alone be sufficient to permit forced medication, even when it is not required to prevent danger to self or others.

Conclusion: Raising the Bar

The execution of the mentally ill after forcing them to take medication has been upheld in several U.S. courts. The logic behind such decisions is flawed for several reasons. Mentally ill individuals so severely disordered that they cannot function are not forced to stand trial, nor are they required to answer for their crimes in a standard proceeding. They are allowed an insanity defense that allows them to seek treatment and eventually apply to reenter society. It does not make sense that a mentally ill person can be force-fed medications so that they become sane enough to be executed when defendants cannot be force-fed medications merely for the purpose of understanding their crime and standing trial.

The health care profession is built on a foundation of not harming others. It is inconsistent to ask its members to provide medical treatment that will ultimately result in the death of that patient. Executing the mentally ill or the mentally retarded is constitutionally suspect, especially given that those same individuals would not be required to stand trial if their illness had manifested at the time of their proceedings. It is time to apply stricter standards to this debate — standards that prevent severely mentally ill people from being compelled to take medications that will make them well enough to be executed.