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This article summarizes the evolution of the U.S. Supreme Court's standard for assessing defendants' competency for execution. In Ford v. Wainwright (1986), the Court categorically exempted insane defendants from execution but failed to agree on how to define insanity. In Panetti v. Quarterman (2007), the Court ruled that defendants may be executed only if they rationally understand why they are being punished. In its most recent decision, the Supreme Court ruled in Madison v. Alabama (2019) that defendants who cannot remember committing the original crime may be executed, but dementia may prevent defendants from rationally understanding why they are being punished. The Court remanded the case to Alabama's trial court with instructions to re-determine Mr. Madison's competency. This article concludes by recommending best practices for those who evaluate defendants for competency to be executed., (© 2020 American Academy of Psychiatry and the Law.)

During its 2018-2019 term, the United States Supreme Court considered the constitutionality of executing a prisoner with dementia. In Madison v. Alabama, the Court ruled that, in certain circumstances, executing a prisoner with dementia violates the Eighth Amendment's ban on cruel and unusual punishment. Vernon Madison was sentenced to death for killing a police officer in 1985. After many years on Alabama's death row, he had a series of strokes and was diagnosed with vascular dementia. In 2016, Madison's lawyers unsuccessfully sought a stay of execution, arguing that, in light of his cognitive impairments, imposing the death penalty would violate the Constitution. After Alabama set a 2018 execution date, lawyers returned to the state court, arguing that the finding of competence should be reversed because Madison's cognitive impairments had worsened. When the trial court refused to grant the stay of execution, Madison's lawyers asked the Supreme Court to review the constitutionality of the state court decision., (© 2019 The Hastings Center.)

As death row prisoners age, a new set of issues arises regarding their competence to be executed. Can a prisoner with dementia who no longer remembers the crime be put to death? What if the dementia has progressed to the point that the prisoner no longer understands that he or she faces execution, or why? These issues were considered by the U.S. Supreme Court in its recent decision in Madison v. Alabama . Implicitly rejecting the cruelty of executing a highly impaired prisoner, the court clarified the conditions that could preclude execution and the degree of impairment that must be present.

In Dusky v. United States, the United States Supreme Court established "rational understanding" as a necessary component of a defendant's competency to stand trial. Yet, rational understanding has engendered misunderstanding, stemming from inconsistent court rulings and lack of systematic attention given to definitions of rationality. The purpose of this article is to assist with the conceptualization of rational understanding as it relates to competency to proceed to trial. This will be accomplished through a review of legal decisions and scholarly papers that provide various definitions of rationality. We discuss the suitability of standardized instruments of competency and how they may assist in providing a valid metric for evaluating rational abilities. We also provide discussion of how case law, in conjunction with psycholegal research, can be used to gain nuanced insight into operationalizations of rational understanding. By gaining a thorough understanding of rationality in competency to proceed to trial evaluations, clinicians may improve on the quality and foundation of their evaluations., (© The Author(s) 2014.)

The United States Supreme Court has ruled on the question of persons with intellectual disability and capital punishment in several notable cases, including Penry v. Lynaugh (1989) and Atkins v. Virginia (2002). In 2014, the U.S. Supreme Court revisited the subject in Hall v. Florida. Although Florida Statute § 921.137 prohibits imposing a sentence of death on a defendant convicted of a capital felony if it is determined that the defendant is intellectually disabled, the Florida Supreme Court strictly interpreted the law so that, because Mr. Hall's IQ was not below the cutoff of 70, further evidence could not be presented to show that he had an intellectual disability. In Hall v. Florida, the Court analyzed the relevance of the standard error of measurement of IQ testing, whether there is a consensus among the states regarding capital punishment, and whether there is a consensus among professional associations regarding these questions. The Court also adopted the term "intellectual disability" as opposed to "mental retardation," following changes in both the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the U.S. Code and Code of Federal Regulations. We examine the Court's decision and offer commentary regarding the overall effect of this landmark case., (© 2015 American Academy of Psychiatry and the Law.)

The U.S. Supreme Court addressed competency to be executed in Ford v. Wainwright, holding that execution of the insane violates the Eighth Amendment. More than 20 years later, the Court defined this standard in its landmark decision in Panetti v. Quarterman. The Panetti ruling held that an inmate's factual awareness of the reasons for his execution was not sufficient to determine his competence. The Court advised that a prisoner must have a rational understanding of the reasons for his death sentence. The Panetti Court declined to establish specific competency criteria and acknowledged that rational understanding is difficult to define. Following Ford and Panetti, lower courts have struggled to apply the standards articulated in these two landmark cases. This struggle was recently highlighted in Ferguson v. Florida (2013), a case that received substantial attention and was decided by the Florida Supreme Court and the Eleventh Circuit Court. Ferguson featured majority and concurring opinions that, although consistent in their ultimate conclusions, expressed differing interpretations of their application of the Panetti standard. Although the Panetti Court declined to set a national standard for competency to be executed, Ferguson v. Florida is a cautionary reminder that more tangible guidelines are necessary for consistent application of a conclusion that cannot be revised., (© 2014 American Academy of Psychiatry and the Law.)

There has been little consideration, in either the caselaw or the scholarly literature, of the potential impact of neuroimaging on cases assessing whether a seriously mentally disabled death row defendant is competent to be executed. The Supreme Court's 2007 decision in Panetti v. Quarterman significantly expanded its jurisprudence by ruling that such a defendant had a constitutional right to make a showing that his mental illness "obstruct[ed] a rational understanding of the State's reason for his execution." This article considers the impact of neuroimaging testimony on post-Panetti competency determination hearings, and looks at multiple questions of admissibility of evidence, adequacy of counsel, availability of expert assistance, juror attitudes, trial tactics, and application of the Daubert doctrine, and also considers the implications of the lesser-known Panetti holding (that enhances the role of expert witnesses in all competency-to-be-executed inquiries). It warns that the power of the testimony in question has the capacity to inappropriately affect fact-finders in ways that may lead "to outcomes that are both factually and legally inaccurate and constitutionally flawed.", (Copyright © 2010 John Wiley & Sons, Ltd.)

Under Atkins v. Virginia, the Eighth Amendment exempts from execution individuals who meet the clinical definitions of mental retardation set forth by the American Association on Intellectual and Developmental Disabilities and the American Psychiatric Association. Both define mental retardation as significantly subaverage intellectual functioning accompanied by significant limitations in adaptive functioning, originating before the age of 18. Since Atkins, most jurisdictions have adopted definitions of mental retardation that conform to those definitions. But some states, looking often to stereotypes of persons with mental retardation, apply exclusion criteria that deviate from and are more restrictive than the accepted scientific and clinical definitions. These state deviations have the effect of excluding from Atkins's reach some individuals who plainly fall within the class it protects. This article focuses on the cases of Roger Cherry, Jeffrey Williams, Michael Stallings, and others, who represent an ever-growing number of individuals inappropriately excluded from Atkins. Left unaddressed, the state deviations discussed herein permit what Atkins does not: the death-sentencing and execution of some capital defendants who have mental retardation.

More than 1.5 million Americans have participated in combat operations in Iraq and Afghanistan over the past seven years. Some of these veterans have subsequently committed capital crimes and found themselves in our nation's criminal justice system. This Essay argues that combat veterans suffering from post-traumatic stress disorder or traumatic brain injury at the time of their offenses should not be subject to the death penalty.Offering mitigating evidence regarding military training, post-traumatic stress disorder, and traumatic brain injury presents one means that combat veterans may use to argue for their lives during the sentencing phase of their trials. Alternatively, Atkins v. Virginia and Roper v. Simmons offer a framework for establishing a legislatively or judicially created categorical exclusion for these offenders, exempting them from the death penalty as a matter of law. By understanding how combat service and service-related injuries affect the personal culpability of these offenders, the legal system can avoid the consequences of sentencing to death America's mentally wounded warriors, ensuring that only the worst offenders are subject to the ultimate punishment.

In recent years, the U.S. Supreme Court has created two categorical exemptions to the death penalty. In Atkins v. Virginia, the Court exempted mentally retarded offenders. Three years later, in Roper v. Simmons, the Court extended the protection to juveniles. Based on these cases, the practices of foreign countries, and the opinions of professional organizations with relevant expertise, legal scholars speculate that the Court may, in the future, categorically exclude severely mentally ill offenders from the death penalty. This Note examines the feasibility of such an exemption for the mentally ill and considers its possible repercussions.

The ABA has studied extensively the constitutionally minimum requirements for executing mentally ill offenders. That study has led the Association to conclude that execution of such an offender is constitutionally permissible only if the offender "not only ... [is] 'aware' of the nature and purpose of punishment but also ... 'appreciate[s]' its personal application in the offender's own case, that is, why it is being imposed on the offender." Report in Support of Resolution 122A (Aug. 2006) (emphasis in original). The court below held that a death row inmate who, due to a serious mental disability, suffers from the delusion that the actual reason he is to be executed has nothing to do with his crime is nevertheless competent to be executed. To survive constitutional scrutiny, however, capital punishment must serve the purpose of retribution. The Fifth Circuit's holding breaks that link because it does not require that the offender have any understanding of why he is being put to death--that is, of the retributive purpose of his execution.

In Atkins v. Virginia 2002, the U.S. Supreme Court held that the Eighth Amendment prohibits executing offenders who are mentally retarded. Rather than adopting a uniform definition of mental retardation, the court charged each state with defining mental retardation in a manner that enforces the constitutional restriction. An unanswered question is how states define mental retardation after Atkins, which has implications for capital defendants and forensic evaluators who conduct capital mitigation evaluations. This project identified the statutory definitions of mental retardation in each state, and grouped the definitions based on consistency with accepted clinical criteria for mental retardation. Results show that definitions of mental retardation vary considerably by state. The large majority of states, both overall and specifically among death penalty states, use criteria for mental retardation that are not entirely consistent with accepted clinical standards. As such, it is not clear whether the majority of states are effectuating the intent of Atkins. The implications of these findings for both policy and practice are discussed., (Copyright (c) 2007 John Wiley & Sons, Ltd.)

Recent cases raise a series of questions regarding the involuntary administration of treatment intended to restore or maintain competence to proceed in the criminal process. As is often the case, these matters take on a special urgency in the context of capital punishment. The analysis presented in this paper suggests that the relevant interests that courts should consider in deciding whether to order the involuntary administration of treatment to restore or maintain competence converge to a greater degree than one might initially expect. When the applicable conception of medical interests is appropriately defined and the state's interest in protecting the integrity of the process is given appropriate weight, the legally protected state and individual interests converge to a substantial degree. Protecting both sets of interests may require a variety of procedures designed to avoid misguided interventions with the potential to undermine both sets of interests. Finally, this analysis provides an approach that allows the courts to grant appropriate weight to the professional ethics of those who perform evaluations and deliver treatment in these contexts., (Copyright (c) 2006 John Wiley & Sons, Ltd.)

The issue of whether mental health professionals should be involved in conducting evaluations of competency for execution is a topic that has elicited controversy and heated debate. This article picks up at a point beyond the controversy and addresses issues of professionalism and the objective assessment of competency for execution. Specifically, this article identifies professional standards for conducting competence for execution (CFE) evaluations, describes current practices in this area, and provides an interview checklist that can be used as an evaluation guide by involved professionals., (Copyright 2002 John Wiley & Sons, Ltd.)

Singleton v. Norris is a decision by the Eighth Circuit Court of Appeals stating that forced psychotropic medication can be continued after the date of execution is set if the medication had been given previously to prevent the inmate from being dangerous in the prison setting under a Harper-type review. The defendant had argued that after the date of execution was set, it was no longer in his medical interests to continue the medication. In the decision, the majority held that the fact that an execution is in the offing does not alter the medical interests for which the medication had been prescribed, and physicians should just continue to treat the medical condition. This decision may raise ethics problems for physicians in such settings, because they may be in violation of the American Medical Association (AMA) Code of Ethics if the original override is dubious.

I discuss six issues that may cut against the majoritarian grain. They are: (1) The U.S. Supreme Court's view of children; (2) the American Psychological Association's view of people with mental retardation; (3) the dilution of autonomy in favor of beneficence; (4) Tarasoff's undermining of fidelity to therapy clients; (5) the misuse of the PCL-R in death penalty litigation; and (6) the criminal law's rejection of determination.

Mental health evaluations at capital sentencing represent a complex and specialized arena of practice. The moral culpability focus of capital sentencing is distinct from guilt-phase considerations of criminal responsibility, and has a specialized literature. Capital violence risk assessment is uniquely oriented to a prison context, relying on past adjustment to incarceration, as well as group statistical data specific to capital offenders and other inmate groups. Personality testing is a more complex consideration in capital sentencing evaluations. The implications of interviewing the defendant, as well as the parameters and documentation of an interview, make full disclosure and informed consent of particular importance. Defense- and prosecution-retained experts are subject to specific ethical vulnerabilities. These are examined in this paper through the lens of current professional standards., (Copyright 2001 John Wiley & Sons, Ltd.)

Death row prisoners may elect to forgo appeals, thus hastening execution. There are many reasons for such a decision, including depression, psychosis, incompetence, conditions in prison, and others. Due to the gravity of the sentence, and the states' duty to ensure fairness, some jurisdictions impose restrictions on the waiver. An inmate who lacks trial competence may be subject to a habeas corpus hearing and the appointment of a "next friend," often a family member. Moreover, the Constitution forbids execution of the "insane." The decision, then, may be taken out of the inmate's hands. The author outlines the various tests for competence to waive appeals. The Pennsylvania case of Gary Heidnik (In re Heidnik, 112 F.3d 105 (3rd Cir. 1997); and In re Heidnik, 720 A.2d 1016 (Pa. 1998)) illustrates the issues surrounding waiver of appeals that concern psychiatrists, attorneys, and judges. Following a discussion of Heidnik and related cases, the author offers a proposal for a classification of types of inmates requesting waiver.

In October 1992, the Louisiana Supreme Court ruled that that state could not forcibly medicate condemned, mentally ill prisoners to make them competent to be executed. State v. Perry has been seen as a victory for psychiatrists, but the decision contains bad news as well as good: although the Court extricated psychiatrists from having to medicate convicts involuntarily in preparation for their execution, the Court justified its decision by invoking a distortion-filled, highly critical interpretation of standard psychiatric treatment for psychoses. This article summarizes the Perry case and the Court's opinion, describes the perceptions of antipsychotic medication that animated the majority's legal conclusions, and reviews subsequent decisions in which Perry has been influential. The article suggests that Perry's description of pharmacotherapy may not have been motivated by a reasoned view of neuroleptic therapy so much as the Court's desire to uphold the institution of capital punishment. By studying the Perry majority's opinion, psychiatrists can appreciate how certain characterizations or descriptions of psychotic symptoms and antipsychotic therapy lend themselves to distortion and misunderstanding by legal decisionmakers. Recently developed conceptions of schizophrenic symptoms and pharmacological therapy may provide psychiatrists with sophisticated modes of explanation that courts will find more difficult to misconstrue or misrepresent.

The question of whether to provide mental health treatment to prisoners under death sentence who have been judged incompetent for execution presents a powerful ethical dilemma for mental health professionals. Arguments that favor or oppose the provision of treatment are discussed in the context of the nature of the disorder to be treated, the type of treatment to be provided, the goals of treatment, and the relevant legal standard for determining competency for execution. Arguments against treating the incompetent include 1) the need to avoid harming those who are treated, 2) the risk that disclosures in therapy will be used for assessment purposes, 3) the need for paternalism when sufficient harm is necessary, 4) the adverse impact on the clinician, 5) the potential undermining of patient and public perceptions of mental health professionals, and 6) the poor allocation of limited resources. Arguments for treating the incompetent include 1) respect for the wishes of the prisoner, 2) the need to clarify the values underlying the refusal to treat, 3) the low risk of harm from some forms of treatment, and 4) the adverse impact on the milieu stemming from failure to treat. The authors conclude that treating incompetent prisoners may not violate ethical standards under some circumstances, and that some forms of treatment will require the informed consent of the prisoner.