Execution: an unwanted side-effect

Abstract

Treatment successful—patient dead; rather than another cynical headline commenting on a new medical or surgical therapy, this could be the accurate and legitimate summary of future events, were the recent ruling of the federal appeals court in St Louis, USA, upheld and implemented.The court ruled on Feb 10, with a narrow majority of six to four and one abstention, that Charles Laverner Singleton, on death row since 1979 for murder of a grocery store clerk, can be given antipsychotic treatment by force to make him competent for execution. Singleton was first given medication for anxiety and depression while on death row but his mental health deteriorated in 1987 when he started to believe that his cell was occupied by demons. He was diagnosed with schizophrenia and placed on antipsychotic treatment, which he initially took voluntarily but later had to be forced to take with the justification that he posed a danger to himself and others. Whether the state has the power to treat a mentally ill prisoner with antipsychotic drugs against his will was established in the landmark Harper case in 1990, when the US Supreme Court ruled that a mentally ill prison inmate may be forcibly treated “if the inmate is dangerous to himself or others and the treatment is in the inmate's medical interest”. Singleton then filed a habeas corpus petition in 2000, once his execution date had been set, arguing that the state could not constitutionally restore his competency through forced medication and then execute him. His petition was denied by the district court but a stay of execution was granted on appeal.In a landmark case in 1986, Ford v Wainwright, the US Supreme Court had addressed for the first time the limits imposed by the eighth amendment that forbids cruel and unusual punishment on a state's power to execute an insane prisoner with a clear ruling against executing mentally ill people. The Singleton case, however, is the first at federal level to address the question of treatment with the purpose to make someone competent to be executed or, as a supporter of the ruling put it, of treatment with the “unwanted consequence of eligibility for execution”. In a strong dissenting statement, Judge Gerald W Healey wrote “to execute a man who is severely deranged without treatment, and arguably incompetent when treated, is the pinnacle of what Justice Marshall [in the Ford case] called ‘the barbarity of exacting mindless vengeance”’. He added that the medical community was being forced to practise in a manner contrary to its ethical standards.In the only other such case in 1992, Louisiana's high court held that such involuntary medication constitutes punishment, not therapy, and thereby violates the state's constitution. This case was dismissed by the majority of the federal appeals court with the comment “state courts may interpret their constitutions as they see fit”.Clearly, in the definition of “a patient's best medical interest” doctors cannot stop short of considering the long-term effect of successful treatment, which in this case is death by execution. But can doctors let a patient suffer intolerable hallucinatory symptoms to avoid the long-term effect? Can a person be kept in a hospital untreated or undertreated so that the death penalty cannot be applied? The American Medical Association states that “a physician may provide medical care to a condemned person if the individual gives informed consent, the medical care is used to heal, comfort, or preserve the life of the condemned individual, and the medical care would not enable or facilitate the execution of the condemned person”. Despite these guidelines, psychiatrists have taken part in both assessing and restoring competence in previous cases arguing that they act as administrators or agents of justice or that they act in the immediate best medical interest irrespective of the consequences. Such a position is unethical, inhumane, and against agreed principles of the medical profession.If—as is likely—the Singleton case goes to the US Supreme Court, the Court has the chance to build on its recent ruling to outlaw execution of the mentally retarded (see Lancet 2002; 359: 2259). It must rule against the practice of forced medical treatment of the mentally ill to restore competence for execution as a medically and ethically untenable dilemma. This would constitute another small victory for human rights and a further step away from inhumane punishment. Treatment successful—patient dead; rather than another cynical headline commenting on a new medical or surgical therapy, this could be the accurate and legitimate summary of future events, were the recent ruling of the federal appeals court in St Louis, USA, upheld and implemented. The court ruled on Feb 10, with a narrow majority of six to four and one abstention, that Charles Laverner Singleton, on death row since 1979 for murder of a grocery store clerk, can be given antipsychotic treatment by force to make him competent for execution. Singleton was first given medication for anxiety and depression while on death row but his mental health deteriorated in 1987 when he started to believe that his cell was occupied by demons. He was diagnosed with schizophrenia and placed on antipsychotic treatment, which he initially took voluntarily but later had to be forced to take with the justification that he posed a danger to himself and others. Whether the state has the power to treat a mentally ill prisoner with antipsychotic drugs against his will was established in the landmark Harper case in 1990, when the US Supreme Court ruled that a mentally ill prison inmate may be forcibly treated “if the inmate is dangerous to himself or others and the treatment is in the inmate's medical interest”. Singleton then filed a habeas corpus petition in 2000, once his execution date had been set, arguing that the state could not constitutionally restore his competency through forced medication and then execute him. His petition was denied by the district court but a stay of execution was granted on appeal. In a landmark case in 1986, Ford v Wainwright, the US Supreme Court had addressed for the first time the limits imposed by the eighth amendment that forbids cruel and unusual punishment on a state's power to execute an insane prisoner with a clear ruling against executing mentally ill people. The Singleton case, however, is the first at federal level to address the question of treatment with the purpose to make someone competent to be executed or, as a supporter of the ruling put it, of treatment with the “unwanted consequence of eligibility for execution”. In a strong dissenting statement, Judge Gerald W Healey wrote “to execute a man who is severely deranged without treatment, and arguably incompetent when treated, is the pinnacle of what Justice Marshall [in the Ford case] called ‘the barbarity of exacting mindless vengeance”’. He added that the medical community was being forced to practise in a manner contrary to its ethical standards. In the only other such case in 1992, Louisiana's high court held that such involuntary medication constitutes punishment, not therapy, and thereby violates the state's constitution. This case was dismissed by the majority of the federal appeals court with the comment “state courts may interpret their constitutions as they see fit”. Clearly, in the definition of “a patient's best medical interest” doctors cannot stop short of considering the long-term effect of successful treatment, which in this case is death by execution. But can doctors let a patient suffer intolerable hallucinatory symptoms to avoid the long-term effect? Can a person be kept in a hospital untreated or undertreated so that the death penalty cannot be applied? The American Medical Association states that “a physician may provide medical care to a condemned person if the individual gives informed consent, the medical care is used to heal, comfort, or preserve the life of the condemned individual, and the medical care would not enable or facilitate the execution of the condemned person”. Despite these guidelines, psychiatrists have taken part in both assessing and restoring competence in previous cases arguing that they act as administrators or agents of justice or that they act in the immediate best medical interest irrespective of the consequences. Such a position is unethical, inhumane, and against agreed principles of the medical profession. If—as is likely—the Singleton case goes to the US Supreme Court, the Court has the chance to build on its recent ruling to outlaw execution of the mentally retarded (see Lancet 2002; 359: 2259). It must rule against the practice of forced medical treatment of the mentally ill to restore competence for execution as a medically and ethically untenable dilemma. This would constitute another small victory for human rights and a further step away from inhumane punishment. US Supreme Court drops death penalty for mentally retarded murderersThe US Supreme Court's ruling on June 20 that executing mentally retarded prisoners is unconstitutional, may spare hundreds of prisoners from execution, said opponents of the death penalty. Full-Text PDF