Competency Restoration and Execution Essay

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Restoration to competency through various means, including forcible medication of defendants or inmates with mental illness, is permitted throughout the legal process. In the 1990 case of Washington v. Harper, the U.S. Supreme Court decided that a mentally ill inmate could be forcibly medicated in the interest of preserving prison safety if four conditions were met. First, that inmate must be a danger to himself or others, second and third, the medication must be in the inmate’s best interest and medically appropriate and fourth, medication must be the least intrusive way to treat the inmate and reduce his dangerousness.

In the 1992 case of Riggins v. Nevada, the Supreme Court found that a defendant can be forcibly medicated to restore competency to stand trial if that medication is necessary to ensure safety, is medically appropriate, and is the least intrusive way of providing treatment. In the 2003 case of Sell v. United States, the Supreme Court set strict limits on lower courts’ ability to force defendants to take medication in order to restore their competency for trial. However, nowhere is this issue fraught with more ethical dilemmas than when restoration to competency for the purposes of execution is under consideration.

In 1986, the Supreme Court decided in the landmark case Ford v. Wainwright that execution of the insane was unconstitutional. However, Ford left several questions unanswered, among them whether it is legally and ethically permissible to work to restore a prisoner’s competency with the express purpose of executing him or her. This question came to prominent light in the case of Gary Alvord. Gary Alvord escaped from a mental hospital in Michigan in 1973 and strangled three women to death in Tampa, Florida, in that same year. One of the women was raped before her murder. He was convicted of the crimes and sentenced to death, but his attorney raised the issue of his competency to be executed after his conviction, meaning that Alvord was so incompetent as to be unaware of the punishment he was about to suffer and the reasons for it.

A commission of psychiatrists found Alvord incompetent to be executed and the governor ordered his transfer to the state mental hospital. For the staff there, treating inmates with mental illness was nothing new, but treating an inmate to restore his competence for execution was. The staff found itself in an ethical conundrum, wanting to alleviate the suffering Alvord was experiencing as a result of his mental illness, but hesitant to provide treatment that might render him competent enough to be executed. The hospital’s Human Rights Advocacy Committee vowed to support any staff member who refused to treat Alvord, but even with those reassurances, the staff remained conflicted about what to do and where their allegiances were, to Alvord and his mental health or to the state. Staff were additionally concerned that the other patients at the hospital would view their treatment of Alvord with skepticism and that treating Alvord in order to restore his competency for execution would undermine the trust they had established with the patients.

Alvord was diagnosed by hospital staff with paranoid schizophrenia and antisocial personality disorder and prescribed Thorazine. He refused individual counseling, and his symptoms and social skills were inconsistent during much of the three years he was at the hospital; but upon discharge, he was pronounced stable on medication. He was transferred back to the prison, where he refused, on his attorney’s advice, to participate in a hearing designed to determine whether he was competent for execution. Alvord remained on death row in Florida, in large part because to go through the procedures outlined above, namely referral to the hospital, stabilization on medication, return to the prison, and evaluation by psychiatrists, would very likely result in the same outcome, Alvord’s refusal to cooperate with the latter and a resulting inability to determine whether he was competent for execution.

The state of South Carolina was grappling with this same issue in 1983 when Fred Singleton sentenced to death for killing an elderly woman. He was deemed incompetent for execution due to a psychotic disorder that resulted from brain damage. His brain damage meant that he was likely never to become competent again whether he received treatment or not. The South Carolina Supreme Court ruled in 1993 that inmates under the death sentence cannot be executed unless they understand the legal proceedings, they understand the nature of and reason for the application of the death penalty, and they can rationally communicate with their attorneys.

More importantly, the court ruled that forcibly medicating inmates in order for them to achieve this competency is an invasion of privacy and is prohibited. This leads to another question left unanswered by Ford, the legal and ethical permissibility of forcibly medicating a prisoner to restore competence for execution. This dilemma is illustrated in the case of Perry v. Louisiana. Michael Perry was charged with the 1983 murders of his parents, nephew, and cousins and was convicted and sentenced to death. The Louisiana state Supreme Court affirmed the sentence in 1986 and suggested he be evaluated for competency prior to his execution. By 1988, Perry’s competence was extremely unclear. He was actively delusional unless he was taking a psychotropic medication known as Haldol.

The trial court ordered the Louisiana Department of Corrections to continue to force Perry to take his Haldol in support of the state’s interest in executing him for his crimes and not necessarily for the relief it brought him from the symptoms of his mental illness. The case reached the U.S. Supreme Court in 1990, which remanded it back down to the Louisiana state Supreme Court, which ruled that inmates could not be forcibly medicated in order to maintain competency for their execution. In its finding, the Louisiana Supreme Court drew on existing state level laws that determined forcible medication in order to execute was cruel and usual punishment and that forcible medication violated the right to privacy.

A more recent case highlighting these issues was the 2003 case of Singleton v. Norris. Charles Singleton was convicted of robbery and murder and sentenced to death in Arkansas in

  1. While on death row, Singleton developed symptoms of profound mental illness, including hallucinations, delusions, and disorganized and bizarre thinking. He was prescribed medication and sometimes had to be forced to take it. He was only occasionally competent while on medication and was not competent when he was unmedicated. Singleton claimed that forced medication under a Harper order because of his dangerousness was not in his best medical interest once his execution date was set for 2000, as medication would only serve to keep him competent enough to be executed. In 2001, the Eighth Circuit Court of Appeals commuted his death sentence to life in prison without parole, but this stay was vacated in 2003, with the court citing Singleton’s initial willingness to take medication and minimal side effects as reasons for him to continue taking medication up to his execution. The Supreme Court declined to hear the case and Singleton was executed in 2004.

Like Alvord’s case, Perry and Singleton illustrate the ethical dilemma faced by medical and mental health professionals when they are directed to forcibly medicate an inmate in order to restore competency for execution. Medical and mental health professionals abide by the Hippocratic Oath, which requires that they “above all, do no harm.” Being directed to forcibly medicate inmates in order to restore their competency for execution puts them in an unenviable position of either refusing to treat the inmates on the grounds that treatment will lead inexorably to execution but leaving the inmate to suffer from what is usually profoundly debilitating mental illness, or treating inmates in order to alleviate their suffering though treatment that may lead to their eventual execution.

Some medical and mental health professionals will refuse to treat those who are to be executed once their competency is restored because they believe the negative long-term effect (i.e., execution) outweighs the short-term benefits of the alleviation of suffering due to mental illness. Others take the opposite view and believe that withholding treatment to inmates who are suffering from mental illness, even if they will one day face the executioner, ignores their short-term needs, is a dereliction of duty, and is impermissible under the oath they took to do no harm.


  1. Hensl, Kursten. “Restoring Competency for Execution: The Paradoxical Debate Continues With the Case of Singleton v. Norris.” Journal of Forensic Psychology Practice, v.5 (2005).
  2. Miller, Kent and Michael Radelet. Executing the Mentally Ill: The Criminal Justice System and the Case of Alvin Ford. Newbury Park, CA: Sage, 1993.
  3. Zonna, Howard. “Competency to Be Executed and Forced Medication: Singleton v. Norris.” Journal of the American Academy of Psychiatry and the Law, v.31 (2003).

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