Psychiatric News March 21, 2003
Volume 38 Number 6
© 2003 American Psychiatric Association
p. 2
Court Allows State to Medicate Death-Row Inmate Forcibly
Ken Hausman
A federal appeals court muddies the perennially troubled waters swirling around the issue of medicating psychotic prisoners who could then be executed if they regain mental competence.
Arkansas prison officials have won the right to force severely mentally ill inmate Charles Singleton to take antipsychotic medication, so he will regain enough of his sanity to understand that he will soon be executed.
This action will take place as the result of a February 10 ruling from a federal appeals court saying that involuntarily medicating a psychotic death-row inmate as a prelude to putting him to death does not violate the U.S. Constitution.
Barring a successful appeal to the U.S. Supreme Court, Singleton’s fate was sealed by a divided appeals court—the St. Louis-based 8th Circuit—that voted 6 to 5 in favor of Arkansas’ contention that it should be allowed to medicate Singleton forcibly.
APA President Paul Appelbaum, M.D., thinks the court came to a wrong and troubling conclusion. "Physicians violate their ethical obligations as healers when they treat condemned prisoners for the purpose of restoring competence to be executed," he told Psychiatric News. "The only humane alternative in these situations is for the state to commute the prisoner’s sentence to life in prison, so that treatment can take place without being darkened by the shadow of death."
He pointed out that this is the position both APA and the AMA have taken on this issue.
Howard Zonana, M.D., medical director of the American Academy of Psychiatry and the Law and a professor of psychiatry at Yale University, said he was "distressed" by the ruling. "It makes something legal that in certain circumstances is clearly unethical," he said. "Psychiatrists need to be aware of the AMA ethical guidelines on this issue and of APA’s participation in their preparation."
Singleton’s legal saga began in 1979 when an Arkansas court convicted him of capital felony murder and aggravated robbery. His execution was originally scheduled to take place in June 1982.
Soon after the conviction, he petitioned the district court that tried him for a stay of execution on several grounds, one of which was that he was incompetent and thus ineligible for the death penalty in accord with the U.S. Supreme Court’s 1986 decision in Ford v. Wainwright. That decision held that it is cruel and unusual punishment to execute a severely mentally ill inmate.
A series of appeals then followed in which his death penalty was changed to life without parole and then reinstated by the same appeals court that issued last month’s ruling. In 1992 he petitioned to have his death sentence vacated because his mental illness—he has schizophrenia—rendered him incompetent. At the same time he asked to have his antipsychotic medication halted, after which he wanted a mental competency examination performed.
Both the trial court and the Arkansas Supreme Court rejected his requests, and the death penalty was allowed to stand. He continued to take his medication voluntarily, which, he acknowledged, made him competent to understand what his fate was and why.
Five years after those decisions, he had stopped taking the medication voluntarily—with the consent of a prison psychiatrist, according to the decision—so Arkansas prison officials forced Singleton to take it, the appeals court decision notes, "after a medication review panel unanimously agreed that he posed a danger to himself and others." Once on the medications, his psychotic symptoms largely abated.
With his execution scheduled for March 1, 2000, Singleton filed a habeas corpus petition. He argued that in light of the Supreme Court’s Ford decision saying it is unconstitutional to execute a mentally incompetent inmate, the state is prevented from forcibly restoring his mental competence by medicating him with antipsychotics. When the Arkansas courts rejected his arguments, he took his case to the federal appeals court.
Competing Interests Weighed
In its February ruling the appeals court weighed the competing interests of Singleton in avoiding being forced to take medication that paves the way for his execution against the government’s interest in punishing offenders whose crimes are so heinous they qualify for the death penalty.
The court decided that not only does Singleton have a history of wanting to take the powerful drugs rather than remaining psychotic, but also he "has suffered no substantial side effects" from the drugs.
On these facts, the majority decided, "the state’s interest in carrying out its lawfully imposed sentence is the superior one."
(The development of such side effects was part of the U.S. Supreme Court’s reasoning in the 1992 Riggins v. Nevada case, which established limits on a state’s ability to medicate a mentally ill prisoner involuntarily. States were to first seek less-intrusive alternatives and then to medicate only if the safety of the patient or others was at risk.)
The appeals court did acknowledge that there is no less-intrusive treatment for alleviating Singleton’s psychosis, but that the potential side effects "do not overwhelm the benefits of the medicine."
The court also looked at Singleton’s argument that while taking the medication may be in his "best medical interest," being executed is not, and it is the only "unwanted consequence of the medication."
The majority disagreed with this argument, however, saying that in this case "the best medical interests of the patient must be determined without regard to whether there is a pending date of execution," thus allowing the state to medicate him forcibly. They added that "since states have the right to interpret their constitutions as they see fit," they elected to not undertake an inquiry of the state’s motives in wanting to medicate Singleton beyond its desire to provide required medical care. That is, they did not evaluate whether the state’s primary motive was punitive rather than medical, which would likely be interpreted as unconstitutional.
The court’s ultimate conclusion was that a state does not violate a prisoner’s Eighth Amendment protections against cruel and unusual punishment "when it executes a prisoner who became incompetent during his long stay on death row but who subsequently regained competency through appropriate medical care."
Dissenting Opinion
The dissenting minority’s opinion, however, emphasizes that "to execute a man who is severely deranged without treatment, and arguably incompetent when treated, is the pinnacle of what Justice Marshall [in Ford v. Wainwright] called ‘the barbarity of exacting mindless vengeance.’ "
They cited Supreme Court cases, "the overwhelming majority of scholarly commentary, and the ethical standards of the medical profession" in concluding that the majority justices’ ruling was wrong.
The dissenting justices also distinguished between being cured and having symptoms masked by medication. They noted that the latter situation characterized Singleton and that no authorities claim that antipsychotics cure schizophrenia. "One of the pitfalls of equating true sanity with its medically coerced cousin," they said, "is that drug-induced sanity is temporary and unpredictable" and that the drug may affect the individual differently each time it is administered. In Singleton’s case, the medications he took have never kept him free of schizophrenia symptoms, they pointed out.
Regarding the majority’s refusal to examine the state’s motives, the dissenting justices concluded, "At the very least, setting an execution date calls into question the state’s motivation for administering the medication." Once that date was set, the argument that medicating him was in his medical interest evaporated, they maintained.
Should psychiatrists be asked to participate in these end-stage, death-penalty decisions, Zonana strongly urged them to "not feel overly pressured by state governments to do things that are personally or professionally unacceptable." 
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