Singleton's Story: Choosing between Psychosis and Execution

In early 2003, an episode of "The Practice" featured a psychotic death row inmate who stopped taking medication in order to avoid execution. The court forced the prisoner to take the medication but then commuted the sentence to life imprisonment on the grounds that executing someone who is mentally ill would be cruel and unusual punishment. In real life cases where death row convicts think about foregoing antipsychotic medication, few endings are happy. Mentally ill convicts are sometimes executed, competent or incompetent, while being medicated forcibly, voluntarily, or not at all.¹

The Constitution requires defendants and convicts to be mentally competent at all stages of the criminal process. To be competent for execution, the prisoner must understand that he is to be executed and why. Applying that principle to the mentally ill, the Supreme Court's 1986 Ford opinion held that the "Eighth Amendment ban on cruel and unusual punishment prohibits a State from carrying out a sentence of death upon a prisoner who is insane."² The majority opinion did not mention antipsychotic medication and its potential for improving mental capacity, although these drugs had by then been used to treat the mentally ill for at least two decades. However, a footnote in a concurring opinion stated that "if [Ford] is cured of his disease, the State is free to execute him."³ This opened up the possibility—a loophole for the prosecution—that antipsychotic drugs or some other treatment might make a mentally ill capital convict sane enough to meet the minimal competency requirement for execution, even though the treatment would not actually "cure" the underlying illness.

Ford has been followed by extensive litigation about the forcible medication of mentally ill convicts. Because the Constitutional privacy right to refuse unwanted intrusion into the body applies to the incarcerated as well as to the free, the Court has held that a prisoner may be medicated involuntarily only if he is dangerous to himself or others and the medication is in his best medical interest. ⁴ In 2003, however, the Court upheld and refined the Eighth Circuit's Sell decision, holding that under limited circumstances the Eighth Amendment permits forcible psychotropic medication to make a nondangerous defendant competent to stand trial.⁵

A few months later, the Court declined to review Singleton, in which the same federal appeals court had denied an Eighth Amendment claim by a capital convict, Charles Singleton, that he should not be forcibly medicated to be made competent for execution.⁶ The Eighth Circuit majority opinion made much of the fact that Singleton was already taking psychotropic medication voluntarily. It allowed Singleton to be put to death when his voluntary medication had the incidental effect of making him competent to be executed. Thus the only way for Singleton to postpone or possibly escape death was to stop taking medication, regress to psychosis, become dangerous to himself or others, lose his ability to understand that he was to be executed and why—and then start the whole cycle over again. He chose not to take this path. Charles Singleton—taking antipsychotics voluntarily, formally competent yet hearing voices—was executed by lethal injection on January 6, 2004. His last words were "a largely rambling missive peppered with Biblical references."⁷

Sell and Singleton keep alive the question that Ford seemed to settle in 1986. Although the Supreme Court let the Eighth Circuit's Singleton opinion stand, it has not itself ruled on forcible medication for competence to be executed, and no other circuits have followed Singleton. What will happen when the case of a Charles Singleton who continues to refuse medication arrives at the Court, as it surely will?

Certainly the Court will not treat a condemned prisoner's rights and interests as cavalierly as the Eighth Circuit did in Singleton. It will use Sell's "generic" test, which was designed to balance the state's interest in moving toward a final criminal judgment with the convict's right to refuse medication.⁸ However, the Court found that the Sell test did not permit forcible medication of Charles Sell himself, at least on the...