American Journal of Law & Medicine

The perils of Singleton v. Norris: ethics and beyond.


Nearly 20 years ago, in Ford v. Wainright, the Supreme Court held that it is unconstitutional to execute a legally incompetent inmate. (1) Due to advancements in pharmacological therapy and the ability to make inmates legally competent through medication, various courts since Ford have determined the mechanisms by which competency through medication can be accomplished. Those decisions led to cases involving the legality of forcibly medicating inmates to make them competent to stand trial and to be executed. One recent case involving execution competency is the Eighth Circuit's decision in Singleton v. Norris. (2)

In Singleton, the Eighth Circuit held that execution as an ultimate consequence of administering psychotropic medication to legally incompetent inmates cannot be considered in the determination of whether it was proper to forcibly medicate that inmate. (3) The Eighth Circuit's decision permitted the execution of Charles Singleton, a schizophrenic who fought against involuntary administration of the medications that rendered him competent to be executed. (4) This Note will discuss how the Eighth Circuit's failure to include the possibility of execution in the analysis of what is "medically appropriate" for a mentally ill inmate implicates not only medical ethics, but the fundamental nature of the inmate's treatment. More specifically, the decision to permit the forcible medication of death row inmates has grave ethical ramifications for physicians and mental health professionals who treat condemned inmates. These ethical consequences jeopardize the professional identity and integrity of these health providers. The effect of those ethical breaches and the treatment decisions often dictated by medicating-for-execution-competence situations, also negatively impacts the prisoner's mental health treatment.

First, most medical and psychological professional organizations, including the American Medical Association and the American Psychiatric Association prohibit their members from participating in executions. (5) Though some argue that prescribing competency-inducing medication to death row inmates is not "participation" in the execution process, (6) these organizations clearly believe such action constitutes participation. This posture places prison-employed physicians in a precarious ethical dilemma that impacts their professional integrity, their employment relationships, their relationships with their patients, and thereby the efficacy of the patients' treatment.

Second, the standard of what is "medically appropriate," in the context of medicating mentally ill inmates also implicates ethical principles and treatment ramifications for involuntary medication. This term "medically appropriate" encompasses a wide range of issues, including severity of psychological symptoms, side effects, and efficacy. The Supreme Court's decision in Sell v. United States (7), more specifically defines the medically appropriate standard in the context of competency to stand trial. (8) Singleton specifically stated that a pending execution cannot be considered in assessing what is in the "best medical interests" of an incompetent inmate. (9) By failing to address the ethical implications and to make adequate consideration of the treatment ramifications, the Eighth Circuit essentially rendered the "medically appropriate" standard unimportant.

Third, prescription and administration of medications to unwilling patients negatively impacts the already-strained physician-patient relationship that exists in prisons. The psychiatrist-patient relationship is essential in facilitating the effective diagnosis and treatment of mental illnes. (10) Involuntary administration of medications and the problem of dual loyalty that it creates irreparably harms this important relationship by destroying trust and impeaching personal dignity. The fact that a psychiatrist willingly jeopardizes such an essential aspect of his patient's well-being may very well violate ethical guidelines, and most assuredly negatively impacts the physician-patient relationship.

Fourth, and similar to the effect on the physician-patient relationship, the ethical dilemma and simple participation in the execution process also impact an inmate's mental health treatment. In prisons, where mental health treatment is anything but ideal, (11) participation in and ethics regarding execution negatively affect mental health professionals who render treatment decisions and competency determinations. More specifically, physician choices regarding treatment options, dosages, acceptable side effects, and the difficulty in determining competency, are all influenced by the physician's role as an employee of the prison, and by ethical guidelines. This, too, is an unacceptable consequence of physician participation in executions.

Section II discusses the prevalence of mental illness in the criminal justice system. Three cases involving the medication of mentally ill defendants or inmates against their will are reviewed. Section III discusses four cases that specifically address the involuntary medication of incompetent death row inmates. Section IV discusses physician participation in executions throughout the United States, and the ethical principles and guidelines of various medical and psychological organizations. Section V argues that the appropriate determination of a patient's best interests should include not only the ethical ramifications for physicians, but also the impact on the physician-patient relationship and the overall mental health treatment. Section VI reiterates the flaws in the Eighth Circuit's decision and discuss possible improvements on the medically appropriate standard.



There are staggering numbers of mentally ill inmates in the general prison population and on death row. A 1999 Department of Justice report found that 16% of all inmates in state and federal prisons, approximately 283,000 inmates total, were afflicted with schizophrenia, bipolar disorder, major depression, or some severe mental illness. (12) Yet only six out of ten mentally ill state prisoners reported receiving treatment for their mental illnesses. (13) A 2003 study conducted by the British Broadcasting Company found that approximately 10% of death row inmates in America are mentally ill. (14) Advances in the treatment of mental illness, especially the prominence of psychopharmacological agents, has led to a line of decisions regarding forcible administration of medication to mentally ill prisoners.


1. Washington v. Harper

In Washington v. Harper, (15) the Supreme Court addressed the issue of "whether a judicial hearing is required before [a] [s]tate may treat a mentally ill prisoner with antipsychotic drugs against [the prisoner's] will." (16) In its decision, the Supreme Court balanced the legitimate state interest in preventing dangerous activity by mentally ill inmates (17) with the inmate's "substantial" liberty interest in being free from unwanted medication under the Due Process Clause of the Fourteenth Amendment. (18) As the Supreme Court stated, "[w]here an inmate's mental disability is the root cause of the threat he poses to the inmate population, the State's interest in decreasing the danger to others necessarily encompasses an interest in providing [the inmate] with medical treatment for his illness." (19) The Supreme Court held that under the Due Process Clause, forcibly medicating a prison inmate is permissible in only two instances: (1) when the prisoner poses a danger to himself or others; or (2) when the treatment is in the prisoner's medical interests. (20)

2. Riggins v. Nevada

Riggins v. Nevada (21) expounded upon the medical interest standard set forth in Harper. To forcibly administer antipsychotic medications to a defendant who is incompetent to stand trial, the government must meet the due process requirement set forth in Washington v. Harper. (22) More specifically, the medication must be: (1) "medically appropriate"; and (2) necessary for the safety of the inmate or the safety of others. (23) In developing the medically appropriate standard, the Court recognized the negative impact of a medication's unpredictable side effects, which could possibly affect the defendant's appearance, testimony, ability to follow the proceedings, and ability to communicate with defense counsel. …

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