(Slip Opinion) OCTOBER TERM, 2018 1 

Syllabus 

NOTE: Where it is feasible, a syllabus (headnote) will be released, as is 

being done in connection with this case, at the time the opinion is issued. 

The syllabus constitutes no part of the opinion of the Court but has been 

prepared by the Reporter of Decisions for the convenience of the reader. 

See United States v. Detroit Timber & Lumber Co., 200 U. S. 321, 337. 

SUPREME COURT OF THE UNITED STATES 

Syllabus 

MADISON v. ALABAMA 

CERTIORARI TO THE CIRCUIT COURT OF ALABAMA, MOBILE 

COUNTY

No. 17–7505. Argued October 2, 2018—Decided February 27, 2019 

In Ford v. Wainwright, 477 U. S. 399, this Court held that the Eighth 

Amendment’s ban on cruel and unusual punishments precludes executing a prisoner who has “lost his sanity” after sentencing. Id., at 

406. And in Panetti v. Quarterman, 551 U. S. 930, the Court set out 

the appropriate competency standard: A State may not execute a 

prisoner whose “mental state is so distorted by a mental illness” that 

he lacks a “rational understanding” of “the State’s rationale for [his] 

execution.” Id., at 958–959. 

 Petitioner Vernon Madison was found guilty of capital murder and 

sentenced to death. While awaiting execution, he suffered a series of 

strokes and was diagnosed with vascular dementia. In 2016, Madison petitioned the state trial court for a stay of execution on the 

ground that he was mentally incompetent, stressing that he could not 

recollect committing the crime for which he had been sentenced to 

die. Alabama responded that Madison had a rational understanding 

of the reasons for his execution, even assuming he had no memory of 

committing his crime. And more broadly, the State claimed that 

Madison failed to implicate Ford and Panetti because both decisions 

concerned themselves with gross delusions, which Madison did not 

have. Following a competency hearing, the trial court found Madison 

competent to be executed. On federal habeas review, this Court 

summarily reversed the Eleventh Circuit’s grant of relief, holding 

that, under the “demanding” and “deferential standard” of the Antiterrorism and Effective Death Penalty Act of 1996 (AEDPA), 

“[n]either Panetti nor Ford ‘clearly established’ that a prisoner is incompetent to be executed” because of a simple failure to remember 

his crime. Dunn v. Madison, 583 U. S. ___, ___. But the Court “express[ed] no view” on the question of Madison’s competency outside of 
 

 

 

 

 

2 MADISON v. ALABAMA 

Syllabus 

the AEDPA context. Id., at ___. When Alabama set a 2018 execution 

date, Madison returned to state court, arguing once more that his 

mental condition precluded the State from going forward. The state 

court again found Madison mentally competent. 

Held: 

1. Under Ford and Panetti, the Eighth Amendment may permit executing a prisoner even if he cannot remember committing his crime. 

Panetti asks only about a person’s comprehension of the State’s reasons for resorting to punishment, not his memory of the crime itself. 

And the one may exist without the other. Such memory loss, however, still may factor into the analysis Panetti demands. If that loss 

combines and interacts with other mental shortfalls to deprive a person of the capacity to comprehend why the State is exacting death as 

a punishment, then the Panetti standard will be satisfied. Pp. 9–11.

2. Under Ford and Panetti, the Eighth Amendment may prohibit

executing a prisoner even though he suffers from dementia or another disorder rather than psychotic delusions. The Panetti standard focuses on whether a mental disorder has had a particular effect; it has 

no interest in establishing any precise cause. Panetti’s references to 

“gross delusions,” 551 U. S., at 960, are no more than a predictable 

byproduct of that case’s facts. Ford and Panetti hinge on the prisoner’s “[in]comprehension of why he has been singled out” to die, 477 

U. S., 409, and kick in if and when that failure of understanding is 

present, irrespective of whether one disease or another is to blame.

In evaluating competency, a judge must therefore look beyond any 

given diagnosis to a downstream consequence. Pp. 12–14.

3. Because this Court is uncertain whether the state court’s decision was tainted by legal error, this case is remanded to that court for 

renewed consideration of Madison’s competency. The state court’s 

brief 2018 ruling—which states only that Madison “did not prove a

substantial threshold showing of insanity[ ]”—does not provide any 

assurance that the court knew a person with dementia, and not psychotic delusions, might receive a stay of execution. Nor does that 

court’s initial 2016 opinion. The sole question on which Madison’s 

competency depends is whether he can reach a rational understanding of why the State wants to execute him. In answering that question—on which this Court again expresses no view—the state court 

may not rely on any arguments or evidence tainted with the legal errors addressed by this Court. Pp. 14–18. 

Vacated and remanded. 

KAGAN, J., delivered the opinion of the Court, in which ROBERTS, 

C. J., and GINSBURG, BREYER, and SOTOMAYOR, JJ., joined. ALITO, J., 

filed a dissenting opinion, in which THOMAS and GORSUCH, JJ., joined.

KAVANAUGH, J., took no part in the consideration or decision of the case. 
 

 

 

 

_________________ 

_________________ 

Cite as: 586 U. S. ____ (2019) 1 

Opinion of the Court 

NOTICE: This opinion is subject to formal revision before publication in the

preliminary print of the United States Reports. Readers are requested to 

notify the Reporter of Decisions, Supreme Court of the United States, Washington, D. C. 20543, of any typographical or other formal errors, in order

that corrections may be made before the preliminary print goes to press. 

SUPREME COURT OF THE UNITED STATES 

 No. 17–7505 

VERNON MADISON, PETITIONER v. ALABAMA 

ON WRIT OF CERTIORARI TO THE CIRCUIT COURT OF 

ALABAMA, MOBILE COUNTY 

[February 27, 2019]

 JUSTICE KAGAN delivered the opinion of the Court. 

The Eighth Amendment, this Court has held, prohibits 

the execution of a prisoner whose mental illness prevents

him from “rational[ly] understanding” why the State seeks

to impose that punishment. Panetti v. Quarterman, 551 

U. S. 930, 959 (2007). In this case, Vernon Madison argued that his memory loss and dementia entitled him to a 

stay of execution, but an Alabama court denied the relief.

We now address two questions relating to the Eighth

Amendment’s bar, disputed below but not in this Court.

First, does the Eighth Amendment forbid execution whenever a prisoner shows that a mental disorder has left him

without any memory of committing his crime? We (and,

now, the parties) think not, because a person lacking such

a memory may still be able to form a rational understanding of the reasons for his death sentence. Second, does the 

Eighth Amendment apply similarly to a prisoner suffering

from dementia as to one experiencing psychotic delusions? 

We (and, now, the parties) think so, because either condition may—or, then again, may not—impede the requisite

comprehension of his punishment. The only issue left, on 

which the parties still disagree, is what those rulings 
 

2 MADISON v. ALABAMA 

Opinion of the Court 

mean for Madison’s own execution. We direct that issue to 

the state court for further consideration in light of this

opinion. 

I 

A 

This Court decided in Ford v. Wainwright, 477 U. S. 399 

(1986), that the Eighth Amendment’s ban on cruel and

unusual punishments precludes executing a prisoner who

has “lost his sanity” after sentencing. Id., at 406. While 

on death row, Alvin Ford was beset by “pervasive delusion[s]” associated with “[p]aranoid [s]chizophrenia.” Id., 

at 402–403. Surveying both the common law and state 

statutes, the Court found a uniform practice against taking the life of such a prisoner. See id., at 406–409. Among 

the reasons for that time-honored bar, the Court explained, was a moral “intuition” that “killing one who has 

no capacity” to understand his crime or punishment “simply 

offends humanity.” Id., at 407, 409; see id., at 409 (citing

the “natural abhorrence civilized societies feel” at performing such an act). Another rationale rested on the lack of 

“retributive value” in executing a person who has no comprehension of the meaning of the community’s judgment. 

Ibid.; see id., at 421 (Powell, J., concurring in part and 

concurring in judgment) (stating that the death penalty’s

“retributive force[] depends on the defendant’s awareness 

of the penalty’s existence and purpose”). The resulting

rule, now stated as a matter of constitutional law, held “a 

category of defendants defined by their mental state”

incompetent to be executed. Id., at 419. 

The Court clarified the scope of that category in Panetti 

v. Quarterman by focusing on whether a prisoner can 

“reach a rational understanding of the reason for [his]

execution.” 551 U. S., at 958. Like Alvin Ford, Scott 

Panetti suffered from “gross delusions” stemming from

“extreme psychosis.” Id., at 936, 960. In reversing a 
Cite as: 586 U. S. ____ (2019) 3 

Opinion of the Court 

ruling that he could still be executed, the Panetti Court set 

out the appropriate “standard for competency.” Id., at 

957. Ford, the Court now noted, had not provided “specific 

criteria.” 551 U. S., at 957. But Ford had explored what

lay behind the Eighth Amendment’s prohibition, highlighting that the execution of a prisoner who cannot comprehend the reasons for his punishment offends moral 

values and “serves no retributive purpose.” 551 U. S., at 

958. Those principles, the Panetti Court explained, indicate how to identify prisoners whom the State may not 

execute. The critical question is whether a “prisoner’s

mental state is so distorted by a mental illness” that he

lacks a “rational understanding” of “the State’s rationale 

for [his] execution.” Id., at 958–959. Or similarly put, the 

issue is whether a “prisoner’s concept of reality” is “so

impair[ed]” that he cannot grasp the execution’s “meaning 

and purpose” or the “link between [his] crime and its 

punishment.” Id., at 958, 960. 

B 

Vernon Madison killed a police officer in 1985 during a 

domestic dispute. An Alabama jury found him guilty of 

capital murder, and the trial court sentenced him to 

death. He has spent most of the ensuing decades on the

State’s death row. 

In recent years, Madison’s mental condition has sharply 

deteriorated. Madison suffered a series of strokes, including major ones in 2015 and 2016. See Tr. 19, 46–47 (Apr. 

14, 2016). He was diagnosed as having vascular dementia,

with attendant disorientation and confusion, cognitive

impairment, and memory loss. See id., at 19–20, 52–54. 

In particular, Madison claims that he can no longer recollect committing the crime for which he has been sentenced

to die. See Tr., Pet. Exh. 2, p. 8. 

After his 2016 stroke, Madison petitioned the trial court

for a stay of execution on the ground that he had become 
 

 

4 MADISON v. ALABAMA 

Opinion of the Court 

mentally incompetent. Citing Ford and Panetti, he argued

that “he no longer understands” the “status of his case” or 

the “nature of his conviction and sentence.” Pet. for Suspension in No. CC–85–1385.80 (C. C. Mobile Cty., Ala., 

Feb. 12, 2016), pp. 11, 14. And in a later filing, Madison

emphasized that he could not “independently recall the 

facts of the offense he is convicted of.” Brief Pursuant to 

Order (Apr. 21, 2016), p. 8. Alabama countered that Madison had “a rational understanding of [the reasons for] his

impending execution,” as required by Ford and Panetti, 

even assuming he had no memory of committing his crime.

Brief on Madison’s Competency (April 21, 2016), pp. 4–5,

8. And more broadly, the State claimed that Madison

could not possibly qualify as incompetent under those two

decisions because both “concerned themselves with ‘[g]ross

delusions’”—which all agree Madison does not have. Id., 

at 2; see ibid. (Madison “failed to implicate” Ford and 

Panetti because he “does not suffer from psychosis or 

delusions”).

Expert reports from two psychologists largely aligned 

with the parties’ contending positions. Dr. John Goff, 

Madison’s expert, found that although Madison “underst[ood] the nature of execution” in the abstract, he did

not comprehend the “reasoning behind” Alabama’s effort 

to execute him. Tr., Pet. Exh. 2 (Apr. 14, 2016), p. 8; see 

id., at 9. Goff stated that Madison had “Major Vascular

Neurological Disorder”—also called vascular dementia—

which had caused “significant cognitive decline.” Ibid. 

And Goff underscored that Madison “demonstrate[d]

retrograde amnesia” about his crime, meaning that he had 

no “independent recollection[ ]” of the murder. Id., at 8; 

see id., at 9. For his part, Dr. Karl Kirkland, the courtappointed expert, reported that Madison “was able to 

discuss his case” accurately and “appear[ed] to understand

his legal situation.” Tr., Ct. Exh. 1, pp. 10–11. Although

Kirkland acknowledged that Madison’s strokes had led to 
 

 

 

Cite as: 586 U. S. ____ (2019) 5 

Opinion of the Court 

cognitive decline, see id., at 10, the psychologist made no mention of Madison’s diagnosed vascular dementia. Rather, 

Kirkland highlighted that “[t]here was no evidence of 

psychosis, paranoia, or delusion.” Id., at 9; see ibid. (Madison “did not seem delusional at all”). 

At a competency hearing, Alabama similarly stressed 

Madison’s absence of psychotic episodes or delusions. The 

State asked both experts to affirm that Madison was 

“neither delusional [n]or psychotic.” Tr. 56; see id., at 22. 

And its closing argument focused on their agreement that

he was not. As the State summarized: “He’s not psychotic.

He’s not delusional.” Id., at 81. On the State’s view, that 

fact answered the competency question because “[t]he

Supreme Court is looking at whether someone’s delusions 

or someone’s paranoia or someone’s psychosis is standing 

in the way of ” rationally understanding his punishment. 

Id., at 82. Madison’s counsel disputed that point. “[T]he

State would like to say, well, he’s not delusional, he’s not 

psychotic,” the attorney recapped. Id., at 83. But, she 

continued, “[t]hat’s not really the criteria” under Panetti. 

Tr. 83. Rather, the Court there barred executing a person

with any mental illness—“dementia” and “brain injuries” 

no less than psychosis and delusions—that prevents him

from comprehending “why he is being executed.” Ibid. 

The trial court found Madison competent to be executed.

Its order first recounted the evidence given by each expert

witness. The summary of Kirkland’s report and testimony 

began by stating that the psychologist had “found no 

evidence of paranoia[,] delusion [or] psychosis.” Order 

(Apr. 29, 2016), p. 5 (2016 Order). The court then noted 

Kirkland’s view that Madison could “give details of the 

history of his case” and “appear[ed] to understand his

legal situation.” Ibid. Turning to the Goff report, the 

court noted the expert’s finding that Madison was “amnesic” and could not recollect his crime. Id., at 6; see id., at 

7. In a single, final paragraph, the court provided both its 
 

 

 

 

6 MADISON v. ALABAMA 

Opinion of the Court 

ruling and its reasoning. Madison had failed to show, the 

court wrote, that he did not “rationally understand the

punishment he is about to suffer and why he is about to 

suffer it.” Id., at 10. The court “accept[ed] the testimony

of Dr. Kirkland as to the understanding Madison has 

concerning the situation.” Ibid. “Further,” the court 

concluded, “the evidence does not support that Mr. Madison is delusional.” Ibid. 

Madison next sought habeas relief in federal court,

where he faced the heavy burden of showing that the 

state-court ruling “involved an unreasonable application 

of[] clearly established federal law” or rested on an “unreasonable determination of the facts.” Antiterrorism and 

Effective Death Penalty Act of 1996 (AEDPA), 28 U. S. C. 

§2254(d). The District Court rejected his petition, but the 

Court of Appeals for the Eleventh Circuit ruled that Madison had demonstrated both kinds of indisputable error.

See Madison v. Commissioner, 851 F. 3d 1173 (2017).

This Court then summarily reversed the appeals court’s

decision. See Dunn v. Madison, 583 U. S. ___ (2017) (per 

curiam). We explained, contrary to the Eleventh Circuit’s 

principal holding, that “[n]either Panetti nor Ford ‘clearly

established’ that a prisoner is incompetent to be executed” 

because of a simple failure to remember his crime. Id., at 

___ (slip op., at 4). And we found that the state court did 

not act unreasonably—otherwise put, did not err “beyond 

any possibility for fairminded disagreement”—when it

found that Madison had the necessary understanding to 

be executed. Ibid. (internal quotation marks omitted).

But we made clear that our decision was premised on 

AEDPA’s “demanding” and “deferential standard.” Id., at 

___, ___ (slip op., at 3, 4). “We express[ed] no view” on the

question of Madison’s competency “outside of the AEDPA

context.” Id., at ___ (slip op., at 4).1 

—————— 

1Neither did we opine on—or even mention—the subsidiary legal 
 

Cite as: 586 U. S. ____ (2019) 7 

Opinion of the Court 

When Alabama set an execution date in 2018, Madison 

returned to state court to argue again that his mental

condition precluded the State from going forward. In his 

petition, Madison reiterated the facts and arguments he

had previously presented to the state court. But Madison 

also claimed that since that court’s decision (1) he had 

suffered further cognitive decline and (2) a state board had 

suspended Kirkland’s license to practice psychology, thus 

discrediting his prior testimony. See Pet. to Suspend

Execution in No. CC–85–1385.80 (C. C. Mobile Cty., Ala.,

Dec. 18, 2017), pp. 1–2, 16–19.2 Alabama responded that

nothing material had changed since the court’s first competency hearing. See Motion to Dismiss (Dec. 20, 2017), 

p. 9. The State also repeated its argument that Panetti 

permits executing Madison, pointing to the experts’

agreement that he is “not delusional or psychotic” and 

—————— 

question whether a mental disorder other than delusions may render a 

person incompetent to be executed. Alabama told the Eleventh Circuit 

that it could not, thus reprising the claim the State had made in the 

trial court. See Madison, 851 F. 3d, at 1188 (describing Alabama’s 

argument that “only a prisoner suffering from gross delusions can show

incompetency under Panetti”); Recording of Oral Arg. in No. 16–12279 

(CA11, June 23, 2016), at 26:36–26:45 (“In this case, what we have is 

someone who claims to have a mental illness, dementia,” but does not 

have “delusions, which is what Panetti requires”); id., at 26:48–27:21 

(When asked if someone with “severe dementia” but no delusions could

be executed, the State responded “I think so because . . . they don’t have 

delusions”). (Alabama alternatively argued that the state court’s 

decision was not based on that view, see Brief for Appellee in No. 16–

12279 (CA11), pp. 37–38; the quotations the dissent picks out, see post, 

at 10, n. 4, come from that additional argument.) The Eleventh Circuit 

rejected the State’s contention that dementia could not preclude an 

execution as “inconsistent with the principles underlying” Ford and 

Panetti. 851 F. 3d, at 1188. But we had no reason to address that 

holding in light of the errors we saw in other parts of the appeals 

court’s analysis. 2As Madison’s petition recounted, the license suspension followed the 

opening of a criminal investigation into whether Kirkland had committed narcotics offenses. See Pet. to Suspend Execution 17–19. 
 

8 MADISON v. ALABAMA 

Opinion of the Court 

asserting that neither “memory impairment [n]or dementia [could] suffice to satisfy the Panetti and Ford standards” without “an expansion” of those decisions. Motion to 

Dismiss 4, 10. A week before the scheduled execution, the 

state court again found Madison mentally competent. Its 

brief order stated only that Madison “did not provide a 

substantial threshold showing of insanity[ ] sufficient to

convince this Court to stay the execution.” App. A to Pet.

for Cert. 

Madison then filed in this Court a request to stay his

execution and a petition for certiorari. We ordered the 

stay on the scheduled execution date and granted the

petition a few weeks later. See 583 U. S. ___, ___ (2018). 

Because the case now comes to us on direct review of the 

state court’s decision (rather than in a habeas proceeding), 

AEDPA’s deferential standard no longer governs. (And for

that reason—contrary to the dissent’s suggestion, post, at 

12—our decision on Madison’s habeas petition cannot help 

resolve the questions raised here.) 

II 

Two issues relating to Panetti’s application are before 

us. Recall that our decision there held the Eighth

Amendment to forbid executing a prisoner whose mental

illness makes him unable to “reach a rational understanding of the reason for [his] execution.” 551 U. S., at 958; see 

supra, at 2–3. The first question presented is whether 

Panetti prohibits executing Madison merely because he 

cannot remember committing his crime. The second question raised is whether Panetti permits executing Madison

merely because he suffers from dementia, rather than 

psychotic delusions.3 In prior stages of this case, as we 

—————— 

3The dissent is in high dudgeon over our taking up the second question, arguing that it was not presented in Madison’s petition for certiorari. See post, at 1–6. But that is incorrect. The petition presented 

two questions—the same two we address here. The first question asked 
 

 

 

 

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Opinion of the Court 

have described, the parties disagreed about those matters. 

See supra, at 4–8. But at this Court, Madison accepted 

Alabama’s positon on the first issue and Alabama accepted

Madison’s on the second. See, e.g., Tr. of Oral Arg. 11, 36. 

And rightly so. As the parties now recognize, the standard

set out in Panetti supplies the answers to both questions.

First, a person lacking memory of his crime may yet rationally understand why the State seeks to execute him; if 

so, the Eighth Amendment poses no bar to his execution.

Second, a person suffering from dementia may be unable 

to rationally understand the reasons for his sentence; if so,

the Eighth Amendment does not allow his execution.

What matters is whether a person has the “rational understanding” Panetti requires—not whether he has any 

particular memory or any particular mental illness. 

A 

Consider initially a person who cannot remember his

crime because of a mental disorder, but who otherwise has 

—————— 

whether the Eighth Amendment bars executing Madison because he 

has no “memory of his commission of the capital offense.” Pet. for Cert. 

iii. The second question asked whether that Amendment bars his 

execution because his “vascular dementia” and “severe cognitive dysfunction” prevent him from either remembering his crime “or understanding the circumstances of his scheduled execution.” Ibid. So the 

first question concerned whether memory loss alone could form the 

basis of a Panetti claim and the second whether the varied consequences 

of dementia could do so. The body of the petition, to be sure, devoted 

more space to the first question. But it clearly referenced the second.

See Pet. for Cert. 18 (“[T]his Court has never sought to constrain the 

world of maladies that can give rise to a finding that a prisoner is 

incompetent to be executed”); id., at 25 (“[C]ourts have recognized

dementia and attendant cognitive decline and memory impairment as a 

basis for a finding of incompetency to be executed”). And in any event, 

the number of words spent on each is not what matters. Our Rule 

states that the Court will consider “[o]nly the questions set out in the 

petition, or fairly included therein.” This Court’s Rule 14.1(a). Here, 

we consider, in order, the two questions set out in Madison’s petition. 
 

 

 

10 MADISON v. ALABAMA 

Opinion of the Court 

full cognitive function. The memory loss is genuine: Let

us say the person has some kind of amnesia, which has

produced a black hole where that recollection should be.

But the person remains oriented in time and place; he can 

make logical connections and order his thoughts; and he 

comprehends familiar concepts of crime and punishment.

Can the State execute him for a murder? When we considered this case before, using the deferential standard 

applicable in habeas, we held that a state court could 

allow such an execution without committing inarguable 

error. See Madison, 583 U. S., at ___ (slip op., at 4) (stating that no prior decision had “clearly established” the 

opposite); supra, at 6. Today, we address the issue 

straight-up, sans any deference to a state court. Again, is

the failure to remember committing a crime alone enough

to prevent a State from executing a prisoner? 

It is not, under Panetti’s own terms. That decision asks 

about understanding, not memory—more specifically,

about a person’s understanding of why the State seeks

capital punishment for a crime, not his memory of the 

crime itself. And the one may exist without the other.

Do you have an independent recollection of the Civil War?

Obviously not. But you may still be able to reach a 

rational—indeed, a sophisticated—understanding of that 

conflict and its consequences. Do you recall your first day 

of school? Probably not. But if your mother told you years

later that you were sent home for hitting a classmate, you 

would have no trouble grasping the story. And similarly,

if you somehow blacked out a crime you committed, but 

later learned what you had done, you could well appreciate the State’s desire to impose a penalty. Assuming, that 

is, no other cognitive impairment, loss of memory of a 

crime does not prevent rational understanding of the

State’s reasons for resorting to punishment. And that 

kind of comprehension is the Panetti standard’s singular 

focus. 
Cite as: 586 U. S. ____ (2019) 11 

Opinion of the Court 

The same answer follows from the core justifications 

Panetti offered for framing its Eighth Amendment test as

it did. Echoing Ford, Panetti reasoned that execution has 

no retributive value when a prisoner cannot appreciate the 

meaning of a community’s judgment. See 551 U. S., at 

958–959 (citing 477 U. S., at 407–408); supra, at 3. But as 

just explained, a person who can no longer remember a 

crime may yet recognize the retributive message society

intends to convey with a death sentence. Similarly, Ford 

and Panetti stated that it “offends humanity” to execute a

person so wracked by mental illness that he cannot comprehend the “meaning and purpose of the punishment.”

477 U. S., at 407; 551 U. S., at 960; see id., at 958. But 

that offense to morality must be much less when a person’s mental disorder causes nothing more than an episodic

memory loss. Moral values do not exempt the simply

forgetful from punishment, whatever the neurological

reason for their lack of recall. 

But such memory loss still may factor into the “rational 

understanding” analysis that Panetti demands. If that 

loss combines and interacts with other mental shortfalls to 

deprive a person of the capacity to comprehend why the 

State is exacting death as punishment, then the Panetti 

standard will be satisfied. That may be so when a person

has difficulty preserving any memories, so that even newly 

gained knowledge (about, say, the crime and punishment) 

will be quickly forgotten. Or it may be so when cognitive

deficits prevent the acquisition of such knowledge at all, so 

that memory gaps go forever uncompensated. As Panetti 

indicated, neurologists, psychologists, and other experts

can contribute to a court’s understanding of issues of that 

kind. See id., at 962. But the sole inquiry for the court 

remains whether the prisoner can rationally understand

the reasons for his death sentence. 
 

 

 

12 MADISON v. ALABAMA 

Opinion of the Court 

B 

Next consider a prisoner who suffers from dementia or a 

similar disorder, rather than psychotic delusions. The 

dementia, as is typical, has compromised this prisoner’s

cognitive functions. But it has not resulted in the kind of 

delusional beliefs that Alvin Ford and Scott Panetti held. 

May the prisoner nonetheless receive a stay of execution 

under Ford and Panetti? Or instead, is a delusional disorder a prerequisite to declaring a mentally ill person incompetent to be executed? We did not address that issue 

when we last considered this case, on habeas review; in 

that sense, the question is one of first impression. See 

supra, at 6, n. 1. 

But here too, Panetti has already answered the question. Its standard focuses on whether a mental disorder 

has had a particular effect: an inability to rationally understand why the State is seeking execution. See supra,

at 2–3. Conversely, that standard has no interest in establishing any precise cause: Psychosis or dementia, delusions or overall cognitive decline are all the same under 

Panetti, so long as they produce the requisite lack of comprehension. To be sure, Panetti on occasion spoke of 

“gross delusions” in explaining its holding. 551 U. S., at 

960. And similarly, Ford talked about the “insane,” which 

sometimes refers to persons holding such irrational beliefs. See, e.g., 477 U. S., at 401, 410.4 But those references are no more than a predictable byproduct of the two 

cases’ facts. At the same time (and interchangeably), 

Panetti used more inclusive terms, such as “mental ill-

—————— 

4Alternatively, however, the term may also be used to encompass 

persons with other mental conditions, so long as they are “severe

enough [to] prevent[] a person from having legal capacity and excuse[ ] 

the person from criminal or civil responsibility.” Black’s Law Dictionary 914 (10th ed. 2014). In that different understanding, “insanity” 

connotes a general standard of legal competency rather than a more 

limited description of delusional disorders. 
 

Cite as: 586 U. S. ____ (2019) 13 

Opinion of the Court 

ness,” “mental disorder,” and “psychological dysfunction.”

551 U. S., at 936, 959, 960; see Ford, 477 U. S., at 408– 

409, n. 2 (referring to prisoners with “mental illness”). 

And most important, Panetti framed its test, as just described, in a way utterly indifferent to a prisoner’s specific 

mental illness. The Panetti standard concerns, once again, 

not the diagnosis of such illness, but a consequence—to 

wit, the prisoner’s inability to rationally understand his

punishment.

And here too, the key justifications Ford and Panetti 

offered for the Eighth Amendment’s bar confirm our conclusion about its reach. As described above, those decisions stated that an execution lacks retributive purpose 

when a mentally ill prisoner cannot understand the societal judgment underlying his sentence. See Panetti, 551 

U. S., at 958–959; Ford, 477 U. S., at 409; supra, at 2–3. 

And they indicated that an execution offends morality in 

the same circumstance. See 551 U. S., at 958, 960; 477 

U. S., at 409; supra, at 2–3. Both rationales for the constitutional bar thus hinge (just as the Panetti standard 

deriving from them does) on the prisoner’s

“[in]comprehension of why he has been singled out” to die. 

477 U. S., at 409; see supra, at 2–3. Or said otherwise, if 

and when that failure of understanding is present, the 

rationales kick in—irrespective of whether one disease or 

another (say, psychotic delusions or dementia) is to blame. 

In evaluating competency to be executed, a judge must 

therefore look beyond any given diagnosis to a downstream consequence. As Ford and Panetti recognized, a 

delusional disorder can be of such severity—can “so impair 

the prisoner’s concept of reality”—that someone in its 

thrall will be unable “to come to grips with” the punishment’s meaning. Panetti, 551 U. S., at 958; Ford, 477 

U. S., at 409. But delusions come in many shapes and 

sizes, and not all will interfere with the understanding

that the Eighth Amendment requires. See Panetti, 551 
 

 

 

 

 

14 MADISON v. ALABAMA 

Opinion of the Court 

U. S., at 962 (remanding the case to consider expert evidence on whether the prisoner’s delusions did so). And 

much the same is true of dementia. That mental condition 

can cause such disorientation and cognitive decline as to 

prevent a person from sustaining a rational understanding

of why the State wants to execute him. See supra, at 11– 

12. But dementia also has milder forms, which allow a 

person to preserve that understanding. Hence the need— 

for dementia as for delusions as for any other mental

disorder—to attend to the particular circumstances of a 

case and make the precise judgment Panetti requires. 

III 

The only question left—and the only one on which the 

parties now disagree—is whether Madison’s execution 

may go forward based on the state court’s decision below.

Madison’s counsel says it cannot because that ruling was 

tainted by legal error—specifically, the idea that only 

delusions, and not dementia, can support a finding of

mental incompetency. See Tr. of Oral Arg. 12, 21, 25, 27.

Alabama counters that the state court did not rely on that

(concededly) incorrect view of the law. See id., at 37–41. 

But we come away at the least unsure whether that is 

so—especially given Alabama’s evidence and arguments in

the state court. 

As noted earlier, the 2018 ruling we review today contains only one sentence of explanation. See supra, at 7–8. 

It states that Madison “did not provide a substantial

threshold showing of insanity[ ] sufficient to convince this 

Court to stay the execution.” App. A to Pet. for Cert. If 

the state court used the word “insanity” to refer to a delusional disorder, then error occurred: The court would have 

denied a stay on the ground that Madison did not have 

that specific kind of mental illness. And the likelihood 

that the court made that mistake is heightened by the 

State’s emphasis, at that stage of the proceedings (as at 
Cite as: 586 U. S. ____ (2019) 15 

Opinion of the Court 

others), that Madison was “not delusional or psychotic” 

and that “dementia” could not suffice to bar his execution 

absent “an expansion of Ford and Panetti.” Motion to 

Dismiss 4, 10; see supra, at 4–8; but see post, at 9–10, and 

n. 4 (disregarding those arguments).5 Alabama argues,

however, that the court spoke of “insanity” only because 

the state statute under which Madison sought relief uses 

that term. See Tr. of Oral Arg. 37; Ala. Code §15–16–23 

(2011) (allowing a stay of execution “on account of the 

[convict’s] insanity”). But even if so, that does not advance 

the State’s view that the state court properly understood 

the Eighth Amendment bar when assessing Madison’s 

competency. Alabama told this Court in opposing certiorari that its statute covers only those with delusional

disorders, and not those with dementia. See Brief in 

Opposition 12 (“[T]he sole question to be answered under

the state statute was whether Madison was insane, not 

whether he suffered from dementia”). The state court’s 

(supposed) echoing of statutory language understood in 

that way cannot provide assurance that the court knew a 

person with dementia might receive a stay of execution; 

indeed, it suggests exactly the opposite. The court’s 2018 

order thus calls out for a do-over. 

Alabama further contends, however, that we should look 

past the state court’s 2018 decision to the court’s initial 

2016 determination of competency. (The dissent similarly 

begins with the 2016 ruling, see post, at 6–7, even though 

that is not the decision under review here.) According to 

the State, nothing material changed in the interim period, 

see supra, at 7; thus, we may find the meaning of the later 

ruling in the earlier one, see Tr. of Oral Arg. 36–37. And, 

—————— 

5The State once again repeated that argument in its Brief in Opposition to Madison’s certiorari petition. See Brief in Opposition 11–12 

(“Madison does not argue that he is insane. Instead, he argues that he

suffers from dementia” and that his execution should be barred “under 

a yet-unannounced expansion of Ford and Panetti”). 
 

 

 

16 MADISON v. ALABAMA 

Opinion of the Court 

the State continues, the 2016 opinion gets the law right.

Alabama’s proof is that the court, after summarizing the 

psychologists’ testimony, found that “Madison has a rational[] understanding, as required by Panetti,” concerning the “punishment he is about to suffer and why he is 

about to suffer it.” 2016 Order, at 10; see Tr. of Oral Arg. 

39; supra, at 5–6. (The dissent quotes the same passage. 

See post, at 7.)

But the state court’s initial decision does not aid Alabama’s cause. First, we do not know that the court in 

2018 meant to incorporate everything in its prior opinion.

The order says nothing to that effect; and though it came

out the same way as the earlier decision, it need not have 

rested on all the same reasoning. Second, the 2016 opinion itself does not show that the state court realized that 

persons suffering from dementia could satisfy the Panetti 

standard. True enough, as Alabama says, that the court 

accurately stated that standard in its decision. But as 

described above, Alabama had repeatedly argued to the

court (over Madison’s objection) that only prisoners suffering from delusional disorders could qualify as incompetent 

under Panetti. See, e.g., Brief on Madison’s Competency 2 

(Madison “failed to implicate” Ford and Panetti because he 

“does not suffer from psychosis or delusions”); Tr. 82 (“The

Supreme Court [in Panetti] is looking at whether someone’s delusions or someone’s paranoia or someone’s psychosis is standing in the way of ” rationally understanding 

his punishment); see also supra, at 4–5; but see post, at 9– 

10, and n. 4 (disregarding those arguments). And Alabama relied on the expert opinion of a psychologist who

highlighted Madison’s lack of “psychosis, paranoia, or

delusion,” while never mentioning his dementia. Tr., Ct. 

Exh. 1 (Apr. 14, 2016), p. 9. That too-limited understanding of Panetti’s compass is reflected in the court’s 2016 

opinion. In its single paragraph of analysis, the court 

“accept[ed] the testimony” of the State’s preferred psy-
 

 

 

Cite as: 586 U. S. ____ (2019) 17 

Opinion of the Court 

chologist.6 And the court further found that “the evidence 

does not support that Mr. Madison is delusional”—without 

ever considering his undisputed dementia. 2016 Order, 

at 10. 

For those reasons, we must return this case to the state 

court for renewed consideration of Madison’s competency 

(assuming Alabama sets a new execution date). See, e.g., 

Kindred Nursing Centers L. P. v. Clark, 581 U. S. ___, ___ 

(2017) (slip op., at 9) (remanding when “uncertain” whether 

“an impermissible taint occurred”); Clemons v. Mississippi, 

494 U. S. 738, 751–752 (1990) (similar). In that proceeding, two matters disputed below should now be clear.

First, under Ford and Panetti, the Eighth Amendment 

may permit executing Madison even if he cannot remember committing his crime. Second, under those same 

decisions, the Eighth Amendment may prohibit executing 

Madison even though he suffers from dementia, rather 

than delusions. The sole question on which Madison’s 

competency depends is whether he can reach a “rational 

understanding” of why the State wants to execute him. 

Panetti, 551 U. S., at 958. In answering that question—on 

which we again express no view, see supra, at 6—the state 

court may not rely on any arguments or evidence tainted

with the legal errors we have addressed. And because 

that is so, the court should consider whether it needs to 

supplement the existing record. Some evidence in that 

record, including portions of the experts’ reports and 

testimony, expressly reflects an incorrect view of the 

relevance of delusions or memory; still other evidence

might have implicitly rested on those same misjudgments. 

—————— 

6The court well understood that expert’s exclusive focus on whether 

Madison had psychotic delusions. In summarizing his testimony, the 

court began as follows: “Dr. Kirkland in his exam found no evidence of 

paranoia or delusion at the time of his examin[ation], on March 31, 

2016. He also found that there was no psychosis present.” 2016 Order, 

at 5; see supra, at 5. 
 

18 MADISON v. ALABAMA 

Opinion of the Court 

The state court, we have little doubt, can evaluate such 

matters better than we. It must do so as the first step in 

assessing Madison’s competency—and ensuring that if he

is to be executed, he understands why.

We accordingly vacate the judgment of the state court 

and remand the case for further proceedings not inconsistent with this opinion. 

It is so ordered.

 JUSTICE KAVANAUGH took no part in the consideration

or decision of this case. 
_________________ 

_________________ 

Cite as: 586 U. S. ____ (2019) 1 

ALITO, J., dissenting 

SUPREME COURT OF THE UNITED STATES 

No. 17–7505 

VERNON MADISON, PETITIONER v. ALABAMA 

ON WRIT OF CERTIORARI TO THE CIRCUIT COURT OF 

ALABAMA, MOBILE COUNTY 

[February 27, 2019]

 JUSTICE ALITO, with whom JUSTICE THOMAS and 

JUSTICE GORSUCH join, dissenting. 

What the Court has done in this case makes a mockery 

of our Rules. 

Petitioner’s counsel convinced the Court to stay his

client’s execution and to grant his petition for a writ of 

certiorari for the purpose of deciding a clear-cut constitutional question: Does the Eighth Amendment prohibit the

execution of a murderer who cannot recall committing the

murder for which the death sentence was imposed? The 

petition strenuously argued that executing such a person

is unconstitutional. 

After persuading the Court to grant review of this question, counsel abruptly changed course. Perhaps because 

he concluded (correctly) that petitioner was unlikely to

prevail on the question raised in the petition, he conceded

that the argument advanced in his petition was wrong,

and he switched to an entirely different argument, namely,

that the state court had rejected petitioner’s claim that he

is incompetent to be executed because the court erroneously 

thought that dementia, as opposed to other mental conditions, cannot provide a basis for such a claim. See Brief 

for Petitioner 16. 

This was not a question that the Court agreed to hear;

indeed, there is no mention whatsoever of this argument 

in the petition—not even a hint. Nor is this question 
 

 

2 MADISON v. ALABAMA 

ALITO, J., dissenting 

fairly included within those on which the Court granted

review. On the contrary, it is an entirely discrete and 

independent question.

Counsel’s tactics flagrantly flouted our Rules. Our 

Rules make it clear that we grant certiorari to decide the 

specific question or questions of law set out in a petition

for certiorari. See this Court’s Rule 14.1(a) (“Only the

questions set out in the petition, or fairly included therein, 

will be considered by the Court”). Our whole certiorari 

system would be thrown into turmoil if we allowed counsel 

to obtain review of one question and then switch to an 

entirely different question after review is granted. In the 

past when counsel have done this, we have dismissed the 

writ as improvidently granted. See, e.g., Visa, Inc. v. 

Osborn, 580 U. S. ___ (2016); City and County of San 

Francisco v. Sheehan, 575 U. S. ___ (2015). We should do 

that here. 

Instead, the majority rewards counsel’s trick. It vacates 

the judgment below because it is unsure whether the state

court committed the error claimed in petitioner’s merits 

brief. But not only was there no trace of this argument in

the petition, there is nothing in the record showing that

the state court ever adopted the erroneous view that petitioner claims it took. 

I 

The question on which we granted review was an outgrowth of our per curiam decision in Dunn v. Madison, 583 

U. S. ___ (2017), which concerned an Eleventh Circuit 

decision granting petitioner federal habeas relief. Prior to 

that decision, this Court had held in Ford v. Wainwright, 

477 U. S. 399 (1986), that the Eighth Amendment prohibits the execution of a person who is “insane,” and in Panetti 

v. Quarterman, 551 U. S. 930 (2007), the Court elaborated 

on this rule, explaining that a person cannot be executed if

he lacks a rational understanding of the reason for the 
 

Cite as: 586 U. S. ____ (2019) 3 

ALITO, J., dissenting 

execution. The Eleventh Circuit interpreted those cases to

mean that petitioner could not be executed because he did 

not remember killing his victim, Mobile, Alabama, police

officer Julius Schulte. 

We summarily reversed. Under the relevant provision

of the federal habeas statute, 28 U. S. C. §2254(d), which 

was enacted as part of the Antiterrorism and Effective

Death Penalty Act of 1996 (AEDPA), petitioner could not

obtain federal habeas relief unless the state court’s rejection of his memory-loss claim represented an unreasonable

application of federal law as clearly established at the

time by decisions of this Court. We held that neither Ford 

nor Panetti clearly established that a person cannot be 

executed if he does not remember committing the crime for 

which the death sentence was imposed. 

Our opinion stated, however, that it “express[ed] no

view on the merits of the underlying question outside of 

the AEDPA context.” Dunn, 583 U. S., at ___ (slip op., at 

4). And a concurring opinion authored by JUSTICE 

GINSBURG and joined by JUSTICES BREYER and 

SOTOMAYOR teed up this question for review in a later 

case. Id., at ___ (slip op., at 1) (“The issue whether a State

may administer the death penalty to a person whose

disability leaves him without memory of his commission of 

a capital offense is a substantial question not yet addressed by the Court. Appropriately presented, the issue 

would warrant full airing”).

Taking this cue, petitioner then sought relief in state 

court based on his inability to remember his crime, and 

when that effort failed, he filed the petition at issue now. 

II 

The centerpiece of the petition and petitioner’s 11thhour application for a stay of execution1 was the argument 

—————— 

1Petitioner sought and obtained a stay of execution based on this 
 

 

4 MADISON v. ALABAMA 

ALITO, J., dissenting 

that he could not constitutionally be executed because he

did not remember killing Officer Schulte. The petition

repeatedly noted petitioner’s inability to remember his 

crime. See Pet. for Cert. i, iii, 1, 2, 8, 10, 11, 12, 18, 22, 23, 

25, 26, 27, 28. And the petition was very clear about the

question on which review was sought: 

“[T]his case presents this Court with the appropriate

vehicle to consider the substantial question of whether 

the execution of a prisoner with no memory of the underlying offense is consistent with the evolving standards of decency inherent in this Court’s Eighth

Amendment jurisprudence.” Id., at 2. 

This same point was made time and again: 

● “[B]ecause [petitioner’s] disability renders him unable 

to remember the underlying offense for which he is to 

be punished, his execution does not comport with the

evolving standards of decency required by this Court’s

Eighth Amendment jurisprudence.” Id., at 18. 

● “[I]mposing death on a prisoner, who, like Mr. Madison, suffers from substantial memory deficits by virtue of multiple stroke and resulting vascular dementia 

serves no retributive or deterrent purpose.” Id., at 22. 

● “[E]xecuting an individual with no memory of the underlying offense serves no retributive purpose.” Ibid. 

● “[W]here the person being punished has no memory of

the commission of the offense for which he is to be executed, the ‘moral quality’ of that punishment is lessened and unable to match outrage over the offense.” 

Id., at 22–23. 

—————— 

same argument. See Application for Stay of Execution 2, 6 (moving the

Court to stay petitioner’s execution so that it could address the “substantial” and “critical” question whether executing petitioner, “whose

severe cognitive dysfunction leaves him without memory of his commission of the capital offense,” would violate the Eighth Amendment). 
 

Cite as: 586 U. S. ____ (2019) 5 

ALITO, J., dissenting 

● “Mr. Madison’s severe memory impairments as a result of vascular dementia render him incompetent to 

be executed under the Eight Amendment.” Id., at 25 

(quotation altered). 

In sum, the body of the petition makes it clear that 

review was sought on the question invited by the Dunn 

concurrence, and the thrust of the wording of the two 

questions was the same. They read as follows: 

“1. Consistent with the Eighth Amendment, and this 

Court’s decisions in Ford and Panetti, may the State

execute a prisoner whose mental disability leaves him

without memory of his commission of the capital offense? See Dunn v. Madison, [583 U. S. ___, ___ 

(2017) (GINSBURG, J., joined by BREYER and 

SOTOMAYOR, JJ., concurring).]

“2. Do evolving standards of decency and the Eighth 

Amendment’s prohibition of cruel and unusual punishment bar the execution of a prisoner whose competency has been compromised by vascular dementia 

and multiple strokes causing severe cognitive dysfunction and a degenerative medical condition which

prevents him from remembering the crime for which

he was convicted or understanding the circumstances

of his scheduled execution?” Pet. for Cert. iii. 

With the exception of the final phrase in question two

(“or understanding the circumstances of his scheduled 

execution”), both questions solely concern the effect of 

memory loss on an Eighth Amendment analysis. The final 

phrase in question two and certain passages in the petition, if read with an exceedingly generous eye, might be 

seen as a basis for considering whether the evidence in the 

state-court record shows that petitioner’s dementia rendered him incapable of having a rational understanding of

the reason for his execution. But that is the sort of factbound question on which we rarely grant review, see this 
 

6 MADISON v. ALABAMA 

ALITO, J., dissenting 

Court’s Rule 10, and it is questionable whether we did so

here. 

But whether or not the petition may be fairly read to

present that factbound question, it is a travesty to read it

as challenging the state-court order on the ground that the

state court erroneously believed that dementia cannot 

provide a basis for a Ford/Panetti claim. There is no inkling of that argument in the petition. Although the petition described the state-court order at numerous places,

the petition never claimed that the order was based on an 

impermissible distinction between dementia and other

mental conditions. See, e.g., Pet. for Cert. ii, 2–3, 16. And 

in fact, there is a point in the petition where such an

interpretation of the state-court order would surely have 

been mentioned if the petition had intended to raise it as a 

ground for review. The petition noted that “courts have

recognized dementia and attendant cognitive decline and

memory impairment as a basis for a finding of incompetency to be executed,” id., at 25, but the petition did not 

follow that statement by claiming that the state court in

this case took a contradictory position. 

Because the petition did not raise—indeed, did not even

hint at—the argument on which the Court now grants

relief, the Court’s decision is insupportable.2 It violates 

our Rule that “[o]nly the questions set out in the petition,

or fairly included therein, will be considered by the Court.” 

See Rule 14.1(a). 

III 

Even if it were proper for us to consider whether the 

order below was based on an erroneous distinction between dementia and other mental conditions, there is little 

reason to think that it was. After a full evidentiary hear-

—————— 

2The Court is unable to cite a single place in the petition that makes 

any reference to the argument that the state court failed to understand

that dementia could satisfy the Ford/Panetti test. 
 

Cite as: 586 U. S. ____ (2019) 7 

ALITO, J., dissenting 

ing in 2016, the state court rejected petitioner’s 

Ford/Panetti claim based on a correct statement of the 

holding of those decisions. It found that petitioner “ha[d] 

not carried his burden [of showing] by a preponderance of

the evidence . . . that he . . . does not rationally understand 

the punishment he is about to suffer and why he is about 

to suffer it.” Order (Apr. 29, 2016), p. 10. The court’s 

order went on to say that it “specifically [found] that Madison has a rationa[l] understanding, as required by Panetti, 

that he is going to be executed because of the murder he 

committed and a rationa[l] understanding that the State 

is seeking retribution and that he will die when he is 

executed.” Ibid. 

In concluding that the state court might have drawn a 

distinction between dementia and other mental conditions, 

the majority seizes upon the wording of the order issued 

after a subsequent hearing in 2018. Ante, at 14. In that 

order, the same judge wrote: “Defendant did not provide a 

substantial threshold showing of insanity, a requirement

set out by the United States Supreme Court, sufficient to 

convince this Court to stay the execution.” Order (Jan. 16,

2018), p. 1 (emphasis added). The majority worries that

the state-court judge might not have applied the same 

standard in 2018 as he had two years earlier and might 

have viewed “insanity” as something narrower than the

standard mandated by Ford and Panetti. This concern is 

unfounded. 

Taken out of context, the term “insanity” might not be

read to encompass dementia, but in context, it is apparent

that the state court’s use of that term was based on the 

way in which it was used in Ford and Panetti. The state 

court did not simply refer to “insanity.” It referred to 

“insanity, a requirement set out by the United States

Supreme Court.” Thus, it followed the term “insanity” 

with an appositive, which is a word or phrase that renames the word or phrase that precedes it. In other 
 

 

 

8 MADISON v. ALABAMA 

ALITO, J., dissenting 

words, what the state court clearly meant by “insanity”

was what this Court termed insanity in Ford and Panetti. 

What was that? 

In Ford, the Court held that the Eighth Amendment

prohibits the execution of a person who is “insane,” and in

the portion of Justice Marshall’s lead opinion that was 

joined by a plurality, Justice Marshall equated insanity 

with a mental condition that “prevents [a person] from

comprehending the reasons for the penalty or its implications.” 477 U. S., at 417. Justice Powell, who provided the

fifth vote for the decision, took a similar position. See id., 

at 422–423 (opinion concurring in part and concurring in

judgment). In Panetti, which built on the holding in Ford, 

the Court used the term in a similar way. See 551 U. S., 

at 958–960. Accordingly, a defendant suffers from “insanity,” 

as the term is used in Ford and Panetti, if the prisoner

does not understand the reason for his execution. 

Today’s decision does not reject this interpretation of the

state-court order; it says only that it is vacating and remanding because it is “at the least unsure” whether the

state court used the term “insanity” in this way. Ante, at 

14. The majority cites two reasons for its uncertainty, but

both are weak. 

First, the majority attributes to the state court an interpretation of the term “insanity” that was advanced by the 

State in this Court in its brief in opposition to the petition

for certiorari. Ante, at 15. In that submission, the State 

argued that certiorari should be denied because petitioner

had sought relief in state court under the wrong provision

of state law, namely, Ala. Code §15–16–23 (2011), which

authorizes the suspension of the execution of an inmate 

who is “insane.” The State argued that petitioner’s 

memory loss did not render him “insane” within the meaning of this statute and that if he wished to argue that the 

Eighth Amendment bars the execution of an inmate who 

cannot remember his crime, he “should have filed a peti-
 

Cite as: 586 U. S. ____ (2019) 9 

ALITO, J., dissenting 

tion for post-conviction relief ” under Alabama Rule of 

Criminal Procedure 32.4. Brief in Opposition 11–12.

The majority’s argument based on the State’s brief in

opposition suffers from multiple defects. For one thing,

nothing suggests that the state court rejected petitioner’s

application on the ground that he invoked the wrong 

provision of state law; the State’s filing in the state court 

made no mention of the argument set out in its brief in

opposition filed here. Moreover, if the state court had 

rejected petitioner’s application on the ground that he

moved under the wrong provision of state law, it is doubtful that we could review that decision, for then it would 

appear to rest on an adequate and independent state-law 

ground. And to top things off, the majority’s argument

distorts what the State’s brief in opposition attempted to

say about the term “insane.” The State did not argue that 

a defendant who lacks a rational understanding of the

reason for his execution due to dementia is not “insane” 

under Ala. Code §15–16–23. Instead, the State’s point

was that a defendant is not “insane” in that sense merely 

because he cannot remember committing the crime for

which he was convicted. 

The majority’s other proffered basis for doubt is that the 

State “repeatedly argued to the [state] court (over Madison’s objection) that only prisoners suffering from delusional disorders could qualify as incompetent under Panetti.” 

Ante, at 16. The majority, however, cites no place where

the State actually made such an argument. To be sure, 

the State, in contending that petitioner was not entitled to

relief under Ford and Panetti, argued strenuously that he

was not delusional. (The State made this argument because petitioner’s counsel claimed that petitioner was in 

fact delusional and fell within Ford and Panetti for that 

reason.3) But arguing, as the State did, that petitioner 

—————— 

3Petitioner’s papers emphasized again and again that he suffers from 
 

 

 

10 MADISON v. ALABAMA 

ALITO, J., dissenting 

was not entitled to relief because the claim that he was 

delusional was untrue is not the same as arguing that

petitioner could be executed even if his dementia rendered 

him incapable of understanding the reason for his execution. The majority cites no place where the State made

the latter argument in the state court.4 And even if the 

—————— 

delusions. See Pet. for Suspension in No. CC–85–1385.80 (C. C. Mobile 

Cty., Ala., Feb. 12, 2016), p. 1 (“Mr. Madison has long suffered from 

serious mental illness, marked by paranoid delusions and other disabilities”); id., at 5 (“At Mr. Madison’s trial, Dr. Barry Amyx established 

that Mr. Madison suffers from a delusional disorder that has existed 

since he was an adolescent”); ibid. (“This well-documented history of

paranoia was one of the reasons Dr. Amyx concluded that Mr. Madison 

had a delusional disorder in a paranoid, really a persecutory type” 

(internal quotation marks omitted)); ibid. (“Dr. Amyx noted that Mr. 

Madison exhibited delusional thinking about . . . medication and 

believed that he was being used as a guinea pig in medical experiments”); id., at 6 (emphasizing a “more recent observation” that “ ‘Mr. 

Madison consistently presented with paranoid delusions’ ”); id., at 8 

(“Mr. Madison exhibited delusional and disoriented behavior in June

2015”); id., at 14 (“decades of delusional thinking and psychotropic

medications”); see also Pet. for Suspension in No. CC–85–1385.80 (C. C.

Mobile Cty., Ala., Dec. 18, 2017), pp. 6–7 (detailing similar statements). 

This line of argument fell apart when petitioner’s own expert testified

that he found no indication that petitioner was “[e]ither delusional or 

psychotic.” Tr. 56 (Apr. 14, 2016). 4Unable to cite any place where the State made this argument to the 

state court, the Court claims that the State did so in the Eleventh 

Circuit. Ante, at 6–7, n. 1. But even if that were so, it is hard to see 

what that would have to do with the question whether the state court 

thought that dementia could not satisfy the Ford/Panetti test. And in 

any event, the Court does not fairly describe the State’s argument in 

the Eleventh Circuit. The State’s Eleventh Circuit brief argued that 

merely suffering from a mental condition like dementia is not enough to 

render a prisoner incompetent to be executed; instead, the prisoner

must also establish that he lacks a rational understanding of the 

reason for his execution. See Brief for Appellee in No. 16–12279 

(CA11), pp. 37–38 (Brief for Appellee) (“The fairest reading of the state

court’s opinion is that it assumed that dementia and memory loss 

caused by strokes is a mental illness and went straight to the rational 

understanding question. Thus, it is not that the trial court refused to 
 

 

 

 

Cite as: 586 U. S. ____ (2019) 11 

ALITO, J., dissenting 

—————— 

consider Madison’s claims pertaining to dementia—Madison cannot 

point to any portion of the state court order that says this—it is that 

the trial court correctly noted that Madison failed to prove that any

dementia interfered with Madison’s ability to have a rational understanding of his execution, including the reasons therefor”); id., at 27 

(“The Supreme Court has not held that a petitioner can show incompetence without demonstrating a mental illness or that dementia and 

memory loss definitively preclude rational understanding”); id., at 29 

(“To the extent the state court followed the lead of the Supreme Court, 

this Court, and the ABA and required Madison to show that a mental

illness prevented him from having a rational understanding of his 

punishment, doing so was not an unreasonable application of clearly 

established federal law”). 

It is true that the State’s brief, in addressing the standard for 

granting federal habeas relief under 28 U. S. C. §2254(d), stated that 

this Court “ha[d] never held that dementia or memory loss is sufficient

to show a lack of rational understanding,” Brief for Appellee 29, but

that was because a claim under §2254(d) must be based on a clearly 

established Supreme Court holding. See Recording of Oral Arg. in No. 

16–12279 (CA11, June 23, 2016), at 32:37–33:30 (State rejecting a 

suggestion that Panetti holds “if you don’t remember committing the 

crime at all, and it is clear based on the medical testimony that you 

don’t remember committing this crime, then you don’t have a rational 

understanding of the factual basis for the imposition of the death 

penalty”: “First of all, under AEDPA deference, I think that that is not

the holding of Panetti. . . . I think under AEDPA deference, it’s pretty 

clear that the holding of Panetti is very narrow. . . . I would say the 

holding in Panetti is that documented mental illness that results in a 

delusion has to be considered when talking about rational understanding”); id., at 36:00–36:30 (“I think the Supreme Court has never held 

that not remembering something is equivalent to not having a rational 

understanding. I think that is just undeniably true. And if AEDPA 

deference applies, then I don’t think the state court could have been 

unreasonable in rejecting the view that memory is required”). The 

State did not argue either that dementia cannot satisfy Ford and 

Panetti or that the state court based its decision on that ground. On 

the contrary, Alabama wrote that “even if the trial court had determined that dementia and severe memory loss—or even total amnesia— 

are insufficient to meet the rational understanding test, that finding

would not contradict clearly established federal law.” Brief for Appellee

29; see also id., at 30 (“Even assuming the state court held, as a matter 

of law, that amnesia is not sufficient to show a lack of rational understanding, that determination was not unreasonable in light of clearly 
 

 

12 MADISON v. ALABAMA 

ALITO, J., dissenting 

State had made such an argument, what matters is the 

basis for the state court’s decision, not what counsel for 

the State wrote or said. 

I add one more comment regarding the majority’s uncertainty about the basis for the state-court decision: Our 

decision two years ago in Dunn evinced no similar doubts. 

There, we said that the state court “held that, under this 

Court’s decisions in Ford and Panetti, Madison was entitled to relief if he could show” that he lacks a rational 

understanding of the circumstances of his punishment.

583 U. S., at ___ (slip op., at 2) (quotation altered). And 

we said that the state court “determined that Madison is 

competent to be executed because—notwithstanding his

memory loss—he recognizes that he will be put to death as

punishment for the murder he was found to have committed.” Id., at ___ (slip op., at 4); see also ibid. (referring to

the state court’s “finding that Madison understands both 

that he was tried and imprisoned for murder and that

Alabama will put him to death as punishment for that 

crime”). Why the majority cannot now see what it understood without any apparent difficulty two years ago is 

hard to grasp. 

For all these reasons, what the Court has done in this 

case cannot be defended, and therefore it is hard to escape

thinking that the real reason for today’s decision is doubt

on the part of the majority regarding the correctness of the 

—————— 

established federal law”). 

The majority acknowledges that the State made this concededly

correct habeas argument, but then oddly writes it off as an “additional” 

or alternative argument. Ante, at 7, n. 1. Yet, as the State’s brief and 

oral argument illustrate, the State’s core contention was that the state

court did not unreasonably apply clearly established law under Panetti’s “very narrow” holding. (And as we later held in Dunn, the State 

was correct.) The majority simply cannot escape the inconvenient fact 

that the State never argued, as a non-AEDPA matter, that petitioner could be executed even if his dementia precluded a rational

understanding. 
 

 

Cite as: 586 U. S. ____ (2019) 13 

ALITO, J., dissenting 

state court’s factual finding on the question whether Madison has a rational understanding of the reason for his 

execution. There is no question that petitioner suffers

from severe physical and mental problems, and the question whether he is capable of understanding the reason for 

his execution was vigorously litigated below. But if the 

Court thinks it is proper for us to reach that question and

to reverse the state court’s finding based on a cold record, 

it should own up to what it is doing. 

* * * 

Petitioner has abandoned the question on which he 

succeeded in persuading the Court to grant review, and it

is highly improper for the Court to grant him relief on a

ground not even hinted at in his petition. The writ should 

be dismissed as improvidently granted, and I therefore

respectfully dissent.