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

I. INTRODUCTION 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 States7, 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 illness.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 wellbeing may very well violate ethical guidelines, and most assuredly negatively impacts the physician-patient relationship. …