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¶6 After the Supreme Court’s decisions in Thompson v. Oklahoma,18 it is probably unconstitutional to execute anyone for a crime committed while under 16.19 In any event, no state affirmatively permits execution of such youth.20 Twelve states and the federal government prohibit execution of people who are mentally retarded, an apparent trend;21 as recently as 1989 only two states did so.22 These prohibitions, based primarily on perceptions of culpability for the crime committed, exists independently of the eighth amendment bar, recognized in Ford, that prohibits execution of a person who is “incompetent” at the appointed time of execution.
¶7 In sharp contrast to the immunity from execution granted to children and people with mental retardation, no state prohibits execution of a person who was mentally ill at the time of the offense. The fourteenth amendment’s injunction requiring equal protection under the law is violated by this difference in treatment because there is no good reason for it; although, as noted in Part I, there are psychological differences between people with mental retardation and people with mental illness, there are no significant, legally relevant differences between these two groups, or between them and children. Thus, a state that does not treat all three groups similarly in terms of eligibility for execution is acting unconstitutionally.
¶16Due process of law is clearly lacking when the state fails to follow its own statutory provisions.58 If, contrary to the law in every death penalty state, mental illness is treated as an aggravating factor in the death sentence determination, a flagrant due process violation has occurred. For reasons developed below, acceptance of this proposition could be the basis for a prohibition on all death sentences for those who are mentally ill; at the least, it would invalidate many of them.
¶18 Roughly two-thirds of state capital sentencing statutes explicitly incorporate one or more of the mitigating factors found in the Model Penal Code,62 which lists, inter alia: (1) whether the defendant was suffering from “extreme mental or emotional disturbance” at the time of the offense (2) whether “the capacity of the defendant to appreciate the criminality [wrongfulness] of his conduct or to conform his conduct to the requirements of law was impaired as a result of mental disease or defect or intoxication”; and (3) whether “the murder was committed under circumstances which the defendant believed to provide a moral justification or extenuation of his conduct.”63 The first factor mimics the Code’s provocation formulation for reducing murder to manslaughter, minus the reasonableness requirement.64 The second factor uses the Code’s insanity defense language, but with the deletion of both the mental disease or defect predicate and the requirement that the incapacity be “significant.”65 The third factor invites a completely subjective analysis of the offender’s motivations. In short, the mitigating impact afforded to mental dysfunction under death penalty statutes is wide open, not even requiring a showing of mental illness as defined in this essay.
¶27 Although these arguments are substantial, two counter-arguments suggest that due process does not require a complete ban on death sentences for those with mental illness. First, one might make a distinction between situations where the mitigating and aggravating circumstances both go to culpability (as in Huckaby), and where the aggravating circumstance goes to something else (as in Miller). While a (mitigating) finding of extreme mental or emotional stress is hard to square with a finding that the killing was heinous (which Webster’s defines as “hatefully or shockingly evil”92), a conclusion that a person’s mental illness makes him less blameworthy but more dangerous is not necessarily incoherent.93 Second, the potential for improper use of mental illness is presumably not realized in every case. After all, many mentally ill capital defendants are not sentenced to death, which suggests that evidence of a defendant’s mental illness is not always the cause of those death sentences that are imposed.
¶28 As a way of dealing with these various concerns, the following proposal, which builds on one made by Ellen Berkman,94 should be considered as a way of providing due process of law to mentally ill capital defendants. The defendant would be required to raise a reasonable doubt that, but for evidence of mental illness, a particular aggravating circumstance would not have been found. It would then be up to the prosecution either to show beyond a reasonable doubt that mental illness is unrelated to that factor or to convince the court that the aggravator may justifiably be the consequence of mental illness. Although this proposal does not completely remove the defense attorney’s dilemma described above, it will give the attorney some idea of when evidence of mental illness can be used to best advantage, especially after appellate courts clarify which, if any, aggravating circumstances may be based on mental illness.
¶29 Ford v. Wainright’s holding that the eighth amendment bars execution of a person who is incompetent left two significant questions unanswered: What is the rationale for the competency requirement, and what is the content of the competency standard? The response to the first question determines the answer to the second. If, as this essay argues, the most plausible basis for the competency requirement is society’s interest in retribution, then the standard defining competency to be executed is not as low a threshold as many have suggested, and a significant number of mentally ill people on death row today do not meet it.
¶34 That this standard has teeth is demonstrated by the case of Horace Kelly, recently found competent by a California jury. The jury concluded that Kelly was able to describe both the consequence of the death penalty (death) and why he deserved it (he killed two woman and an 11 year-old boy).104 Thus he met the austere version of Justice Powell’s test. But under a competency standard properly informed by the retributive premise, he should not have been found competent to be executed. The evidence indicated that Kelly, who was both mentally retarded and mentally ill, talked in rambling and incoherent sentences, thought that his mother would eventually take him home after one of her visits, and from time to time believed prison was a college.105 Kelly had a shallow cognitive understanding of his legal situation, but comprehended neither the enormity of his punishment or the societal condemnation associated with it.
¶36 There are several reasons why the U.S. Supreme Court may ultimately reject this reasoning. It could easily find, for instance, that the state’s interests in meting out a justly imposed sentence and deterring malingering outweigh the extra indignity that forcible medication visits on the mentally ill offender.110 Moreover, offenders who refuse medication, on their own or through their attorneys, probably do so primarily to avoid execution (rather than, for instance, out of a desire to avoid the side effects of medication); if so, the individual interest to be balanced against the state’s is entitled to virtually no weight. Finally, and most importantly, if the basis for the competency requirement is society’s interest in retribution, the individual’s interests should count for little or nothing in any event.
¶39 Most mentally ill people who are convicted on capital charges should not be executed, for one of three reasons. First, such executions would violate equal protection of the laws in any jurisdiction in which execution of children and people with mental retardation is barred. Second, many death sentences imposed on people with mental illness violate due process because their mental illness is treated by the factfinder as an aggravating factor, either directly or to bolster a separate aggravating circumstance. Third, many mentally ill offenders who are sentenced to death will be so impaired at the time of execution that they can not emotionally appreciate the significance of their punishment and thus cannot be executed under the eighth amendment; the latter conclusion is required even if they are restorable through treatment, given the unethical and medically inappropriate role in which such treatment casts mental health professionals.
1. Stephen C. O’Connell Professor of Law, University of Florida Fredric G. Levin College of Law. I would like to thank Jonathan Cohen, James Ellis, and Michael Radelet for their comments on this essay.
2. Compare MICHAEL PERLIN, THE JURISPRUDENCE OF THE INSANITY DEFENSE 38-39 (1994)(depicting medieval views) with Amerigo Farina et al., Role of Stigma and Set in Interpersonal Interaction, 71 J. ABNORMAL PSYCHOLOGY 421 (1966)(mentally ill persons described as less desirable friends and neighbors than criminals).
3. See generally GARY MELTON Et Al., PSYCHOLOGICAL EVALUATIONS FOR THE COURTS: A HANDBOOK FOR MENTAL HEALTH PROFESSIONALS AND LAWYERS 190-93 (2d ed. 1997).
4. These range from the crusades of Dorothea Dix in the late nineteenth century (see ALBERT DEUTSCH, THE MENTALLY ILL IN AMERICA: A HISTORY OF THEIR CARE AND TREATMENT FROM COLONIAL TIMES 131 (2d ed. 1949)), to system-wide litigation championing treatment rights for people with mental illness (see Wyatt v. Stickney, 344 F.Supp. 373 (1972).
5. See infra text accompanying notes 58-64.
6. 477 U.S. 399 (1986).
7. This essay will, in essence, define “mental illness” as psychosis. See infra Part I. A survey of 15 adult death row inmates found that 40% (six) were chronically psychotic (evidencing, e.g., loose, illogical thought processes, delusions and hallucinations). Dorothy O. Lewis et al., Psychiatric, Neurological, and Psychoeducational Characteristics of 15 Death Row Inmates in the United States, 143 AM. J. PSYCHIATRY 838, 840 (1986). A survey of 40% of the juvenile population on death row in the U.S. found that 50% (seven out of 14) suffered from psychosis. Dorothy O. Lewis, et al., Neuropsychiatric, Psychoeducational, and Family Characteristics of 14 Juveniles Condemned to Death in the United States, 145 AM. J. PSYCHIATRY 584, 585 (1988). According to one confidential source in the Florida Department of Corrections, as of December, 1999, approximately 5% of the 369 inmates on death row suffer from some sort of psychosis.
8. See infra text accompanying notes 66-83.
12. Psychosis has been defined as “[a] severe mental disorder characterized by gross impairment in reality testing, typically shown by delusions, hallucinations, disorganized speech, or disorganized or catatonic behavior.” AMERICAN PSYCHIATRIC ASSOCIATION, AMERICAN PSYCHIATRIC GLOSSARY 175 (7th ed. 1994).
13. See generally, AMERICAN PSYCHIATRIC ASSOCIATION, DIAGNOSTIC AND STATISTICAL MANUAL 151-52 (dementia due to general medical conditions); 285-86 (schizophrenia); 301 (delusional disorder); 332 (manic disorder)(4th ed. 1994)(hereinafter DSM-IV).
14. Id. at 633 (general definition); 637-38 (paranoid); 645 (schizotypal); 649-50 (antisocial); 654 (borderline) & 612 (intermittent explosive).
16. One estimate is that roughly 30% of those who suffer from mental retardation also suffer from mental illness. FRANK MENOLASCINO, CHALLENGES In MENTAL RETARDATION: PROGRESSIVE IDEOLOGY AND SERVICES 126-27 (1977). It should be noted that the American Psychiatric Association’s treatment of mental retardation as a “disorder” akin to mental illness has been rejected by at least one body of mental retardation professionals. See AMERICAN ASSOCIATION OF MENTAL RETARDATION, CLASSIFICATION IN MENTAL RETARDATION (Herbert Grossman ed. 1983).
17. See, e.g., infra note 51 and accompanying text and note 102.
18. 487 U.S. 815 (1988).
19. Justice O’Connor, one of the five-member majority voting to prohibit such executions, rested her decision on the ground that offenders younger than 16 “may not be executed under the authority of a capital punishment statute that specifies no minimum age at which the commission of a capital crime can lead to the offender’s execution.” 487 U.S. at 857-58 (O’Connor, J., concurring). Thus, if a state explicitly permitted execution of 15 year-olds, she might permit it. At present, there are no such statutes. 487 U.S. at 829.
21. Denis W. Keyes et al., Mental Retardation and the Death Penalty: Current Status of Exemption Legislation, 21 MENTAL & PHYSICAL DISABILITY L. REP. 687 (1997).
22. Jamie Marie Billotte, Is It Justified?–The Death Penalty and Mental Retardation, 8 NOTRE DAME J. L., ETHICS & PUB. POL’Y. 333, 333-34 (1994).
23. 509 U.S. 312 (1993).
25. Schweiker v. Wilson, 450 U.S. 221, 235 (1981).
26. JOHN E. NOWAK & RONALD D. ROTUNDA, CONSTITUTIONAL LAW 601 (5th ed. 1995).
29. Although the Court canvassed a number of reasons given by City for its decision, most boiled down to a fear of people with mental retardation, to which the Court responded, “mere negative attitudes, or fear, unsubstantiated by factors which are properly cognizable in a zoning proceeding, are not permissible bases for treating a home for the mentally retarded differently from apartment houses, multiple dwellings, and the like.” Id . at 448.
32. LAURENCE TRIBE, AMERICAN CONSTITUTIONAL LAW 1443-46 (2d ed. 1988).
33. Id.; Gayle Lynn Pettinga, Rational Basis With Bite: Intermediate Scrutiny By Any Other Name, 62 IND. L.J. 779, 793-99 (1987); WILLIAM B. LOCKHART Et Al, CONSTITUTIONAL LAW: CASES– COMMENTS –QUESTIONS 1161 62 (8th ed. 1996).
34. 509 U.S. 312, 319.
35. Cf. William M. Wilson, III, Romer v. Evans: "Terminal Silliness," or Enlightened Jurisprudence?, 75 N.C. L. REV. 1891, 1931 (1997)(describing how the Court’s decision in Romer v. Evans, 517 U.S. 620 (1996), striking down a Colorado constitutional provision that prohibited protective legislation for gays, “may have loaned more credence to a standard of review that it specifically disavowed in Heller”); Alfonso Madrid, Comment–Rational Basis Review Goes Back to the Dentist’s Chair: Can the Toothless Test of Heller v. Doe Keep Gays in the Military?, 4 TEMP. POL. & CIV. RTS. L. REV. 167, 192 (1994)(distinguishing Cleburne from Heller in part because the facts of Heller “do not demonstrate the blatant discrimination that was apparent in Cleburne”). Note also that Cleburne cannot be distinguished from Heller on the ground that the latter case, like the context at issue here, involved discrimination between two mentally disabled groups; such a conclusion would be tantamount to saying race is not a suspect classification when the government discriminates between two minority races.
36. Rehabilitation, often listed as the fourth purpose of punishment, obviously does not apply in this context.
37. Michael L. Perlin, The Supreme Court, the Mentally Disabled Criminal Defendant, and Symbolic Values: Random Decisions, Hidden Rationales, or “Doctrinal Abyss?”, 29 ARIZ. L. REV. 1, 98 (1987)(the fear of successful deception by people feigning mental illness has “permeated the American legal system for over a century.”).
38. Psychotropic medication has been quite successful at eliminating psychotic symptomatology within a few weeks, whereas habilitation of people with mental retardation is a slow process. Compare HAROLD I. KAPLAN & BENJAMIN J. SADOCK, COMPREHENSIVE TEXTBOOK OF PSYCIATRY 990 (6th ed. 1989)(response time to medication is four to five weeks) with AMERICAN PSYCHIATRIC PRESS, TEXTBOOK OF PSYCHIATRY 710-11 (John A. Talbott, et al. 1988)(discussing need for “long-term” programs for those with mental retardation).
39. Research suggests that jurors consider the defendant’s ability to obtain treatment relevant to the viability of an insanity defense. Norman J. Finkel & Christopher Slobogin, Insanity, Justification, and Culpability: Toward a Unifying Schema, 19 L. & HUM. BEH. 447, 458 (1995).
40. As two experts on people with mental retardation have stated, “the cardinal difference [between retardation and mental illness] is that . . . [m]entally ill people encounter disturbances in their thought processes and emotions; mentally retarded people have limited abilities to learn.” James W. Ellis & Ruth A. Luckasson, Mentally Retarded Criminal Defendants, 53 GEO. WASH. L. REV. 414, 424 (1985). With children, it is as much the opportunity as the ability to learn that is diminished.
41. That is certainly the public’s perception. See, e.g., Bernice A. Pescosolido et al., The Public’s View of the Competence, Dangerousness, and Need for Legal Coercion of Persons with Mental Health Problems, 89 AM J. PUB. HEALTH 1339, 1341 (1999)(reporting that, while 17% of a random sample of citizens felt that the a “troubled person” was “very likely” or “somewhat likely” to be violent, 33.3% said the same of the depressed person, and 60% said the same of a person with schizophrenia). A fifth possible argument is that, because of the greater likelihood they will confess to crimes they did not commit, people with mental retardation are more likely to be victims of miscarriages of justice. Cf. ROBERT PERSKE, UNEQUAL JUSTICE (1991). That argument, however, is logically relevant only to whether conviction should be overturned, not to whether the death penalty ought to be imposed.
42. See DSM-IV, supra note 13, at 39-40 (“there is a measurement error of approximately 5 points in assessing IQ” and “impairments in adaptive functioning [a relatively amorphous construct], rather than a low IQ, are usually the presenting symptoms in individuals with Mental Retardation.”).
43. 509 U.S. 312, 322.
44. For a related argument, see John J. Gruttadaurio, Consistency in the Application of the Death Penalty to Juveniles and the Mentally Impaired: A Suggested Legislative Approach, 58 U. CINN. L.REV. 211, 236 (1989).
45. Professor Perlin asserts that “there is virtually no evidence that feigned insanity has ever been a remotely significant problem of criminal procedure, even after more `liberal’ substantive insanity tests were adopted. A survey of the case law reveals no more than a handful of cases in which a defendant free of mental disorder `bamboozled’ a court or jury into a spurious insanity acquittal.” PERLIN, supra note 2, at 238. He also notes that research on malingering among offenders indicates that most inmates feign sanity, not insanity, id. at 240-42 & n.48, and that advances in detection of malingering can discern faking in over 90% of the cases when it does occur. Id. at 239-40.
46. David Wexler, Inducing Therapeutic Compliance through the Criminal Law, 14 L. & PSYCHOLOGY REV. 43, 50-52 (1990)(discussing hypothetically the scenario in which a person with mental illness engages in “reckless endangerment” by refusing medication that will curb dangerous propensities). Note that in the analogous situation involving lack of mens rea due to substance abuse, the law has traditionally recognized a defense for first degree murder, although if a person drinks (or fails to seek medication) with the purpose of making crime easier, then such culpability might be present. See generally, Paul Robinson, Causing the Condition of One’s Own Defense: A Study in the Limits of Theory in Criminal Law Doctrine, 71 VA. L. REV. 1 (1985). See also, Robert Pear, Few Seek to Treat Mental Disorders, a U.S. Study Says, N.Y TIMES, Dec. 13, 1999 at A1 (study shows that most people with mental disorder never seek treatment because they “do not realize that effective treatments exist, . . . they fear discrimination because of the stigma attached to mental illness [or they] cannot afford treatment because they lack insurance that would cover it.”).
47. Ellis & Luckasson, supra note 40, at 430 & 439 (“Many mentally retarded individuals expend considerable energy attempting to avoid this stigma,” even though “proper teaching can equip most retarded persons to tailor their actions to social expectations”).
48. HOWARD N. SNYDER & M. SICKMUND, JUVENILE OFFENDERS AND VICTIMS: 1999 NATIONAL REPORT (1999)(40% of males with a violent career and 34% of females come into contact with the justice system prior to age 13).
49. DSM-IV, supra note 13, at 40.
50. A person with schizophrenia has at least two of the following five symptoms: delusions (fixed false beliefs); hallucinations; disorganized speech (e.g., frequent derailment or incoherence); grossly disorganized or catatonic behavior; “negative symptoms”, i.e., affective flattening (emotionlessness), alogia (a high degree of speechlessness) or avolition (lack of objectives). DSM-IV, supra note 13, at 285. A person with “mild” mental retardation, although less developed intellectually, is “educable,” “develops social and communication skills during the preschool years,” has “minimal impairment in sensorimotor areas,” acquires academic skills up to approximately the sixth-grade level by the late teens, and “during [the] adult years usually achieve[s] social and vocational skills adequate for minimum self-support, but may need supervision, guidance, and assistance, especially when under unusual social or economic stress.” Id. at 41. Both groups obviously fall short in terms of capabilities when compared to normal teenagers (13 and over), and even to many pre-teens.
51. Id. at 637 (one symptom of paranoid personality disorder is reading “hidden demeaning or threatening meanings into benign remarks or events”) & 654 (a symptom of borderline personality disorder can be “transient, stress-related paranoid ideation or severe dissociative symptoms”).
52. Cf. Woodson v. North Carolina, 428 U.S. 280, 304 (1976)(“A process that accords no significance to relevant facets of the character and record of the individual offender or the circumstances of the particular offense excludes from consideration in fixing the ultimate punishment of death the possibility of compassionate or mitigating factors stemming from the diverse frailties of humankind”).
55. James Bonta et al., The Prediction of Criminal and Violent Recidivism Among Mentally Disordered Offenders: A Meta-Analysis, 123 PSYCHOL. BULL. 123 (1998); Marnie Rice & Grant Harris, The Treatment of Mentally Disordered Offenders, 3 PSYCHOL., PUB. POL’Y. & L. 126, 132 (1997)(“[W]hen compared with other criminal or psychiatric patients, there is evidence that those who have a major mental illness may be less likely to commit another criminal or violent offense upon release.”).
56. Compare supra notes 50 & 51 with Ellis & Luckasson, supra note 40, at 426 (“The best modern evidence suggests that the incidence of criminal behavior among people with mental retardation does not greatly exceed the incidence of criminal behavior among the population as a whole.”); EMILY F. REED, The PENRY PENALTY: CAPITAL PUNISHMENT AND OFFENDERS WITH MENTAL RETARDATION 17 (1993)(describing data showing a link between mental retardation and crime) and SNYDER & RICKMUND, supra note 48, at 62 (nationally, juveniles committed 27% of violent victimizations). This latter fact supports the point in the text when juxtaposed with the facts that virtually all serious crimes committed by juveniles were by children between the ages of 10 and 18, id. at 54 & 13, a group which comprises only 12.8% of the population. STATISTICAL ABSTRACTS OF THE UNITED STATES 16 (1998) (table showing that ages 10 through 17 constituted 32.64 million out of a total 267.637 million).
57. “It is true . . . that the mentally retarded as a group are indeed different from others not sharing their misfortune . . . . But this difference is largely irrelevant unless [they] threaten legitimate interests of the city . . . .” 473 U.S. 432, 448.
58. “[With respect to] the nature of the `process’ that is `due’, [i]n all instances the state must adhere to previously declared rules for adjudicating the claim or at least not deviate from them in a manner which is unfair to the individual against whom the action is to be taken.” Nowak & Rotunda, supra note 26, at 511.
59. See Ellen Fels Berkman, Mental Illness as an Aggravating Circumstance in Capital Sentencing, 89 COLUM. L. REV. 291, 296-98 (1989).
60. 438 U.S. 586 (1978).
61. Id. at 604 (emphasis in original). See also, Eddings v. Oklahoma, 455 U.S. 104 (1982) (holding that trial court’s refusal to consider an offender’s emotional problems violated the eighth and fourteenth amendments).
62. Berkman, supra note 59, at 298.
63. See AMERICAN LAW INSTITUTE, MODEL PENAL CODE § 210.6(4).
64. Compare id. at § 210.3(1)(b).
65. Compare id. at § 4.01(1).
66. Gary Goodpaster, The Trial for Life: Effective Assistance of Counsel in Death Penalty Cases, 58 N.Y.U. L. REV. 299, 332 (1983)(“much of the defense evidence which would be presented at the guilt phase, such as evidence of diminished capacity or insanity, also may be presented at the penalty phase in mitigation.”).
67. Note, A Study of the California Penalty Jury in First-Degree-Murder Cases, 21 STAN. L. REV. 1297 (1969).
68. DAVID BALDUS Et Al., EQUAL JUSTICE AND THE DEATH PENALTY 644, 645 (1990)(two tables, each looking at 15 factors but using different statistical models, showing that assertion of a defense of “insanity or delusional compulsion” correlated with a death sentence at an extremely high level of statistical significance; p $ .0000).
69. Id. See also id. at 640-41 (table depicting almost 50 factors, with assertion of an insanity defense showing a correlation coefficient below only number of aggravating factors; scientific evidence other than ballistics or medical evidence involved; kidnapping involved; or killing motivated by desire to avoid arrest).
70. David Baldus et al., Racial Discrimination and the Death Penalty in the Post-Furman Era: An Empirical and Legal Overview, with Recent Findings from Philadelphia, 83 CORNELL L. REV. 1638, 1688-89 (1998)(Table 6).
71. Id. at 1689. The factor was significant at the .10 level; social science convention is to accord statistical significance only to factors that reach the .05 level. See JOHN MONAHAN & LAURENS WALKER, SOCIAL SCIENCE IN LAW 78 (1994).
72. Julie Goetz & Gordon P. Waldo, Why Jurors in Florida Vote for Life or Death: The Florida Component of the Capital Jury Project, presented at the conference on Life Over Death XV, Ft. Lauderdale, Fl., September 27, 1996, at 34.
73. Lawrence T. White, Juror Decision Making in the Capital Penalty Trial: An Analysis of Crimes and Defense Strategies, 11 L. & HUM. BEH. 113, 125 (1987).
74. Wainright v. Witt, 469 U.S. 412 (1985).
75. Phoebe C. Ellsworth et al., The Death-Qualified Jury and the Defense of Insanity, 8 L. & HUM. BEH. 81 (1984).
77. Stephen P. Garvey, The Emotional Economy of Capital Sentencing, ___ N.Y.U. L.REV. ___ (forthcoming 2000).
78. Id. at ___ (tbls. 9 & 8).
79. Id. at ___ (text accompanying notes 25 & 26).
80. Consistent with the lay distinctions discussed in Part II, Garvey also found that, while jurors were “more likely to have felt sympathy or pity for the defendant” both when a defendant was mentally retarded and when he was “emotionally unstable or disturbed,” they were more likely to be simultaneously “disgusted or repulsed” only by the latter type of defendant. Id. at ___ (tbl. 7).
81. Several researchers with the Capital Jury Sentencing Project, which involved interviewing people who sat on capital juries, have observed that dangerousness is the paramount concern of most capital sentencing jurors regardless of their jurisdiction’s law on the matter. See, e.g., Austin Sarat, Violence, Representation, and Responsibility in Capital Trials: The View from the Jury, 70 IND. L.J. 1103, 1131-33 (1995); Joseph L. Hoffmann, Where’s the Buck?–Juror Misperception of Sentencing Responsibility in Death Penalty Cases, 70 IND. L.J. 1137, 1153 (1995); James Luginbuhl & Julie Howe, Discretion in Capital Sentencing Instructions: Guided or Misguided?, 70 IND. L.J. 1161, 1178-79 (1995)(tbls. 5, 6); Marla Sandys, Cross-Overs–Jurors Who Change Their Minds About the Punishment: A Litmus Test for Sentencing Guidelines, 70 IND. L.J. 1183, 1199-1200, 1216-17 (1995). See also, William J. Bowers, The Capital Jury Project: Rationale, Deign, and Preview of Early Findings, 70 IND. L.J. 1043, 1091 (1995)(tbl. 7)(32% of capital-sentencing jurors accept the clearly erroneous premise that the death penalty must be imposed if the defendant is dangerous).
82. See Bruce Link & Ann Stueve, New Evidence on the Violence Risk Posed by People with Mental Illness, 55 ARCH. GEN. PSYCHIATRY 403 (1998)(“There is a widespread belief among the American public that people with mental illness pose a significant violence risk [and] the prevalence of this belief seems to have increased since the 1950s . . . . To date, nearly every modern study indicates that public fears are way out of proportion to the empirical reality.”); John Monahan, Mental Disorder and Violent Behavior: Perceptions and Evidence, 47 AM. PSYCHOLOGIST 511, 511 (1992)(discussing, inter alia, how public fears about the purported link between mental illness and dangerousness “drive the formal laws and policies governing mental disability jurisprudence”); Gregory Leong et al., Dangerous Mentally Disordered Criminals: Unresolvable Societal Fear? 36 J. FORENS. SCI. 210, 215 (1991); Pescosolido et al., supra note 41, at 1343 (“After control for the nature of the problem and evaluation of case severity, respondents reported . . . increased expectations of violence if they labeled the vignette person as having a mental illness.”).
83. Cf. Lawrence T. White, The Mental Illness Defense in the Capital Penalty Hearing, 5 BEH. SCI. & L. 411, 419 (1987)(concluding that research suggests that the reason mental illness defenses at the capital sentencing phase are ineffective is because, inter alia, the evidence leads the jurors to believe the defendant has a high probability of future dangerousness).
84. 462 U.S. 862 (1983).
85. Id. at 885 (emphasis added).
86. See James S. Liebman & Michael J. Shepard, Guiding Capital Sentencing Discretion Beyond the “Boiler Plate”: Mental Disorder as a Mitigating Factor, 66 GEO. L.J. 757, 791-806 (1978)(describing the prevalent mitigating role that mental disorder has played in the law of capital punishment).
87. 343 So.2d 29 (Fla. 1977).
89. 373 So.2d 882 (Fla. 1979).
91. See Randy Hertz & Robert Weisberg, In Mitigation of the Penalty of Death: Lockett v. Ohio and the Capital Defendant’s Right to Consideration of Mitigating Circumstances, 69 CALIF. L.REV. 317, 333, 340-41 (1981).
92. WEBSTER’S NEW COLLEGIATE DICTIONARY (1998).
93. Cf. Penry v. Lynaugh, 492 U.S. 302, 323-24 (1989); State v. Gretzler, 135 Ariz. 42, 659 P.2d 1 (1983). Of interest on this score, however, is that Zant cited Miller in the course of its suggestion that mental illness could not be used as an aggravating circumstance. 462 U.S. 862, 885. Furthermore, several states do not permit dangerousness to be considered as an aggravating factor. Christopher Slobogin, Should Juries and the Death Penalty Mix?A Prediction about the Supreme Court’s Answer, 70 IND. L.J. 1249, 1264 n. 56 (1995). In those states, the argument can be made that, given the strong tendency to think of people with mental illness as dangerous, any death sentence imposed on such people is likely to be illegitimate.
94. See Berkman, supra note 59, at 305-08.
95. 3 E. COKE, INSTITUTES 6 (6th ed. 1680).
96. 477 U.S. 399, 406-11.
99. See, e.g., Geoffrey C. Hazard Jr. & David W. Louisell, Death, the State, and the Insane: Stay of Execution, 9 UCLA L. REV. 381 (1962); Barbara A. Ward, Competency for Execution: Problems in Law and Psychiatry, 14 FLA. ST. U. L. REV. 35, 48-57 (1986).
100. 477 U.S. 399, 420.
101. For a skeptical assessment of the death penalty’s deterrent value, based on an analysis of the data up to that time, see NATIONAL ACADEMY OF SCIENCE, PANEL ON RESEARCH ON DETERRENT AND INCAPACITATIVE EFFECTS, DDETERRENCE AND INCAPACITATION: ESTIMATING THE EFFECTS OF CRIMINAL SANCTIONS ON CRIME RATES (Alfred Blumstein et al. eds., 1978).
102. See Hazard & Louisell, supra note 99, at 387; Ward, supra note 99, at 56 (This article also puts forward a “nontraditional”, “tacit clemency” rationale to the effect that the competency requirement is an indication of our ambivalence toward the death penalty. Id. at 56) . See also Michael Radelet & George Barnard, Ethics and the Psychiatric Determination of Competency to be Executed, 14 BULL. AM. ACAD. PSYCHIATRY & L. 37, 39 (1986)(“the exemption [of the incompetent] can be understood if . . . the primary goal of capital punishment is retribution.”).
103. Musselwhite v. State, 60 So.2d 807, 809 (Miss. 1952). Professor Ward objects that this standard “would automatically exempt sociopaths from execution as well as inhumanely require the obliteration of psychological coping mechanisms.” Ward, supra note 99, at 68. While the standard might mandate an incompetency finding for some people with antisocial personality disorder (the modern version of sociopathy), it does not require remorse for the crime (a feeling this type of person often lacks), only an appreciation of the penalty. And, if one agrees with the argument made below that people may not be forcibly restored to competency, “coping mechanisms” with respect to the death penalty will be rendered irrelevant, although “obliterating” them in someone who is about to be executed is arguably no more inhumane than executing someone who has no such mechanisms.
104. Bob Egelko, Federal Court Blocks Killer's Execution: New Hearing Ordered on Right to Appeal, ORANGE COUNTY PRESS, June 10, 1998, at A04 (Marin County Superior Court jury approved Kelly’s execution on a 9 3 vote, finding that he was aware he was about to be executed and why).
105. Victoria Slind-Flor, Is Convict Sane Enough to Execute? THE NATIONAL LAW JOURNAL, April 20, 1998, at A8 (col. 1). See also, Death Row Inmate Horace Kelly Gets Go-Ahead for New Hearing, THE SAN FRANCISCO CHRONICLE, June 27, 1998 at A24.
107. 494 U.S. 210 (1990).
108. State v. Perry, 610 So.2d 746 (La. 1992).
109. Id. at 761. The court also based its decision on Louisiana’s privacy provision, id. at 755-61, and, as discussed below, the notion that forcible medication in this context violates professional ethical constraints.
110. Virtually every court which has considered the matter allows forcible medication of criminal defendants to restore their competency to stand trial. MICHAEL PERLIN, MENTAL DISABILITY LAW § 14.09 (1989 & 1997 supp). Cf. Riggins v. Nevada, 504 U.S. 127 (1992) (holding that the state may not overmedicate a criminal defendant in its attempts to restore competency to stand trial, but refusing to address whether appropriately titrated medication may be forced on an incompetent defendant).
111. 610 So.2d 746, 754.
112. Id. at 751. The Court also noted: “[T]he forcible medication of a prisoner merely to improve his mental comprehension as a means of rendering him competent for execution actually prevents the prisoner from receiving adequate medical treatment for his mental illness.” Id. at 752. See also, David L. Katz, Perry v. Louisiana: Medical Ethics on Death Row Is Judicial Intervention Warranted?, 4 GEO. J. LEGAL ETHICS 707 (1991).
113. This maxim comes from the Hippocratic Oath, which has been called “the most important rule in practice” from the perspective of the doctor-patient relationship. V. TAHKA, THE PATIENT-DOCTOR RELATIONSHIP 38 (1984).
115. This line of reasoning could extend to other types of professional involvement in capital cases, such as testimony and evaluation. However, these latter roles merely provide the state with information relevant to the decision to execute, whereas “the express purpose of competency treatment is to guarantee that the patient will be killed. Each treatment strategy to heal the inmate is in fact another strategy to ensure his death.” Rochelle Graff Salguero, Medical Ethics and Competency to be Executed, 96 YALE L.J. 167, 178-79 (1986). This reasoning might also bar treatment even of the consenting offender; here, however, both ethical rules and the doctrine of informed consent may require the doctor to follow the wishes of the autonomous patient. See generally, Richard J. Bonnie, Dilemmas in Administering the Death Penalty: Conscientious Abstention, Professional Ethics, and the Needs of the Legal System, 14 L.& HUM. BEH. 67, 81-82 (1990); Heilbrun et al., supra note 114, at 601.
116. See Trop v. Dulles, 356 U.S. 86, 100-101 (1958)(“The basic concept underlying the Eighth Amendment is nothing less than the dignity of man. While the State has the power to punish, the Amendment stands to assure that this power be exercised within the limits of civilized standards. . . . The Amendment must draw its meaning from the evolving standards of decency that mark the progress of a maturing society.”).
117. Maryland commutes the incompetent person’s death sentence to a life sentence without parole, Md. Ann. Code art. 27 § 75A(d)(3), although it is unclear whether a person who can be restored to competency is considered incompetent under the statute. See Perry, 610 So.2d 770-71. Cf. Michael L. Radelet & George W. Barnard, Treating Those Found Incompetent for Execution: Ethical Chaos with Only One Solution, 16 BULL. AM. ACAD. PSYCHIATRY L. 297 (1988) (recounting professionals’ ethical difficulties in dealing with the treatment issue and concluding that commutation is the only solution).

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