Psychiatric Issues Leave Court in a State of Mental Disorder

In a series of decisions concerning the rights of mentally disordered persons, the U.S. Supreme Court has demonstrated a disquieting confusion of scientific and moral issues. Although the court routinely questions the scientific status of psychiatry --in cases involving involuntary hospitalization and the rights of hospital patients, for example--it simultaneously grants unjustified power to mental-health professionals to influence and even to decide non-psychiatric questions involving fundamental liberties and dignity.

In its latest example, Ford vs. Wainwright, the court held that it is unconstitutional to execute a prisoner who had been fairly convicted of a capital crime and sentenced to death but had become insane at the time of execution.

While the court did not dictate the exact nature of the proceeding required to determine a prisoner’s competence to be executed, it assumed that the question was largely one of psychiatric fact that required extensive psychiatric input for resolution. Justice Lewis F. Powell Jr. suggested that the decision could be placed in the hands of psychiatric decision-makers rather than judges or other laypersons.

But deciding who is competent to be executed, like deciding who is legally insane or who should be involuntarily committed, is not primarily a psychiatric or medical issue.

Rather, it is a moral, social, political and ultimately a legal issue that should be recognized and decided as such. After all, concern for human dignity--the underlying rationale for not executing the insane--is clearly a moral and political value that long antedates modern psychiatry.

In a pluralistic and democratic society, judges and juries--the moral and social representatives of society--should decide these issues. Although mental-health professionals, educated and skilled as they are, could be consulted on the decision-making process, their views should not be the final word on a case. They are neither representatives of society as a whole nor experts on moral and legal issues.

Consider, too, the test for competence. Today the most common standard that states have adopted to decide if a prisoner is too insane to execute--a standard that the majority of the court seems to accept--is whether the condemned person understands the punishment that he or she is about to suffer, and why he or she is to suffer it. But deciding how much understanding is sufficient to execute is again a moral and political question, not a mental-health issue. For example, a “tough” jurisdiction or decision-maker might execute anyone with any glimmer of understanding, whereas a “tender” jurisdiction or decision-maker might require quite substantial understanding before allowing the imposition of capital punishment.

Disentangling psychiatric and non-psychiatric questions would encourage more rational legal decision-making. For example, misconceptions about medical and moral issues cause the court to confuse disputes about factual issues, such as what a defendant understood, with disputes about legal/moral issues, such as whether that degree of understanding is sufficient to warrant execution.

Here, mental-health professionals should surely be encouraged to help us understand factually what a prisoner understands about his punishment. This would help the decision-maker decide if a person who has that degree of understanding also meets the legal/moral standard needed for execution. But irrelevant and confusing disputes about diagnosis and the mental-health professionals’ non-expert and distracting opinions on the ultimate legal issues could be avoided.

Deciding who will be executed, held non-responsible for crime or locked up in a mental hospital involves moral and political issues of dignity, responsibility and liberty. Such decisions are far too important to be considered technical and delegated to experts. By obscuring the distinction between medical and moral issues, the law abdicates its responsibility to face hard issues squarely and reflects a magical belief that there are scientific or medical “answers” to non-scientific questions.

The Supreme Court, legislators and others should resist the ever-increasing tendency to adopt misguided scientific “fixes” by deferring moral decisions to experts, and should limit mental-health professionals to providing legally relevant, scientific and clinical information.