Competency and Dementia

Anyone who has watched a police procedural like Law and Order knows what a competency evaluation is, but few have seen it applied in a real-world context. Generally, a competency evaluation occurs before a trial begins and is usually defined as a defendant’s ability to understand the charges against them and assist in their own defense. Either the prosecution or defense can question the defendant’s competency, which leads to a hearing in which one or more doctors testify about the patient’s condition. If the court finds the victim incompetent, he/she is  institutionalized to determine if cognitive capacity can be restored. The length of institutionalization cannot exceed the maximum sentence of the alleged crime, but doctors are allowed to medicate unwilling defendants if they believe it will facilitate their competency restoration and, occasionally, extend the length of confinement if the individual is a danger to themselves or to the public.

Competency is sometimes confused for the insanity defense, but these two terms refer to the defendant’s mental state at two different periods. Competency refers to the defendant’s cognitive abilities at the time of trial.  By contrast, insanity, or criminal responsibility, refers to the mental state the defendant had while committing the alleged crime. Competency can, in some cases, be restored; criminal responsibility cannot. However, with the case of Vernon Madison, the Supreme Court has now ruled that competency can wane and, when it does, the conditions of one’s sentence may change.

Madison was serving time on death row in Alabama for the 1985 murder of a police officer. Madison’s case is interesting for a number of reasons: first, he actually had three trials but the first two convictions were overturned due to prosecutorial misconduct. Second, in his final trial, the jury sentenced him to life in prison but a trial judge overruled its decision, remanding him to death row. The Supreme Court ruled that this practice is unconstitutional in 2017, but the new law did not apply to sentences before 2002. 

Madison suffered a series of strokes in 2015 and 2016 that greatly reduced his cognitive function, leaving him blind, incontinent, and unable to recite the alphabet past the letter G. He insists his mother should be alerted of his strokes and he states, through slurred speech, that he has no recollection of murdering anyone. The Supreme Court first stayed his execution in 2016 but did not definitively rule until February 27, 2019. 

The Madison ruling simultaneously upholds prior Supreme Court precedent forbidding the execution of those with diminished mental capacity and creates new precedent for individuals who lose capacity while in prison. In 1986, the Supreme Court ruled in Ford v. Wainwright that the Eighth Amendment’s cruel and unusual punishment clause prohibits the execution of “those who are unaware of the punishment they are about to suffer and why they are to suffer it.” Following this line of reasoning, Madison’s execution was not prohibited because he was unable to remember his crime; rather, it was prohibited because he could not understand why he was being executed. The Court ruled that Madison’s dementia constituted a form of insanity. This is the first time the Supreme Court has ruled that dementia can be categorized in such a way, but has left an exception for individuals with dementia or cognitive dysfunction who could, in theory, understand why they are being executed.

With the average lifespan continuing to increase, the problem of individuals with a life sentence developing dementia and other related illnesses raises the same central question: can they understand why they are being punished? Generally speaking, when an individual with dementia is taken into custody they are usually released in a somewhat timely fashion to the care of a relative or to a secure facility once officers are made aware of their condition. However, individuals who are already incarcerated do not always enjoy this luxury. In fact, the federal government created a specialized unit to care for prisoners with dementia and several states have followed suit. This costs taxpayers more money and is, at the very least, ethically questionable; dementia itself has been referred to as a “cruel and unusual” disease, coupling this with a prison sentence for a crime one does not remember creates an environment of permanent confusion, added stress, and fear for incarcerated individuals with diminished capacity.

With projections indicating that the 33% of the U.S. prison population will be over the age of 55 by 2030, this is a problem that needs to be solved quickly. With the addition of dementia-specific units in prison, it appears that the government already has its answer. The question now is: will the answer remain the same as costs rise and the public becomes aware of the conditions for individuals with dementia in the prison system?