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The Royal College of Psychiatrists Improving the lives of people with mental illness

Midwestern adventures into the mind: coffee and the death penalty

Miriam Saey Al Rifai blogs about her medical elective in St Joseph, Missouri on

"The medical elective is often seen as the highlight of medical school, the final task/holiday that the school sets before you are sent out into the big wide world."


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05/06/2015 14:48:38

Coffee and the death penalty

In this extract from, Miriam discusses the ethical dilemma of assessing someone's competency to face the death penalty.

Coffee maker

During the day there is always a window of opportunity to pass by Dr Reynolds's office and catch up on how the day is going. I really enjoy these chats, as more often than not, the ‘catch up’ turns into an hour long (plus!) discussion about interesting cases, ethical dilemmas etc. So I usually top up my coffee en route to his office.

(Here I must add that there is a constant supply of free, fresh coffee for all the staff in the hospital in every department. Britain, please take note.)

One of my first ‘catch ups’ with Dr Reynolds involved a lengthy discussion on the Death Penalty, a relevant topic to being a forensic psychiatrist in the state of Missouri.

He must have sensed my curiosity in the matter before I even voiced it. Missouri is one of 5 states that make up 65% of the executions that take place in the US. There have been 82 executions in the state of Missouri since 1976, all by lethal injection.

I, as I suspect many Brits would, struggle with the whole idea of the death penalty. Are we really still doing this in 2015?

For and against the death penalty

The opinions that still drive the existence of the death penalty include views such as ‘it is the ultimate punishment’, ‘proportionality for the crime committed’ and that this form of ‘justice’ would act as a ‘deterrent’. Some also believe that an execution would save the state money on appeals and imprisonment.

However, those states that have outlawed executions have based this on their views that

  • executions are a violation of the 8th amendment of the US constitution (‘Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted’)
  • execution is irreversible and does not allow for rehabilitation
  • the paucity in evidence that execution acts as an effective deterrent
  • other countries without the death penalty often have lower crime rates 
  • the risk of executing an innocent person.

The psychiatrist's role

I wanted to know what role a forensic psychiatrist had in all of this. Is it like abortions in the UK, where if you are morally opposed you do not have to take part?

Thankfully this is the case. When a forensic psychiatrist is asked to be involved in the assessment of a defendant who is at risk of facing the death penalty, the psychiatrist can refuse to take on the case. The only forensic psychiatric issue exclusive to death penalty cases, concerns the competency to be executed. If found incompetent, an execution cannot be carried out, due to: 'prohibition of execution of an insane prisoner'.

I wondered that if the forensic psychiatrist’s evaluation ultimately results in the defendant being executed, does this indirectly conflict with the doctor’s oath of ‘thou shalt do no harm?’

Dr Reynolds was able to assist me with this ethical dilemma as he previously worked on a death penalty case and spent a considerable amount of time in the lead up to the trial researching the ethics of his involvement. He informed me that many people agree that whilst it is ethical for a forensic psychiatrist to comment on a defendant’s competency, it is not ethical to assist in the execution itself, with regards to administering drugs and confirming death.

Dr Reynolds also shared with me other considerations he had had to make: what if a defendant was facing the death penalty and you not getting involved in the case may mean that another, perhaps less qualified / experienced doctor got involved instead, misperceived a defendant as competent, and then they incorrectly get executed?

With this in mind, is it not more ethical to involve yourself in a case if you feel confident about your clinical skills, and know that you will act honestly?

What would I do if I was working in Missouri and was asked to assist in a Death Penalty case?

I am going to be honest. I am most definitely against the Death Penalty, and prior to my chat with Dr Reynolds I would have said with confidence that I would refuse to take on a Death Penalty case.

However, if I had the opportunity to look over the case first, I may take it on if I felt confident that the patient was in fact incompetent and that my involvement would prevent the defendant facing the Death Penalty.

However, if the trial did not go my way could I live with the thought that perhaps I underperformed in my ability to convince the court of my clinical findings? Or if I discovered that, on closer assessment, the patient was in fact competent and I must therefore act with honesty and inform the court?

Honestly, I am just glad that this is one ethical minefield that we do not have to deal with back home in the UK.


Read more of Miriam's experiences.

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Miriam Saey Al Rifai is a final year medical student from Barts and the London on a medical elective in St Joseph, Missouri.

She has been based at Northwest Missouri Psychiatric Rehabilitation Centre, a forensic psychiatric hospital.

Her inspiration for choosing an elective in forensic psychiatry came about after work experience with consultant forensic psychiatrist Dr Scott Mackenzie.

Miriam's interest in psychiatry stems from her work at the Maudsley Hospital, on a neuropsychiatric unit prior to starting medical school. She has secured her foundation training in South Thames deanery, which will include a psychiatric rotation at the Royal Sussex County Hospital in Brighton.

Miriam has been blogging her elective experiences on