from the United States District Court for the Southern
District of Alabama D.C. Docket No. 1:16-cv-00191-KD-M
WILSON, MARTIN, and JORDAN, Circuit Judges.
MARTIN, Circuit Judge.
years ago, the Supreme Court held that the Eighth Amendment
prohibits the execution of a person who is
incompetent. Ford v. Wainwright,
477 U.S. 399, 409-10, 106 S.Ct. 2595, 2602 (1986). The Court
has since clarified that a person cannot be executed if he
lacks a "rational understanding" of the reason for
his execution. Panetti v. Quarterman, 551 U.S. 930,
954-60, 127 S.Ct. 2842, 2859-62 (2007). This standard
requires the prisoner to be able to rationally understand the
connection between the crime he committed and the punishment
he is to receive. See Ferguson v. Sec'y, Florida
Dep't of Corr., 716 F.3d 1315, 1336 (11th Cir.
2013). The Supreme Court told us that if the prisoner does
not understand this connection, "the punishment can
serve no proper purpose" and cannot be carried out.
Panetti, 551 U.S. at 960, 127 S.Ct. at 2862.
habeas petitioner, Vernon Madison, is a 66-year-old man on
death row for the murder of a police officer over three
decades ago. In recent years, Mr. Madison has suffered
strokes resulting in significant cognitive and physical
decline. His lawyers argue here that he is mentally
incompetent to be executed under Ford and
Panetti. Finding that Mr. Madison had made a
substantial threshold showing of incompetency, an Alabama
trial court held a competency hearing. At the hearing, Mr.
Madison presented unrebutted testimony from Dr. John Goff
that his strokes caused major vascular disorder (also known
as vascular dementia) and related memory impairments and
that, as a result, he has no memory of committing the
murder-the very act that is the reason for his execution. To
the contrary, Mr. Madison does not believe he ever killed
anyone. Dr. Goff testified that due to his memory
impairments, Mr. Madison does not have a rational
understanding of why the state is seeking to execute him. The
State presented expert testimony from Dr. Karl Kirkland. Dr.
Kirkland testified that Mr. Madison was able to accurately
discuss his legal appeals and legal theories with his
attorneys and-on pretty much this basis alone-concluded that
Mr. Madison has "a rational understanding of [his]
sentence." Accepting the testimony of Dr. Kirkland, the
Alabama trial court decided that Mr. Madison is competent to
be executed. Mr. Madison argues that the trial court's
decision relied on an unreasonable determination of the facts
and involved an unreasonable application of the law. We
holding, we are mindful of the great deference due to state
court decisions on federal habeas review, particularly when
the state court is applying a general standard like the one
in Panetti. See Harrington v. Richter, 562
U.S. 86, 101, 131 S.Ct. 770, 786 (2011) ("The more
general the rule, the more leeway courts have in reaching
outcomes in case-by-case determinations." (quotation
omitted)). But "even a general standard may be applied
in an unreasonable manner." Panetti, 551 U.S.
at 953, 127 S.Ct. at 2858. Panetti may set out a
general standard for competency, but the focus of the inquiry
is clear. Panetti doesn't ask whether the
prisoner can talk about the history of his case or legal
theories with his attorneys. Instead, Panetti
requires courts to look at whether the prisoner is able to
rationally understand the connection between the crime he
committed and the punishment he is to receive. See
Panetti, 551 U.S. at 960, 127 S.Ct. at 2862. One of the
experts testified that due to a mental disorder, Mr. Madison
was not able to make this connection. The other expert never
addressed this question at all. This record is therefore
wholly insufficient to support the trial court's
decision. We conclude that the state court's decision
that Mr. Madison is competent to be executed rested on an
unreasonable determination of the facts and involved an
unreasonable application of Panetti. We therefore
reverse the District Court's denial of habeas relief.
BACKGROUND AND PROCEDURAL HISTORY
Madison has been tried three times for killing a police
officer in 1985. Madison v. State, 718 So.2d 90, 94
(Ala.Crim.App.1997). His first two convictions were reversed.
At his third trial, the jury found Mr. Madison guilty of
capital murder and recommended a life sentence by an 8-4
vote. See id. The trial judge overrode the
jury's recommendation and sentenced Mr. Madison to death.
Id. His conviction and sentence were affirmed by the
Alabama Court of Criminal Appeals, id. at 104, and
the Alabama Supreme Court. Ex parte Madison, 718
So.2d 104, 108 (Ala. 1998).
February 2016, following the denial of state and federal
habeas relief, Mr. Madison filed a petition for suspension of
his death sentence in the Circuit Court of Mobile County,
Alabama, arguing that he was incompetent to be executed under
Ford and Alabama law. See Ala. Code §
15-16-23 (providing that the trial court shall suspend the
execution of a death sentence if "it is made to appear
to the satisfaction of the trial court that the [prisoner] is
then insane"). The Alabama trial court found that Mr.
Madison had made a preliminary showing of incompetency,
ordered that Mr. Madison be evaluated by a court-appointed
expert, and scheduled a competency hearing. At the competency
hearing, the court heard testimony from the court-appointed
expert as well as Mr. Madison's expert. The court issued
an order on April 29, 2016, finding that Mr. Madison was
competent to be executed. Under state law, this ruling is not
subject to review by any other Alabama court. See
Ala. Code § 15-16-23.
Madison then filed a motion for a stay of execution and a
petition for federal habeas relief in the U.S. District
Court. The District Court found that Mr. Madison had
exhausted his Ford claim, but it denied relief on
the merits. Mr. Madison appealed, and we
granted Mr. Madison's motion for a certificate of
appealability, stayed his execution, and ordered expedited
briefing on the merits of his Ford claim.
MADISON'S CURRENT MEDICAL CONDITION
Madison, who is 66 years old, has a history of physical and
mental impairments. He is legally blind, cannot walk
independently, is incontinent, and has slurred speech. He has
also suffered at least two recent strokes-one in May 2015 and
another in January 2016. The May 2015 stroke was severe, and
affected Mr. Madison's vision while also causing a
substantial deficit in motor coordination. After this stroke,
he showed signs of memory loss, repeatedly asking that his
mother be informed that he had a stroke despite the fact that
she had passed away several years earlier. On January 4,
2016, Mr. Madison had another stroke. He was found in his
prison cell, unresponsive and incontinent. Medical records
document that Mr. Madison was in an altered mental status
after the January 2016 stroke. He appeared "very
confused" and disoriented, and he exhibited signs of
these strokes, Mr. Madison's legal team noticed a
significant decline in his mental status, including memory
loss, difficulty communicating, and profound disorientation
and confusion. Mr. Madison reported frequently urinating on
himself because "no one will let me out to use the
bathroom, " although he has a toilet in his cell. And
Mr. Madison told his attorney during a visit in February 2016
that he planned to move to Florida after his release from
prison. As a result, Mr. Madison's attorneys
requested-and the Alabama trial court granted-a hearing to
determine whether Mr. Madison is competent to be executed.
STATE COURT COMPETENCY HEARING
the hearing, Mr. Madison was evaluated by Dr. Kirkland, the
court-appointed psychologist, and Dr. Goff, a
neuropsychologist retained by Mr. Madison's counsel. Both
experts reviewed Mr. Madison's medical records and
examined him. Both experts testified at the hearing and
prepared written reports that were admitted into evidence.
The Expert Reports
report, Dr. Kirkland acknowledged that Mr. Madison's
strokes had caused significant physical and cognitive decline
and found no indication of malingering. Despite this decline,
Dr. Kirkland found that Mr. Madison was able to accurately
describe the history of his case regarding his appeals and
was aware that the trial judge had overridden the jury's
life sentence. Dr. Kirkland also noted that Mr. Madison could
discuss details from his youth, such as where he attended
elementary and high school. The report concluded that
"Mr. Madison appears to be able to have a rational
understanding of the sentence, the results or effects of the
sentence, and to still be able to discuss defense and legal
theories with his attorneys."
Goff's report also concluded that Mr. Madison had
suffered "significant cognitive decline" due to his
strokes and that there was no clinical indication of
malingering. He administered the fourth edition of the
Weschsler Adult Intelligence Scale (WAIS-IV) and calculated a
General Ability Index of 72, which falls within the
borderline range of intelligence. According to Dr. Goff's report, this
score marked a very significant decline from Mr.
Madison's previous levels of function. The report
explained that Mr. Madison's Working Memory Index of 58
reflected "a very substantial deficit" in regard to
working memory and that Mr. Madison had "a significant
cognitive deficit." 
Goff diagnosed Mr. Madison with major vascular neurological
disorder (vascular dementia) and reported that Madison
suffered from retrograde amnesia. As a result, Mr. Madison
could not recall certain past events that happened before his
January 2016 stroke. Dr. Goff's report explained that if
Mr. Madison was told a fact or a series of facts he might be
able to recall this new information, but he would not be able
to recall any memories affected by the retrograde amnesia.
According to Dr. Goff, Mr. Madison didn't have an
independent recollection of his crime or the identity of the
victim. Dr. Goff reported:
When [I] asked [Mr. Madison] where he was convicted from he
said, "It must have been Mobile" although he seemed
unsure. Again he was able to tell me that the crime
"must have been a murder." He could not identify
the name of the victim. . . . [H]e indicates that he does not
believe that he ever killed anybody because, "I never
went around killing folks."
report noted that Mr. Madison was not able to tell Dr. Goff
the sequence of events from the offense to his arrest to the
trial or any related details. During the interview, Mr.
Madison said that he had been told by others that he had
three trials and that the judge had overridden the jury's
Goff reported that Mr. Madison understood the meaning of
"execution" and "the idea of being dead."
Dr. Goff concluded that Mr. Madison understood what he had
been tried for but-because he could not remember the
underlying crime and didn't believe he had ever killed
anyone-"[h]e does not seem to understand the reasoning
behind the current proceeding [his execution] as it applies
The Evidentiary Hearing
Kirkland, Dr. Goff, and Mr. Madison's prison warden
testified at the competency hearing. Dr. Kirkland emphasized
Mr. Madison's ability to discuss the details of his legal
appeals and the current status of his case. Dr. Kirkland also
testified that Mr. Madison was aware of his execution. On
redirect examination, Dr. Kirkland acknowledged that Mr.
Madison's mental condition had significantly
deteriorated, but he testified that Mr. Madison was able to
talk "about very specific things that would indicate
that he could remember specific things about the time of the
offense." In response to the court's question of
whether Mr. Madison understood that the state was seeking
retribution for an act that he had committed, Dr. Kirkland
replied: "Certainly. [Mr. Madison] talked specifically
about [a] death sentence versus life without [parole] in the
original trial and the first retrial and in the second."
Goff's testimony at the evidentiary hearing largely
followed his report. Dr. Goff testified that the stroke Mr.
Madison suffered in January 2016 likely caused his memory
problems. Dr. Goff described this event as a thalamic stroke-
a type of stroke that commonly results in memory problems as
well as other difficulties-and this conclusion was in keeping
with an MRI report showing a "[t]iny focal acute to
subacute infarct in the right thalamus." According to
Dr. Goff, areas of Mr. Madison's brain have essentially
died as a result of his strokes, and this is consistent with
Mr. Madison's medical records. It appeared to Dr. Goff that the basis of
Mr. Madison's knowledge about his case was information he
learned from his attorneys. Dr. Goff testified that Mr.
Madison understood that the State was seeking retribution but
didn't understand the past act for which he was being
punished. Dr. Goff concluded that Mr. Madison understood he
was being executed but-because he lacked memories of his
past-didn't understand why.
state called as a witness Warden Davenport, who had served
the death warrant on Mr. Madison. Mr. Davenport testified
that he read the court order setting the execution date to
Mr. Madison and that Mr. Madison said "my lawyers are
supposed to be handling that." The Warden also testified
that prisoners are assigned mental health codes if they
receive mental health care. According to Mr. Davenport, Mr.
Madison's mental health code was zero, which indicates
that Madison was not receiving treatment for a mental health
ALABAMA COURT'S COMPETENCY DECISION
Alabama trial court issued a written order in which it held
that Mr. Madison was competent to be executed. The court
identified Ford and Panetti as the relevant
standards. It stated that the burden of proof was on Mr.
Madison to show, by a preponderance of the evidence,
"that [he] suffers from a mental illness which deprives
[him] of the capacity to rationally understand that he is
being executed as a punishment for a crime." The
court's order summarized the evidence from the competency
hearing, including the testimony of Dr. Kirkland and Dr.
Goff. It then found that Mr. Madison had failed to prove his
incompetence by a preponderance of the evidence. The court
"accept[ed]" the testimony of Dr. Kirkland
regarding Mr. Madison's understanding of his execution.
It found that Mr. Madison "has a rational
understanding, as required by Panetti, that he is
going to be executed because of the murder he committed and a
rational understanding that the State is seeking
retribution and that he will die when he is executed."
STANDARD OF REVIEW
appeal is governed by 28 U.S.C. § 2254, as amended by
the Antiterrorism and Effective Death Penalty Act of 1996
(AEDPA). AEDPA imposes a "highly
deferential standard for evaluating state-court
rulings." Renico v. Lett, 559 U.S. 766, 773,
130 S.Ct. 1855, 1862 (2010) (quotation omitted). It bars
federal courts from granting habeas relief on a claim that
was adjudicated on the merits in state court unless the state
court's decision (1) "was contrary to, or involved
an unreasonable application of, clearly established Federal
law, as determined by the Supreme Court of the United States,
" or (2) "was based ...