After hearing that one of his most mentally ill patients was being hauled to court under warrant for a March 9 hearing in northern Texas, Dr. Joseph Penn grew alarmed.

As the director of mental health services at the University of Texas Medical Branch, the vast hospital system caring for nearly the entire inmate population in Texas, Penn worried that transporting the patient, a death row inmate named Andre Lee Thomas, to a courthouse near the Oklahoma state line more than five and a half hours away could "exacerbate his fragile psychotic illness."

So on Feb. 27, the doctor scrambled to write a four-page letter making clear to the court in Grayson County that, by any stretch, Thomas was an atypical patient — and that removing him from the prison medical unit where he's housed was a bad idea.

Thomas, the letter explained, gouged out both of his eyes and is now "legally blind." He took out the right one while in custody in a county jail in 2004, awaiting trial for murdering his wife, her 1-year-old daughter and their 4-year-old son.

He then removed the left one — and ate it — while locked up on death row, later explaining that he did so because "I was in love with my wife and I don't want to look at somebody." He also cut his own throat, opening a gash that was 8 centimeters in length and half a centimeter in depth.

Since at least 2008, when he was placed in the Texas Department of Criminal Justice's Wayne Scott Unit, a facility outside Houston housing mentally ill prisoners, Thomas has been suffering from schizoaffective disorder, a serious mental illness that causes him auditory hallucinations, impulsive and unpredictable behaviors, and grandiose delusions.

"God has given me special powers," he once said. "If I pull my eye out, I will be able to control electricity."

In the letter to the Grayson County court, Penn warned that shuttling Thomas out from the Scott Unit, where he receives extensive, round-the-clock medical and psychiatric care, to a location unfamiliar to him risked triggering a psychotic, possibly violent response.

"I share these serious concerns regarding Mr. Thomas' immediate risk of harm to self or others or clinical deterioration and risk of grave disability in a new and unfamiliar setting," Penn said in the letter, which includes distressed statements from Thomas' care team at the unit.

Ironically, the hearing which Penn argued Thomas was too mentally ill to attend focused on a key aspect of his legal case: his mental competence to be executed.

Despite his symptoms, Thomas, 43, has so far been deemed "sane" under state law. And even as his prison system doctors underscore his mental illness and how it affects his daily life, the Grayson County District Attorney's Office has engaged in a relentless effort to ensure Thomas is put to death.

A spokesperson for the office did not respond to requests for comment. Thomas' attorneys declined to comment.

Thomas is one of several people on death row in Texas and other states who have been diagnosed with severe mental illnesses at some point in their lives. Their experiences are at the center of an ongoing debate as to whether their conditions make it morally or legally permissible to execute them.

In the 1986 ruling in Ford v. Wainwright, the U.S. Supreme Court held that the Eighth Amendment bars the execution of people who do not understand that they are being executed or why the state plans to put them to death. But the court's 5-4 ruling stopped short of setting out a clear, objective standard for determining when a person's mental illness is severe enough to make an execution unconstitutional.

The Supreme Court returned to the issue two decades later in Panetti v. Quarterman, a case involving Scott Panetti, a Texas man who had been sentenced to death for killing his in-laws.

There, the justices in 2007 explained that a person's mere knowledge of an imminent execution and knowledge of the state's stated reason for carrying out the death sentence are not enough. Instead, a person must have a rational understanding of the relationship between the crime and the punishment in order to be considered competent for execution.

Greg Wiercioch, who successfully represented Panetti before the high court, told Law360 that courts still sometimes fail to correctly apply the standard set by his client's case, instead falling back on an overly simplistic approach focusing only on whether prisoners can repeat the official reason they are on death row.

Panetti, who died in May 2025 at age 67, could say that he had been sentenced to death for killing his in-laws. But if questioned further, he would explain that he believed the "real" reason for his execution was that the state of Texas conspired with the devil to try to stop him from preaching the gospel, Wiercioch said.

That kind of delusional thinking, Wiercioch said, showed that Panetti could state the facts of his case without having the rational understanding the Supreme Court requires. He now sees similar dynamics in Thomas' case.

Thomas can at times explain that he is on death row for killing his wife and children, Wiercioch said, but deeper questioning reveals what he described as a profoundly delusional belief system.

According to an expert report filed in his case, Thomas has said he believes the state wants to execute him because officials fear the supernatural powers God has given him, and that even if they tried to kill him, he would survive the execution.

"In my opinion, Andre Thomas is certainly one of the most profoundly mentally ill people in the modern era of the death penalty," Wiercioch said. "It's discouraging that the state is so adamant about wanting to execute someone like Andre Thomas or Scott Panetti, when there is so much evidence that this person is simply not capable of having that deeper, rational understanding of why they're being executed."

A Look at Thomas' Case

Thomas slayed his wife, Laura Boren, her daughter Leyha Hughes, and their son Andre Jr., one Saturday morning in March 2004, answering to what he later described as a call from God to kill them. He was 21 at the time.

Even by the standards of death row, which often involve cases described as heinous or brutal, Thomas' triple-murder stood out for its graphic and ritualistic nature.

He stabbed the victims to death, then cut out the hearts of the two children and removed a part of one of Boren's lungs, so that they could all be "freed from evil." He used a different knife on each victim to ensure he would not mix their bloods, something he considered crucial to fulfill what he described as his divine mission. He then left a folded $1 bill exposing the pyramid with the eye in the middle, stabbed himself in the chest, and lay down next to his wife. Later that day, he turned himself in and confessed, according to a federal habeas petition filed on his behalf in March 2010.

Thomas grew up in an environment marked by severe poverty, abuse, addiction and widespread family mental illness, according to the petition. Thomas reportedly began hearing voices around age 9 or 10, attempted suicide repeatedly as a child and adolescent, and increasingly struggled with hallucinations, paranoia and religious delusions as he got older.

By the time he was 19, Thomas was experiencing worsening auditory hallucinations, intense feelings of déjà vu, and a growing fear that he was "not right." He also was increasingly obsessed with religious delusions, according to the petition.

The petition argues that Thomas attempted suicide twice in the three weeks leading up to the killings, and repeatedly tried to get psychiatric help but never received meaningful treatment.

Following his arrest and the incident involving his right eye. Thomas was found incompetent to stand trial. But after spending 47 days at Vernon State Hospital, he was deemed competent.

In a medical opinion accompanying his discharge report, Dr. B. Thomas Gray wrote that Thomas was likely faking his psychosis in a bid to avoid prosecution.

"Mr. Thomas has been diagnosed with malingering. He has clearly exaggerated symptoms that he may be experiencing and may have even fabricated some symptoms of psychosis. It is possible that he may engage in gestures or behaviors, including possibly those involving self-harm, in a bid to appear more seriously mentally ill than he is and to avoid the consequences of the current charges he faces," the report says.

A jury ultimately convicted Thomas of capital murder for killing Leyha. At sentencing, the jury found that Thomas would pose a future danger and rejected mitigating evidence that could have warranted a sentence less than death. The trial judge then sentenced him to death.

The Texas Court of Criminal Appeals affirmed Thomas' conviction and death sentence, and denied state habeas relief.

Thomas' federal habeas case focused on several points. His lawyers argued his criminal case was tainted by racial prejudice. Thomas is Black, while his wife and the two children were white or mixed-race. The attorneys alleged the prosecution relied on racial stereotypes about Black men, and that three people in the all-white jury that convicted Thomas were opposed to interracial relationships and procreation.

"Are you going to take the risk about him asking your daughter out, or your granddaughter out?" the lead prosecutor told the jurors during closing arguments, according to a transcript cited in the petition.

But the crux of the habeas case was that Thomas was incompetent to stand trial, psychotic and unable to understand the proceedings or assist his lawyers. The petition claimed he received ineffective legal representation because his counsel failed to investigate his mental illness and suicide attempts and did not challenge the decision declaring him competent after his stay at Vernon State Hospital.

"Mr. Thomas's execution would make a mockery of our system of justice. His blind, psychotic presence on Texas' death row ridicules the system that led him there," the petition says.

Thomas' habeas arguments were rejected by lower federal courts, and his case eventually reached the U.S. Supreme Court, which declined to take it up in October 2022 over the objections of Justices Sonia Sotomayor, Elena Kagan and Ketanji Brown Jackson.

"The errors in this case render Thomas' death sentence not only unreliable, but unconstitutional. I would not permit the State to execute Andre Thomas in light of the ineffective assistance that he received," Justice Sotomayor said in a dissenting opinion, which focused on the tainted jury issue.

Following the certiorari denial, litigation focusing on Thomas' competency picked up steam in July 2023, when Grayson County Judge Jim Fallon found that Thomas had made a "substantial showing of incompetency" under Texas' execution-competency statute.

The court then appointed two mental health experts, one suggested by each side, to evaluate Thomas. The two experts reached sharply different conclusions. Psychologist Mary Alice Conroy, proposed by the state, evaluated Thomas in March 2024 and concluded he was competent to be executed.

Meanwhile, George Corvin, a psychiatrist proposed by Thomas' lawyers, examined the prisoner over two days in July 2024 and concluded he was not competent under Texas law.

"Mr. Thomas delusionally believes that the government would most likely be unsuccessful if it were to try to execute him, such that if his heart were to stop, it would immediately start again and he would get up off the gurney in a different form," Corvin wrote in his report. "Because of his continued psychosis, Mr. Thomas lacks an understanding of the reality that he is to be executed. He does not believe, also as a result of his delusions, that his execution is imminent, nor does he believe that the government's stated reason for executing him is the true reason it has given."

Because those evaluations had become stale by late 2025, Thomas' lawyers asked for updated examinations closer in time to a final competency hearing. Since then, the litigation has focused on disputes over how and where Thomas should be reevaluated.

The competency hearing has been postponed indefinitely and no new hearing date appears to have been set.

How State Legislatures Have Tried to Address Mental Illness on Death Row

In 2021, Ohio became the first state to bar the death penalty for people who had severe mental illness — defined narrowly to include schizophrenia, schizoaffective disorder, bipolar disorder and delusional disorder — when they committed their crimes.

The measure drew bipartisan backing and included a limited retroactivity provision, allowing people already on death row one year to ask courts to set aside their death sentences. In 2025, there were 28 postconviction relief petitions based on serious mental illness pending in state court, according to a report by the Ohio attorney general.

Kentucky enacted a similar law in 2022, though it has no retroactivity provision.

The same year, California adopted a different approach: rather than exempting defendants from the death penalty based on mental illness at the time of the offense, the state enacted the first law in the country that allows courts to determine whether a death row prisoner is permanently incompetent to be executed because of mental illness. If so, the death sentence is converted to life without parole.

In the years since, lawmakers in several other states have introduced measures that took Ohio and Kentucky as blueprints, though none have become law.

Robin M. Maher, the executive director of the Death Penalty Information Center, told Law360 in an email that the broader lack of legal protections from the death penalty for individuals who have serious mental illness leaves the most active death penalty states "without adequate safeguards for some of the most vulnerable people in the criminal legal system."

In Texas alone, four other people — Steven Staley, Larry Hatten, Emanuel Kemp and Marcus Druery — have been described in court filings or by advocates as suffering from severe mental illness, most often paranoid schizophrenia, and remain on death row.

"People with serious mental illness are often unable to conform their behavior to the requirements of the law or meaningfully appreciate the punishment they may face — some of the same reasons that led the U.S. Supreme Court to prohibit the execution of people with intellectual disability," Maher said. "There is no principled reason that the same legal protections should not also be recognized for those with serious mental illness."

A Demanding Standard

The Eighth Amendment to the U.S. Constitution prohibits cruel and unusual punishments. In the Ford decision, the U.S. Supreme Court interpreted those words to mean that people who are not competent at the time of their execution cannot be put to death. Since that ruling, only a fraction of death row prisoners have raised competency-for-execution claims, and most of those claims have failed.

In a study published in March 2025, a trio of scholars at Cornell University referenced a 2014 paper finding that 141 death row prisoners — about 2% of those sentenced to death between 1986 and 2012 — filed Ford claims, but only 21 succeeded. The leading author of the paper, Dr. I-An Su, told Law360 that data until 2024 shows that there were a total of 152 Ford claims filed, of which only 29 were successful.

The 2025 study found that successful Ford claimants were all diagnosed with severe mental illnesses, but those most likely to prevail were prisoners with schizophrenia (86%), personality disorders (39%), depressive disorders (29%), and substance use disorders (29%). More than three-quarters of the prisoners who ultimately won Ford claims had previously raised other competency issues during their cases, according to the study.

John H. Blume, director of Cornell University Law School's Death Penalty Project and one of the paper's authors, told Law360 that although it is possible for prisoners to become mentally ill after they are incarcerated on death row, even to the point of being not competent for execution, those cases are only a small fraction.

"The majority of the cases are just where it's not discovered or not fully investigated and presented," Blume said.

Blume said schizophrenia is especially prominent in Ford cases because hallucinations and delusions often affect the very issues courts are supposed to evaluate: whether  prisoners rationally understands why the state wants to execute them and what death means. Some prisoners, he said, believe they are part of a government conspiracy, that they cannot die or that they are being executed for reasons unrelated to their crimes.

That is why, Blume said, courts sometimes get the Ford-Panetti standard wrong. It is not enough for prisoners to simply repeat that they were convicted of murder and sentenced to death. The prisoners must rationally believe it.

Blume said the facts in Thomas' case show that he has never been competent, even after doctors found him to be so in the past.

"When somebody plucks out their own eye and eats it, you should maybe take a step back and decide whether you think this person is competent or not," he said. "And when they do it again, that seems to me to be unassailable proof of incompetence."

--Editing by Alex Hubbard and Tim Ruel.

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