Generally, when a death row inmate is found incompetent, the execution must be stayed and appropriate treatment must be provided. Upon recovery, the execution may be reinstated. This paper first discusses the purpose of the death penalty, rationales for the competency rule, and the standards of competency for execution. The author argues that the justifications for capital punishment should suggest why some inmates receive the death penalty and others are exempted. The principles underlying the competency requirement for the death penalty, in turn, should determine the impairment level that must be met before an inmate is spared execution. The principles and rationales underlying the competency requirement should also determine the procedural protections for an inmate who claims incompetency for execution. The overarching problem is the lack of a social consensus about why the incompetent are exempt from execution, what the competency standard should be, or the procedural protections to be provided. Other issues discussed are the implications of the use of antipsychotic drugs, informed consent for treatment, the right to refuse treatment, the role of the psychiatrist-examiner, and standards for the psychiatric examination. An appended survey of State statutory and common law for standards of competency for execution and 335 footnotes. (Author summary modified)