Vernon Madison was sentenced to death and later suffered strokes and vascular dementia while awaiting execution. He argued that the Eighth Amendment barred execution because his mental condition left him unable to rationally understand why Alabama sought to execute him. The state court found him competent, and the Supreme Court reviewed that ruling after earlier habeas proceedings. The Court held that the constitutional competency standard does not require psychotic delusions and does not turn solely on whether a prisoner remembers committing the crime. Dementia or another disorder may satisfy the standard if it prevents rational understanding of the State’s reason for the execution. Because the state court’s brief ruling did not make clear whether it applied that standard or properly evaluated Madison’s condition, the Court remanded for renewed consideration. Justice Alito dissented, arguing that the majority was deciding factual issues from a cold record and granting relief on a question not properly presented.