Within mental health law, the legal defense of insanity has received a disproportionate amount of attention. Classified as a legal excuse, the insanity defense generally negates legal blameworthiness for criminal defendants who successfully prove that at the time of the offense, they did not know right from wrong or were unable to conform their conduct to the requirements of the law, due to an underlying mental health condition. The insanity defense has a lengthy history in the United States, with several different formulations and numerous court decisions addressing various aspects of the defense. Despite its firm entrenchment in U.S. criminal law, with almost all states and the federal courts having some version of the insanity defense, the United States Supreme Court has demonstrated a startling level of confusion when deciding cases involving the insanity defense and related but distinct concepts. This article (a) discusses the nature of the insanity defense by distinguishing it from related but distinct mental health law defenses, (b) provides a detailed analysis of United States Supreme Court cases that illustrate the Court’s confusion regarding the insanity defense, and (c) explores why the Court’s confusion is detrimental in multiple ways and to multiple stakeholders and offers suggestions for how the Court can meaningfully move forward to alleviate the effects of its longstanding confusion.



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