Ninety-five countries throughout the world retain the death penalty. All make provision for excluding the ‘insane’ from liability to capital punishment (Hood, 1990). Psychiatrists and other mental health professionals are therefore involved in the process leading up to capital sentencing and execution in many of these countries. Such involvement may take many forms though, with the notable exception of the USA, very little is known of its nature or extent in practice. Whatever form psychiatric involvement takes, and however much it may be shaped in different places by social, economic and cultural variables, as well as the configuration of particular criminal justice systems, certain fundamental ethical questions arise which do not admit of simple answers. It might be argued that these ethical dilemmas no longer have relevance to European countries because they have all effectively abolished capital punishment. However, others may claim that the death penalty, as the most spectacular example of the extra clinical harm to which a psychiatrist's dealings with patients may contribute, ought to be of central concern when practitioners come to consider the uncertain balance between their duty to an individual patient and society at large.