Medico-legal approach of the psychiatric patient

M o h a m e d S e d k yP s y c h i a t r i c S p e c i a l i s t

B M H HJ a n . 2 0 1 7

Mental capacityMental capacity

Mental Capacity

a person’s capacity shall be assessed on the basis of his or her ability to understand, at the time that a decision has to be made, the nature and that a decision has to be made, the nature and consequences of the decision to be made by him or her in the context of available choices at that time.

Factors Affecting Capacity

• Attention

• Awareness

• Memory

• Planning• Planning

• Execution

• Sequencing

• Appreciation

• Supervision of behavior

• Abstraction/ insight

Domains of Mental Capacity over time

Past capacity: Civil cases - contesting a will or contract

Criminal cases - criminal responsibility (insanity)

Present and future capacity Determine if someone can assist in own defense

Decisional capacity Decisional capacity

Testamentary capacity

Testimonial capacity

Capacity to sign contracts

Divorce and child custody

Determine if someone needs a guardian

Capacity to consent to or refuse medical treatment

Criminal responsibility

• In 1843 an Englishman Daniel McNaughton shot and killed the secretary of the British Prime Minister.

• He believed that the Prime Minister was conspiring against him and claimed that the “voice of God” ordered him to kill Prime Minister Robert Peel, but mistakenly , he murdered Peel’s private Minister Robert Peel, but mistakenly , he murdered Peel’s private secretary instead.

• The court acquitted McNaughton "by reason of insanity," and He was placed in a mental institution for the rest of his life.

• However, the case caused a public uproar, and Queen Victoria ordered the court to develop a stricter test for insanity.

Legal Standards of Insanity

McNaughton Rule

States that, in order to establish insanity, it must be proven thatat the time of a crime, the accused had a mental defect (i.e.such as a mental disease) so that she/he did/could not know thenature or quality of their crime at the time of offense or if theaccused did not know that what she/he did was wrong.accused did not know that what she/he did was wrong.

The Durham Rule

States that the accused is not criminally responsible if her/hisunlawful conduct is or was the product of mental disease ordefect.

The Insanity Defense

Not Guilty By Reason Of Insanity

Assumed not to be acting out of his free will.

Not criminally responsible for his actions.

Mentally IllMentally Ill

Relationship between Competency and Mental Illness

Not all mentally ill people are incompetent

IncompetentIncompetent

All incompetent people are “mentally ill”

The Insanity Defense

To establish a defense on the ground of insanity, it must be clearly proved that, at the time of the committing of the act, the party accused was laboring under such a defect of reason, from laboring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing; or, if he did know it, that he did not know he was doing what was wrong.

Diminished responsibility

The Insanity Defense

Diminished responsibility

Guilty But Mentally Ill

Defendants are considered guilty but mentally ill (GBMI) if they are guilty of the crime, were mentally ill at the time it was committed, but were not legally insane at that time.at that time.

A defendant found GBMI is sentenced in the same manner as any criminal, but the court can order treatment for the mental disorder as well.

Elements of A crime

ACTUS REUS = “guilty act”

MENS REA = “guilty mind” MENS REA = “guilty mind”

Competence to Stand Trial / Fitness to plead

Competence: involves defendants’ ability to understand the legal proceedings that are taking place against them and to participate in their own defense.

Incompetence: a person is considered incompetent to Incompetence: a person is considered incompetent to stand trial if, because of mental illness, he is unable to do one or more of the following:

Understand the nature or object of the proceedings.

Understand the possible consequences of the proceedings.

Communicate with their lawyer.

Competence to stand trial versus criminal responsibility

Competence to stand trial and criminal responsibility are twodifferent concepts.

This means that even if the person is found mentally competent tostand trial, a later assessment may still show that — when thecrime was committed — he was not well enough to understandcrime was committed — he was not well enough to understandthe nature and consequences of his act and should be found notcriminally responsible.

Conversely, the person could be found incompetent to stand trialin the present, but a psychiatric assessment might show that heknew what he was doing at the time of the act and therefore, mustbe held criminally responsible for it.

Mental capacity and the civil law

Testamentary Capacity

• Capacity to make a will

• For a will to be legal, individual must be able to:

Understand what a will is.

Recollect nature and extent of own property.

Remember and understand relationship to living descendants and others who will be affected by will.

Testimonial Capacity

• Comes into play when an impaired person appears in court to testify.

• Court may decide that individual lacks testimonial individual lacks testimonial capacity.

Capacity to Sign Contracts

• Understanding what a contract is and the consequences of the contract.

For proper consent, • For proper consent, individual must: Have mental capacity to contract.

Understand the transaction.

Act voluntarily, free from threats or force.

Divorce and child custody

• Spouses of mentally ill patients may require psychiatrists' evidence in the court of law in the matter of divorce.divorce.

• Questioning the competence of mentally ill parents to care for their children.

Need for guardianship

• Basic civil rights are removed.

• Loss of function in multiple arenas - making very poor decisions– and lack of insight (appreciation) into deficits.

• No expectation to recover.• No expectation to recover.

• Clear and convincing evidence.

• Beyond reasonable doubt.

• Considered as a last resort.

Consent to medical treatment

Patient Refusing Treatment

psychiatrist is called to assess medical decision-making capacity in patients with psychiatric illness who with psychiatric illness who are refusing care.

How to assess mental capacity ?

Every adult has the right to make their own decisions

The principles of capacity

Lack of capacity

Determination of lack of capacity is a tow stage process:

Stage 1

presence of impairment of or disturbance in the functioning of mind or brain.mind or brain.

Stage 2

Due to the impairment the person unable to:– understand information relevant to the decision– retain the information in their mind– use or weigh the information as part of the decision-making process, or– communicate their decision (any form of communication is sufficient)

Capacity is time and decision specific

some people may be unable to make one decision, but retain capacity for other decisions.

Capacity can fluctuate and change over time. Capacity can fluctuate and change over time.

Capacity is a legal concept

• Law – black & white

• Medicine – shades of grey

Sliding scale of capacity assessment

Case assessment

Preliminary matters

• Is it appropriate to take this case?

• Ensure instructions are clear and adequate.

• Request more information if necessary.• Request more information if necessary.

• Gather all relevant information before interviewing case.

Case assessment

Interviewing the case

• Appropriate setting and timing Further information / investigations

• Interviewing informants (collateral History)

• Review of notesReview of notes- Medical notes

- Police interviews

- Witness statements

• Diagnostics:- Lab. investigations

- Brain scan

- Neuropsychological testing

Writing of court reportsWriting style

• Clarity.

• Minimal use of technical language.

• Structure.

• Stick to your expertise – no comment on legal issues.

• Awareness that you might have to defend your opinion / wording.

Writing of court reportsStructure and content

Report should include the following:

Item specifications

Introduction brief summary of case

Sources of information Interview with accused / Review of notes / Sources of information Interview with accused / Review of notes / Interview of other informants / Further investigations / Any difficulties with assessment

Background history Medical and Psychiatric history including substance misuse

Interview and mental state Current mental state and metal state during the offend if applicable

Diagnosis Psychiatric illness, personality, mental disability

Conclusion and recommendations Answer questions