FORENSIC PSYCHIATRY

32 FORENSIC PSYCHIATRY
Chee Kuan Tsee / Fones Soon Leng, Calvin
Introduction
Forensic Psychiatry concerns the application of psychiatry in legal procedures. In
general, it involves assessment of issues regarding credibility, culpability, competency,
compensation and custody (Slovenko). The areas covered in this chapter relate to:
1. Laws regulating admission/detention and treatment of patients in mental hospital.
2. Consent to treatment.
3. Civil laws, e.g. capacity to contract, sign documents or make a will.
4. The mentally abnormal offender.
A. Admission Laws to Mental Hospital
The Mental Disorders and Treatment Act (Revised Edition) 1985, governs the
procedures regulating the admission and detention of persons with psychiatric disorder in a
mental hospital viz. Woodbridge Hospital. Such laws exist to protect the interest of both the
patient and the public. A person who is mentally disordered may be detained in the mental
hospital for the following reasons:
1. When he is found by the Court to be of unsound mind and incapable of managing
himself and his affairs (under Section 25).
2. When he is reported to be of unsound mind and is believed to be dangerous to
himself or other persons by reason of unsoundness of mind and is brought to the
mental hospital by the duty bound police (under Section 32 and subsequently in
accordance with Section 35).
3. When he is supposed to be of unsound mind and is not under proper care and
control or is cruelly treated or neglected by any relative or other person having the
charge of him (under Section 33 and subsequently in accordance with Section 35).
The gist of Section 35 is that the person should be detained in hospital for treatment
if the medical officer at the mental hospital, after examining the person who is suffering from
a mental disorder is of the opinion that:
(a)
(b)
he is suffering from a mental disorder which warrants the detention of that person in
a mental hospital for treatment; and
it is necessary in the interests of that person’s health or safety or for the protection of
other persons that the person should be detained.
If the patient refuses voluntary admission and treatment then the medical officer on
duty is empowered to detain him for up to 72 hours by signing Form 1. A second doctor can
extend the period of inpatient treatment for a further one month by signing Form 2.
Subsequent separate examinations by a psychiatrist and a medical officer of Woodbridge
Hospital allow for a further detention for up to one year by signing Form 3.
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No one with any fiduciary relationship to the patient should sign any order under the
Act. Discharge from the hospital can take place once the patient is considered fit by the
psychiatrist.
B. Consent to Treatment
For medical (psychopharmacological) treatment of psychiatric patients, no formal
consent is obtained and is implied if no objections are made. If the treatment is necessary
but there is refusal because of impaired judgement arising from illness, the patient can be
made an involuntary patient and treated.
For electroconvulsive therapy (ECT), permission should be sought from all patients
who are able to understand and give consent after explanation. If the patient is not
competent to give consent, this can be obtained from the next of kin or an immediate family
member. If none is available then a second opinion and concordance should be sought from
another consultant psychiatrist.
Sometimes, the psychiatrist is consulted regarding whether a mentally ill individual is
able to give consent for a surgical procedure. Provisions governing consent to medical
treatment in Singapore is found in sections 87-92 of the Penal Code. In essence, it requires
that a person giving consent is able to understand the nature and consequence of the
procedure. As far as possible the patient should give his own consent.
Some mental conditions fluctuate in severity and consent may be obtained during a
lucid period, as long as he is, at the time able to understand the nature of the operation, the
risks involved and consequences. If the patient is unable to give consent, the next-of-kin can
give consent on his /her behalf. In the event of emergencies, a procedure done in good faith
for a person who is unable to give consent, is not considered an offence provided it is for the
purpose of treatment.
C. Civil Laws
Civils laws concern the rights and obligations of individuals to one another and deal
with matters like property and inheritance or contracts.
Psychiatric input is sought at times concerning fitness to make a will, validity of
marriage contracts or guardianship, or capacity to manage one’s own affairs.
1. Testamentary Capacity
This refers to an individual’s capacity to make a will. A will made by someone with
mental illness may be challenged by potential beneficiaries who query its validity. Psychiatric
opinion about whether a person is of “sound disposing mind” would entail assessing if the
person knows:
a) What a will is and what the consequences of it are.
b) The nature and extent of his property.
c) Who the potential beneficiaries are.
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Most importantly, the psychiatrist determines whether the existence of a mental
illness has affected judgement pertaining to the above factors. The presence of a mental
illness in and of itself need not necessarily affect the patient’s ability to make a will.
2. Capacity to Manage own Property and Affairs
Relatives of patients who are in possession of valuable estates e.g. property, money,
shares etc. may be concerned about the effect of mental illness on their capability to
manage their affairs. A patient may give written authorization, i.e. power of attorney, to
someone else to act on his behalf.
However if the person is alleged to be mentally disordered, is of unsound mind and
incapable of managing himself and his affairs then the Court may appoint a committee or
committees of the person and his estate and the management thereof.
3. The Marriage Contract
A marriage can be considered invalid if one party was mentally unwell such that
he/she was unable to understand the nature of the contract. Alternatively, one partner may
have been ignorant that the other was having a mental illness.
“Mental cruelty” has also been cited as grounds for divorce, in that one party feels
he/she has become mentally ill as a result of ill treatment by the spouse.
Mental illness is also grounds for divorce if a spouse has been mentally ill for more
than five years despite continuous treatment or causes exceptional hardship or irretrievable
breakdown of marriage.
D. The Mentally Disordered Offender
Persons may be admitted and detained for assessment in Woodbridge Hospital on a
Warrant of Remand from the Court, if they are charged with a criminal offence and are
suspected to be of unsound mind. The psychiatrist is called upon to give his opinion to the
Court as to the individual’s:
1) Fitness to plead.
2) Criminal responsibility.
3) Treatment and disposal.
a. Fitness to Plead
A basic right of a person accused of a crime is the right to defend himself/herself. In
determining fitness to plead, the psychiatrist is interested in whether the defendant:
i. Understands the nature of the offence.
ii. Knows the difference between pleading guilty and not guilty.
iii. Can follow court proceedings.
iv. Is able to take instructions from and advise counsel.
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These criteria are in practice fairly relative. If the individual is incapable of pleading,
he/she will be remanded till fit or under the minister’s order.
b. Criminal Responsibility
A basic principle in law is that a person is guilty of an act only if he had control over
his own behaviour and chose to commit the unlawful act. Of key importance then, is the
individual’s mental state at the time of the act, whether he had the capacity to form a guilty
intent (mens rea).
A defence can be raised on the following psychiatric grounds that an accused did not
have a sufficient degree of mens rea:
i. Not guilty by reason of insanity.
ii. Diminished responsibility.
iii. Automatism implying absence of or incapacity to form intent.
i. Not guilty by reason of insanity
Section 84 of the Penal Code states that “nothing is an offence which is done by a
person, who, at the time of doing it, by reason of unsoundness of mind, is incapable of
knowing the nature of the act or that he is doing what is either wrong or contrary to law”.
It means that a person with severe mental illness may be unable to discern his
actions or that he had committed an offence. Although acquitted of his crime, such a person
will have to be detained at Woodbridge Hospital until it can be determined that he no longer
poses a danger to himself or others.
ii.
Diminished responsibility
This is used as a defence to murder or at times charges which carry capital
punishment. Thus in exception 7 to Section300 of the Penal Code:
“Culpable homicide is not murder if the offender was suffering from such abnormality of mind
(whether arising from a condition of arrested or retarded development of mind or any
inherent causes or induced by disease, or injury) as substantially impaired his mental
responsibility for his acts and omissions in causing the death or being a party to causing the
death.”
The psychiatrist is involved in establishing the cause of “abnormality of mind” which
is really a legal definition by the Court.
iii.
Automatism
Technically if a person has no awareness and/or control over his actions, he cannot
be held responsible for it. Such lack of control over one’s actions can arise from conditions
like epilepsy or somnambulism, or from external causes like hypoglycaemia or head injury.
However different courts have made different rulings regarding this. It seems that if the
automatism is due to inherent or psychotic cause there is no culpability but also no acquittal.
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c. Treatment and Disposal
Psychiatric opinion is also made on the sort of treatment that is needed. The
assessment of risk of violence is important in recommending a patient for long-term inpatient
treatment. The Criminal Procedure Code empowers the remand of mentally disordered
offenders in hospital. An appointed visitors’ board periodically reviews such patients and
recommends discharge when they feel the patient is no longer a danger to himself or others.
References
1. Kok LP, Cheang M, Chee KT. Diminished Responsibility (with special reference to
Singapore). Singapore: Singapore University Press, 1990.
2. Buglass R, Bowden P. Principles and Practice of Forensic Psychiatry. Edinburgh:
Churchill Livingstone, 1990.
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