FORENSIC PSYCHIATRY

The word “forensic” means “belonging to the courts of law”, and at various times, psychiatry
and the law converge. Forensic psychiatry covers a broad range of topics that involve
psychiatrists' professional, ethical, and legal duties to provide competent care to patients; the
patients' rights of self-determination to receive or refuse treatment; court decisions, legislative
directives, governmental regulatory agencies, and licensure boards; and the evaluation of those
charged with crimes to determine their culpability and ability to stand trial. Finally, the ethical
codes and practice guidelines of professional organizations and their adherence also fall within
the realm of forensic psychiatry.

Forensic psychiatry is the branch of psychiatry that deals with issues arising in the interface
between psychiatry and the law, and with the flow of mentally disordered offenders along a
continuum of social systems. Modern forensic psychiatry has benefited from four key
developments: the evolution in the understanding and appreciation of the relationship between
mental illness and criminality; the evolution of the legal tests to define legal insanity; the new
methodologies for the treatment of mental conditions providing alternatives to custodial care;
and the changes in attitudes and perceptions of mental illness among the public.

“A medical subspecialty that includes research and clinical practice at the interface between
psychiatry and the law .”

“Subspecialty of psychiatry which deals with the application of psychiatric knowledge to legal
issues (Psychiatry in law) and application of legal knowledge to psychiatric issues (law in
psychiatry)”

Law can be divided into 2 branches –

 Criminal law – Defines certain acts as offences against the state and in doing so makes
them punishable. Enforced by, or on behalf of the state
 Civil law – Actions are brought by individuals to establish their rights against another
person, and not by the state.

Case Example #1

A 73-year-old man with terminal lung cancer presents with a GI bleed. His oncologist has told
him he will likely die from his cancer within the next two years. With treatment, he has a 95%
chance of surviving the bleed. Without treatment, his death is near certain. He declines
treatment, stating his quality of life is poor and he does not wish to extend it.

Is this a competent decision?

What questions should we ask?

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Modern forensic psychiatry has benefited from four key developments: the evolution in the
medico-legal understanding and appreciation of the relationship between mental illness and
criminality; the evolution of the legal tests to define legal insanity; the new methodologies for
the treatment of mental conditions that provide alternatives to custodial care; and the changes in
public attitudes and perceptions about mental conditions in general. These four moments
underlie the expansion recently seen in forensic psychiatry from issues entirely related to
criminal prosecutions and the treatment of mentally ill offenders to many other fields of law and
mental health policy.

The theories and practices of forensic psychiatry, as well as their wider ethical and political
implications, have been and continue to be marked by conflict between various views. The
central question of forensic psychiatry – the accountability of human action – relates to
fundamental discussions about what man is and should be, and how human behavior can be
explained. It deals with issues which are situated in the borderland of ethical principles and
scientific knowledge about man. Central modern Western values – human freedom, autonomy
and self-determination – have been and continue to be at stake. Whereas the Christian view of
man stressed freedom of will and responsibility, the enlightened standpoint vacillated between
philosophical voluntarism and scientific determinism.

  Two main interactions:  

1. Psychiatry as applied to the law , i.e. criminal responsibility, competency to stand trial
evaluations, testamentary capacity, malpractice, disability
2.   The law as applied to psychiatry , i.e. laws that affect psychiatric practice,
confidentiality

History of forensic psychiatry:

A) Corpus Juris Civilis – Insane person is compos mentis non est (does not have control of
his mind or non-compos mentis)
B) Henry de Bracton – 1265, devised “wild beast test” Crime is not committed unless a
will to harm is present, and intent is lacking in children and mad men.
C) 1349 – Giovanni was exculpated on grounds of insanity
D) Constitutio Criminalis Carolina – Published in Germany in 1532, recognized that
homicide was not punishable if offender was deprived of his understanding.
E) 1553 – Fitz-Herbert
F) 17th century – Sir Matthew Hale – Understanding pertained to what is right and wrong
(test). Recognised insanity could be partial or limited. Allowed for 2 verdicts – 1. Not
guilty 2. Committed the act but was non-compos mentis
G) Paulus Zacchias, the personal physician of the Pope in 17th century declared that
physicians should have competence in pathological mental states called amentias.
Regarded as father of Forensic psychiatry.

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First important case with regard to criminal responsibility came in 1800 (Hadfield case) . James
Hadfield or Hatfield (1771/1772 – 23 January 1841) attempted to assassinate George III of the
United Kingdom in 1800 but was acquitted of attempted murder by reason of insanity. Hadfield's
early years are unknown but he was severely injured at the Battle of Tourcoing in 1794. Before
being captured by the French, he was struck eight times on the head with a sabre On the evening
of 15 May 1800, at the Theatre Royal, Drury Lane, during the playing of the national anthem,
Hadfield fired a pistol at the King standing in the royal box but missed. Hadfield was tried for
high treason and was defended by Thomas Erskine

The Criminal Lunatics Act 1800 (39 & 40 Geo 3 c 94) was an Act of the Parliament of Great
Britain that required and established a set procedure for the indefinite detention of mentally ill
offenders. It was passed through the House of Commons in direct reaction to the trial of James
Hadfield, who attempted to assassinate King George III Hadfield had developed a bizarre
delusion that God was going to destroy the world and the only way to prevent it was to sacrifice
his own life. The verdict of not guilty was secured.

MCNAUGHTEN CASE

Scottish woodturner who assassinated English civil servant Edward Drummond while suffering
from paranoid delusions.On the afternoon of 20 January 1843 the Prime Minister's private
secretary, civil servant Edward Drummond, was walking towards Downing Street from Charing
Cross when M'Naghten approached him from behind, drew a pistol and fired at point-blank
range into his back. M'Naghten appeared at Bow Street magistrates' court the morning after the
assassination attempt. He made a brief statement in which he described how persecution by the
Tories had driven him to act: “The Tories in my native city have compelled me to do this. They
follow, persecute me wherever I go, and have entirely destroyed my peace of mind... It can be
proved by evidence. That is all I have to say”

Both defense and prosecution agreed that M'Naghten suffered from delusions of persecution.
The prosecution argued that in spite of his "partial insanity" he was a responsible agent, capable
of distinguishing right from wrong, and conscious that he was committing a crime. The verdict in
M'Naghten's trial provoked an outcry in the press and Parliament. Queen Victoria, who had been
the target of assassination attempts, wrote to the prime minister expressing her concern at the
verdict, and the House of Lords revived an ancient right to put questions to judges.

MCNAUGHTEN RULE

Five questions relating to crimes committed by individuals with delusions were put to the 12
judges of the Court of Common Pleas. Mr Justice Maule declined to answer and Chief Justice
Tindal delivered the unanimous answers of the other 11 to the House of Lords on 19 June 1843.
The answer to one of the questions became enshrined in law as the M'Naghten Rules and stated:

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“To establish a defence on the ground of insanity it must be clearly proved, that, at the time of
committing the act, the party accused was labouring 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 that what he was doing was wrong.”

‘ACTUS NON FACIT REUM, NISI MENS SIT REA’ (An act does not make a person guilty
unless his mind is guilty).

INDIAN PENAL CODE (ACT 45 OF 1860, IPC): “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.”

Three major subgroupings

1.   Criminal forensic psychiatry: competence to stand trial, assess criminal responsibility

(insanity), sentencing considerations/capital mitigation, risk/dangerousness, etc.
2.   Civil forensic psychiatry: contracts, testamentary capacity, negligence & malpractice,
disability determination, psychic injury, child abuse & neglect, custody issues, etc.
3. Legal/Regulatory/Admin forensic psychiatry: Ethics (involuntary treatment), risk
assessment, dangerousness, special issues in correctional settings, etc.

Models for the delivery of mental health care to mentally disordered offenders:
 Ambulatory treatment within prison: Mental patients remain with other
inmates in the regular cells and tiers of the prison and come for visits to the
infirmary during psychiatric clinic
 Special wing within the prison: Mental patients are transferred to this wing for
the duration of the episode or duration of their incarceration
 Specialized security hospitals (penitentiary hospitals): Mental patients or those
with special criminal pathology such as sexual offenders are transferred out to
these hospitals, usually for the duration of their incarceration
 Contractual arrangements with outside psychiatric facilities: Mental patients
are transferred out to these hospitals or psychiatric units for the duration of the
episode
 Forensic community corrections: Every effort is made to prevent that mental
patients enter the prison system or, if released from prison, to ensure that they not
go back

Forensic nursing: The International Association of Forensic Nurses (IAFN, 2007) defines
forensic nursing as:

The application of nursing science to public or legal proceedings; the application of the
forensic aspects of health care combined with the biopsychosocial education of the registered

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nurse in the scientific investigation and treatment of trauma and/or death of victims and
perpetrators of abuse, violence, criminal activity and traumatic accidents.

Hufft and Peternelj-Taylor (2003) present the following definition: A nursing specialty practice
that integrates nursing science and forensic science to apply the nursing process to the health
and well-being of individual clients, their families, and communities to help bridge the gap
between the healthcare system and the criminal justice system. (p. 414)

Hancock (2007) suggests that: Forensic nursing is the application of clinical and scientific
knowledge to questions of law, and the civil or criminal investigation for survivors of
traumatic injury and/or patient treatment involving court-related issues. Because this area of
nursing is a continuing pioneering effort, roles, definitions, and educational programs are still
being formulated.

The IAFN (2007) has identified a variety of assignments within which the forensic nurse may
practice. They include the following:

● Interpersonal Violence

A) Domestic violence/sexual assault

B) Child and elder abuse/neglect
C) Physiological/psychological abuse
D) Drug/alcohol abuse

● Public Health and Safety

A) Environmental hazards
B) Food and drug tampering
C) Holistic death investigation
D) Illegal abortion practices
E) Epidemiological issues
F) Anatomical gifts (tissue/organ donation)

● Emergency/Trauma Nursing

A) Automobile and pedestrian accidents

B) Traumatic injuries
C) Suicide attempts
D) Work-related injuries
E) Fatal/near-fatal injuries

● Patient Care Facilities

A) Accidents/injuries/neglect
B) Inappropriate treatments/medication administration
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● Police and Corrections

A) Custody
B) Abuse