Issues of Responsability

I have been taking some time to think about things, since there has been a lot going on in this country and the world over the first few months of the year. Reacting is easy, writing thoughtfully not so much.

One thing that has been on my mind the last while has been the Li trial, which was recently concluded in Manitoba. Let me state first of all that I am neither a legal scholar, nor a graduate in either Psychiatry or Psychology. I am not about to pretend to have expertise in these areas. Like anyone else in the blogosphere, I comment on what I observe. With these caveats in mind, here I go.

My understanding of a charge of first degree murder is that there are two requirements that must be proven - Mens Rea and Actus Reus - the intent and the action resulting in the causation of death. In the Li case, the action causing death was certainly beyond a doubt. There were several witnesses, but couldn't the fact that he had a rather large knife and some plastic bags in his possession be a clear indication of intent? I have been pondering that one for a while and this is where my lack of psychiatric knowlege comes in.

We have been told that Li is Schizophrenic. From what little I do understand about this condition, it isn't something I would wish on my worst enemy. It is a very serious mental illness where the patient can be tormented by halucinations and delusions causing them to act in ways harmful to themselves and/or those around them. While it can be treated, the success of these treatments is highly dependent on support systems and ensuring that the patient keeps up their medications and therapy. And this is where the problems come in.

During the trial, it was learned that Li was picked up in March of 2005 wandering the highway in Ontario. He was taken to a hospital in Etobicoke where he was first diagnosed with schizophrenia and was given medication. He refused to take it. While the doctors did place him on involuntary admission certificates, which allowed them to keep him hospitalized for 2 weeks, he left the hospital after 10 days. No one wants to comment on how this happened, but barring any information to the contrary, he just left. It appears that no one sought to apprehend him.

If the doctors felt that strongly about him being a potential danger to himself that they went to the extraordinary measure of placing him on two involuntary admission certificates, why did no one go looking for him? Part of the reason may have involved Ontario's own laws, which state that the doctor must clearly demonstrate that the patient may cause harm to themselves or others. That can be rather difficult to prove at the best of times, and doctors are not lawyers.

With the massive de-institutionalization of mental patients and closure of these specialized facilities, the burden of dealing with these types of patients in crisis has fallen to General Hospitals, which are not necessarily equipped to deal with these situations. Because they don't always have secure wards available for the sequestration of these types of patients, it is easy to see how it would be possible that he could have left of his own accord. Even with the precautions that they have in Alzheimer's wards there are still people who manage to get out.

The long and the short of it, though, is that Li had been diagnosed, declined medication, and left hospital against medical advice. Three and a half years later a blameless man who had the misfortune of being in the wrong place at the wrong time was murdered. His family has been left without closure or a sense of justice being done because of a verdict of Not Criminally Responsible. They further face the fact, on a yearly basis, that there is a possibility that Li may walk free in the commumity (without a record) if a medical review panel deems him fit for release.

At the end of the day then, who is responsible? The doctors? They did everything they legally could to hospitalize Li. They could only hold him for 14 days. They could not force him to take his medication. What we don't know is if they sent anyone after Li when he left the hospital, or if they had reported it that someone else declined to act on it since he was near the end of the certificates anyway.

What about Mr. Li himself? He was alerted to his condition by doctors, who offered him treatment which he declined. He actively avoided getting treatment. Should someone who has been told that they are mentally ill be held accountable for actions resulting from their illness if they have consciously declined treatment? Again, this is where my lack of knowledge comes in. Would a person who is schizophrenic, who is told he is schizophrenic believe that the doctors telling him this are part of a grand conspiracy out to do him harm?

This case should be the start of a number of discussions that are long overdue:

• Should a Not Criminally Responsible verdict not come with some type of a record attached to the person so that police/hospitals/employers are aware of this pre-existing condition and can plan to deal with an episode if something triggers it?
• Should the devolution of psychiatric patients from specialized institutions be re-examined?
• Should responsible individuals (parent, sibling, spouse) have the right to intervene and force the treatment of their relative in cases where they know that they are not following their treatment?
• Should someone who is diagnosed with a mental illness where they could potentially do harm to themselves or others, or be victimized/harmed by others be allowed to decline treatment?

For me, the last two are especially sticky. My prefered answer would be that adults should be responsible for their own decisions, but that premise assumes rational actors. The honest answer is that sometimes, intervention is necessary. The unfortunate reality is that well-intentioned activists, jurists and politicians have pretty much made that impossible.