Forensic psychiatry and

law in relation to
psychiatry
Dr RJ

No person can treat another person without

that persons consent

If he tries to treat, by injecting him when he

refuses treatment, or even draw blood, it
will be assault

The person who tried to treat is committing

an offence and could be prosecuted

However if the person develops a mental

illness which needs treatment, he has to be
treated even if he refuses

Why?

Because he could be a danger to self and

others if untreated, because of the nature of
some mental illnesses

The person who gets the mental illness also

has a fundamental right to be free of the
illness as he could be suffering

So treatment has to be provided by the

state

But how can you treat a person who refuses

treatment?

Laws have been passed so that the

mentally ill could be treated even against
their will

These laws form the Mental Health Act

(MHA) and most countries in the world have
such laws.

In Sri Lanka the MHA is rather outdated,

having been enacted in the 19 century

These laws in Sri Lanka are called Lunacy

Ordinance of 1873 enacted by the British
when the country was part of their Empire

There have been minor modifications since

then

Last one was in 1957

A new Mental Health Act has been under

preparation from at least 2000

There is a final draft which has been agreed

upon by the relevant parties in 2007

It is yet to be passed in our parliament

So we still follow the Lunacy Ordinance

which is 140 years old with few
modifications

Where can we treat such a patient against

his wishes?

The place or (hospital) should be gazetted

as a designated hospital

Under the MHA valid at present, there is

only one such hospital in Sri Lanka i.e.
Mental Hospital, Angoda now called the
National Institute of Mental Health (NIMH)

In practice, psychiatric patients who are ill

and who have no insight and refuse
admission are still treated against their will
in other psychiatric units in the country

This is a practical necessity though not

quite legal

Otherwise what are the problems?

We are using the in best interests of the

patient clause, in treating such patients
even though against the law and
psychiatrists are putting themselves at risk
of litigation

How can a patient get admitted for

treatment of a psychiatric condition?

He can willingly get admitted like for any

other illness

Then it is called a voluntary admission

This could be to any psychiatric unit or to NIMH Angoda

A patient on voluntary admission has the right and can

discharge himself from the hospital if he decides to go
home

After treatment, he can be discharged, if the

psychiatrist or the medical officer-in-charge decides he
is fit to take treatment outside

Most patients are admitted and discharged this way in

Sri Lanka at present

If a psychiatrically ill patient refuses

admission or treatment, the MHA can be used

A relative has to apply to a District Court (DC)

with a medical report from any medical officer
that the person needs observation and
treatment for a mental disorder

The District Judge then decides and orders

admission to NIMH as a DC admission

This order is to detain the patient in the NIMH up to 28 days

He can be discharged only by the District Judge. The

psychiatrist has to send a report to the DC. If the
psychiatrist reports that he is fit for discharge, the Judge
will discharge him. If he reports that he needs further
treatment and requests extension, the Judge will order him
detained further.

If at the end of 28 days patient has made progress but still

needs treatment which he is willing to take, he can be
made a voluntary patient to remain in NIMH for whatever
period he needs, for a more complete recovery

If a person behaves irrationally in a public

place the police have the power to take him
to NIMH and he will be admitted for 72
hours on an emergency order

He has to be examined by a psychiatrist

and if found ill the admission is converted
to a DC admission by reporting to DC. If the
psychiatrist finds him not ill he would be
discharged

If a person who has committed a crime is

suspected to be mentally ill, the judge who
is the Magistrate, (as such cases are first
heard in a magistrates court (MC) ) would
order the suspect be assessed by a
psychiatrist who may report that he be
assessed in a mental hospital viz. NIMH

Such persons are admitted as MC

admissions to a secure ward there

The psychiatrist has to assess the accused

and has to decide whether he is fit to
plead

If he has a major psychiatric illness, he may

be unfit to plead

Then he has to be treated in the secure

ward

If he recovers from the illness he may

become fit to plead, then the case against
him will proceed

If he is found guilty of the crime but he is

also mentally ill, it is not proper for a
civilised society to punish a mentally ill
person

What should we do?

Should we release him?

But he has committed a crime so we cannot

do that

He should not be sent to prison but to a

hospital

For how long should he be kept in hospital?

His dangerousness and the odds of him

doing a crime again have to be considered

This is very difficult to predict

So in some countries they are never

released

They are the criminally insane

The psychiatrist has to give evidence in

courts for the judge to decide whether the
mentally ill person is guilty of the crime or
not guilty by reason of insanity

In Sri Lanka McNaughton rules are used in

this decision

In 19 century Briton, McNaughton

developed a belief that the Liberal party
which was governing the country was
persecuting him. So he wanted to kill the
leader of the party Sir Robert Peel who was
the Prime Minister. He shot at the person
who he thought was the PM and killed him,
but it was his secretary who got shot.

The public wanted McNaughton hanged but he

was clearly deluded and insane

So the judges brought in some rules to decide

what should be done in similar cases when an
insane person has committed a major crime

The rules are called McNaughton rules and are

very strict and very few will be found not guilty
by reason of insanity if they are strictly applied

Sometimes the person has committed the major

crime but his mental state may have influenced
his thinking

So is he fully responsible?

The concept of diminished responsibility is

considered here

This concept looks very rational but it is not in

Sri Lankan law yet

Infanticide

Killing of a child below 12 months by the mother

When it occurs within 24 hours of the birth, mother is not usually

mentally ill, baby is unwanted, mother is distressed, often young
and unable to cope to bring up the child

When the killing is after 24 hours, the mother usually has a mental
illness e.g. post partum psychosis, psychotic depression

There is obvious diminished responsibility here

Maximum sentence is two years in contrast to murder which could

be life

What sort of psychiatric illnesses cause

patients to commit crimes?

Personality disorders antisocial,

Schizophrenia may carry out command

hallucinations, matricide

Delusional disorders jealous patients may

kill their spouses/partners

Depressions some mothers kill their

children due to delusions, then kill
themselves, it is recognised that some
depressives do minor crimes like shop-lifting

Very occasionally manic patients

Patients with alcohol and drug abuse

Testamentary capacity capacity to make a

will

Medical doctors could be asked to assess this

capacity

Whether person understands what a will is,

whether he knows the extent of his possessions,
whether he knows to whom he should give his
property in normal circumstances, whether his
judgement is intact and not affected by any
psychiatric phenomena like delusions