Abraham Rudnick, MD, PhD, CPRP, FRCPC, CCPE.
Professor Department of Psychiatry and Behavioural
Neurosciences, McMaster University Email:harudnick@hotmail.com
Abstract: The legal determination “not criminally responsible”
in Canada and its equivalents elsewhere seem to be based on an assumption that
severe mental illness (when active) disrupts choice and hence eliminates or
reduces responsibility for the person’s behaviour. I demonstrate that choice,
as a fundamental characteristic of being human, is an important determinant of behavior
that is not necessarily impacted by severe mental illness (even when active). I
argue that choice may be influenced in part by the person’s moral reasoning. I
suggest implications for primary, secondary and tertiary prevention related to facilitating
moral reasoning and hence acceptable choice and behaviour.
Keywords: Behaviour, choice, criminal responsibility, mental
illness, moral reasoning
Acknowledgement: This article is based in part on the author's presentation at
the Radical Collaborations conference in Hamilton, Ontario, Canada on December
4, 2015.
Disclosures: None.
Disclosures: None.
Soon after the advent of modern psychiatry, a medico-legal
assumption seems to have spread, at least in much of the Western world, such
as with the M’Naghten rule in England (http://legal-dictionary.thefreedictionary.com/M'Naghten+Rule). This is the assumption that severe mental illness
(when active) disrupts choice – by disrupting knowledge (of the related behaviour
as harmful) or judgment (that it is wrongful to harm others with this behaviour)
– and hence eliminates or reduces the person’s responsibility for the related behaviour.
This seems to still be the case, such as the determination of “Not Criminally
Responsible” (NCR) in Canada and equivalents in other jurisdictions. Yet the
relation between severe (or other) mental illness and choice is not a simple
one.
Existentialist scholars, such as Sartre, have argued
that choice is fundamental to human existence, i.e., to being a person (https://www.youtube.com/watch?v=qpXNRrtuo38). Furthermore, choice is arguably constrained but
never eliminated for a person, e.g., even at gunpoint or when fully paralyzed a
person can choose to think in more than one way about the situation. Are people
with severe mental illness such as schizophrenia excluded from this category of
personhood?
A biblical example that is not far removed from forensic
psychiatry’s experience may help clarify matters. Abraham, the first Jew, chose
to sacrifice his son Isaac at God’s heard command (Genesis, chapter 22, verses
2-3). In contemporary society, if someone tries to harm his or her relative
because a voice (psychiatrically considered to be a psychotic experience) tells
him or her to do that, they would typically be considered NCR. Could someone
like Abraham choose differently? Obviously yes, e.g., at the risk of being
punished by God.
For our purpose, the question of the related cost-benefit calculation is secondary to the question of the existence of choice. In this light, only if the person thought that he or she was acting in self defence, e.g., that the kin intends to kill him or her now and that there is no physical escape as an alternative to self defence, would his or her choice to harm the kin be morally acceptable, at least according to common morality (http://jme.bmj.com/content/37/10/588.full.pdf+html). So the mere fact of being psychotic while behaving violently does not necessarily remove moral responsibility of the mentally ill offender.
For our purpose, the question of the related cost-benefit calculation is secondary to the question of the existence of choice. In this light, only if the person thought that he or she was acting in self defence, e.g., that the kin intends to kill him or her now and that there is no physical escape as an alternative to self defence, would his or her choice to harm the kin be morally acceptable, at least according to common morality (http://jme.bmj.com/content/37/10/588.full.pdf+html). So the mere fact of being psychotic while behaving violently does not necessarily remove moral responsibility of the mentally ill offender.
What could explain such choice and related behaviour?
I suggest that moral reasoning (http://plato.stanford.edu/entries/reasoning-moral/) is key to making choices, including difficult ones
such as whether to follow a commanding voice to harm another person. With such
moral reasoning, Abraham may have refused God’s command to sacrifice Isaac (in
which case Judaism may have developed differently if at all). Thus, moral
reasoning may influence choice, involving a set of mediators of choice in
relation to behavior. As such, it could be rigorously studied and intervened on
pre-morbidly, as part of early intervention, and for recidivism, to try to
reduce risk of violence at all levels of prevention. Basic and applied research
is needed to examine the relation between moral reasoning, choice and behaviour
of mentally ill people and others.
