Call Whom Irresponsible?

by James S. Reinhard, MD, FAPA I don’t remember being taught a lot about responsibility during residency training. I mean our patient’s responsibility, not ours. Sure, we had plenty of indoctrination, directly and indirectly, into the responsibilities of being a physician. We learned quickly enough what responsibilities we had that first night on call. We remember well those first medication orders written, endorsed with just our name, with no co-signer to blame.

Our broad responsibilities as physicians are clear. But what about individuals suffering from mental illness? That is not so well defined. There is a wide range of responses to the behavior exhibited by those with psychiatric illnesses. For example, some mental health professionals believe that just a hint at a self-injurious thought by a person with a history of Axis II traits automatically shifts the responsibility for ensuring safety to the professional rather than the person presenting the problem. Other providers wouldn’t think twice about pressing charges against the assaultive, floridly paranoid person who had just been pulled out of his cardboard home near the interstate overpass. Execution of people with mental retardation has recently been and continues to be debated in this nation’s supreme court and in our Commonwealth’s General Assembly. Lay people are understandably confused about assigning responsibility for behavior exhibited by those with mental illness and mental retardation, if the professionals are worlds apart.

Very few don’t have an opinion about behavior such as that exhibited by Mrs. Yates, who is the most recent focus of the ongoing controversy about the utility of the insanity defense. Views range from outrage and enthusiastic endorsement of a capital sentence to the frequently heard, “She’d HAVE to be out of her mind to do something like that!”

Forensically trained psychiatrists and other clinicians have experience evaluating and formulating an opinion about criminal responsibility. We can recite landmark cases from M’Naughten to the Wild Beast Test. From the Durham Rule to the American Law Institute that outline standards that courts use and have used to determine the culpability of a person who has committed a criminal act. But it is harder to codify the actual essence of responsibility. It is much more difficult for us to explain what we are really evaluating; what are the minimum requirements that make a human being responsible for his or her behavior.

The ability to reflect upon ourselves and reflect on what we are doing appears to be a unique feature of human consciousness. Another basic and unique human thought process is the Theory of Knowledge (TOK) concept of appreciating that there are separate thoughts and experiences going on in the head of another human being. These basic thought functions not only separate us from other animals, but are usually present in driving the vast majority of human behavior. Obviously there are brain conditions where these functions are impaired. A few of these types of basic cognitive processes may be able to be identified as the essential requirements for being held accountable for behavior in our society.

It is critical that our profession become clearer about that for which we are responsible and that for which our patients are responsible. To ascribe more responsibility to those who don’t have the tools to be responsible is an injustice. To hold those who can be held responsible to a lesser standard is not only an injustice, but may enable, infantalize, or further stigmatize people who already have their fair share of stigma.

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