Psychiatry and the law

In Rex vs. Arnold (1724) it was held that to avail himself of the defense of insanity "a man must be totally deprived of his understanding and memory, so as not to know what he is doing, no more than an infant, a brute, or a wild beast." Although there has been some modification of this formula in most jurisdictions, the courts still operate under the McNaghten Rule (1843) which is no more logical and actually is more difficult to apply. That such a situation exists in 1956 is a reflection on the indifference of society-and particularly the courts which it elects-as well as on the failure of modern psychiatry to communicate its viewpoint to society. If we are to correct the sad formulae of the "right and wrong" and "policeman at the elbow" tests, we must have more study and better methods of communication in this area.A similar state of confusion exists in the methods of commitment of mentally ill people to psychiatric hospitals. The methods prescribed by law are archaic and cruel-and again reflect the failure of modern psychiatry to communicate its understanding to the legislatures and courts. There are many other areas of conflict between law (which looks to the past for its insights) and psychiatry (which seeks for its concepts in the current scientific advances).     

Final report of the Netherlands State Commission on Euthanasia: an English summary

An unofficial summary is provided of the Final Report of the Netherlands State Commission on Euthanasia, submitted to the Minister of Welfare, Health and Cultural Affairs and the Minister of Justice on 19 Aug 1985. It describes the establishment of the State Commission, its working methods, and its recommendations for changes in the Criminal Code with regard to euthanasia and assisted suicide. The Commission proposes that the Code be amended so that the intentional termination of another person's life at the latter's request would not be an offense if carried out by a doctor on a patient who is "in an untenable situation with no prospect of improvement." It makes recommendations regarding minors, the mentally handicapped, and prisoners, and regarding procedures for funeral arrangements and death certificates, the noninvolvement of parties other than patients and physicians in decision making, and the preparation and dispensing of drugs designed to terminate life.     

Neuroscience and legal determination of criminal responsibility

Neuroscience is increasingly identifying associations between biology and violence that appear to offer courts evidence relevant to criminal responsibility. In addition, in a policy era of 'zero tolerance of risk', evidence of biological abnormality in some of those who are violent, or biological markers of violence, may be seized on as a possible basis for preventive detention in the interest of public safety. However, there is a mismatch between questions that the courts and society wish answered and those that neuroscience is capable of answering. This poses a risk to the proper exercise of justice and to civil liberties.     

Proximate personhood as a standard for making difficult treatment decisions: imperiled newborns as a case study

... The standard of personhood is gaining increased attention and prominence. The essential claim is that only individuals with capacities for significant cerebral functioning possess a morally unique claim to existence. Persons are defined as individuals who are self-aware and capable of self-direction (Engelhardt), able to enter meaningful relationships (McCormick), capable of minimal independent existence (Shelp), and in possession of a minimal 20-40 I.Q. (Joseph Fletcher). These are "high standard" personhood positions (those holding higher-brain related criteria). It is a commonplace with most such positions that newborns -- all newborns -- are not, strictly speaking, persons. That is, newborns are not self-aware, intentionally choosing individuals.... The thesis of this essay is that a developing individual's right to life increases as he or she approaches the threshold of personal life. That is, the more a newborn approximates -- or is proximate to -- undisputed personhood (e.g. the status of readers of this essay), the greater his or her claim to life. The two pivotal criteria for determining personhood are the potentiality for and development toward becoming an undisputed personal being. I am presupposing, for purposes of argument, that the handicapped infant would not be an excessive familial burden or an inordinate financial load for society, one an ancient and the other a modern criterion. That condition granted, this essay contends that if an imperiled newborn is reasonably projected to reach at least minimal personal capacity, treatment should be given.     

Ouderen die ‘klaar met leven’ zijn

There has been a debate for over a decade in The Netherlands about whether physicians should be allowed to provide assistance with suicide to older people who are 'weary of life'. Actual knowledge about these older people is missing in this debate. The purpose of this article is to explore and discuss the expectations older people who are 'weary of life' have of their future, and to what extent they perceive their suffering as hopeless. In this qualitative study, 31 older people who were 'weary of life' were interviewed. The results of this study show that most respondents who were 'weary of life' did not plan to end their life within a short time frame. The burden to their loved ones played a large role in their decision in addition to the awareness of still having reasons to live. Most respondents tried not to think too much about the future, and hoped death would come soon. Most respondents could not name a condition that would diminish their wish to die, that they also found desirable and feasible. The results of this study suggest that people who develop thoughts about death do so when they give up finding solutions to improve their situation.     

Some fallacies in the computation of paternity probabilities.

Legal identification of fathers by means of a "paternity probability" has been used in European courts for decades, and has recently been introduced into American courts and accepted by some of them. The voluminous literature on this topic contains virtually no fundamental criticism of the logical basis for the probabilistic computations. Here I suggest that the "paternity probability" suffers from three basic fallacies: (1) contrary to claims, the figure is not, in fact, the probability that the alleged father is the true father, (2) the denominator of the likelihood ratio used in the computation is driven by (sometimes self-contradictory) assumptions and is not based on facts, and (3) post-inclusionary computations are based on speculation about genotypes that does not constitute scientific evidence. It is recommended that pending the resolution of these difficulties "paternity probabilities" should not be computed or introduced as positive evidence of paternity.     

Implementation of shared decision making by physician training to optimise hypertension treatment. Study protocol of a cluster-RCT

ABSTRACT: BACKGROUND: Hypertension is one of the key factors causing cardiovascular diseases which make up the most frequent cause of death in industrialised nations. However about 60% of hypertensive patients in Germany treated with antihypertensives do not reach the recommended target blood pressure. The involvement of patients in medical decision making fulfils not only an ethical imperative but, furthermore, has the potential of higher treatment success. One concept to enhance the active role of patients is shared decision making. Until now there exists little information on the effects of shared decision making trainings for general practitioners on patient participation and on lowering blood pressure in hypertensive patients. METHODS: In a cluster-randomised controlled trial 1800 patients receiving antihypertensives will be screened with 24 h ambulatory blood pressure monitoring in their general practitioners' practices. Only patients who have not reached their blood pressure target (approximately 1200) will remain in the study (T1 -- T3). General practitioners of the intervention group will take part in a shared decision making-training after baseline assessment (T0). General practitioners of the control group will treat their patients as usual. Primary endpoints are change of systolic blood pressure and change of patients' perceived participation. Secondary endpoints are changes of diastolic blood pressure, knowledge, medical adherence and cardiovascular risk. Data analysis will be performed with mixed effects models. DISCUSSION: The hypothesis underlying this study is that shared decision making, realised by a shared decision making training for general practitioners, activates patients, facilitates patients' empowerment and contributes to a better hypertension control. This study is the first one that tests this hypothesis with a (cluster-) randomised trial and a large sample size.Trial registrationWHO International Clinical Trials: http://apps.who.int/trialsearch/Trial.aspx?TrialID=DRKS00000125.     

General practitioners,court reports,and alcohol related offences.

General practitioners may have to submit medical reports to the courts on patients who have a suspected alcohol problem, 98% of such requests coming from magistrates courts. When, however, a defendant decides to plead "not guilty" to an offence on the grounds of intoxication general practitioners are often asked to prepare a report to support the plea. We present guidelines on preparing such reports and discuss the implications of the contents.     

SIMPLE: implementation of recommendations from international evidence-based guidelines on caesarean sections in the Netherlands. Protocol for a controlled before and after study

Background

Caesarean section (CS) rates are rising worldwide. In the Netherlands, the most significant rise is observed in healthy women with a singleton in vertex position between 37 and 42 weeks gestation, whereas it is doubtful whether an improved outcome for the mother or her child was obtained. It can be hypothesized that evidence-based guidelines on CS are not implemented sufficiently. Therefore, the present study has the following objectives: to develop quality indicators on the decision to perform a CS based on key recommendations from national and international guidelines; to use the quality indicators in order to gain insight into actual adherence of Dutch gynaecologists to guideline recommendations on the performance of a CS; to explore barriers and facilitators that have a direct effect on guideline application regarding CS; and to develop, execute, and evaluate a strategy in order to reduce the CS incidence for a similar neonatal outcome (based on the information gathered in the second and third objectives).

Methods

An independent expert panel of Dutch gynaecologists and midwives will develop a set of quality indicators on the decision to perform a CS. These indicators will be used to measure current care in 20 hospitals with a population of 1,000 women who delivered by CS, and a random selection of 1,000 women who delivered vaginally in the same period. Furthermore, by interviewing healthcare professionals and patients, the barriers and facilitators that may influence the decision to perform a CS will be measured. Based on the results, a tailor-made implementation strategy will be developed and tested in a controlled before-and-after study in 12 hospitals (six intervention, six control hospitals) with regard to effectiveness, experiences, and costs.

Discussion

This study will offer insight into the current CS care and into the hindering and facilitating factors influencing obstetrical policy on CS. Furthermore, it will allow definition of patient categories or situations in which a tailor-made implementation strategy will most likely be meaningful and cost effective, without negatively affecting the outcome for mother and child.

Trial registration

http://www.clinicaltrials.gov: NCT01261676     

Genes,environment and responsibility for violent behavior: “Whatever genes one has it is preferable that you are prevented from going around stabbing people”

For the legal system to function effectively people are generally viewed as autonomous actors able to exercise choice and responsible for their actions. It is conceivable that genetic traits associated with violent and antisocial behavior could call into question an affected individual's responsibility for acts of criminal violence. Evidence concerning genes associated with violent and antisocial behavior has been introduced in criminal courts in the USA and Italy, either alone or with associated environmental factors. One example of a “genetic defense” is based on low levels of monoamine oxidase A (MAOA) activity, with a prevalence of around 30% in Caucasian males. In countries with trial by jury it is particularly relevant to consider the views of publics on criminal liability and the significance they assign to evidence citing genetic influences on behavior. This article draws on largely qualitative research looking at participants' explanations of, and assigning of responsibility for, violent and antisocial behavior where environmental or genetic influences are claimed. Genetic factors were not viewed deterministically by participants but were considered by most to be irrelevant to personal responsibility. Notions of human agency, free will and choice were crucial to explanations of problem behaviors and ensured that offenders could be held responsible despite evidence on environmental and genetic factors.     

Cost-Effectiveness of Including a Nurse Specialist in the Treatment of Urinary Incontinence in Primary Care in the Netherlands

Objective

Incontinence is an important health problem. Effectively treating incontinence could lead to important health gains in patients and caregivers. Management of incontinence is currently suboptimal, especially in elderly patients. To optimise the provision of incontinence care a global optimum continence service specification (OCSS) was developed. The current study evaluates the costs and effects of implementing this OCSS for community-dwelling patients older than 65 years with four or more chronic diseases in the Netherlands.

Method

A decision analytic model was developed comparing the current care pathway for urinary incontinence in the Netherlands with the pathway as described in the OCSS. The new care strategy was operationalised as the appointment of a continence nurse specialist (NS) located with the general practitioner (GP). This was assumed to increase case detection and to include initial assessment and treatment by the NS. The analysis used a societal perspective, including medical costs, containment products (out-of-pocket and paid by insurer), home care, informal care, and implementation costs.

Results

With the new care strategy a QALY gain of 0.005 per patient is achieved while saving €402 per patient over a 3 year period from a societal perspective. In interpreting these findings it is important to realise that many patients are undetected, even in the new care situation (36%), or receive care for containment only. In both of these groups no health gains were achieved.

Conclusion

Implementing the OCSS in the Netherlands by locating a NS in the GP practice is likely to reduce incontinence, improve quality of life, and reduce costs. Furthermore, the study also highlighted that various areas of the continence care process lack data, which would be valuable to collect through the introduction of the NS in a study setting.     

Canadian Mennonites and individuals residing in the Friesland region of the Netherlands share the same molecular basis of 17α-hydroxylase deficiency

Summary A common mutation within the CYP17 gene that causes 17-hydroxylase deficiency, a form of congenital adrenal hyperplasia, has been found by direct sequencing of polymerase chain reaction (PCR) fragments of genomic DNA from six families residing in the Friesland region of the Netherlands. The mutation is a 4-base duplication within exon 8 of the CYP17 gene, which alters the reading frame encoding the C-terminal 26 amino acids of cytochrome P45017. This mutation has previously been found in two Canadian patients who are members of ostensibly unrelated Mennonite families. The Mennonite Churches derive their name from Menno Simons, an early leader of the sect in Friesland. Presumably this 4-base duplication appeared within the Friesian population prior to emigration of the Mennonites from the Netherlands.     

Lessons for health care rationing from the case of child B.

More details have emerged about the child B leukaemia case with the publication of the All England Law Report on the Appeal Court decision. At the time the view was widely held that the controversy might have been avoided if the responsible health authority had consulted the public. The law report reveals, however, that the courts adopted a moral language widely at variance with that of the patient''s doctor. The courts were concerned to support a utilitarian decision procedure based on calculations of the greatest overall good; the doctor was concerned with the best interests of a sick child. The doctor-patient relationship may be damaged when public consideration transforms the issue in this way. Also, the Appeal Court supported a decision which claimed to have "weighed" opposing evaluations, but it excused the health authority from describing how that weighing took place. One of the main criticisms of the utilitarian approach, however, is that weighing of this type is extremely difficult to justify. By its ruling the court has made legal challenge on the grounds of inadequate consultation virtually impossible to substantiate.     

SHOULD A BRAIN-DEAD PREGNANT WOMAN CARRY HER CHILD TO FULL TERM? THE CASE OF THE “ERLANGER BABY”

In October 1992 a young woman died in a car accident. She was pregnant and her fetus appeared to be unhurt, so a decision had to be made: should the mother's body be artificially supported in order to give the fetus a chance to live? The situation became a public question that split the nation in two. One side demanded -- that the young woman -- and her child -- be left to die in dignity. The other side referred to the unborn child's right to live and therefore wanted the body of the woman maintained until the fetus could be born. The following report consists of four parts. The first describes the case. In the second part the decision and its official justification are presented. The third part offers an impression of the unusual emotional reactions to which the case of the "Erlanger Baby" has given rise. The final part is a discussion of the issue and some comments.     

A case of the adoption of an infant chimpanzee by a suckling foster chimpanzee

Chimpanzees in captivity have grown up in a rather unnatural social environment and there frequently are problems when they have to nurse their own offspring. It is most remarkable that a chimpanzee mother in a captive colony, who had lost her child almost immediately after birth, adopted without problems a five-week-old infant, which had been reared by humans from the day of its birth. Successful adoption has not been reported for feral chimpanzees; similar cases in captivity are not known.     

Prognostic value of X-chromosome inactivation in symptomatic female carriers of dystrophinopathy

Background

Neonatal screening for Pompe disease has been introduced in Taiwan and a few U.S. states, while other jurisdictions including some European countries are piloting or considering this screening. First-tier screening flags both classic infantile and late-onset Pompe disease, which challenges current screening criteria. Previously, advocacy groups have sometimes supported expanded neonatal screening more than professional experts, while neutral citizens' views were unknown. This study aimed to measure support for neonatal screening for Pompe disease in the general public and to compare it to support among (parents of) patients with this condition. The study was done in the Netherlands, where newborns are not currently screened for Pompe disease. Newborn screening is not mandatory in the Netherlands but current uptake is almost universal.

Methods

A consumer panel (neutral group) and (parents of) patients with Pompe disease (Pompe group) were sent information and a questionnaire. Responses were analyzed of 555 neutral and 58 Pompe-experienced informants who had demonstrated sufficient understanding.

Results

87% of the neutral group and 88% of the Pompe group supported the introduction of screening (95% CI of difference -10 to 7%). The groups were similar in their moral reasoning about screening and acceptance of false positives, but the Pompe-experienced group expected greater benefit from neonatal detection of late-onset disease. Multivariate regression analysis controlling for demographics confirmed that approval of the introduction of screening was independent of having (a child with) Pompe disease. Furthermore, respondents with university education, regardless of whether they have (a child with) Pompe disease, were more likely to be reluctant about the introduction of screening than those with less education, OR for approval 0.29 (95% CI 0.18 to 0.49, p < 0.001).

Conclusions

This survey suggests a rather high level of support for newborn screening for Pompe disease, not only among those who have personal experience of the disease but also among the general public in the Netherlands. Optional screening on the basis of informed parental consent is probably unrealistic, underlining the need for new guidelines to help policymakers in their consideration of newborn screening for broad phenotype conditions.     

Documenting wife abuse: a guide for physicians

An estimated 12% to 30% of women are assaulted by their male partners at least once during the relationship. Therefore, in their everyday practice, physicians are likely to encounter women who have suffered domestic abuse. The authors define wife abuse, outline epidemiologic aspects and discuss common signs and symptoms. In cases of suspected or confirmed abuse, it is very important for physicians to document the details of the injuries, the patient visit, any treatment and follow-up as well as to screen for associated conditions and ensure that any samples taken are not tampered with. When asked to disclose information by police or courts, physicians need to know when they are obliged to submit copies of their patients'' medical records, when patient consent is required, what information should be divulged and how to defend this information in court. The authors present information about the necessary, relevant and appropriate evidence to be collected and documented for both medical and legal purposes. They also discuss the criminal justice system and the role of physicians in legal proceedings concerning wife abuse.     

PSYCHIATRY AND THE LAW

In Rex vs. Arnold (1724) it was held that to avail himself of the defense of insanity “a man must be totally deprived of his understanding and memory, so as not to know what he is doing, no more than an infant, a brute, or a wild beast.” Although there has been some modification of this formula in most jurisdictions, the courts still operate under the McNaghten Rule (1843) which is no more logical and actually is more difficult to apply. That such a situation exists in 1956 is a reflection on the indifference of society—and particularly the courts which it elects—as well as on the failure of modern psychiatry to communicate its viewpoint to society. If we are to correct the sad formulae of the “right and wrong” and “policeman at the elbow” tests, we must have more study and better methods of communication in this area.A similar state of confusion exists in the methods of commitment of mentally ill people to psychiatric hospitals. The methods prescribed by law are archaic and cruel—and again reflect the failure of modern psychiatry to communicate its understanding to the legislatures and courts.There are many other areas of conflict between law (which looks to the past for its insights) and psychiatry (which seeks for its concepts in the current scientific advances).     

Darwinian criminality theory: a tragic chapter in history.

Darwinists once believed that individual human beings occasionally reverted, both physically and mentally, to a prehuman stage of evolutionary development. This person was called an atavistic criminal type. As a result of this belief, the focus in Darwinian criminology was on identifying the criminal type who should be imprisoned permanently to protect society, even if the particular offense committed was minor. Conversely, if a "non-criminal type" committed even a serious offense, it was an aberration, and therefore, they concluded, imprisonment would serve no purpose. Darwinian criminologists believed punishment must fit the criminal and not the crime. Criminologists widely adopted this theory to explain crime and, as a result, it influenced both public opinion and official policy. The "criminal physical type" stereotype is still very much with us, even though the theory of evolutionary throwbacks (atavisms) as a causative factor in criminality was empirically disproved decades ago.     

A case study of mother-son transfer in mountain gorillas

In mountain gorillas (Gorilla g. beringei), male immigration in bi-sexual units is rare. This paper presents the case of a nearly weaned male infant gorilla who followed his mother in her transfer. This case was recorded in the study population at the Kariske Research Center in 1988. The data come from observation in Group B (on 12 days just prior to the transfer and on 54 days after the transfer over a period of 6 months). The situation of the infant did match the conditions in which infanticide occurs in gorillas, but he was not killed, despite receiving male aggression and being wounded twice. In fact, both the mother and the infant received male aggression more frequently than the long term residents in the group. The aggression received by the mother decreased after she mated with the males and after she weaned the infant. The aggression received by the infant, however, did not decrease after his mother mated with the males, and increased in intensity. The infant reacted fearfully to male aggression, in marked contrast to his mother, who reacted either with indifference, or by simply avoiding the males. The aggression eventually stopped, and the infant became a blackback in Group B. Evolutionarily, the death of the infant would not have markedly accelerated the mother's return to estrus, but the death of the infant could still have benefitted the males, by decreasing the reproductive output of a competitor. Adult male gorillas are also presumably selected to resist male immigration. Proximately, the aggression directed towards the infant was not related to mating access to the mother. The sex of the infant may contribute to explain the post-transfer male aggression, but data on the integration of old female infants in a new group is needed to test whether the sex of the infant has an effect on their vulnerability to infanticide. Also, the intense fear displayed by the infant may have played a role in prompting male aggression.