Critically evaluate the evolution of the meaning of 'disease of the mind'.

University Degree Medicine and Dentistry

Insanity Essay – Written Work, Spring Term

Critically evaluate the evolution of the meaning of ‘disease of the mind’:

The purpose of this essay is to examine a number of insanity cases paying particular attention to how the meaning of ‘disease of the mind’ has developed and come to the meaning that it currently adopts today.

Disease of the mind in this context is a legal term not to be confused with that used by the medical profession in relation to what constitutes a ‘mental disorder’. The law’s main interest is concerned with the question whether the accused is to be held legally responsible for his acts. A person cannot be legally blameworthy for an offence if his mental state was not fitting with the alleged crime. The criteria as to a person’s sanity are laid down in the M’Naghten Rules (1943):

Every man is presumed to be sane and possess a sufficient degree of reason to be responsible for his crimes until the contrary is proven.

(2) To establish the defence of insanity, it must be proven that, at the time of committing the act, the defendant was labouring under such a defect of reason, arising from a disease of the mind, that he did not know the quality of the act. Alternatively, if he did know the nature and quality of the act, that he did not know that what he was doing was wrong.

Problems arise between the different terminology employed by psychiatrists and the lawyer. The medical witness has to decide whether to adopt the psychiatric register or convert these terms to keep in line with legal jargon. The difficulty between these two ‘languages’ begins when what constitutes disease of the mind in a medical sense is not necessarily the same as that which meets the criteria of insanity in law. This in turn could lead to confusion on part of the jury when it comes to determining whether the accused was legally insane at the time the act was committed.

In order to address the question of what constitutes disease of the mind it is necessary to examine the case of R v. Kemp [1957] 1 QB 399. Here it was argued that ‘disease of the mind’ meant there had to be an organic disease of the brain which had caused degeneration of the brain. The accused was charged with causing grievous bodily harm to his wife after attacking her with a hammer. He suffered from ateriosclerosis and although the disease had not reached a stage at which he demonstrated any sign of mental trouble, it led to a congestion of blood in the brain causing a temporary lapse of consciousness in which state the attack was made. In this case their was conflicting medical evidence. Dr Fenton argued that this physical disease induced a mental condition of melancholia and that it was as a result of this that the accused committed the act. Melancholia was accepted as being a disease of the mind for the purposes of this case. Conversely, Dr Gibson did not view this episode as a result of a disease of the mind, rather a temporary disturbance of the faculty of understanding. Devlin J. said, “In my judgement the condition of the brain is irrelevant and so is the question of whether the condition of the mind is curable, transitory or permanent.” Temporary insanity is sufficient to satisfy M’Naghten Rules. It does not matter whether it is incurable and permanent or not.

This is a preview of the whole essay

Devlin J. stated in his judgement, “Hardening of the arteries is a disease which is shown on the evidence to be capable of affecting the mind in such a way as to cause a defect, temporarily, or permanent, of its reasoning, understanding etc., and so is in my judgement a disease of the mind which comes within the meaning of the Rules”. Devlin J. continued that the words ‘disease of the mind’ were included in the M`Naghten to limit the words ‘defect of reason’ which were not intended to apply to defects of reason ‘caused simply by brutish stupidity without rational power’. This sought to distinguish the untrained mind from the diseased mind. Devlin J. rejected the arguments of the defence that this was merely a case of automatism and ruled that the defence being raised was one of insanity. The jury in Kemp reached the verdict of guilty but insane.

Lord Denning, in the case of Bratty v. A.-G for Northern Ireland [1963] A.C 386, approved the decision of Devlin J. that arose in Kemp. Lord Denning furthered the case by stating, “any mental disorder which has manifested itself in violence and is prone to recur is a disease of the mind. At any rate it is the sort of disease for which a person should be detained in hospital rather than be given an unqualified acquittal.” This area of law lacked validity since diseases of the mind may manifest themselves in other ways that do not involve violence, such as pyromania. Furthermore, there are conditions which manifest themselves in violence which do not fall within the definition of disease of the mind.

The determining criteria as to whether a condition amounts to disease of the mind is whether it arises from a factor internal to the defendant (i.e. it must arise from some psychosis, organic or functional disorder, injury or other inherent condition). If the defect of reason arises from some factor external to the defendant, there can be no finding of insanity however it may give rise to non-insane automatism. An important case to be considered in relation to this issue is that of R v. Quick [1973] QB 910. Here the appellant (Q) was a diabetic nurse at a mental hospital and was charged with assaulting a patient occasioning actual bodily harm. Q pleaded not guilty and relied on the defence of automatism. He gave evidence that he had taken insulin as prescribed on the morning of assault, had drunk a quantity of spirits and eaten little food thereafter and had no recollection of the assault. The appellant called medical evidence to the effect that his condition at the material time was consistent with that of hypoglycaemia. The judge ruled that that evidence could only support a defence of insanity, not automatism. Q then pleaded guilty and later appealed against conviction. The Court of Appeal quashed his conviction ruling that the cause of his condition was not his diabetes but his use of insulin which was an external factor and his defence of automatism should have been left to the jury. Lawton LJ interpreted the phrase ‘disease of the mind’ to mean a ‘malfunctioning of the mind caused by disease’ whereas a ‘malfunctioning of the mind of transitory effect caused by some external factor such as violence, drugs including anaesthetics, alcohol and hypnotic influences cannot fairly be said to be due to disease’.

The next case to be considered is that of R v. Sullivan [1984] AC 156. Here the appellant was charged with inflicting GBH on P his friend by kicking him about the head and body. The appellant claimed that the attack was committed in the course of an epileptic seizure and he was not aware of doing it. The appellant had pleaded guilty to assault occasioning ABH after the trial judge ruled that his defence of automatism to a charge of inflicting GBH was really a defence of insanity. Lord Diplock stated that automatism would be available as a defence where temporary impairment resulted from an external physical factor. The appellant was convicted of assault occasioning ABH and appealed against this conviction. The Court of Appeal upheld the judge’s ruling and dismissed the appeal.

The case of R v. Hennessy [1989] 2 All ER 9, again examines the factor of insanity arising out of an inherent defect. The appellant was a diabetic who failed to take his proper dose of insulin and consequently suffered from hyperglycaemia. The appellant claimed that he failed to take the proper dose of insulin due to stress, anxiety and depression. The defendant in his alleged state of automatism drove a car whilst disqualified. The trial judge rejected the defence of automatism and said that if it existed, the appellants mental condition was caused by disease (diabetes) and therefore fell within the legal definition of ‘insanity’ under the M’Naghten Rules. The appellant subsequently changed his plea to guilty and was convicted.

He appealed on the grounds that the judge’s ruling was incorrect contending that stress, anxiety and depression which had caused or contributed to his state of mind were external factors and not caused by disease of the mind. The appeal was dismissed. Lord Lane CJ stated that “stress, anxiety and depression were not in themselves, either separately or together, external factors of the kind capable in law of causing or contributing to a state of automatism since they were neither unique nor accidental factors but constituted a state of mind which was prone to recur”. The hyperglycaemia, caused by an inherent defect and not corrected by insulin, was a disease and the functioning of the appellant’s mind was disturbed by disease and not some external factor.

The case of R v. T [1990] Crim LR 256, deals with the defence of non-insane automatism. T, amongst others, was arrested and charged with robbery and further charged with causing ABH. T claimed to have been raped 3 days prior to her arrest, suffered from PTSD (post-traumatic stress disorder) and at the time of the offence had entered a dissociative state and was not acting with a conscious mind. The defence submitted the defendant of Non-Insane Automatism which was open to T on the grounds that rape is an application of an “external force” (Quick).

The crown argued the defendant had recollection of what had happened, and that opening a blade of a pen-knife required a controlled and positive act by the defendant, therefore this was a case with “partial control” and the only defence open to T was “insane automatism” under the M’Naghten Rules. It was held that there had been no previous case in which an incident of rape had been held to be “an external factor” causing a malfunctioning of the mind laid down in Quick. The external factor had to be quite extreme for the defendant to use the defence of non-insane automatism. T acted as though she was ‘in a dream’.

In the case of R v. McFarlane, The Independent, 11 September 1990, Judge Bertram Wakely gave a direction to the jury in open and express defiance of the decision of the House of Lords in Sullivan. D was charged with inflicting ABH on a policeman during a search of her home for supposed stolen property. The defendant had suffered from epilepsy for a period of 14 years. The defence claimed that the defendant had hit the policeman during an epileptic fit induced by the stress of the dawn raid by several officers. Instead of directing the jury on the special verdict, Judge Wakely directed them that if they believed that D might have been having an epileptic fit they should return a verdict of not guilty. The jury acquitted the defendant. Despite not having applied the authoritative law declared in Sullivan, his judgement was an application of the spirit of Lawton LJ’s dictum in Quick.

The next case to be addressed is that of R v. Burgess [1991] 2 QB 92. The appellant was tried on a count of wounding with intent to do GBH, contrary to s.18 of the OAPA 1861. He relied on the defence that he lacked the necessary intent in that, during the undisputed violence to the victim, he was sleepwalking and suffering from non-insane automatism. In light of the medical evidence the judge was found right to conclude that the appellants state was an abnormality or disorder which, albeit transitory and was unlikely to recur. The violence was due to an internal factor, whether functional or organic, and had manifested itself in violence and has the possibility to recur, and therefore amounted to a ‘disease of the mind’. The jury found the appellant not guilty by reason of insanity.

Finally, in the case of R v. Parks (1992) 95 DLR (4th) 27, the defendant was charged with murder. The undisputed facts were that while, according to the defendant, he was asleep, he drove his car to the house of his wife’s parents where he stabbed both of them killing his mother-in-law and seriously injuring his father-in-law. A number of experts in sleep disorders gave evidence to the effect that sleep walking is not regarded as a disease of the mind, mental illness or mental disorder. The trial judge directed the jury that if the accused was in a state of somnambulism at the time of the killing, then he was entitled to be acquitted on the basis of non-insane automatism. The defendant was acquitted of both offences. Sleep was viewed as a “natural, normal condition”.

To conclude this essay on the evolution of ‘disease of the mind’ it has become apparent that over the years from the 1950s until the present day, the phrase ‘disease of the mind’ has changed and adapted in light of cases that have arisen on insanity. It has been argued that in order for a defence of insanity to succeed, the accused must be shown to suffer from an internal factor that brought about the act. It has also been shown that some defences put forward claiming non-insane automatism have not been accepted by the court, and hence a defence of insanity has been substituted. This in turn can lead to the accused feeling pressured into changing his plea to guilty of the initial offence in order to avoid being labelled as ‘legally insane’ and subsequently being admitted to a mental unit for constant supervision.

This area of law has been considerably influenced by policy considerations involving the need to protect the public from those who display such dangerous behaviour and who may be susceptible to repeated episodes of a similar nature and in a state which they cannot control their behaviour.

A defendant receiving a special verdict of insanity in being sent to a metal institution/hospital can appeal against this verdict and the hospital committal claiming that they are incompatible with Article 5 of the European Convention of Human Rights which provides that:

Everyone has the right to liberty and security of person.

No one shall be deprived of his liberty save in the following cases and in accordance with a procedure prescribed by law; . . .

the lawful detention . . . of persons of unsound mind . . .

This creates confusion when a disease which is legally classified as insane, such as diabetes or epilepsy, in a Mental Health Review Tribunal may not be regarded by an objective medical expert as a mental disorder. Hence, the defendant may be let off on early release for no longer being considered mentally ill since detention of a person who is not of ‘unsound mind’ would be a breach of Art. 5.