Last month, I was quite shocked to hear about the French psychiatrist, Dr Daniele Canarelli, who was given a one-year suspended sentence and a £7,000 fine because one of her patients with paranoid schizophrenia, Mr Gaillard, killed somebody.
I've been reading various blogs surrounding this issue with interest. As far as I understand, the doctor had sectioned this man several times in the past against his will. However on this occasion, he had apparently escaped during a consultation. Despite the doctor's attempt to resolve the situation by contacting the police, Mr Gaillard killed his grandmother's 80-year-old partner with an axe around three weeks later. He was thought to be psychotic at the time, not responsible for his actions, and therefore exonerated. I believe the French courts found that Dr Canarelli had been negligent by underestimating the risk, by not taking into account previous episodes of violence.
I do not personally feel that I know enough of the details about this case to make a decent judgement about accountability. Clearly many people who have contributed to the various blogs don't share this burden. What a luxury it must be to not allow insignificant, menial things like facts, to hinder one's ability to be judgemental.
My first reaction was that if Dr Canarelli informed the police that Mr Gaillard had escaped, then realistically, what more else could she have done? Even if she had underestimated the risk profile of this man, if the police were not able to physically find him, would it have been possible for anybody to prevent his egregious crime? I suppose the counter argument could be that if she had explicated exactly how potentially dangerous Mr Gaillard is, the police may have utilised more resources, thereby increasing the chances of apprehending him.
In the various newspaper articles I've read, it does not appear that Dr Canarelli is a forensic psychiatrist. This is the specialty of psychiatry that I work within on a daily basis; we are supposedly experts in the assessment and treatment of people with mental illnesses, who potentially pose a risk to others. It's possible that Dr Canarelli did not have the experience or virtuosity to deal with this cohort of patients. Perhaps her incompetence was in not seeking an expert opinion.
In this particular case, apparently Dr Canarelli had not taken into account the views of other colleagues, and hadn't fully considered his previous history of violence. Perhaps there were short-comings in her treatment. However, we must understand that in many other cases, as unpalatable as it may be, the risk is not always predictable; even experts can't prognosticate the future. Signs or behaviours that are a harbinger to future violence are not always apparent. It would be completely inhumane, insensible and unacceptable to indefinitely or permanently detain somebody who has committed violence just because they suffer from a mental illness.
Therefore, the best that we can do is to treat symptoms as far as possible and rehabilitate patients by utilising a variety of medications and psychological therapy. First the patient's mental state has been optimised, and then their risk to other people has to be tested gradually using extended periods of escorted and unescorted leave, and allowing increasing independence. Eventually, a decision about discharge needs to be made.
I got an uneasy feeling in some of the blogs that I have read, that some people feel in the above scenario, regarding the French psychiatrist, that somebody deserves to suffer; either patient or the doctor. I think this is a very dangerous way to think and would admonish against it. Sometimes when people are plagued by mental illness, they are not in control of their thoughts and actions. They often can commit actions that are completely out of character for them. They need to be treated and rehabilitated. It is archaic and barbaric to automatically wish to punish them, without first looking at the circumstances and try to improve them. I wonder if the bloggers who are so quick to advocate castigation would feel the same if a member of their family committed an uncharacteristic act of violence whilst not in control of their actions due to mental illness.
"Men are only clever at shifting blame from their own shoulders onto others" - Titus Livitius, Roman historian.
If the French court's ruling set a precedent, then I fear that we have troubled times ahead. If psychiatrists (and other doctors for that matter) are forced to act in such a defensive manner to avoid incarceration, there is a real risk that we have to act in an extremely overcautious manner; e.g. not letting patients with a history of violence ever have a chance at having leave, being independent, being discharged, and having freedom. This means that hospitals would become replete with patients that we would be too worried about discharging. Without extra resources, we would be depriving other non-forensic patients from having the psychiatric care and input they need and deserve. This is already happening to a degree in the UK due to a lack of funding, and due to an enforced shift for patients to be in the community rather than in hospital. It could force us to be more punitive, and less caring. And how would patients feel knowing that their doctor would be forced to prioritise their own impunity ahead of treating others?
Having said all that, I can understand why the people would want some accountability for lax psychiatrists who allow dangerous events to occur through incompetence. I just think that it is dangerous to assume that all violence is predictable and preventable. In England we have a very thorough system of forensic psychiatry. Patients are assessed carefully and cautiously over a long period of time. A high level of support and rehabilitation is offered during admission, as well as follow-up afterwards. Decisions about discharge not taken lightly, and usually involve many different healthcare professionals that know the patient well. Patients' families are often involved in the process. Organisations, such as the General Medical Council (GMC), whose role it is to weed out and punish doctors' incompetent practice are already extant. They commit to this role zealously, and can initiate legal proceedings if necessary. Do we really need the heavy hand of the law to intervene as well?
The blogosphere is reminiscent of an angry mob from ye olden days. It's easy to bay for blood and gesticulate with verbal pitchforks and sticks.
It's a shame; by simplifying these very intricate issues, instead of creating a forum to discuss so many complexities, these commentators invalidate their own points, some of which are actually quite reasonable.