HEALTH LAW

Ananthagoma.M

Unit 4
Defining Medical Insanity
Medical insanity, often referred to as mental weakness, encompasses a range of mental health conditions
that may impair an individual’s cognitive or emotional functioning. This umbrella term includes
disorders such as anxiety, depression and other psychiatric conditions that may necessitate medical
attention and treatment. However, being medically insane does not necessarily render an individual
legally insane.

Legal Insanity: A Different Perspective

Legal insanity is a recognised defence in criminal law and it implies that, at the time of committing an
offence, the accused was not in a state to understand the nature and consequences of their actions.
To benefit from legal insanity, the accused must establish, often through psychiatric or psychological
evaluations, that they were not in control of their reasoning faculties during the commission of the
prohibited act. This defence is often anchored in statutes, such as Section 84 of the Indian Penal Code,
which outlines the conditions under which an individual can be considered legally insane.
Burden of Proof and Legal Insanity
One of the critical distinctions between medical and legal insanity lies in the burden of proof. In cases of
legal insanity, the onus is typically on the accused to prove their mental state at the time of the
offence.

The accused must present a prima facie case, supported by reasonable materials, to establish their legal
insanity. This may involve presenting evidence of their conduct before, during or immediately after the
offence, along with relevant medical documentation. The objective is to convince the court that, due to
mental incapacity, the accused should be exempt from full criminal responsibility.

Legal Precedents and Historical Foundations

Understanding the roots of legal insanity requires a glance back in time. The first recorded case dealing
with the law of insanity dates back to 1724 in the United Kingdom with R v. Arnold. In this case,
Edward Arnold attempted to kill Lord Onslow and evidence revealed that Arnold was suffering from a
mental disorder.
The legal response to insanity has evolved over centuries, with jurisdictions adopting different standards
to assess an individual’s mental state at the time of committing a crime. The M’Naughten Rule,
established in 19th-century England, remains a foundational test in many jurisdictions, assessing whether
the accused knew the difference between right and wrong during the commission of the offence.

The pivotal case of R v McNaughton (1843) introduced the ‘Right and Wrong Test‘under what is now
known as ‘McNaughton’s Rule,’ truly establishing ‘insanity’ as a defence. In this case, Daniel
McNaughton, a woodworker from Glasgow, Scotland, attempted to assassinate the British Prime
Minister, Sir Robert Peel, mistakenly believing that the Troy Political Party was targeting him.

This verdict laid the foundation for the legal definition of ‘insanity’ and established the principles of
‘McNaughton’s Rule,’ which include:
● Presumption of sanity: Unless proven otherwise, all individuals are considered sane and possess
reasoning capabilities.
● Defect of reason: It must be demonstrated that the accused was operating under a defect of
reason at the time of the act.
● Lack of knowledge: The accused must be shown to be unaware of the nature and qualities of
their actions.
These principles formed the basis for evaluating the defense of insanity in subsequent criminal trials.

What is Mc Naughton’s Rule?

According to McNaughton’s Rule, a person can be found not guilty because of insanity if, at the time of
committing the act, they had a mental disorder that rendered them:
● Unable to understand the nature and quality of their actions: They were incapable of
comprehending the nature of the act they were committing or the consequences that could arise
from it.
● Unaware that what they were doing was wrong: They could not distinguish between right and
wrong due to their mental condition, and thus, they genuinely believed that their actions were
morally justified or in accordance with the law.

Applicability of The Mc Naughton’s Rule in India

Section 84 of the Indian Penal Code

In the context of the Indian legal system, Section 22 of the BNS is pivotal in addressing the defence of
legal insanity. This section states that an act committed by a person of unsound mind is not an offence
unless the person knows the act is wrong or contrary to the law.

This section follows the basic principles of criminal jurisprudence, such as the maxim “Actus Facit
Reum Nisi Mens Sit Rea,” which means that an act does not make someone guilty unless they had a
criminal intention or committed the act with a guilty mind.
Therefore, if an offence is committed by an individual proven to be of unsound mind, it is assumed that
the accused lacked mindfulness, rational thinking or a guilty intention to commit the crime. Consequently,
the accused is not held liable for any criminal liability.

Amrit Bhushan v. Union of India

In the case of Amrit Bhushan v. Union of India (1976), the Supreme Court clarified that the M’Naghten
rules define and explain the term “insanity” of the accused, while Section 84 of the Indian Penal Code
describes “unsound mind,” which is considered equivalent to insanity.
This step was taken by the drafters of the Indian Penal Code to provide a broader interpretation of the
term “unstable mind” and also recognised the concept of non-compos mentis (not in one’s right mind) as
a defence of insanity under criminal law. To claim the defence under Section 84, certain essential
elements must be fulfilled:
● The accused’s mind should be incapable of being aware of the nature of the act.
● The act should be contrary to the law.
● The act should be morally wrong.
To establish the insanity or unsound mind of the defendant, it must be demonstrated that their cognitive
abilities were impaired to the extent that they did not know the nature of their actions or the consequences
thereof.

Emerciano Lemos v. State

In the case of Emerciano Lemos v. State (1969), the accused slit open a person’s throat while
experiencing hallucinations and having an unbalanced mind. Despite having knowledge of the nature or
quality of the act and understanding that it was wrong, the accused did not refrain from committing it.
Therefore, the accused could not invoke the defence of insanity under Section 84 of the Indian Penal
Code.
The court prescribed a test of responsibility to be applied when an accused pleads unsound mind under
Section 84. This test aimed to determine the criminality of the act. This case also affirmed that the
M’Naghten rules are the fundamental source of Section 84 of the Indian Penal Code, as both contain
similar provisions.

Criticism of the M’Naghten Rule

1. Outdated and Narrow:

The rule is based on old ideas and doesn't reflect modern medical knowledge about mental
illness.
2. Legal vs Medical Mismatch:
○ People who are not medically insane can still be forced into hospital care under the rule.
○ The law’s view of insanity doesn’t always match with doctors’ understanding.
○ For example, illnesses like epilepsy or diabetes, which can cause brief mental confusion,
aren't always accepted under this legal test.

3. Public Safety Issues:

● The rule doesn’t properly assess whether someone is a danger to society.

 ● It also makes it hard to tell the difference between short-term (temporary) and long-term
(permanent) mental illness.

4. Too Lenient in Some Cases:

● People with serious mental illness might avoid punishment even if their actions caused serious
harm.
● This raises concerns about justice and accountability.

Difference between medical and legal insanity

Aspect Medical Insanity Legal Insanity

Definition Refers to mental illness Legal determination of lack of

requiring medical treatment. criminal responsibility.

Purpose Focuses on health and well- Pertains to legal system,

being of the individual. assessing criminal liability.

Decision-Making Capacity May not necessarily impact Often implies a lack of

general decision-making. decision-making capacity in
legal matters.

Determining Factors Diagnosed by healthcare Determined by legal standards,

professionals based on medical often involving assessments by
criteria. mental health experts.

Consequences Leads to medical treatment and Can result in legal

therapy. consequences, such as
commitment to a psychiatric
institution.

Burden of Proof Typically diagnosed based on The accused often bears the
medical evidence. burden of proving legal
insanity.

Mental Healthcare Act

The National Human Rights Commission (NHRC) gas raised concern over the Deplorable Condition of
many Mental Healthcare Institutions (MHIs) in India, violating Mental Healthcare Act (MHA), 2017.
Background MHA, 2017?

● Before MHA 2017, the Mental Healthcare Act, 1987 existed, which prioritized the
institutionalization of mentally ill people and did not afford any rights to the patient.
● The Act provided disproportionate authority to judicial officers and mental health
establishments to authorize long-stay admissions, often against the informed consent and
wishes of the individual.
● Consequently, several persons continue to be admitted and languish in mental health
establishments against their will.
● It embodied the ethos of the colonial-era Indian Lunacy Act of 1912, which linked
criminality and madness.
○ Asylums were places where “abnormal” and “unproductive” behaviour was
studied as an individual phenomenon, isolating the individual from society.
The intervention is meant to correct an inherent deficit or “abnormality”,
thereby leading to “recovery”.
● In 2017, the MHA dismantled the clinical heritage attached to asylums.

Objective The Mental Healthcare Act, 2017 aims to provide mental healthcare and services for persons
with mental illness and ensure these persons have the right to live a life with dignity by not being
discriminated against or harassed.

The Act defines “mental illness” as a substantial disorder of thinking, mood, perception, orientation or
memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the
ordinary demands of life, and mental conditions associated with the abuse of alcohol and drugs.

But does not include mental retardation, which is a condition of arrested or incomplete development of a
person’s mind, especially characterised by sub-normality of intelligence.

Mental Healthcare Act Provisions

● Rights of Persons with Mental Illness:

● Every person will have the right to access mental healthcare from services which are
operated or funded by the government.
● It also includes good quality, easy and affordable access to services.
● It also provides for the right to equality of treatment, seeks to protect such persons from
inhuman treatment, access to free legal services, their medical records, and the right to
complain in the event of deficiencies in provisions.
● Advance Directive:
● This provision empowers a mentally-ill person to have the right to make an advance
directive that explains how she/he wants to be treated for the requisite illness and who
her/his nominated representative shall be.
● This directive has to be vetted by a medical practitioner.
 ● Mental Health Establishments:
● Every mental health establishment has to be registered with the respective Central or
State Mental Health Authority.
● For registration, the concerned establishment needs to fulfil different criteria as
mentioned in the Act.
● The act also outlines the procedure and process for admission, treatment and subsequent
discharge of mentally ill persons.
● Mental Health Review Commission and Board:
● It is a quasi-judicial body responsible for reviewing procedures for making advance
directives.
● It will also advise the government on the protection of mentally ill persons’ rights.
● It further states that the body in agreement with the state governments constitutes Mental
Health Review Boards in states’ districts.
● Decriminalising Suicide and Prohibiting Electro-Convulsive Therapy:
● The most notable of all is the provision that effectively decriminalises suicide attempts
under the Indian Penal Codeby mentally ill persons by making it non-punishable.
● Electroconvulsive therapy, which is allowed only with the use of anaesthesia, is however
barred for minors.

Mental Healthcare Act Criticisms

● The Act does not provide for the advance directive to minors, as per Section (5) of the said Act.
● All the services are to be ensured by both Central and State governments. The expenditures
estimated will not meet the obligations under the act.
● The Centre and State, both have responsibilities as per the Act; it does not provide sharing of
funds between them.
● If a person no longer demands an order of supported admission to the mental health
establishment, the Act provides that they may continue to remain in the mental health
establishment as an independent patient and does not clarify for how long and what procedure is
to be adopted to give the person an effective chance to live in the community.
● The definition of a mental health professional in the act is limited to clinical psychiatrists and
specialists containing a postgraduate degree in Ayurveda, Homeopathy, Siddha, and Unani.
Psychotherapists and psychoanalysts are excluded from the act as per the current definition.
● Although the law to punish the person committing suicide has been prohibited, a lot still needs to
be done for mentally ill people.

What is a tort?

A tort is a civil wrong committed upon an individual or as typically termed in healthcare, medical
malpractice which falls under the legal doctrine of negligence. Strict liability (like medically defective
products) is a legal doctrine that causes someone to be liable for the damages their actions or product
causes regardless of fault. Tort liability is determined by the premises that: (1) one individual should not
intentionally injure another person or their property. (2) Everyone should exercise reasonable care and
caution in the conduct of their affairs. The main difference between intentional torts and negligence is
intent which is present in intentional torts but not in negligence.

Negligence

Negligence is a lesser form of fault than intentional torts, so damages in negligence cases are limited to
actual damages, not punitive damages. It can be carelessness resulting from a deviation from the standard
of care. Unlike the intentional tort, negligence rests on a spectrum of lesser faults. Negligence claims are
generally restricted to the redress of “actual damages,” as opposed to the punitive damages reserved for
more egregious misconduct. At its core, it stems from a failure to uphold a requisite standard of care,
resulting in foreseeable harm.

Types of Negligence

Types of Negligence Definition Example

Minor deviation from the A doctor forgets to order a

Slight Negligence
expected standard of care routine blood test.

Failing to do what a reasonably A driver rear-ends another car

Ordinary Negligence
prudent person would do while distracted.

Intentional disregard for safety A surgeon leaves an instrument

Gross Negligence
or a reckless act inside a patient.

Proof of Negligence

Proof of negligence is determined by four elements: duty, breach, causation, and damages.

● Duty: The defendant has a duty or obligation to act reasonably to avoid harming others. This duty
is based on the relationship between the defendant and the plaintiff. Did a physician-patient
relationship exist?
 ● Breach: The defendant breached their duty of care by failing to act reasonably. This means that
the defendant did not take the precautions that a reasonable person would have taken in the same
situation. This is a deviation from the standard of care or failure to adhere to an obligation. Did
the physician fail to meet the standard of care?
● Causation: The defendant’s breach of duty must have caused the plaintiff’s injuries. This means
that the plaintiff’s injuries would not have happened if the defendant had not breached their duty.
Did the physician fail to meet the standard of care?
● Damages: The plaintiff must have suffered actual damages (foreseeable injury) as a result of the
defendant’s negligence. This means that the plaintiff must have suffered some type of financial or
physical loss. Did the patient incur actual damages as a result of the breach?

Intentional Torts

Intentional torts involve (1) interference with the personal freedom of an individual, (2) interference with
property rights, (3) interference with economic relations, and (4) wrongful communications.

1. Assault
2. Battery is defined as the harmful touching of someone without their consent.
3. False imprisonment is the unlawful physical restraint of a patient. For example, when a patient is
locked in a room and not permitted to leave.
4. Invasion of privacy which occurs with improper disclosure of medical treatment information and
violations protected under HIPAA. All patients have a right to the reasonable expectation of
privacy. Other circumstances also exist outside of the medical industry, including phone tapping
and the use of photos or images without permission.
5. Mental Distress is a tort that occurs when someone intentionally or recklessly causes another
person severe emotional distress. It can be caused by the high-pressure tactics of collection
agencies, including violent cursing and accusations of dishonesty. However, it is not a tort when
someone simply insists on their legal rights, even if they know that it will cause emotional
distress.

Tortious liability refers to the legal responsibility that arises when someone commits a tort — a
wrongful act (other than a breach of contract) that causes harm to another person, for which the injured
party can seek compensation through a civil lawsuit.

Essential Elements of Tortious Liability

1. Duty of Care
The defendant must owe a legal duty to the claimant.
2. Breach of Duty
The defendant must have failed to fulfill that duty.
 3. Causation
There must be a direct link between the breach and the harm caused.
4. Damage
Actual harm (physical, emotional, or financial) must have occurred.

Tortious Liability in the Health Care Sector

This applies when a medical professional or institution breaches their duty of care. See examples under
medical negligence:

● Wrong medication given to a patient

● Failure to warn of treatment side effects
● Surgery done without informed consent
● Misdiagnosis leading to harm

Legal Remedies for Tortious Acts

● Compensatory Damages: For medical bills, pain, lost income, etc.

● Punitive Damages: To punish egregious behavior (in some jurisdictions)
● Injunctions: Court orders to stop harmful behavior

Defenses to Tortious Liability

● Volenti non fit injuria (Consent): Patient knowingly accepted the risk.
● Contributory/Comparative Negligence: Victim was partly responsible.
● Inevitable accident: Harm couldn’t have been avoided even with care.

Defenses

In a tort case, the plaintiff must prove that the defendant’s actions were negligent and that the negligence
caused the plaintiff’s injuries. The defendant can then raise an affirmative defense to try to avoid liability.
The two main affirmative defenses in tort law are the assumption of risk and contributory/comparative
negligence.

● Contributory/comparative negligence is a defense that applies when the plaintiff’s own

negligence contributed to their injuries. Awards to the plaintiff may be reduced or eliminated if
the defendant can show that the plaintiff was negligent. For example, if a patient is noncompliant
with treatment (medication regimes).
● Assumption of risk is a defense that applies when the plaintiff voluntarily and knowingly
exposes themselves to the risk of harm. For example, if a person signs a waiver before
participating in a dangerous activity, they may be assuming the risk of injury. For medical
malpractice, the assumption of risk is more closely related to the doctrine of informed consent.
The defendant has the burden of proof for affirmative defenses. This means that the defendant is
responsible for proving that the defense applies. The concept of informed informed consent consent is
related to the assumption of risk. Informed consent means that the plaintiff voluntarily agrees to an
activity after being fully informed of the risks involved. If the plaintiff does not give informed consent,
they may be able to recover damages even if they assumed the risk of injury. Finally, tort claims may be
dismissed if they are not filed within the time of the statute of limitations. The statute of limitations is a
law that sets a time limit on how long after an injury a person can file a lawsuit. If a lawsuit is not filed
within the statute of limitations, it will be dismissed. The following must be disclosed for informed
consent to be effective:
a. The diagnosis
b. What the recommended treatment is, and its purpose
c. Benefits and risks of this treatment
d. What alternatives are available, including no treatment
e. Benefits and risks of alternatives

Informed consent shields the medical personnel from liability concerning procedures described in the
consent, or if an unexpected circumstance is addressed and the patient is unable to be consulted. An
example is life-saving measures during surgery.