Editorial Note: The last three posts give examples of medical kidnapping happening now. The Doctor Munchausen series of posts on David Healy in July and August 2014 give some more examples. This post and two to follow outline how we ended up in a position where people can be kidnapped.
Medical Kidnapping goes back a bit. In 1706, Daniel Defoe, perhaps the first journalist and, with Robinson Crusoe, one of the very first novelists, reported on the case of a woman wrongfully locked up as mad by a husband in an effort to dispose of her. This was, it seems, close to the start of a new trade in kidnapping.
Before 1700 for the most part the mentally ill, the elderly infirm and mentally handicapped were looked after by their families and communities. If they were poor and annoying or antisocial, they might land in prison along with beggars, vagrants and criminals. If they broke the law they were tried and punished.
A 1714 British Act distinguished for the first time between impoverished ‘lunatics’ and ‘rogues, vagabonds, sturdy beggars and vagrants’. Under this Act two Justices of the Peace could authorize those who were ‘furiously mad and dangerous’, who were probably almost always delirious, to be apprehended and locked up in a secure place where, if necessary, they could be restrained but only during the period of madness (delirium).
This Act appeared in parallel with the emergence in Britain of a market in mental health care. It didn’t address the linked abuses that might happen.
Eliza Haywood, perhaps the first female novelist and journalist, in a 1726 play ‘Love in a Mad-house’ shows there was no legislation to prevent anyone, sane or insane, being taken off to a private madhouse by force where the proprietor made a living out of detaining residents for unspecified periods of time.
In an effort to curb the growing abuses, in 1774 a Madhouse Act required anyone who was housing more than one lunatic to have a licence for the purpose.
In 1828, there was another effort to curb abuse in an Insane Person’s Act. This required that a person had to be certified as mad. People could not be carted off to a madhouse willy-nilly. The order for detention had to be signed by a Justice of the Peace and it had to have a medical certificate signed by two doctors who had seen the person.
In 1845, two Acts were passed in Britain – The County Asylums Act and The Lunacy Act. The Asylums Act mandated the building of asylums. These were based on a new idea that good food, clean air, temperance, personal cleanliness and work could bring about recovery in many people who had gone insane.
Under the Lunacy Act if it was decided that someone, by virtue of the specific alienation of reason that a mental illness can produce, was incapable of exercising the correct judgement in terms of their own safety, or health or the safety of others, with the agreement of their family, that person could be detained.
At the time, there was a presumption that asylum care would produce a benefit so that in the foreseeable future the person would be able to take their affairs back into their own hands.
The previous Acts had aimed at curbing a variety of abuses. The 1848 Act was permissive – it was about getting treatment to people who might need it. It was recognized that in some instances in the domain of lunacy, families could do unfortunate things, especially when money was involved, but it was also recognized that the bulk of caring of people with mental disorders was being undertaken by families and communities. The asylum was a new therapeutic instrument, which it was hoped might support families and community efforts.
The Lunacy Act was not about disposing of problems. It was about treatment. A mental health patient was someone whom their families thought had a problem even though they might not be obviously delirious or a clear public threat. Where doctors’ were involved, their judgement had to dovetail with the assessment of a family who described to a magistrate the behaviors they felt incapable of managing at home.
This was the era in which the notion of a medical patient was properly born. These Acts created a new framework based on therapeutic optimism. Specialist treatment would enable patients to recover. In this – as in so much else – psychiatry blazed a path for the rest of medicine.
Treatment in the asylum depended on the consent of the family. The decision to detain was theirs. The family could discharge the patient ‘against advice’ if they believed the proposed benefits were not being realized, or the patient might remain in hospital when families felt unable to cope with them after discharge. Some patients were discreetly given shelter if there was a concern that the patient might be vulnerable.
In 1845, the new asylums came with a hope that moral treatment was highly likely to produce a good outcome. The data supported that presumption. For the first forty years of the asylum era, schizophrenia was rare and the psychoses and melancholias that came into hospital were turned around within a 3 to 6 month period. Detention was an evidence based treatment.
It was fifty years later, heading towards 1900, as admissions for chronic psychoses became more common that the specter of commitment to a hospital without the prospects of a benefit began to raise concerns. The notion of a warehouse for the insane began to take shape. In addition, the asylum filled with the elderly infirm and mentally handicapped. New stories of sane people being incarcerated emerged to parallel the accounts by Daniel Defoe and Eliza Haywood – but these were rare. In fifty years worth of records in North West Wales between 1875 and 1924, the number of cases that might fall under this heading can be counted on the fingers of one hand.
There are two points to make.
- All interventions, both medical and legal can have unintended consequences. Drugs with a short term benefit can produce long term harms. In a similar manner the asylum system was not intended for long stay patients. With longer stays the problems of institutionalization emerged.
- Once a medical system and a legal process is put in place, some component of what happens next will, on a simply bureaucratic basis, involve actions by the system to perpetuate itself. This will give rise in some instances to perceptions of a conspiracy. This is an almost inevitable consequence of any intervention in human affairs.
To be continued.