The limits of responsibility

Sir: I would like to take the opportunity to reply to my correspondents on the subject of responsibility (Bristow, Psychiatric Bulletin, November 2001, 25, 412-413).

While Mr Howlett (Psychiatric Bulletin, November 2001, 25, 414-415) is right to say that there may be duties imposed on physicians and surgeons regarding follow-up of their patients, none of these duties concern the patients' behaviour. If a person is arrested for homicide the fact that he/she has recently consulted an orthopaedic or gastrointestinal specialist will not even be remarked upon. But let it be known that he/she has seen a psychiatrist and it will be automatically assumed that the patient is incapacitated and the psychiatrist is culpable by omission for the homicide. An expensive ‘independent’ inquiry will then follow that, even if all parties are exonerated, will undoubtedly convey the impression that there is no smoke without fire, to the detriment of all concerned.

Mr Howlett also avers that responsibility should last as long as the patient is still considered a patient and has a responsible medical officer. We have to ask whose decision it is whether a patient remains a patient. Is a patient a patient just because he or she wants to be, or because current health policy says he or she should be so? Or does there have to be a reliable treatment for his/her disorder that can be administered whatever the degree of concordance. I think that to establish any sort of negligence the latter must be a condition. There are no such treatments for either personality disorder or substance misuse.

A recent case (R. v Crowley) attracted a fair degree of comment from, among others, Mr Howlett. In this case, where a mentally disordered offender was arrested after stalking and threatening a minor, it was reported that a crucial decision was taken in court to offer him bail against the advice of a forensic psychiatrist who considered him dangerous (Vasagar & Hopkins, 2001). He thereupon killed the individual he had stalked. If a psychiatrist had taken this decision he would have been subject to a media witch trial. But because it was a judge that took the decision we have seen no such comments.

What increasingly separates us now from physicians and surgeons, apart from the self-imposed exile so accurately described by Wessely (1996), is the lack of definition of our job, especially true in general adult psychiatry. First we had the ‘severely mentally ill’, then the challenge posed by ‘dangerous severe personality disorder’. In my trust, and possibly in others there has been an attempt to foist child protection work on community mental health team members. If that wasn't enough we have the vague blandishments of the National Service Framework and the National Plan, which entitle virtually anyone at any time to any service they think they need.

Sorting out this issue of definition is crucial if we are going to attract any new entrants to the profession, not to mention keep the ones we've got.