Moral Principles and Medical Practice: The Basis of Medical Jurisprudence

by Charles Coppens

Nor is it at all certain that a lunatic’s brain, if it could be examined with a microscope while he is alive, would exhibit the marks of any disorder to the eye of the observer. It is stated by Dr. Storer that the results show that “insanity may exist without structural changes of the brain, and that structural changes in the brain may exist without insanity.” Dr. Bell, of the Somerville Asylum, says that “the autopsies of the insane generally present no lesion of the brain.” Dr. Bucknil maintains that “the brains of the insane appear to be certainly not more liable than those of others to various incidental affections.” Nor has the microscope discovered in the demented any exudation or addition to the stroma of the brain, or any change in size, shape, or proportional number of its cells. Dr. Storer concludes: “It is thus seen not merely that there is no direct correspondence between the exterior of the skull and mental integrity, any more than between the exterior of the skull and the shape and consistence of its contents” (Wharton and Stillé, “Mental Unsoundness,” sec. 323). In the cases of insanity among women, the causes are largely to be found in derangement of their productive organs, and are to be met by special local treatment (ib.).

It does happen, however, at times, that the brain itself is diseased, idiopathically diseased, as it is technically called; but at other times it is merely affected by sympathy with some other organ that is physically deranged. A physical cause there is for all mental insanity, and that physical cause determines its kind of mania or melancholia, its duration, its chances of a perfect cure. But what that cause is in a given case is often very hard if not impossible to determine. Besides natural and inherited predispositions—some taint of derangement in the family, often betrayed by fits of epilepsy, hysterics, etc.—exciting causes are usually traceable. Every form of disease may bring on sympathetic affection of the brain when the circumstances for such affection are favorable.

But while affirming that the disease usually arises in the body, and even frequently in parts far removed from the brain, we must not deny nor ignore the fact that intellectual and protracted worry, or sudden and violent grief, can also be the direct cause of disturbance in the brain. For the brain is the organ not of the imagination alone, which is put to an unhealthy strain by excessive mental labor, but probably also of the passions, whose emotions when excessive may cause even permanent lesion. Hence mental insanity may and does often arise from ill-subdued passions.

The knowledge of all this may enable the physician to remove the exciting cause or to mitigate its influence; it may also aid expert witnesses, judges, lawyers, and jurymen to ascertain the main fact with which the courts are concerned, namely, the presence or absence of mental insanity at the time of a given civil or criminal action.

V. Supposing then that, in the case before the court, the fact of insanity is established, the next question of Jurisprudence to determine is this: How far and why ought such unsoundness of mind to exclude responsibility for deliberate acts?

It is a clear principle of reason that no man can justly be blamed or punished for doing what he cannot help doing; now an insane man cannot help judging wrong at times; he cannot then justly be blamed for acting on his mistaken judgments. If he invincibly judges an act to be morally good whereas it is morally bad, no matter how criminal the act may be—say the killing of his own father or child—if he commits the deed with the full conviction that he is doing right, he cannot be blamed or punished for committing that awful crime.

The principle then is clear that an insane man is not to be held responsible to God or man for his insane acts. For the root and reason of our responsibility for an act lies in the fact that we do the deed of our own free choice; knowing its moral nature, being masters of our own free will, so that, if we do one act in preference to another, we wilfully take upon ourselves the consequences of this preference as far as we can know or suspect them.

If we do what we are firmly convinced is right, just, worthy of a man, we deserve praise; if we do what we are convinced or suspect is wrong, unjust, unworthy of a man, we deserve blame and punishment. But an insane man may do the most unjust act, and yet feel invincibly convinced that it is just; he cannot then be held responsible for doing it, because the root of responsibility is then wanting.

I do not, however, maintain that one who is insane on any one point is thereby made irresponsible for all his actions. If he does what he thinks to be wrong, he acts against the dictates of his conscience, he deserves punishment from God; and if he violates a just law of the land, and it can be proved that his deed proceeded from a bad will, he may be punished by the civil courts as well, even though he is insane on other points. For instance, if a young man were to have a crazy notion that his father disliked him, that he is often in various ways unjust to him, and if, in consequence of this insane conviction, he were to attempt his father’s life, he should be punished for the criminal act; because, even according to the way he views the matter, he could not be justified in killing his father for such a reason. It were different if he insanely imagined that his father was in the act of killing him, and that he could not escape death but by killing his father first; for then he could plead the right of self-defence against an unjust aggressor, as he foolishly imagines his father to be.

The conclusion then from all this explanation is that an insane man should not be held responsible for a deed which he insanely thinks to be right; but he is responsible for all his other acts.