Letters

James R. Merikangas

doi:10.29158/JAAPL.200076-20

Editor:

The excellent, thought-provoking editorial by Manish Fozdar discusses the quandary of the court in determining whether a person with dementia can form “a rational understanding of the reasons for his death sentence” (Ref. 1, p 151). The premise is that it is not punishment to kill someone unless they know why. But why does that matter? Will the dead person have learned his lesson if he understands why he is being killed? Will he suffer more or less if he knows his death is in retribution or for vengeance? Is he being killed to deter others from crime, or to suffer torture equivalent to that which he may have inflicted? To opine whether a person understands why he is facing the death penalty, as Dr. Fozdar concludes, does not depend on a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM) or a brain image, but on the same sort of reasoning that goes into determining whether one is competent to make a will or get married. Arguments about free will versus determinism make little sense when applied to delusional or delirious patients. A psychotic person may feel it is morally correct to kill someone when he wrongly thinks it is self-defense. In some jurisdictions he is still not considered “insane” because he knows he is killing. How does that differ from a suicide bomber, who, though not psychotic by any other measure, kills himself and scores of others for religion? Dr. Fozdar correctly concludes that giving a diagnostic label (from a DSM committee) does not come close to explaining human behavior, nor does a brain image or neuropsychological test substitute for a complete neuropsychiatric evaluation. As there are many forms of dementia, there are many causes of psychosis, some temporary and some chronic, the consequences of which must be considered in a judicial setting before passing judgment on a given behavior. Arguments between forensic experts about diagnosis are simply embarrassing to the profession.