To what extent could we hold people with mental illness responsible for their own disturbed states of mind? And what would this mean for those individuals with mental illness who are charged with criminal offences? These questions are explored by Edward W. Mitchell in an erudite and complex analysis of what he terms ‘meta-responsibility’. He offers both a conceptual analysis, and an empirical investigation of how mock jurors would judge a defendant who had committed a violent offence while non-compliant with prescribed psychotropic medication.

Mitchell found that his mock jurors gave intriguing answers to questions of meta-responsibility. Although some took the view that the defendant was criminally responsible because of the causal link between non-compliance and relapse, they also took the view that he could not be responsible because he had relapsed. There was also a suggestion that it was the decision to come off medication that should be judged for culpability, and not the offence itself.

The issues Mitchell raises are of profound importance for both psychiatrists and mental health service users. Current Department of Health policy emphasises the importance of involving patients in the management of their condition; of treating the patient as their own ‘expert’. However, when it comes to mental health, government policy seems to assume that service users cannot be trusted to manage their own condition, and are uniformly incapacitous in terms of responsibility for criminal offences. Numerous homicide inquiries have criticised professionals who have tried to share clinical decision with their patients and allowed the patients some control over their medication.

As clinicians, we know that mental illness does not necessarily abolish the capacity to form meaningful and competent intentions. There must therefore be some pressure on those with mental illness who have acted violently to explain why their disorder should be both an explanation, and exculpation, for their behaviour. From my own clinical experience, these questions are as troubling for patients who have been violent when psychotic as they are for the rest of us.

The more expert and autonomous the patient seeks to be, the more responsibility they must take for their actions. In ethical terms, not to respect autonomy when present is both to act disrespectfully and to act unjustly. However, this approach is a radical challenge to the traditional belief that those with mental illnesses should not be held responsible for their behaviours. The circular which mandates inquiries after homicide is evidence of a widespread social assumption that any history of any mental illness throws responsibility into doubt. The beneficent ideal of medicine assumes that we take care of patients because they cannot take care of themselves; it is only recently that the assumed incapacity of psychiatric patients has come to be questioned.

Mitchell ends his book with an entertaining fantasy that Dr Jekyll is put on trial for taking a substance that allows Mr Hyde to emerge. His argument deserves attention. Although not always an easy read, his book is thought provoking and I recommend it.