Dáil Éireann debate -
Wednesday, 16 Dec 1953

Vol. 143 No. 14

Mental Treatment Bill, 1953—Second and Subsequent Stages.

Minister for Health (Dr. Ryan)

I move that the Bill be read a Second Time. The purpose of this small but rather complicated Bill is twofold: first, to authorise the detention in mental institutions of certain patients who, in the light of a recent judicial decision, appear to be illegally detained because of defects in the reception procedure; and second, to correct technical omissions in the Mental Treatment Act, 1945, which have created serious difficulties in the machinery for the provision of institutional treatment for mental patients.

In habeas corpusproceedings which were recently before the High Court a temporary patient in a mental institution was discharged by order of the court on the ground that the reception order on which the patient was detained was not properly made.I should mention in this connection that in the case of a chargeable patient of unsound mind, as distinct from a temporary patient received in a district mental hospital, the Act expressly provides that any medical officer acting on behalf of the resident medical superintendent may make the reception order, and it had been understood that another medical officer could also sign a reception order in respect of a temporary patient. The High Court has, however, ruled in effect that no person other than the person in charge—in a district mental hospital the resident medical superintendent—can make a reception order for a temporary patient; that any such order made by a person other than the person in charge is void and of no effect and that the detention of a patient in pursuance of such an order is illegal.

Reception orders in respect of a considerable number of temporary patients in mental institutions have, in fact, been made by officers other than the person in charge. The position is that these patients are medically unfit for discharge and must be detained for their own safety or the safety of the public. A number of them are actively or potentially suicidal, others are undergoing treatment the interruption of which might have serious consequences, and still others would constitute a public danger if discharged. It is urgently necessary, therefore, to give authority for their detention and the necessary provision for the purpose is being made in Section 3 of the Bill.

In district mental hospitals particularly having regard to the size and population of the institutions and the wide range of duties devolving on the resident medical superintendent, it would obviously be impracticable for that officer to sign all reception orders at all times or, indeed, to perform in person all the duties assigned to him under the Mental Treatment Act. Provision is accordingly being made in Section 3 of the Bill to enable the powers and duties of the resident medical superintendent in his capacity as the person in charge, or chief medical officer, or resident medical superintendent to be exercised or performedby any other medical officer of the institution authorised by the mental hospital authority. Similar provision is being made also in respect of private mental institutions.

The judgment of the High Court also revealed that the arrangements for the reception of a temporary patient are defective in another respect. There is no authority under the Act for the removal of a patient to hospital when the medical certificate, which must accompany the application for a reception order, has been signed. It is essential that authority for this purpose should be given in urgent cases and provision for the purpose is included in Section 5.

The remaining provisions of the Bill are designed to correct two obvious defects in the Act which have given rise to serious difficulties. Section 2 of the Bill is intended to correct an anomaly in Section 5 of the Act of 1945 so as to enable the nearest available dispensary medical officer to act for the dispensary medical officer in a district where there is only one such officer where the latter is not available.

At present there is no power to have a patient received as a temporary patient if he is outside his mental hospital district at the time urgent hospital treatment is required. Section 4 of the Bill will remedy this position.

The authorisation of the detention of patients whose reception was irregular is a matter of great urgency, and I ask the House to agree that the Bill will be passed through all stages to-day.

Dr. Esmonde

We accept the fact that this Bill is necessary. It appears from the judgment in the court the other day that, unfortunately, there are many defects in the 1945 Act. I take it that the purpose of this Bill is to seal up the leaks for the time being but that it is not intended to be final. In the light of what has happened, it is obvious that more extensive legislation will have to be introduced to cover the whole question.

I think I might recapitulate the points which the Minister has made. It is the intention that anybody acting on behalf of the resident medical superintendent will from now on be ina position to make the reception order for a patient, to remedy the existing situation wherein only the resident medical superintendent could do so. That applies to what are known as temporary patients and chargeable patients.

The second point which was discovered to be defective was that a dispensary doctor was unable up to this to have a patient removed forthwith to hospital, and I take it this legislation will cover that point and make it possible, in case of emergency, as so many of these cases are emergency cases, for the patient to be removed to hospital forthwith, without waiting for the reception order from the resident medical superintendent.

Another point which arises is that up to this it was possible for the dispensary doctor of the said district only to apply for the reception order. The legislation before us provides that where the dispensary doctor, though technically on duty, may not be available, the nearest available dispensary medical officer may act in such circumstances. I want to suggest, though it may be more a matter for Committee Stage, that that does not quite meet the case. In nine out of ten cases it will do so, but there could be a situation wherein it is a matter of acute emergency that an application should be made for a reception order for a temporary chargeable patient and the usual dispensary doctor may not be available. The position would then arise that those concerned with having the patient transferred forthwith to hospital would have to seek the services of another dispensary doctor.

It very often happens that many of these cases are dealt with in the more populous centres but in the case of the smaller towns there is usually one dispensary doctor, together with the local hospital doctor and one or more private practitioners. If we have to deal with an emergency and it is a question of getting a patient to hospital for his own protection and the protection of those around him, it does not seem to meet the case if it is necessary to look for a second dispensarydoctor. It may be necessary to go five or six miles out into the country in one direction for the doctor and he may not be available and going five miles in another direction may also fail to secure a doctor. The dispensary doctor who is technically on duty 24 hours out of the 24 usually allocates his functions to the nearest doctor and I suggest that this provision should be copper-fastened by an amendment on the lines of substituting for "the nearest available dispensary officer" the words "any registered medical practitioner recognised as being in practice". That would make it entirely safe and ensure that a patient will be removed to hospital for temporary treatment forthwith.

There is another portion of the Bill about which I am not clear and would like to have some clarification from the Minister. Section 176 of the Principal Act makes provision for the case of a patient who at the time he is found to require hospital treatment is outside the mental hospital district in which he ordinarily resides. In such circumstances the patient may be received into the district mental hospital for the district in which he is at the time, but he can only be received as a person of unsound mind. I think there is provision in the Bill for that case.

Dr. Ryan

Section 4 deals with that.

Dr. Esmonde

May I take it, then, that if a person is outside his own area and requires urgent mental treatment under the temporary provisions it will be possible to have that person dealt with in such a way as to enable him to be admitted to the local institution immediately?

Dr. Ryan

Yes.

Dr. Esmonde

And, furthermore, that that person may be maintained and treated in that institution and paid for by the local authority in the area from which he comes. Is that fully covered in the Bill? If it is not, it is a matter for the Minister's serious consideration. It has been put to me that the position obtaining at the moment is that if a person is admittedto an institution outside his own district for temporary treatment, the superintendent or whoever is responsible for the finances of that institution is unable to recover from the local authority. I should like the Minister to look into that.

We are perfectly willing to facilitate the Minister in every way in getting this Bill through, because we realise it is necessary, but I do not think any of us can be very satisfied, the defects in the 1945 Act having been so obvious and so many representations having been made to the Minister's Department, that we had to wait until a judgment was given by the courts to have a Bill of this kind rushed through. I know that experts on this matter have made repeated representations to the Minister's Department and put to him that the very state of affairs that has arisen could have arisen any time in the past few years. It seems to be entirely wrong that we should have to wait until this crisis is on us to bring in this Bill and rush it through.

I should like to have an assurance from the Minister that he intends to introduce a new measure with considerable amendments. I am of the opinion that the majority of the patients are curable and that treatment in a mental hospital is the same as any other kind of treatment. This system whereby we have a third method of certification by which a person can be sent into an institution as being a person of unsound mind is, in my opinion, becoming obsolete. I think we ought to be able under a new Act to devise a scheme whereby all these cases could be dealt with under the system. The Minister should take advice, and I suggest that he should take the advice of experts, because this is an extremely difficult subject to deal with. We are to-day discussing temporary treatment provisions and all those cases should be sent in for temporary treatment. Afterwards, where necessary, it will be possible to extend the period of detention in an institution. I think it can be extended indefinitely. If we send all those cases in for temporary treatment, we will remove for ever the unnecessary stigmafrom people who are sent to mental institutions.

It is an accepted fact that all these cases can be cured. The Minister should make it quite clear that he is introducing a further Bill. I would ask him to give consideration to that. If the Minister is going to draft further legislation, I suggest that he should take the advice of experts. I do not say that in any derogatory way to the Minister for Health or any other Minister for Health. I believe this is one of the most difficult subjects we have to deal with—the control and treatment of mental patients. The Minister should take the advice of experts who are mental specialists and who have been dealing with these cases all their lives and treating them. He should also consult with dispensary doctors who have a lot to do with this, besides. I also think that ancillary bodies should be consulted in the matter so that the best advice possible could be procured and, when legislation is introduced again, I hope all these anomalies will be removed.

Patients are a source of anxiety to those who depend upon them and who are fond of them. There is always a ray of hope in connection with practically most of these cases. Every patient should be sent in as a temporary patient under these temporary treatment provisions. At least, they could look forward to the future and they would know that a day would dawn when they would come out cured and in good health.

Mr. Dillon

I yield to no one in my admiration for the medical profession, but it rather makes my blood run cold when I hear my distinguished colleague, Deputy Dr. Esmonde, exhort the Minister for Health, when he comes to consider the larger medical treatment Bill, to consult fully with all the experts, alienists, psychiatrists, dispensary doctors and any other body that generally has charge of the bodies of their fellow-citizens. Might I humbly and respectfully submit that, when the doctors are reaching conclusions as to how they propose to dispose of us all, having consulted the psychiatrists, the alienists and thedoctors, they would deign to consult the intended victims of their ministrations? I begin to feel that any day walking down D'Olier Street somebody might whisk me off to Grangegorman in a Black Maria and tell me they brought me there to reassure themselves that I was not daft.

Mark you, it is very often difficult to stir a quiescent legislature into a realisation of the dangers that, with the best intentions in the world, we may ourselves engender. Nothing can be more natural than that in a House so constituted as ours the mention of mental affliction evokes an ardent sympathy on all sides and Deputies are prepared to strive one with another in helping to resolve the difficulties begotten of so grievous an affliction, but in their desire to help they lose sight of the implications of some things that with imprudent sympathetic ardour they rush precipitately to do.

When this amending Bill was first submitted the Minister was gracious enough, in view of the fact that expedition was necessary in dealing with it, to communicate the substance of the proposed Bill to the Opposition and was further gracious enough to discuss certain anxieties that some of us had in regard to some of the provisions he proposed and, piling Pelion on Ossa, he has outdone himself in civility in submitting a draft amendment to-day, which he has most suitably done, to meet one apprehension that some of us expressed, but in our desire to tidy things up and make things better than they were over and above circumnavigating the difficulties that had arisen under the habeas corpusapplication it appears that under the Mental Health Act, as amended by this Bill, it would have been possible for anybody over 21, who could persuade any dispensary doctor in Ireland that it was necessary to remove one to a mental hospital, to get one shifted. That was so, but it had to be done over the counter-signature of some medical officer, not necessarily the resident medical superintendent, if this Bill had been passed in its original form. While it is true thatyou could not be detained longer than 12 hours without the resident medical superintendent examining and certifying whether you should be detained longer or not, any citizen anywhere in Ireland was liable to be removed from his own home to a mental hospital at any time on the certificate of one doctor.

Think for a moment of the conditions we live in in Ireland. Ours is mainly a rural community. I just mentioned the matter on this occasion so that Deputies would turn their minds to the possible implications of legislation of this kind unless it is very carefully examined. In rural Ireland it not infrequently happens that there is a family dispute and it is apprehended that someone who disposes of property is about to make an irrevocable deed alienating that property from a person who has a legitimate claim, whereupon it becomes the desire of that person to get the intending executor of the deed into a mental hospital if only for a day so that when the deed comes to be impugned in court evidence will be called to show that the person who executed the deed was a mental hospital case if only for a day.

There may have been a family settlement which involved the making of a will by a person whose death may reasonably be anticipated in the near future. That person may enter into a second marriage or do something else. That may not be a good example as a second marriage invalidates the first will. Interested parties may think that the person who executed the will contemplates making a new will and if they can get that person into a mental hospital for a day then, when the will comes to be tested in court, they will say that they propounded the will before ever he went into a mental hospital. They now want to make the case that the first will was the right will and that the second was made after the poor man lost his reason. Therefore, there could be great inducement in certain circumstances in the rural communities improperly to have people removed to a mental hospital. While anxious to do everything in ourpower to cure, help and relieve the distress of those who are really mentally afflicted, it is nevertheless essential to take precautions to ensure that the provisions we make for such people are not abused by persons of bad intention for an entirely ulterior motive.

I am obliged to the Minister, whether he agreed entirely or not with the submissions made to him, for seeing that at least there were legitimate grounds for apprehension and, accordingly, as I understand the amendment, he has provided that if the applicant secures from one doctor a certificate of the necessity to remove a citizen to a mental institution that removal cannot be effected until (1) the person to be removed has been told that he has a right to a second opinion, (2) if he elects for that right a second independent doctor is summoned and (3) that second independent doctor has issued a further certificate that he agrees it is necessary to remove the patient.

I thank the Minister for coming so far to meet us and I entirely agree with Deputy Dr. Esmonde that we intend to provide the Minister with every facility to get this urgent legislation through in order to meet the specific problems before us. I also would like to ask the Minister to take the occasion of concluding on the Second Stage of this Bill to tell us if he has the intention of having a more comprehensive amending Bill introduced at a later stage which would be the fruit of more mature consideration than necessarily this particular Bill can be.

There is one other point to which I would like to draw the Minister's attention in relation to sub-section (3) of Section 3 of this Bill. Sub-section (1) provides for the delegation of powers by a medical superintendent, the chief medical officer or the person in charge of a district mental hospital. Sub-section (2) provides for the delegation of duties of the chief medical officer of a mental institution other than a district mental hospital. Sub-section (3) differs from the other two in this detail, that the powers delegated in sub-sections (1) and (2) must be delegated to a person with medical qualifications but when you are dealing with sub-section (3) we are dealing, Igather, with mental institutions which may be managed by a person who has not medical qualifications. I take it that there are certain institutions where you would have a medical officer but the manager would be an unqualified man or woman.

Dr. Ryan

I do not know of any case but I think in such circumstances the matron would be the authorised person.

Mr. Dillon

Yes. I want to put this to the Minister. If we authorise a qualified doctor to delegate a duty of his under this Bill to another qualified doctor we have a certain security. But suppose the central authority charged with the supervision of all mental patients chooses a lay person and says: "We will give that particular lay person the powers provided under this Bill because we know him to be a responsible and prudent person." Can we properly allow that person to delegate those powers to any officer of the institution authorised in that behalf by the person in charge?

I do not know if the Minister's attention was directed to a story that appeared in this morning's newspapers which may or may not be true, where a councillor of the Clare County Council complained that a young woman whose body was encased in plaster of paris was deemed fit to have the plaster of paris removed but that instead of the medical officer or a prudent matron being charged with the task of removing the plaster which covered her entire body the hall porter was sent up with a pliers to perform this extremely intimate and delicate operation, a decision which I think would appear to all of us to be singularly inappropriate.

There are many grave matters of delegation envisaged under the Mental Treatment Act. I can see that we may be justified in allowing a doctor in an institution to delegate one of his duties to a colleague on the staff who is himself or herself a doctor. But should we give to an unqualified person whom the Minister has recognised as the manager of a mental home on his personal merit, personalsuitability, personal prudence and discretion, the right to delegate his functions to the charwoman who washes the floor, to the hall porter or to any minor employee who would come within the description of an officer of the institution authorised in that behalf by the person in charge?

Remember, we are dealing with people mentally afflicted who have nothing to stand between them and ill-usage but the high professional standards of their custodians and the perennial surveillance of the Department of Health. No amount of perennial surveillance can guarantee right treatment for the afflicted, day in, day out. We are thinking now of the effect of sub-section (3) in an institution the manager of which is not a person with medical qualification. Such a place—I think I am right, if not the Minister will correct me—would invariably be a very small establishment. Should we not either provide that in such cases there should be no delegation or that the delegation shall be only to an officer of the institution with medical qualifications authorised in that behalf by the person in charge? Surely we ought to put some limitation on the power of delegation by an unqualified manager of a mental hospital.

I will concede this at once, that I do not feel this point is one of urgency. I do not think any difficulty will arise if the Minister says: "While considering the point to be of value I will ask to be excused from considering it here and now but I shall deal with it affirmatively or negatively when the further legislation comes before the House." Subject to that I do not want to press the Minister about that particular detail, but I think it is a detail of substance. However, I do not foresee that anything terrible is likely to happen in the course of the next three or six months if this cannot be done here and now. If we could dispose of it here and now so much the better, but if that would cause unnecessary delay or inconvenience it could be postponed to another day.

Major de Valera

There is only one remark that I want to make in connectionwith this Bill, and it seems to me that the point is covered now by this amendment. It is not often that I find myself in general agreement with Deputy Dillon, but I had thought of coming in to make a somewhat similar point to his—that is, the dangers in certification from the point of view of abuse. There is one aspect of that which does need consideration, and that is, that if you leave too wide a power of certification it is not so much a question of positive malicious abuse of it on the part of the person exercising the power, but it is more a question of the danger of the easy way out being taken. There was a loophole for that in the proposals, and the loophole was like this. First of all, in a case where there was to be delegation. In other words, an order had to be sent and some other medical officer called in for the purpose. There was always the danger that any doctor called in in such circumstances would find himself in the position of having to exercise considerable responsibility, in the first place, and, secondly, he would then know that that would be re-examined within a number of hours.

In that situation the temptation would be there to do the safe thing from the doctor's point of view, to certify and to let the thing be regularised. That brings up precisely the danger that Deputy Dillon spoke about. In other words, it may be possible to bring about a state of affairs which will appear to a doctor, called in like that, as being sufficient to warrant certification without appreciating all the consequences that can flow from that. There will be the added temptation, if you like to use the word temptation, of saying: "Well, this is not final and there will be no harm done," not realising that there could be a great deal of harm done in the specific instance that was mentioned by Deputy Dillon which also had occurred to myself as regards this question of testamentary capacity.

There can be no doubt but that a mere committal, even for a matter of ten minutes, might have the most serious results. A certificate from the point of view of testamentary capacitymight prejudice the whole position afterwards. However, I take it that Deputy Dillon is satisfied with the amendment that has been circulated. So far as I can see, the amendment meets the position as far, I think, as it is humanly possible to legislate for such cases.

Mr. Dillon

Hear, Hear!

Major de Valera

We have also to think of the other side and of what motivated the Minister immediately in bringing in this Bill. It is the question that there are other consequences that can flow through not acting quickly enough. We know that where a person suddenly becomes mentally ill he can do things either to himself or to others where it would mean criminal negligence not to act immediately. In my opinion, the amendment goes as far as can be, and paragraph (b) of the sub-section is, in the particular circumstances, naturally desirable. That was actually the only point on which I wanted to intervene in the debate on this Bill.

Now as the matter has come up and as the Department is interested in lunacy procedure generally I think it would be well that we should look at our legal procedures and other procedures in regard to certain types of mental disability. The medical side is the Minister's immediate concern and I think that is getting attention. I would rather leave that to the experts who know something about it. But on the legal side, that is with regard to the mechanism and the consequences of certification, the suits that can evolve in regard to the disposal of an estate and the consequences generally that will attach the property——

Mr. Dillon

And our rights as free men.

Major de Valera

For the moment let me deal with property. Our rights as free men——

Mr. Dillon

Many of the Deputy's colleagues would cheerfully put me in a mental hospital if they dare.

Major de Valera

If certain medical officers in these institutions had the power to certify at convenience I could not help thinking of a rather Gilbertian situation arising.

Mr. Dillon

It is not in a mental hospital that I would put some of them but should I have the freedom to do that?

Major de Valera

However, to come back seriously to this matter.

Mr. Dillon

Seriously, do you not think that individual liberty is an important element in all this mental hospital legislation?

Major de Valera

It is an important element in everything. There is also the question of abuse on the part of the individual concerned but as regards individual liberty you have to take the community's angle into account as to whether the abuse is intentional or accidental through mental aberration. In regard to property, the Minister will need time to go into details. I think it might be conveniently considered in connection with the freedom of the individual which Deputy Dillon speaks about. Frankly, accepting that you are able to provide appeals, and there is an appeal here and certain safeguards of that nature, I am afraid that in cases like this you must of necessity accept an invasion of personal liberty in the interests of the community.

Mr. Dillon

This amendment is a great improvement.

Major de Valera

In all this there is, if you like, an invasion of personal liberty, but that invasion of personal liberty is absolutely essential from the point of view of the community, and very frequently from the point of view of the individual concerned.

Mr. Dillon

But it should be strictly controlled.

Major de Valera

Everyone concedes that. On the other hand, the control must be effective. There must be real control. We might very easily lose sight of the fact here, in our anxiety to find a legal formula that might look very well from the legal point of view,that we were creating a situation which would completely hamper or render ineffective the effective steps that would have to be taken in a particular case. Suppose, for example, someone with murderous tendencies walked down O'Connell Street and started to kill off half the population in the street. It is a question of balance.

On the whole, I think that the Minister in this amendment has gone as near as he could to meet this point. If the whole question is being later examined, I think that the property angle of it, with a simplification of procedures, is desirable. Sometimes we introduce very elaborate mechanisms. That has been done before by legislatures introducing elaborate mechanisms designed to safeguard some particular right or preserve some particular freedom, but these mechanisms, instead of working out beneficially, have often worked out as loopholes. In other cases, where there should not be loopholes, these mechanisms have failed to achieve their objective.

A more simple procedure which might seem a little more radical on its face will often work out very well. The danger in that argument is that it might be the thin edge of the wedge, but still there has to be taken into account that there is a practical job of work to be done here. It involves the medical officers concerned from the word "go" to the final stages, the hospitals, and the staffs concerned, and maybe it involves the police in certain cases. All these have a practical problem when it arises. They must be in a position to move with a certain degree of certainty and clarity in the situation without any danger of unforeseen or unfair repercussions when they are trying, bona fide, to do their proper duties. All these things have to be considered. On the whole, and having regard to the particular service concerned, and in view of the urgency of the case, I think the Minister must get his Bill, and as quickly as possible, but if the matter is being examined again I would like to have the points I mentioned considered in connection with the whole question.

Mr. Finan

I fully appreciate the necessity for urgency in this case, and I want to say that the attitude which the Minister adopted in informing Deputies through the Whips of the different Parties of the matter contained in the Bill is appreciated by the House, and has, I think, helped to facilitate the passage of the measure. For that reason, I think this measure will not be examined too microscopically. I think, also, for that reason, the sooner the comprehensive legislation for this whole matter is brought in the better. While it is important—and most important—that the law should be such that an insane person can be committed with the utmost expedition, it is vitally important, too, that the law should be such that a person who is not insane could not possibly be committed to an institution of this kind. It is not necessary to remind the Minister that on the comprehensive measure the greatest care will have to be exercised and every clause will have to be examined to ensure that injustice will not be done and that no risks will be taken because the law is such that the person who is really dangerous cannot be committed, or through the law being so loose that a person who is not insane can be committed. With these remarks, I give my agreement to this measure.

Mr. Briscoe

I just want to make a short observation. I am speaking as one member of the House who has some experience on the management board of a mental hospital. I do not know whether the others who have spoken have any such experience.

Listening to Deputy Dillon talking, one would imagine that there was no clear line of demarcation between a sane person and an insane person. Deputy Dillon has on many occasions in this House described the members of this Party as "daft.""Daft" is an expression you apply to people who are not well balanced mentally.

We have made extraordinary progress in this country in bringing our laws with regard to the mentally afflicted up to what one might call a very high standard. The Bill of 1945 was recognised all over the world asa step ahead of most democratic countries in the treatment and control of these people who are unfortunately afflicted.

Deputy Dillon spoke of the man who might on the certificate of a doctor be sent to an institution and the resident medical superintendent of that institution might hold that he was not mentally afflicted at all or not to the extent which would warrant his being detained. That man goes out of the hospital with a certificate of sanity. Most of us have not got it. None of us can prove that we are not insane but that man at least can. If there is any discussion about a will he wants to make afterwards, at least it can be held that he was medically examined before he made it and was certified to be fully in control of his senses.

I have seen painful situations in my time where you would imagine in conversations over long periods that certain people were normal and very often those people are quite normal—as normal as ourselves—but they are, unfortunately, people who suffer from a particular obsession and on that obsession, they can work themselves up to what you might call insanity.

After all, the suspicion attaching to the actions of medical practitioners in certifying people is what is being expressed here. We always have court cases arising from wordings of Acts of Parliament which raise doubts as to what is meant in them, and this amendment arises from the same thing. The intention in the original Bill is exactly what is intended by this amendment, but it has been expressed in a court of law that there is some doubt, and in order to have it cleared up we have this amendment.

I want to assure Deputy Dillon, from my own experience in two large hospitals of this nature, there are no more rigidly-controlled institutions than these institutions. Every patient is not only under the control of the medical staff of the institution, but also under the control of special inspectors from the Department. Patients have special rights of appeal, either by themselves or through their relations. Unless you are dealing with bad people, I imaginethat if the individual referred to by Deputy Dillon existed—I do not say he knows such a person, but he expressed the fear he had about such a person wanting to have another who has some property certified, because he is afraid that person may alter a will—I can assure the Deputy it is a very difficult thing unless there is collusion with a member of the medical profession; and it is very unusual and very unlikely that you could say that the medical practitioners do not carry out their duties with the highest degree of conscientiousness. They are not likely to certify somebody just to oblige a member of a family who, for selfish reasons, wants to take this step.

Deputy Dillon talked about the manager not being a medical person. The resident medical superintendent and his other medical staff, and the nursing staff—specially trained male and female nurses who look after patients—have certain functions, but on the issue of the patient himself, as to his mental capacity or otherwise, the medical people are the deciding people. Other people have to be in the institution, managing the laundries, the food supplies, the heating requirements, and so forth, but nobody in his wildest stretch of imagination can imagine that any medical practitioner is going to delegate medical matters to anybody who is not properly qualified.

Mr. Dillon

Is the removal of plaster of paris from the patient's body the proper function for the hall porter?

Mr. Briscoe

The Deputy is now talking about an ordinary hospital, not a mental institution.

Mr. Dillon

I am talking about the doctor.

Mr. Briscoe

Many things happen that should not happen. I do not know the circumstances of this case except what I read in the paper this morning like the Deputy, and I suppose we will hear more about it. We are now discussing the treatment of those who are committed because of a lack of balance mentally.

Mr. Dillon

And alcoholics and addicts.

Mr. Briscoe

The addicts and the alcoholics are separately dealt with in the main Bill.

Mr. Dillon

The Deputy is mistaken. This relates to alcoholics, addicts and temporary patients.

Mr. Briscoe

They are all specially dealt with in the main Bill.

Mr. Dillon

No.

Mr. Briscoe

There are special references to addicts and alcoholics.

Mr. Dillon

That is not so.

Mr. Briscoe

We had a special discussion on that here.

Mr. Dillon

The Minister will explain that to the Deputy.

Mr. McQuillan

Will someone clarify this?

Mr. Briscoe

There are such people as half-mad people, not sufficiently unbalanced to be certified but sufficiently unbalanced for a number of people to wish they were certified.

Mr. Dillon

Exactly, and now we are getting to the kernel of the matter.

Major de Valera

It is in these cases that these difficulties mainly arise.

Mr. Briscoe

The case of the halfmads. Who will strike the balance as to whether a half-madman should be put into an asylum or left loose on the community? I want to have that point cleared up. From my own personal knowledge and experience over a number of years in relation to the management of the mental hospitals, I know that the greatest care is taken to ensure that the liberty of the individual is not interfered with unless that is absolutely necessary. We all meet from day to day people whose ability to remain carrying on their normal life we feel inclined to question and we feel sorry that they do not try to get cured voluntarily.

Mr. Dillon

So long as the Deputy's sorrow does not carry him away to the extent of putting such people in, I do not mind. But the Deputy could get too sympathetic.

Mr. Briscoe

I am not inviting the Deputy to follow what I am suggesting and I do not know what the Deputy meant by interjecting. In mental institutions patients have the right to ask to see the governor. I have had the experience of interviewing a patient in Grangegorman who appeared to me, after an hour's conversation, to be apparently more sane than I am myself or Deputy Dillon. I went to the resident medical superintendent and told him I could not find anything wrong with the man. I said I had discussed everything with him and that he knew what was going on in the world outside, what was going on in the City of Dublin, and so forth. The doctor told me to go back and tell the man that he would be released that afternoon. I went back and I told him that and he said: "Can I take my antennae with me?" I said: "What antennae?" and he replied: "Can you not see it; this is what gets me into trouble when I try to get on the bus; it gets in the way." Then I realised that he suffered from this hallucination. I do not think Deputy Dillon need work himself up into this attitude of suspicion on this amendment.

Mr. Dillon

What suspicion? I have commended the Minister on the amendment. Is the Deputy for the amendment or against it?

Mr. Briscoe

I am for it.

Mr. Dillon

Then we are all agreed.

Mr. Briscoe

We knew in advance that the Fine Gael Party agreed with this amendment. I know no more of what Deputy Dillon was talking about than he knows what I am talking about.

Mr. Dillon

Sure, it was I who got this amendment drafted.

Mr. Briscoe

I am not questioning the amendment. The Minister has agreed to amend the Bill.

Mr. Dillon

And I am very much obliged to him.

Mr. Briscoe

We are all in agreement. We want to make this Bill operate in the sense that it was intended to operate the Act when itwas originally passed. People may take different views and it must be remembered that we have travelled very far in the treatment of the mentally afflicted. We no longer bring them to the District Court in a Black Maria and have them sentenced as criminally insane. We now have a more humane approach. I venture to suggest that the same thing could happen to Deputy Dillon or myself as happened to a gentleman who accompanied a friend anxious to go in for treatment voluntarily as an addict. When he reached the hospital he left the waiting room for a moment and outside he told an attendant to be careful of the fellow inside: "I am sneaking away now and you will have great trouble locking him up," and the addict who was supposed to be going in for voluntary treatment left the hospital and his friend remained behind and it was the friend who was put into a padded cell because of his efforts to resist being held there for examination.

Mr. Dillon

Se non é véro ben trovato.

Mr. Briscoe

If a Black Maria came to pick any of us up our efforts to resist would make the gentleman in charge really believe we were lunatics because we would not have the patience to wait until the medical officer put us through some examination in order to certify us or release us.

Mr. McQuillan

Is it not quite possible that the medical officer might be as daft as the people under his care?

Mr. Briscoe

That is perfectly true.

Dr. Ryan

Deputy Dr. Esmonde raised a few points with which I would like to deal. So far as this Bill is concerned, I merely set out to deal with difficulties which were discovered as a result of the habeas corpusaction before the courts recently. I tried to keep as closely as possible to the principle of the main Act and to leave any other changes that may be necessary for an amending Bill which is actually in course of preparation. Later I shall refer to that amending Bill again.

As the Act stands in relation to who certifies, it is the dispensary doctor who certifies as insane a person who goes into a district mental hospital. The same regulation applies to a temporary patient. The dispensary doctor certifies that person and the person is admitted, as the Act stands at the moment, on the reception order of the chief medical superintendent. We are proposing to alter that now and say that a reception order can be signed by an assistant or someone nominated for that purpose by the local authority.

When the other Parties got the draft of the Bill—I think it is only reasonable that in a Bill like this I should not make things easier for the committal of a person to an institution— they were quite within their rights in saying they did not want to have any principal change but, on the other hand, they did not want to remove some of the safeguards that are in existence already. I promised to see if I could draft this amendment and that is the amendment now submitted to the House. The amendment will make it at least as difficult to get a person in as a temporary patient as it has been up to this because, though we are making it a bit easier at the reception end, we are making it a bit more difficult before the actual reception order is asked for and, therefore, things should balance out fairly well. It should not be any easier in future to get a person in.

Deputy Esmonde raised the point that the dispensary medical officer is required under existing legislation to certify and if he cannot be found the patient cannot be committed. That is the difficulty. An urgent case might arise and the dispensary doctor might not be available; in such circumstances those concerned must wait until he is found as the law stands. Under the present law, where there is more than one dispensary doctor in an area, it is specifically laid down that either can sign. If neither can be found, then the nearest dispensary doctor can sign the certificate. Obviously, that is necessary where there is only one dispensary doctor in an area, and, therefore, in Section 2 we are making it possible in future, where the dispensary doctor proper to the area cannot befound, to avail of the services of the nearest available dispensary doctor.

The point Deputy Esmonde makes is that it should be just as effective to have "any medical practitioner" put in. That is a matter that could be argued on the amending Bill, because I would regard that as a change of attitude or of principle in the principal legislation. I have not gone back to consider why "dispensary doctor" was put in. I am sure there was good reason for it. It would be wrong to make any fundamental change such as that at this stage. It could be argued on the amending Bill.

Mr. Dillon

Is it sub-section (2) that does this?

Dr. Ryan

Section 2 makes it possible to get the nearest available dispensary doctor. I am just arguing the point. I would not like to say "available doctor." I would prefer to retain "dispensary doctor," which is there already. I do not want Deputy Esmonde to conclude that I am absolutely committed to dispensary doctors. I am only committed to the principle that is there. We can discuss the principle on the amending Bill as to whether we should retain "dispensary doctor" or not.

As to the case of the person outside his own district, one could quote numerous instances but the most effective example I can give is a woman coming from, say, Wexford to a maternity hospital in Dublin. Unfortunately, a woman at that stage or when the baby is born sometimes gets a bit mental. As the law stands, in order to get that woman removed for mental treatment, the dispensary doctor from County Wexford would have to be brought up to certify her or she would have to be brought to him. That is absolutely unreasonable. In a case like that a dispensary doctor who is available should be sufficient to certify her. That would be covered by Section 2.

Another point arises. As the law stands, she should be sent to Enniscorthy, not to Dublin. Section 4 will make that right. Under Section 4 shecan be sent to the nearest institution and the nearest institution will notify her county. The county then must pay for her maintenance there up to the time they are notified. Then they have their choice of either continuing to pay for her there or taking her back.

Dr. Esmonde

Can the patient stay indefinitely in that institution for as long as treatment is necessary?

Dr. Ryan

If her own county agrees, yes, and they will pay. We have been preparing an amending Bill in the Department of Health for some time. The 1945 Bill was a radical departure from the concept of the preventive treatment of mental diseases up to that time. We had not even very much experience of other countries to guide us. That Bill was a wonderful success in the preventive treatment of mental diseases but, naturally, a Bill of that magnitude, a Bill containing such very big principles and introducing departures from big principles was almost certain to require amendment as time went on. We have been compiling points that would come up for amendment as soon as time could be found. That amending Bill will come.

The 1945 Bill, first of all, was a departure in stressing prevention rather than cure and, secondly, in stressing cure rather than detention. It had the effect of making our mental hospitals hospitals and not places of detention. The work that has been done under that Act has been very good indeed in the short time that it has been in operation—less than seven years. I do not know when the amending Bill will be introduced. Possibly it may be a matter of 12 months or so, but I should not like to be tied to any promise of that kind. An amending Bill will be necessary. We will seek advice from every expert possible. We are hoping to get the advice of the men who have been working the Act, medical superintendents or whoever they may be. Naturally, we will get advice, if not from individual dispensary doctors, from doctors incorporated as a body. We will get whatever advice they have to give us before we draft the Bill.

Mr. Dillon

You will not forget toget advice from the potential consignee?

Dr. Ryan

I will take that to myself. Deputy Dillon expressed fears, not only to-day but when he saw this Bill first, of malpractices. I am glad to be able to say that I have not been able to find any instance of malpractice in the last seven years but I quite agree with Deputy Dillon that that is not sufficient. As Deputy Dillon put it, and I quite agree, to put a person in wrongly is a much more serious thing than to leave a person out who should be in. I suppose there are many people out who should be in, but we have to tolerate that. It would be a very serious thing indeed to have a person put in who should not be put in. Subject to practicability and so on I would be prepared to consider any proposal in that respect.

Deputy Dillon in particular drew attention to sub-section (3) of Section 3. Sub-section (3) was put in to cover the case where there is not a medical man in charge of a private mental hospital, as sometimes happens. As I said when Deputy Dillon asked me the question, I only know of a case where there is a matron in charge but there may be cases where there is a layman in charge. It could happen, if the Minister sanctions it. We say that she or he may appoint a deputy. I do not like to insert a clause there which would be a departure from the principle followed in the principal Act, that it must be a medical man, but certainly the question should be considered on the amending Bill as to whether we should allow anybody except a medical man to occupy a position of that kind. That can be discussed fully on the amending Bill.

Mr. Dillon

May I suggest that the provision be made that if there were delegation under sub-section (3) it could only be done subject to the Minister's approval?

Dr. Ryan

I am afraid that even to put that in would be a difficulty at this stage.

Mr. Dillon

I do not press for that.

Dr. Ryan

The person concerned must be approved.

Mr. Dillon

Exactly.

Dr. Ryan

And if the person concerned is unreasonable the approval could be withdrawn. That perhaps would meet the point. I do not think there is any other question of any importance. I want to thank all Parties for giving this Bill their consideration.

Dr. Esmonde

Would the Minister care to refer to the point I made about removing, in future legislation, the phrase "unsound mind"?

Dr. Ryan

Oh yes, I did take a note of that. I can assure Deputies here that the tendency for the numbers of people going into mental hospitals now under the heading of "unsound mind" is becoming less and less and the number going in as temporary patients—that is, requiring mental treatment—is becoming more and more. I think that in a few years' time if there is an amending Bill coming in it could be considered because there would be so few going in as persons of unsound mind. On the other hand Deputies must bear this in mind, that as the law stands a person who goes in for mental treatment can only be kept for six months and then if the superintendent thinks that he would benefit by further treatment he gets the permission of the Minister for another six months. That can be arranged but only to the limit of two years. Under the law a temporary patient must be let out in two years' time and that would, of course, be creating difficulty.

Dr. Esmonde

The Minister could meet that by extending the period.

Dr. Ryan

That might be going too far on the other side.

Mr. Dillon

Hear, hear!

Dr. Ryan

Take, for instance, the addict that Deputy Dillon spoke about. I have power actually to keep an addict for two years but in practice my predecessor, Deputy Dr. Browne,did not ever keep an addict in more than 12 months, nor do I ever, because we are advised by our advisers that if they do not make a job of an addict within 12 months they should not be in at all.

Mr. Dillon

Hear, hear!

Dr. Esmonde

It is the Minister who makes the renewal. It is covered by the fact that the Minister need not make the renewal for the addict.

Dr. Ryan

No. He need not. He can refuse.

Dr. Esmonde

That covers that, then.

Question put and agreed to.

Agreed to take the remaining stages now.

Bill considered in Committee.

Sections 1 and 2 agreed to.

Question proposed: "That Section 3 stand part of the Bill."

Mr. Dillon

Agreed, subject to the Minister undertaking at a later stage to consider the matter mentioned in regard to sub-section (3).

Dr. Ryan

Yes.

Question put and agreed to.

Section 4 agreed to.

SECTION 5.

Dr. Ryan

I move amendment No. 1:—

Before sub-section (3) to insert a new sub-section as follows:—

(a) Notwithstanding sub-section (1) of this section, where a medical certificate has been given under Section 184 of the Principal Act and it is proposed to exercise the power conferred by paragraph (a) of that sub-section—

(i) the applicant shall, before exercising the said power, inform the person to whom the application relates of the nature of the medical certificate and of the fact that such person may request a second medical examination, and

(ii) if such request is made, the said power shall not be exercised unless such second examination has been made and the registered medical practitioner who made it has signified in writing that he agrees with the medical certificate.

(b) A registered medical practitioner shall not signify under this sub-section his agreement with a medical certificate relating to a person if such practitioner is the husband or wife, father, step-father or father-in-law, mother, stepmother or mother-in-law, son, step-son or son-in-law, daughter, step-daughter or daughter-in-law, brother, step-brother or brother-in-law, sister, step-sister or sister-in-law, or guardian or trustee of the person.

I do not think it is necessary to explain this amendment as we have already discussed it.

Mr. Dillon

Agreed.

Amendment put and agreed to.

Section 5, as amended, put and agreed to.

Section 6 and Title agreed to.

Bill reported with amendment, and received for final consideration.

Question proposed: "That the Bill do now pass."

Mr. Dillon

On the Final Stage, it is clear that the Bill contains adequate indemnity for all parties against whom proceedings might lie in the event of actions for damages being instituted, and in case there should be any lacunae would it not be advisable for the Minister, at this Fifth Stage, to say that it is the clear intention of the Oireachtas that if such lacunae should subsequently transpire he would pass retroactive legislation effectively indemnifying any persons for carrying out what they conceived to be their duty under the Act under the habeas corpusproceedings?

Dr. Ryan

There is a difficult point there. Perhaps the Deputy would not mind if I was not pressed to go intoit, but all the officers concerned are covered.

Mr. Dillon

I do not press the Minister to deal with the matter now.

Dr. Ryan

What I mean to say is that I am advised that the officers concerned are covered, but I would not like to go further. I think that to cover the local authorities would be difficult.

Mr. Dillon

I am not particularly solicitous about the local authorities. They have protection enough from P.A.P.A.

Question put and agreed to.