Seanad Éireann debate -
Thursday, 17 Dec 1953

Vol. 43 No. 4

Public Business. - Mental Treatment Bill, 1953—Second and Subsequent Stages.

Question proposed: "That the Bill be now read a Second Time."

Minister for Health (Dr. Ryan)

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 corpus proceedings 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 developing on the resident medical superintendent, it would obviously be impractical 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 performed by 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 be passed through all stages to-day.

Mr. O'Higgins

I think this is a sensible measure and one which, on the recital of the facts given by the Minister, is necessary. For that reason, I have no doubt that the House will facilitate him in getting the Bill through quickly because it is one of urgency. I think it is right once more from these benches to raise some protest against this kind of thing happening time and time again to the Seanad. I do not know if the Minister for Health realises it, but practically every day the Seanad meets some Minister of the Government comes in here and makes an excuse as to why the Bill is coming before the Seanad at short notice and makes a case for the Seanad giving all stages of the Bill. In cases of genuine urgency, it is probably unknown for the Seanad to refuse a Minister these facilities, but I think it is right to say that some of us in these benches are perturbed by the frequency with which these requests are being made. If the Seanad is to perform a serious function, it should be treated seriously by the Government and adequate time for consideration and discussion of these measures should be given. I want to make it clear again that those remarks do not apply to this particular Bill.

This Bill has been occasioned because of a technical flaw, if you like, in the earlier Act, and the amendments which the Minister is proposing to introduce by means of this Bill governing admission and retention in mental hospitals are amendments which I personally think are very desirable. Probably most of us, from time to time—certainly those of us in the legal profession—have come up against situations in which we can visualise the very grave difficulties that would be encountered if the law, as it stands at present, by virtue of a court decision were allowed to remain unaltered. Probably, every day of the week the medical staff of mental hospitals are confronted with problems which must be dealt with in a hurry. If by reason of the existing legislation, it is to become necessary for a particular officer and no one else to sign admission orders or discharge orders, I can see the situation would be quite impossible. Sections 3, 4 and 5 of the present Bill propose very common-sense amendments of the existing legislation, amendments which I think will be accepted by the House and I believe we should give the Minister this particular Bill in all its stages.

Mr. S.T. Ruane

I take it this Bill has some connection with another Mental Treatment Bill of which many Senators will have a recollection of having gone through the House several years ago, the provisions of which led many of us to believe that something very novel, revolutionary and beneficial was about to be introduced into the country in the method of treatment for mental illness. Many of us were led to believe at the time that dispensary doctors in the different districts would have clinics at which cases in the early stages of mental trouble might obtain treatment and that there would be specialised treatment afforded at the various mental hospitals. I do know that specialised treatment is carried on in some of the hospitals and with good effect now but I have not heard of any case—and doctors from time to time are confidential with some public or local representatives—that had been treated at a local dispensary.

I do not wish to be ruled out of order but let me say that as a result of specialised treatment in institutions big bills are coming before the local bodies for special clinics. As a matter of fact, one was before the Mayo County Council less than a week ago which, carried by a majority of the council, will involve the county in expenditure to the extent of £60,000 for establishing a clinic. I have no objection to this Bill going through but I think it might be opportune to take the Minister's mind back to the particular occasion on which the last Bill was passed, and get information as to what progress, if any, has been made in this particular trouble. Some of us have not seen the benefits flowing from that Bill that at the time we expected would flow from it.

Professor Cunningham

We have been told that this Bill, which is an effort to modify and make more rational the Mental Treatment Act of 1945, was necessary because of a recent case in the High Court whereby a patient who was detained as a temporary patient in a mental hospital was discharged for the reason that the reception order under which he was detained was not properly executed. We have been told that the decision of the High Court has drawn attention to the defects in the Act.

I received a copy of this Bill yesterday. I have not had an opportunity of studying it very thoroughly or of studying the Act itself, but from a rather quick persual of the Bill and of the Act I can see that the original Act contains a great number of anomalies. At the time when the Act was drafted in 1945 the Minister and his Department I am quite sure had ample opportunity of consulting someone and seeking advice from people who would be in a position to tell them the best way of drafting a difficult Bill of that kind. There are plenty of people in this country associated with mental disease in one way or another, either professionally or on the lay board of some of these hospitals and, therefore, very familiar with the requirements. Whether the Minister at that time did seek their advice I do not know. If having sought the advice he followed it or not I do not know. I do know that during the past eight years I have heard this Act discussed on several occasions in medical circles and I know that a number of doctors associated with the treatment of mental disease have been very perturbed and worried about it. I have been told by them that they made protests to the Department of Health in writing on several occasions and asked to have certain amendments and regulations altered and that nothing has happened. It was not until some legal person saw the defect in the Act and applied in the High Court to have a patient discharged that anything was done about it. The Act has been in force for eight years.

As I said, I have had very little opportunity of reading this Bill but I am sure the Minister will correct me if I am wrong in the points I am about to put. As a result of this Act and the way it was drafted and the numerous anomalies it contains it is not only one patient that was detained illegally. I believe that the number runs into 2,000, and for that reason this Bill is urgently necessary and, therefore, I give it my support.

It appears to me that the whole Act requires re-drafting and I hope that the Minister when he has an opportunity will introduce an amending Bill and alter the whole thing. I think the idea behind it is very good, but it has been so badly drawn and it is so full of mistakes and errors that it is likely to lead to a great deal of trouble. In this Act you have classified three types of patient. There is the voluntary patient who goes voluntarily into a mental hospital for treatment.

An Cathaoirleach

I am afraid we cannot have a discussion on the principal Act.

Professor Cunningham

On the amendment suggested in this Bill?

An Cathaoirleach

The matter must be related to the amendments involved.

Professor Cunningham

These are merely explanatory things. The difficulty arises about the question of temporary patients.

An Cathaoirleach

The difficulty of the Chair is that the discussion may become so wide that there will be no possibility of getting through the business.

Professor Cunningham

I will not be very long. I do not think I can explain very thoroughly unless Senators understand what a temporary patient is. The main object of the Bill is to change the method of admission of a temporary patient. A temporary patient is one looked upon as being ill only for a short period of time and who, after some treatment, will be cared. The other person is a permanent patient, looked upon as a person of unsound mind and likely to be detained for some time. The trouble about the amending Bill is that it does not go far enough to change the old regulations. The difficulty is about admitting a temporary patient.

A temporary patient is admitted on an order signed by the dispensary doctor. The order is then sent to the hospital and the medical superintendent has to sign it. That has been the difficulty. The change being introduced now is that it may be signed in the hospital by anybody who represents the medical superintendent —for instance while the medical superintendent is absent on holidays. Under the amendment, authority may be given to any properly qualified person who deputies for him. We have the difficulty that the dispensary doctor also may be absent. Under the Act, if he is absent it cannot be signed. Under the new amendment, if he is absent, the nearest dispensary doctor may sign the document. To my mind, that is not a very wise arrangement. The nearest dispensary doctor may be 15 or 20 miles away and there might be great delay searching for him. I suggest to the Minister that in the absence of the dispensary doctor for the district any registered medical practitioner should be allowed to sign. That would save a great deal of time.

In the case of a patient of unsound mind, the permanent type of patient, the certificate can be signed by the dispensary doctor and the patient sent to the hospital without the medical superintendent signing any document. He is examined on admission. I cannot understand why there is a difference between the two types. One has to be signed for by the medical superintendent of the hospital or his deputy before he even sees the patient, but in the other case the person of unsound mind is sent to the hospital on the order of the dispensary doctor or whosoever deputises for him. That means that the admission of a person as a permanent patient is very much easier than the admission of a temporary patient. That has not been changed in this new Bill. Therefore, the tendency is, if you are going to have a difficulty in getting a person into a mental hospital, to certify him as a permanent patient. It is very much easier. If you want him to go as a temporary patient, you have to get someone to take the certificate to the doctor who may be a long distance away and then get it signed by the medical superintendent and then bring it back again.

Some of these cases are very urgent ones, and when the dispensary medical officer is absent I think the nearest doctor should be allowed to sign, as in acute cases, maternity cases and so on, where if the dispensary doctor is not available you may get the nearest medical doctor. Mental disease should be treated on the same lines. These acute cases are very important. There is the protection of the patient himself; he may be suicidal. Secondly, there is the protection of persons around who may be attacked. Thirdly, a very important point, which has not been mentioned, there is the importance of very early treatment of these patients.

Therefore, any legislation brought in with regard to the admission of any patient with any mental illness to a hospital should be done in the easiest and quickest way possible.

Another point I want to make in this connection is that a dispensary doctor or any doctor in any kind of practice outside the practice of mental diseases is not the competent person to certify whether a person is a temporary patient or a permanent patient. That is a matter that should be decided only by those who are competent to do so, i.e., those people who are accustomed to and who are constantly dealing with mental illness.

A person may be mentally ill—he may be extremely ill for a time—but he may be curable. Very often, these people in mental hospitals are unable to decide when they first see a patient, and they may be unable to decide even at the end of the first week and sometimes even at the end of a month whether the patient will be temporary or permanent. I think it should be left entirely to the medical officers in these mental hospitals to reach the proper diagnosis. I do not think anybody else is competent to do so.

In my view, all patients with mental illness should be sent to hospital, just as other patients are, and examined and observed and treated there until the doctors can come to a conclusion as to how long exactly the patient must be detained.

I come now to the question of payment between the hospitals. Suppose a person happens to be up in Dublin for a holiday and becomes mentally deranged and is admitted to hospital, even though he happens to belong to another part of the country. If he is admitted as a temporary patient to a mental hospital in Dublin then his local county council will not pay for him, but if he is admitted as a permanent patient then they will pay for him. To my mind, it seems absurd if you have a question as to whether he is a permanent patient or a temporary patient. Why should a permanent patient not be paid for and a temporary patient not be paid for? It is very important that any patient should get urgent treatment immediately. If he gets treatment and is cured, it is all to the good. Why refuse to pay for him? The other procedure would be to take him back to his own county by ambulance or some other method of conveyance and then, if it is found that he cannot get the treatment which he requires in his own hospital, he is sent back to Dublin for the necessary treatment. There is far too much red tape involved.

When the Minister is introducing an amending Bill I trust that he will go a little further than he went in the present Bill to try to put mental disease of any kind on the same footing as any other type of disease and to treat it in that way. No matter what type his mental illness may be, the patient should be sent to a mental hospital and he should be sent there on the order of any doctor, if necessary, and if the relatives are not satisfied he should be given the power of having a second opinion. The patient should be sent to hospital for diagnosis and treatment—and sent in, in the first instance, either as a temporary or as a permanent patient.

Furthermore, I thing these silly anomalies about the payments between county councils and hospitals should be removed. They cause a great deal of embarrassment. A person may wrongly be certified as a permanent patient in order that the county council may be compelled to pay for him.

Mr. P.F. O'Reilly

I approve of this Bill. I think that the Minister should be given the Second Reading this evening. I was very interested in Senator Cunningham's contribution to this debate, particularly as he is a medical man. I should like to hear the Minister enlarge on this matter of non-payment in respect of a temporary patient and payment in respect of a permanent patient. If Senator Cunningham is right in what he has said, I think the Minister should give this House some information on that matter.

I should like also to be informed of the full implications of Section 5 of the Bill which relates to Sections 184 and 185 of the principal Act. As I have indicated, I approve of the Bill and I think that the Minister should be given the Second Reading this evening. I understand, however, that it is expected that the Minister will be given all stages this evening. I want to protest that it is unreasonable to ask this House so frequently—even with a good case—to give all stages of Bills without fully considering them.

We have just heard Senator Cunningham's contribution to this debate. I must say that, having heard it, I feel more strongly than I did previously that this Bill should not be given all stages this evening. I feel that we should give the Bill more careful consideration and that if we had time to do so we might perhaps prepare amendments. The position is becoming really ridiculous in regard to the manner with which we deal with Bills, all stages in the one day, without giving them any detailed consideration. So bad has the position become that last evening it was announced from Radio Éireann that the Dáil had passed all stages of the Mental Treatment Bill—and Radio Éireann, knowing its Seanad, then announced that "the Bill will be put through the Seanad to-morrow." If such an organisation, from its knowledge of our speedy methods—to put it euphemistically—can say that a Bill will be put through the Seanad on the following day, it speaks very badly for the Seanad. It speaks badly that we should have the reputation that a Bill has merely to be given to us to be passed here without detailed consideration. Thinking on it again, it is quite a serious matter. Radio Éireann is, apparently, an organisation in the control of which there is no Minister. The Minister whom we might think to be in control of that organisation has indicated that he cannot deal with domestic matters there——

Mr. Hawkins

What has Radio Éireann got to do with the Mental Treatment Bill?

Mr. Hearne

Obviously, this Bill is badly needed.

Mr. O'Higgins

A Mental Treatment Bill is obviously the place to refer to the activities of some of the Ministers.

Mr. P.F. O'Reilly

I am quite satisfied that the Minister for Health is not in any way responsible for the fact that it got abroad that the Bill would be put through the Seanad to-day. I am quite satisfied also that it is not the Minister's fault that the Bill was not introduced in the Dáil earlier. He has made a very good case for urgency. Despite that, the Minister will not be given all the stages, with my consent, this evening.

Mr. Hawkins

One would expect that the case made against the giving of all stages of the Bill this evening by Senator O'Reilly would be a better one, in view of his position. He based his argument on a statement which he said was made from Radio Éireann that, because of the speedy passage of the Bill through the Dáil, and its urgency, this House would act as sensibly as the Dáil in a matter of this kind and give the Minister all the stages to-day.

At the outset, the Minister pointed out the urgency which gave rise to the introduction of this Bill. So far as I have read the Bill, I have not seen any provision in relation to the matters raised by Senator Cunningham. He raised the question of payment by county councils for patients, whether permanent or temporary.

This Bill is a simple measure designed to legalise a form of admission to and retention in a mental hospital and it arises out of an action in the High Court. That is all that the Bill contains. Senator O'Reilly knows, as well as I do if not more so, that it is not within his province or the province of any member of this House to amend the Bill in the way in which he wishes because the Bill does not relate to the matters which he raised.

Mr. O'Higgins

What about Section 4?

Dr. Ryan

I must apologise to the Seanad for bringing this Bill in at such short notice, but I should like to point out that the Dáil, which usually takes a considerable time to deal with Bills, realising the urgency of the Bill, put it through all stages in one day—in fact, on the day after it was introduced, although Bills are usually introduced for some time before they are discussed. In my opening speech, I asked the Seanad to deal with it as expeditiously as the Dáil dealt with it, because, as Senator Hawkins pointed out, we are dealing only with matters arising out of the court judgement. An amending Bill in relation to the 1945 Act is being prepared—in fact it has been prepared for a couple of years. As is usual in the case of these big Bills, when matters arise which would appear to be worthy of consideration for amendment, they are put into the file which is being built up for the amending Bill.

It would be rather remarkable, indeed, if an amending Bill was not necessary in respect of the 1945 Act, because it was a radical measure, a complete departure from the concept of legislation up to that time, and we did not have even the advantage of being able to take our ideas from other countries, because it was such a complete departure from what existed previously. The matters raised by Senator Cunningham will be considered for the amending Bill which will come along in due course, though I cannot say exactly when. Senator Ruane asked if it had any connection with that Bill and, of course, it has. This Bill is an amendment of the 1945 Act, dealing with flaws pointed out by this judgement given some few days ago.

The Senator is wrong in thinking that there was no result from the promises made at the time of dispensary treatment of mental diseases. There are clinics in practically all counties which are doing very good work. If anybody reads the report of the Department of Health for last year—the next report for the year ending 31st March, 1953, will be out in the course of a few weeks—he will see that there is a very big increase in the number of both voluntary and temporary patients in mental hospitals, whereas the number of permanent patients has not increased. There is also a very big increase in the number of discharges from mental hospitals, so the point is that, under that Act, people are undoubtedly going in earlier, being cured and coming out more quickly, which was the aim of that legislation. The success of these clinics has been very satisfactory, due, of course, to the enthusiasm with which the resident medical superintendents in the various hospitals and their assistants have taken up that part of the scheme of mental treatment.

Senator Cunningham raised the point that any medical officer should be eligible to sign the certificate for a person going into a mental hospital. In the main Act, the dispensary doctor is mentioned. I had not very much time in drafting this Bill to think about principles in the main Act—I could think only about the defects— but I presume that there was some principle on which the decision that the dispensary doctor should sign the certificate was based.

Mr. O'Higgins

That is, for chargeable patients?

Dr. Ryan

Yes, and temporary patients, too, but not for voluntary patients.

Mr. O'Higgins

For all patients who are not paying themselves?

Dr. Ryan

Yes, chargeable patients. If a person is going into a private institution, any doctor is eligible to sign, but there must be two doctors.

Mr. O'Higgins

Even if he is going in as a temporary private patient in the local authority institution?

Dr. Ryan

Yes. The point I was making was that while I might agree with Senator Cunningham if I studied the matter, I had not time to do so. I had to say: "We will stick to the principle of the main Act and amend only in so far as the judgment compels us to amend, leaving the discussion of change of principle to the amending Act which is to come along." I can assure Senator Cunningham and other Senators that I have an open mind on the question—at the moment at least —until I see what the arguments were for the dispensary doctor being designated as the person to sign.

Senator Cunningham said—and from the medical point of view I am sure he is quite right—that it is important when a person is mentally deranged that he should be removed to an institution for his own safety and the safety very often of his neighbour, and that it is also important from the point of view of effecting a cure. Therefore, Senator Cunningham reasons, the more quickly he is got there the better. From the medical point of view there is no doubt that he is correct but if the Senator had listened to the discussion in the Dáil he would have found a very opposite point of view expressed—that we should not make it too easy to get a person into a mental hospital because relatives are sometimes interested in getting a person in there in order to prevent a change of will or for some other reason. In any Bill which might be brought before the Oireachtas we have to hold the balance, at is were, between what is necessary and advisable from the medical point of view and what is necessary, on the other hand, for the safety of the individual.

A further point raised by Senator Cunningham is covered in the Bill. If a person is outside his own district and if he should need to be brought into a mental hospital—take the example of a person from my own county of Wexford who is in Dublin —the Bill provides that he can legally be brought to the mental institution if he is certified as being of unsound mind or as a person requiring mental treatment as a temporary patient, and the parent county will be responsible for the expenses of his treatment there.

Mr. O'Higgins

Is that what Section 108 of the Principal Act provided? The trouble is that Senators have not had an opportunity of consulting the Principal Act.

Dr. Ryan

I know that. That is Section 4 of this Bill which refers back to the Principal Act. Another point made by Senator Cunningham was that it is the resident superintendent, or whoever is acting for him, who is the person who should decide into what category a patient should be put. That appears to me to be very sound and it is a matter which could be discussed when we bring in the amending Bill. Sometimes, as Senators are very well aware, a doctor is, perhaps, inclined when he knows very well that a person should be put into an institution, to make it soft for the relatives by saying: "We will send him in as a temporary patient. He will be cured in a short time and will be out again." He may know very well that he will be there for a long time and should really be put in as a person of unsound mind and as a permanent patient, but out of the kindness of his heart, he classifies him as a temporary patient. These, however, are matters which could very usefully be discussed when the amending Bill is brought along.

I put it to the Seanad that it was, on the whole, better to confine the amendments in this Bill to matters arising out of the recent court judgment. These matters are, first of all, that the reception order can now be signed not only by the resident medical superintendent but by any other medical member of the staff who is authorised by the mental hospital authority. Secondly, the judgment lays down that if a person is rushed to hospital on a certificate of the dispensary doctor he is illegally removed if the reception order was not signed before he was removed. It will be legal, when this Bill is passed, to have him brought and the reception order signed when he arrives there by the superintendent of the hospital or by the person authorised by the mental hospital authority.

On the other hand, a safeguard is being brought in because the Dáil thought it was making it too easy to get a man put in. The person concerned may ask for a second medical opinion before being removed and if he does the second medical officer must be produced and must agree, of course, with the first man before a person can be removed. Thirdly, is a point which was not mentioned in the judgment but which, I think, would follow consequentially. The district medical officer, strange to say, where there is only one district medical officer in the district, must sign and nobody can deputise for him. In the original Act where there was more than one either could sign and if neither could sign, then the nearest district medical officer could sign.

It is obviously an oversight that the same provision was not put in here. There was only one. We are putting it in now because it was obvious to me and my Department that if a judge held that nobody could deputise for a resident medical superintendent, then nobody could deputise either for the district medical officer unless we put it into this Bill. We have, therefore, confined the amendments in this Bill to matters arising out of the judgment. We have not departed from that. It does not, of course, in any way interfere with our intentions to proceed with an amending Bill to the original Act which will be a much bigger measure. I do not know what size it will be but I should say that it will deal with a number of matters in the Principal Act and will amost inevitably deal with some of the questions raised here by Senator Cunningham. If I do not myself proceed to amend in the direction in which Senator Cunningham has suggested, Senators, of course, will have an opportunity of raising these points when that amending Bill comes along.

Question put and agreed to.

Agreed to take the remaining stages to-day.

Bill considered in Committee.

Sections 1 to 4, inclusive, put and agreed to.

SECTION 5.

Question proposed: "That Section 5 stand part of the Bill."

Mr. O'Higgins

Would the Minister tell us to what do Sections 184 and 185 of the Principal Act refer? Apparently Section 5 here deals with the particular category of cases grouped under these sections in the Principal Act.

Dr. Ryan

Section 184 deals with chargeable patients and Section 185 with private patients.

Question put and agreed to.

Section 6 agreed to.

Title agreed to.

Bill reported without amendment and received for final consideration.

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

Mr. P.F. O'Reilly

I dissent.

Question put and agreed to.