I was flying back home whilst reading about the loss of Germanwings flight 4U 9525. The plane I took had on board about as many people who were lost. Speculation regarding terrorist implications had by then rapidly given way to the revelation of co-pilot’s mental health issues. Believing his career was over with the imminent revelation of his severe depression, he apparently stated to his ex-girlfriend “One day I’m going to do something that will change the system, and everyone will know my name and remember.”
His name escapes me, but there are already signs that “the system” may change. German newspapers have responded to the mental health angle to the story by querying the role of doctor-patient confidentiality. The Sueddeutsche Zeitung noted, “The case of Andreas Lubitz has already sparked a debate on whether medical confidentiality for professions like pilots must be limited”.
Before talking about confidentiality, one needs a brief primer on forensic mental health. The issue comes to the question of “mens rea” (guilty mind) and “actus rea” (guilty act). One is determined to be potentially culpable after carrying out a criminal act – however, to actually be a criminal, one must have a mind that knows that the act is wrong.
In 1843, Daniel M’Naughten was acquitted of the murder of Edward Drummond due to psychotic delusions. The House of Lords determined then that a person can only have a defense of insanity if ” at the time of the committing of the act, the party accused was labouring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing; or, if he did know it, that he did not know he was doing what was wrong.” These concepts – now called the M’Naughten rules – lay the foundation of most forensic mental health law in the world.
It’s important to note that not many mental illnesses actually do interfere with the knowledge of right and wrong – and even then only when severe and untreated, both fortunately rare occurrences in the present time. A 2009 review by Large and colleagues found homicide rates amongst patients with schizophrenia strongly correlated with total homicide rates. Mr Drummond was only murdered because Mr M’Naughten mistook him for the Tory Prime Minister, who he believed was persecuting his mind.
Depression interferes with the ability of a person to experience positive emotions and greatly limits their functioning and capacity for expression – this may drive a person to commit suicide, but there is absolutely no reason for this to contribute to homicide.
At the end of the day, a person made a decision with full knowledge of how it was going to impact on others, as well as full capacity to differentiate between right and wrong. This story has nothing to do with confidentiality. As a psychiatrist, I sympathise with his suffering from illness. And that is the limit of my sympathy.