LAHORE: Last year, the man who attempted to assassinate Ronald Reagan in 1981 was released from a Washington psychiatric institution. John Hinckley had shot six bullets that wounded Reagan and three others and in the court proceedings, he was diagnosed with acute psychosis, major depression and narcissistic personality disorder. He was found `not guilty’ by reason of insanity and committed to psychiatric care where he spent 35 years till doctors declared he was in “full, stable and sustained remission from the first two diagnoses for more than two decades”.

This is the standard legal procedure for convicts diagnosed with mental illnesses in advanced countries. Usually, a forensic psychiatrist is involved as soon as a crime is established and consideration is accorded as to whether suspects are capable of defending themselves in a court of law. Neither of these was available to Khizar Hayat, Imdad Ali or Kaneezan Bibi — who were convicted without consideration of the status of their mental health and now await possible execution in prisons in Punjab.

An open letter titled, ‘Upcoming execution of a mentally ill prisoner violates human dignity, international law and medical standards’, written this week by 17 eminent psychiatrists notes that “Not only is our current practice lagging behind the standards set by international law and the practice of nations, but also that thus far we have failed to learn any lessons from our previous mistakes”.

It says: “Public perception about mental illness has started to shift, and we are seeing more and more changes to our legislation which reflect a more appropriate understanding of this complex area of medicine. Law does not allow such execution of prisoners suffering from this nature of mental disorder in which the prisoner is having a psychotic illness and is unable to comprehend the reasons for his execution and the consequence of this punishment.”

Dr Sadaf Rashid, head of the psychiatry department at Lahore’s Fatima Jinnah Medical University and a signatory to the letter, explains doctors felt there was a need to reach out to the government and the public at large. These patients were given severe punishments because the courts had failed to factor in their mental health complications, she says. Furthermore, their capacity to defend themselves wasn’t taken into consideration.

In October, the Supreme Court denied murder convict Imdad Ali clemency, saying: “In our opinion, rules relating to mental sickness are not subjugative to delay the execution of death sentence which has been awarded to the convict.”

Relying on two definitions of the term ‘schizophrenia’ and a 1988 judgement by the Indian SC, the verdict says: “It is, therefore, a recoverable disease, which, in all the cases, does not fall within the definition of ‘mental disorder’.”

Another signatory to the letter, Dr Ali Madeeh Hashmi, an associate professor of psychiatry at King Edward Medical University and Mayo Hospital, questions: “Would it be justified to execute a child of four or a person who is not aware of their actions?”

When establishing a heinous crime, it is crucial to establish soundness of mind, he says.

Section 84 (act of a person of unsound mind) of the PPC states: Nothing is an offence which is done by a person who, at the time of doing it, by reason of unsoundness of mind, is incapable of knowing the nature of the act, or that he is doing what is either wrong or contrary to law.

Dr Hashmi says Hinckley was not sentenced to death as the courts established the state of his mind at the material time. That is the basis of making a right judgement. But in the case of Imdad Ali, the first medical examination of his mental health was ordered in 2008 — almost seven years after he had committed the crime, and becomes a part of his court medical records in 2012 — 10 years after he is sentenced to death.

Dr Tahir Feroze, a psychiatrist, examined Ali at 40 different occasions. He expresses astonishment that no one had wised up to Ali’s odd behaviour in court, where he expressed bizarre ideations and delusions of grandeur. Even when his wife told the court in 2001 that Ali was mentally unsound, the pleas fell on deaf ears. The M’Naghten Rule applies in this case: “A criminal defendant is not guilty by reason of insanity if, at the time of the alleged criminal act, the defendant was so deranged that she did not know the nature or quality of her actions or, if she knew the nature and quality of her actions, she was so deranged that she did not know that what she was doing was wrong.”

While there are no medical records to go by, save a ‘medical certificate’ that was later rescinded by the issuing doctor, he says, the symptoms and a case history were there.

Delusions of grandeur

In 2000, Ali was deported from Saudi Arabia where he had acted upon his delusions of grandeur and offended Saudi authorities at a holy site. Dr Feroze had also submitted an affidavit. Ali has exhibited first-ranked symptoms of paranoid schizophrenia and now has a disintegrated personality, he says. “I tried treating him with anti-psychotics and there has been no improvement whatsoever.”

When he was sentenced to death in 2012, it came as a surprise that the court had chosen to forego Ali’s medical examination report.

Last November, after staying execution orders for Ali, the SC accepted a plea for formation of a medical board to assess his mental health and moved him to Adiala Jail.

Even as the judgement in Ali’s case is pending, a lower court issued black warrants for another such prisoner.

The letter notes: “It is surprising that the black warrant for Khizar was issued despite not only a pending writ petition to stay his execution in the Lahore High Court but also given that Imdad’s case also remains open before the Supreme Court.”

Dr Usman Hotiana, who has been involved in Hayat’s case since 2014, says there have been persistent symptoms suggesting chronic mental illness, even after he was prescribed anti-psychotics since 2008.

Dr Hotiana had submitted an affidavit in the court, suggesting that Hayat needed specialised healthcare and a forensic psychiatry institution would be the best place for him. He was reminded, however, that the Punjab Mental Health Authority (PMHA) existed only on paper and the law in this regard has never really been implemented.

He stresses the need to raise awareness regarding mental health prognosis in the courts and establishing a forensic psychiatry department. He says they have prepared certain recommendations for amendments to the Punjab Mental Health Act and certain suggestions for the PMHA, hoping it would improve the state of affairs.

The letter notes that: “We must immediately stay Khizar Hayat’s execution and remedy the lacuna in our law that leaves the fate of people like Imdad, Khizar and Kaneezan hanging in the balance.”

Published in Dawn January 28th, 2017