PML ASSIGNMENT 5

SEBIN JAMES

ROLL NO. 1246

VIII.A
 Table of Contents
I. CHILD CUSTODY..............................................................................................................3
II. Civil rights of the patient ..................................................................................................7
III. THE RIGHT TO TREATMENT .................................................................................... 14
IV. SECLUSION AND RESTRAINT .................................................................................. 16
V. INFORMED CONSENT ................................................................................................ 20
VI. Nature and Historical Perspective of Criminal Behaviour ............................................... 30
VII. Suicide and Homicide ..................................................................................................... 33
 I. CHILD CUSTODY
Child custody is a legal term regarding guardianship which is used to describe the legal and
practical relationship between a parent or guardian and a child in that person's care. Child
custody consists of legal custody, which is the right to make decisions about the child, and
physical custody, which is the right and duty to house, provide and care for the child.Married
parents normally have joint legal and physical custody of their children. Decisions about child
custody typically arise in proceedings involving divorce, annulment, separation, adoption or
parental death. In most jurisdictions child custody is determined in accordance with the best
interests of the child standard.

Following ratification of the United Nations Convention on the Rights of the Child in most
countries, terms such as parental responsibility, "residence" and "contact" (also known as
"visitation", "conservatorship" or "parenting time" in the United States) have superseded the
concepts of "custody" and "access" in some member nations. Instead of a parent having
"custody" of or "access" to a child, a child is now said to "reside" or have "contact" with a
parent.

Legal custody

Legal custody involves the division of rights between the parents to make important life
decisions relating to their minor children.Such decisions may include choice of a child's school,
physician, medical treatments, orthodontic treatment, counselling, psychotherapy and religion.

Legal custody may be joint, in which case both parents share decision-making rights, or sole, in
which case one parent has the rights to make key decisions without regard to the wishes of the
other parent.

Physical custody

Physical custody establishes where a child lives and who decides day-to-day issues regarding the
child. If a parent has physical custody of a child, that parent's home will normally be the child's
legal residence (domicile). The times during which parents provide lodging and care for the child
is defined by a court-ordered custody parenting schedule, also known as a parenting plan.

The different forms of physical custody include:

  Sole custody, an arrangement whereby only one parent has physical custody of the
child. The other non-custodial parent would typically have regular visitation rights.
 Joint physical custody, a shared parenting arrangement where both parents have the
child for approximately equal amounts of time, and where both are custodial parents.
 Bird's nest custody, a type of joint physical custody whereby the parents go back and
forth from a residence in which the child always reside, placing the burden of
upheaval and movement on the parents rather than the child.
 Split custody, an arrangement whereby one parent has sole custody over some
children, and the other parent has sole custody over the remaining children.
 Alternating custody, an arrangement whereby the child lives for an extended period of
time with one parent and an alternate amount of time with the other parent. This type
of arrangement is also referred to as Divided custody.
 Third-party custody, an arrangement whereby the children do not remain with either
biological parent, and are placed under the custody of a third person.

Child Custody Laws In India

If a marriage breaks down and ends up in separation of a couple, the person(s) who suffers the
most is the child or children born out of the marriage. The Indian Law, while keeping in mind the
parents’ right to the custody of a child, holds the welfare of the child as the most important factor
of consideration when deciding upon who gets the custody of a minor child.

Welfare of the child, broadly, includes the following factors:

 Safe-keeping of the child

 Ethical upbringing of the child
 Good education to be imparted
 Economic well-being of the guardian

Where Does A Minor Child Go After A Divorce?

The mother and father both have an equal right to the custody of a child. Who gets the custody of
the child, however is a question which the court decides upon. While the statutes are conflicting
when it comes to personal laws as opposed to secular enactment in the form of The Guardian and
Wards Act, 1890, the court of competent jurisdiction strives to strike a balance between the two,
all the while holding the welfare of the child as the paramount importance. However, just
because the custody of a minor has been awarded to one parent, it does not mean that the other
parent cannot see or be in contact with the child. The courts in India are very strict to ensure that
a child gets the affection of both the parents. The other parent gets visitation rights, the
conditions of which are determined by the court.

Types Of Child Custody Arrangements In India

Primarily, a court of competent jurisdiction in India orders the custody of a child in the following
three forms:

1. Physical Custody

Physical custody when awarded to a parent, implies that the minor will be under the guardianship
of that parent with visitation and periodical interaction with the other parent. The aim behind
such a custody award is that the child lives in a safe and fulfilling environment but is also not
deprived of the affection of the other parent during his formative years.

2. Joint Custody

Joint custody of a child does not mean that the parents will both live together because of the
child even though that what Indian courts believe is best for the welfare if a minor. It simply
means that both the parents will take turns keeping the child in their custody. The rotation of a
child between the parents’ custody may vary from certain days or a week or even to amonth.
This not only benefits the child as the affection of both the parents is not lost and the parents also
get to be a part of their child’s life in those young years.

3. Legal Custody

Legal custody of a child differs from physical custody in more ways than one but the
fundamental difference between the two is that legal custody does not necessarily entail having
the child with you or being with your child at all times. Legal custody of a child basically means
that the parent granted the legal custody takes every decision for the child. From where will the
child study and what doctor will the child be treated by is part of legal custody. In most
instances, courts grant legal custody to both the parents together but if the divorce is messy and
the parents are, apparently, never going to agree with each other, the court grants the legal
custody of the child to one parent.

Unless and until the order of the court specifically mention conditions similar to the ones
discussed above, the parent who is awarded the custody of a child is not just awarded the
physical custody but also the legal custody. Any other type of custody will be specifically
mentioned in the order of a court and made clear to both the parents.

Who Can Claim Custody Of A Child?

The custody of a child can be primarily claimed by either the mother or the father. In case either
of the two are deceased or not in the picture because of operation of any other law, the maternal
and paternal grandparents, any other relative(s) of either of the parents strictly out of compassion
towards the child can seek custody of the child. The Court can also appoint a third person to be
the guardian of the child.

The Hon’ble Supreme Court and other courts in India have reiterated time and again that in the
proceedings for custody of a minor, the welfare of the minor is the only consideration,
irrespective of the claims of the parties to the custody.

The Mother of a minor cannot be discarded as the guardian just because she earns less than the
father. The father has to provide for the child’s maintenance in such a case as it is a well-
established principle of law that a step-mother has primary obligation of affection towards her
own children and the father would be at work all day, and hence, the mother would be the better
guardian for the welfare of the minor child.

While dealing with a case of custody of a child removed by a parent from another country to
India in contravention of the orders of the court where the parties had set up their matrimonial
home, the Hon'ble Supreme Court has held that a child can seek refuge under the parents patriae
jurisdiction of the Courts in India. Further, the Apex Court has noted that India is not yet a
signatory to the Hague Convention of 1980 on “Civil Aspects of International Child Abduction”,
and Courts in India must consider the question on merits bearing the welfare of the child as of
paramount importance.
The consideration of paramount importance in a proceeding for the custody of a minor is the
welfare of the child. No legal right, preferential right or any other right holds more importance
than the well-being of the child. Any court of law grants custody to that party who can assure the
court that the welfare of the child best lies with them.

II. Civil rights of the patient

Patients are entitled to the full range of human rights. Health care providers must respect each
patient’s dignity and autonomy, right to participate in making health care decisions, right to
informed consent, right to refuse medical treatment, and right to confidentiality and privacy. The
attention, treatment, and care that each health care provider gives to a patient must respect the
human rights of every one of his or her patients.

The human rights-based approach to patient care draws from standards contained in the
international human rights framework, which are often mirrored in regional treaties and national
constitutions. It differs from patients’ rights, which codify particular rights that are relevant only
to patients. Human rights standards apply to all stakeholders in the delivery of health care—
including both patients and care providers.

A human rights-based approach seeks, above all, to uphold the inherent human dignity of all
actors in the care provider-patient relationship. This relationship can be a complex one,
especially when coupled with health care delivery. For example, as medicine becomes ever more
advanced, providers and patients must work together to make diagnostic and therapeutic
decisions. Financial and quality issues are always present in health care delivery and can lead to
inequality and discrimination. Greater understanding is needed of the social determinants of
health that straddle the lines between traditional medicine and a broader concept of health, as
well as of the interdependence of the right to health and the realization of all human rights.A
human rights-based approach uses the human rights framework to analyse these elements of
patient care, among others.
Below are some common human rights issues that arise in patient care settings. This list is not
comprehensive. The list alternates between highlighting issue areas and highlighting
marginalized groups whose human rights are frequently violated in the health care setting.

Right to information

Patients are often unaware of their rights, including the right to information on their condition
and the right to access their medical records. In a study conducted at four hospitals in Lithuania,
85% of the staff and 56% of the patients surveyed had heard of or read about patients’ rights
laws. Moreover, only 50% of professionals and 69% of patients thought it was necessary for
patients to have information about diagnosis, treatment results, and alternative modes of
treatment. Another study in Macedonia found that 82% of respondents stated that there are
patient rights, but 56% did not know what their rights were.

Patients have the right to information about their health status, treatment options and reasonable
alternatives, and the likely benefits and risks of proposed treatment and non-treatment. Patients
also have the right to access their medical chart and medical history.

Right to privacy and confidentiality

Patients have the right to have their health information and data kept confidential. According to
Gostin et al., “Health data may include not only a patient’s sensitive health status, but also those
facts or circumstances that the patient reveals to [health care workers] as part of seeking medical
treatment.” The “right to privacy and confidentiality must be applied sensitively, with respect for
different cultural, social, and religious traditions.”

For certain vulnerable groups, the right to privacy and confidentiality is an essential aspect of
obtaining health care. For example, privacy and confidentiality are crucial to realizing sexual and
reproductive rights for women and adolescents.In General Comment 14 on the right to health, the
Committee on Economic, Social and Cultural Rights states that “the realization of the right to
health of adolescents is dependent on the development of youth-friendly health care, which
respects confidentiality and privacy and includes appropriate sexual and reproductive health
services.”
Privacy and confidentiality are also crucial for patients seeking diagnosis and treatment of
illnesses with which stigma is attached, such as HIV/AIDS and mental illness. Depending on the
type of care an individual is seeking, some health care centres may only allow specific providers
to access the patient’s health information. For example, a nurse who is vaccinating a patient may
not access that individual’s private mental health records because the information is not relevant
to the treatment being provided at that current moment.

The right to confidentiality of health information should not interfere with the right to access of
private health information. While a holder of private health information should be prohibited
from sharing that information with anyone who is not essential to providing health care to the
individual, the holder must provide the individual access to their private health information upon
the individual’s request. Patients have the right to access their own health information, to be able
to control how the information is shared with them (for example, being able to indicate to where
mail or phone calls are directed), and to be able to authorize the disclosure of information when
desired. The right to confidentiality of private health information, as well as the right to
accessibility of private health information, should be upheld and not compromised in respecting
the rights of the patient.

Right to informed consent to treatment

The UN Special Rapporteur on the right to health, Anand Grover, defines informed consent as
the following:

Informed consent is not mere acceptance of a medical intervention, but a voluntary and
sufficiently informed decision, protecting the right of the patient to be involved in medical
decision-making, and assigning associated duties and obligations to health-care providers. Its
ethical and legal normative justifications stem from its promotion of patient autonomy, self-
determination, bodily integrity and well-being.

The right to informed consent is central to the right to health. Issues that arise concern the
competency or legal capacity of the patient to consent, respect for personal autonomy, the
sufficiency and completeness of information, and circumstances compelling limits on the need
for informed consent.
The complexity of informed consent is mirrored by patients’ lack of understanding of its
meaning and importance. For example, in a 2006 study of 732 European surgical patients in
obstetrics and gynaecology during a six-month period, about 46% believed that the primary
function of the written consent form was to protect the hospital, and 68% thought that the form
allowed doctors to take control, while only 41% believed consent forms expressed their own
wishes for treatment.

Derogations, or departures, from the right to informed consent are necessary at times, but the
question of when derogations may be permitted is a complicated one. When a patient is
unconscious, medical providers must seek consent from a legally entitled representative.
However, if there is an emergency situation where the patient’s life is in danger, medical
providers may presume that consent is given. Issues of informed consent also arise from public
health policies that require compulsory testing, compulsory vaccinations, or mandated quarantine
during epidemics. Procedural safeguards are crucial to derogations from informed consent, to
ensure that proper circumstances are met and to provide a means to challenge the departure from
the law. Some groups are particularly vulnerable to violations of the right to informed consent.
The UN Special Rapporteur on the right to health brought attention to children, elderly persons,
women, ethnic minorities, indigenous peoples, persons with disabilities, persons living with
HIV/AIDS, persons deprived of liberty, sex workers, and persons who use drugs.

The Inter-American Court points out the issues surrounding free and voluntary consent when it
comes to women’s sexual and reproductive rights. Access to information on sexual and
reproductive health is crucial for women to make free and informed decisions. According to the
Inter-American system, access to information on sexual and reproductive health “involves a
series of rights such as the right to freedom of expression, to personal integrity, to the protection
of the family, to privacy, and to be free from violence and discrimination.”

There is also particular concern and confusion regarding the right to informed consent for
persons with disabilities or mental health illness, two groups whose rights are frequently
violated. Treatment decisions are often based on inappropriate factors such as ignorance or
stigma surrounding disabilities, and indifference or expediency from staff. The Special
Rapporteur on the right to health writes, “These inappropriate considerations are inherently
incompatible with the right to health, andthe prohibition of discrimination on the ground of
disability … In these circumstances, it is especially important that the procedural safeguards
protecting the right to informed consent are both watertight and strictly applied.”For more
detailed information on disability and health, please see Chapter 9.

Persons unable to provide informed consent

Patients may be deemed legally incompetent to make decisions on their own behalf, including
providing informed consent to treatment. Patients who are declared legally incompetent can
include unconscious patients; minors; patients experiencing confusion or other altered mental
states (this includes the elderly); those under the influence of sedatives or other drugs that affect
alertness and cognition; and on occasion, persons with disabilities, depending upon their
perceived impairment.

Many countries have a system in which a guardian or representative is authorized to make

decisions on behalf of the legally incompetent individual. Depending on the jurisdiction and
circumstances, health providers might also have the authority to commit a person involuntarily to
a health care facility. Involuntary commitment is generally reserved for severe cases where the
person is in immediate danger of harming him/herself or others.

There are frequent issues with guardianship and involuntary commitment because these
processes involve denying an individual their autonomy to make decisions. It is crucial that the
system be as formal and transparent as possible and to establish procedural safeguards to ensure
that the dignity and rights of the individual are upheld. An example of a procedural safeguard for
involuntary commitment is to allow courts or tribunals access to challenge the admission. For
more information, please see Chapter 9 on Disability.

Prisoners

Prisoners who are ill often face violations of their rights as patients. Prisoners have the same
rights as other patients, including the right to refuse treatment, the right to informed consent, the
right to privacy and confidentiality, and the right to information. For example, they have the right
to refuse treatment, including abortions and medical testing. Conducting these procedures
without informed consent would be coerced or forced and in violation of the prisoner’s right to
refuse treatment. Derogations from the right to refuse treatment in prison include the prevention
and control of communicable diseases and the treatment of mental illness, but both are subject to
specific conditions and should be implemented in line with international standards. The prison
population includes especially vulnerable groups with special needs, including prisoners with
mental health care needs, elderly prisoners, and prisoners with terminal illness. These vulnerable
sub-populations may require special attention to ensure that their rights to health and life with
dignity are realized.

Women

Women are particularly vulnerable to violations of their rights while seeking health care,
especially for sexual and reproductive health care services. For example, Human Rights Watch
documented abuse of pregnant women during health care visits in South Africa:

[Forms of abuse] include ridiculing or ignoring women’s needs when in pain, especially during
labour, unnecessary delays in providing treatment, leaving women to deliver their babies without
help, accusing women who appear not to be following nurses’ orders of wanting to harm their
babies, verbal insults and degrading treatment, such as asking women to clean up their own
blood, or intimidation and threats of harm. Physical abuse involves slapping, pinching, rough
treatment and a deliberate refusal to give pain-relieving medication.

Other issues include independent and autonomous access to sexual and reproductive services,
forced sterilization and forced contraception, and physical and sexual abuse by the care
giver. Violence and assault against women in sexual and reproductive health care settings
perpetuates stigma and discrimination against women that denies them human dignity.

The Special Rapporteur to health notes, “Stigma and discrimination against women from
marginalized communities, including indigenous women, women with disabilities and women
living with HIV/AIDS, have made women from these communities particularly vulnerable to
such abuses.” The Special Rapporteur on water explains, “Stigma is, by its demeaning and
degrading nature, antithetical to the very idea of human dignity. Stigma as a process of
devaluation, of making some people “lesser” and others “greater”, is inconsistent with human
dignity, which is premised on notions of the inherent equality and worthiness of the human
person. It undermines human dignity, thereby laying the groundwork for violations of human
rights.”Female patients from marginalized populations have the right to seek health care in a
manner that is non-discriminatory and respects their dignity.

Access to essential medicines

Access to essential medicines is lacking in many developing countries. An estimated 1.3 to 2.1
billion people worldwide have no access to essential medicines. According to a 2011 study,
about one third of the world population lacks regular access to essential medicines. Only 10% of
pharmaceutical research and development spending is directed to health problems that account
for 90% of the global disease burden. A small number of companies dominate global production,
trade, and sale of medicines. Ten companies account for almost half of all sales. However,
“Inequity in access to essential medicines is part of inequity in health care.” An expert
consultation on access to medicines recommended in 2011 that “From the right to health
perspective, access to medicines must be equitable. Additionally, more research and
development is needed to promote the availability of new drugs for those diseases causing a
heavy burden on developing countries.”

High pricing is another factor that hinders access to medicines. Companies that develop new
medicines are often granted a patent, which permits that company to be the sole manufacturer of
that medicine for a designated period of time. The expert consultation on access to medicines
explains:

While intellectual property rights have the important function of providing incentives for
innovation, they can, in some cases, obstruct access by pushing up the price of medicines. The
right to health requires a company that holds a patent on a lifesaving medicine to make use of all
the arrangements at its disposal to render the medicine accessible to all.

Access to essential medicines is considered an integral part of the right to health. However, 60
countries do not recognize the right to health in their national constitutions and more than 30
countries have not yet ratified the International Convention on Economic, Social, and Cultural
Rights. General Comment 14 says that States must make public health and health care facilities
available, including “essential drugs, as defined by the WHO Action Programme on Essential
Drugs.”
 III. THE RIGHT TO TREATMENT

In an emergency situation, a patient has a right to treatment, regardless of ability to pay. If a situa
tion is likely to cause death, serious injury, or disability if not attended to promptly, it is an emer
gency. Cardiac arrest, heavy bleeding, profound shock, severe head injuries, and acute psychotic
states are some examples of emergencies. Less obvious situations can also be emergencies: broke
n bones, fever, and cuts requiring stitches may also require immediate treatmet.

Both public and private hospitals have a duty to administer medical care to a person experiencing
an emergency. If a hospital has emergency facilities, it is legally required to provide appropriate
treatment to a person experiencing an emergency. If the hospital is unable to provide emergency
services, it must provide a referral for appropriate treatment. Hospitals cannot refuse to treat pros
pective patients on the basis of race, religion, or national origin, or refuse to treat someone with
HIV or AIDS.

If individuals do not carry health insurance, they are still entitled to hospital emergency care,
including labour and delivery care, regardless of their ability to pay. The federal Emergency
Medical Treatment and Active Labour Act (EMTALA), 42 U.S.C. § 1395, which is a separate
section of the more comprehensive 1985 Consolidated Omnibus Reconciliation Act (COBRA),
mandates minimum standards for emergency care by hospital emergency rooms. The law
requires that all patients who present with an emergency medical condition must receive
treatment to the extent that their emergency condition is medically “stabilized,” irrespective of
their ability to pay for such treatment.

An emergency medical condition is defined under federal law as one that manifests itself by
acute symptoms of sufficient severity (including severe pain, psychiatric disturbance, and/or
symptoms of substance abuse) such that the absence of immediate medical attention could
reasonably be expected to result in the following:

 placing the health of the individual (or unborn child) in serious jeopardy
  the serious impairment of a bodily function

 the serious dysfunction of any bodily function or part

 the inadequate time to effect a safe transfer of a pregnant woman to another hospital
before delivery, or, that the transfer may pose a threat to the health or safety of the
woman or unborn child

The law goes on to define “stabilization” as meaning “that no material deterioration of the
condition is likely within reasonable medical probability to result from or occur during the
transfer of the patient from a facility” (or discharge).

However, once the emergency is over and a patient’s condition is stabilized, the patient can be
discharged and refused further treatment by private hospitals and most public hospitals. If the
individual seeks routine medical care or schedule a doctor’s appointment for non-emergency
medical problems, doctors have a general right to refuse treatment if they have no insurance or
any other means of paying for the provided care.

There are numerous protections for HIV-positive and AIDS patients that prohibit hospitals and
facilities from refusing treatment if the facility’s staff has the appropriate training and resources.
However, most private physicians and dentists are under ethical but not legal obligations to
provide treatment.

Individuals also have a legal right to not be released prematurely from a hospital. If they are
advised to vacate their hospital room because of a standardized “appropriate length of stay”
generally approved for their specific condition, they have the right to appeal that discharge if
they believe that they are not well enough to leave. They should consult both their doctors and a
hospital patient representative for procedural information regarding an appeal. However, the
policy generally works in a way that makes them liable for payment of excess hospital stays if
they should lose the appeal.

Individuals have the right to refuse treatment and leave a hospital at any time, assuming that they
are mentally competent. The hospital may ask them to sign a document releasing it from liability
if their medical condition worsens as a result of their refusal to accept the recommended
treatment.
If individuals lose mental competency and appear to be a danger to themselves or others, they
may be taken to a hospital against their will and held for involuntary “commitment.” Most states
require an immediate written statement or affidavit affirming the reasons for their involuntary
commitment. However, within a short period of time (e.g., 72 hours), most states require a full
examination by a medical and psychiatric doctor, a diagnosis, and (within a certain number of
days) a hearing at which they will have the right to be represented by counsel. The purpose of the
hearing is to establish whether there is sufficient information to justify their continued
commitment or whether they should be released. Also, their attorneys will advise them as to
whether there had been sufficient cause to justify holding them against their will in the first
place.

IV. SECLUSION AND RESTRAINT

Restraint and seclusion are behavioural management interventions that should be used as a last
resort to control a behavioural emergency. Behavioural emergencies are often the result of unmet
health, functional, or psychosocial needs, and you can often reduce, eliminate, or manage such
emergencies by addressing the conditions that produced them.

Restraints include the use of physical force, mechanical devices, or chemicals to immobilize a
person. Seclusion, a type of restraint, involves confining a person in a room from which the
person cannot exit freely.

Restraint and seclusion are not therapeutic care procedures. In fact, restraint and seclusion can
induce further physical or psychosocial trauma. In short, these procedures pose a safety risk to
the emotional and physical well-being of the person and have no known long-term benefit in
reducing behaviours.

Behavioural emergencies are often a manifestation of unmet health, functional, or psychosocial

needs that can often be reduced, eliminated, or managed by addressing the conditions that
produced them. Restraints include the use of physical force or mechanical devices to immobilize
a person, as well as chemical restraints. Seclusion, a type of restraint, involves confining a
person in a room from which the person cannot exit freely. Restraint and seclusion are not
therapeutic care procedures. In fact, restraint and seclusion can induce further physical or
psychosocial trauma. In short, these procedures pose a safety risk to the emotional and physical
well-being of the person and have no known long term benefit in reducing behaviours. Thus, the
position of this module is that any restraint should be considered an intervention of last resort
and should, at most, only be used temporarily in a behavioural emergency

TYPES OF RESTRAINT

“Restraint” can have different meanings and interpretations depending on the setting. In the
mental healthcare context, “restraint” typically refers to the application of some level of
restriction to physical movement, or state of mental awareness. Typically, restraints are divided
into three categories:

 environmental,

 physical/mechanical, and

 chemical (sometimes referred to as Acute Control Medication (ACM)).

Though different forms of restraint may be needed to respond to a particular situation, it is

important to note that no one form of restraint is less traumatizing than another. For all forms of
restraint, once applied, close or continual observation and monitoring is required.

Environmental

Environmental restraint can include:

 limiting access beyond the unit (i.e., locked unit);

 limiting access beyond the patient’s room (i.e., locked room); and

 placement of the patient in a separate room that is locked (i.e., seclusion).

Locked units are generally used to ensure the safety of persons at risk of harm to self or others by
preventing them from leaving the unit except with appropriate supervision. In many instances,
patients on locked units may be allowed to leave the unit once they have appropriately signed out
at the nursing station.
A seclusion room is a specific and separate room that confines a patient and from which he or
she cannot exit freely. They are used when a person is unable to control his or her violent
emotions and there is the potential for immediate, harmful behaviour to self or to others. These
rooms are designed to keep the person safe (i.e. they are free of hazards that the person could use
to harm him or herself) and allow for observation by clinical staff. In some instances where
separate seclusion rooms are not available, seclusion can also refer to confinement to the
person’s room.

Seclusion is a temporary measure and should not be used for persons who may be experiencing
suicidal ideation or may otherwise be at risk of harm to themselves (e.g., banging head against
wall). Seclusion may exacerbate their distress and causes of suicidal ideation. Similarly, it should
not be used for persons who have medical conditions that require close monitoring (e.g. someone
who has cardiac or respiratory issues and may experience subtle signs of physical distress that
might be missed otherwise).

Physical restraint

Physical and manual restraints are never part of treatment. They are an intervention of last resort
where the person’s behaviour cannot be managed by any other means and there is a need for
continued verbal interventions from staff to help calm the person. Extreme caution is needed in
their application to prevent injury. When a person is physically restrained, that person is
physically/bodily held by others (e.g., care staff, security) to restrict his or her movement for a
brief period of time, in order to calm the individual. This does not refer to holding a person in
order to apply a mechanical restraint.

Mechanical restraint

A mechanical restraint is a device or an appliance that restricts or limits freedom of movement.

Such devices can include vest restraints, lap belts, pelvic restraints, chairs that prevent rising,
wrist restraints, and sheets. Mechanical restraint is not temporary immobilization for medical
reasons (e.g., splint), transportation (e.g., belt on stretcher), or devices for body position (e.g.,
harnesses for persons with paralysis).

Chemical restraint
In mental healthcare settings, there are instances where medications may be used to both treat
symptoms and manage behavioural emergencies. Therefore, not included in the definition of
chemical restraint are psychotropic medications that are used for treatment purposes as part of an
ongoing plan of care for an established diagnosis. Medication that is prescribed for PRN (“as
needed”) and established with the person as part of his or her plan of care is also excluded.
Chemical restraint or Acute Control Medication (ACM) therefore refers to the administration of
psychotropic medication in situations where a person may have already lost behavioural control
or where there is imminent risk of loss of control in behaviour that will lead to harm to self or
others.

Factors related to use of restraints

 Behaviours

A prior history of violence and aggressive behaviours is the most common factor predictive of
restraint use among persons receiving inpatient mental health services. While this prior history
suggests that the person is more likely to act out in distressing situations and thus increases the
likelihood of restraint use, it is important that restraint not be the de facto care response.

 Age and sex

Although violent behaviour is related to age and sex, the key message regarding age and sex and
the use of restraints is that the decision to consider restraint should not be based solely on these
factors. Rather, the decision should rest on contextual factors specific to the behavioural
emergency (e.g., failure of all other behaviour management strategies).

 Cognitive/communication factors

Persons with impaired cognitive functioning, including those with delirium or dementia, may be
more likely to exhibit behaviours that increase the likelihood of restraint. This is possibly due to
the difficulty communicating distress and/or impaired cognitive performance. Research has
shown that persons who are incapable of consenting to treatment, presumably due to cognitive
deficits, are more likely to be restrained than those who can consent. This finding underscores
the importance of involving substitute decision makers in the care planning process and
identifying opportunities to avoid restraint.
  Mental health and clinical symptoms

Persons with cognitive disorders such as dementia tend to experience the highest rates of
restraint of all kinds in mental health settings – followed by persons with bipolar disorders and
schizophrenia. All are much more likely to be restrained than persons with depression. This may
be because the delusional thoughts or command hallucinations associated with these disorders
may more frequently lead to agitated states. Persons with substance use disorder or personality
disorder are more likely to receive chemical restraint than other mental health conditions but no
more likely to experience other forms of restraint.

 Staff training and experience

Higher rates of restraint and seclusion use have been found where there is a lack of staff
expertise and training as well as where staff perceive the need to exercise control. Attitudes of
control among staff may stem from a lack of knowledge of alternative management strategies for
behavioural emergencies or from assumptions or myths that staff believe justify the use of
restraints. The following is a summary of ongoing myths and reality associated with restraint
practices

In managing behavioural emergencies, restraint use should be the intervention of last resort since
among other reasons, all forms of restraint have the potential to be traumatizing to the person.
When it is used, restraint is most appropriately used to halt an ongoing incident where the person
presents imminent risk of harm to self or others and cannot be managed in any other way.
Moving an organization’s patient safety culture to one of least or a non-restraint practice requires
strong organizational leadership to support the transition.

V. INFORMED CONSENT
Informed consent is a process for getting permission before conducting a healthcare intervention
on a person, or for disclosing personal information. A health care provider may ask a patient to
consent to receive therapy before providing it, or a clinical researcher may ask a research
participant before enrolling that person into a clinical trial. Informed consent is collected
according to guidelines from the fields of medical ethics and research ethics.
An informed consent can be said to have been given based upon a clear appreciation and
understanding of the facts, implications, and consequences of an action. Adequate informed
consent is rooted in respecting a person's dignity.[1] To give informed consent, the individual
concerned must have adequate reasoning faculties and be in possession of all relevant facts.
Impairments to reasoning and judgment that may prevent informed consent include basic
intellectual or emotional immaturity, high levels of stress such as posttraumatic stress disorder
(PTSD) or a severe intellectual disability, severe mental disorder, intoxication, severe sleep
deprivation, Alzheimer's disease, or being in a coma.

Obtaining informed consent is not always required. If an individual is considered unable to give
informed consent, another person is generally authorized to give consent on his behalf, e.g.,
parents or legal guardians of a child (though in this circumstance the child may be required to
provide informed assent) and conservators for the mentally disordered, or consent can be
assumed through the doctrine of implied consent, e.g., when an unconscious person will die
without immediate medical treatment.

In cases where an individual is provided insufficient information to form a reasoned decision,

serious ethical issues arise. Such cases in a clinical trial in medical research are anticipated and
prevented by an ethics committee or Institutional Review Board.

Informed consent can be complex to evaluate, because neither expressions of consent, nor
expressions of understanding of implications, necessarily mean that full adult consent was in fact
given, nor that full comprehension of relevant issues is internally digested. Consent may be
implied within the usual subtleties of human communication, rather than explicitly negotiated
verbally or in writing. In some cases consent cannot legally be possible, even if the person
protests he does indeed understand and wish. There are also structured instruments for evaluating
capacity to give informed consent, although no ideal instrument presently exists.

Thus, there is always a degree to which informed consent must be assumed or inferred based
upon observation, or knowledge, or legal reliance. This especially is the case in sexual or
relational issues. In medical or formal circumstances, explicit agreement by means of
signature—normally relied on legally—regardless of actual consent, is the norm. This is the case
with certain procedures, such as a "do not resuscitate" directive that a patient signed before onset
of their illness.

Brief examples of each of the above:

1. A person may verbally agree to something from fear, perceived social pressure, or
psychological difficulty in asserting true feelings. The person requesting the action may
honestly be unaware of this and believe the consent is genuine, and rely on it. Consent is
expressed, but not internally given.

2. A person may claim to understand the implications of some action, as part of consent, but
in fact has failed to appreciate the possible consequences fully and may later deny the
validity of the consent for this reason. Understanding needed for informed consent is
present but is, in fact (through ignorance), not present.

3. A person signs a legal release form for a medical procedure, and later feels he did not
really consent. Unless he can show actual misinformation, the release is usually
persuasive or conclusive in law, in that the clinician may rely legally upon it for
consent. In formal circumstances, a written consent usually legally overrides later denial
of informed consent (unless obtained by misrepresentation).

4. Informed consent in the U.S. can be overridden in emergency medical situations pursuant
to 21CFR50.24, which was first brought to the general public's attention via the
controversy surrounding the study of Polypheme.

Valid elements

For an individual to give valid informed consent, three components must be present: disclosure,
capacity and voluntariness.

 Disclosure requires the researcher to supply each prospective subject with the
information necessary to make an autonomous decision and also to ensure that the subject
adequate understands the information provided. This latter requirement implies that a
written consent form be written in lay language suited for the comprehension skills of
subject population, as well as assessing the level of understanding through conversation
(to be informed).
  Capacity pertains to the ability of the subject to both understand the information provided
and form a reasonable judgment based on the potential consequences of his/her decision.

 Voluntariness refers to the subject's right to freely exercise his/her decision making
without being subjected to external pressure such as coercion, manipulation, or undue
influence.

Waiver of requirement

Waiver of the consent requirement may be applied in certain circumstances where no foreseeable
harm is expected to result from the study or when permitted by law, federal regulations, or if an
ethical review committee has approved the non-disclosure of certain information.

Besides studies with minimal risk, waivers of consent may be obtained in a military setting.
According to 10 USC 980, the United States Code for the Armed Forces, Limitations on the Use
of Humans as Experimental Subjects, a waiver of advanced informed consent may be granted by
the Secretary of Defence if a research project would:

1. Directly benefit subjects.

2. Advance the development of a medical product necessary to the military.

3. Be carried out under all laws and regulations (i.e., Emergency Research Consent Waiver)
including those pertinent to the FDA.

While informed consent is a basic right and should be carried out effectively, if a patient is
incapacitated due to injury or illness, it is still important that patients benefit from emergency
experimentation. The Food and Drug Administration (FDA) and the Department of Health and
Human Services (DHHS) joined together to create federal guidelines to permit emergency
research, without informed consent.However, they can only proceed with the research if they
obtain a waiver of informed consent (WIC) or an emergency exception from informed consent
(EFIC).

The doctrine of informed consent relates to professional negligence and establishes a breach of
the duty of care owed to the patient. The doctrine of informed consent also has significant
implications for medical trials of medications, devices, or procedures.
Requirements of the professional

Until 2015 in the United Kingdom and in countries such as Malaysia and Singapore, informed
consent in medical procedures requires proof as to the standard of care to expect as a recognised
standard of acceptable professional practice (the Bolam Test), that is, what risks would a medical
professional usually disclose in the circumstances (see Loss of right in English law). Arguably,
this is "sufficient consent" rather than "informed consent." The UK has since departed from the
Bolam test for judging standards of informed consent, due to the landmark ruling in Montgomery
v Lanarkshire Health Board. This moves away from the concept of a reasonable physician and
instead uses the standard of a reasonable patient, and what risks an individual would attach
significance to.

Medicine in the United States, Australia, and Canada also takes this patient-centric approach to
"informed consent." Informed consent in these jurisdictions requires healthcare providers to
disclose significant risks, as well as risks of particular importance to that patient. This approach
combines an objective (a hypothetical reasonable patient) and subjective (this particular patient)
approach.

The doctrine of informed consent should be contrasted with the general doctrine of medical
consent, which applies to assault or battery. The consent standard here is only that the person
understands, in general terms, the nature of and purpose of the intended intervention. As the
higher standard of informed consent applies to negligence, not battery, the other elements of
negligence must be made out. Significantly, causation must be shown: That had the individual
been made aware of the risk he would not have proceeded with the operation (or perhaps with
that surgeon).

Optimal establishment of an informed consent requires adaptation to cultural or other individual

factors of the patient. For example, people from Mediterranean and Arab appear to rely more on
the context of the delivery of the information, with the information being carried more by who is
saying it and where, when, and how it's being said, rather than what is said, which is of relatively
more importance in typical "Western" countries.

The informed consent doctrine is generally implemented through good healthcare practice: pre-
operation discussions with patients and the use of medical consent forms in hospitals. However,
reliance on a signed form should not undermine the basis of the doctrine in giving the patient an
opportunity to weigh and respond to the risk. In one British case, a doctor performing routine
surgery on a woman noticed that she had cancerous tissue in her womb. He took the initiative to
remove the woman's womb; however, as she had not given informed consent for this operation,
the doctor was judged by the General Medical Council to have acted negligently. The council
stated that the woman should have been informed of her condition, and allowed to make her own
decision.

Obtaining informed consents

To document that informed consent has been given for a procedure, healthcare organisations
have traditionally used paper-based consent forms on which the procedure and its risks and
benefits are noted, and is signed by both patient and clinician. In a number of healthcare
organisations consent forms are scanned and maintained in an electronic document store. The
paper consent process has been demonstrated to be associated with significant errors of
omission, and therefore increasing numbers of organisations, including Imperial College
Healthcare NHS Trust,are using digital consent applications where the risk of errors can be
minimised, a patient's decision making and comprehension can be supported by additional lay-
friendly and accessible information, consent can be completed remotely, and the process can
become paperless.

Electronic consent methods have been used to support indexing and retrieval of consent data,
thus enhancing the ability to honour to patient intent and identify willing research
participants. More recently, Health Sciences South Carolina, a state-wide research collaborative
focused on transforming healthcare quality, health information systems and patient outcomes,
developed an open-source system called Research Permissions Management System (RPMS).

Competency of the patient

The ability to give informed consent is governed by a general requirement of competency. In

common law jurisdictions, adults are presumed competent to consent. This presumption can be
rebutted, for instance, in circumstances of mental illness or other incompetence. This may be
prescribed in legislation or based on a common-law standard of inability to understand the nature
of the procedure. In cases of incompetent adults, a health care proxy makes medical decisions. In
the absence of a proxy, the medical practitioner is expected to act in the patient's best interests
until a proxy can be found.

By contrast, 'minors' (which may be defined differently in different jurisdictions) are generally
presumed incompetent to consent, but depending on their age and other factors may be required
to provide Informed assent. In some jurisdictions (e.g. much of the U.S.), this is a strict standard.
In other jurisdictions (e.g. England, Australia, Canada), this presumption may be rebutted
through proof that the minor is 'mature' (the 'Gillick standard'). In cases of incompetent minors,
informed consent is usually required from the parent (rather than the 'best interests standard')
although a parents patriae order may apply, allowing the court to dispense with parental consent
in cases of refusal.

Deception

Research involving deception is controversial given the requirement for informed consent.
Deception typically arises in social psychology, when researching a particular psychological
process requires that investigators deceive subjects. For example, in the Milgram experiment,
researchers wanted to determine the willingness of participants to obey authority figures despite
their personal conscientious objections. They had authority figures demand that participants
deliver what they thought was an electric shock to another research participant. For the study to
succeed, it was necessary to deceive the participants so they believed that the subject was a peer
and that their electric shocks caused the peer actual pain.

Nonetheless, research involving deception prevents subjects from exercising their basic right of
autonomous informed decision-making and conflicts with the ethical principle of respect for
persons.

The Ethical Principles of Psychologists and Code of Conduct set by the American Psychological
Association says that psychologists may conduct research that includes a deceptive compartment
only if they can both justify the act by the value and importance of the study's results and show
they could not obtain the results by some other way. Moreover, the research should bear no
potential harm to the subject as an outcome of deception, either physical pain or emotional
distress. Finally, the code requires a debriefing session in which the experimenter both tells the
subject about the deception and gives subject the option of withdrawing the data.
Abortion

In some U.S. states, informed consent laws (sometimes called "right to know" laws) require that
a woman seeking an elective abortion receive information from the abortion provider about her
legal rights, alternatives to abortion such as adoption, available public and private assistance, and
other information specified in the law, before the abortion is performed. Other countries with
such laws (e.g. Germany) require that the information giver be properly certified to make sure
that no abortion is carried out for the financial gain of the abortion provider and to ensure that the
decision to have an abortion is not swayed by any form of incentive.

Some informed consent laws have been criticized for allegedly using "loaded language in an
apparently deliberate attempt to 'personify' the foetus," but those critics acknowledge that "most
of the information in the [legally mandated] materials about abortion comports with recent
scientific findings and the principles of informed consent", although "some content is either
misleading or altogether incorrect."

Children

As children often lack the decision making ability or legal power (competence) to provide true
informed consent for medical decisions, it often falls on parents or legal guardians to
provide informed permission for medical decisions. This "consent by proxy" usually works
reasonably well, but can lead to ethical dilemmas when the judgment of the parents or guardians
and the medical professional differ with regard to what constitutes appropriate decisions "in the
best interest of the child". Children who are legally emancipated, and certain situations such as
decisions regarding sexually transmitted diseases or pregnancy, or for unemancipated minors
who are deemed to have medical decision making capacity, may be able to provide consent
without the need for parental permission depending on the laws of the jurisdiction the child lives
in. The American Academy of Paediatrics encourages medical professionals also to seek the
assent of older children and adolescents by providing age appropriate information to these
children to help empower them in the decision making process.

Research on children has benefited society in many ways. The only effective way to establish
normal patterns of growth and metabolism is to do research on infants and young children. When
addressing the issue of informed consent with children, the primary response is parental consent.
This is valid, although only legal guardians are able to consent for a child, not adult siblings.
Additionally, parents may not order the termination of a treatment that is required to keep a child
alive, even if they feel it is in the best interest. Guardians are typically involved in the consent of
children, however a number of doctrines have developed that allow children to receive health
treatments without parental consent. For example, emancipated minors may consent to medical
treatment, and minors can also consent in an emergency.

Informed consent is part of the ethical clinical research as well, in which a human subject
voluntarily confirms his or her willingness to participate in a particular clinical trial, after having
been informed of all aspects of the trial that are relevant to the subject's decision to participate.
Informed consent is documented by means of a written, signed, and dated informed consent
form.In medical research, the Nuremberg Code set a base international standard in 1947, which
continued to develop, for example in response to the ethical violation in the Holocaust.
Nowadays, medical research is overseen by an ethics committee that also oversees the informed
consent process.

As the medical guidelines established in the Nuremberg Code were imported into the ethical
guidelines for the social sciences, informed consent became a common part of the research
procedure.However, while informed consent is the default in medical settings, it is not always
required in the social science. Here, research often involves low or no risk for participants, unlike
in many medical experiments. Second, the mere knowledge that they participate in a study can
cause people to alter their behavior, as in the Hawthorne Effect: "In the typical lab experiment,
subjects enter an environment in which they are keenly aware that their behavior is being
monitored, recorded, and subsequently scrutinized."In such cases, seeking informed consent
directly interferes with the ability to conduct the research, because the very act of revealing that a
study is being conducted is likely to alter the behaviour studied. List exemplifies the potential
dilemma that can result: "if one were interested in exploring whether, and to what extent, race or
gender influences the prices that buyers pay for used cars, it would be difficult to measure
accurately the degree of discrimination among used car dealers who know that they are taking
part in an experiment." In cases where such interference is likely, and after careful consideration,
a researcher may forgo the informed consent process. This is commonly done after weighting the
risk to study participants versus the benefit to society and whether participants are present in the
study out of their own wish and treated fairly.Researchers often consult with an ethics committee
or institutional review board to render a decision.

The birth of new online media, such as social media, has complicated the idea of informed
consent. In an online environment people pay little attention to Terms of Use agreements and can
subject themselves to research without thorough knowledge. This issue came to the public light
following a study conducted by Facebook Inc. in 2014, and published by that company
and Cornell University.Facebook conducted a study where they altered the Facebook News
Feeds of roughly 700,000 users to reduce either the amount of positive or negative posts they
saw for a week. The study then analysed if the users status updates changed during the different
conditions. The study was published in the Proceedings of the National Academy of Sciences.

The lack of informed consent led to outrage among many researchers and users.Many believed
that by potentially altering the mood of users by altering what posts they see, Facebook put at-
risk individuals at higher dangers for depression and suicide. However, supports of Facebook
claim that Facebook details that they have the right to use information for research in their terms
of use.Others say the experiment is just a part of Facebook's current work, which alters News
Feeds algorithms continually to keep people interested and coming back to the site. Others
pointed out that this specific study is not along but that news organizations constantly try out
different headlines using algorithms to elicit emotions and garner clicks or Facebook shares.They
say this Facebook study is no different than things people already accept. Still, others say that
Facebook broke the law when conducting the experiment on user that didn't give informed
consent.

The Facebook study controversy raises numerous questions about informed consent and the
differences in the ethical review process between publicly and privately funded research. Some
say Facebook was within its limits and others see the need for more informed consent and/or the
establishment of in-house private review boards.

Conflicts of interest

Other, long-standing controversies underscore the role for conflicts of interest among medical
school faculty and researchers. For example, coverage of University of California (UC) medical
school faculty members has included news of ongoing corporate payments to researchers and
practitioners from companies that market and produce the very devices and treatments they
recommend to patients.Robert Pedowitz, the former chairman of UCLA's orthopaedic surgery
department, reported concern that his colleague's financial conflicts of interest could negatively
affect patient care or research into new treatments.In a subsequent lawsuit about whistle-blower
retaliation, the University provided a $10 million settlement to Pedowitz while acknowledging
no wrongdoing. Consumer Watchdog, an oversight group, observed that University of CA
policies were "either inadequate or unenforced...Patients in UC hospitals deserve the most
reliable surgical devices and medication…and they shouldn't be treated as subjects in expensive
experiments."Other UC incidents include taking the eggs of women for implantation into other
women without consent and injecting live bacteria into human brains, resulting in potentially
premature deaths.

VI. Nature and Historical Perspective of Criminal Behaviour

As long as there have been people, there has been crime. Criminology is the study of crime and
the criminal element, its causes, and the suppression and prevention of it. The history of
criminology is in many ways the history of humanity. As human society has evolved over
thousands of years, so, too, has our understanding of the causes of crime and society's responses
to it.

Ancient Views of Crime and Punishment: In ancient times, the common response to crime was
revenge—the victim or the victim’s family would exact what they felt to be an appropriate
response to the crime committed against them.

Often, these responses were not measured or proportionate. The original criminal would often
perceive himself as the victim as a result, due to the actions taken against him that he felt didn't
match the crime committed. Blood feuds often developed that could sometimes last for
generations.

The First Laws and Codes: Laws that clearly defined crimes and corresponding punishments
were established to both quell crime and to put an end to the blood feuds that resulted from the
victims’ revenge. These early attempts still allowed the victim of a crime to issue the
punishment, but they sought to clarify that a response to a particular crime should be equal to the
severity of the crime itself. The Code of Hammurabi is one of the earliest of these endeavors, and
it's perhaps the best-known attempt to establish a set punishment scale for crimes. The principles
set out in the code are best described as the “law of retaliation.”

Religion and Crime: Many of the early ideas about crime and punishment were preserved in the
Old Testament of the Bible in western culture. The concept is most easily recognized as the
expression, “an eye for an eye.” Crime, along with most everything else, was viewed in the
context of religion in early societies. Criminal acts offended the gods or God. Acts of revenge
were therefore justified as a means to appease the gods for the affront committed against them.

Early Philosophy and Crime: Much of our modern understanding of the relationship between
crime and punishment can be traced to the writings of the Greek philosophers Plato and
Aristotle, although it would take more than a millennium for many of their concepts to take root.
Plato was among the first to theorize that crime was often the result of poor education. He felt
that punishments for crimes should be assessed based on their degree of fault, allowing for the
possibility of mitigating circumstances.

Aristotle developed the idea that responses to crime should attempt to prevent future acts, both
by the criminal and by others who might be inclined to commit crimes. Punishment for crime
should serve as a deterrent to others.

Secular Law and Society: The Roman Republic was first society to develop a comprehensive
code of laws, including criminal codes. The Romans are widely regarded as the true precursors
to the modern legal system, and their influences are still seen today. The Latin language is
preserved in much of our legal terminology in the 21st century. Rome took a more secular view
of crime, viewing criminal acts as an affront to society rather than God or the gods. It took on the
role of determining and delivering punishment as a governmental function as a means of
maintaining an ordered society. A lack of a strong central authority led to a step backward in
attitudes toward crime with the decline of the Roman Empire.

Crime and Punishment in the Middle Ages: The introduction and spread of Christianity
throughout the west brought a return to a religious connection between crime and punishment.
Criminal acts became thought of as the works and influences of the devil or Satan. Crimes were
equated with sin. In contrast to ancient times when punishments were often carried out to
appease the gods, punishments were now exacted in the context of "doing God’s work." Harsh
punishments were meant to purge criminals of sin and free them of the influence of the devil.

Foundations for the Modern View of Crime: Christianity introduced the merits of forgiveness
and compassion at the same time, and views toward crime and punishment began to evolve.
Roman Catholic theologian Thomas Aquinas best expressed these notions in his treatise,
“Summa Theologica.”

It was believed that God had established a “natural law,” and crimes violated that law. Anyone
who committed a crime had also committed an act which separated herself from God. Society
began to understand that crimes hurt not only the victim, but the criminal as well. While
criminals were deserving of punishment, they were also to be pitied because they had placed
themselves outside of God’s grace. Although these ideas were derived from religious studies,
the concepts continue to prevail in our secular views of crime and punishment.

Modern Criminology and the Secular Society: Kings and queens of earlier times claimed their
totalitarian authority on the will of God, taking the position that they had been placed in power
by God and were therefore acting within His will. Crimes against persons, property, and state
were all viewed as crimes against God and as sins. Monarchs claimed to be both of heads of state
and heads of church. Punishment was often swift and cruel, with little regard for the criminal.

Ideas about crime and punishment took a more secular and humanistic form as the notion of
separation of church and state began to take root. Modern-day criminology developed out of the
study of sociology. Modern criminologists seek to learn the root causes of crime and to
determine how to best address and prevent it. Early criminologists advocated a rational approach
to dealing with crime, pushing against the abuses by governmental authorities.

A Call for Reason in Modern Criminology: In his book, "On Crime and Punishment," Italian
writer Cesare Beccaria advocated for a fixed scale of crime and corresponding punishment based
on the severity of the crime. He suggested that the more severe the crime, the more severe the
punishment should be. Beccaria believed that the role of judges should be limited to determining
guilt or innocence, and that they should issue punishments based on guidelines set out by the
legislatures. Excessive punishments and abusive judges would be eliminated.
The Link Between Biology, Psychology, and Crime: Italian psychiatrist Cesare Lombroso
studied cause of crime based on individual biological and psychological characteristics in the late
19th century. Most notably, he suggested that many career criminals were not as evolved as other
members of society. Lombrosso discovered certain physical attributes shared among criminals as
well, and this led him to believe that there was a biological and hereditary element that
contributed to an individual’s potential to commit a crime.

Modern Criminology: These two lines of thinking—biological and environmental—have

evolved to complement each other, recognizing both internal and external factors that contribute
to the causes of crime. The two schools of thought formed what is considered the discipline of
modern criminology.

Criminologists now study societal, psychological and biological factors. They make policy
recommendations to governments, courts, and police organizations to assist in preventing crimes.
As these theories were being developed, the evolution of the modern police force and of our
criminal justice system was occurring as well. The purpose of police was refined to prevent and
detect crimes, as opposed to simply react to crimes that had already been committed. The
criminal justice system now serves to punish criminals for the purpose of deterring future crimes.

VII. Suicide and Homicide

Suicide: It's often difficult to imagine what led a friend, family member, or celebrity to commit
suicide. There may have been no clear warning signs, and you may wonder what clues you might
have missed. Often, many factors combine to lead a person to the decision to take their own life.
It's often an act made during a storm of strong emotions and life stresses rather than after careful
consideration.

Depression and Mental Illness: While there are many factors that can influence a person's
decision to commit suicide, the most common one is severe depression. Most people make the
decision to attempt suicide shortly before doing so impulsively rather than planning it out
extensively.
Depression can make people feel great emotional pain and loss of hope, making them unable to
see another way to relieve the pain other than ending their own life. According to the American
Foundation for Suicide Prevention, depression is present in about half of all suicides. Other
mental illnesses besides depression can also play a role in suicide. For example, a person with
schizophrenia or other illnesses that produce psychosis might be hearing voices that command
them to kill themselves. Bipolar disorder, an illness in which a person experiences alternating
periods of high and low moods, can also increase a person's risk for dying by suicide.1
Borderline personality disorder is another condition with a high rate of suicide. Eating disorders,
including anorexia and bulimia, also have a high rate of death by suicide.

Traumatic Stress: A person who has had a traumatic experience, including childhood sexual
abuse, rape, physical abuse, or war trauma, is at a greater risk for suicide, even many years after
the trauma. In a survey of nearly 6,000 U.S. adults, nearly 22% of people who have been raped
had attempted suicide at some point while 23% who experienced physical assault tried to take
their own life at some point.

Being diagnosed with post-traumatic stress disorder (PTSD) or multiple incidents of trauma
raises the risk even further. This is partly because depression is common after trauma and among
those with PTSD, causing feelings of helplessness and hopelessness that can lead to suicide.

The Connection between Suicide and PTSD:

Substance Use and Impulsivity: Drugs and alcohol can also influence a person who is feeling
suicidal, making them more impulsive and likely to act upon their urges than they would be
while sober. Substance and alcohol use can contribute to other reasons people commit suicide,
such as the loss of jobs and relationships. The rates of substance use and alcohol use disorder are
also higher among people with depression and other psychological disorders. Put these together
and the risks increase.

Loss or Fear of Loss: A person may decide to take their own life when facing a loss or the fear
of a loss. These situations can include:
Hopelessness: Hopelessness, either in the short-term or as a longer-lasting trait, has been found
in many studies to contribute to the decision to commit suicide. The person may be facing a
social or physical challenge and may see no way the situation can improve.

When people feel they have lost all hope and don't feel able to change that, it can overshadow all
of the good things in their life, making suicide seem like a viable option. While it might seem
obvious to an outside observer that things will get better, people with depression may not be able
to see this due to the pessimism and despair that go along with this illness.

Chronic Pain and Terminal Illnesses: If a person has chronic pain or illness with no hope of a
cure or reprieve from suffering, suicide may seem like a way to regain dignity and control of
their life. In some states, assisted suicide is legal for this very reason.

According to a study in the American Journal of Preventative Medicine, the following health
conditions were associated with a higher risk of suicide:

Chronic pain can also bring on anxiety and depression, which can also increase your risk of
suicide. According to research, people with chronic pain are four times more likely to have
depression or anxiety than those who are pain-free.

Chronic Disease and Mental Health

Belief Your Life Is a Burden to Others: A person with chronic pain or a terminal illness can also
feel like a burden to others, as it becomes harder and harder to ask for yet another ride to the
doctor's office or more help with household duties or assistance paying for hospital bills. In fact,
many people who decide to commit suicide often state that their loved ones or the world, in
general, would be better off without them.

This type of rhetoric is a common warning sign of suicide. People often see themselves as a
burden to others or feel worthless due to the overwhelming emotional burden they are carrying
within.

Social Isolation: A person can become socially isolated for many reasons, including losing
friends or a spouse, undergoing a separation or divorce, physical or mental illness, social anxiety,
retirement, or due to a move to a new location. Social isolation can also be caused by internal
factors such as low self-esteem. This can lead to loneliness and other risk factors of suicide such
as depression and alcohol or drug misuse.

The Health Consequences of Loneliness: Sometimes people attempt suicide not so much
because they really want to die, but because they simply don't know how to get help. Suicide
attempts are not a cry for attention but a cry for help. It becomes a way to demonstrate to the
world just how much they are hurting.

Unfortunately, these cries for help may sometimes prove to be fatal if the person misjudges the
lethality of their chosen method. People who make a failed attempt are also at a much higher risk
of trying again, and their second attempts are much more likely to be lethal.

Accidental Suicide: There are some situations where what appears to be a suicide is actually an
accidental death. The dangerous "choking game" (also known as “pass-out challenge,”
“flatliner,” and "space monkey”) where teens attempt to asphyxiate themselves in order to feel a
high, as well as autoerotic asphyxiation, are examples. Accidental suicides can also include
unintentional overdoses, poisonings, and firearm deaths.

A. Homicide

Computed across a lifespan of 75 years, there is a 1 in 200 chance that an individual in the
United States will be murdered. The frequency of homicide and this startlingly high statistic
warrant more concerted efforts to research the psychological underpinnings motivating
homicide. The history of the study of the psychology of homicide is replete with theoretical
shifts—some of which have led to empirical dead ends and others to tremendous advances.
Explaining the motivations of a murderer historically has been a difficult task for psychologists
because of the wide array of individual, situational, and cultural variables influencing the
development of homicidal behavior. Recent psychological research includes both theoretical and
methodological advances that have allowed for new, unprecedented insights into the psychology
of homicide.

Theoretical Perspectives on Homicide: Several theories have been developed over the brief
history of psychology seeking explanations of the patterns of homicide. These theories have
followed larger movements within psychology. Movements have proceeded from individualistic
explanations of homicide in the late 19th and early 20th centuries to more environmental
explanations throughout much of the past century. Modern theories seek to address the
limitations of previous theories by accounting for a broader range of causes of human behavior.
Rather than discussing all the theories, this entry expands on those that are particularly
influential and provides an organizational framework to anchor and interpret the changes in these
theories.

George Vold organized various theories of the mid 20th century into spiritistic and naturalistic
explanations. To focus on scientific explanations of human behavior, we will not discuss
spiritistic accounts of homicide. Naturalistic explanations include those that lend themselves to
empirical scrutiny and include hereditary and defectiveness theories, mental deficiency theories,
and mental illness theories. Hereditary and defectiveness theories view homicide as the product
of biological and genetic causes. Mental deficiency theories argue that homicide is the product of
low intelligence. Mental illness theories, espoused first by Sigmund Freud, have been better
received than mental deficiency theories. Although Freud’s psychoanalytic theory was a starting
point for explaining the psychology behind homicide, psychoanalytic theory is now recognized
as empirically barren. Freud’s influence was lasting, however, with many later contributions
revealing Freudian pedigree. Evidence of views of homicide as the product of psychopathology
is revealed by the first study on homicide, published in 1898 in the psychology journal American
Journal of Insanity by Charles Bancroft. Continuing to the present day is the perspective of
understanding homicide as the result of pathological psychological manifestations. The theories
mentioned so far focus primarily on characteristics internal to an individual that may influence
homicidal behavior. There was a focus on more environmental explanations of homicide in the
early to mid 20th century, largely in reaction to the previous focus on intra-individual
explanations of homicidal behavior.

Environmental Theories of Homicide: Environmental theories can be described generally as

focusing on sources or causes of homicidal behavior outside the individual. Examples of such
theories include socialization theories, symbolic interactionism, social structural theories, control
theory, and social ecology theory. Socialization theories of homicide and aggression have
historically been among the most popular and influential accounts of the motivations for
homicide. The sex difference in the commission of violent crimes— including homicide—was
one of the first and most obvious observations demanding explanation. Men are more often than
women both the offenders and the victims of homicides. Socialization theories argue that men,
more than women, have been socialized to view aggression as a permissible means to achieve
certain ends. This differential socialization for aggressive behavior in men and women, it is
argued, can explain the greater homicide rates among men. While this theory has been well
received within psychology, there is growing evidence that an exclusive reliance on this
theoretical position to explain homicide patterns leads to incomplete conclusions. Socialization
theories push back one step many of the most intriguing questions psychologists working to
understand homicide have tried to answer. Why are men and women differentially socialized to
behave aggressively? Why are boys and girls differentially receptive to certain aspects of
environmental input? Socialization theories cannot provide answers to such questions. Despite
the limitations of environmental theories, insight has been gained from the research conducted by
social scientists focusing on social and cultural influences. One notable finding reflecting the
cultural and demographic variables within cultures has resulted from research on homicide rates
across the United States.

Social scientists have identified key sociocultural beliefs and attitudes that vary by region and
have analyzed homicide rates as a function of these different beliefs and attitudes. The Southern
states in the United States adhere more strongly to a “culture of honor” than other regions. In the
Southern states, men act more aggressively than men in the Northern states to protect their honor
and their reputation. This difference is arguably generated by exposure to a culture in which
honor and reputation are very important in protecting resources. Of the state executions that have
occurred since 1977, 82% have occurred in the Southern region of the United States. In addition
to these social explanations of homicide, recent breakthroughs have been made in understanding
the biological roots of homicide.

Biological Theories of Homicide: Advances in technology now provide researchers with an

unprecedented window into the brain activity of murderers. These technological advancements
include functional magnetic resonance imaging, electroencephalography, computed tomography,
and positron emission tomography, all of which can be used to study neurological and
neuroanatomical abnormalities in the brains of individuals who have perpetrated homicide.
Research has shown distinct neurological activity in individuals who have homicidal thoughts or
who exhibit violent behaviors.

One perspective explicit in the call for integration of biological (e.g., genetic predispositions),
psychological (e.g., psychological disorders), and social (e.g., poverty) explanations of homicide
has been aptly named the biopsychosocial perspective. There are limitations to this theory
because many of the bidirectional relationships between these three metafactors have not yet
been fully explored. Although this is a promising theoretical position, a wealth of new research is
yet to be conducted exploring the links between these factors. Inherited predispositions for
particular personality disorders may influence how an individual is perceived and treated by
others. The way an individual is perceived and treated by others provides a feedback loop,
altering cognitions about relationships with others that can influence personality. In sum, there
are numerous potential pathways to homicide, and we will be better positioned to expand on
these interrelationships with future research.

In many of the cases, links between abnormal cognition and brain activity have been
documented. Murderers have been diagnosed with psychological disorders such as antisocial
personality disorder or other personality disturbances, psychological stressors, various types of
childhood trauma, and drug and alcohol abuse problems. Not all these psychological disorders,
however, apply to all killers. Many known factors combine to result in individual differences in
brain patterns and cognition and complicate our understanding of the psychology of homicide.
We believe that insight gained from various areas of the psychological and other behavioral
sciences will provide greater clarity into the motivations and development of homicidal thoughts
and behavior. Various theories have recently shed light on homicidal psychology in ways that
have previously escaped psychologists.

Evolutionary Perspectives on Homicide: One particularly powerful theoretical perspective that

has yielded insight has been the application of evolutionary perspectives to the study of
homicide. An evolutionary psychological approach to homicide is relatively new and allows for
stronger anchoring of the psychological sciences with the biological sciences. Evolutionary
psychologists argue for distinctions between various types of homicide. Inroads into the
psychology of homicide have been made by an attempt to understand the relationships between
the victim and the offender. There is a debate among evolutionary psychologists on whether
there exist evolved psychological adaptations for homicide or whether homicide occurs as a by-
product of adaptations selected for in response to other sets of social adaptive problems (e.g.,
sexual jealousy, same-sex competition, aggression). An evolutionary psychological approach
informs us of many areas in the psychology of homicide that have not been fully explored. If
homicides were a recurrent feature of our ancestral environment, for example, selection would
have favored antihomicide psychological adaptations (e.g., avoid being killed, minimize the
threats posed by others). Research on the existence of these possible evolved psychological
adaptations is currently under way.

In many homicides, the offender and the victim are individuals with a history of previously close
romantic or familial relationships. There are many known factors linked with homicide among
romantic partners, including sexual jealousy and prolonged abuse of women by their partners.
These variables demand a deeper understanding of interpersonal relationships that can add to the
body of research informing the psychology of homicide. A particularly dangerous time for many
women comes when they terminate a romantic relationship. From an evolutionary perspective,
this termination prompts psychological adaptations in men that may have functioned in ancestral
environments to retain a mate. These adaptations may prompt behavior such as vigilance over
the partner’s whereabouts, reassessment of the relationship, or, more dangerously, stalking
behavior and homicidal rage over the termination of the relationship and a newly established
relationship with a rival male.

Among homicides occurring between parents and children, men are more likely than women to
kill their children when the children are older, whereas women are more likely to kill their
children when the children are younger. Many of the results of analyses of filicides follow from
predictions made by evolutionary psychologists. Men, relative to women, may harbor
psychological adaptations that monitor genetic relationships between themselves and their
putative children (e.g., cues such as female infidelity and their own similarity to the child). The
features of homicides by mothers perpetrated against children are very different from those of
homicides perpetrated by fathers against children. Mothers more often than fathers kill their
children because of factors related to current states (e.g., absence of investing father, resource
demands from children) or future prospects (e.g., bias toward future children rather than current
children). Prior to the work done by evolutionary psychologists, no research platform had
identified the presence of stepparents as a risk factor for child homicide. Researchers have
documented a risk factor of filicide that is 100 times greater when a stepparent resides in the
household.

Siblicides account for only 1% of all homicides, but analysis of this type of homicide has given
us glimpses into the psychology of sibships. Among siblicides, for example, older siblings are
more often the perpetrators earlier in life. In contrast, younger siblings are more often the
perpetrators later in life—perhaps as an attempt to secure larger portions of inheritance that
might otherwise be channeled to older siblings. Additionally, features of the precipitating
conflict within the relationship may be revealed by the method of murder. Among siblings, for
example, full siblings use a less brutal method of homicide than stepsiblings or half-siblings.