MENTAL DISORDERS AND TREATMENT (AMENDMENT) BILL

Order for Second Reading read.

3.00 p.m.

The Minister for Health and Home Affairs (Mr Chua Sian Chin): Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time."

This Bill is intended to bring the law up-to-date in regard to the admission and detention, treatment and discharge of persons of unsound mind in a mental hospital. The modern trend is to regard mental illness in much the same light as physical illness and disability. The provisions in the existing Act were laid down as far back as 1934, probably modelled on the provisions of the Mental Treatment Act, 1930, of England and Wales. These provisions were consolidated in the existing Act in 1952. They are, therefore, very much outmoded.

The emphasis in 1934 was on the compulsory detention of persons of unsound mind. The main aim was to prevent such persons from causing harm to the community. The role of the mental hospital was mainly confined to one of legal custody for persons of unsound mind. At that time there was no effective or simple treatment for such persons except preventing them from causing injury to themselves or other persons or damage to property. Since 1934 there have been revolutionary changes and discoveries in the treatment of persons of unsound mind. The trend began with the use of Electro-convulsive Therapy (1934), the discovery and use of psychotropic drugs (1957) and anti-depressive drugs (1959) and outpatient treatment. At present, the trend is towards community care and this is provided for by the Mental Health Act, 1959, of England and Wales as far as United Kingdom is concerned.

The principal changes which this Bill seeks to bring about are as follows:

The new sections 31 to 34 relate to the types of persons who may be sent to the mental hospital for admission for treatment. Conspicuously omitted from the amendments are the provisions for the reception of a mentally unsound person into a mental hospital by an order of a Court. In accordance with the changed attitude towards mental diseases, persons of unsound mind are not regarded as "criminals". The person can be received in a mental hospital, as any other sick person, if he comes voluntarily, if he is sent by a medical practitioner or if, being of unsound mind, he is considered a danger to himself and to others or is being neglected or cruelly treated by those who should be responsible for his care.

Under clause 5, section 31 is amended to enable a person who requires treatment for any mental disorder to be admitted to or to remain in any mental hospital without any order or directive rendering him liable to be detained at a mental hospital. At present admission to the mental hospital is almost exclusively by a detention order made by a Court or a commitment order for "observation". Both connote incarceration rather than treatment.

Under clause 5, the new section 32 will enable and, in fact, require a police officer who has apprehended a person who is reported to be of unsound mind and a danger to other persons to bring such person direct to a medical officer at a mental hospital for examination. At present the procedure to admit such a person is unnecessarily involved. The police officer is required to bring the person, first, to a medical officer and if, and only if, the medical officer agrees, will he be sent to a mental hospital. In practice, this step has been found to be redundant.

I shall, however, be making a further amendment to this section in Committee. This is being made on the suggestion of the Singapore Medical Association which has made some representations to me on the Bill since the last adjournment of Parliament. The Association had suggested that there might be the odd occasion where the police, in apprehending a person who is mentally ill and a danger to himself or to others, should have the discretion to take the person to any medical officer first, instead of directly to a medical officer in a mental hospital. While the occasion to take the person of unsound mind to any medical officer first, instead of directly to a medical officer at a mental hospital, will be rare indeed, the flexibility nevertheless should be provided.

Subsections (1) and (3) of section 33 will also be re-amended by the amendments which I shall be moving in Committee. This section refers to the case where a person of unsound mind is neglected or cruelly treated. It provides the Magistrate with powers to require the persons who have responsibility for their care to produce the person of unsound mind or to require the police officer to check on such a report. If in his enquiries the Magistrate has reason to believe that such a mentally ill person is indeed being ill-treated or neglected, he can refer the person to a mental hospital for treatment and care.

The Magistrate has powers under this section to impose penalties on the persons who are responsible for the care of the person of unsound mind, if they fail to comply with the order to produce the person for examination.

However, the Singapore Medical Association has suggested that the penalty imposed should be extended to charge the persons responsible for the person of unsound mind for all medical costs arising from the care of the person in a mental institution. The motivation behind the suggestion is understandable. But the practical realities would render the provision a dead letter. If the relatives or persons responsible for the care of the person of unsound mind are already negligent in the care of the person, it will be unlikely that any order made for the cost of the person's maintenance in a mental hospital would be implemented. Further, any such order to pay the Costs of maintenance is an open-ended one as the person's stay in the mental hospital could go on indefinitely. It is for these reasons that I have not accepted the recommendations of the Singapore Medical Association on this section.

Section 34 provides for the reference by any registered practitioner of a person of unsound mind to a mental hospital. This provision is found in the old Act. The Singapore Medical Association had made a recommendation on this provision. It recommended that it should be provided that in the event of a person whom a registered medical practitioner believes to be of unsound mind as to require psychiatric treatment and who refuses to go for treatment, the registered practitioner can request and the police officer will have a duty to take such person to a mental hospital. I do not agree to this suggestion. This is because a person who is merely suspected to be mentally ill should not be subject to coercion and the indignity of being taken to a mental hospital by force. The type of conditions requiring psychiatric treatment range from the mild psychogenic headache and fainting attacks to overt insanity. It would be a breach of a person's civil rights for a police officer to send, for example, a person who has a mild psychiatric illness to a mental hospital if he refuses to do so. Such a person can exercise judgement whether or not he wishes to be under treatment in a mental hospital and the police should not be made party to force him to get treatment against his wishes. This is quite different from the case where the person may be a danger to himself as in attempting suicide, or a danger to others and causing destruction to property. Under these circumstances, it is right and proper for the police to apprehend the person and take him to a mental hospital. This duty is provided under section 32.

Revised provisions are made in section 35 under clause 5 laying down procedures which are intended to ensure that no person is detained in the hospital for any period longer than is necessary for his treatment. After examination by a medical officer, a person can be initially detained for 72 hours for treatment. Before the expiry of this period, another medical officer must examine the patient and, if he is of the opinion that further treatment in the hospital is required, he may sign an order detaining the patient for a further period up to one month. Before the month is up, two medical officers (one of whom is to be a psychiatrist) will be required to examine the patient separately. If both medical officers consider that the patient requires further treatment as an inpatient, they must sign two separate orders which will allow the patient to be detained in the hospital for a further period but not exceeding 12 months. After the expiration of 12 months, if the patient should be detained for further treatment, then the order for detention must be made by a Magistrate on the application of the visitors of the hospital.

The Singapore Medical Association had made some suggestions on this section. The suggestions proposed were generally for more stringent provisions under which the extension orders for commitment to a mental hospital are made. Thus, for the initial commitment of 72 hours, the Association proposed that the order be made by two medical officers, one of whom may be a registered medical practitioner. The first extension order extending to one month must be signed by a psychiatrist, not a medical officer, and the second extension order up to one year to be signed by two medical officers, as presently provided, but the difference being that one of the two medical officers should be a psychiatrist different from the first psychiatrist who ordered the extention of the commitment by one month.

I have considered the proposals carefully to see if there might be any merit from the view-point of safeguards over the present amendments. I have come to the conclusion that it will not be necessary to provide for the more stringent provisions proposed by the Association. For one thing, they are not realistic, nor do they take into account the organisation of the mental hospital. It must be remembered that a person coming to the mental hospital may do so at any time of the day or at night when there is only a single medical officer on duty. It would be impractical if the person who needs urgent admission cannot be admitted immediately merely because a second medical officer is not available. Even under the existing Act, only a single medical officer's commitment order is required for initial commitment. There has been no occasion where it has been found that this provision has been abused.

To require the extension order of one month to be signed by psychiatrists would be merely requiring a statutory function on the psychiatrists in the service adding to the paper work, without any advantage. The medical officers in the hospital work directly under the psychiatrists. Patients admitted will certainly be brought to the attention of the psychiatrists and if a person requires extended treatment, it will also certainly be with the cognizance or instructions of the psychiatrist. The medical officer on his own would not sign the extension order without first having ascertained the views and obtained the approval of the psychiatrist.

Further, there are adequate safeguards in the Act against wrongful detention: -

(i) The Board of Visitors have a duty (under section 30) to check on every person who has been admitted to the hospital. Visits are made monthly.

(ii) Under section 59 there are penalties for improper detention. Not once has it been necessary for the Board of Visitors to object to the commitment of any of the persons admitted to the hospital and not once has it been necessary to take action against persons for improperly committing a person to the mental hospital.

Further protection against wrongful detention is accorded the patient by the provisions of section 36 of clause 5 which prohibit any medical officer from signing any order under the Act who is a relative (defined in detail in that section) or who stands in any fiduciary relationship to the patient.

Under section 37 in clause 5, the Medical Superintendent or a psychiatrist at the mental hospital will be empowered to order the discharge of a patient. It has been found that in a number of cases, it would be in the interest of the patient to be treated as an outpatient rather than an inpatient of the hospital, so that he could live in an environment which is conducive to his recovery. Under the existing law, the discharge of a person committed to the hospital can be effected only by a Court Order in the case of a person admitted by Court Order, and in all other cases, by a Board of Visitors or the Medical Superintendent.

Finally, I refer to some minor re-amendments which I shall be moving in Committee. Section 2 refers to the definition of a psychiatrist. The definition has been reworded to make it more precise. This was made at the suggestion of the Singapore Medical Association; the operative wording being that a psychiatrist is one who has experience and holds qualifications in psychiatry which are approved by the Director of Medical Services. In the original amendment, the reference to psychiatry has been left out and it might presumably be conceived that the psychiatrist could merely, on approval of the Director of Medical Services, be any medical practitioner who is acceptable to him.

Sir, I beg to move.

Question proposed.

3.16 p.m.

Mr Hwang Soo Jin (Jalan Kayu): Mr Speaker, Sir, the Minister has stated in his speech that:

"in a number of cases, it would be in the interest of the patient to be treated as an out-patient rather than an inpatient of the hospital, so that he could live in an environment which is more conducive to his recovery".

While I have no doubt that some patients are best treated as outpatients, in practice I wonder how thorough is the investigation into the home environment of a patient, particularly the financial position of the family concerned, in deciding upon the desirability of outpatient treatment.

During the course of my work on the ground, I have come across a number of cases of complaint from families that they are unable to look after the patients, and that they would like the patients to be detained for a longer period; but the mental hospital invariably is quite reluctant to do so. There was at least one case I know of where the parent of a patient came to me with a very badly damaged head. In another case, after a patient was released and sent home the whole family could not get any sleep for nights because he threatened to burn down the house. These are two of the several cases which I have received. Generally a family would come along and complain that as soon as a patient was brought home, he would suffer a relapse, or that his condition was no better than when he was first put into the mental hospital.

This question of investigating into the family background as to whether the family adequately understand the circumstances of caring for the patient or whether they are financially able, should be looked into very carefully. I suspect that it is rather a question of lack of facilities at the mental hospital that causes many patients to be treated as outpatients. Perhaps we should seriously think of expanding the facilities at the hospital.

Mr Chua Sian Chin: Mr Speaker, Sir, this point that I have put forward, that mental patients can recover better if they are gradually returned to their own home environment where there is family care and family love, is a modern trend. From the medical point of view, it is a sound one.

The Member for Jalan Kayu has brought up some problems, such as the family not being in a financial position to maintain the member of the family who is a mental patient or that the family is quite reluctant to take on their social responsibility of trying to rehabilitate a member of their family. Of course, before releasing the patient, we do send our social workers to go and investigate the family background, and so on. But this responsibility cuts both ways. The public should realise that they just cannot dump on the lap of the Government to take care of everything. That should not be the attitude. They must also play their part. It is a matter of the doctors on the one side and the members of the family on the other, or the social workers coming in between, to see that these mental patients are brought back slowly into the home environment. It is all for the benefit of the patients. But, of course, you do find families who are psychologically averse to taking back a person whom they thought is not in a sound state of mind. If they adopt such an attitude, of course, the patient will never recover. These are the odd cases that have come up. My report is that quite a great number of those patients who have been brought back to a home environment have recovered. But, of course, the odd cases will always come up. When they do come up, Members of Parliament may have to deal with them. And in dealing with them, they will have to put their problems to me, as far as mental cases are concerned.

With regard to the facilities at the hospital, may I say that, as I have announced in an earlier sitting, we are establishing a half-way home in Sembawang for the slow rehabilitation of mental patients. I think this will meet the problem which the Member for Jalan Kayu has posed.

Mr Hwang Soo Jin: Mr Speaker, Sir, I do agree that it is the social responsibility of the family to try to help in the recovery of the patient. But all that I am concerned with is whether the home environment of a patient is investigated into before he is sent home. That is my question.

Mr Chua Sian Chin: Mr Speaker, Sir, the answer is yes.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

The House immediately resolved itself into a Committee on the Bill. - [Mr Chua Sian Chin].

Bill considered in Committee.

[Mr Speaker in the Chair]

3.28 p.m.

Clause 1 ordered to stand part of the Bill.

Clause 2 -

Amendments made:

In page 1, line 13, to leave out "medical officer" and insert "registered medical practitioner". - [Mr Chua Sian Chin].

In page 1, line 15, to leave out "disorder" and insert "disorders". - [Mr Chua Sian Chin].

Mr Chua Sian Chin: Mr Speaker, Sir, I beg to move,

In page 1, to leave out lines 16 to 19 inclusive and insert -

`a recognized diploma in psychiatry or other equivalent qualification approved by the Director of Medical Services;";'.

Sir, the reasons for this amendment and the amendments to clause 5 which I shall move later have already been explained by me in my speech on the Second Reading of the Bill.

Amendment agreed to.

Clause 2, as amended, ordered to stand part of the Bill.

Clauses 3 and 4 ordered to stand part of the Bill.

Clause 5 -

Amendments made:

In page 2, to leave out lines 38 to 43 inclusive and insert -

"without delay to -

(a) any medical officer for an examination and such medical officer may thereafter act in accordance with section 34 of this Act; or

(b) any medical officer at a mental hospital and such medical officer may thereafter act in accordance with section 35 of this Act.".- [Mr Chua Sian Chin].

In page 3, to leave out lines 10 to 20 inclusive and insert "the charge of him, the Magistrate may after due inquiry make an order for such person to be sent to ". - [Mr Chua Sian Chin].

In page 3, to leave out lines 30 to 34 inclusive and insert "sergeant may visit any person supposed to be of unsound mind in the care of any friend or relative of such person for the purpose of ascertaining whether or not such person is under proper care and control or is cruelly treated or neglected by any relative or other person having the charge of him, and any such friend or relative". -[Mr Chua Sian Chin].

In page 5, line 7, to leave out "medical officer" and insert "registered medical practitioner". - [Mr Chua Sian Chin].

In page 5, line 20, after "shall", to insert "also". - [Mr Chua Sian Chin].

Clause 5, as amended, ordered to stand part of the Bill.

Clauses 6 to 13 inclusive ordered to stand part of the Bill.

The Schedule ordered to stand part of the Bill.

Bill reported with amendments; read a Third time and passed.