How to deal with dementia patients who break the law: Opinion

It was far from typical behaviour for a 76-year-old former junior college teacher. Lim See Poi was recently sentenced to 15 months jail for a string of molestation offences. One key point to note here is that Lim suffered from frontotemporal dementia. As Singapore ages and more people are afflicted with neurodegenerative disease, such cases could become more common and bring into focus the criminal responsibility of dementia patients.

Memory loss is just one aspect of dementia. Lim’s condition impacts impulse control and judgment. It can result in socially deviant behaviours. While judges sympathise with dementia patients, they also cannot overlook the harm caused to the victims. In 2019, Yong Kok Kwong, a 69-year-old man with dementia, was jailed for 12 weeks after a fatal altercation with his roommate. Both our legal and healthcare systems will have to brace themselves for such cases.

Individuals with dementia may exhibit uncharacteristic behaviours, particularly as they find themselves unable to control their impulses. This could lead to offences such as shoplifting, littering and undressing in the public.

When individuals with dementia commit offences, it challenges our conventional understanding of criminal culpability and raises complex questions about free will and responsibility. The courts have recognised that criminal culpability may be diminished if mental illness is a substantial contributing factor to the offence committed. Was the offender able to appreciate the wrongfulness of their conduct? Did they lose their capacity to exercise self-control and restraint? The courts will increasingly find themselves asking such questions and, even if the offender is found guilty, their mental illness could potentially influence sentencing. In some cases, the courts may order the offender to undergo a psychiatric treatment regime as a part of the sentence.

How dementia affects behaviour

One’s frontal lobes can influence intellectual function and behaviour. They serve as the command centre in regulating emotion, empathy, social behaviour, insight, and decision-making. They develop gradually, maturing into the 20s, and this explains why children exhibit poor emotional control and judgment. When we describe a child as “mature”, we are essentially acknowledging advanced frontal lobe development manifesting itself through sophisticated decision-making and emotional intelligence. This neurological maturation process underlies the moral reasoning that we associate with adulthood, including the ability to feel and care for others.

It was a case in the 19th century that provided compelling evidence of how frontal lobe damage could fundamentally alter personality. Phineas Gage was an American railroad construction foreman who survived a freak accident in which an iron rod penetrated his skull and devastated the left frontal lobe. After this, Gage transformed from an efficient, capable worker into someone his colleagues barely recognised. Dr. John Harlow’s seminal 1849 description painted the picture of a man who became impulsive, fitful, grossly profane, and childlike in intellectual capacity yet displaying the drives and passions of a strong man. This case, while dramatic, illustrates the crucial role of the frontal lobes in maintaining personality, coherence and social behaviour.

This also raises intriguing questions about the nature of autonomy itself. “Freedom” often connotes unconstrained action and doing what satisfies our desires. However, a person who is governed by his emotions cannot be construed as free but rather enslaved. The question is whether you are free to choose how you behave.

This is where the frontal lobes come in. They allow us to inhibit inappropriate responses and align actions with values rather than instincts. They enable us to balance personal autonomy with social responsibilities. This capacity for self-regulation and thoughtful decision-making forms the basis of personal responsibility – the basis of true agency.

When frontal lobe function is compromised through dementia or brain injury, the capacity for free choice becomes limited. This raises complex questions about criminal responsibility: What degree of frontal dysfunction might excuse criminal behaviour?

These questions do not lend themselves to easy answers. They have to be determined on a case-by-case basis. Lim, for example, had been warned twice before but repeatedly breached the conditions imposed on him and went on to molest several more females, including two 12-year-olds. Although the judge took into consideration Lim’s reduced responsibility due to frontal lobe dementia, he could not ignore the harm the victims suffered. Legal systems will increasingly face such challenging decisions as dementia becomes more prevalent.

How societies can respond

Here’s an interesting parallel. As frontal lobes mature, they enable us to think in nuanced ways, beyond binary responses. Similarly, advanced societies develop sophisticated approaches to complex issues like criminal culpability in brain dysfunction cases. It’s all a matter of perspective and the ability to appreciate diverse viewpoints.

On the one hand, we are all vulnerable to illness, ageing, and death. On the other hand, we were made to live with societies and designed for communion rather than isolation. This interdependence on one another appears hardwired in the frontal lobes which help us transcend immediate self-interest to consider the greater good. In the same vein, social learning takes place within the dynamics of a family and social progress can also be seen as looking out for one another – but on a larger scale. 

As we get a better understanding of how the frontal lobe function can affect behaviour, it can have a bearing on how we approach rehabilitation, treatment and legal responsibility in cases of brain injury or illness. The desire to balance justice with compassion becomes complex in cases involving elderly offenders with neurodegenerative conditions. It calls for a nuanced approach.

We could draw lessons from the Nordic countries which place much emphasis on medical treatment for offenders with such conditions. The goal is to see if they can be rehabilitated, possibly under community supervision, without compromising public safety.

Many pieces need to be put in place. Families, for example, must be equipped with necessary resources and skills to support offenders. Crisis intervention teams will have to be on hand to handle mental health emergencies. We will also need community treatment programmes with professional oversight. An offender, for example, might require medical treatment for his dementia, while his family is supported to care for him. It would be helpful to establish day facilities with trained professionals to care for such offenders while their family members are at work.

As a society matures, its approach to justice and punishment evolves. We need to strike the balance between justice and mercy, without compromising public safety and social order. We should start thinking of these issues now, as such cases are likely to become more common as dementia becomes more widespread. Together, let us build communities that are both dementia-friendly and competent.

Dr Faisal Johandi is a senior resident and Dr Philip Yap is a senior consultant at the department of geriatric medicine at Khoo Teck Phuat Hospital. Dr Yap is also chairman, Dementia Singapore.

Source: The Straits Times © SPH Media Limited. Permission required for reproduction.

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