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Would you let him out of the box?

Yesterday’s Sunday Times carried a story to break your heart: “‘Life in a box’: young autistic man confined in hospital’s former file room”.

The first thing to say is that the headline is clickbait. It gives the impression that he’s locked in a cubbyhole. In fact quite a lot of money has been spent by the state to construct a purpose-built apartment with bedroom, bathroom, “snug room”, lounge, an unlabelled room, and a garden. It is not a dungeon. But it is a jail – this young man, referred to as “Patient A”, is has been confined there alone for years. In terms of lack of privacy his “secure apartment” at Cheadle Royal Hospital is worse than a conventional jail: he is monitored by closed circuit TV at all times.

Behind a serving hatch with a small Perspex window, a figure of a young man shuffles into view and reaches out to receive a pizza box being pushed through the hole by his mother.

“Mum, please, put me in the car and take me home,” the 24-year-old says. “I don’t want to be here any more.”

His mother, Nicola, 50, does her best not to cry. “I would if I could,” she replies. “I’m trying my best.”

Patient A, a young autistic man, has been confined to his small secure apartment in a hospital since September 2017.

A Saturday night takeaway pizza, pushed through the hatch by his mother and eaten alone in his room, is the highlight of his week.

Why is he imprisoned? Because he is violent. After a relatively happy and normal childhood his behaviour began to deteriorate in adolescence, until…

Eventually he was admitted to a unit for patients with severe mental illness at the Countess of Chester Hospital, where his behaviour was put down to “neurodevelopmental difficulties”.

There, he was restrained for the first time by clinical staff. The experience left him terrified. He stayed on the ward for three weeks, losing half a stone. He was prescribed risperidone and sent home — but the attacks continued.

“He would just constantly want to hit you,” Nicola said. “He would want to run at my mum. Run at my dad. All of us. You couldn’t stop it. I’ve never seen anything like it. He would open his eyes, and the moment he woke up he was on us.”

The Sunday Times report is much better than its irresponsible headline would suggest. It goes on to describe in depressing detail the failure of various treatments. The young man continues to attack the hospital staff, with the result that they are no longer willing to play football or computer games with him. Ever more isolated, he gets worse.

It’s horrible. But what would you have them do? His mother wants him to be released into supported housing in the community. This was due to happen, but at the last moment the care provider lined up for him pulled out. “They said his behaviour had become too challenging,” Nicola [his mother] said. “But his behaviour is challenging because of where he is.” I hate to say it but her second sentence, while undoubtedly true, does not solve the problem described in the first. Can an organisation be forced to take on the care of someone who constantly attacks their staff? To an extent, that is what is happening now at Patient A’s secure apartment at Cheadle Royal Hospital. The state does what it is obliged to by law. But care in the community for a potentially violent patient requires more intelligent and responsive supervision than keeping someone in prison. No company providing paid care is willing to provide that level of supervision for Patient A. It has been established that his family cannot do it; part of his mother’s torment is that she herself was the person who started his imprisonment by calling the police while her son attacked his grandmother.

In any case, though supported care in the community has transformed many lives for the better, it can go horribly wrong. One of the comments mentions the case of Jonty Bravery. He was the man who threw a six year old boy from the roof of the Tate Modern gallery because he wanted to be on the TV news. He caused the child life-changing injuries. Before the attack Bravery had been living in just such a placement, with two-to-one care, no less.

Back and forth the arguments go…
“Mum, please, put me in the car and take me home.”
“He would open his eyes, and the moment he woke up he was on us.”

I was going to ask, “What is the Libertarian solution to this?”, but forget Libertarianism – what is any solution to this?

19 comments to Would you let him out of the box?

  • William H. Stoddard

    There seem to be two different frameworks of thought here. One is of moral innocence: We have a person who does things not because they chose to conduct themselves in that way, but because of neurological problems. But the other is of physical danger to other people. We don’t allow fires to burn unchecked, or cars to sit on hilltops with the brakes off, or tigers to prowl through city streets, not because we consider them guilty or punishable, but because they will do harm that we aren’t prepared to accept. The first priority has to be to prevent harm.

    Of course, in this case, preventing harm seems to mean confining or restraining a self-aware being. But the claims of self-aware beings to have rights rest on their self-awareness enabling them to respect others’ rights.

    What’s the situation of the young man (he’s not a boy, by age) in the news article?

    On one hand, suppose that he’s aware that he attacks people, but has no volitional control over those attacks, but is a helpless passenger as his body hits people. It seems that he’s being deprived of freedom for something he can’t control. But I don’t think it’s that simple. If he knows his body is attacking people, then shouldn’t he want not to have his body do that? Shouldn’t he, in fact, consent to be restrained, since he can’t restrain himself? If he doesn’t consent, if he insists on going free, then isn’t he somewhat like the person who chooses to leave his car parked on a hill with the brakes off? He’s asking not to be restrained because he doesn’t choose to hit people, but if he chooses not to be restrained he IS choosing to hit people.

    On the other hand, suppose the situation is even worse: Maybe he not only can’t stop hitting people, but can’t even recognize that he’s hitting people. But in that case he seems to be outside the framework of moral discourse entirely. Restraining him has no more moral dimension than capturing a tiger or a bear that’s wandering city streets. It may be humane to stop him without killing him, and to put him somewhere where he’s not a danger, but whatever it takes to protect the lives of moral agents from him needs to be done.

    Or I think that’s how I would analyze it.

  • llamas

    William H. Stoddard brings a most-thoughtful answer.

    Here’s another example, of which I immediately bethought myself when I read the story of this unfortunate young man.

    It concerns the fate of one Robert Edwin Nitz, late of Waterford Michigan. He is sadly no longer with us, having passed away at the State prison in Jackson, MI, in 2004, the cause of death being complications resulting from a self-inflicted injury.

    The term ‘self-inflicted injury’ is a polite journalistic shorthand for what this man did to himself – dozens of times. I suggest you not Google for a description if you are of a sensitive and humane nature. Suffice it to say that, from the age of 8, when he embarked on a career of petty crime, he would respond to the interventions of the criminal justice system by mutilating himself in the most ghastly, florid and theatrical ways you probably can’t imagine. I never witnessed this myself, but I know of a deputy in a local department who was placed in psychiatric care himself after being involved in one of these episodes, so egregiously ghastly was the spectacle. Nitz made himself more-or-less unarrestable in SE Michigan for anything but the most serious offences – he had a penchant for arson – and all but the largest and best-equipped departments would avoid dealing with him at all, because the outcomes were so predictable, so horrific, and so costly. One local department provided an accounting showing that this one person had cost them well in excess of a million dollars (and these were 1990s dollars) in medical expenses and the vast panoply of services required just to have him on the premises. At the end, he was held in more-or-less Hannibal Lector-type conditions. Even the State prison system, better-equipped to deal with the many mental-health issues of serious criminals, could barely contain him, holding him first in a special self-harm unit in Ypsilanti before moving him to a similar unit at the State prison. Even that wasn’t enough, and he finally harmed himself so utterly that he died as a result.

    He wasn’t mad, in the conventional sense. He was very high-functioning, and more than one person I know who met and dealt with him described him as likable, personable and excellent company – as well he might be, since for months at a time he was never out of the immediate presence of corrections officers. He never harmed an officer in all these events, except, perhaps, psychologically. His life of petty crime involved mostly property crimes and he never appeared to want to harm others. He just had this one, particular and possibly-unique behaviour, which harmed only himself, but which left a trail of misery and vast, almost incalculable expense wherever he went.

    As our valued columnist wrote:

    ‘I was going to ask, “What is the Libertarian solution to this?”, but forget Libertarianism – what is any solution to this?’

    and this may be an even-more-apposite case than the one initially quoted since Nitz only ever (seriously) harmed himself.

    Happy New Year, everyone.

    llater,

    llamas

  • bobby b

    ” . . . what is any solution to this?”

    Cure autism.

    Short of that, we just have to find safe and humane ways to deal with its ramifications. As these folk seem to be attempting.

    They should do exactly what they’re doing. Nothing evil or untoward or anti-libertarian about that. We could spend oodles on better facilities, but we could also use oodles to help poor folk, or uneducated ones, or disabled ones, or demeaned ones, or bored ones, or . . . all the way up to helping people like me who really want the new Tesla. We’ll never lack for needs and desires. We just do the best we’re willing to do.

  • staghounds

    Release him to the custody of the people who believe he should be released. Let them take care of him if they are so eager for him to be out.

  • Fred Z

    There is no solution and probably never will be, other than confinement and care.

    Thank God we are rich enough and compassionate enough to do that.

    Until the leftists get done with us. Useless mouths and all that. Remember?

  • Fraser Orr

    When I first really started being interested in Libertarianism (I think mostly inspired by my admiration of Thatcher) I had the benefit of several interesting people to discuss my questions with. This was around the time of the birth of the web, so there was a lot of stuff out there. Many people answered many questions, but the one question I never got an answer to, which seems both relevant to both this post and to the times we live in is this: what to do with Typhoid Mary? She had no hostility, immoral or unethical behavior, she simply, due to an accident of nature, carried a disease that could make people very sick and die just from contact with her. As you probably know she spent most of her life locked up by the state of New York.

    The details of the specific woman are rather different from the myth; some of her choices made her somewhat culpable. But if we think only of the myth, what to do with her? If, for example, there was a worldwide pandemic in which people communicated the disease to others, is the state justified in forcing them to stay home, abandon school, not use pubs and restaurants, on the justification that allowing them to do so would cause others harm?

    The underlying principle that I believe leads to a fair and just society is that we should use collective force only to prevent someone from harming another or stealing their stuff. It seems to me that in these outlying cases that it is justified to do so, though surely individuals should have the right to take reasonable alternative precautions to whatever precautions the government insists on.

    I’d also add that liberty is the possession of the morally culpable and capable. Children are not granted liberty, because they are neither able to take responsibility for their decisions or even equipped to make them. So we transfer their liberties to their parents who, with that liberty, take on responsibility. So too with dementia or insanity. Their lack of capability and culpability means they are not qualified to exercise liberty, and so we must transfer it to a responsible person who is willing and able to take it on.

    The plaintive cry of “Please take me home Mom”, tugs at our heart strings. But that man is not unique. Many an insane person, or suffer from dementia might make the same heartfelt appeal, but we have no more power to help them than this man. Liberty without responsibility is an extraordinarily dangerous thing.

  • Earnest Canuck

    Hard problems here Natalie, rough cases and maybe bad law. It should be noted that in practical reality a Nitz or similar horrorshow is likely to be violently stopped by non-state actors, for merely cultural and intrapersonal reasons, leaving us in an uncomfortable position where lynching and vigilantism produce a result better than any law. I think Cormac McCarthy talked about this in a gross little novel called “Child of God.”

  • Johnathan Pearce

    Fraser Orr and William H Stoddard frame the discussion very well. And I would add my tuppence to Fraser’s point by noting that this is why lasting powers of attorney exist under the English Common Law (usually applied to cases of elderly people suffering cognitive decline and a big issue in many developed countries today). But LPAs can lead to some nasty legal wrangles, usually connected to money. https://www.hcrlaw.com/blog/dangers-of-a-wrongly-executed-lasting-power-of-attorney/

  • Nicholas (Unlicensed Joker) Gray

    Since Libertarians also believe in self-defence, I would let him loose, and might shoot him if he tried to attack me.

  • Lord T

    It is cases like this that test our society.

    I’m stuck. I certainly don’t want him out in the publics. Until we have a Matrix type prison then there is going to be no right thing to do. Even then there would be moral implications.

    I believe what is going on is the best we can do.

    As far as his mum started it by calling Plod. Not true. He started it with violence.

  • The Fyrdman

    Let the mother live in there with him if it’s a problem that he’s alone. No one should have to risk injury from this proven danger unless they are volunteering to do so.

  • William H. Stoddard

    Fraser Orr: Two things about the Typhoid Mary scenario:

    We have to distinguish between the moral judgment implicit in criminal law, and the prevention of injury through forcible restraint. When a Typhoid Mary is discovered, it’s wrong to punish her for infecting others, because she didn’t do so by choice, or knowingly. As traditional legal phrasing has it, she had no mens rea. On the other hand, leaving her at liberty means that she will continue to infect others who have a right not to be exposed to risk; so it may be justified to confine her, not as punishment, but as a safety measure. (Though once she has been shown to be a continuing source of contagion, if she knowingly escapes and exposes other people, that could be treated as a crime, assuming she has the mental capacity to understand that she’s a danger.)

    However, forcible restraint is properly justified for people who are infected and contagious, but not for those who simply might be. Once you start restraining people in advance of actual harm or threat, there are no limits on how far such restraint might go. You can’t have any liberty if you have preventive public health. Private households or businesses may choose to exclude people who don’t take precautions, and the legal authorities may defend their right to do so, but it’s not the business of those authorities to dictate that certain people must be excluded on purely preventive grounds.

  • NickM

    bobby b,
    “cure autism”? Is autism a thing. Considering the exceptionally wide range of autistic symptoms I suspect it’s maybe like cancer – a whole load of diseases lumped together. Of course it is possible (though unlikely) that a magic bullet could be found it is much more likely that it will be a very hard slog through all the forms much as improved cancer treatments have been and still are.

    Having said that at least the poor lad is being treated in a C21st manner because in the past they would’ve thought him demonically possessed and burnt him at the stake.

    Makes you wonder what folks will think of our C21st methods a hundred years from now.

  • The classical NHS approach was to use a “chemical cosh” and confine him to bed while his mind wanders and turns to jelly and his mouth drools. By comparison, physical restraint in a secure unit might actually be the more humane treatment. He is prevented from assaulting staff and visitors while still having full use of his faculties. Not ideal, but balanced against his needs and the needs of his family and society.

    Excluding the eugenics argument, longer term the only solution seems to be continued isolation. It is unfortunate, but we can’t have violent nutters wandering the streets, regardless of whether their actions are voluntary or involuntary.

  • bobby b

    NickM
    January 4, 2022 at 2:50 pm

    “cure autism”? Is autism a thing.

    Yeah, no real clue. My point was that Ms. Solent’s set of circumstances don’t involve some willing moral/immoral actor that is causing the pain – it’s a disease, a fact of nature. The harm of which she speaks doesn’t flow from a callous society treating the boy badly or from the boy’s willing behavior. It’s simply everyone trying to make the best of a bad situation. The most direct way to ameliorate the harm is to fix the disease. Everything else is simply bandaids.

  • SteveD

    ‘If, for example, there was a worldwide pandemic in which people communicated the disease to others, is the state justified in forcing them to stay home, abandon school, not use pubs and restaurants, on the justification that allowing them to do so would cause others harm?’

    Well, this is a somewhat farfetched scenario but I would say that you still have to prove that the person in question is both contagious and able to transmit the disease to others. I would also say that the disease has to be above a certainly fatality level since we don’t house-arrest people who have colds, RSV or even the flu but Ebola (and probably Typhus) is a different story. Furthermore, if the person is willing to self-isolate that should be the first choice.

    ‘so it may be justified to confine her, not as punishment, but as a safety measure.’

    Right. You make her as comfortable as possible given the circumstances and release her as soon as she is no longer a threat to others.

  • Paul Marks

    In the past if a man (and someone of 24 is a man) endlessly attacked people – he would be badly beaten.

    And if he kept attacking people, he would continue to be beaten.

    One of two things would happen – either he would learn to stop attacking people, or he would die.

    Not nice (certainly not) – but that is the way it was for most of human history.

    Nothing to do with burning anyone at the stake – that is not what would have happened.

  • Snorri Godhi

    Cure autism.

    As a matter of fact, there is some evidence that a low-carb diet helps to deal with autism* and several other mental-health issues.

    * the article begins with anecdotal evidence; scroll down to find clinical evidence…if you still trust clinical studies.

    See also this review.

    And as i have said here 2 or 3 times, there is epidemiological evidence that seed oils increase murder rates, and clinical evidence that counter-balancing seed oils with omega-3 supplements reduces aggressive and self-harm behavior.

    My own experience makes the above studies seem very plausible to me.
    (Although i no longer avoid root vegetables: i just segregate them from protein-rich food. Meat OR potatoes, never meat AND potatoes.)

    There is no guarantee that this would work with Patient A, but what’s the harm in trying? almost certainly less than trying HCQ for the Xi virus.

  • Yet if we contain a tiger or bear in a cage with no natural environment or stimulation we get protestors showing up at the gates….

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