Some final thoughts on the Yates case (update: see today’s Houston Chronicle piece, “Yates defense targets appeal,” for the latest on the enormous gaffe by the state’s star witness, Dr. Park Dietz), using Reason associate editor Brian Doherty’s Hartford Courant essay as a sort of springboard. Doherty’s text will be blockquoted; my responses — which will include more general responses to those of you’ve who’ve been interested enough to engage in this debate — will extend to the margins.

Yates Jury Did The Only Sane Thing

Andrea Yates drowned her five children in Texas this past June. She has now been found guilty for three of the murders. (She was not being tried for the other two at this time.)

It took the jury less than four hours to deliberate. The decision seems to have been easy for them. And indeed it should have been. Yates confessed to the murders, and neither she nor her lawyers disputed that she committed them.

One of the most prominent rhetorical moves I’ve noticed in discussions on the Yates case is evident here: Doherty claims that Yates confessed to the “murders.” Of course, no such thing ever happened. Yates confessed to the killings, to be sure; but it was to “murder” that she pled not guilty by reason of mental defect. As one reader pointed out (wish I knew your name, “DWL”): “The point that is so often missed […] is that murder is not killing per se, it’s killing in a particular state of mind […] The insanity defense has to do with whether an individual is capable of forming the relevant state of mind. Thus, it’s silly to argue that Andrea Yates is ‘objectively’ guilty of murder based on the acts she performed, because murder is not just an act but a combination of an act with a particular state of mind.”

What she and her lawyers did argue is that she was not responsible for having committed them. They said she should be found not guilty by reason of insanity.

Again, “responsible” is misleading in this context. Yates was indeed responsible, in the strictest sense, for the killings; after all, she physically drowned her children. The question, though, is whether or not she was in any state of mind to be held legally accountable for those physical actions. The crux of her insanity defense was that she should not be. If an epileptic undergoing a seizure were to strike someone in the throes of that seizure, would said epileptic be open to charges of assault? Similarly, had Yates’ illness taken another of its manifestations — catatonia (when she first arrived at the Devereaux facility, she was described by the admitting physician as being “nearly catatonic”) — and had her children died as a result of her inaction (say, she left something cooking on the stove, and her children perished in a fire, but she did not, or she drove the car into a swimming pool, killing the kids but not herself), would she be held legally responsible for their deaths?

The difference in this case is that Yates’ actions appear (to “objective” observers — not, it should be noted, to most of her doctors) to be premeditated and purposeful in the sense we normally understand such things. It is crucial to remember, however, that these actions appear such from the perspective of normal behavior. As Psychiatry24x7 notes: “The sudden onset of severe psychotic symptoms” (an acute psychotic episode) “is a mental state involving hallucinations (disturbances of perception) and / or delusions (false yet strongly held personal beliefs that result from an inability to separate real from unreal experiences) […] People with paranoid and psychotic symptoms,” — which Yates’ doctors claim she was suffering from and “which can become worse if medications are discontinued” (as were Ms. Yates’ anti-psychotic meds 11 days before the killings) — “may […] be at higher risk for violent behaviour. When violence does occur, it is most frequently targeted at family members and friends, and most often takes place at home.

“[…] People with schizophrenia may have perceptions of reality that are extremely different from that shared by others around them. They often suffer terrifying symptoms such as hearing internal voices not heard by others, or believing that other people are reading their minds, controlling their thoughts, or plotting to harm them. Living in a world distorted by hallucinations and delusions, people with schizophrenia may feel frightened, anxious, and confused, and may be left fearful and withdrawn […] Partly because of the unusual realities they experience, people with schizophrenia may behave very differently at various times. Sometimes they may seem distant, detached, or preoccupied and may even sit rigidly, not moving for hours or uttering a sound. At other times they may move about constantly, always occupied, appearing wide-awake, vigilant, and alert.”

Yates’ entire documented history of mental illness — which included two stints in the hospital within a few months of the killings (and, subsequently, outpatient and drug-therapy treatment) — points to her psychosis.

Not everyone believes this, however. In his response to my earlier postings on this case, Alex Knapp writes, “When we get to the Yates case, with the facts as I understand them, the nature of her illness did not prevent her from appreciating the nature and quality of her actions.” To this line of argument, I can offer no effective counters; those who believe Yates did not suffer from any form of psychosis are correct to dismiss her insanity defense (because clinical depression, for instance, doesn’t alter behavior in the way requisite to affect the kind of delusional paradigm Yates’ defense claims she was operating under at the time of the killings). And in fact, Dr. Mohammad Saeed — the last psychiatrist to treat Yates before the drownings — argues just that — though nurses’ notes and the observations of Dr. Ellen Allbritton (the psychiatrist who first admitted Yates to the Devereaux facility) would seem to indicate otherwise.

Yates is labeled as having had postpartum depression. But the proof that this illness somehow compelled her deeds amounts to nothing more intellectually serious than, ‘She did something we can’t imagine anyone in their right mind would do.’

This is true, however, of all sorts of criminals – especially the worst kind. There is no objective lab test that tells us whether or not she is suffering from some disease that makes her unequivocally not responsible for what she did, in the sense that a hemophiliac is not responsible for bleeding continually when cut.

First, Yates’ “postpartum depression” was alternatively diagnosed as paranoid schizophrenia — and Doherty, we must assume, is well aware of this. At the very least, Yates seems to have been suffering from postpartum psychosis — a far more serious ailment than depression (though Dr. Saeed, remarkably, disputes this). The proof is in the treatment: Yates was prescribed Haldol,* an anti-psychotic drug, in addition to anti-depressants. Doctors treating her in prison, in fact, lowered her dosage to 10mg, only to re-up the dosage to 15mg when they noticed adverse changes in behavior. Dr. Saeed, you’ll remember, has Ms. Yates taper off Haldol by June 7th, 11 days before the killings — testifying in court that “I believe I had advised discontinuing Haldol because, so far during the course of the treatment, there was no definitive indication of psychosis from my observation, from other trained staff and from Mr. Yates” — a statement vehemently challenged both by other Devereaux staffers and Mr. Yates. Anti-psychotic drug withdrawal, you’ll recall, increases the risk of severe psychotic episodes. Dr. Saeed’s decision to take Yates off the anti-psychotics while keeping her on outpatient status is somewhat troubling, if only in retrospect.

Doherty writes that there is “no objective lab test that tells us whether or not she is suffering from some disease.” Presumably, however, there was a time in our medical past when an “objective lab test” for, say, brain tumors or lung cancer, likewise didn’t exist (and in fact it’s not hard to visualize a time when labs themselves didn’t exist) — which of course has no bearing whatsoever on the actual existence of a disease. I’ve never been to China, for instance, but that doesn’t mean I don’t believe it exists…

Her lawyers did not call in medical experts to talk of brain scans or blood chemistry. Instead, psychiatrists testified about what she said and how she behaved. And the jury already knew the most important fact about how she behaved: She had drowned all her children, an act requiring a great deal of planning and effort.

“Experts do agree,” according to Psychiatry24x7, “that the [schizophrenia] is due to abnormalities in brain function, some of which have been detected. Schizophrenia is a disease of the mind, the symptoms of which are attributed to abnormalities in the transfer and processing of information within the brain […] The ability to examine the brains in living people with computer-assisted tomography (CAT) scans has led to findings that some people with schizophrenia have abnormalities in the structure of the brain.” Not all sufferers, however, show such abnormalities. Yates, to my knowledge, was never given a CAT scan in the course of her treatment — a revelation that renders Doherty’s point moot.

Doherty suggests here that the act of drowing her children required “a great deal of planning and effort” — a rhetorical flourish that dodges the facts: In order to drown her children, Yates had to 1) fill up the bathtub, and 2) hold the children under the water until they stopped struggling. This is chilling imagery, certainly — but the act itself didn’t require any “great deal of planning,” and the “effort” was mediated (sadly) by Yates’ delusional sense of purpose.

In Texas, legal responsibility in insanity defense cases hinges on whether the defendant knew the difference between right and wrong. All available objective evidence definitely indicates that she knew what she was doing was wrong. She called 911 to report herself, called her husband and told a police officer that ‘I realize that it’s time to be punished.’

Here, finally, Doherty is completely correct: In Texas, legal responsibility in insanity defense cases does hinge on whether the defendent knew the difference between right and wrong. But there is some question as to whether or not Ms. Yates’ having called the police or acquiescing to punishment is a tacit admittance of guilt in the sense we normally conceive of it. As Rand Simberg noted in his March 7 FOXNews column: “Yes, [Ms. Yates] called the police because she knew that drowning her children was illegal. But if she (insanely, in my humble opinion) thought that the alternative was to consign them to hell, the she also thought that what she was doing was not wrong […] The larger point is that all this is immoral is not necessarily illegal, nor should it be. And vice versa. Yes, we all know that killing your own children is wrong, but not simply because there is a law against it. And not all things that are illegal (such as not reporting the location of the Jews in Nazi Germany) are wrong […] Just because Andrea Yates reported her crime to the authorities, and was willing to accept the consequences…does not mean that she properly understood the moral implications of her act.”

And Rand, too, is correct: Yates knew her husband would try to stop her. So too would she’ve stopped were a police officer to be present in the room (a standard hypothetical raised by prosecutors to determine a defendant’s ability to judge “right from wrong”). Nevetheless, Yates was being held to higher standards than those demanded of her by societal strictures — at least, she thought so, given the nature of her delusions. As Dr. Phillip Resnick, the director of the division of Forensic Psychiatry at Case Western Reserve University School of Medicine in Cleveland, testified, Yates “faced a cruel dilemma […] If she did nothing, because the children were not being raised righteously, they would burn in hell. She could allow them to end up in hell burning for eternity or take their lives on Earth. It was a horrible dilemma for any mother to have.” In short, in her mind, Yates was protecting her children from the Devil. Society couldn’t be trusted to recognize the “truth” of her children’s dire situation — and in fact, Yates “recognition” that she alone was privy to this information is (perversely) what compelled her to act as she did. Such is the nature of paranoid delusions. The “logic” of her worldview determined her course of action.

Why would she think that? For those willing to take Yates seriously as a human being – not a mindless puppet of wonky brain waves – she has given hints. She told a police officer that she had been thinking of killing her kids for two years, ‘since I realized I had not been a good mother to them.’

Was her thinking of the murders for two years proof that she was insanely obsessed and thus not responsible – or proof that the crime was premeditated, which traditionally makes the criminal more responsible? It depends on how you choose to look at it, not on objective psychiatric science.

Here, Doherty attempts to tether his argument to several powerful ideological beams: personal responsibility and free will. He suggests that any consideration of Yates’ illness depends on vagaries in the process of formulating a coherent narrative of the illness and the killings, not on “objective psychiatric science”; and having raised the specter of interpretative relativism, he then goes on to imply that we have a choice about how we can “read” Yates’ claims to illness (and so to her insanity defense). To Doherty’s way of thinking, the only way to “take Yates seriously as a human being” is to concede that she had free will — that her illness didn’t control her. And free will suggests choice — which carries with it an appeal to personal responsibility. But no one would think to accuse a gravely ill cancer patient of being “a mindless puppet of wonky tumors,” or an Alzheimers sufferer of being “a mindless puppet of wonky artery hardenings” — though it’s quite clear that these diseases affect behavior in specific ways.

Great literature from the Bible to Shakespeare and beyond is full of stories of people driven by the dark impulses of the human heart to commit awful acts. Did Lady Macbeth imagine bloodstains on her hands because she was mentally ill or because she was wracked with guilt and grief?

Huh? Lady MacBeth isn’t real, first of all, but even so, the imaginary bloodstains on her hands don’t appear until Act IV, three acts after she convinces Macbeth to kill Duncan. Is it crazy to believe in the prophecies of a gaggle of witches? Probably so. But certainly not for the same reasons Yates believed the voices in her head…

We don’t know why Andrea Yates felt that she had not been a good mother and deserved punishment. Such knowledge requires a deeper understanding of her heart than psychiatrists’ obsession with chemicals will ever lead them to. But she tells us that that is what she felt. Those who embrace the insanity defense seem scared to admit that a human being could choose to commit evil acts. But they can, and they do.

On the contrary, I believe humans choose to commit evil acts all the time. And when they do, the weakness in their moral center should be exposed for what it is. But Doherty begs the question here: he’s suggesting that Ms. Yates’ actions were “evil” (and by extension that she chose to act in an evil way). But it is Yates’ very ability to chose that is at issue in this case.

To my way of thinking, those who acknowledge (“embrace” the insanity defense, Brian? Like, give it a hug, you mean? A pat on the ass, that sort of thing? C’mon…) the existence of severe mental illness are willing to acknowledge that not all tragic events are the product of design. Consequently, you can have “evil” results following from accidental causes.

The jury did the right thing. It looked at the clear facts, not muddy speculations about mental states, and judged fairly. By the standards Yates and her lawyer presented, any criminal with a motive other than one everyone might agree is ‘rational’ – like monetary gain – ought not be held responsible for his or her crimes. That standard makes a mockery of both responsibility and the integrity of the criminal justice system.

The death penalty, which Yates might face, complicates the question in the minds of those opposed to that most final of punishments. But by any civilized standards, Yates deserves a serious punishment for her most serious of crimes.

Well, the jury did what it could, given the legal parameters it was allowed to operate within, and given the purview of the law. But consider that “The law also barred any mention to jurors of what Yates’ future would have been like had she been acquitted” — (potentially) leaving jurors with no legal savvy with the belief that a “not guilty” verdict could mean certain freedom for Yates…

*Myria adds this note, in answer to Richard Bennett’s query about Dr. Saeed’s desire to wean Ms. Yates off of Haldol. Dr. Saeed testified that he thought the Haldol might be interfering with the anti-depressants Yates was taking — though Russell Yates reported in a follow-up visit 2 days before the killings that she is not improving:

Haldol (Haloperidol) comes in a couple of different forms, Haloperidol is given orally. Haloperidol Lactate is given orally, via IM, or via IV injection or infusion. Haloperidol Decanoate is given via IM. I can’t say for sure, of course, but my assumption is that Mrs. Yates would have been taking an oral as the IM seems mostly to be used in cases of noncompliance (very long half-life – about three weeks) and the IV in emergencies.

In some instances Haldol can cause impaired liver function and/or obstructive jaundice, although those two fall into the “rare or very rare” category. The pharmacology information I could dig up was somewhat sketchy (not uncommon, we’re really unsure of how a lot of these drugs work exactly), but based on basic hepatic physiology (specifically the first pass effect) my assumption would be that the risk of that is higher – probably substantially – with the oral form than it would be with IM. It may be dose dependant (probably is) but it doesn’t appear to be a long-term issue. Somewhat to my surprise, hepatoxicity is *not* a known adverse reaction. Not that it much matters, but some recent studies indicate that Silymarin would probably counteract the negative liver effects, not that her doctors probably knew that.

Looking at the adverse effects list it seems pretty clear that the major negative effects of Haldol fall into two categories – CNS (unsurprising) and endocrine (also unsurprising).

The potential CNS adverse effects can include severe parkinsons, severe hallucinations, and neuroleptic malignant syndrome, among others – NMS can be fatal. Tardive Dyskinesia and Tardive Dystonia can occur, the risk appears to be dose and duration dependant, and can be irreversible and even fatal.

On the endocrine side, looking at the list I’d guess that most of it is caused by a large increase in prolactin caused by the drug. Prolactin is tied in an inverse loop to dopamine (likely explaining the prolactin increase as, among other things, Haldol acts as a dopamine receptor antagonist), but it is also tied indirectly to estrogens and progestogens as well as IGF. Those are in turn tied to the LH/FSH axis, SHBG levels, and a host of other feedback loops. In other words, effect one and you have a kind of cascade effect the severity of which is going to vary. Among other things, gynocomastia (presumably in men), breast engorgement/lactation/pain, various forms of menstrual changes, skin photosensitivity, and various forms of libido changes have all been reported. There is some debate about an increase of breast cancer risk, though apparently no hard data. In the absence of data to the contrary it’s probably safer to assume there is, given that most breast cancers are hormonally dependant. While not mentioned, many doctors seem to feel that a sustained increase in prolactin levels increases the chance of a prolactinoma. I’ve my doubts, seems to me that’s backwards (high prolactin levels area symptom, yes, but probably not a cause), but it can’t be discounted entirely.

There’s some discussion of potential cardiovascular and hematologic effects, but those appear to be mostly dose dependant and/or mostly transient.

Looking at the adverse effects list I don’t see anything that would indicate long term hepatic damage as a major risk. Doesn’t mean it isn’t, just that it apparently isn’t a generally accepted risk factor. However this drug is certainly not something you’d want to be taking long term if you can at all avoid it. Any drug of this type is going to be fairly nasty on the bod, it’s the nature of the beast, and this one is a lot more mild than some of the ones I’ve looked at, but still. Further, titrating drug type and dose is a common practise, as is trying to get someone off of a drug like this if you feel they’re manageable.

That she was taken off of it just doesn’t surprise me that much, nor does it seem certain that the temporal connection implies causality. If she was on the IM there certainly would not be a connection – again the half-life is 3 weeks. For the oral I didn’t see a half-life given, but it would be present in detectable amounts at least 28 days later. You don’t just stop a drug like this and have its effects go away the next day – ain’t how it works.