The Sagamihara Incident


An incident of such gravity as to leave an indelible stain on Japan’s postwar history has occurred: a former employee of a disability center entered the facility and stabbed 19 of its inmates to death and wounded 26. On the following day, the US and British press and even the Russian state news agency broadcast news of the incident, remarking how extremely rare mass murder was in Japan. The incident shook Japanese society, which had been a stranger to incidents of this sort in its recent history, to its very core.
The incident had a number of peculiarities. First, it was an unprecedented and tragic case of a single suspect illegally entering a facility during the night with a knife and proceeding to attack the residents there, who were incapable of defending themselves, one after the other, leaving many dead or injured.
Second, the victims were all individuals with severe mental or physical disabilities, and the scene of this tragedy was a facility dedicated to the care of such individuals. Moreover, the suspect had apparently been driven by the desire to kill severely disabled individuals. Third, the suspect himself had a history of hospitalization under the Act for the Welfare of Persons with Mental Disabilities, a fact which might have served as a warning of his actions in the current incident. The suspect had earlier come to the attention of the police when he attempted to hand a letter to the chairman of the lower house intimating his intention to commit murder. According to the press, as a result of this action, he was hospitalized in a psychiatric ward only to be released not two weeks later.
[The significance of this shocking incident]
Despite its considerable economic might and sizable population, Japan was, until recently, a nation with an exceptionally low incidence of violent crimes, let alone murder. For me, my shock on hearing the news confirmed my erstwhile vague anxiety that the safety which we had taken so much for granted in this country may no longer be assured. After the incident, the press were rife with criticisms of the poor security measures in place at the facility; window glass can easily be shattered, commented one television panelist with a grave demeanor, hence they should be fitted with iron bars to prevent unlawful entry. I could scarcely believe my ears; if fitting the windows of a care facility with iron bars was the only way to guarantee the safety of its residents, what value would such safety have? In European and American cities, even high street shops lower metal shutters over their storefront at closing time to prevent burglaries during the night. Until recently, burglaries of this sort, which occur so frequently abroad, were virtually unknown here. Our society boasted an unrivaled degree of safety. But now, strong-arm robberies of jewelry shops and other businesses are on the rise, leading me to wonder if I am alone in feeling that the safety of our society is eroding little by little, that something that had until recently served as the basis of our safety is now crumbling away by degrees in places where we rarely, if ever, direct our gaze. Unless we seek out the causes that are undermining our safety and trust in society in order to implement drastic measures for their correction, rather than reflexively fitting windows with iron grating because of some perceived external threat, we will never so much as come close to a solution to this problem.
The fact that the victims were living in isolation from the rest of society coupled with the fact that the suspect had targeted these individuals precisely for who they were, has left me with feelings of disquiet, even of remorse, which I cannot explain away simply by my rage at this heinous act.
According to news reports, the suspect explained his motives in targeting severely disabled persons by claiming that he was “visited one day by Hitler’s thoughts.” As we all know, the Nazis had a policy of euthanizing countless persons with severe mental or physical disabilities in gas chambers. Yet Hitler alone did not decide this policy of extermination. People with high legal or psychiatric expertise abetted the formulation of this monstrous policy, which was able to be put into action thanks, above all, to the tacit assent of the majority of Germans. In Japan as well, the government, following the example set by the Nazis, created their own national eugenics program, which continued for a long time after the war had ended under the guise of the Eugenics Protection Law. While Japan also had a history of sterilizing the disabled, we thankfully never stooped to the barbarism of their mass extermination. Yet the diabolic voice that whispers, “Some lives don’t matter!” is emphatically not a symptom of psychiatric illness confined to those we would call abnormal—the same voice may whisper in our own minds if we relax our vigilance. What I found unnerving about the Sagamihara incident was that the suspect had not only brazenly owned up to these horrific thoughts and impulses, which we normally confine to the deepest recesses of our mind with the aid of reason, but had actually acted on them. Although I am a psychiatrist, I knew little about facilities that house persons with severe physical and mental disabilities. In fact, it had never occurred to me to learn about them. All my life, I had almost no interest in the lives of persons who are incapable of surviving in society on their own. This, despite the fact that I had more opportunities than people in other walks of life to ponder precisely such matters. This being the case, my own lack of concern for people with disabilities must share some fundamental similarities with the extremism of the suspect. This possibility frightens me greatly indeed. But am I alone in thinking this way? The temptation to say that this was an isolated incident, that the enforcement of corrective ‘treatments’ by the police and the psychiatric establishment will remove the danger for good—this is nothing but a reflex of the anxiety that this incident has provoked. Am I irrational in thinking that in the reactions of the press, the various, relevant organizations, and even the responses of the Ministry of Health, Labour and Welfare, there is an unconscious, backward-looking element that eschews engaging with reality?
Humanity’s naked desires are hardly pleasant to look upon when we shine the light of civilization—at any rate our own modern civilization–upon them.
Our genes, the evolutionary result of the pressure to survive competition, have fatefully linked us to an extremely egotistical principal of action. Unless we are able to discipline our primitive impulses through education, training, culture, reason, morals, and above all, our ceaseless efforts to achieve our higher ideals, conflict will forever abide in our society, and we will never be able to assure its weaker members safety and peace of mind.
Today in Japanese society, we are seeing more and more individuals publicly airing their discriminatory views not only on the disabled, but also on ethnic minorities and the poor. The rapid diffusion of anonymous means of communication, such as social networks, have emboldened people to spread their immature and crude opinions; these in turn have debased the minds of persons in receipt of these views such that we now live in a society where statements which one could not have uttered in public several years ago for profound shame are bandied about with perfect equanimity. Regulating hate speech with legal restrictions is not social progress, but a sign of social deterioration. Indeed, the multiplication of legal strictures on behavior may be said to be inversely related to the level of our social mores.
[What is involuntary hospitalization?]
Involuntary hospitalization is a policy of forcibly hospitalizing individuals with a psychiatric disability by the order of the governor. The description of the involuntary hospitalization policy, which states that patients may be subjected to involuntary hospitalization if they pose a “risk of harm to themselves or others,” may mislead one into thinking that this measure is intended to isolate psychiatric patients. The Mental Welfare Act distinguishes between hospitalization for medical protection (emergency hospitalization), in which a person may be admitted without giving his or her consent, and involuntary hospitalization. As a service, medical care is generally provided in accordance with the patient’s desire to be treated, and for this reason, we administer treatments as often as possible after obtaining the consent of the patient. However, in not a few psychiatric cases, patients deny being ill and refuse treatment. In such cases, when the required treatment cannot be administered due to the patients’ refusal to be treated, the patients are subjected to involuntary hospitalization if deemed to pose a significant risk to their own safety. However, compelling persons to be hospitalized without, or despite, their explicit consent, signifies a flagrant violation of their basic human rights, which are guaranteed under Japan’s constitution. For this reason, the due process of law is vital. In a nutshell, this describes what is meant by “hospitalization for medical protection” and “involuntary hospitalization.”
Hospitalization for medical protection is a system which enables the hospitalization of a person based on the consent of a designated psychiatrist and the person’s family when the individual in question is unwilling to give his or her consent to be hospitalized to receive the minimum necessary treatment. On the other hand, involuntary hospitalization is mandatory and based on orders issued by the governor of Tokyo. Compared with hospitalization for medical protection, this system restricts an individual’s basic human rights to a far greater degree. Moreover, the administration of the treatment constituting the grounds for involuntary hospitalization can be enforced by the governor’s orders regardless of the patient’s refusal. Even if the patients were to try to avoid treatment by blockading themselves in their own home, the physician would be authorized to enter their home with the help of the police to administer the required treatment. In other words, in contrast to hospitalization for medical protection, with which it shares the similarity of being enforceable regardless of the patient’s will, involuntary hospitalization represents a significant intrusion of the state’s power in the life of citizens. For this reason, its application is restricted to cases in which persons are deemed to pose a significant danger to themselves or others if left to their own devices and cannot be applied more broadly to persons with a psychiatric disability who merely require inpatient therapy. While there is no denying that the involuntary hospitalization policy was formulated with the public’s protection in mind, the stipulation that the persons in question be deemed to pose a significant risk not only to others but also to themselves aims to curtail the unbridled application of coercive inpatient treatments for psychiatric disorders.
[The Protection of Human Rights in Clinical Psychiatry]
For a psychiatrist, ensuring the protection of the patients’ human rights is so important as to be tantamount to being an integral facet of the treatment itself. However, protecting patients’ human rights is more easily said than done. When we consider the issue of coercive medical treatment as I have described it thus far, it should be clear that patients not only have the right to live freely (the right of individual liberty) but also have the right to receive the social support (social rights) they need to live a healthful and productive social life. Both of these rights are vital aspects of the basic human rights guaranteed under the Japanese constitution. In clinical practice, therefore, a correct balance must be struck between patients’ right to individual liberty and their social rights in accordance with the specific conditions of each case.
Moreover, patients clearly do not live in isolation in society; thus, respect for their individual liberties at times conflicts with the basic human rights of their neighbors. For instance, if a patient with schizophrenia who is in the habit of holding loud monologues in his or her apartment refuses hospitalization, he or she may infringe on the right of the other residents to live undisturbed. If the neighbors then decide to flee their predicament by moving, the landlord may stand to suffer from the loss of rental income. In the worst-case scenario, one might imagine a patient committing murder due to delusions of persecution, etc., with the result that an innocent individual will have lost his or her life as the price for protecting the patient’s right to individual liberty (of course the relevance of this scenario to the Sagamihara Incident depends entirely on determining whether the suspect’s actions stemmed from a psychiatric disorder). Striking the correct balance between the patients’ right to individual liberty with the human rights of those around them, or with the well-being of society as a whole, as the case may be, is more difficult than resolving the conflict between the patients’ dual claims to individual liberty and social rights.
When I was much younger, in my youthful ardor to protect the rights of patients, I frequently neglected those of the people around them. But turning the world against oneself and one’s charge is to declare an unwinnable fight—the fallout from which invariably comes to rest on the patient’s shoulders—and I realized in the end that I was only hurting the cause of my patients by fighting these battles out of some misguided need for self-satisfaction.
Many patients with a psychiatric disorder live in what is for us, an unimaginably harsh reality. After some 40 years of experience as a psychiatrist, I firmly believe that the function of the psychiatrist is to support patients’ efforts to lead a peaceful life in society while helping them to maintain the delicate balance in their relationship with family and neighbors.
[Responses to the Sagamihara Incident]
In response to this incident, the Ministry of Health, Labour and Welfare established a committee of psychiatric experts to assess the circumstances surrounding the involuntary hospitalization of the suspect and his subsequent release, as well as measures to prevent a recurrence of similar incidents.
It is important that we clarify the connection between the treatment that the suspect received through a careful review of his medical records before rushing to find fault with the system. Some of the contributory factors in this case may be acute organic mental disorder brought on by the use of illegal drugs containing hashish, chronic personality disorder caused by repeated drug use (such as loss of impulse control and personality changes), physical and psychological drug dependency or the presence of other psychiatric comorbidities—the list goes on—without the careful assessment of which, we cannot determine whether or not the involuntary hospitalization system functioned as it should in this case. The job of the Ministry’s expert committee is therefore of crucial importance.
I suspect that there will be no disagreement as to the importance of having in place a follow-up policy to monitor patients after they are released from involuntary hospitalization. While the Ministry appears to be considering a new policy with coercive force to guarantee the follow-up treatment of patients after they are discharged from involuntary hospitalization, our clinical experience following the enactment of the Revised Mental Health and Welfare Act in 2013 has shown that problems in the treatment of patients often arise before patients are discharged.
Involuntary hospitalization involves severely restricting the behavior of patients, and a hospital faces the prospect of serious civil liability should a patient manage to escape confinement and harm someone. For this reason, after a patient is discharged from involuntary hospitalization, a series of gradually less restrictive treatment measures, such as hospitalization for medical protection and voluntary hospitalization, are implemented to administer the treatments the patient needs to return to life in society. The passage of the Revised Mental Health and Welfare Act in 2013, however, prohibits hospitalization for medical protection if the patient’s family refuse. As a result, it has become difficult to discharge involuntarily hospitalized patients without family members who agree to cooperate actively in their treatment. In the past, the mayor of a municipality could approve a patient’s hospitalization in lieu of family members when the latter were not available for this purpose, but under the revised act, this is no longer possible even in cases where the patient does have family, if the family refuse their give their consent to hospitalization. In such cases, patients are required to endure extended involuntary hospitalization and suffer prolonged restrictions on their activities while the hospital, under the new restrictions imposed by the revised act, bears increased legal liability for any mishaps that may occur to the patients in its efforts to deliver the care they need to return to normal life in society. Clearly, the system needs to be revised so that the restrictions imposed on the human rights of patients can be gradually loosened to facilitate their rehabilitation and return to social life while guaranteeing the provision of continued outpatient treatment.
Reports following the incident raised the question of whether the patient had been released too soon and criticized the apparent lack of coordination between the hospital and the police. While the lack of an adequate follow-up policy is an issue worthy of serious consideration, the demand that patients’ discharge be communicated to the police or that local residents be informed of the fact as part of a new follow-up policy would distort the fundamental principals of the current involuntary hospitalization system and undermine the grand design of the Mental Health and Welfare Act.
The police cannot detain persons based merely on the suspicion that they might commit a crime. Nor can a psychiatrist determine the need for involuntary hospitalization based solely on ‘dangerous’ opinions uttered by a patient, even when the probability that the patient may act on his or her threats is high, unless the case can be made that this behavior stems from a psychiatric disorder.
The reason for this is that both situations have a direct bearing on citizens’ basic human rights. We all have to bear a certain amount of risk to ensure the protection of our liberty. At the same time, we must formulate policies carefully with an eye to containing risks within acceptable limits. It is indeed an issue that
potentially affects the basic human rights guaranteed under the Japanese constitution. “This incident is outrageous, we won’t put up with its likes again!” “Find out who’s responsible!” are some of the outcries heard from various quarters. But we mustn’t be swept up by our emotions into making hasty decisions.
The present incident is disturbing for reasons beyond the fact that it has incited anxiety and terror by its heinous and tragic nature because, I think, the words and actions of the suspect exposed to the clear light of day the selfsame ugliness that each of us harbors somewhere in his or her heart. It is easy and comforting to reduce the significance of the incident by ascribing it to the abnormal actions of an abnormal individual and then to believe that similar incidents can be prevented in the future through the application of coercive medical treatments and the exercise of police authority. The opinions prevailing in the mass media and the response of the government show a strong inclination towards this view. But this, to my mind, is mistaken.
Signs that our society is experiencing disruptive changes are everywhere to be seen. Moreover, these disruptions are evident not only in Japan, but also among the developed nations of the west. In the results of the US republican presidential nomination, the vote on the Brexit referendum, and the rise of right-wing populist movements in Europe, one sees the emergence of individuals proclaiming loudly, and with perfect equanimity, downright embarrassing and shameful views that one would never have imagined possible from opinion leaders vested with the duty of leading the world, who rise to power by exploiting the discontent of the masses.
Faced with a string of terrorist attacks, the French government resolved to extend its period of martial law, with the public scarcely demurring. Under marital law, the police and security forces can now enter the homes of ordinary persons without a warrant and invade the privacy of those suspected of being terrorists, in some cases placing them under arrest. Amid the continuing threat of indiscriminate terrorism, any insistence on the need to defend the civic rights of citizens is quickly drowned out by the outcry of the masses, “What about the rights of the many who have become the victims of terror!” In Japan as well, if cases of mass-murder continue, fewer people will object to measures aimed at preventing their occurrence. Be that as it may, there is no argument that can validate a policy which aggrandizes the surveillance powers of the police, subjects individuals to coercive hospitalization or allows the untrammeled restriction of the liberty of individuals
Surely, what we must consider in the aftermath of this horrific incident is not ways to increase the state’s powers to surveil private individuals. We mustn’t be swept along by our emotional responses to the incident to create a less free society; we must instead reflect on what our society has lost and create new values that will allow us to regain our erstwhile security while keeping the coercive intrusion of state powers into our life to a minimum. To this end, we must all, I believe, reflect seriously once more on what sort of society, what sort of nation, indeed what sort of world we would like to build.