The Crime We Diagnose
The Murder of Iryna and the Medicalization of Violence
As a husband, father, and citizen, I am horrified by the brutal murder of Iryna Zaruska. As an ER physician, I am not surprised. She was killed by Decarlos Brown, an unstable, violent schizophrenic of the type I and other ER doctors see daily. Her murder is only the most recent instance of a pattern so familiar in emergency departments across the country that it is now regarded as routine. Brown had been arrested fourteen times before this killing. I would wager, from my own professional experience, that this number does not capture the full scope of his encounters with law enforcement. When a man like Brown erupts in public, whether through drug-fueled aggression, incoherent shouting, or physical violence, police are often able to sidestep the responsibility of prosecuting him by reclassifying the behavior as a medical problem. In these moments, the jail becomes the hospital, and the criminal becomes the “patient.”
Police often bring them to me not because they require medical treatment, but because the hospital is the easier option. The police do not admit this openly, but it is standard practice. Officers often present detainees with the choice: jail or hospital. Most choose the latter, as the hospital means a warm bed, food, and no charges. The police can then claim they acted responsibly while circumventing the work of charging and prosecuting crime. To the police, the hospital removes a difficult case from the criminal justice system and hands it to doctors who have no real authority to deal with it. It’s a bureaucratic shell game: violence is reframed as psychiatric pathology, and medicine becomes the release valve for a justice system unwilling or unable to address the scope of violent disorder in our cities.
Once the individual arrives in the emergency department, the responsibility shifts to me, but my powers are circumscribed. I cannot protect the public from men like Decarlos Brown. At most, I could sedate him with haloperidol and lorazepam, then file a writ of detention that holds him in the psychiatric ward for seventy-two hours. After three days, unless he has made a specific, imminent threat against a named person, he walks free. Multiple laws prevent me from warning his neighbors, his coworkers, or the broader public. I cannot place him in long-term care. I cannot protect society from his next outburst. If law enforcement chooses to consider his violence to be medical rather than criminal, nothing durable can be done about it under our current healthcare framework.
It wasn’t always this way. In the middle of the twentieth century, America confined vast numbers of mentally ill and violent individuals in state hospitals. Many of these institutions were perceived by the public, not unjustifiably, as overcrowded and abusive. The push for “deinstitutionalization” in the 1960s promised a more humane alternative: close the asylums, discharge the patients, and build a network of community mental health centers to treat them voluntarily and outside of confinement.1 The Kennedy administration poured federal money into this vision with the 1963 Community Mental Health Act.2 The facilities were never built in sufficient numbers, and the state hospitals closed anyway. Moreover, the plan for voluntary outpatient treatment requires cooperation and active participation on the part of the patient, a totally unrealistic prerequisite which doomed the plan to failure. Predictably, when the asylums closed, the seriously mentally ill did not seek and adhere to outpatient treatment but instead wound up on the streets, in jails, or in ERs.
The collapse of the asylum system was compounded by legal changes that made long-term confinement nearly impossible. California’s 1967 Lanterman-Petris-Short Act, later imitated by other states, sharply limited the grounds for involuntary commitment.3 The 1975 Supreme Court case O’Connor v. Donaldson further cemented the idea that mental illness alone was not sufficient to justify confinement without proof of imminent danger.4 Civil liberties were elevated over public safety. By the 1980s and 1990s, inpatient psychiatric capacity across the country had been reduced by hundreds of thousands of beds.5
At the same time, laws intended to safeguard privacy built walls between doctors, law enforcement, and the public. HIPAA, passed in 1996, makes it illegal for me to warn a community that a violent man has been released from my care, unless he has made a specific and credible threat against a named individual.6 The Tarasoff ruling created a narrow “duty to warn” in such circumstances, but it does not allow me to disclose general dangerousness.7 Thus the public is left unprotected until the violence is carried out.
Criminal behavior and mental illness are not the same thing, though our society increasingly treats them as interchangeable. Much of modern crime strikes law-abiding citizens as irrational. We can all understand a starving man stealing food. That is a rational if immoral choice. But we cannot understand rape, child molestation, or the random murder of a stranger on a train. These actions appear so monstrous that we cannot imagine choosing them ourselves. Yet our inability to empathize with such choices does not mean that those who commit them are stripped of agency or responsibility. A choice can be incomprehensible to us and still be a choice.
Today’s framework, however, draws the opposite conclusion. It assumes that if someone commits an act so heinous that no sane person could imagine it, then the act itself becomes prima facie evidence of insanity. These are not things that a sane person would do, therefore the person who did them is insane, and therefore they are not responsible for doing the horrible things that they did. The criminal is no longer viewed as a perpetrator but as a patient. His violence is proof not of moral guilt but of medical pathology. Even more perverse, the murderer is not only a patient but also a victim himself, deserving not punishment but compassion for the mental illness from which he suffers. This is the intellectual sleight of hand that allows rape, murder, and predation to be diverted from prison cells into hospital beds. But under this framework, how are we to ever punish the worst crimes, the ones so brutal and monstrous that they are beyond our understanding?
The incoherence becomes even clearer in cases like Brown’s, where there is genuine severe mental illness. If he was so psychotic, so enslaved to delusion that he lacked the ability to choose at all, then why is he afforded the same civil liberties as any other citizen? What does it mean to say that someone has rights? Rights presuppose responsibility. For freedom to mean anything at all, one must be able to exercise free will, which means responsibility for the actions one freely chooses.
To say that a man has freedom is to say that he has agency, and if he has agency, then he is culpable for how he uses it. Conversely, if he has no agency, if he cannot meaningfully choose, then he cannot meaningfully possess rights. If men like Decarlos Brown are so mentally ill that they do not actually have free will and are not capable of making choices in any meaningful sense, then what does it even mean to say that they have rights? To grant him freedom on the basis of his rights while simultaneously absolving him of responsibility because of his illness is a contradiction.
We must choose one path or the other. Either men like Brown are responsible agents who can be punished for their choices, or they are incapable of choice and must be confined for the protection of society. Prison or asylum. What we cannot do is pretend both are true, absolving them of guilt while granting them liberty. That is the incoherent middle ground in which we now live, and it is why innocent people like Iryna Zaruska are left to pay the price.
The cumulative effect is exactly what we see today: the revolving door of brief hospitalizations, discharges, re-arrests, and returns to the ER. Violent men like Brown cycle endlessly through hospitals and jails without ever being removed from society in any enduring way. The police treat medicine as a pressure valve. The courts insist on ever-narrower criteria for involuntary treatment. Doctors like me are left to bear responsibility without authority, expected to manage threats we cannot contain.
It is ritual theater in which everyone pretends that violent behavior is a medical diagnosis, when in fact it is a moral and legal problem. Psychiatry cannot rehabilitate every dangerous man. Many of these individuals are not curable in any meaningful sense. What society requires is not another prescription for antipsychotics and a packet of discharge instructions, but rather the long-term separation of chronically violent individuals from the public. If that separation is to occur in a prison or in a psychiatric hospital is a political question, but one thing is clear: the current system of brief involuntary holds, followed by release into the same neighborhoods, guarantees more victims like Zaruska.
Doctors cannot be both healers and jailers. If we insist on continuing down this path, where violent crime is recast as a medical disorder but physicians are denied the tools to prevent recurrence, then tragedies like this will proliferate. If Brown had been imprisoned for his prior crimes or committed to a psychiatric facility for his psychosis—if either coherent path had been followed—Iryna Zaruska would still be alive.
What we call compassion for men like Brown is, in truth, cruelty toward their victims. To spare him prison or asylum is to extend mercy to the murderer while abandoning the innocent. A good shepherd does not abandon his sheep out of compassion for the wolf. Nor is it truly compassionate toward Brown himself. If he has agency, divorcing choices from consequences deprives him of the structure that might restrain his worst impulses. If he has no agency, then leaving him free is only to abandon him as a slave to his psychosis, hastening his self-destruction. In either case, what we call compassion is merely neglect disguised as mercy.
But even this gets the order of things wrong. Compassion belongs to medicine, and justice belongs to law. The doctor must show compassion to the individual patient before him, while law enforcement and the courts must secure justice for the victim. When crime is reclassified as disease, we strip violence of its moral dimension and remove it from the sphere of justice. We isolate the perpetrator from the harm he has done to others and treat him only as an individual case of pathology, and we abandon the pursuit of justice altogether.
Compassion without justice is not compassion, and a society that confuses the two will end with neither.
Deinstitutionalization in the United States. Wikipedia. Updated July 13, 2024. Accessed September 10, 2025. https://en.wikipedia.org/wiki/Deinstitutionalization_in_the_United_States
Community Mental Health Act. Wikipedia. Updated July 24, 2024. Accessed September 10, 2025. https://en.wikipedia.org/wiki/Community_Mental_Health_Act
Lanterman–Petris–Short Act. Wikipedia. Updated August 21, 2024. Accessed September 10, 2025. https://en.wikipedia.org/wiki/Lanterman%E2%80%93Petris%E2%80%93Short_Act
O’Connor v Donaldson, 422 US 563 (1975). https://en.wikipedia.org/wiki/O%27Connor_v._Donaldson
Torrey EF, Entsminger K, Geller J, Stanley J, Jaffe DJ. The Shortage of Public Hospital Beds for Mentally Ill Persons. Treatment Advocacy Center; 2008. Accessed September 10, 2025.
https://tac.nonprofitsoapbox.com/storage/documents/the_shortage_of_publichospital_beds.pdf
American Psychiatric Association; Treatment Advocacy Center. Better data for better mental health services. Issues in Science and Technology. Published December 4, 2017. Accessed September 10, 2025.
https://issues.org/better-data-for-better-mental-health-services
Health Insurance Portability and Accountability Act. Wikipedia. Updated September 5, 2025. Accessed September 10, 2025. https://en.wikipedia.org/wiki/Health_Insurance_Portability_and_Accountability_Act
Tarasoff v Regents of the University of California, 17 Cal 3d 425, 551 P2d 334 (Cal 1976). https://en.wikipedia.org/wiki/Tarasoff_v._Regents_of_the_University_of_California