The ethics of forensic psychiatry

PURPOSE OF REVIEW: Forensic psychiatrists find themselves at the crossroads of disparate ethical demands stemming from their basic identification as physicians versus obligations of their professional activities that often involve working for third parties and upholding the principles of law. Ethical demands in law may collide with those of the ethics of medicine. RECENT FINDINGS: This review focuses on theoretical articles in which the two ethical paradigms impacting the forensic practice are discussed. In addition, this review includes some articles that bring new insights into old problems such as coercion and articles dealing with an emerging controversy, the use of medical information or medical personnel in interrogations. SUMMARY: The controversy on the two paradigms under which forensic psychiatrists operate has not been exhausted; no definite position has been advanced about the virtues of one over the other or how best to reconcile the two. Old issues such as coercion remain topics of concern and new areas of debate such as intelligence interrogations, which eventually will have an impact on forensic psychiatry, are now starting to permeate the ethical discourse.     

Einwilligungsfähigkeit als relationales Modell Klinische Praxis und medizinethische Analyse

The doctrine of informed consent has become a legal and ethical standard in psychiatry today. However, ethical problems arise if patients lose the capacity to give informed consent due to their psychiatric disorders. Particularly in the field of psychiatry, the assessment of competence of informed consent to medical treatment and participation in clinical trials is a controversial issue. New empirical data suggest that a high percentage of psychiatric patients are incompetent according to defined standards for assessing their capacity to make treatment decisions. Assessing competence according to a sliding scale integrates the ethical principles of autonomy and beneficence and provides help in assessing competence in clinical practice.     

Ethical issues in psychiatric research on children and adolescents

Psychiatric research on children and adolescents is ethically justified by the need to reduce the burden that mental illnesses place on young people, their families, and society. Such research must be conducted with careful attention to the ethical principles of beneficence, justice, and respect for persons. Child and adolescent psychiatrists who collaborate on research trials or advise patients and families about research participation should consider nine domains when evaluating the ethical acceptability of particular protocols. These domains include scientific merit and design; expertise, commitment, and integrity; risks and benefits; confidentiality; participant selection and recruitment; informed consent and decisional capacity; incentives; institution and peer/professional review; and data presentation. Special ethical issues in child and adolescent psychiatry research concern the use of randomized, controlled treatment trials; the informed consent process for research involving adolescents; the therapeutic misconception; and conflicts of interest in physician referrals.     

Ethical principles governing research in child and adolescent psychiatry.

This paper examines the ethical principles governing research in child and adolescent psychiatry. The guidelines for protection of children and adolescents are research subjects are discussed. These include the principle of nonmaleficence and beneficence (the risk-benefit ratio), the principle of autonomy (informed consent and confidentiality), and the principle of justice (fair distribution of benefits and burdens of research). In the light of recent national efforts to help promote responsible research practice, the ethical standards relating to the protection of scientific integrity as well as research advocacy, training, and stewardship are also discussed.     

Les principes éthiques de l’électroconvulsivotherapie

ECT or electroconvulsive therapy (ECT) is a therapeutic technique invented in 1935 but which was really developed after World War II and then spreading widely until the mid 1960s. The source of this technique, and some forms of stigma including films, have participated widely to make it suspect from a moral point of view. The ethical principles that support the establishment of a treatment by ECT are those relating to any action in psychiatry and are based on the one hand on the founding principles of bioethics: autonomy, beneficence, non-malfeasance, and justice, and on the other hand on the information on the technical and consent to this type of care.     

Ethics in child and adolescent forensic psychiatry

Ethical concerns are ever present in the practice of all branches of psychiatry. They are likely to be more acute and commonplace in the practice of child and adolescent psychiatry because of the complication introduced by the immaturity of the patient. Children, depending on their age and developmental stage, may be incapable of giving meaningful consent, and situations in which breaking confidentiality must be considered arise more often. The field of forensic psychiatry is fundamentally different from clinical psychiatry because of the universal involvement of third parties and because interactions with evaluees do not occur within the context of a doctor patient relationship. Arguably, these conditions compel the forensic psychiatrist to function as a double agent. According to Appelbaum, an influential psychiatric ethicist, forensic practice calls for a different set of ethical guidelines that, while humane, do not either imply or derive from the existence of a doctor patient relationship. Others argue that a mix of forensic and clinical ethics is more appropriate. New developments in psychiatry, including the use of the Internet for E-mail and telepsychiatry, require continuing vigilance by the profession so that ethical standards can evolve to cover new circumstances at the frontiers of psychiatric practice.     

Position and role of forensic psychiatry in integrative psychiatry

The integrative approach to psychiatry has gained more importance in recent years. Is it justified or not, does it improve theory or practice, those are only some of the questions to which we are looking for answers, but in this paper we shall underline the necessity of enrolling forensic psychiatry into integrative, modern psychiatry. The reason and the motive for that integration is the fact that nowadays the content and the activities of contemporary forensic psychiatrists are totally reduced to executing the tasks given by courts. It is therefore entirely right to say that current forensic psychiatry finds itself in the passive role of executing orders of the court. Our aim is to point out how important it is that forensic psychiatry becomes an interdisciplinary profession in interaction with psychiatry but also with other medical branches just as with judiciary, educational institutions, moral-ethical institutions and religious institutions in producing preventive programmes and by participating in individual decision making process likewise. Our primary goal is to present the status and the position of contemporary forensic psychiatry and to specify the necessary improvements and its place in integrative psychiatry. It should be better, more meaningful and more ethical, both for the individual and the society in total. We want forensic psychiatry to include a protective and therapeutic role for each individual forensic examinee, i.e. a person who has already been in forensic examination and for whom one evaluates mental competence because of a mental disorder. We also want it to get a far larger and more active general role in society in terms of preventing criminal acts among the mentally ill and in society in total.     

Ethics in forensic psychiatry publishing

Several organizations have developed guidelines to help authors and editors of medical journals negotiate ethics dilemmas in publishing, but very little is known about how these guidelines translate to the context of forensic psychiatry. In this article, we explore the important topic of ethics in forensic psychiatry publishing. First, we review the historical development of ethics principles in medical and psychiatric publishing. We then analyze eight ethics dilemmas that have arisen in the publication of The Journal of the American Academy of Psychiatry and the Law (The Journal) from 2000 to 2009, including disputes about authorship, conflict of interest, redundant publication, bias in peer reviewers, confidentiality in case reports, and others. We identify ethics principles that were relevant to the dilemmas and discuss how they were resolved by the editors of The Journal. We conclude by using the principles identified in the practical resolution of ethics dilemmas to derive a conceptual foundation for ethics in forensic psychiatry publishing.     

Forensic psychiatry in the USA and the UK: a clinician's view

The UK and the USA share a fundamental belief in the rule of law, but they have different beliefs about the relationship between government and the individual. The laws which govern forensic and general psychiatric practice reflect those differences. The two countries differ also in forensic psychiatry training and practice and in the organisation of forensic mental health services. Strengths in the UK include the extensive training of forensic psychiatrists and the integrated forensic health and social care systems. The two countries face common ethical problems, and common problems of service delivery to forensic patients. Copyright © 1996 Whurr Publishers Ltd.     

Ethics and forensic psychiatry.

This article has attempted to outline some of the important ethical issues faced by the psychiatrist in the forensic role. Much of forensic psychiatry is practiced by general psychiatrists without specific forensic training who must thereby familiarize themselves with the problem areas likely to be encountered in this work. They should also be knowledgeable about the ethics guidelines prepared by forensic psychology and forensic psychiatry organizations that are subject to frequent modification. Ethical problems often occur when psychiatrists exceed their expertise, their role as contracted, or the actual facts in the case. Psychiatric experts usually represent just a small part of most litigation, and an attitude of humility rather than grandiosity is appropriate. Expert witnesses serve as educators rather than decision makers in the case [21]. Given the complexity and uncertainty of medical decision making generally, whether in clinical or forensic medicine, forensic psychiatric opinions should be appropriately qualified by their limitations, acknowledged affirmatively rather than only on cross-examination. Expert witnesses commonly take an oath to "tell the truth, the whole truth." Forensic psychiatrists are not experts in moral matters and should not be rendering moral judgments or misusing their authority as psychiatrists to advance their own political or social ideology [19]. Testimony should be based on data and theory generally accepted in the profession, recognizing that there will always be minority views. Psychiatrists, however, should not be testifying based upon idiosyncratic views unsupported by at least a respectable minority of the profession. As in clinical psychiatry, complex or challenging forensic cases often require consultation from a knowledgeable colleague.     

Commentary: Mapping a changing landscape in the ethics of forensic psychiatry

In 1984, Alan Stone, writing in the Bulletin of the American Academy of Psychiatry and the Law, stated that "forensic psychiatrists are without any clear guidelines as to what is proper and ethical," adding that because of the nature of psychiatry and the realities of the law, no such guidelines can be drawn. Put starkly, his conclusion was that the practice of forensic psychiatry is fundamentally unethical. In the same issue, several contemporary commentators criticized his position, arguing that he misunderstood the social context of forensic psychiatry and that, in any case, he was wrong to say that ethics standards did not exist. In this article, these questions are reviewed again, starting from the principle articulated by the philosopher, A. J. Ayer, that that there is no such thing as an ethical fact.     

General principles of forensic report writing

OBJECTIVE: The aim of this paper is to provide an update of principles of forensic report writing, to guide and assist registrars, junior consultants and psychiatrists considering working within the forensic arena. METHOD: The literature was reviewed for information on principles of report writing from a variety of jurisdictions. Additionally, literature on medical ethics was examined. RESULT: Writing reports is a professional activity that most psychiatrists undertake at some point in their careers. The report represents the psychiatrist's professional opinion. It is important that information is accurate, relevant and ethical. In writing medico-legal reports, psychiatry deviates from traditional medical ethics. CONCLUSION: It is important that psychiatrists who write reports have a good understanding of the process and behave ethically and competently.     

Criteria for involuntary hospitalisation.

OBJECTIVE: The aim of this paper is to provide an overview of the ethical bases of compulsory commitment legislation. METHOD: The ethical principles of beneficence and autonomy are examined and used to identify criteria for the commitment of mentally ill patients. RESULTS: Two aspects of beneficence, medical paternalism and social paternalism, are discussed. It is argued that social paternalism is insufficient ethically to warrant involuntary admission, and that the basis for compulsory hospitalisation is medical paternalism. CONCLUSION: The central role of autonomy in medical ethics suggests a patient should have a diminished capacity for autonomous decision-making and a potential to benefit from hospitalisation, as well as a risk of harm to self (including self-neglect) to warrant committal. In specific circumstances, the risk of harm to others may also justify committal. These ethical principles may be at odds with public attitudes.     

Medical ethics in neurology and neurosurgery

The author presents several basic concepts in contemporary medical ethics. Much of the discussion centers on self-determination and beneficence, two basic but sometimes opposed ethical principles in neurology and neurosurgery. These are applied to decision-making in competent and incompetent patients, using living-will legislation and recent legal decisions about withholding treatment as examples. The Baby Doe case is discussed in detail to demonstrate the importance of medical ethics in contemporary medical practice.     

Howard Zonana and the transformation of forensic psychiatry

In recognition of Howard Zonana's contributions, I take stock of the progress of the field of forensic psychiatry over three decades. As forensic psychiatrists, you are the voice of psychiatry in the law and the interpreter of law to your colleagues in psychiatry. I offer provisional impressions of your collective accomplishments under three themes: expertise, influence, and integrity. First, you have established and nurtured the expertise and authority of forensic psychiatry, which has become increasingly evidence-based and reflects a prudent sense of humility. Second, you have had a significant influence on the design and daily application of mental health law in both criminal and civil spheres. Through the American Academy of Psychiatry and the Law (AAPL) and relevant components of the American Psychological Association, you have been a strong and effective advocate for protecting both the needs and rights of people with mental illness and have had demonstrable influence in the Supreme Court as well as at the grassroots. Finally, you have nurtured and protected the ethical integrity of the profession in the face of ever-increasing challenges, due in no small measure to the habits of ethical reflection that Howard Zonana has modeled and taught over the course of his extraordinary career.     

Many faces of the dual-role dilemma in psychiatric ethics

OBJECTIVE: To identify the various potential manifestations of the dual-role dilemma in the psychiatric ethics literature. METHOD: The terms 'dual role', 'dual agency', 'overlapping roles', and 'double agency' were searched on the electronic databases PubMed, Medline, Embase and PsychInfo. Classic papers in the field of psychiatric ethics and their references were manually searched. Papers were selected for relevance to the topic of the dual-role dilemma in relation to psychiatry. RESULTS: The dual-role dilemma is most explicitly addressed in the literature on forensic psychiatry and military psychiatry. Review of the ethics literature in other fields of psychiatry indicates many instances of the dilemma of psychiatrists facing conflicting obligations akin to the dual-role problem identified in the literature on forensic psychiatry. Many of these dilemmas are characterized by the presence of a powerful third party to whom the psychiatrist has some perceived obligations. CONCLUSIONS: In psychiatric ethics, the dual-role dilemma refers to the tension between psychiatrists' obligations of beneficence towards their patients, and conflicting obligations to the community, third parties, other health-care workers, or the pursuit of knowledge in the field. These conflicting obligations transcend a conflict of interest in that the expectations of the psychiatrist, other than the patient's best interests, are so compelling. This tension illustrates how the discourse in psychiatric ethics is embedded in the social and cultural context of the situations encountered. It appears that as society changes in its approach to the value of liberal autonomy and the 'collective good', psychiatrists may also need to change.     

Ethics of medical records and professional communications

In child and adolescent psychiatry, medical records and professional communications raise important ethical concerns for the treating or consulting clinician. Although a distinction may be drawn between internal records (eg, medical records and psychotherapy notes) and external communications (eg, consultation reports and correspondence with pediatricians), several ethical principles apply to both types of documentation; however, specific considerations may vary, depending upon the context in which the records or communications were produced. Special care is due with regard to thoroughness and honesty, collaboration and cooperation, autonomy and dignity of the patient, confidentiality of the patient and family members, maintaining objectivity and neutrality, electronic communications media, and professional activities (eg, political advocacy). This article reviews relevant ethical concerns for child and adolescent psychiatrists with respect to medical records and professional communications, drawing heavily from forensic and legal sources, and offers additional recommendations for further reading for clarification and direction on ethical dilemmas.     

Knowing and practicing ethics.

The interrelationship between ethics and child and adolescent psychiatry is discussed, particularly as it relates to clinical practice. Three principles for ethical clinical practice are presented from a philosophical perspective and illustrated with two case vignettes. A formulation is reached that states that ethical theory parallels clinical theory.     

PEG-Ernährung bei fortgeschrittener Demenz

Lacking clear empirical evidence and ethical obligations, decision-making about tube-feeding in patients with advanced dementia often presents as a difficult problem in clinical routine. Based on the principles of beneficence, non-maleficence and autonomy, an ethical analysis of the empirical evidence shows that tube-feeding should be avoided in many patients with advanced dementia: Recent studies demonstrate (1) that there is no proof of any benefit, (2) that tube-feeding often results in further harm to the dementia patient and (3) that the patient's will is not sufficiently taken into consideration. A practical model for interdisciplinary decision-making can account for these various difficulties and might improve the empirically and ethically highly complex process of decision-making about tube feeding in patients with advanced dementia.     

Ethics and involuntary treatment

This article reviews the ethical issues related to involuntary psychiatric treatment. These include the conflicts between the principles of beneficence, autonomy and nonmaleficence with regard to involuntary treatment for the patients' interests versus those of society. Moral problems often revert to disagreements about the patient's decision-making autonomy and the risk-benefit analysis of the proposed treatment.