Wyatt v. Stickney: a consent decree

On September 22, 1986, Judge Myron Thompson issued a consent decree in the Wyatt v. Stickney litigation. The settlement occurred 14 years after Judge Frank M. Johnson, Jr. rendered his landmark decision in this case. The consent decree included termination of the court's active supervision of the state's mental health system, termination of the receivership, and termination of the court monitor's powers. The state agreed to adhere to Wyatt standards, maintain Title XIX accreditation, continue deinstitutionalization efforts, and develop an internal advocacy and quality assurance program. Mechanisms are also to be put in place to apprise the plaintiffs' attorneys of progress in these efforts.     

Mercy killing without consent. Historical comments on a controversial issue

In recent discussions on euthanasia the question about mercy killing without consent of mentally ill persons has turned up, particularly in cases of hopeless suffering among senile or chronically insane patients. Possible analogies to the actions under the German Naziregimen and relations to the concept of Social Darwinism with suggestions about active eugenic control as propagated in the early part of this century are outlined in a historical review. The implications and obvious dangers of misuse of any such kind of active euthanasia in psychiatry are discussed on this background.     

The use of aversive stimuli in treatment: the issue of consent*

ABSTRACT. It has been argued that, in the consideration ofthe use of aversive stimuli in treatment, the issues are ideological and philosophical as well as technical. Adopting Homer's (1990) definition of what is meant by‘aversive’in the ideological debate, it is suggested that the crucial issue is the inability of making clients to give their informed consent. It is proposed that proxy consent might be an alternative, but that this would be unacceptable if aversive procedures could be shown to be never'm the best interests ofthe client, or shown to violate clients’rights or to be against the interests of society because of anticipated harm or injustice to others. It is concluded that it is difficult to be certain that it is ever in the best interests ofthe client for aversive procedures to be employed, that aversive interventions appear not to violate clients’rights necessarily (except possibly the right to dignity and respect while the intervention is operating, and perhaps the right to choice at the beginning of the intervention), but that the inescapable difficulty in the use of aversive interventions is the likelihood that they will be misused with other clients than the ones for whom they may be initially designed.     

Brewster v Dukakis: developing community services through use of a consent decree

Filed against the state of Massachusetts in 1977, Brewster v Dukakis involved the claim that psychiatric patients living in state hospitals or at risk of being hospitalized in these facilities have a right to treatment in community settings. The decree that emanated from the suit resulted over a 5-year period in a tenfold increase in state expenditures for community mental health services, a 48% decline in the state hospital census, and a 15% drop in the state hospital admission rate in the region of the state targeted by the suit. Factors that facilitated this outcome are described, as well as the dangers and limitations of exclusive reliance on the judicial process to promote the development of community services.     

Informed consent: special problems for psychiatry.

There is a growing demand for more patient autonomy in the doctor-patient relationship, and legal reformers believe that an expanded dodctrine of informed consent is the key to change. Informed consent is meant to force the doctor to give the patient the knowledge that will make his an equal bargaining partner. However, most evidence demonstrates that the majority of patients do not comprehend or retain medical information. Further, the legal doctrine of informed consent has never been coherently worked out. Informed consent in psychiatry is particularly complicated, because of the constitutional implications of right-to-refuse-treatment litigation and because patients may be incompetent to give informed consent as a result of their illness. One of the special problems for psychiatry is that complex consent requirements have been mandated by those who oppose certain somatic therapies. The author discusses the implications of these legal developments. He lists the kinds of informed-consent and refusal-to-consent situatons psychiatrists face and comments briefly on the most troublesome.     

Wyatt v. Stickney: assessing the impact in Alabama.

In 1971 U.S. District Judge Frank M. Johnson, Jr., ruled that patients involuntarily committed to Alabama mental institutions have a constitutional right to treatment. The following year he issued a court order containing 35 minimum constitutional standards for adequate treatment of the mentally ill and appointed human rights committees at the institutions to oversee their implementation. Focusing primarily on Bryce Hospital in Tuscaloosa, the author examines the extent to which compliance with the standards has been achieved, problems that have arisen in implementing the standards, and issues that still must be dealt with. He briefly discusses changes in the state's mental health system that preceded the filing of the case, and he emphasizes that those changes may have contributed significantly to the improvements that have occurred in mental health care in Alabama after Wyatt.     

Informed consent and adolescents.

OBJECTIVE: To explore the doctrine of informed consent and the development of capacity in adolescents with psychiatric problems to help clinicians better reflect on the relevant ethical issues. METHOD: We discuss the relevant literature and explore the role of psychiatric impairment in adolescents' ability to consent. RESULTS: In common law, there is no minimum age at which individuals are able to consent to medical treatment and no age below which they are unable to consent. Adolescents' right to self-determination is based on their ability to understand and appreciate the information relevant to the medical decision and on their ability to consent voluntarily and freely. There is a consensus in the literature that, around age 14 years, adolescents have the cognitive ability to understand information necessary for consent. However, there are limited empirical data regarding adolescents' ability to appreciate the information and to make a voluntary decision. CONCLUSION: Clinicians need to involve adolescents in the consent process to the extent possible and assess the elements of capacity to consent to treatment on an individual case basis, recognizing that capacity may evolve as adolescents' cognitive capacities and values mature.     

Informed consent without bureaucracy.

A comparison is drawn between informed consent in medicine and consenting practices in other areas of human activity, and an underlying conceptual unity is detected in all of these consenting practices. We insist on obtaining consent, in medicine and elsewhere, because of the value we place on personal autonomy. The conceptual unity of informed consent and consenting practices outside of medicine is defended against a series of objections. On the basis of the comparison with consenting practices in other areas of human activity, it is argued that bureaucratic informed consent processes in medicine are both unnecessary and unwarranted.     

Polygraphy revisited: U.S. v. Scheffer

U.S. v. Scheffer is a case that poses two questions. First, must a defendant who wishes to place polygraphic evidence before the court be allowed to do so for fear that refusal will create a Constitutional issue by depriving him of due process? Second, is polygraphic evidence admissible evidence at all, as defined by the Military Rule of Evidence or the Federal Rules of Evidence? The case, originally tried in Court-Martial, was reviewed by two military courts of appeal, with resulting judicial dissention leading to the granting of certiorari by the U.S. Supreme Court. In its decision, the Supreme Court affirmed the refusal of the Court-Martial to admit the requested polygraphic evidence.     

Psychiatrists' documentation of informed consent: a representative survey.

OBJECTIVE: To review psychiatrists' documentation of informed consent and present data on Canadian psychiatrists' attitudes and practices regarding documentation of the informed consent process. METHOD: We surveyed a stratified random sample of psychiatrists practising in Ontario, using a mailed self-report questionnaire. RESULTS: The response rate was 72%. Among respondents, 63% routinely documented the consent process, with younger respondents reporting more documentation than older ones. Although most respondents (77%) favoured recording the consent process, only 11% felt signed consent forms were necessary. CONCLUSION: There are differences in the self-reported documentation behaviour of younger and older psychiatrists. Psychiatrists should document the consent process in the clinical record.