Sex on the wards: Conundra for clinicians.

Should psychiatric inpatients be allowed to engage in sexual activities? Do clinicians have a right to prevent them from doing so? If so, when may sexual interaction be restricted? What sorts of clinical issues and problems are posed for nursing staff, and how should psychiatrists and administrators respond to these? These and related questions have received little attention from either medical or legal scholars, in sharp contrast to the extensive analysis devoted to other issues affecting the lives of psychiatric inpatients, and in especially sharp contrast to our culture's inundation with media messages about sex. This article summarizes the modest body of scholarship concerning sexual interactions among hospitalized patients, the clinical and administrative questions faced by psychiatrists who work with inpatients, and the potential medicolegal problems that inpatients' sexual activities can create. It concludes with a conceptual framework that clinicians can use to devise solutions to the problems arising from inpatients' sexuality.

Myths, realities, and the political world: the anthropology of insanity defense attitudes.

The author presents the case that society's efforts to understand the insanity defense and insanity-pleading defendants are doomed to intellectual, moral, and political gridlock unless we are willing to take a fresh look at the doctrine through a series of filters-empirical research, scientific discovery, moral philosophy, cognitive and moral psychology, and sociology-in an effort to confront the single most important (but rarely asked) question: why do we feel the way we do about "these people" (insanity pleaders)? He examines this question finally through a model of structural anthropology and concludes that until we come to grips with the extent to which ours is a "culture of punishment," we can make no headway in solving the insanity defense dilemma.

Therapeutic jurisprudence and the civil rights of institutionalized mentally disabled persons: hopeless oxymoron or path to redemption?

This article examines, from a therapeutic jurisprudence (TJ) perspective, the rights of institutionalized mentally disabled persons to determine whether TJ is compatible with positions advancing civil rights and liberties, and whether lawyers for such individuals should look more closely to TJ as a source of rights. It concludes (a) that despite harsh criticisms of mental disability law reform, most of the important decisions in the areas of involuntary civil commitment, right to treatment, and right to refuse treatment law have a strong TJ component and (b) that TJ analyses may be the appropriate tool to reinvigorate this area of mental disability law.

Law and the delivery of mental health services in the community.

Little attention has been paid to the question of the right of the mentally disabled to voluntary mental health services in community settings. This article examines the case law, the social context in which the important cases arose, the expected impact of the recent passage of the Americans With Disabilities Act, and the applications of therapeutic jurisprudence principles to the underlying questions.

Psychiatry and the homeless mentally ill: a reply to Dr. Lamb.

Homeless mentally ill persons are highly visible subjects of ongoing public discussion and potent symbols of a host of contemporary social problems. They present psychiatry with a scientific challenge that calls for further elucidation of the sources of their mental illness and for fashioning possible solutions to their problems. They also present a moral challenge that requires psychiatrists to acknowledge the cultural, political, legal, and economic context of the mental problems of the homeless in the course of deciding what should be done to help them. H. Richard Lamb has proposed a program of aggressive outreach and psychiatric hospitalization for the homeless mentally ill. The authors believe that his proposal misconstrues the problems and needs of homeless mentally ill individuals; it would also needlessly infringe upon their freedom, further stigmatize them, and probably not help them. The authors offer an alternative understanding of the plight of the homeless mentally ill which places their problems within a larger context of social trends and domestic issues that society has been reluctant to confront. Psychiatrists can help the homeless mentally ill by championing their liberty rights and by focusing public discourse on the broad national need for improved access to medical and psychiatric care.

Morality and pretextuality, psychiatry and law: of "ordinary common sense," heuristic reasoning, and cognitive dissonance.

The thesis of this paper is that we will not make significant progress in understanding the tensions between the legal and mental health systems until we look carefully at a series of dissonances that affect both systems. We must consider the way that the law frequently condones pretextuality as a way of dealing with troubling or cognitively dissonant information, and the way that mental health professionals encourage a self-referential concept of morality as a way of subverting legal doctrines with which they disagree. These dissonances must be considered contextually in connection with the ways that courts generally read social science data and the ways that jurors and legislators employ such cognitive devices as "ordinary common sense" and heuristic reasoning in their judgments of cases involving mental disability questions. To ameliorate the current dilemma, we must redefine institutional and professional roles, reconsider the way we privilege expertise, recalibrate our allocation of "moral jurisdiction" over these matters, and consciously confront the way our simplifying thinking mechanisms distort the underlying social and political issues.

AIDS-related dementia and competency to stand trial: a potential abuse of the forensic mental health system?

Public health officials, hospital administrators, forensic directors, jail wardens, judges, prosecutors, and defense attorneys must confront the issue: how should cases of individuals with AIDS dementia be treated when they are found to be permanently incompetent to stand trial? Although charges are sometimes dismissed in advanced cases of dementia, the more common pattern involves placement of the defendant in a public facility while awaiting trial. The refusal of some state facilities to accept these patients raises a host of legal, moral, and medical questions that virtually every urban state's forensic system will have to consider in the near future.

Recent developments in mental health law.

The author presents the practicing psychiatrist with an attorney's understanding and knowledge of both criminal and civil law and outlines all the recent developments in such areas as dangerousness standards, involuntary commitment, right to treatment, right to refuse treatment, and right to aftercare.