From posts to protection: Ethical considerations regarding forensic psychiatrists and a duty to warn based on social media.

Increasing use of social media in forensic mental health evaluations will lead to new challenges that must be resolved by forensic practitioners and the legal system. One such dilemma is the discovery of information that would typically trigger a legal duty and professional ethics obligation for mental health professionals to breach doctor-patient confidentiality to promote public safety and prevent harm to vulnerable third parties. Although the law and professional organizations offer clear guidance for practitioners in the treatment role, there is currently no clarity from the law or instruction from professional organizations on what mental health professionals should do if they discover such information during a confidential forensic evaluation. For example, a forensic evaluator may find evidence on social media of an evaluee's threats to seriously harm others, abuse of children and the elderly, or severely impaired driving. There are no clear guidelines for how a forensic psychiatrist should respond in these complicated situations. We review the legal concepts and historical evolution of confidentiality, privilege, and mandated reporter duties that forensic practitioners should consider in these legally ambiguous situations. Finally, we discuss ethics frameworks practitioners can implement to determine their most ethical course of action when faced with such dilemmas.

Ethics, Empathy, and Detached Concern in Forensic Psychiatry.

Clinical medical ethics are ruled by the principles of beneficence and non-maleficence. In forensic psychiatry, however, the duty to serve as an agent of the justice system overrules these principles; thus, examination subjects may indeed experience harms incurred by the psychiatrist's testimony. Alan Stone argued more than 30 years ago that the participation of psychiatrists in legal proceedings runs two essential and opposing risks: skewing justice to serve patients and deceiving patients to serve justice. In this article, we review the major lines of response and critique stemming from Stone's article. We focus on the use of empathy in examination and evaluation, a topic central to the ongoing discussion and debate. We then describe detached concern, a concept with a long history in medical education but new to discussions of ethics and empathy in forensic psychiatry. We conclude by proposing this concept as a useful addition to thought, discussion, and, above all, practice. We argue specifically that detached concern can help practitioners, seasoned and novice alike, to avail the benefits and manage the ethics risks of using empathy in evaluations.

What does impartiality mean in medico-legal psychiatry? An international survey.

Medico-legal psychiatry is the field of forensic psychiatry that consists of reporting to criminal, civil and administrative authorities and testifying in courts of law. As a forensic science, medico-legal psychiatry is based on the principle of impartiality. However, the notion of impartiality is not clearly defined and can be understood in many different ways. The purpose of this study was to explore the meaning that expert psychiatrists attribute to this notion. Members of the forensic sections of the World Psychiatric Association, the European Psychiatric Association and the American Academy of Psychiatry and the Law were surveyed by e-mail using a vignette and a questionnaire. One hundred and thirty-one responses were received. When commenting on the case presented in the vignette, a large majority of respondents considered that the personal moral convictions of the doctor were the main factor likely to cast doubt on the impartiality of the expert, followed by past personal experience and the fact that the expert was the treating doctor of the examinee. In the answers to the questionnaire, 54% of participants considered that the question of impartiality was similar in both the inquisitorial and adversarial systems. Impartiality was considered by most participants as both an ethical and a legal concept. The main factors considered as likely to affect the impartiality of an expert were past personal experience, personal beliefs and perceptions, and the fact that the expert was the treating doctor of the examinee. Training in forensic psychiatry and past professional experience were considered to be the most important factors that could enhance the impartiality of an expert. When asked about their own definition, 70% of respondents defined impartiality as a choice specific to the expert, and 27% of participants defined impartiality as a result of external factors. The term 'objectivity' was used in 30% of responses. Results revealed a rather unified view of the issue of impartiality by medico-legal psychiatrists, irrespective of their country and practice conditions. The notions of honesty and striving for objectivity, which are emphasized in several guidelines of forensic psychiatry associations, were cited by many participants. Impartiality appears to be considered as a coherent concept in both normative and consequentialist ethics and represents a useful reference in the practice of medico-legal psychiatry.

Forensic patients, treating psychiatrist and the Mental Health Review Tribunal - An ethical question?

OBJECTIVE: In inpatient forensic settings, a psychiatrist is expected to wear 'Two Hats', as a treating physician and as an expert to provide risk assessments and expert advice to the judicial authorities for leave and release decisions. Although dual roles have long been accepted as an inevitable part of independent forensic practice, there are additional ethical challenges for the treating psychiatrist to provide an expert opinion. This paper examines the specific ethical ambiguities for a treating psychiatrist at the interface of legal process related to leave and release decisions in the treatment of forensic patients. CONCLUSIONS: While respect for justice is the prevailing ethical paradigm for court-related forensic work, the medical paradigm should remain the key ethical framework for psychiatrists in treatment settings. Thus, psychiatrist should be aware of possible adverse consequences in acting as forensic experts for their patients. A conscientious adherence to clinical facts and awareness of the 'Two Hats' ethical pitfall can serve as important reference points in framing the psychiatric evidence in the decision-making process and safeguard treating psychiatrist's role.

Professional Identity, the Goals and Purposes of Forensic Psychiatry, and Dr. Ezra Griffith.

Dr. Ezra Griffith's retirement as Editor of The Journal motivated this reflection on his contributions to forensic psychiatry. In 1998, Dr. Griffith published a response to Dr. Alan Stone's views and Dr. Paul Appelbaum's theory on ethics in forensic psychiatry. This response has been often labeled as the "cultural formulation" perspective. This article reviews some of the major contributors in the development of ethics and professionalism for forensic psychiatry and offers a perspective on Dr. Griffith's contributions in this evolving and relatively young sub-specialty within psychiatry. With his scholarly contributions to the field of ethics, Dr. Griffith has offered a bridge that connects past attempts to define our sub-specialty to a future formulation of the goals and purposes of forensic psychiatry, something that the author recommends as a next step.

Humane Forensic Practice Serves Social Justice.

In response to a call for revision of the current procedures for involuntary treatment in Massachusetts, this commentary explores the ethics basis for such institutional reform. In the decades since the landmark Rogers v. Commissioner decision of 1983, the ethics foundation for forensic psychiatry has evolved from a purist approach that prioritized legal values above therapeutic ones. Building on systemic approaches by Gutheil et al. and Ciccone and Clements, Candilis and Martinez, for example, have argued that a robust professional ethic requires moving beyond the strict role theory of the adversarial system to consider broader approaches that integrate multiple perspectives: the ultimate goal is protection of vulnerable people and ideas. In this commentary, we suggest that the current system for involuntary treatment does not protect the vulnerable people it ought to serve, failing the neglected goal of social justice.

Response to Disclosure as an Indicator of Competence to Stand Trial.

Ethics guidelines recommend that forensic mental health professionals begin in-person assessments by explaining the nature and purpose of the examination. To learn whether evaluees have understood and can give consent, forensic practitioners may ask evaluees to paraphrase the explanation. This article explores how a forensic evaluee's disclosure response (DR) reveals substantive information relevant to the purposes of a forensic examination. We examined archival data from 255 reports on competence to stand trial (CST) that a Midwest public sector hospital had previously submitted to courts. We classified each evaluee's DR at one of three levels: DR = yes (accurate paraphrasing), DR = no (inability to paraphrase or provide a relevant response), or DR = other (an intermediate level implying a less-than-accurate response). None of the 28 DR = no evaluees was CST, and only 7 (17%) of the 48 DR = other evaluees were CST. Thus, a CST evaluee who cannot paraphrase an examiner's explanation is likely to be incompetent to stand trial, and an examiner would need to adduce a strong argument to support any opinion to the contrary.

Truth as Humility Nourishing Compassion Through Wisdom.

Among the strengths of forensic psychiatry as a profession is its ability to support lively discussion of critical questions, such as how to characterize its own essence and whether it belongs to the practice of medicine. The American Academy of Psychiatry and the Law is fortunate that Michael Norko has taken the occasion of his presidential address to describe in depth the results of the advanced stage of his probing on a truly spiritual level the fundamental place of compassion in the practice of forensic psychiatry. In so doing, he casts inevitable light on the seamless connections binding forensic psychiatry and medicine, particularly the importance for both of practicing compassion in our search for truth.

Forensic psychiatry, one subspecialty with two ethics? A systematic review.

BACKGROUND: Forensic psychiatry is a particular subspecialty within psychiatry, dedicated in applying psychiatric knowledge and psychiatric training for particular legal purposes. Given that within the scope of forensic psychiatry, a third party usually intervenes in the patient-doctor relationship, an amendment of the traditional ethical principles seems justified. RESULTS: Thus, 47 articles, two book chapters and the guidelines produced by the World Psychiatric Association, the American Association of Psychiatry and the Law, as well as by the Royal Australian and New Zealand College of psychiatrists, were analyzed. The review revealed that the ethics of correctional forensic psychiatry and those of legal forensic psychiatry do not markedly differ from each other, but they are incongruent in terms of implementation. METHODS: In an effort to better understand which ethical principles apply to forensic psychiatry, a chronological review of the literature published from 1950 to 2015 was carried out. CONCLUSION: The ethics of correctional forensic psychiatry are primarily deontological. The principle of justice translates into the principle of health care equivalence, the principle of beneficence into providing the best possible care to patients, and the principle of respect of autonomy into ensuring confidentiality and informed consent. The ethics of legal forensic psychiatry are rather consequentialist. In this latter setting, the principle of justice is mainly characterized by professionalism, the principle of beneficence by objectivity and impartiality, and the principle of respect of autonomy by informed consent. However, these two distinct fields of forensic psychiatry share in common the principle of non maleficence, defined as the non collaboration of the psychiatrist in any activity leading to inhuman and degrading treatment or to the death penalty.

Conducta homicida en el trastorno esquizotípico. Presentación de un caso / Homicidal behavior in schizotypical disorder. A case presentation

Introducción: El trastorno esquizotípico se manifiesta desde edades tempranas como un patrón general de déficit social e interpersonal, comportamiento excéntrico, capacidad reducida para las relaciones personales y distorsiones cognoscitivas, incomprensibles psicológicamente. Objetivo: Fundamentar la responsabilidad médico-legal de un caso de trastorno esquizotípico que cometió homicidio. Presentación de caso: Individuo de 22 años, soltero, sin hijos, técnico medio, sin historia de trastornos mentales que es peritado por psiquiatría forense debido a que agredió a su abuelo materno con un arma blanca, y causó la muerte. Se le realizó examen psiquiátrico, se aplicó la Escala de Valoración de Impulsividad, se realizó electroencefalograma y valoración psicológica, que incluyó la aplicación de las pruebas proyectivas Bender, Machover y Rorschach. El diagnóstico propuesto por el equipo evaluador fue trastorno esquizotípico, sin enajenación mental. Conclusiones: El trastorno esquizotípico no es un diagnóstico frecuente en Psiquiatría. Cuando se involucra en conductas delictivas, estas ocurren en solitario y suelen estar relacionadas con agresiones hacia otras personas. Es determinante de semi-imputatibilidad o imputabilidad y no se recomienda su permanencia en régimen penitenciario(AU)

Introduction: Schizotypical disorder appears at very early ages as a general pattern of social and interpersonal deficit; eccentric behavior; reduced capacity to maintain personal relations; and cognitive distortions, which are psychologically inexplicable. Objective: To establish the medico-legal implications in a case of schizotypical personality disorder that committed homicide. Case presentation: A 22 years old individual, single, without children, technician, without history of mental disorders who is studied by Forensic Psychiatry because he attacked his maternal grandfather with a knife, which caused his death. Psychiatric examination was done; the Impulsiveness Scale was applied; and an enlectroencephalogram (EEG) and a psychological evaluation were carried out, which included Bender, Machover, and Rorschach tests. The evaluating staff made the diagnosis of Schizotypical disorder, without mental derangement. Conclusions: Schizotypical disorder is not a frequent diagnosis in Psychiatry. When it is involved in criminal behaviors, they occur in isolation and they are usually related to attacks to other persons. It is a determinant condition of semi-imputability or imputability. Prison system is not recommended(AU)

[Failure of a study in forensic psychiatric hospitals : Clinical trial to investigate the additive effect of triptorelin on the efficacy of psychotherapy]. / Vom Scheitern einer Studie in Maßregelvollzugskrankenhäusern : Klinische Prüfung zum additiven Effekt von Triptorelin auf die Wirksamkeit von Psychotherapie.

BACKGROUND: A testosterone-lowering medication is relatively commonly used as a form of treatment for sexual offenders with severe paraphilic disorders in German forensic psychiatric hospitals; however, a double-blind, controlled and randomized study, which investigates the efficacy of this medication, is still lacking. AIM: This article describes the process from the planning to the rejection of a clinical trial over the period from 2009 to 2015. METHODS AND RESULTS: Despite the careful planning with an interdisciplinary team and giving special consideration to the complex legal situation, the Federal Institute for Drugs and Medical Devices (BfArM) rejected the proposed trial in a brief formal letter with reference to the German Drug Law (§ 40 para. 1 p. 3 nr. 4 AMG). The ethics committee of the Hamburg Medical Association considered that clinical research is basically not possible with patients detained in a forensic psychiatric hospital. DISCUSSION: In the opinion of the authors, the described facts illustrate how legal regulations that should protect vulnerable groups in medical research, in a specific case can lead to the fact that a therapy form relevant to the corresponding patient group cannot be scientifically investigated.

The compulsory psychiatric regime in Hong Kong: Constitutional and ethical perspectives.

This article examines the compulsory psychiatric regime in Hong Kong. Under section 36 of the Mental Health Ordinance, which authorises long-term detention of psychiatric patients, a District Judge is required to countersign the form filled out by the registered medical practitioners in order for the detention to be valid. Case law, however, has shown that the role of the District Judge is merely administrative. This article suggests that, as it currently stands, the compulsory psychiatric regime in Hong Kong is unconstitutional because it fails the proportionality test. In light of this conclusion, the author proposes two solutions to deal with the issue, by common law or by legislative reform. The former would see an exercise of discretion by the courts read into section 36, while the latter would involve piecemeal reform of the relevant provisions to give the courts an explicit discretion to consider substantive issues when reviewing compulsory detention applications. The author argues that these solutions would introduce effective judicial supervision into the compulsory psychiatric regime and safeguard against abuse of process.

Psychiatric/ psychological forensic report writing.

Approaches to forensic report writing in psychiatry, psychology, and related mental health disciplines have moved from an organization, content, and stylistic framework to considering ethical and other codes, evidentiary standards, and practice considerations. The first part of the article surveys different approaches to forensic report writing, including that of forensic mental health assessment and psychiatric ethics. The second part deals especially with psychological ethical approaches. The American Psychological Association's Ethical Principles and Code of Conduct (2002) provide one set of principles on which to base forensic report writing. The U.S. Federal Rules of Evidence (2014) and related state rules provide another basis. The American Psychological Association's Specialty Guidelines for Forensic Psychology (2013) provide a third source. Some work has expanded the principles in ethics codes; and, in the third part of this article, these additions are applied to forensic report writing. Other work that could help with the question of forensic report writing concerns the 4 Ds in psychological injury assessments (e.g., conduct oneself with Dignity, avoid the adversary Divide, get the needed reliable Data, Determine interpretations and conclusions judiciously). One overarching ethical principle that is especially applicable in forensic report writing is to be comprehensive, scientific, and impartial. As applied to forensic report writing, the overall principle that applies is that the work process and product should reflect integrity in its ethics, law, and science. Four principles that derive from this meta-principle concern: Competency and Communication; Procedure and Protection; Dignity and Distance; and Data Collection and Determination. The standards or rules associated with each of these principles are reviewed.

Effects of alcohol on the offender's sanity-Issues of criminal law and psychiatry in light of findings of research.

The present report is the result of research on the causes of insanity or issuing opinions about the causes of insanity or diminished sanity perpetrators in criminal proceedings conducted in Poland (CEE). Research has shown the impact that has, in fact, use or abuse of alcohol and other alcoholic diseases on the status of the accused in criminal proceedings. This publication presents not only the results but also the basic regulations - valid in Poland and in other European countries - with respect to the responsibility of the perpetrators insane, with diminished sanity and being in a state of inebriation at the time of committing a criminal act.

Are Forensic Experts Already Biased before Adversarial Legal Parties Hire Them?

This survey of 206 forensic psychologists tested the "filtering" effects of preexisting expert attitudes in adversarial proceedings. Results confirmed the hypothesis that evaluator attitudes toward capital punishment influence willingness to accept capital case referrals from particular adversarial parties. Stronger death penalty opposition was associated with higher willingness to conduct evaluations for the defense and higher likelihood of rejecting referrals from all sources. Conversely, stronger support was associated with higher willingness to be involved in capital cases generally, regardless of referral source. The findings raise the specter of skewed evaluator involvement in capital evaluations, where evaluators willing to do capital casework may have stronger capital punishment support than evaluators who opt out, and evaluators with strong opposition may work selectively for the defense. The results may provide a partial explanation for the "allegiance effect" in adversarial legal settings such that preexisting attitudes may contribute to partisan participation through a self-selection process.

[Coercive procedures in forensic psychiatry : Current treatment practice in forensic psychiatric hospitals from a medical ethics perspective]. / Zwangsmaßnahmen in der forensischen Psychiatrie : Aktuelle Behandlungspraxis im Maßregelvollzug aus medizinethischer Perspektive.

BACKGROUND: In 2011 the legal foundations of coercive treatment in German forensic psychiatric clinics were declared to be unconstitutional. In the present study we analyzed the frequency of coercive procedures in forensic psychiatric hospitals before and after 2011, the consequences for medical care as well as the ethical assessments by attending chief physicians. METHODS: By a questionnaire-based survey of views of attending chief physicians in forensic psychiatric clinics in 2013, data on the current state of patient care were collected and analyzed from an ethical perspective. These were compared with treatment data from a large forensic psychiatric clinic collected over the period 2007-2013. RESULTS: Even after 2011 coercive forms of treatment were applied in forensic psychiatric hospitals. In practice, there is a high degree of legal uncertainty regarding the limits of coercive treatment. Of all patients treated in forensic psychiatric clinics in 2012, on average 13 % had been in isolation at least once, approximately 3 % had been treated under fixation at least once and 2.2 % had been subjected to coercive medical treatment at least once. CONCLUSION: From an ethical perspective an open debate about the practice of coercive treatment is urgently required. Legal regulations, ethical guidelines and treatment standards have to be developed for the special situation of patient care in forensic psychiatric hospitals.