Ethical problems

The history of forensic psychiatry emphasizes the complex ethical problems that are confronted by practitioners and patients. They include the abuse and misuse of psychiatry, the conflicting demands of confidentiality and the duty to the court and third parties, consent to treatment and incapacity, the civil rights of patients and mental health law relating to detention, and the dual responsibilities of practitioners to the court and the patient/client. Other continuing problems are dangerousness and risk assessment, the nature of antisocial personality disorder, and the contrasting roles of prison and hospital.

There are some ethical issues of special relevance to the practice of forensic psychiatry. The person who is being assessed is not seeking a medical opinion in the ordinary clinical sense; he or she is not a patient and may not have requested the assessment. There is a third party—a defence lawyer or prosecuting authority—which places the doctor and the patient in a special position. What the patient/client reveals may influence not his future health but his liberty. What the expert says in court may extend beyond medical matters to questions of responsibility and capacity. The extent to which medical experts should pronounce on these questions or provide opinions on future behaviour, or continued risk, has been discussed by Stone (!3> and ChiswickA4)

Other problems concern psychiatrists working with patients who are in secure environments such as prisons, secure hospital units, and police custody. Such persons are vulnerable; they have restricted autonomy and are dependent upon others, but they retain civil rights including the right to legal advice and a standard of medical care, confidentiality, and right to consent to or refuse treatment which would be expected in other circumstances.

Psychiatrists in some parts of the world may be expected to play a part in assessing a person for his competency to receive the death penalty. Involvement in this process involves serious and profound ethical dilemmas. The World Psychiatric Association has condemned participation by psychiatrists. Cope and Chiswick (15) have helpfully reviewed the issues.

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