Tuesday, September 23, 2014

Professional ethics in forensic psychiatry

Even if I work at the Centre for Ethics, Law and Mental Health (CELAM) at the University of Gothenburg, I am no specialist in ethics and have never studied practical philosophy. This post is thus not written by an expert in ethics, and I doubt that my colleagues who hold such qualifications would agree with much of it. Nevertheless, I want to argue for some positions I have arrived at through my work as a clinician and researcher. Forensic psychiatry is a medical speciality operating in the interface towards law. It is sometimes argued that we have a “dual task” of promoting our patients’ health and protecting society from violent (re-)offending. I reject this idea, and will outline the reasons for this here.

My position is that, as health professionals, our sole duty is to further the best interest of our patient. By health professionals, I refer to board licensed MDs, psychologists, psychotherapists, social workers, nurses and other professions employed in the health care system. Being a health professional requires that other people put their trust in you in very special ways. Therefore, we have ethical rules that must always be adhered to. To do our work, we can literally ask a fellow human to undress or to reveal his/her innermost secrets. Sooner or later, most of us will need a health professional. In the vulnerable position of the care seeker, and to get good treatment, we must be able to trust that the professional is dedicated to promoting our health and not serving two masters. 

Before going further into the arguments for my position, let me state that it is never in the patient’s best interest to commit a violent crime, having drugs prescribed without medical indication, false certificates issued or the similar.

Psychiatrists may give court expertise on evaluations and treatment, if the patient waives professional secrecy. In cases of diminished or incapacitated accountability, special legislation is at hand to safeguard the patient’s best interest. But the model in which a psychiatrist may “change hats” and give evidence against someone, working for the state or the prosecution, putting aside normal medical ethics, damages medicine at large. 

The reason the court asks for a psychiatric or psychological opinion is that the expert has specialist training (based in the confidence of patients and research subjects) and clinical knowledge (that demands access to information that the patient has provided under the impression of confidentiality, either directly to the expert or to other experts, who have entered it into files). Being a qualified health professional also brings credibility and power imbalance, making it difficult for the person described to question the expert’s opinion.

It does not suffice to merely state that “this opinion is made as expert for XXX” as established titles, such as MD, will create certain expectations in those receiving the evaluation. In contrast, it could be possible for a psychologist to work as a behavioual analyst and give expertise in that role. Such cases have to be handled with great caution, however, in order not to confuse previous or future clients.  

But with these requirements, how could medical doctors work in forensic medicine or with societal response to contagious diseases? Frankly, I do not know how ethical frame-works, especially for the latter, have been developed, but I do not find clear analogies to forensic psychiatry. Psychiatry has a rather weak inter-rater reliability, and courts tend to believe us more easily than our colleagues do, who often disagree with our opinions. And without trust from patients, we are completely lost. So I do not find the responsibilities and benefits of assuming the role of “(s)he who knows” in the courtroom worth the risks for our profession. 

Not doing harm is our first duty. How is that possible when giving expert opinions in situations where we have no control over how the expertise is used, disseminated or understood? Instead, I think that we should use our scarce resources to develop good health services to incarcerated or otherwise sentenced persons, evidence-based treatments for aggressive behaviours and public mental health education.

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