Some ethical problems in forensic psychiatry

1. Someethical problems in forensic psychiatry Jozsef Kovacs, MD, PhD, Brigitta Baran MD, PhD Semmelweis University, Budapest

2. What is forensicpsychitry? • It „..includesallaspects of thecare and treatment of offenderswithmentaldisorders.”* • „Forensicpsychiatry is a subspeciality of psychiatryinwhichscientific and clinicalexpertise is appliedinlegalcontexts…”** • *Sen P, Gordon H, Adshead et. al.: Ethicaldilemmasinforensicpsychiatry: twoillustrativecases. J MedEthics 2007;33:337-341 • --*AAPL EthicsGuidelinesforthePractice of ForensicPsychiatry , 2005

3. The challanges of a forensicexpert • Sheworksnotwithhercolleagues • Sheworkswithpofessionals of differentdisciplines • Basic questionsforan expert

4. Forensicpsychiatristas an expertwitness • Forensicpsychiatristsasexpertwitnessesexaminedefendents (and notpatients) • The client of theforensicexpert is notthedefendant, butthecourt * • *Grubin, D.: Commentary: mapping a changinglandscapeintheethics of forensicpsychiatry J Am AcadPsychiatry Law 36:185-190, 2008 (p. 186) Cit: J L Knoll IV. EthicsinForensicPsychiatry. (In: R. I. Simon—L.H. Gold: Textbook of ForensicPsychiatry (Seconded.) • *

5. The vulnerability of forensicpatients • The source of vulnerability* • Theirmentaldisability • Some of them are detainedagainsttheirwill • *Sen P, Gordon H, Adshead et. al.: Ethicaldilemmasinforensicpsychiatry: twoillustrativecases. J MedEthics 2007;33:337-341

6. Vulnarabilitiescreatedbynewbrainimaging technology • Neuorethicsas a newdiscipline • „Mind reading” maysignificantly limit traditionalfreedoms • Someexamples

7. The four principles of medical ethics • The modern „mantra”: the four principles • The principle of respect for the autonomy of the patient • The principle of nonmaleficience • The principle of beneficence • The principle of justice

8. The principles of forensic psychiatry according to AAPL* • Respect for Persons • Honesty • Justice • Social responsibility • *AAPL Ethics Guidelines for the Practice of Forensic Psychiatry, 2005

9. Respect for Persons • The corollary of this principle • informed consent • The prerequisite of informed consent is the competency of the evaluee

10. The InsanityDefence • A distinctionshould be made between • Legalinsanity • Clinicalinsanity • The twostandards of theinsanitydefense* • Cognitive standard • Volitional standard • *R M Wettstein (2014): Insanity and theInsanityDefenseIn: Bioethics, 4th Edition

11. Honesty and Striving for Objectivity* • The forensicexpertshouldnot be a „hiredgun” • „Treatingpsychiatristsshould…avoidactingasexpertwitnessfortheirpatientsorperformingevaluations of theirpatientsforlegalpurposes.” • *AAPL EthicsGuidelinesforthePractice of ForensicPsychiatry , 2005

12. Objectivity versus Advocacy • The pitfalls of theadvocacyrole

13. Confidentiality • This fundamental ethical principal has limits in forensic psychiatry • Warning must be given to examinees about the limitations of confidentiality • The differences between a forensic examination and a clinical examination should be carefully explained

14. SpecialHungarianproblems • Providingpsychiatriccare and treatment of potentiallyviolentpatientswithoutmedium and highsecurityunits • Forensicpsychiatricexpertisewithouteducation/qualificationinpsychiatrybutforensicmedicine • Forensicpsychiatricexpertisewithoutpsychiatricpractice –institutes of forensicsciences (establishedsince 1960-s)

15. Contestedtopics I. Surgicalcastration of sex offenders* • The problem • The debatewithinthe EU • The criticism of the European CommitteeforthePrevention of Torture and InhumanorDegradingTreatmentorPunishment (CPT) • *McMillan J: The kindestcut? Surgicalcastration, sex offenders and coerciveoffersJ MedEthics 2014;40:583-590

16. Contestedtopics II. Psychiatrists and theDeathPenalty • 1.) Is a forensicpsychiatristallowedtocarry out competence-to-be-executedevaluations? • 2.) Is a forensicpsychiatristallowedtotreat an inmatewho is incompetentto be executed, forthepurpose of restoringcompetence? • 3.) Is thesateallowedtoforciblymedicatean incompetentdefendanttomakehimcomptentto be executed?

17. Physicianparticipationinexecutions • The AMA (American MedicalAssociation) opinion • The distinctionbetweentreatment and evaluation

18. Contestedtopics III. Psychiatrists and Interrogations • Physicians and torture • The APA (American PsychiatricAssociation) statement

19. 12.8.The Interrogation of a Guantanamo Prisoner (Adaptedby J. Kovacs. Source: R.M. Veatch—A.M. Haddad—D.C. English (2010): CaseStudiesinBiomedicalEthics. Oxford: OxfordUniversity Press.) • „American soldiers captured a man, and transferred him to the detention center at Guantanamo Bay. The man was labelled a „high-value detainee.” • In 2002, Former Secretary of Defense Donald Rumsfeld authorized extraordinary interrogation techniques for high-value detainees. He also mandated that these interrogations be subject to oversight by health professionals. Special teams were created to work on interrogations called Behavioral Science Consultation Teams (BSCTs). These teams were headed by a psychologist or psychiatrist. Their job was not simply to monitor interrogations but to employ their knowledge of human psychology to better exploit a prisoner’s psychological and cultural vulnerabilities for the purposes of extracting information. • The prisoner in question was interrogated using very aggressive and controversial techniques. These included being deprived of sleep for more than a week at a time, having hypothermia induced by air conditioning, being exposed to barking, growling dogs, to which the prisoner has a phobia, being forced to take many bags of intravenous fluids and then to urinate on himself. Throughout the prisoner’s interrogation he was monitored daily by physicians. • A psychologist suggested that the prisoner be placed in a swivel chair so that he could be prevented from focusing his eyes on one spot. The interrogators employed dehumanizing techniques such as leashing the prisoner like a dog and making him bark, and remarking that the prisoner’s life was worse that that of the rats inhabiting the compound. „

20. The WiderDebateAboutParticpationinInterrogations • National securityasjustification • Utilitarian vs. Deontologicalarguments

21. Normative theories of ethics • Each of them answers the question: How should I live? • Deontological theories • (deon=duty) You must fulfill your duties, irrespective of its consequences • Consequentialist theories • The moral value of an act depends on the non-moral consequences of that act

22. General characteristics of deontological theories of ethics • One must obey the known moral rules • The moral rules are absolute (without exception) • The rules must be obeyed even if breaching them would produce greater good • There are possibly more than one morally acceptable solutions in any moral dilemma

23. Utilitarian dilemmas • If 10 innocent persons are to be executed, and one is offered to save nine of them by intentionally killing one of them, is it permissible to accept the offer? • Deontological answer: no, one must follow the rule: Do not kill! • Act utilitarian answer: one can accept the offer, if this really saves 9 innocent lives

24. Counterarguments* • Interrogationtechniques, borderingtorture • may lead tofalseinfomation • mayradicalize and fanaticizetheenemy • maytraumatizethoseusingtorture *Steven H. Miles (2014): Warfare: Torture. In: Bruce Jennings (ed.) (2014): Bioethics. (4th edition) San Francisco—New York: Gale, CengageLearning. (p. 3179-3183)

25. Thank you for your attention!