Transcript The paradox of bioethics expertise

Some ethical problems in
forensic psychiatry
Jozsef Kovacs, MD, PhD,
Brigitta Baran MD, PhD
Semmelweis University, Budapest
What is forensic psychitry?
It „..includes all aspects of the care and
treatment of offenders with mental
disorders.”*
 „Forensic psychiatry is a subspeciality of
psychiatry in which scientific and clinical
expertise is applied in legal contexts…”**
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*Sen P, Gordon H, Adshead et. al.: Ethical dilemmas in forensic psychiatry: two illustrative cases. J Med Ethics
2007;33:337-341
--*AAPL Ethics Guidelines for the Practice of Forensic Psychiatry , 2005
The challanges of a forensic
expert
She works not with her colleagues
 She works with pofessionals of different
disciplines
 Basic questions for an expert

Forensic psychiatrist as an
expert witness
Forensic psychiatrists as expert witnesses
examine defendents (and not patients)
 The client of the forensic expert is not the
defendant, but the court *
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*Grubin, D.: Commentary: mapping a changing landscape in the ethics of forensic psychiatry J Am Acad
Psychiatry Law 36:185-190, 2008 (p. 186) Cit: J L Knoll IV. Ethics in Forensic Psychiatry. (In: R. I. Simon—L.H.
Gold: Textbook of Forensic Psychiatry (Second ed.)
The vulnerability of forensic
patients

The source of vulnerability*
– Their mental disability
– Some of them are detained against their will
–
*Sen P, Gordon H, Adshead et. al.: Ethical dilemmas in forensic psychiatry: two illustrative cases. J Med
Ethics 2007;33:337-341
Vulnarabilities created by new
brain imaging technology
Neuorethics as a new discipline
 „Mind reading” may significantly limit
traditional freedoms
 Some examples
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The four principles of medical
ethics

The modern „mantra”: the four principles
– The principle
the patient
– The principle
– The principle
– The principle
of respect for the autonomy of
of nonmaleficience
of beneficence
of justice
The principles of forensic
psychiatry according to AAPL*
Respect for Persons
 Honesty
 Justice
 Social responsibility
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*AAPL Ethics Guidelines for the Practice of Forensic Psychiatry, 2005
Respect for Persons

The corollary of this principle
– informed consent
– The prerequisite of informed consent is the
competency of the evaluee
The Insanity Defence

A distinction should be made between
– Legal insanity
– Clinical insanity

The two standards of the insanity
defense*
– Cognitive standard
– Volitional standard
–
*R M Wettstein (2014): Insanity and the Insanity Defense In: Bioethics, 4th Edition
Honesty and Striving for
Objectivity*
The forensic expert should not be a „hired
gun”
 „Treating psychiatrists should…avoid
acting as expert witness for their patients
or performing evaluations of their patients
for legal purposes.”
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*AAPL Ethics Guidelines for the Practice of Forensic Psychiatry , 2005
Objectivity versus Advocacy

The pitfalls of the advocacy role
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

Special Hungarian problems
Providing psychiatric care and treatment
of potentially violent patients without
medium and high security units
 Forensic psychiatric expertise without
education/qualification in psychiatry but
forensic medicine
 Forensic psychiatric expertise without
psychiatric practice –institutes of forensic
sciences (established since 1960-s)

Contested topics I. Surgical
castration of sex offenders*
The problem
 The debate within the EU
 The criticism of the European Committee
for the Prevention of Torture and Inhuman
or Degrading Treatment or Punishment
(CPT)
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*McMillan J: The kindest cut? Surgical castration, sex offenders and coercive offers J Med Ethics 2014;40:583590
Contested topics II. Psychiatrists and the
Death Penalty
1.) Is a forensic psychiatrist allowed to carry out
competence-to-be-executed evaluations?
 2.) Is a forensic psychiatrist allowed to treat an
inmate who is incompetent to be executed, for
the purpose of restoring competence?
 3.) Is the sate allowed to forcibly medicate an
incompetent defendant to make him comptent
to be executed?
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Physician participation in
executions
The AMA (American Medical Association)
opinion
 The distinction between treatment and
evaluation
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Contested topics III.
Psychiatrists and Interrogations
Physicians and torture
 The APA (American Psychiatric
Association) statement
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12.8.The Interrogation of a
Guantanamo Prisoner
(Adapted by J. Kovacs. Source: R.M. Veatch—A.M. Haddad—D.C. English (2010): Case Studies in Biomedical Ethics. Oxford:
Oxford University Press.)
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„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 Wider Debate About
Particpation in Interrogations
National security as justification
 Utilitarian vs. Deontological arguments
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Normative theories of ethics
Each of them answers the question: How
should I live?
 Deontological theories
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– (deon=duty) You must fulfill your duties,
irrespective of its consequences
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Consequentialist theories
– The moral value of an act depends on the
non-moral consequences of that act
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
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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
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Counterarguments*
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Interrogation techniques, bordering
torture
– may lead to false infomation
– may radicalize and fanaticize the enemy
– may traumatize those using torture
*Steven H. Miles (2014): Warfare: Torture. In: Bruce Jennings (ed.) (2014): Bioethics. (4th edition) San
Francisco—New York: Gale, Cengage Learning. (p. 3179-3183)
Thank you for your attention!