Ethical Issues In Prison Psychiatry

Recent surveys demonstrate a high and possibly increasing prevalence of mental disorders in prisoners. They have an increased risk of suffering from a mental disorder that transcends countries and diagnoses. Ethical dilemmas in prison psychiatry arise from resource allocation and include issues of patient choice and autonomy in an inherently coercive environment. Ethical conflicts may arise from the dual role of forensic psychiatrists giving raise to tensions between patient care/protection of the public.This book describes models and ethical issues of psychiatric healthcare in prison in several countries. Relevant issues are: the professional medical role of a psychiatrist and/or psychotherapist working in prison, the involvement of psychiatrists in disciplinary or coercive measures; consent to treatment, the use of coercion in forcing a prisoner to undergo treatment, hunger strike, confidentiality. The book ends with consensus guidelines concerning good practice in Prison Psychiatry.

In the past 30 years, the population of prisoners in the United States has expanded almost 5-fold, correctional facilities are increasingly overcrowded, and more of the country's disadvantaged populations—racial minorities, women, people with mental illness, and people with communicable diseases such as HIV/AIDS, hepatitis C, and tuberculosis—are under correctional supervision. Because prisoners face restrictions on liberty and autonomy, have limited privacy, and often receive inadequate health care, they require specific protections when involved in research, particularly in today's correctional settings. Given these issues, the Department of Health and Human Services' Office for Human Research Protections commissioned the Institute of Medicine to review the ethical considerations regarding research involving prisoners. The resulting analysis contained in this book, Ethical Considerations for Research Involving Prisoners, emphasizes five broad actions to provide prisoners involved in research with critically important protections: • expand the definition of "prisoner"; • ensure universally and consistently applied standards of protection; • shift from a category-based to a risk-benefit approach to research review; • update the ethical framework to include collaborative responsibility; and • enhance systematic oversight of research involving prisoners.

Ethical medical practice and treatment in psychiatry are based on the concept of first do no harm. However, this cannot, and does not, apply to forensic cases where there is no doctor–patient relationship and the forensic psychiatrist may indeed cause harm to the examinee. In this book, Robert Sadoff analyzes the ethical issues affecting forensic psychiatric practice, especially those promulgated by the American Academy of Psychiatry and the Law. Within those guidelines, he looks at individual bias, vulnerability of the examinee, and potential harm to the mental health professional. The book discusses each of the procedures of the forensic expert separately with respect to minimizing harm. It has been written with an international audience in mind and features chapters reviewing the European and UK perspectives, by Emanuele Valenti and John Baird, respectively. Robert Sadoff addresses the long-term harm that can be either avoided or minimized through careful planning and application of ethical principles. He is not advocating that the harm can be totally eliminated, because that is impossible in the adversarial system in which forensic psychiatrists work. However, there are means by which harm may be minimized if care is taken during the assessment, the report writing, and the testimony phase of the proceedings. The book develops the scope of forensic psychiatry from the standpoint of administrative, civil and criminal cases. It presents the practical issues involved in conducting forensic psychiatric assessments under various conditions plus special considerations, such as bias, minimizing harm, developing a therapeutic approach, and elaborating on various vulnerable individuals who are frequently examined in forensic cases. These include juveniles, mentally retarded, autistic, sexual assault victims, the elderly, the organically damaged, the psychotic, and mentally disabled prisoners. Immigrants are covered in a chapter by Solange Margery Bertoglia. The ethical issues in conducting forensic psychiatric examinations and presenting psychiatric testimony in court are examined and discussed. Cases illustrating the difficulties involved punctuate the presentation. The book closes with a fascinating account of the legal perspective by Donna Vanderpool. In summary, this book illustrates the ethical and practical issues that affect forensic psychiatric practice. The question is not what we do, but how we do it, and which standards, ethical guidelines and personal values contribute to the total picture. Despite the fact that we cannot always adhere to the doctrine of "primum non nocere," we can minimize the harm caused inherently by the adversarial system in which we participate. Praise for Ethical Issues in Forensic Psychiatry "One of the founding giants of the forensic psychiatric field has written here far more than a "mere" ethics textbook. Instead, this compendium serves multiple purposes: it is a valuable primer on forensic techniques of examination and testimony, a model of best forensic practices, and an instruction on the most appropriately civilized way in which to conduct oneself as a forensic psychiatrist. The success of these multiple accomplishments clearly derives from characteristics of the author. In both sage advice to practitioners and in many revealing case examples, Dr. Sadoff displays the tact, good manners and sensitivity of a consummate gentleman – a term not always associated with the hurly-burly of courtroom work. The book's primary focus on avoiding harm to all the parties involved in the work places it on the moral high ground of the legal system in which participating clinicians must find a place." Thomas G. Gutheil, MD, Professor of Psychiatry and Co-Founder, Program in Psychiatry and the Law, Beth Israel Deaconess Medical Center, Harvard Medical School

This work explores and discusses the ethical dilemmas clinicians face in everyday forensic psychiatry practice. We discuss and reflect on ethical issues involving treatment decisions such as antipsychotic polypharmacy, high doses antipsychotics and prescribing anti-libidinal medications. Ethical issues surrounding the use of technology for the management of mentally disordered offenders are explored in depth. The use of the polygraph test, a controversial method of truth facilitation for sex offenders, is discussed. Similarly, we discuss the use of "tagging" for serious offenders that despite being used in the United States of America for a while it has been heavily criticized and opposed. Tagging is gradually being introduced in the UK and other European countries, making consideration of the ethical issues and dilemmas surrounding its use both timely and necessary. This work is a valuable guide for clinicians working in forensic psychiatry settings, particularly when faced with ethical dilemmas concerning decisions around interventions.

The process of aging is frequently associated with changes in the physical and mental functioning of older adults, challenging their autonomy and rendering them vulnerable to exploitation. Certain illnesses that are more common in older adults can affect their capacity to function independently. These include the capacity to make medical decisions, live independently, manage finances, to name a few. Healthcare professionals, especially psychiatrists are often entrusted with the responsibility of assessing an older adult’s capacity to perform one or more functions. This makes it imperative for them to be cognizant of these issues, understand the need for these evaluations, and be able to conduct them in a comprehensive manner. Another way of protecting an older person’s rights and facilitating a life based on their own decisions even after they lose decision making capacity is Advanced Health Care Planning (AHCP). Health care professionals are required to initiate a discussion about AHCP with their patients and their families and review it periodically. Lastly, the older adults incarcerated in prisons is a group that is growing in numbers. They have unique needs at the intersection of the geriatric and forensic services, but are often marginalized by both services. The combination of poor quality of life and increasing costs makes the care of older adults in the criminal justice system makes this topic an important public health concern. There is a pressing need for better training of prison staff in issues of geriatric psychiatry. Assessment of criminal responsibility and competence to stand trial in aging offenders are other complex but under-studied issues. This proposed book will provide a comprehensive view of ethical, medicolegal, and forensic issues that will be useful in clinical practice. There will be three sub-sections, each focusing on ethical, medicolegal and forensic issues respectively. The first section will focus on ethical issues. Its first chapters will provide an overview of the how age and the process of aging influence decision-making and introduce unique ethical dimensions to clinical care. This will be followed by a discussion of the concepts of informed consent and capacity evaluation. The next chapters will focus on common scenarios that arise in the care of elderly patients and offer a practical approach to understanding and managing them. These will include assessments of the capacity to make medical decisions, the capacity to live independently, manage finances, drive a vehicle, have sexual relations etc. A chapter on ethical issues specific to dementia will outline issues related to diagnostic disclosure and genetic testing. Research ethics issues in geriatric psychiatry will also be outlined. The next section of the book will focus on surrogate decision making in an older adult who has been deemed to lack the capacity to serve one or more functions independently. The first chapters in this sub-section will focus on patient directed advance health care planning tools, namely, living will and power of attorney. This will be followed by an overview of default surrogate making. Guardianship will subsequently be covered. A separate chapter will cover the issue of elder abuse and discuss an approach to assessing it. The last section of the book will cover forensic issues in geriatric psychiatry. The first chapter will discuss aging older adults in the criminal justice system from an epidemiological perspective. The growing numbers of incarcerated older adults, their illness burden, the challenges in the diagnosis and management of neurocognitive disorders in the prison setting will be elucidated. The following chapter will discuss competence to stand trial with reference to elderly offenders. This will be followed by a discussion of the concepts of medical reprieve, compassionate release as well as model programs and policies currently in the works for older incarcerated adults.

This textbook brings together leading experts to provide a comprehensive and practical review of common clinical, organisational, and ethical issues in correctional psychiatry.