Legal & Ethical Issues in Clinical Practice

Legal & Ethical Issues

Patients' Rights and Clinical Practice Guidelines

  • Encompasses civil commitment and criminal commitment.

APA Ethical Principles

  • General Principles:
    • Broad, aspirational goals.
  • Ethical Standards:
    • Specific ethical issues.
    • Comprehensive, but not exhaustive.
  • American Psychological Association:
    • Ethical Principles of Psychologists and Code of Conduct.

Mental Health and the Law

  • Managing care for people with serious mental illness requires balancing:
    • Patient’s rights as an individual.
    • Patient’s individual safety.
    • Society’s right to safety and security.
  • These factors may be difficult to determine and may conflict.

Civil Commitment

  • Involuntary commitment to a mental hospital:
    • Laws vary by state; there is no uniform standard.
    • Government caring for the “mentally ill” is a relatively new concept.
    • First commitment laws in the late 1800s.
    • Previously, care was provided by family or the individual was abandoned.
  • Evolving area of law.
  • Abuses by the state and individuals have occurred.
  • Recent history trends:
    • “Liberal era” (1960-1980):
      • Emphasized the rights of the individual.
    • “Neoconservative era” (1980-present):
      • Emphasized the rights of the majority.

Government Authority & Commitment Criteria

  • Government uses its authority through:
    • Police power.
    • Parens patriae (state as parent).
  • Possible commitment criteria:
    • Person has a “mental illness” and needs treatment.
    • Is dangerous to self or others.
    • “Gravely disabled” – inability to care for self.

Legal Proceedings

  • Legal proceedings to assess status:
    • Person fails to seek help.
    • Others feel that help is needed.
    • Petition is made to a judge on behalf of the person.
    • The individual must be notified of the commitment process.
    • Judge makes a decision, informed by expert opinion.
    • Usually waived for short-term emergency situations that require immediate action.

Criteria: Have a “Mental Illness”

  • Legal concept:
    • Severe thought/emotional disturbance affecting health/safety.
  • APA definition:
    • “Severe mental disorder”.
  • Exclusions:
    • Often excludes drug abuse, personality disorders, and mental retardation.
  • DSM-5 diagnosis ≠ “mental illness” in legal terms.

Criteria: Dangerousness

  • Psychologists are good at predicting general trends, but not specific acts.
  • Misconception:
    • People with mental illness are more likely to be dangerous.
    • Perpetuated by sensational media portrayals.
    • Stereotypes/bias: Ethnic minorities are more likely to be seen as dangerous.
  • The vast majority of people with mental illness are NOT dangerous.
  • Goes against basic legal rights (innocent until proven guilty).

Criteria: Grave Disability

  • Unable to provide for own “basic needs.”
  • Professionals (and laws) differ widely on what this specifically means.
  • Goes against the rights of the individual, which are protected in the US Constitution.

Legal Rulings

  • Rouse v. Cameron (1966):
    • Right to treatment and not just a therapeutic environment.
    • Must use proven treatments.
    • Supposed to treat the individual, not punish.
  • Wyatt v. Stickney (1972):
    • Constitutional right to treatment.
    • Right to privacy and dignity.
    • Right to the least restrictive regimen necessary.
    • Freedom from unnecessary/excessive medications.
    • Right to send sealed mail and use the telephone.
    • Individual treatment plan that is periodically reviewed.
  • Mental Health Systems Act (1980) Sec. 501:
    • Advisory law – not mandated.
    • Appropriate treatment and services.
    • No treatment without informed consent.
    • Not restrained unless in extreme circumstances.
    • Confidentiality of records.
    • Inform about treatment/condition in a timely manner.
    • Participate in/be informed about the treatment course.

Civil Commitment: Problems

  • Unintended consequences & ongoing issues:
    • Deinstitutionalization:
      • Closing of large hospitals.
      • Increase in homelessness.
    • Criminalization of the mentally ill.
    • Transinstitutionalization:
      • Mentally ill in community care.

Criminal Commitment

  • “Competency” & “insanity”.
  • Process used when:
    • One is accused of committing a crime and is detained in a mental health facility until assessment and/or legal proceedings.
    • AND/OR
    • One invokes the claim of “not guilty by reason of insanity”.

Competency

  • Are able to understand proceedings?
  • Do need treatment for mental illness?
  • Oriented to person, place, & time?
  • Know role of lawyers, judge, & jury?
  • Understand nature of crime/charges?
  • Understand what might happen to you?

Criminal Commitment - Necessary Elements & Insanity

  • Necessary elements for criminal guilt:
    • actus rea – “wrongful deed”.
    • mens rea – “criminal intent”.
  • “Insanity”:
    • Legal concept – not a psychological one.
    • Frequently portrayed (poorly) in media, but the use is rare in the real world.
    • The insanity defense is an affirmative defense.
    • Acknowledge the act but dispute mens rea.

Assessing Insanity

  • M’Naghten rule (1843):
    • Daniel M’Naghten acting on “voice of God”.
    • One of the first times that psychiatric testimony was ever used in a murder trial.
    • Did the person know right from wrong?
    • Widely used in the US, either alone or with other rules (approximately ½ of states use the rule alone).
    • Now used in the context of whether to try children as adults.
  • Durham test (1954):
    • Was the criminal act a product of a mental disease or mental defect?
    • If so, then not responsible for actions.
    • Generally judged to be too broad & overly dependent on psychiatrists’ judgments.
    • Only New Hampshire still uses this test.
  • American Law Institute Rule (1972):
    • Able to appreciate the wrongfulness of his/her conduct AND.
    • Able to conform his/her conduct to the law?
    • Does not include abnormality that is only antisocial or criminal behavior.
    • Used in 21 state courts.
    • More specific than Durham.
    • More broad than M’Naghten.
  • Insanity Defense Reform Act (1984):
    • Passed after John Hinckley tried to kill President Reagan.
    • Dropped volitional aspect of trying crime – “could the impulse be stopped?” (Was the impulse irresistible or simply not resisted?).
    • Before, prosecution had to prove that the defendant was sane.
    • Now, the defense has to prove that the defendant is insane.

Ongoing Issues

  • Can people be forced to take meds to be ruled “competent?”
  • What should happen to individuals who commit crimes while “insane?”
  • What diagnoses (if any) should be excluded from the insanity defense?..