Ethics in Forensic Psychiatry Publishing
========================================

* Reena Kapoor
* John L. Young
* Jacquelyn T. Coleman
* Michael A. Norko
* Ezra E. H. Griffith

## Abstract

Several organizations have developed guidelines to help authors and editors of medical journals negotiate ethics dilemmas in publishing, but very little is known about how these guidelines translate to the context of forensic psychiatry. In this article, we explore the important topic of ethics in forensic psychiatry publishing. First, we review the historical development of ethics principles in medical and psychiatric publishing. We then analyze eight ethics dilemmas that have arisen in the publication of *The Journal of the American Academy of Psychiatry and the Law* (*The Journal*) from 2000 to 2009, including disputes about authorship, conflict of interest, redundant publication, bias in peer reviewers, confidentiality in case reports, and others. We identify ethics principles that were relevant to the dilemmas and discuss how they were resolved by the editors of *The Journal*. We conclude by using the principles identified in the practical resolution of ethics dilemmas to derive a conceptual foundation for ethics in forensic psychiatry publishing.

Publishing in medical journals can bring many professional benefits to authors: recognition of expertise, funding for future projects, promotion, and tenure on the academic ladder. Not surprisingly, as these benefits have been increasingly recognized, the business of medical publication has grown rapidly in the past few decades.1 The number of papers published in medical journals has increased almost fivefold since 1966,2 and the number of authors per paper has doubled over approximately the same period.3,4 With this rapid growth has come significant variation in the quality and format of medical publications. Cases of fraud and misconduct began to emerge in the 1970s and 1980s,5 in part as a result of the nearly impossible task of recognizing before publication plagiarism and falsified data among the hundreds of thousands of articles submitted each year. Faced with public embarrassment, the medical publishing community became aware of the need to establish standards and guidelines, including ethics guidelines, to safeguard the integrity and credibility of the literature.

One of the earliest attempts to establish ethics guidelines for medical publishing came in Dr. Richard Hewitt's 1954 article, “Ten Commandments for Medical Expositors,” which articulated a code of ethical conduct for medical writers and provided the first substantive definitions of authorship, plagiarism, and inappropriate citation.6 When Dr. Franz Ingelfinger took over editorship of *The New England Journal of Medicine* in 1967, he expanded on these principles by establishing a prohibition against duplicate publication, which became known as the Ingelfinger Rule.7 This rule—that a paper can be submitted only to one journal at a time—revolutionized the field and was eventually adopted by many scientific publications.

In 1978, a group of editors of medical journals ushered in the modern era of publishing ethics when they met in Vancouver, Canada, to establish guidelines for manuscripts submitted to their journals.8 This group, initially known as the Vancouver Group, evolved into the International Committee of Medical Journal Editors (ICMJE) and published *Uniform Requirements for Manuscripts Submitted to Biomedical Journals*8 in 1979. This document outlined, among other things, a code of conduct for authors and editors of medical journals. The ICMJE has frequently revised and updated the *Uniform Requirements* over the past 30 years, most recently in April 2010, and it has become a key source of information on such important ethics-related matters as authorship, editorship, plagiarism, peer review, conflict of interest, confidentiality, duplicate publication, and protection of human subjects in research.

In the years since the first appearance of the *Uniform Requirements*, interest in publishing ethics and the peer review process has exploded. In the 1990s, the Committee on Publication Ethics was formed in the United Kingdom,9 and several other groups, including the World Association of Medical Editors and the Council of Science Editors, have joined the growing number of organizations releasing position statements on ethics in medical publishing.10,11 International congresses on peer review and biomedical publishing have taken place every four years since 1989.12 The federal government has established an oversight office for scientific conduct (which includes medical research), the Office of Research Integrity (ORI), which has conducted investigations into allegations of misconduct since 1992, publishing its findings in an annual report and on its website.13

Despite the numerous resources available to guide authors and editors through ethics dilemmas, breaches of ethics in medical publishing have not been eradicated. As recently as December 2009, the dean of the Yale University School of Medicine sent an e-mail to the faculty reminding them of the prohibition of “ghostwriting” in academic publishing.14 The ORI identifies several new cases of scientific misconduct each month.15 Although, at first glance, many of the recent cases of fraud and misconduct appear to have been perpetrated by rogue individuals with blatant disregard for the established rules, some of these incidents are associated with prestigious academic faculty, as the recent example of a Harvard researcher demonstrates.16 Furthermore, some genuine controversies and gray areas are still present in publishing ethics.

As many authors have articulated, the foundation of medical ethics is complex.17,18 Pellegrino18 acknowledges that the role of the physician can be conceptualized in many ways but argues that the role of healer supersedes all others and forms the foundation of medical ethics. In forensic psychiatry, the healing role of the physician may be, to some, less clear than in other subspecialties of medicine, which has led to the development of several derivative conceptualizations of ethics in the field.19,–,24 The debate about ethics in forensic psychiatry continues to evolve, and it raises an important question that we wish to examine in this article: Where does the foundation of ethics in forensic psychiatry publishing lie? Is it rooted in the healing relationship between physician and patient that Pellegrino describes, or is it more akin to the derivative conceptualizations of ethics in forensic psychiatry? Alternatively, are forensic psychiatry publishing ethics linked more closely to ethics in fields outside of medicine, such as those of journalism or business?

Many articles have addressed the ethics of publishing clinical case material and its impact on the relationship between patient and therapist.25,–,29 However, to our knowledge, only two papers, both by Walter *et al.*,30,31 have systematically examined the broader scope of ethics in psychiatric publishing. The first article, published in 2001, discussed publishing ethics in psychiatry, and the second, published in 2008, discussed the same topic in child and adolescent psychiatry. The cases of publishing misconduct identified in these articles are relatively few, comprising only a tiny fraction of the overall number of articles published each year. For example, only 2 of the 261 articles that have been retracted by MEDLINE over a 15-year period were psychiatric (Ref. 30, p 29). Nevertheless, Walter *et al.* identified several cases of unethical conduct in the psychiatric literature, which are summarized in Table 1.

View this table:
[Table 1](http://jaapl.org/content/39/3/332/T1)

**Table 1** 
Ethics Dilemmas in Psychiatric Publishing Identified by Walter *et al.*30,31

In this article, we build on the small body of existing literature related to publishing ethics in psychiatry by turning our attention to the subspecialty of forensic psychiatry. To our knowledge, this is the first article regarding publishing ethics within forensic psychiatry. We examine eight ethics dilemmas that have arisen in the publication of *The Journal of the American Academy of Psychiatry and the Law* (*The Journal*) over the past 10 years and how they were resolved by the editors. We hope to stimulate a discussion about conflicting ethics principles and contribute to developing a conceptual framework for ethics in forensic psychiatry publishing, not to articulate rigid rules of conduct for the field. In this way, we shall make a first effort at formulating a response to the question posed earlier about the foundation of forensic psychiatry publishing ethics.

## Method

The editors of *The Journal* identified all of the ethics-related dilemmas that had arisen during the 10-year period between January 2000 and December 2009. From these dilemmas, we chose eight to discuss in this article. The eight topics were chosen because we found them to be universal enough to appeal to a broad audience, particularly grave, or important to AAPL. We excluded dilemmas that were unresolved at the time of submission of this article. In addition, we excluded situations that, although controversial, were not of educational value and discussion of which would not shed new light upon the matter.

For each of the dilemmas, we briefly describe the facts of the situation as the editors encountered them. We identify the ethics principles that were considered relevant to resolution and state how each situation was resolved. In each case, the resolution is meant to be interpreted as one of several possible solutions, not as the sole correct one or as a directive for future conduct. The chosen resolution often raised additional ethics questions for the editors; these are also discussed.

## Results and Analysis

### Case Reports

*The Journal* instructs authors who submit manuscripts about projects involving human or animal subjects to provide documentation that the appropriate institutional review board (IRB) has either approved the project or exempted it from review. IRBs do not adopt a uniform approach, but in the editors' experience, most articles that discuss single case reports are exempted from IRB review. This exception leaves the editors with the challenging task of working directly with the author to balance competing ethics principles: the advancement of scientific knowledge, which encourages publishing the case report with as much detail as possible for the benefit of the reader, and respect for persons, which encourages asking for permission and removing excess detail from the article to protect the identity of the subject.

Although every medical journal must undertake this task to some extent, forensic psychiatry cases can be particularly challenging to publish, as the details of a particular case can much more readily identify the subject than in other branches of medicine. For example, an article written by a forensic psychiatrist discussing the details of how and why a man killed his parents could much more easily lead a reader to the killer's identity than an article written by a hematologist about a man's platelets. Thus, forensic psychiatrists—both authors and editors—must be particularly sensitive to the information that they choose to include in a case report. This is no easy task. Case reports submitted to *The Journal* frequently undergo several revisions to deidentify the subject and maintain his confidentiality to the extent possible.

However, the concept of respect for persons extends beyond just maintaining the confidentiality of the subject. There is another important principle that must be considered when deciding whether to publish a case report: ownership of the information to be published. For example, who owns the details of how and why the man killed his parents? Even if he is not identifiable in the case report, could the man not argue that the forensic psychiatrist has no right to publish information about him without his consent? Simply put, the man owns his life story. Although an argument can be made for publishing the information against the wishes of the subject (or simply without asking) for the advancement of knowledge in the field of forensic psychiatry, on balance, the editors have become increasingly sensitive to this problem and have risked erring on the side of respect for persons. Thus, in addition to a statement about IRB approval or exemption, authors are asked to discuss with the editors the manner in which informed consent was obtained from the subjects in case reports or the reasons that it could not be. In some cases, the editors have required substantial revision of manuscripts before publication, even at the expense of the authors' ability to illustrate all the points that they wished to convey. At times, authors have been displeased with this approach, which has left the editors to grapple with the question of whether there is a better way to advance scientific knowledge while still preserving respect for persons. It is also possible that the editors will encounter situations in which the subject's permission does not suffice, and the permission of the subject's attorney may also be needed to publish some details. Whether the subject has ownership of details revealed in open court is another unresolved question.

### Commentary on AAPL Practice Guidelines

*The Journal* has published AAPL practice guidelines related to several types of common forensic evaluations: the insanity defense, competence to stand trial, and psychiatric disability.32,–,34 Each of the guidelines was written by a small committee and then made available for review and commentary before publication as a supplement to *The Journal*. It was customary for the editors to solicit and publish commentaries by authors who were knowledgeable about the subject of each of the guidelines, but had not participated in their creation or the prepublication review. The commentaries appeared in issues published at the same time as the supplements. The appropriateness of such commentaries was the subject of a vigorous debate at an AAPL Council meeting.

The primary objection to publishing the commentaries was that AAPL members had already been given a chance to make comments before publication, and so they should not be afforded an opportunity to make additional critiques of the work in *The Journal*. The secondary concern was that the power of the organization and its consensus-driven guidelines would be weakened by internal critique. The editors were very sensitive to these viewpoints, as they knew that much time and effort had gone into the crafting of the practice guidelines, and the members of the committees were respected colleagues and friends. However, some Council members insisted that patients and other constituent groups have a right to read thoughtful commentary and analysis of guidelines intended to influence physicians' behavior. Thus, the editors were left with the task of balancing the ethics principles of intellectual honesty, academic rigor, and editorial independence from AAPL (by publishing thoughtful commentaries) with their desire to respect the opposing argument that consensus-driven guidelines directly benefit patients and evaluees and should be allowed to stand alone.

Ultimately, a compromise position was reached. Commentaries were solicited and published, but they were written as legal commentaries from U.S., U.K., and Canadian perspectives.35,–,38 In the editors' view, this diversity accomplished the goal of providing an intellectual counterweight to the views expressed by the authors of the guidelines without unnecessarily pitting colleagues against one another in the small community of forensic psychiatrists. It also maintained the consistent style of *The Journal* and its editorial independence from authors and the AAPL council. One could reasonably question whether the editors should have chosen one side or the other rather than arriving at a compromise position in this dilemma. By trying to strike a balance, did the editors sacrifice both intellectual rigor and respect for the needs of the parent organization?

### Institutional Review Board Approval

In one case, an author stated in an article that a research protocol had been approved by an institutional review board (IRB). The editors were later contacted by the IRB and told that the research protocol had not been approved by that organization. When the editors were made aware of the IRB's concerns, they contacted the lead author of the paper. At the request of the editors, an impartial committee was appointed to look into the matter, which eventually led to a published correction and disclosure statement by the editors and a formal response from the authors explaining how the error had occurred.

This incident highlighted the importance of the ethics governing intellectual honesty, respect for research subjects, and respect for colleagues. IRB approval is considered important by the editors of *The Journal* because it demonstrates concretely that an author has given sufficient thought to respecting the research subjects. In addition, the episode demonstrated the importance of respecting one's colleagues by not jumping to conclusions once an ethics-related concern has been raised. In this case, the editor had an obligation to investigate the matter in a fair and respectful manner. An independent, neutral committee was formed, and the authors were allowed to explain their side of the story in print. Thus, the readers were allowed to draw their own conclusions.

The manner in which this situation was handled raises additional questions. For example, how much investigation should editors conduct regarding authors' affirmations of compliance with *The Journal*'s requirements, taking into account the required costs and staffing? Furthermore, is an external committee the best vehicle for resolving such an issue, or should it have been handled by the editors?

### Authorship

Criteria for authorship in medical publishing have been discussed and debated at great length across all specialties of medicine. Forensic psychiatry is no different, although, to our knowledge, only Wettstein39 has addressed the topic of authorship in a forensic psychiatry journal. The editors of *The Journal* have long been aware of the viewpoint expressed by many that there are problems with the current system of authorship.1,5,40 Most notably, concern has been raised about the frequent mismatch between intellectual contribution and authorship, as evidenced by the practices of “gift authorship” (listing as an author an individual who did not substantially contribute to the work) and “ghost authorship” (omitting as an author an individual who substantially contributed to the work).41

In contrast to the large body of literature discussing authorship criteria, the topic of the order of authorship arises much less frequently. Wettstein pointed out the lack of formal guidelines regarding the order of authorship (Ref. 39, p 271), and our attempt to research the issue resulted in some thoughtful discussion, but no real consensus.42,43 Thus, it seems that the order of authorship is currently determined exclusively by the authors themselves, which can, of course, lead to significant conflict. Particularly when one considers the practice at some universities of basing promotions on order of authorship and providing greater monetary compensation to the first and last authors of a paper than to the other authors, one starts to understand why some have advocated “prenuptial agreements” between co-authors to avoid disputes.44 These disputes are perhaps most sensitive when they involve senior faculty and trainees or junior faculty, where the potential for exploitation and abuse of power is greatest.

Although we concede that the decision about order of authorship is probably best left in the hands of the authors themselves, we echo concerns that the absence of uniform definitions of terms such as “first author,” “senior author,” and “last author” creates serious potential for confusion on the part of authors and readers alike. The editors are not aware of specific authorship disputes that have arisen concerning articles submitted to *The Journal*, but debate about the topic has occurred several times over the years. At present, *The Journal* follows the three-pronged ICMJE guidelines to determine authorship: substantial contributions to conception and design of the study, to acquisition of data, and to analysis and interpretation of the data; drafting or revising the manuscript for intellectual content; and final approval of the manuscript. The editors do not ask authors to provide proof demonstrating that they meet these criteria.

The principal ethics-related concern raised by the question of authorship is one of intellectual honesty, and a secondary concern is one of respect for colleagues. The editors continue to consider the idea of moving away from the current system of authorship to a system similar to the contributorship model that is advocated by Wettstein (Ref. 39, p 272) and has been adopted in publications such as *The Journal of the American Medical Association* (*JAMA*) and *The Lancet*. In a contributorship model, authors specify the nature of their contributions and take responsibility for specific sections of the work, in addition to taking collective responsibility for the final manuscript. As Wettstein and others have indicated, a contributorship system potentially provides greater transparency in allocating credit. However, the editors of *The Journal* have not adopted this system so far because of its lack of wide acceptance in academia and concerns about its applicability outside of laboratory research. In addition, it is obvious that no model permits editors to know definitively who has or has not contributed to the authorship of an article. To search out the truth would require extensive investigative techniques that are likely to be unpalatable to those in our field and involve massive resources. Thus, the question of whether *The Journal* will eventually adopt a contributorship system remains unresolved.

### Bundled Submissions

The editors of *The Journal* have noticed an increasing trend in recent years for authors to submit two manuscripts on related topics as a bundle. For example, two papers may be submitted simultaneously on a clinical phenomenon such as infanticide: one describing the prevalence of the behavior and characteristics of perpetrators, and the other discussing forensic assessment and risk management strategies. The authors intend for the articles to be published in the same issue of *The Journal*. Therefore, they ask that the papers be distributed to peer reviewers together, to be read and critiqued as a pair.

In some cases, publishing two articles in this manner may be appropriate, as the individual articles may be too long to combine, or they may genuinely highlight different aspects of a topic that the editors feel warrant separate consideration. However, the editors are aware that authors may be serving their own interests in wanting to publish two articles instead of one. Many in the medical publishing community have raised concern about the tendency for authors to submit their work in the smallest publishable units to increase the number of publications that are generated from a single data pool.45 Such practices are considered unethical by some and a necessary evil by others, as the number of publications is still a critical consideration by most universities when deciding promotions and reappointments. Some have argued that all universities should take the position recently adopted by Harvard and the University of California—that of judging the quality of a few representative publications rather than the number of publications as a measure of a physician's productivity (Ref. 30, p 36). This could reduce redundant publication and ease the pressure that causes authors to prioritize numbers over quality.

The editors review bundled submissions to *The Journal* on a case-by-case basis. The primary ethics-related consideration is the principle of advancing knowledge. An additional consideration is the principle of respect for colleagues (i.e., fairness to other authors), as taking up space in one issue of *The Journal* with two bundled submissions may delay the publication of another article. Based on the comments of the peer reviewers, authors are sometimes encouraged to eliminate redundant information and combine two papers into one. In other cases, reviewers have suggested the opposite, that a particularly long paper be divided into two articles. The editors choose the format that provides the information to the reader in the manner that is easiest to comprehend. This case-by-case approach has served the editors well to date, but it raises the question of whether a uniform policy should be adopted. Should the editors always expect individual articles to stand on their own merit, and does taking a case-by-case approach leave *The Journal* open to accusations of bias and lack of objectivity?

### Bias in Peer Review and Editing

Peer review has been a cornerstone of medical publishing for decades, although many have raised concerns about its efficacy in accomplishing its stated goal: improving the quality of scholarship by subjecting it to critical analysis before publication.46,47 *The Journal* uses a blind peer review process, in which reviewers receive copies of articles that have been redacted to remove identifying information, but the attempt to ensure the author's anonymity is often futile. In reality, the forensic psychiatry community is quite small, and only a limited number of people routinely write about a given topic. This, in turn, creates a situation in which only a few people are knowledgeable enough to review critically a scholarly paper about that topic. Given such a small pool, it is often possible for reviewers to discern the identity of the authors, even in redacted manuscripts. Thus, there is always potential for rivalry and personal feelings to affect the peer review process, whether the authors of the paper are known or not.

The editors occasionally encounter instances in which peer reviewers have submitted critiques of articles that could be construed as biased. For example, some reviewers have drawn negative conclusions about a paper, citing their beliefs that a particular topic appears too frequently in *The Journal*. In another case, a reviewer stated that a paper was of poor quality because the reviewer's own work was not cited. Also, some reviews have contained criticism of the authors' work that was clearly meant to be punitive rather than constructive. In each of these cases, the editors sought to avoid perversion of the review process while ensuring the ethical treatment of colleagues, maintaining the advancement of knowledge, and preserving objectivity. Thus, they took into account the display of reviewer bias when making decisions about publication of the articles. However, it may not be possible to detect or remove all bias in a small scholarly community such as ours.

### Use of Pejorative Language

Ethical treatment of one's colleagues extends beyond the peer review process. The editors have occasionally encountered a different type of dispute between colleagues: complaints about pejorative language. In one case, an author was shown a commentary about his article before the publication of both pieces. He contacted the editors with a complaint that he found some of the language in the commentary insulting toward him and his work. He was offended and requested that the editors take action.

When deciding how to proceed, the editors attempted to balance the ethics of ensuring fairness to authors and respect for colleagues with advancement of knowledge. The editors wanted to maintain the spirit of vigorous intellectual debate in *The Journal*, but also to be responsive to the complainant. Several third parties were asked to review the commentary in question. They concluded that the author's language was not intemperate or insulting. Such a response cannot guarantee, however, that the complainant's concerns are fully resolved, and thus some sacrifice of one or more competing interests may be unavoidable. We must admit that there are complicated interactions at the border of legitimate intellectual debate and interpersonal conflict and disagreement.

The editors have also encountered complaints that the language used in some articles has been pejorative or disrespectful to their subjects. For example, the editors were concerned about the use of housewife to describe a woman in an article, believing that the term was derogatory toward women. The authors were asked to add a statement that the subjects were self-described housewives. In another example, *The Journal* now uses the titles Mr. and Ms. for persons involved in the legal system. The editors consider such matters carefully, particularly because so many persons who are the subjects of forensic publications belong to vulnerable groups: persons with psychiatric disabilities, racial minorities, prisoners, and individuals of low socioeconomic status. Efforts are made to respect and protect all groups. The required use of respectful titles for persons is an attempt to convey the appropriate tone, but is clearly not enough to salve the reality of the vulnerabilities of some groups.

### Conflict of Interest

The topic of financial conflict of interest in medical research has rightfully received much attention in the professional literature and the lay media over the past few years, and more stringent standards have been set for disclosure and management of such conflicts.48 The editors have taken notice of this development and have attended more thoughtfully to what might constitute a conflict of interest in forensic psychiatry. As part of that effort, *The Journal* has revised its guidelines and now requires that authors disclose in writing any financial involvement or other potential conflict of interest related to submitted manuscripts. Such disclosures are published in the article, allowing the reader to make determinations about potential biases of the authors.

One such example occurred recently, when an author submitted a manuscript in which there was an obvious financial conflict of interest. When the editors pointed out the conflict, the author readily agreed to disclosure. *The Journal* printed the information according to its policy, and the reader was left to decide what impact the author's financial interest had on the findings and conclusions presented in the article.

In many respects, this example demonstrates in a relatively straightforward manner the ethics of striving for honesty, objectivity, and respect for colleagues. However, in our opinion, conflict of interest can be a very complicated matter, one that is not limited to finances alone. We recognize that this is a thorny area that could be the topic of a separate paper, and we mention it here only to broaden the reader's concept of conflict of interest beyond the exchange of money. We urge consideration of the more inclusive disclosure of conflict of interest advocated by the ICMJE, which includes “non-financial associations that may be relevant to the submitted manuscript.”49 Even this definition of conflict of interest leaves considerable room for debate. For example, which financial involvements are merely involvements, and which are conflicts? How should the editors address more subtle conflicts of interest, such as the desire for academic or professional advancement? How can the editors become aware of conflicts of interest that are not obvious or noted by the authors?

## Discussion and Conclusion

In the analysis of the dilemmas described herein, several important ethics principles emerge: respect for persons, objectivity, intellectual honesty, advancement of knowledge, fairness, and protection of vulnerable groups. We sought to take an inductive approach and work from these principles, which arose in the practical resolution of ethics-related challenges, toward developing a conceptual foundation of ethics standards for publishing in forensic psychiatry. In particular, we hoped to address the question of whether ethics in forensic psychiatry publishing is rooted in the healing relationship between doctor and patient that forms the core of traditional medical ethics, or whether it is more closely related to the ethics of other fields: business, journalism, or even the derivative ethics of forensic psychiatry described by Appelbaum and others.19,–,24 In addressing this question, we hope to spark an exploration of the uniqueness (or perhaps lack thereof) of the ethics involved in forensic psychiatry publishing.

We begin by examining traditional medical ethics. As Pellegrino18 describes, there are multiple models of the physician-patient relationship, with the physician as clinical scientist, body mechanic, business person, social servant, and helper/healer. He argues that the role of healer is primary to all the others, each of which is to be understood as founded on the healing role. He also argues that the true foundation for medical ethics is to be found in what is unique to medicine: the healing relationship between the patient and the physician. In Pellegrino's scheme, for example, one would not look for a mechanic's ethics or an entrepreneur's ethics and work backward to a physician's ethics as body mechanic or business person.

Thus, the question is raised of whether the ethics in forensic publishing is founded in that same healing relationship or at a further derivative level, that of the forensic psychiatrist-evaluee relationship. Pursuit of the former foundation may be more structurally sound because its traditional footings are the result of centuries of crafting. That does not imply, however, a concomitant ease of establishing such a foundation for the ethics of forensic publishing.

Pursuit of the latter foundation has a certain appeal, in that the work of forensic publishing often seems more closely related to the work of forensic practice, especially evaluation practice. The effort to establish an ethics framework for forensic practice has produced varying and at times conflicting results. Stone19 and Stone and MacCourt50 expressed a pessimistic view of establishing such an ethics framework, although Stone recently conceded some progress in that direction. Appelbaum provided what has been termed the “forensicist” model based on respect for persons and truth telling.20 Griffith21,22 emphasized cultural dimensions and narrative. Norko24 discussed compassion as forming a core quality of forensic ethics. Martinez and Candilis23 described robust professionalism in conceptualizing the ethics required for the work. Each of these works has contributed greatly to the understanding of the ethics of forensic psychiatry, but the field continues to evolve, at times in different directions at once.

One solution to the dilemma of these divergent paths may be found in analogizing the phenomenological analysis of medicine by Pellegrino18 to a phenomenological approach to forensic publishing. If we examine the examples of ethics dilemmas given herein, some of the principles outlined are clearly related to the healing relationship between physician and patient. For example, obtaining informed consent and disguising patient identity in case reports can be tied directly to the idea of respect for patients and their autonomy. Obtaining IRB approval for research studies and avoiding the use of pejorative language in describing members of vulnerable groups can similarly be conceptualized as having a basis in the description of the healing relationship between physician and patient: First, do no harm. Thus, the traditional medical ethics principles of beneficence, nonmaleficence, autonomy, and justice are readily apparent in some aspects of forensic psychiatry publishing.

Other dilemmas described in this article, however, are less clearly associated with the healing relationship between physician and patient. For example, the handling of authorship disputes and decisions about publication of bundled article submissions seemingly have very little to do with healing. In these cases, one can regard the task of the physician-author and physician-editor as quite similar to authors and editors in other realms of publishing. Such a concept may lead us to the conclusion that there is nothing unique about physicians engaged in the act of publishing; intellectual honesty, fairness, and advancement of knowledge are universal objectives of publishing.

However, Pellegrino does offer a way in which the two seemingly disparate sets of principles, one unique to medicine and one not, can be merged. He describes the concept of the “virtuous physician” as one who has gained by habit the characteristics that optimize the attainment of the ends of medicine, and he takes a broad and inclusive view of the healing relationship when articulating the ideal characteristics of this virtuous physician. The virtues he outlines are fidelity, benevolence, effacement of self-interest, compassion and caring, objectivity, courage, intellectual honesty, humility, and prudence (Ref. 18, pp 14–15). He emphasizes that medicine and medical knowledge are powerful tools, and these ideals—honesty, humility, objectivity, and prudence—are necessary to temper their potential use to control others.

When applied to forensic psychiatry publishing, the concept of Pellegrino's virtuous physician seems to support all the principles that we empirically derived when examining ethics dilemmas encountered by *The Journal*'s editors. This notion leads us to believe that the ethics foundation of forensic psychiatry publishing can be established in the traditional patient-physician relationship and that looking beyond this relationship to the forensicist-evaluee relationship or to other disciplines such as journalism or business is unnecessary. The concept also implies that forensic psychiatry publishing shares a common ethics foundation with general psychiatry publishing and with publishing in all other medical specialties. One could argue that it also shares an ethics foundation with publishing in any discipline in which healing is a primary goal, such as clinical psychology or social work.

Although we concluded that there is something in traditional medical ethics that should be maintained when examining the foundation of forensic psychiatric publishing ethics, we acknowledge that there are limitations to this model. First, we rely heavily on Pellegrino's concept of the virtuous physician when deriving the point of departure for forensic psychiatry publishing ethics, and some may not agree with our interpretation of Pellegrino or our exclusion of other potentially relevant ethics concepts such as justice or Pellegrino's social servant model (Ref. 18, p 9). In addition, we are aware that our conclusion potentially conflicts with the idea of Appelbaum20 and others that the practice of forensic psychiatry requires a unique conceptualization of ethics. Finally, we have yet to incorporate many of the financial aspects of forensic psychiatry publishing into a “virtuous physician” model. For example, can the editors' role still fit into the concept of the virtuous physician if they must consider fiscal viability in addition to fairness or advancement of knowledge? In this context, some may well argue that, for example, the robust professionalism model of Candilis and Martinez23 is more immediately relevant.

We emphasize that these ideas are only a first attempt at articulating core principles and a foundation for ethics in forensic psychiatry publishing. We invite thoughtful commentary and critique of our work so that the field may move forward in exploring this critically important area.

## Footnotes

*   The authors, except for Dr. Young, are involved in the editorial leadership of *The Journal*. However, the authors did not participate in any aspect of this article's review and acceptance, which were managed by an ad hoc editor who is not a member of the Editorial Board.

*   Drs. Kapoor, Norko, and Griffith acknowledge salary support from the Connecticut Department of Mental Health and Addiction Services.

*   Disclosures of financial or other potential conflicts of interest: None.

*   © 2011 American Academy of Psychiatry and the Law

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