Abstract
Ethics-related dilemmas arise in forensic psychiatry as in all psychiatric practice. Although most can be resolved by following the AAPL Ethics Guidelines and the AAPL Ethics Questions and Answers, the more complex ones inevitably have no easy solutions. Ethics-based duties can conflict without clear guidance on prioritization. Weighing competing factors necessitates more than merely following a rule, since there are potentially conflicting rules, and ethical practitioners may prioritize them differently. Concerns pertaining to the death penalty and defendants who are victims of discrimination are especially difficult. Such considerations usually are in the realm of aspirational ethics, with conclusions open to debate. They need consideration by most practitioners concerned with determining the most ethical course of action. Much as it is insufficient for an ethical citizen merely to avoid breaking the law, it is not enough to avoid violating any one guideline while remaining blind to context. Most such dilemmas need resolution long before testimony and arise first in the way the forensic assessment is conducted and in decisions on the data to be included in a report and how they are presented. Although there can be legitimate differences of opinion about how to weigh and resolve conflicting considerations, ethics-related dilemmas should not be sidestepped.
Buchanan and Norko,1,2 in their paper in this issue and their recent book, focus on the forensic report as reflective of many significant questions that arise in forensic psychiatry. It is clear that many if not most cases are decided on the basis of forensic reports that lead to settlement without testimony, and their publications give the report the attention it deserves. As indicated in their paper,1 the resolution of complex legal problems is reflected in the forensic report. These comments make the point that considerations related to ethics are no exception.
Most of the ethics-related dilemmas should be resolved before and, if not, most certainly during the writing of the report. Initially, questions of ethics are of necessity encountered in the manner in which the interview is conducted and the relevant information collected. They are next encountered in the manner in which the case is analyzed in the report, long before and whether or not the case goes to trial. In addition to the forensic interview itself and before the report is written, questions arise regarding the gathering of information, the relevance of embarrassing information, and obtaining information without the approval of the person being evaluated, all of which must be resolved before the report is written. The decision about these questions is reflected in the way that relevant information is obtained and then subsequently in the way it is presented in the forensic report.
Buchanan and Norko1 recognize that there can be more than one perspective on a case, and the way that facts are described in the report reflects whose perspective is believed. Sometimes the report would do well to include both versions and a discussion of both. The authors raise the option of discussing reasoning at the same time the data are presented. Pollack3 recommended this approach a number of years ago. He thought that only the data relevant to the opinion should be discussed and only in the context of the report's reasoning section. Although few experts today present clinical data solely in the reasoning section of a forensic report, there are serious questions about the inclusion of clinical data that are not relevant to the reasoning about the legal point in question, especially if the information is prejudicial or unnecessarily embarrassing. Such information can be relevant if used to discuss and eliminate hypotheses. An additional valid reason to include clinical data is if the information is relevant to the diagnosis. Inclusion of a diagnosis in a forensic report has become more essential in recent years with the current decreased emphasis on psychodynamic explanations. Unless the information is relevant to the diagnosis or the reasoning section and applying the clinical data to the relevant legal issue, the ethics of including extraneous data may be questionable, especially if the revelation causes unnecessary embarrassment.
This commentary focuses on a discussion of the ethics-based facets of forensic psychiatric work, as reflected in the report. Some aspects are controversial, but dilemmas arise inevitably in forensic work. No simple rule always suffices, just as in the rest of psychiatry. It is impossible to follow any rule rigidly while remaining blind to all other considerations, because any rule on occasion will conflict with some other rule or duty.
There rarely are superordinate rules to decide how to prioritize conflicting ones. Superordinate rules can conflict as well. Even if one rule usually trumps another, it should do so necessarily, if violating the secondary rule could lead to serious harm, but minor harm would follow violation of the usually primary rule. The practitioner would face an ethics-based dilemma requiring balancing of conflicting duties. Most of the time, the majority of practitioners would agree, but in complex situations, ethical practitioners may come to very different conclusions with significant implications. In large part, differences depend on the value and weight each practitioner gives to competing considerations in a specific case. Nonetheless, weighing competing values and ethics principles requires thought with the rationale given for the chosen action or approach.
Some practitioners may not want to make such a complex assessment and analysis and instead always want to give the usual primary consideration precedence over all others. Taking this simple course is impossible though, even in other complex life roles, including psychiatric treatment. Similarly, it might be even ethical to steal something if needed to save a life or if the stakes are high enough. There is no persuasive reason that forensic psychiatrists should be uniquely single-minded and have simple duties.
In contrast to treatment, the problems can be more complex, since the goals and priorities of the very different systems of psychiatry and the law can conflict on occasion in serious ways. Forensic psychiatrists operate at that interface. Even in treatment situations, the need to protect society can be a conflicting consideration. Societal duties can outweigh patient welfare in situations such as reporting child and elder abuse. There, the law gives the societal benefit primacy without exception, and there is no professional ethics requirement to break the law.
Ethics-Based Dilemmas in Forensic Work
It is essential nonetheless to appreciate that, although there may not always be a clear resolution of ethics-related dilemmas that is satisfactory to all or even to most, relative consensus often can be achieved. As in all other fields of psychiatric practice, there are situations in forensic psychiatry in which guidelines and duties can conflict, with no simple solution sufficing. For example, in other practice areas not only do some societal considerations take precedence over helping a patient, but other considerations arise and need balancing in other areas of practice like managed care or research. Some societal duties such as reporting child abuse are spelled out for treating psychiatrists in statutes. Some are more complicated, such as patients who do not meet civil commitment criteria or do not meet the criteria to induce a Tarasoff-type responsibility, but yet are potentially dangerous.
In forensic psychiatry and all psychiatric practice, when there are conflicts between a harm and a good in different areas or two harms or two goods, the decision will not be easy. There are reasonable differences of opinion among practitioners. Rather than require liability or punishment if a forensic psychiatrist acts differently from another practitioner, these situations are best dealt with in the realm of aspirational ethics for those practitioners trying to determine the best or most ethical solution. The especially complex situations encountered by forensic psychiatrists may necessitate that they analyze complex situations and consult with other forensic psychiatrists with expertise in ethics involved in cases in which values are in conflict.
The primary ethics-related problems should be addressed at the outset when accepting a case and performing an evaluation, long before writing the report. These initial decisions are reflected initially in the interviews leading to the report. Those and potentially other decisions are reflected later in the report and what is included in it and later, in testimony. As the case progresses, new dilemmas may arise from the information obtained and require resolution.
One of the challenges of forensic psychiatry in my view is balancing conflicting ethics and other obligations. The ethics-related challenges are not reasons to avoid performing forensic evaluations, any more than one would shy away from clinical practice with difficult patients or administration, for example. They do require an awareness of ethics-based complexities and an acceptance that such analyses in complex cases may well lead to differing but acceptable ethical conclusions by different practitioners. The forensic psychiatrist should be aware of what is at stake and what is being sacrificed.
Despite the complexities, in most situations, an analysis of the ethics of one's actions is clear cut with general consensus and little controversy. Those questions are ones that are reflected in the American Academy of Psychiatry and the Law (AAPL) Ethics Guidelines for the Practice of Forensic Psychiatry4 or the AAPL Ethics Questions and Answers.5 However, guidelines are not the last word in the ethics analysis, just the beginning. It would be like saying a citizen is ethical if he breaks no laws. Not violating the law is a minimum requirement, but is not sufficient to assure that one is an ethical person. Sometimes it is even most ethical to violate an unjust law. There are many situations not addressed in laws that the ethical person still must consider, such as respecting and helping friends and others. Ethical individuals often come to different conclusions because any one person or group gives one consideration more weight than another or because of differences in willingness to confront controversy. These factors could lead to different decisions about the most ethical course of action with no consensus about what is the appropriate action for a good person or citizen, but they are still important to consider and come to a rationale and conclusion.
It is not sufficient ethically to avoid considering anything complex or to decide that simply not breaking the law or a guideline determines the right course of action. In rare instances, the most ethical action may be to break a law in an act of civil disobedience against a bad law, but one must be prepared to face potential legal punishment. In the legal system, such a concept is recognized in the phenomenon of jury nullification, when a jury believes following the judge's instructions and the law would lead to injustice. However, except in the most severe situations, such as genocide, no citizen is required to break a law, even if the law is unjust. Not breaking the law, of course, is just the beginning and not the end of an ethics analysis. Analogous considerations apply to forensic psychiatrists. There is no meaningful distinction between the words ethics and morality. Ethics is the term that tends to be used in the professional context, but the words are used interchangeably in other areas.6
In the forensic context, AAPL Ethics Guidelines4 are the floor and not the ceiling of forensic ethics. They are the beginning minimum and not sufficient and undoubtedly not the maximum or sufficient for forensic ethics. In most instances, the guidelines are more aspirational since they cannot be enforced. In my opinion that is not bad, because ethics guidelines can provide the most useful purpose, if seen primarily as aspirational, to stimulate consideration of ethics-related dilemmas. Punishment should be imposed only for serious violations. Some of the points made in the AAPL Ethical Guidelines do not readily lend themselves to enforcement, even if an organization or agency wanted to enforce the guidelines.
An example would be striving for objectivity. In the extreme, such as not making an effort to interview a defendant or to ask for readily available police reports, it might be clear that there was no attempt to strive to reach an objective opinion since the reports if obtained could have contradicted a convenient opinion, and sanctions could be enforced if an organization wanted to do so. In most such instances, however, it would be difficult to know the extent of the practitioner's striving for objectivity.
Bias is inevitable,7 but the challenge is, despite the inevitable bias, to strive to reach an objective opinion. For this reason, when I chaired the AAPL Ethics Committee, we replaced the requirement of being impartial and objective with honesty and striving for objectivity in the AAPL Ethical Guidelines. We did not think that the guidelines should require an unrealistic standard that would be near impossible to achieve. We also did not think it acceptable for a practitioner to reach a biased, subjective conclusion that would please the hiring side without making an effort to strive to reach an objective opinion despite bias. Minimal self-insight by all of us would reveal bias that needs to be resisted in striving to reach an objective opinion.
No simple rule can always be followed, even if it would be easier to do so, because sometimes there are conflicting rules, some of which can lead to discrepant conclusions. Like other psychiatrists, forensic psychiatrists cannot be in the position of having a simple duty such as answering the legal question without any consideration of competing values in the context in which the question is asked. Such a method of balancing conflicting considerations was described by Hundert.8
The Complexities of Compassion in the Forensic Role
An example of a complex concern is the role of compassion, as discussed by Norko.9 Compassion is expected of physicians, but in the forensic context its application can be especially complex. Even in the treatment role, if one is not careful, compassion can lead to rescue attempts that blur or violate boundaries. Respect for persons was introduced into the forensic context by Appelbaum.10,11 The AAPL Ethical Guidelines also refer to respect for persons, but compassion goes beyond that. On the one hand, it could lead to rescue attempts that can make it difficult to strive for objectivity. On the other hand, if the evaluation is being performed by the side opposite the evaluee, a display of compassion can mislead an evaluee into thinking the evaluator is trying to help. Even if a description of the evaluator's role is made as required by the AAPL Ethical Guidelines, there can be slippage in the understanding of the initial warning. The evaluee may begin to believe that the psychiatrist is trying to help, as he would in the treatment context.
That misconception creates a dilemma. On the one hand, trust might lead to openness and a more accurate and truthful explanation of what happened, thereby facilitating justice. It also could lead to distortions of facts in an effort to impress the perceived sympathetic evaluator with the cleverness of what the individual did. From the ethics standpoint, misleading an evaluee may be appropriate for a police detective, but it is unseemly for a physician who exhibits the helpful veneer that society expects. The role of the professional in the forensic context is complex and can be especially difficult in some situations.12 The role is broad and has been called robust professionalism by Candilis and others.13,14 With the expanded duties of psychiatrists, even in the treatment role in recent years, the complexity in the forensic role in my view is more one of degree than of kind. Traditional medical values, in my opinion, play a role in anything physicians do just by being a physician, regardless of the specific duty or admonitions because the person interviewed if not a career criminal may share perceptions society has that physicians have a duty to help.15,16
Compassion is part of the traditional physician's helping role. The treatment role, however, differs from the forensic role in important ways that should not be obscured. In my opinion, there is a difference in priorities and the differential weighing of competing duties and values, much like what happens in other complex roles. For example, if there were duties only to maximize profits, physicians in the managed care context could consult on how to deny coverage for expensive diseases in a way that would lead to patients' dying of their illnesses and save the plan money thereby. There also would be no problem in the research context in having a physician persuade a subject to remain in a study despite serious deterioration, to get better data, so long as retaining the patient is not explicitly forbidden in the review board-approved protocol. In these examples, competing medical duties require consideration.
Balancing Conflicting Ethics
Even in the treatment role, laws for reporting child and elder abuse always place societal welfare ahead of patient welfare in this treatment context so that the role of a treating psychiatrist is not single-mindedly to help the patient while being blind to all other considerations. To the degree possible, there is some legal recognition of the need to preserve the treatment role, even in this situation.17 Preventing a patient from engaging in a dangerous act will ordinarily help the patient as well as society to minimize conflicts of ethics and resolve any dilemma. However, reporting a threat to the police in a treatment context could help in the future prosecution of the patient if the act is completed. The information could even help the prosecution obtain a death penalty and has been used for that purpose.18 Increasingly, medical boards as well as the American Medical Association19 consider forensic work to be the practice of medicine and not unique.
It is difficult not to see medical duties as being relevant in part, even in the forensic role. The differences are those of priority and weight in various roles and contexts. Answering the question in the legal context does not uniquely preclude any other more traditional medical considerations, although they usually are secondary to honesty and the need to answer the legal question posed truthfully and with the relevant data.
Appelbaum10 has written that respect for persons is one foundation of the ethics-based duties of a forensic psychiatrist. Showing respect is independent of traditional medical duties, but is not inconsistent with them. It also applies to most roles of a physician and of a good person and citizen. Such respect can be especially important in the forensic context, because sometimes the forensic psychiatrist is on the side opposite the person being evaluated or the defendant may have done something terrible. If he is not careful, the forensic psychiatrist in such a position can begin to identify with the prosecuting attorney and begin to behave like attorneys whose main goal is to win the case instead of presenting the whole objective truth to the degree possible. An important difference, though, is that the role of the prosecutor or a defense attorney to win a case is clear.
A defendant who trusts physicians as people who help could be misled. Trust can remain despite any warning at the outset of the different forensic role. In fact, there is a risk that the initial warning could be interpreted as further evidence of the honesty and trustworthiness of the forensic psychiatrist. If, during the course of a case, there is clear slippage of the original warning, the most ethical course of behavior would be to reinforce the warning and make certain that it is understood. Except in the most extreme cases, the need for such a reminder would be more aspirational and would serve as a guide for the practitioner who is trying to be as ethical as possible. It would not be a requirement likely to warrant enforcement by punitive sanctions, because of the subjective nature of the decision regarding what degree of slippage requires restating the warning.
Special Ethics-Related Challenges
Lack of any effort to be objective also can become a concern if the psychiatrist is trying to compensate for perceived or real discrimination, as demonstrated by the behavior of Dr. Leo in 19th century England, as described by Stone.20 As indicated by Griffith21,22 the perspective of groups who have been discriminated against in the legal system may need special consideration, but that does not mean that the opinion on the legal issue should be distorted. Legal restrictions do not entirely preclude an effort to bring such perspectives to a court's attention. Bias without any attempt to strive for objectivity could backfire and result in the complete loss of credibility for the expert. In addition, it can lead to a loss of respect and credibility for all the psychiatric testimony in the case in question and for the entire profession. An attempt to sabotage the system might be heroic in a completely corrupt system, such as that in Nazi Germany or a corrupt, abusive dictatorship, but such heroics are not acceptable in the American justice system, despite its imperfections.
These points might be especially apparent in a death penalty case in which the psychiatrist is working for the prosecution in the penalty phase and trying to present evidence of aggravating factors, although aware of the risk of even intending to facilitate a death penalty verdict or even trying to get such a sentence. There is a common saying in law that death is different. A difference is that minor points of ethics can become major in the death penalty context, since irremediable loss of life can result from an enthusiastic presentation of damaging information. Working for the defense in such cases can also present problems if a psychiatrist is sufficiently opposed to the death penalty or likes a defendant enough to be willing to distort data to help save a defendant's life. Arguably, there should be more concern if psychiatrists act in a questionable manner when working for the prosecution than for the defense in a death penalty trial, since facilitating death is so contrary to the role society expects from physicians and Hippocratic ethics, but neither is ethical or appropriate. In the ethics guidelines of the American Psychiatric Association (APA) and AMA, the injunction is against participation in a legally authorized execution, although it is narrowly interpreted as participation in the actual execution process itself. It implicitly recognizes such a role as inappropriate for a physician.
The Need to Avoid Exaggeration in Forensic Work
It is important not to overstate the case in a report and testimony. For example, it can be easy in a malpractice case to think that if the psychiatrist on trial treated a patient differently from the way a forensic expert would have, with a poor outcome for the patient, the treating psychiatrist must have been negligent or, in the extreme, even unethical. That notion, of course, is misleading and may not be true. A bad outcome does not imply negligence. Even good treatments lead to bad outcomes sometimes. It is all too easy for a jury, if there is a bad outcome, to think after the fact that the treatment must have been negligent and the psychiatrist should have known better and treated the patient differently. A forensic psychiatrist making such assertions can facilitate unjust, erroneous outcomes. Even if the treatment the expert advocates had been used, there could still have been the same or another bad outcome.
In situations of suicide, the best way to reduce risk is never to treat a high-risk patient or to lock the individual up under suicide precautions for lengthy stays, as was done in the past, even though such a solution is not presently common or a realistic standard of care. Such treatment would hurt patients by usually unnecessary incarceration. It is important in deciding whether a treatment was negligent and not just to look at the bad outcome or what a particular forensic expert would have done. Instead, it is necessary to consider whether a substantial number of treating psychiatrists would have treated such a patient in the way the treating doctor did, without the benefit of knowing what the outcome would be at the time the decision was made. It also is unreasonable to think that high-risk suicidal patients will never kill themselves, even if the best treatment is applied. Some chances or risks inevitably must be taken if the patient is not to be locked up under constant observation for months or years. The liability should not increase for undertaking the treatment of a high-risk patient. The ethical forensic psychiatrist should be careful not to misstate the facts or hold others to an unreasonable standard of care that ignores the real risks in treating difficult patients. This subjective standard for the expert again may be aspirational most of the time and hard to enforce, except in extreme situations where there clearly is no basis for what the forensic psychiatrist is claiming. These considerations are essential in trying to do the most ethical thing and can provide guidance.
Conclusion
In summary, the role of the forensic psychiatrist is a challenging one requiring the balancing of conflicting values. Forensic psychiatrists are not and should not be immune from challenges presented by conflicting ethics in determining the right course of action and may encounter them relatively often, with much at stake. Some problems may be less complex for the forensic than for the treating psychiatrist whom a patient has every right to think is there to help, but who then causes the patient serious problems with, for example, a child abuse report. Another example arises in the treatment context in which an accurate disability report would deprive a patient of needed assistance because a completely honest report best describes the estimated period of disability to be shorter than that required to qualify for assistance. It can be even more of a problem in the treatment context, because most patients have good reason to think that a treating doctor will put the patient's welfare above the needs of society. For that reason, some psychiatrists avoid the forensic role. In situations in which a treating psychiatrist is forced to act forensically, an ethics-related dilemma arises as to whether to give primacy to patient welfare or to an honest report that will benefit society more than the patient who legitimately needs help since the treatment of the patient is primary and the forensic role is being forced on to that. Ideally a separate forensic assessment by another psychiatrist would be the cleanest solution and would not mix roles. In a separate forensic capacity, however, it is clear that an honest opinion and report have primacy.
In a disability context, the treating doctor is in an ethics bind. Does the psychiatrist distort the opinion to help the patient if the estimated length of impairment needed for disability payments is unrealistically long? Or does he accept the temporary forensic role that he is forced into and put an honest opinion before the welfare of the patient? This can become even more complex in cases in which a forensic psychiatrist is hired to perform a confidential evaluation for a defense attorney. Does child abuse reporting trump the confidentiality of the evaluation, especially if a prosecutor could use the information to prosecute the individual more than to stop the abuse? What trumps what is a complex legal question as well as one of ethics. There would be less of a problem if the information could not be used against the defendant and could be used solely as a confidentiality violation to stop ongoing abuse without violating privilege so it could not be used against the defendant. Similar concerns arise in a confidential forensic evaluation for a defense attorney when the person being assessed makes serious threats of violence against other people, even if he remains in custody, requiring balancing conflicting duties.
Dangerous patient privilege exceptions reasonably used to prevent future harm invariably can be applied to punish past crimes whenever this line has been crossed historically. When confidentiality is violated, privilege seems to disappear as well with little effort to preserve it. The APA in a position statement for these reasons opposes a dangerous-patient exception to privilege.23 A confidentiality exception would probably be acceptable and desirable if it clearly does not waive privilege and is limited to extrajudicial contexts. There would have to be a sharp line between confidentiality and the misuse of the privilege exception to punish past actions. The problem is that courts invariably have confounded this question when addressing it and either have found no exception or have issued a waiver of all relevant privilege as opposed to developing a balanced approach. In recognition of this invariable pattern and that usually information can be obtained from other sources, it seemed better not to have a dangerous patient privilege exception.
In the forensic realm, answering the legal question trumps patient welfare, but saying it trumps it does not mean that it always should carry the day. There may be some roles that are not appropriate for physicians, even in a forensic capacity. For example, it is not considered ethical to be a participant in a legally authorized execution, although it has been interpreted as restricted only to being part of the execution process itself. There may be other roles that the profession or a particular individual forensic psychiatrist considers unethical, regardless of what others think. In the latter situation, it is best for the psychiatrist not to accept such a case. Since ethics guidelines are consensus documents and represent the minimal ethics requirements in the field, there likely are to be other activities or roles individual forensic psychiatrists would consider unethical.
In the forensic role, answering the legal question is best seen as deserving of more weight than helping the defendant. As opposed to a treating psychiatrist, the forensic psychiatric role is not primarily to help a defendant,24 but that does not make such considerations irrelevant. In rare instances of extreme harm, answering the legal question does not necessarily outweigh all else, and the best solution may be not to accept the case.
Another question is whether who hired the forensic psychiatrist should make a difference. Despite the oath to tell the truth, it is almost impossible for the forensic psychiatrist, even if unintentional, not to spin the truth in the report and testimony at least to some extent in a way to help the side that hired him.7 Despite the unavoidable bias, it is important to strive to reach an objective opinion. That point is acknowledged by AAPL in the ethics requirement to be honest and strive for objectivity. Not only does exaggeration violate a commitment to truth and honesty, it risks undermining the credibility of the expert if good cross-examination makes evident the distortions caused by bias. The absence of good cross-examination risks an unjust outcome consistent with the evaluator's biases.
Balancing conflicting values may not result in clear, easy answers, and there can be legitimate differences of opinion. The situation may not be ideal, but the balancing of conflicting values is inevitably necessary. There are no easy, clear-cut solutions when the requirements for ethical practice conflict. They require acknowledgement of the matter at hand and an effort to reach the most ethical solution. Reaching resolutions is part of what makes forensic psychiatry interesting and challenging. Ethics-related problems are not reasons to avoid forensic work, just as they should not cause the practitioner to avoid the rest of psychiatric practice. There is no persuasive reason that forensic psychiatrists uniquely should have a simple duty, especially since the veneer and training of a physician is usually offered as relevant. There is no reason for forensic psychiatrists to answer the legal question but remain blind to the consequences, any more than treating psychiatrists can be blind to the consequences of placing patient welfare first when it could put others, such as children or the elderly, at serious risk. It is part of all psychiatric practice. The difference is that forensic psychiatrists may encounter these problems more often than treating psychiatrists and give the welfare of the person evaluated a lower priority than required of treating psychiatrists.
Even so, cases are relatively rare in which conflicting values and duties lead to dilemmas with legitimate differences of opinion, but they do occur. Most forensic psychiatrists likely want to do the right thing and not just the minimum needed to avoid trouble. Unlike attorneys, who are expected to advocate for their side and for whom it is acceptable ethically and often perceived as clever to leave distorted impressions that help their side, experts take an oath to tell the whole truth, at least to the degree that the legal system allows it.
Discussions of ethics should go beyond the minimally acceptable standards and involve discussion of the most ethical course of action. It is part of the challenge of forensic psychiatry that should be embraced by practitioners instead of seeking a unique immunity as some do, as if forensic psychiatry uniquely is different entirely from all other psychiatric roles with which there are many commonalities. The need applies to all experts, of course, not just psychiatrists. In my opinion, these more complex ethics facets need more discussion and should not be dismissed or avoided. They should be addressed in the report and assessment, long before trial. Life and all psychiatric practice presents ethics dilemmas and conflicting duties. Forensic psychiatry is no exception. Forensic psychiatrists would do well to embrace and not avoid such challenges and ethics analyses when facing complex dilemmas.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2013 American Academy of Psychiatry and the Law