Abstract
Dr. Ezra Griffith's retirement as Editor of The Journal motivated this reflection on his contributions to forensic psychiatry. In 1998, Dr. Griffith published a response to Dr. Alan Stone's views and Dr. Paul Appelbaum's theory on ethics in forensic psychiatry. This response has been often labeled as the “cultural formulation” perspective. This article reviews some of the major contributors in the development of ethics and professionalism for forensic psychiatry and offers a perspective on Dr. Griffith's contributions in this evolving and relatively young sub-specialty within psychiatry. With his scholarly contributions to the field of ethics, Dr. Griffith has offered a bridge that connects past attempts to define our sub-specialty to a future formulation of the goals and purposes of forensic psychiatry, something that the author recommends as a next step.
Given Dr. Ezra Griffith's prolific scholarship in ethics and forensic psychiatry, how might we understand his work as a bridge to the future in the task of further defining the goals and purposes of this relatively young sub-specialty of psychiatry? What social good do forensic psychiatrists, as individuals and as a professional organization, provide to society? This article reviews some of Dr. Griffith's contributions to forensic psychiatry and examines how his scholarship connects past contributions defining the role of the forensic psychiatrist to current recognition and concerns about social inequities encountered in the everyday practice of forensic psychiatry and forensic psychology. Through his work, Dr. Griffith challenges us to move into the future with greater clarity and understanding of our professional identity and the moral requirements of our work, to identify how we collectively contribute to the social good. Forensic psychiatry has not yet identified a set of goals and purposes that apply to all forensic mental health professionals. This article responds to Dr. Griffith's challenge and acknowledges his contributions as a bridge that links the past to the future in defining our work.
Dr. Griffith's Scholarship
To understand Dr. Ezra Griffith's contribution to forensic psychiatry and ethics, several of his many publications in The Journal are essential reading. In response to proposals on ethics in forensic psychiatry by Dr. Alan Stone and Dr. Paul Appelbaum, Dr. Griffith presented a dramatic alternative in 1998 when he proposed a cultural perspective to Dr. Stone's earlier expressed doubts about the role of the psychiatrist in the courtroom, and to Dr. Appelbaum's proposal that forensic psychiatrists must prioritize ethics principles and remain loyal to the ends of the judicial system over the obligations of physicians to patients.1,–,3 In a response to Dr. Thomas Gutheil's article on the difficulties of truth-telling in the courtroom,4 Dr. Griffith described the problem: “Appelbaum's call for truth-telling is empty if the legal system achieves no just result. Telling the truth for the sake of telling truth is an adaptation of the credo that pushes art for the sake of art…. I for one cannot pat myself on the back when I tell the truth in court and the end is unjust” (Ref. 5, p 430).
Dr. Griffith raises important questions. If fidelity to the legal system is our highest priority in expert work, as promoted in Dr. Appelbaum's theory of forensic ethics,3 that is, if telling the truth contributes to unfair outcomes and perpetuates a system with inequities between nondominant and dominant groups, then such a theory, when denuded of culture, is ineffective. If we contribute to the harms within these systems, then we are not acting ethically, even if we remain faithful to the legal system and its ends. Dr. Griffith would have us examine cultural assumptions contained in our personal narratives to increase the opportunity for ethical outcomes. In his writings, Dr. Griffith challenges forensic psychiatrists to consider professional identity through the lens of culture, to enter into the complexity of this work rather than rest in a set of rules and principles.
Dr. Griffith introduced the concept of personal narrative and perspective as components of forensic practice in addressing a legal system that is not only imperfect, but a system that can perpetuate injustice and inequities within society.6 His perspectives challenge forensic practitioners to consider larger moral obligations given the cultural context that contains individual cases. Dr. Griffith reminds us that we cannot separate our personal narratives and the perspectives derived from our personal stories from our professional activity and judgment. We have an obligation to transform unfair systems, and at minimum avoid contributing to unfair outcomes in those systems.
In addition to his views on culture and ethics, Dr. Griffith reminds us that, while our duty to “strive for objectivity” in our forensic work is laudable,7 we are involved fundamentally in a “performative” activity, both in report writing and in testimony.8,–,10 The premise that forensic reports and testimony are objective and impersonal is untrue. In these important articles, Dr. Griffith and his colleagues identified two central activities of forensic practice as core competencies: the writing of forensic reports and the oral presentation of forensic evaluations and opinions in various settings, including the courtroom.
Dr. Griffith challenged forensic psychiatrists to “seek to be creative, both in developing new ideas relative to their work and in presenting all their thoughts in written form as attractively as they can” (Ref. 8, p 28). Dr. Griffith believes that disseminating information and communicating ideas in both written and oral forms that have major impacts on persons requires significant attention in training. He points out that, unlike other medical specialties where the written word usually describes the intervention and product of an intervention in the form of a chart, in forensic evaluations, the written word and spoken word are the intervention and product. Joining Dr. Robert Simon's view that forensic writing must involve clarity and precision,11 Dr. Griffith and his colleague, Dr. Madelon V. Baranoski, stressed that forensic report writing should be viewed as a core competency of forensic psychiatry.
Dr. Griffith, along with his colleagues, launched an important and novel consideration in the 50-year debate as to the professional role of forensic mental health professionals, hinting at the ethics goals and purposes that are foundational to forensic practice. Dr. Griffith and his colleagues provide a unique conceptualization. As an interdisciplinary thinker and teacher, Dr. Griffith ties together scholars from philosophy, literature, law, other humanities, and science. Borrowing from these disciplines the metaphor of the theater, Griffith and colleagues describe these products of forensic work as “acts of performance, requiring a degree of artistry and cogent argumentation” (Ref. 8, p 27).
While the full breadth and diversity of Dr. Griffith's many intellectual contributions is beyond the scope of this article, he and his colleagues introduced the link between performance, meaning-making, and professional identity in forensic practice. His work on professional identity is particularly relevant to the purposes of this article. In his works addressing performance and narrative, he recognizes that, in forensic work, practitioners are in the unique position to bear witness to human suffering, and in such activities the moral burden is great. Dr. Griffith wrote:
We are not referring to the conventional task of being an expert witness or a fact witness in court…. The usual thought is that we, as expert witnesses, present the results of our forensic evaluations to the court so as to aid the participants in the judicial process to make sense of psychiatric and psychological data…. We should present our narrative view of the story; we should testify as witnesses to our views of meaning-making related to the data. In that way we become participants in the very stories we create… (Ref. 10, p 353).
Historical Background
Bernard Diamond and Seymour Pollack
Before the contributions of Drs. Stone, Appelbaum, and Griffith, and before there was an American Academy of Psychiatry and the Law (AAPL) as we know it today, numerous forensic practitioners tackled many of the same questions that continue to cause reflection about the ethical practice of our profession. Forensic psychiatrists, a generation or two ago, were general psychiatrists or psychoanalysts who came to the legal world from the clinic and were physicians to persons with mental illness. The role of expert evaluator challenged early forensic psychiatrists with problems of redefining confidentiality, applying medical knowledge to legal questions, understanding competing roles, and reconciling loyalties to legal questions with the traditional ethics obligations to patients.12
Dr. Jonas Rappeport wrote about the differences between the clinician psychiatrist and the forensic practitioner,13 emphasizing the important ethic of informing the “patient” of the limitations of confidentiality. Dr. Robert Weinstock considered the legitimacy of the forensic expert as dependent on his medical knowledge and training.14 Dr. Richard Ciccone and Dr. Colleen Clements emphasized the value of applied clinical ethics and case studies as an approach to solve role dilemmas in forensic psychiatry.15 They made important contributions to understanding the forensic psychiatrist as an expert witness,16,17 and they were the first to anticipate the necessity of a systems approach to solving ethics problems in forensic psychiatry.18 Others from this rich history of forensic psychiatry have considered dual roles and conflicts of interest.19
Dr. Bernard Diamond and Dr. Seymour Pollack warrant special attention in linking the past to the work of Dr. Griffith and to recent scholarship on the topic of ethics in forensic psychiatry. Drs. Diamond and Pollack wrote about the role of the forensic psychiatrist and the ethics dilemmas emerging from forensic practice. Many of the current and continuing debates about this role can be found in the writings of these early forensic practitioners.
Dr. Diamond, a California-based psychiatrist, was an expert witness in the Sirhan B. Sirhan trial for the murder of Senator Robert F. Kennedy. He was a proponent of the “diminished capacity” defense, and he left a prolific scholarship in legal and psychiatric journals along with his legacy in education and as an expert witness.20 He argued that the role of the forensic psychiatrist must include willingness to refuse participation when the findings from an evaluation will be used to distort justice.21,22 Dr. Diamond, in 1959,21 emphasized the fiduciary relationship between doctor and patient, and while he acknowledged that the role of the forensic evaluator is different from the traditional role of the physician, he emphasized that the forensic expert must be more than a tool of the law. “The psychiatrist is no mere technician to be used by the law, as the law sees fit, nor is the science, art, and definitions of psychiatry and psychology to be redefined and manipulated by the law as it wishes” (Ref. 22, p 123).
Similar to postmodern philosophers' perspectives on objectivity and truth, Dr. Diamond recognized that the forensic expert could not obtain some form of objective truth, some “impartial, detached, scientifically objective” opinion, but called such a view an “illusion” (Ref. 22, p 124). He was one of the first forensic psychiatry writers who understood the myth of the objective expert, that “there is no such thing as a neutral, impartial witness” (Ref. 21, p 229). He argued that the forensic expert must care about how his opinion is utilized. “I believe that in all cases, the forensic psychiatrist must insist upon full disclosure of the uses to which his testimony is to be put and the ultimate consequences arising from it. If such use and consequences would be contrary to the professional and/or ethical judgment of the expert, he should refuse to participate” (Ref. 22, p 123). Dr. Diamond was critical of the “hired gun” and recommended that organizations such as AAPL should take steps to eliminate such practices by setting high standards of practice and ethics.
Dr. Diamond proposed that while the forensic psychiatrist's primary area of knowledge is in the field of medicine, the forensic practitioner had an obligation to understand the law and therefore anticipate how his opinions might be construed in the legal context. The forensic practitioner must have “sufficient knowledge of the law to take responsibility for the application of their medical skills and knowledge to the law and resist all applications which are in opposition to fundamental principles of justice and to the spirit of humanity inherent in all of medicine” (Ref. 22, p 129). Dr. Diamond envisioned the role of the forensic expert as an educator in the courtroom and to the legal profession, and forensic psychiatric experts' legitimacy started with the fact that they are medical doctors.
Dr. Seymour Pollack spent much of his professional life in California. He was a founding member and the third president of the AAPL.23 Dr. Pollack believed that forensic psychiatry should direct itself to the legal system rather than the goals of medicine. At first glance, it may appear that he stood at the opposite pole from Dr. Diamond. In believing that forensic psychiatry should have fidelity to the ends of the legal system and function separate from the goals of clinical psychiatry, it does appear that way. But on closer read, it is more complicated; his thinking is more nuanced.
Dr. Pollack, in his 1974 article,24 distinguished between the developing field of forensic psychiatry and the field of psychiatry and the law. By distinguishing the difference between the Rule of Law and the rules of law, Dr. Pollack argued that the Rule of Law “embodies our concepts and ideals of social justice” (Ref. 24, p 16, emphasis in original), whereas the rules of law are equated with “legal justice” (Ref. 24, p 17, emphasis in original). Dr. Pollack made a distinction between the ideal aspect of the Rule of Law and its objective of social justice and the operational aspect of the rules of law and its objective of legal justice. Dr. Pollack believed that the rules of law could lead to social injustices when some laws are favorable to certain groups and disadvantageous to other groups. He believed the field of psychiatry and the law is obliged to promote the Rule of Law and social justice. He wrote: “In my opinion, the Rule of Law imposes a social obligation on psychiatrists, as professionals in our society, to assist our legal instruments of social control, social regulation, social learning, and social change. Thus, the field of psychiatry and law supports the law's humanistic posture for the attainment of social justice” (Ref. 24, p 18).
Dr. Pollack described forensic psychiatry as a subset of psychiatry and the law, with a “specific instrumental function, the use of psychiatry for legal purposes” (Ref. 24, p 18). He saw forensic psychiatry then as a tool for legal justice, for resolution of civil and criminal issues in a particular case or situation. He saw the purpose of forensic psychiatry as no different from forensic odontology or forensic toxicology. He coined the term “principle of legal dominance” as a first principle for forensic psychiatry's fidelity to legal ends and argued that therapeutic goals of psychiatry are subservient.25,26
Dr. Pollack, while believing that the forensic expert should not contaminate that role with advocacy for reform, acknowledged that when an expert believes that specific rules of law conflict with one's sense of social justice, the practitioner can simply refuse to participate. A criminal responsibility examination in a capital case may result in a death sentence, even if the forensic evaluator is personally opposed to the death penalty. One option is to refuse to participate. However, if the forensic evaluator chooses to only participate in those legal issues that reflect his values, he loses credibility. He recommended that the forensic expert, when functioning in the expert role, should avoid advocacy for reform, while advocating for one's opinion was appropriate. For Dr. Pollack, there was an assumption that neutrality, detachment, and objectivity are possible, a point of view with which Dr. Diamond disagreed, and which later we see critiqued in the work of Dr. Griffith and others.
Stone and Appelbaum
In 1982, Alan Stone spoke to members of AAPL on “The Ethical Boundaries of Forensic Psychiatry: A View from the Ivory Tower,”2 now an essential reading. Dr. Stone expressed extreme skepticism about the role of the psychiatrist in the courtroom, a position that has driven much discussion in the field of forensic ethics in the last 35 years. For perspective, his talk was given following the trial of John Hinckley, who shot President Ronald Reagan and White House Press Secretary James Brady in 1981. Psychiatry was experiencing a wave of public criticism because of Mr. Hinckley's acquittal.
In his landmark article in 1997,3 Dr. Appelbaum provides a description of Dr. Stone's speech, acknowledging his relationship to Dr. Stone and describing him as a mentor. He summarizes that Dr. Stone in his talk and subsequent article raised three major concerns for the developing sub-specialty of forensic psychiatry. First, Dr. Stone questioned whether psychiatry could offer anything of value in the courtroom. Secondly, he outlined the problem for forensic experts in balancing their obligation to justice and fairness with the inclination to serve the patient's interests. Thirdly, he expressed doubt about the forensic psychiatrist's ability to remain uncorrupted by the adversarial system, offering opinions highly influenced by the side that hired the expert. Dr. Stone argued that forensic experts are out of their element in entering into the moral and legal dimensions of the adversarial system and, therefore, should not be there in the first place.
In response to Stone, Dr. Paul Appelbaum spent a sabbatical working on a theory of forensic ethics. While the relatively young organization of AAPL was attempting to codify a set of principles unique to the forensic specialty, forensic psychiatry lacked a “theory” of ethics to guide practitioners. In 1997, Dr. Appelbaum's now landmark paper, first presented as a presidential address at AAPL, was published in The Journal. He attempted “to draw out and systematize the ethics principles that I thought already immanent in forensic practice…” (Ref. 27, p 196). In his article, Dr. Appelbaum provides a background on the nature of professions and the difference between moral rules and moral aspirations. He provides an eloquent discussion of how aspirations can sometimes transform into rules, and how each profession must struggle with privileging some rules over other moral rules specific to the expectations of society upon that profession.
Dr. Appelbaum provides a cogent argument of why the foundational principles of beneficence and nonmaleficence in the clinical relationship with patients cannot guide forensic practitioners in their role as experts. He argues that the research physician is acting for a different societal value and goal from the physician who is solely engaged in the clinical care of patients, and thus is justified in asking patients to participate in double-blind studies where an individual patient may be subject to a placebo or perhaps a treatment intervention that may turn out to be harmful or minimally beneficial. Dr. Appelbaum utilizes this example to then present a “theory” of ethics for forensic psychiatry that re-orders the importance of certain ethics principles.
Dr. Appelbaum, for his theory, resolves conflicts between principles in forensic practice by making primary the two principles of truth-telling and respect for persons. In terms of truth-telling, Dr. Appelbaum is not suggesting that forensic psychiatrists have some special power to discern ultimate truth, but they should form opinions and testify in a manner that reflects what they honestly believe, which is a form of subjective truth-telling, and those opinions must be consistent with scientific understanding and standards within the medical specialty of psychiatry. Dr. Appelbaum's theory requires that the expert's opinions be the product of thoroughness and competency and possess integrity. In terms of respect for persons, Dr. Appelbaum envisions evaluations that avoid “deception, exploitation, or needless invasion of the privacy” of evaluees (Ref. 3, p 197).
Dr. Appelbaum did not account for the inevitable inequities that exist within the justice system, the nontransparent processes and rituals that move the system forward, but that, on fuller analysis, may lead to unfair outcomes. Dr. Griffith noted this problem and subsequently, in his own work, criticizes Dr. Appelbaum's main premise that led to his prioritization of a set of principles. Dr. Appelbaum did not consider that the processes involved in an adversarial system of justice are full of tensions pulling in one direction or another toward a victorious narrative, often involving distortions of the truth.
In support of Dr. Appelbaum's theory, he made it clear that when he suggested a theory of ethics, he was limiting this theory to those activities involved in the evaluation of individuals for the purpose of generating a report and possibly testifying in an administrative or legal setting (Ref. 3, p 238). The activity of forensic psychiatry has expanded considerably since he offered his theory. Dr. Griffith's work offers guidance as experience teaches that our engagement in the human suffering of forensic work cannot be morally managed with a set of principles alone.
A Bridge to the Future
Dr. Griffith's Cultural Formulation
In his cultural formulation article, Dr. Griffith responds to Dr. Stone's “ivory tower” position, Dr. Appelbaum's theory of ethics, and most importantly, why as “an African-American forensic psychiatrist, it is important for me to stay in the courtroom” (Ref. 1, p 172). In his original presentation and paper, Dr. Stone reviewed the case of Dr. Leo, a Jewish physician who in 1801 testified on behalf of a fellow Jewish defendant who had been arrested for stealing spoons. Because Dr. Leo had been in court testifying on behalf of other patients who were Jewish, the prosecution discredited Dr. Leo as no more than a “hired gun,” obviously biased and unable to offer any objective and impartial testimony. For Dr. Stone, the story of Dr. Leo represented the use of psychiatry to twist justice to help his patient. In Dr. Griffith's perspective, to judge Dr. Leo without attention to “history, morality, and human values” (Ref. 1, p 175), misses the mark. Dr. Leo could sit on the sidelines or could “jump into the fray to be helpful in any way possible” (Ref. 1, p 175). Dr. Griffith poses a sympathetic view of Dr. Leo as he questions how “the nondominant group psychiatrist can stay on the outside of a process directed by the dominant group, which cannot be trusted in its dealing with nondominant group members” (Ref. 1, p 176).
Likewise, Dr. Griffith finds Dr. Appelbaum's elevation of the principles of truth-telling and respect for persons in the service of justice as problematic. Dr. Griffith points out that Dr. Appelbaum assumes the system of justice is value-free, and therefore, if one simply adheres to these principles, there is a worthy role for forensic psychiatry in the courtroom. Dr. Griffith points out that the system itself is full of inequities in its meting out of justice, including racism and other deficiencies, because the judicial system mirrors problems in our society writ large.
To solve these problems, Dr. Griffith argues that a mechanism for what he labels the “cultural formulation” must be incorporated into forensic assessments in the same way such an approach has improved clinical assessment and treatment. Dr. Griffith discusses his participation in the evaluation of Ms. Tawana Brawley, a young African-American woman who was making the claim that she had been raped by several men over several days (Ref. 1, p 181). Dr. Griffith discusses several possible ways he could have participated in the case, and then describes his chosen path that included findings that were not helpful to Ms. Brawley's claims, yet attempted to fully respect Ms. Brawley's nondominant group identity.
Ultimately, Dr. Griffith offers an approach that supports the conscientious forensic psychiatrist's “capacity to pick one's path through the minefield of forensic work that defines the accomplished expert” (Ref. 1, p 182). Dr. Griffith rejects activism in the court room but articulates why, in an imperfect and flawed justice system, forensic experts should not walk away, but instead should keep a watchful eye on the ways the present system utilizes the expert to perpetuate unfairness. When participants in the legal drama distort for purposes of winning, the expert must resist and advocate for a more nuanced complex narrative.
In 2008, Dr. Griffith published a series of articles in response to the 2007 annual AAPL meeting, which featured a panel including Dr. Stone and Dr. Appelbaum to revisit their disagreement. In his own article,28 Dr. Griffith again argues for the importance of recognizing the inequities in the justice system. He reasserts the reasons that forensic psychiatrists should continue to work in the courtroom. He concludes, 25 years after Dr. Stone's challenge to forensic psychiatry in 1982, that the field of forensic psychiatry is evolving and successfully defining itself with the creation of standards of practice and the development of core competencies. He closes with an optimistic statement: “It is in work such as this that the forensic psychiatrist will evolve a more secure professional identity, one effectively grounded in values and technique and less assailable by the whims and fancy of other disciplines” (Ref. 28, p 205).
Professional Identity and Compassion
In addition to his cultural formulation, Dr. Griffith considers the question of the moral foundation that defines professional life. He makes clear that he is a member of the “nondominant black group; and my professional identity is that of a forensic psychiatrist” (Ref. 6, p 372). He then offers a personal narrative to describe the foundation of his own moral development and professional identity. With such an approach, Dr. Griffith not only advocates for an approach directed at understanding professional identity and ethics, but he participates in storytelling, a process that allows for transparency to see how his personal and professional moral worlds interrelate. In addition, Dr. Griffith elaborates on his “cultural formulation” concept when he promotes an ethics in forensic practice that approaches “the work while sensitively recognizing the pain and suffering of the defendants and others we are called to evaluate—recognizing them as one of us. In recognizing their status, we should work hard to make sure we do not exacerbate their suffering, although in some cases it may be unavoidable” (Ref. 6, p 380). Dr. Griffith acknowledges the place of compassion and respect of dignity in forensic practice, themes further developed in the work of Dr. Michael Norko and Dr. Alec Buchanan.29,–,32
Dr. Norko acknowledges Dr. Griffith's influence in his promotion of the virtue of compassion in forensic practice. He notes that in Dr. Griffith's cultural formulation approach, Dr. Griffith references “compassion” on only one occasion but makes clear that at the center of Dr. Griffith's work is recognition that what is viscerally involved in forensic work is the empathic connection of evaluator to evaluee, a compassionate joining with the pain and suffering of others. For Dr. Norko, the challenge in forensic practice is how to remain mindful and aware of this connection, listening and encountering the deep narratives of evaluees, while serving the “disadvantaged without distortions” (Ref. 29, p 387). In a recent article, Dr. Norko provides a thorough and thoughtful extension of his concept of compassion with an invitation to forensic psychiatrists to consider their work as a “calling” and a spiritual activity.30
Dr. Buchanan reminds us that recognizing the inherent dignity or worth of all human beings must take center stage in our work. He makes the distinction that respecting the inherent worth of others requires more than respecting autonomy and the rights of others. While we may at times render opinions that are “harmful” to the persons whom we have been tasked to evaluate, we should not lose sight of the person. We must remain mindful of the subtle and not-so-subtle ways that our behavior and our words may inadvertently objectify others. All persons, even those who have committed horrendous acts, deserve this consideration. Dr. Buchanan recommends that respecting dignity as a primary principle in forensic psychiatry protects the most vulnerable and requires the forensic psychiatrist to be responsible to the relational aspects of the encounter.
Dr. Griffith makes clear that such an approach does not weaken the work of the forensic psychiatrist but causes the evaluator to be more conscientious. He writes: “It is in thinking more carefully about our evaluations—employing data from multiple sources when possible, emphasizing the need for completing the cultural formulation, checking and rechecking information—that we will do justice to the tasks we are hired to carry out. In other words, connecting to our subjects as human beings drives us to do our work professionally and humanely” (Ref. 6, p 380). Dr. Griffith does not reject Dr. Appelbaum's prioritizing of truth-telling and respect for persons, but adds that there must be “humanity and generosity” in our work. Ethics principles without awareness of the unique personal narrative that has brought the forensic expert to this work will not suffice. Dr. Griffith cogently argues for a kind of forensic practice that sees professional practice as a struggle, a process of learning and understanding, where each new case requires self-reflection and awareness of the inner values and motives that bring one to the work. If the work is approached simply as a means to increase income or prestige, the quality and thoroughness of the activity will suffer.
Robust Professional Identity
In previous publications, Dr. Philip Candilis and I proposed the concept of “robust professionalism” as an integrated model for professional ethics in forensic psychiatry.12,33,–,35 From early in our work, we believed Dr. Griffith's contributions laid the groundwork for the development of a new model, a model that incorporated culture, narrative understanding and perspective, skepticism about strict role justifications, and integrity in one's personal and professional morality—all values and perspectives derivative of his work. With backgrounds in professional and health care ethics, we were struck by previous publications from the health care ethics literature that defined professionalism uniquely as moral in nature.36,37 All professional relationships involve moral obligations and commitments that cannot be captured in the concept of a contract and its legalistic limitations. Nor can one morally justify one's actions by claiming one is acting within a defined societal role. Our concept of professionalism is critical of models that define and justify decisions and professional behaviors through strict role considerations. Nazi doctors and recent controversies involving torture of detainees speak forcefully to the ethics problem of strict role justifications. Acting in a societally defined role, playing by the rules of that role, is not enough.
Dr. Candilis wrote a summary of the natural conflict between medicine and law, and forensic psychiatry's historical struggle with divided allegiances. Drawing from some of our earlier collaboration with Dr. Weinstock,38 he provided a description of the ethical habits and skills of the ideal forensic practitioner.39 Dr. Candilis stressed the importance of integrity, self-reflection, self-awareness, awareness of role conflicts, and sensitivity to vulnerable individuals as essential habits and skills to be developed in all forensic practitioners. Dr. Weinstock is an early pioneer in forensic practitioner surveys where he gathered information that characterized the attitudes of forensic practitioners toward important ethics dilemmas in forensic psychiatry.40,41 Dr. Weinstock, when president of AAPL, contributed a model of deliberation for specific ethics dilemmas confronting the forensic practitioner.42 Agreeing with Dr. Diamond, he argues that our legitimacy as forensic practitioners is based on our medical training and expertise as psychiatrists.38,43,44
As medicine underwent changes through managed care reform in the late 1980s and early 1990s, the medical profession began to lose sight of its core purposes and goals, thereby giving rise to uncertainty about the meaning of professional ethics. Through the work of the Hastings Center, one of the first bioethics research centers, an international effort was initiated to build consensus about the foundational purposes and goals of medicine.45 Medical ethicists and others recognized that developing models of professional ethics must be tied to the goals and purposes of professions. Dr. Matthew Wynia, former director of the AMA Institute of Ethics, wrote that professionalism “protects not only vulnerable persons but also vulnerable social values” (Ref. 36, p 1612). He defined professionalism as “an activity that involves both the distribution of a commodity and fair allocation of a social good, but that is uniquely defined according to moral relationships” (Ref. 36, p 1612). Dr. Wynia and his colleagues offered an “archetypal” model of professionalism, the cornerstones of which are devotion to service, public profession of values, and active participation in negotiating for medical values and the medical needs of patients. He and his colleagues argue for a spectrum of activism in the public negotiation for the ends of medical values. Others have characterized frameworks for professionalism that consider core virtues in the health care professional and emphasize competencies and milestones, and there is a developing literature on the concept of professionalism as evolving identity within an individual's life.46,47
In developing a model for professional forensic practice, the concept of professional identity formation over a lifetime is central to our concept of robust professionalism. For those who teach residents and fellows in forensic psychiatry programs, we are mindful of the transitional ritual of fellowship training involving mentoring and active participation in shaping values and identity as the transition from clinician to forensic practitioner unfolds. With a clear bridge to Dr. Griffith, we have expanded on such concepts as professional identity formation and culture, narrative perspectives on forensic report writing,48 the integration of personal and professional values as both assets and potential hazards in forensic practice, and the limitations of an objective perspective, while we have struggled to create a model that would have relevance to all forensic practitioners. Whether involved in clinical care, administrative activities, or expert evaluator and witness roles, we promote a concept of robust professionalism that incorporates aspirational conduct, supports ethics duties and obligations, limits moral justifications based on role identity, and requires consideration of the ethics consequences of our actions and words.
In our view, the forensic psychiatrist sits with the patient or evaluee at the hub of a spoked wheel, and each rod radiating to the outer wheel represents the moral relational links to all those involved in the forensic enterprise. The forensic psychiatrist has the responsibility to recognize and consider these relationships and weigh the relative importance of each link. Whether in the process of treatment, or administrative decisions, or in forensic expert evaluations and opinions, robust professionalism requires integrity in forensic practice that places moral relationships as foundational to all forensic activities, requires mindful reflection and awareness of the many ethics consequences inherent to the enterprise, and acknowledges a place for personal morality while striving for transparency in how personal narrative influences opinions. The practitioner must be aware and conscious of the inherent dignity of all patients or evaluees and approach vulnerable others with compassion and respect.
We support the principles of ethics developed by AAPL, but with the caveat that the current formulation of these principles should be organic and evolve over time as society and culture evolve. We believe that narrative understanding and cultural contextualization, where limitations of objectivity are acknowledged, must become second nature to our professional actions and processes. Finally, our professional identity must be rooted and tied to core goals and purposes of forensic psychiatry, an identification of social goods that are unique to our sub-specialty.
Goals and Purposes of Forensic Psychiatry
With his introduction of the cultural perspective, the importance of transparency of personal narrative, the recognition of the performative aspect of forensic practice, and his concern for intrinsic inequities in the justice system, Dr. Griffith offers the potential for new developments in forensic ethics and professionalism. He has set the stage for a discussion and debate that identifies foundational goals and purposes of forensic psychiatry, goals and purposes that can guide all forensic practitioners. He has laid the ground work for forensic practitioners to delineate the common social goods that practitioners share with medicine and the law, and yet are unique to forensic psychiatry. The division of forensic psychiatry from psychiatry and law as proposed by Dr. Pollack, or the elevation of principles as proposed by Dr. Appelbaum, no longer are adequate for a diverse group of professional practitioners where ethnic, racial, gender, and other identities energize and define our professional organization.
The AAPL ethics guidelines begin with a definition of forensic psychiatry, but they do not provide a consensus statement on the “social goods” of forensic psychiatry.7 While the prioritization of principles, models of the ethical forensic professional, and strategies for ethical decision-making provide guidance for forensic practitioners, we must work toward a consensus about our goals and purposes, that is, the social goods we provide. Just as medicine identified its core social goods in the Hastings Center project45 (i.e., prevention of disease, relief of suffering, care of the ill, and avoidance of premature death), it is time to define such goals for forensic psychiatry.
As a starting point, the following goals and purposes are offered as relevant to all forensic practitioners. This recommendation is not intended to be complete, but intended to promote reflection and discussion:
To provide knowledge and understanding of persons with mental illness within legal, regulatory, administrative, governmental, public, and clinical settings.
To provide competent and respectful care to persons with mental illness in correctional and other clinical settings.
To contribute to the truth-seeking and fairness goals of the legal system.
To witness and narrate from forensic psychiatry's unique perspective the suffering that accompanies mental illness.
To advocate for the de-stigmatization of persons with mental illness in all professional settings.
Dr. Griffith, through his writings and in his choices as Editor of The Journal, has provided an invitation to all forensic psychiatrists. While AAPL in its early development provided a professional home for forensic experts active in the legal system, AAPL has grown to include a variety of dedicated professionals, working in diverse and varied settings, including many individuals from what Dr. Griffith would define as “nondominant” groups, whose personal stories have shaped their perspective and choices. Forensic psychiatry, a historically young and developing sub-specialty, will continue to consider its professional identity and purpose because these impact our work with individuals and the systems within which we practice. Dr. Griffith has invited us to consider culture and personal narrative, to weigh the factors of power contained in the social fabric, and to recognize the privilege of being “called” or perhaps choosing to enter this most unique place of human suffering and conflict. He recognizes the privilege of this work and its unique moral requirements, and he asks that forensic practitioners bear witness to what we see and hear, and to take seriously the complexity involved in reaching opinions and making judgments that contain profound consequences for other human beings.49 Dr. Griffith's contributions will keep us thinking and provide guidance as we move forward, as forensic practitioners and as an organization, reflecting on why and how we should do what we do.
Acknowledgments
Special thanks to Dr. Philip Candilis and Dr. Robert Weinstock for a long and fruitful collaboration. Without discussion and friendship with Dr. Ezra Griffith, Dr. Michael Norko, Dr. Phil Resnick, and Dr. Alec Buchanan, these ideas would not have taken form. Thanks to my GAP colleagues for nurturing the love of writing and shaping ideas. And in Colorado, Drs. Thomas Gray, Neil Gowensmith, Rose Manguso, Patrick Fox, Robert House, Darren Lish, Jeffrey Metzner, and the many fellows who have inspired me and have been receptive to what this work demands. Most important, thanks to my wife Nancy, and my children, April, Isabel, and Nicolas.
- © 2018 American Academy of Psychiatry and the Law
