When I started to write this review, I realized that I had been put in an invidious position. Here I am writing a book review regarding ethics challenges and on reflection I became aware that I have to declare not one but two conflicts of interest. First, I should point out that I am a co-writer of chapter 7. Needless to say, I will omit any comment on that chapter from my review, leaving readers to form their own impression of this chapter.
My second conflict of interest is a more complicated subject. In this tribute issue of The Journal, much will be said about the editor of this book, Dr. Griffith. Many of you may be aware that he and I share a special relationship. We come from different parts of the world, and probably look a lot different, but we share some common interests and peculiarities that bond us together. One of these peculiarities of that friendship is unspoken, instead being played out in the public forum by way of sarcastic rejoinder and repartee. Our readers will, therefore, ask whether I can fairly review this book. All I can do is declare my enormous admiration for Dr. Griffith, and declare my conflict of interest—and then, as we do in forensic work, I will strive for objectivity and honesty and throw myself on the mercy of the reader.
Dr. Ezra Griffith is perhaps best known to many as the editor of the Journal of the American Academy of Psychiatry and the Law (JAAPL). He has also made major contributions, not only to the literature on forensic psychiatry, but also to academic areas such as religion, race, and culture. In addition, he has contributed to the evolving field of ethics in relation to forensic psychiatry, not just in his scholarly work, but also with his devotion to professional organizations. He is ideally suited to edit a book on ethics in forensic psychiatry and psychology.
Forensic psychiatry and psychology are relatively new disciplines. In 1984, Dr. Alan Stone shook the very foundations of forensic psychiatry by suggesting at the annual meeting of the American Academy of Psychiatry and the Law that the ethics boundaries of forensic psychiatry are so difficult to negotiate as to make ethical practice impossible. Over the next 30 years, these fields have developed successive ethics guidelines, informed by academic writing, to position our field to use some tools to create ethics-based solutions in our service to both patients and the legal system. This book, according to the introduction by the editor, seeks not to provide easy answers, rather to provide the tools and the structure to guide practicing forensic specialists as they encounter ethics challenges. It is typical of the pragmatism and humility of the editor that he makes it clear that he does not seek to lecture us about ethics rules, but to encourage us in the Socratic manner to think through these problems ourselves. He seeks to give us an approach to thinking through ethics dilemmata by reflection and consideration, and thereby reach an ethics-based outcome.
The book is divided into three parts. The first part discusses approaches to solving ethics problems in forensic practice. Perhaps the most utilitarian of these is Weinstock's dialectic principlism. This approach advises us to delineate the criteria in an ethics analysis and to balance the relative weights of the criteria to determine the most ethical action in situations, many of which do not have clear guidelines. This approach is brilliant in its simplicity, and the authors give some examples to illustrate the method, which we can all apply to our practice.
The next chapter draws our attention to the fact that medicine in general, and forensic psychiatry and psychology in particular, cannot be exempt or immune from broader social trends, specifically feminism, as discussed in this chapter. An analysis of the development of successive waves of feminism is educational and useful in and of itself. Drawing concepts from this, the authors then apply feminist ethics to forensic practice in a readable manner.
The role confusion engendered by attempting to adopt simultaneously a forensic role and a clinical role is likely the core paradigm confronting forensic practice. A chapter entitled “On Wearing Two Hats” discusses this challenge. Dr. Rebecca Brendel's seminal ethics analysis of this problem provides clarity by separating the obligation of treating physicians, which is to the doctor–patient relationship, from the values arising from an obligation to the justice system, which the forensic specialist has to keep uppermost in his mind. This chapter also discusses the complicated ethics conflict arising out of the role of specialists working within a managed care system. The next chapter discusses the important topic of adversarial allegiance and how to avoid this strong pull to affiliate. One of the solutions suggested is that of peer supervision in consultation, which for a variety of reasons is very difficult to achieve in our field of individualists. Another concept is that of the boundaries of competence, which considers the fact that clinical expertise is not necessarily forensic expertise. Nevertheless, the authors encourage motivated clinicians to accept referrals for new and different cases to expand their repertoire. They advise us that with consultation, supervision, and research we continue to move along the path to be competent evaluators.
The second section of the book focuses on the particular ethics problems encountered in a number of specific areas of forensic practice. These areas include work with children and adolescents, in correctional settings, in the public sector (with a specific focus on the use of involuntary commitment), and in clinical neuroscience. Each of these chapters holds great interest for those working in these specific arenas. Whereas the first section of the book should be compulsory reading for all practicing forensic psychiatrists, the chapters in the second section are not chapters to be read casually, rather chapters to be consulted when the need arises. Each chapter will be helpful for those working in the specific areas or applying their minds to any concern that intersects with these specific topics, but each chapter may not be of general interest to all forensic psychiatrists.
The third section of the book is intended to address ethics dilemmata encountered in the general practice of forensic psychiatry and psychology. This is certainly true for various chapters, for example, a chapter on the use of psychological testing in forensic assessment, video recording in forensic evaluations, the assessment and care of sex offenders, and ethics in violence risk assessment. Some of the chapters, however, are very specific. The individual chapters on working in the care of Guantanamo detainees, forensic evaluations related to national security concerns, and working with asylum petitioners are not really the type of areas that general forensic psychiatrists and psychologists would encounter on a day-to-day basis. These chapters nevertheless may be of interest to readers.
I would have liked to see one chapter summarizing the state of the art of ethics in forensics. With contributing authors who have both defined and refined the field, this would have been possible.
This book covers the major areas of forensic psychiatry and psychology, and it discusses and highlights many of the ethics problems that may be encountered by practitioners in each of these specific subtopics. The book succeeds in its goal of giving the reader not only a framework to recognize ethics dilemmata, which in and of itself is a good start, but also a framework to weigh the competing interests. Further, as the editor says, it enables the reader to identify conflicting obligations. It is from this platform, the editor explains, that with guidance we can formulate a thoughtful approach to creating a solution. The editor rightly cautions us that the goal of this book, and likely any book in the area, is not to give us ready-made solutions but to give us tools and strategies that will inform our forensic practice. It is my opinion that this book achieves what it set out to achieve; in the area of ethics we can ask for no more.
There are a few books that specifically apply ethics analysis to the fields of forensic psychiatry and psychology. One such book, Forensic Ethics and the Expert Witness, by Phillip Candilis et al. (all co-authors of chapters in this book), is the current definitive text in the field. Ethics Challenges in Forensic Psychiatry and Psychology Practice supplements but does not replace the work by Candilis et al.
Ethics Challenges in Forensic Psychiatry and Psychology is an essential book for the practicing forensic psychiatrist and psychologist, and for other forensic mental health professionals. The book is surprisingly easy to read. I read the whole thing on a transatlantic flight beginning to end, and it is nicely and professionally presented. It is an excellent review of different approaches to solving ethics problems in many of the major areas of forensic practice. I would highly recommend it for practicing forensic psychiatrists and psychologists, as well as other forensic mental health workers.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2018 American Academy of Psychiatry and the Law
