Re-examination of forensic psychiatry needs a proper examination of alternatives

Turner & Salter's re-examination of the relationship between forensic and general psychiatry was provocative and rehearsed the criticisms from generalists towards their forensic colleagues (Psychiatric Bulletin, January 2008, 32, ). No doubt it is important for forensic psychiatrists to consider external views in reflecting on their own practice. However, I feel it necessary to highlight the fallacy of simply adopting the US system, as was suggested by the authors. Their approach of effectively separating the treatment of offenders with mental disorders from the contribution of psychiatry to the courtroom brings with it serious ethical problems which should not be overlooked. One line of thinking, as advanced by Stone (1984), argues that clinicians should not act as expert witnesses as they cannot help but use their therapeutic skills at interview which may induce disclosures used by courts for non-medical purposes. However, this raises the unedifying prospect of participants in the legal process unused to delivering psychiatric treatment being responsible for advising the court on mental health disposals. This does not seem to me in the interests of the justice or the best way to ensure treatment needs are met. An alternative view expressed by Appelbaum (1997) argues that psychiatric testimony falls outside traditional medical practice and therefore is not subject to traditional medical ethics, meaning that psychiatrists need not feel bound by medical ethics when acting as expert witnesses. However, it is difficult to see how a trained psychiatrist would not, unwittingly or otherwise, use their specialist interviewing skills in obtaining evidence from a defendant. For this reason they should be bound, at least in part, by the ethics of their profession.

In my view, the most appropriate approach to be taken in the UK was explained by O’Grady (2002), who incidentally provided the response to Turner & Salter's article (2008). O’Grady argues that forensic psychiatrists should adhere to both justice ethics (truthfulness, respect for autonomy and respect for the human rights of others) as well as medical ethics (beneficence and non-maleficence). This type of theory of ‘mixed duties’ was approved by the Royal College of Psychiatrists (2004). It encourages forensic psychiatrists to be highly sensitive to the ethical dilemmas inherent in their sub-specialty. I acknowledge the brief nature of Turner & Salter's article, but feel their suggestion that the problems they perceive could be resolved simply by adopting the US practice is overly simplistic and should have been accompanied by a description of the limitations of this approach.