Dollard Professor of Psychiatry, Medicine & Law; Director, Division of Law, Ethics, & Psychiatry; Director, Center for Research on Ethical, Legal, & Social Implications of Psychiatric, Neurologic, & Behavioral Genetics, Columbia. Past President, American Psychiatric Association Address: New York, New York, United States
Since the start of the program to investigate the ethical, legal, and social implications (ELSI) ... more Since the start of the program to investigate the ethical, legal, and social implications (ELSI) of the Human Genome Project in 1990, many ELSI scholars have maintained that genetic testing should be used with caution because of the potential for negative psychosocial effects associated with receiving genetic information. More recently, though, some ELSI scholars have produced evidence suggesting that the original ELSI concerns were unfounded, exaggerated, or, at a minimum, misdirected. At least in the contexts that have been most studied, large negative impacts have not been found in the vast majority of people studied. What might explain the discrepancy between the original hypothesized outcomes and the growing impression that large negative effects appear to be few and far between? And if the original predictions of large negative psychosocial effects were simply wrong, is it time for ELSI researchers to move on? Should genetic testing be routinized, and would it be appropriate t...
Israel journal of health policy research, Jan 2, 2018
As in much of the world, mental health law in Israel has evolved over the past half-century towar... more As in much of the world, mental health law in Israel has evolved over the past half-century toward greater protection of patients' liberty and an increased emphasis on due process. Part of that process in Israel involved taking decisions about prolonged involuntary hospitalization out of the hands of treating psychiatrists and turning them over to independent review panels. Argo and colleagues examined outcomes of discharge decisions made by these panels compared with treating psychiatrists. In this brief commentary, we describe related trends in mental health law in other countries, especially the U.S., consider countervailing perspectives on the role of review panels, and suggest how the Argo et al. study might be followed up with additional research.
The journal of the American Academy of Psychiatry and the Law, 2017
The APA's Goldwater Rule, precluding psychiatrists from rendering opinions to the media about... more The APA's Goldwater Rule, precluding psychiatrists from rendering opinions to the media about public figures whom they have not examined, has often engendered controversy. Here, I consider the justifications for the rule, how well they stand up to criticism, and the extent, if any, to which modifications might be called for. Although embarrassment to the profession is often cited as the basis for the Rule, it reflects more substantive concerns, including the risk of harm to living persons and discouraging persons in need of treatment from seeking psychiatric attention. The most potent criticisms of the Rule are that it discourages public education about mental illness and its effects and precludes legitimate scholarly endeavors by psychiatrists studying foreign leaders, historical figures, and others. However, there are many ways of providing education about mental illness without violating the Rule, and read properly, it should not prevent legitimate historical investigation, t...
Electronic communications are an increasingly important part of people's lives, and much info... more Electronic communications are an increasingly important part of people's lives, and much information is accessible through such means. Anecdotal clinical reports indicate that mental health professionals are beginning to use information from their patients' electronic activities in treatment and that their data-gathering practices have gone far beyond simply searching for patients online. Both academic and private sector researchers are developing mental health applications to collect patient information for clinical purposes. Professional societies and commentators have provided minimal guidance, however, about best practices for obtaining or using information from electronic communications or other online activities. This article reviews the clinical and ethical issues regarding use of patients' electronic activities, primarily focusing on situations in which patients share information with clinicians voluntarily. We discuss the potential uses of mental health patients...
Psychology, public policy, and law : an official law review of the University of Arizona College of Law and the University of Miami School of Law, 2015
Demonstrations of a link between genetic variants and criminal behavior have stimulated increasin... more Demonstrations of a link between genetic variants and criminal behavior have stimulated increasing use of genetic evidence to reduce perceptions of defendants' responsibility for criminal behavior and to mitigate punishment. However, because only limited data exist regarding the impact of such evidence on decision makers and the public at large, we recruited a representative sample of the U.S. adult population (n=960) for a web-based survey. Participants were presented with descriptions of three legal cases and were asked to: determine the length of incarceration for a convicted murderer; adjudicate an insanity defense; and decide whether a defendant should receive the death penalty. A fully crossed, between-participants, factorial design was used, varying the type of evidence (none, genetic, neuroimaging, both), heinousness of the crime, and past criminal record, with sentence or verdict as the primary outcome. Also assessed were participants' apprehension of the defendant,...
The journal of the American Academy of Psychiatry and the Law, 2008
Twenty-five years ago, Alan Stone expressed his skepticism that forensic psychiatry could be prac... more Twenty-five years ago, Alan Stone expressed his skepticism that forensic psychiatry could be practiced ethically. His remarks have proven a useful goad to the field, focusing attention on the importance of an ethics framework for forensic practice. But Stone remains dubious that any system of ethics--including the "Standard Position" on which he focuses his critique--could be of much value in practice. In contrast, I suggest that Stone's pessimism is not well founded. Immanent in forensic practice itself is a reasonable set of ethics principles, based on truth-telling and respect for persons. Psychiatrists can offer reliable and valid testimony, while resisting seduction into an advocacy role. Indeed, with new structured approaches to assessment, the potential utility of forensic testimony is probably greater than ever. Though problematic behavior still exists, forensic psychiatry offers the factual background and interpretive context to allow legal decision-makers to ...
The journal of the American Academy of Psychiatry and the Law, 2010
As part of the Festschrift in honor of Howard Zonana, MD, this article reviews two important conc... more As part of the Festschrift in honor of Howard Zonana, MD, this article reviews two important concerns that emerged in the ethics of forensic psychiatry in the resolution of which he played critical roles. In the late 1980s and early 1990s, the question arose of what role, if any, was proper for psychiatrists to play with regard to evaluations of competence to be executed and treatment of incompetent prisoners. Dr. Zonana was a major force in developing the American Psychiatric Association's position, in which the rights of prisoners were balanced with protection of the integrity of the medical profession. He was then deeply involved in helping to persuade the American Medical Association to reject a more extreme position and to adopt this approach. Similarly, in the mid-2000s, Dr. Zonana brought to the attention of the American Psychiatric Association (APA) the participation of psychiatrists in interrogation of detainees in national security settings. The policy that he subseque...
Impairments in patients with dementia and other disorders affecting cognition may have a negative... more Impairments in patients with dementia and other disorders affecting cognition may have a negative impact on their capacity to provide consent to treatment or to participation in research. A growing literature confirms that even patients with mild cognitive impairment may experience decrements in decisional abilities, findings that are more pronounced still in the early stages of dementia. However, most patients with mild dementia probably remain competent to provide a valid consent to treatment or research, and even some patients with moderate dementia may retain capacity in particular circumstances. Clinical evaluation of decisional competence has been augmented by structured approaches, including reliable instruments that may be used in the clinical setting. To avoid needlessly depriving patients of their right to make health care decisions, evaluations should be designed to maximize patient performance. However, when substitute consent is necessary, state laws generally provide a...
Although a 1996 U.S. Supreme Court decision affirmed that therapists cannot be compelled to testi... more Although a 1996 U.S. Supreme Court decision affirmed that therapists cannot be compelled to testify in federal proceedings about patients' disclosures, a footnote could be interpreted as creating a "dangerous patient exception" when there is a serious threat of harm. This column describes circuit courts' differing views about whether such an exception exists and the value of an exception. Although the footnote appears to indicate the Supreme Court's inclinations to create an exception to psychiatrist-patient privilege in some cases, opponents have made strong arguments that a dangerous patient exception would inhibit help seeking by those in whose treatment society has the strongest interest -- people who have harmed or are likely to harm others.
Since the start of the program to investigate the ethical, legal, and social implications (ELSI) ... more Since the start of the program to investigate the ethical, legal, and social implications (ELSI) of the Human Genome Project in 1990, many ELSI scholars have maintained that genetic testing should be used with caution because of the potential for negative psychosocial effects associated with receiving genetic information. More recently, though, some ELSI scholars have produced evidence suggesting that the original ELSI concerns were unfounded, exaggerated, or, at a minimum, misdirected. At least in the contexts that have been most studied, large negative impacts have not been found in the vast majority of people studied. What might explain the discrepancy between the original hypothesized outcomes and the growing impression that large negative effects appear to be few and far between? And if the original predictions of large negative psychosocial effects were simply wrong, is it time for ELSI researchers to move on? Should genetic testing be routinized, and would it be appropriate t...
Israel journal of health policy research, Jan 2, 2018
As in much of the world, mental health law in Israel has evolved over the past half-century towar... more As in much of the world, mental health law in Israel has evolved over the past half-century toward greater protection of patients' liberty and an increased emphasis on due process. Part of that process in Israel involved taking decisions about prolonged involuntary hospitalization out of the hands of treating psychiatrists and turning them over to independent review panels. Argo and colleagues examined outcomes of discharge decisions made by these panels compared with treating psychiatrists. In this brief commentary, we describe related trends in mental health law in other countries, especially the U.S., consider countervailing perspectives on the role of review panels, and suggest how the Argo et al. study might be followed up with additional research.
The journal of the American Academy of Psychiatry and the Law, 2017
The APA's Goldwater Rule, precluding psychiatrists from rendering opinions to the media about... more The APA's Goldwater Rule, precluding psychiatrists from rendering opinions to the media about public figures whom they have not examined, has often engendered controversy. Here, I consider the justifications for the rule, how well they stand up to criticism, and the extent, if any, to which modifications might be called for. Although embarrassment to the profession is often cited as the basis for the Rule, it reflects more substantive concerns, including the risk of harm to living persons and discouraging persons in need of treatment from seeking psychiatric attention. The most potent criticisms of the Rule are that it discourages public education about mental illness and its effects and precludes legitimate scholarly endeavors by psychiatrists studying foreign leaders, historical figures, and others. However, there are many ways of providing education about mental illness without violating the Rule, and read properly, it should not prevent legitimate historical investigation, t...
Electronic communications are an increasingly important part of people's lives, and much info... more Electronic communications are an increasingly important part of people's lives, and much information is accessible through such means. Anecdotal clinical reports indicate that mental health professionals are beginning to use information from their patients' electronic activities in treatment and that their data-gathering practices have gone far beyond simply searching for patients online. Both academic and private sector researchers are developing mental health applications to collect patient information for clinical purposes. Professional societies and commentators have provided minimal guidance, however, about best practices for obtaining or using information from electronic communications or other online activities. This article reviews the clinical and ethical issues regarding use of patients' electronic activities, primarily focusing on situations in which patients share information with clinicians voluntarily. We discuss the potential uses of mental health patients...
Psychology, public policy, and law : an official law review of the University of Arizona College of Law and the University of Miami School of Law, 2015
Demonstrations of a link between genetic variants and criminal behavior have stimulated increasin... more Demonstrations of a link between genetic variants and criminal behavior have stimulated increasing use of genetic evidence to reduce perceptions of defendants' responsibility for criminal behavior and to mitigate punishment. However, because only limited data exist regarding the impact of such evidence on decision makers and the public at large, we recruited a representative sample of the U.S. adult population (n=960) for a web-based survey. Participants were presented with descriptions of three legal cases and were asked to: determine the length of incarceration for a convicted murderer; adjudicate an insanity defense; and decide whether a defendant should receive the death penalty. A fully crossed, between-participants, factorial design was used, varying the type of evidence (none, genetic, neuroimaging, both), heinousness of the crime, and past criminal record, with sentence or verdict as the primary outcome. Also assessed were participants' apprehension of the defendant,...
The journal of the American Academy of Psychiatry and the Law, 2008
Twenty-five years ago, Alan Stone expressed his skepticism that forensic psychiatry could be prac... more Twenty-five years ago, Alan Stone expressed his skepticism that forensic psychiatry could be practiced ethically. His remarks have proven a useful goad to the field, focusing attention on the importance of an ethics framework for forensic practice. But Stone remains dubious that any system of ethics--including the "Standard Position" on which he focuses his critique--could be of much value in practice. In contrast, I suggest that Stone's pessimism is not well founded. Immanent in forensic practice itself is a reasonable set of ethics principles, based on truth-telling and respect for persons. Psychiatrists can offer reliable and valid testimony, while resisting seduction into an advocacy role. Indeed, with new structured approaches to assessment, the potential utility of forensic testimony is probably greater than ever. Though problematic behavior still exists, forensic psychiatry offers the factual background and interpretive context to allow legal decision-makers to ...
The journal of the American Academy of Psychiatry and the Law, 2010
As part of the Festschrift in honor of Howard Zonana, MD, this article reviews two important conc... more As part of the Festschrift in honor of Howard Zonana, MD, this article reviews two important concerns that emerged in the ethics of forensic psychiatry in the resolution of which he played critical roles. In the late 1980s and early 1990s, the question arose of what role, if any, was proper for psychiatrists to play with regard to evaluations of competence to be executed and treatment of incompetent prisoners. Dr. Zonana was a major force in developing the American Psychiatric Association's position, in which the rights of prisoners were balanced with protection of the integrity of the medical profession. He was then deeply involved in helping to persuade the American Medical Association to reject a more extreme position and to adopt this approach. Similarly, in the mid-2000s, Dr. Zonana brought to the attention of the American Psychiatric Association (APA) the participation of psychiatrists in interrogation of detainees in national security settings. The policy that he subseque...
Impairments in patients with dementia and other disorders affecting cognition may have a negative... more Impairments in patients with dementia and other disorders affecting cognition may have a negative impact on their capacity to provide consent to treatment or to participation in research. A growing literature confirms that even patients with mild cognitive impairment may experience decrements in decisional abilities, findings that are more pronounced still in the early stages of dementia. However, most patients with mild dementia probably remain competent to provide a valid consent to treatment or research, and even some patients with moderate dementia may retain capacity in particular circumstances. Clinical evaluation of decisional competence has been augmented by structured approaches, including reliable instruments that may be used in the clinical setting. To avoid needlessly depriving patients of their right to make health care decisions, evaluations should be designed to maximize patient performance. However, when substitute consent is necessary, state laws generally provide a...
Although a 1996 U.S. Supreme Court decision affirmed that therapists cannot be compelled to testi... more Although a 1996 U.S. Supreme Court decision affirmed that therapists cannot be compelled to testify in federal proceedings about patients' disclosures, a footnote could be interpreted as creating a "dangerous patient exception" when there is a serious threat of harm. This column describes circuit courts' differing views about whether such an exception exists and the value of an exception. Although the footnote appears to indicate the Supreme Court's inclinations to create an exception to psychiatrist-patient privilege in some cases, opponents have made strong arguments that a dangerous patient exception would inhibit help seeking by those in whose treatment society has the strongest interest -- people who have harmed or are likely to harm others.
Classic psychedelics and related substances have shown promising initial research results. Howeve... more Classic psychedelics and related substances have shown promising initial research results. However, they raise a number of relatively novel ethical and policy challenges in light of their psychoactive properties, their emergence from the unregulated “underground” settings in which they have been used, their rapid commercialization, and the means and speed with which they are moving from a Schedule 1 drug to legalized use. All of these issues are affected by the current limits to the evidence base on use of psychedelics. Here we survey these novel challenges, illustrating the issues raised regarding each, and offering suggestions for how to address them.
In 1973, the federal government classified psychedelics as schedule I substances, rendering posse... more In 1973, the federal government classified psychedelics as schedule I substances, rendering possession illegal, even for research purposes except under tightly regulated circumstances. Although these restrictions have hindered research on the therapeutic uses of psychedelics for decades, recent studies have brought increasing attention and enthusiasm to the potential benefits of psychedelic treatment.1 Accompanying this revival of psychedelic research have been initiatives by states and localities to legalize psychedelic possession and use. Two of the most ambitious measures, in Oregon and California, take different paths to legalization. This Viewpoint reviews these initiatives and the concerns they raise by looking to the cautionary precedents involving the legalization and commercialization of other controlled substances.
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