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Psychiatrists face complex ethics dilemmas in the COVID-19 pandemic era when assessing dangerousness in patients or forensic evaluees who threaten to purposely infect others or spread the virus. Understanding local public health and medical quarantine laws for their jurisdictions can help guide treating psychiatrists in how to handle some of these situations; however, challenges occur when what is ethically best conflicts with the action that will confer the greatest protection against legal liability. Additionally, the calculus of weighing competing ethics considerations changes based on how relevant it is to the duties of a particular role (e.g., treatment, forensic, research, managed care, etc.) as well as the contextual factors of the situation. We present dialectical principlism as a framework to help psychiatrists resolve such ethics dilemmas related to the COVID-19 and future pandemics, illustrating how it can be applied in different roles (i.e., treatment versus forensic) and situations (i.e., when it is clear the danger of viral transmission is secondary to a delusion versus a delusion-like belief) to come to the best outcome that balances patient welfare, legal considerations, and societal safety. Occasionally, the most ethical action may entail small liability risks., (© 2022 American Academy of Psychiatry and the Law.)

Most forensic psychiatrists occasionally face complex situations in forensic work in which ethics dilemmas cause discomfort. They want to determine the most ethical action, but the best choice is unclear. Fostering justice is primary in forensic roles, but secondary duties such as traditional biomedical ethics and personal values like helping society, combating racism, and being sensitive to cultural issues can impinge on or even outweigh the presumptive primary duty in extreme cases. Similarly, in treatment the psychiatrists' primary duty is to patients, but that can be outweighed by secondary duties such as protecting children and the elderly or maintaining security. The implications of one's actions matter. In forensic work, if the psychiatrist determines that he should not assist the party who wants to hire him, despite evidence clearly supporting its side, the only ethical option becomes not to accept the case at all, because the evidence does not support the better side. Sometimes it can be ethical to accept cases only for one side. In ethics-related dilemmas, I call the method of prioritizing and balancing all types of conflicting principles, duties, and personal and societal values in a dialectic to resolve conflicts among them dialectical principlism. This approach is designed to help determine the most ethical action. It is aspirational and is not intended to get the psychiatrist into trouble., (© 2015 American Academy of Psychiatry and the Law.)

Ethics enforcement in psychiatry occurs at the district branch and American Psychiatric Association (APA) levels under the guidance of American Medical Association (AMA) and APA ethics documents. Subspecialty ethics consequently have no formal role in the enforcement process. This reality challenges practitioners to work according to guidelines that may not be sufficiently relevant and challenges ethics reviewers to apply frameworks not intended for the subspecialties. This article offers the theoretical and practical support to amend APA Procedures to permit formal consideration of subspecialty ethics during ethics complaints and to include forensic practitioners on panels reviewing them. This is the first step toward an integration of two conflicting models of ethics enforcement, regulatory and aspirational, that bring together specialty and subspecialty ethics., (© 2014 American Academy of Psychiatry and the Law.)

In 2013, legislation went into effect clarifying that the Tarasoff duty in California is now unambiguously solely a duty to protect. Warning the potential victim and the police is not a requirement, but a clinician can obtain immunity from liability by using this safe harbor. In situations in which a therapist believes warning might exacerbate the patient's risk, however, alternative protective actions can satisfy the duty to protect. For a clinician to be found liable, those alternative actions would have to be proven negligent. This flexibility can sometimes be crucial in protecting potential victims and thereby, indirectly, patients from the consequences of dangerous action. Explaining the reasoning for the action chosen should obviate any significant liability risk of doing the right thing, even without immunity. Legislation was enacted in 2007 as an attempt to clarify the requirement, but the revised immunity statute at the time retained the phrase 'duty to warn and protect', which perpetuated the now-eliminated confusion. Correctly understanding the California law is important to avoid having the restored flexibility eroded again by belief in a nonexistent duty to warn. The Tarasoff duty originated in California, but since many other states later established similar duties, the developments in California may have national implications.

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.

Forensic psychiatrists typically have no role in the process of obtaining confessions. They may believe, as do others, that a confession removes any doubt about guilt, but false confessions are not rare. Like the police, forensic psychiatrists can inadvertently elicit or solidify a false confession through the evaluation process by presuming guilt and forgetting that they are ethically obligated to strive for objectivity. Adolescents are at high risk of making false confessions because of their immaturity and vulnerability, extrinsic factors (such as interrogation techniques), and the dynamic interplay between them. Adolescent immaturity can have a direct bearing on a juvenile's appreciation of his Miranda rights and his vulnerability to making a confession (or a false confession) when exposed to coercive interrogation techniques designed for adults. Adolescents need special protection from such interrogation techniques. Forensic psychiatrists have an obligation to be alert to the potential for false confessions and to avoid compounding the problem by presuming guilt.

The original Tarasoff decision created a duty for California psychotherapists to warn potential victims of their patients. After rehearing the matter two years later, the California Supreme Court, in the landmark second Tarasoff decision, changed the duty to warn to a duty to protect potential victims, with warning as only one of the options for discharging that duty. Despite this change, the Tarasoff duty frequently was referred to erroneously as a duty to warn. This misunderstanding and an ambiguous California immunity statute culminated in "simplified" jury instructions and two appellate court decisions in 2004 in which it was assumed without question that there was a duty to warn, with liability for not doing so regardless of rationale. As a result of persistent lobbying by the California Psychiatric Association and other mental health groups, a recent bill corrected the problem created by the courts, returning the Tarasoff duty to a duty to protect.

Psychiatrists have debated their role in evaluating prisoners accused of capital crimes and in treating prisoners on death row when restoration of competence would result in execution. Despite debate, there are no previous surveys of psychiatrists' opinions on this issue. We sent an anonymous questionnaire to all board-certified forensic psychiatrists in the United States. Of the 456 forensic psychiatrists identified, 290 (64%) returned the survey. Most respondents supported a role, in at least some cases, for psychiatric evaluation of prisoners accused of capital crimes. Respondents were divided on whether or not psychiatrists should treat incompetent death row prisoners if restoration of competence would result in execution. Attitudes about the ethical acceptability of capital punishment were associated with views about the psychiatrists' role but were not determinative in every case.

Diminished capacity survives in California as a severely attenuated mens rea defense known as diminished actuality. Some other states have similar limited strict mens rea defenses. The lost advantages of California's former expanded concept of diminished capacity are reviewed. As opposed to the all-or-none insanity defense, mens rea defenses permit the trier of fact to find gradations of guilt but are generally inapplicable unless the elements of a crime are redefined to permit consideration of motivational aspects, as California had done. The change from diminished capacity to a diminished actuality defense was a return to the complex, somewhat artificial legal concept of intent and a resurrection of confusing and antiquated common law definitions. The change was made in response to an unpopular jury verdict and a political climate in which little interest existed or still exists for understanding the reasons behind the commission of any crime. Some of the later restrictions imposed by the California Supreme Court on allowing voluntary intoxication to reduce murder to voluntary manslaughter logically should not apply to mental illness. Knowledge of the complex mens rea issues and the various relevant current defenses is essential for any forensic psychiatrist evaluating defendants in jurisdictions in which such defenses are admissible.

The delusional misidentification syndromes are characterized by misidentification delusions of others or of the self. Aggressive ideas or behaviors often accompany these delusions. The relationship between delusional misidentification and dangerousness remains for the most part poorly understood. In the present article, we compare a group of dangerous individuals suffering from dangerous misidentification delusions with a group of dangerous individuals suffering from other types of delusions. Individuals with dangerous misidentification delusions were more likely to experience grandiose ideation, thought disorder, generalized hostility, excitement, general psychopathology, and a previous history of violence than dangerous delusional individuals with no delusional misidentification. The group with dangerous delusional misidentification syndromes was less likely to attack others with weapons than were the dangerous delusional group with no delusional misidentification.

Forensic psychiatrists are not as vulnerable to liability as general psychiatrists. The absence of a traditional physician-patient relationship and judicial and quasijudicial immunity are all protective against malpractice actions. Although the absence of a doctor-patient relationship removes an essential element of malpractice, other types of liability such as defamation and ordinary negligence are possible and may not be covered by malpractice insurance. A model is proposed for forensic psychiatry of a partial secondary doctor-patient relationship out-weighted in most circumstances by duties to truth and/or the hiring attorney. Such a model seems most consistent with conflicting duties currently forced on all psychiatrists. This model has advantages of a duty, a violation of which is likely to be covered by malpractice insurance. Rather than deemphasizing partial secondary physician-patient responsibilities, it is advised to stress the important protection provided by judicial and quasijudicial immunity.

As a result of recent decisions by the United States and California Supreme Courts, therapists now have been placed in a position in which they can be forced to testify in death penalty cases for the only purposes of achieving a conviction and a death penalty verdict. Zeal for the death penalty seems to have overcome any concern for the ethics of psychiatrists or even for the welfare of society. In California, therapists can now be forced to testify against their own patients in capital cases even if the patient does not tender his mental state as an issue, despite the presence of a psychotherapist-patient privilege in the state for criminal matters. In California, the only option for therapists who wish to treat potentially dangerous patients may be to conduct the therapy under the umbrella of attorney-client privilege. Otherwise they may not be able to avoid serious ethical problems and personal danger if the patient actually does kill someone during or after therapy. They may be unable honestly and ethically to treat such patients without obtaining truly informed consent to therapy under these potentially "undercover policeman" circumstances. Hopefully, professional organizations will take a more activist position, and courts will appreciate the folly of these decisions and reverse them. Otherwise, they may spread to other states, for which California frequently sets precedents.

The central feature of misidentification syndromes is the presence of a delusion in which either the identity of the self or other persons is misrecognized. Recent psychiatric case reports have noted the dangerousness posed by persons with misidentification delusions. The authors report on a series of 29 individuals whose delusional misidentification was associated with aggressive behaviors. Important parameters which may assist in defining this sample of dangerous delusional misidentification syndrome persons are discussed.

Bernard Diamond would testify only for the defense in criminal cases, but only if the whole psychiatric truth would be introduced during a trial and the facts of the case supported the defense position. Otherwise, he would refuse to participate. Although few other forensic psychiatrists have personal or professional ethical concerns regarding ever participating for the prosecution, many more have such problems in capital cases. Bernard Diamond's approach to forensic psychiatry should be considered at least as an option by those opposed to the death penalty. Bias in capital cases is not a persuasive reason to withdraw from involvement if the forensic psychiatrist remains honest.

A survey was conducted of a sample of AAPL members to determine their opinions on the inclusion of controversial ethical guidelines for forensic psychiatry. Members appear to appreciate the need to consider traditional Hippocratic values as at least one consideration in their functioning as forensic psychiatrists. They appear to balance their duties to an evaluee with duties to society and the legal system and to appreciate the responsibilities of multiple agency. Support was shown for interpreting ambiguities in AAPL's current guidelines in the directions indicated by most of this survey's proposed guidelines.

This article discusses Capgras syndrome and its association with harmful and potentially harmful behaviors. Phenomenological and psychodynamic analysis of a series of cases will highlight danger signals that may be present in Capgras patients.

A survey was undertaken of the opinions of two groups of forensic psychiatrists to determine their views regarding forensic ethical issues. Although AAPL has made significant strides for our profession by adopting ethical guidelines, some important issues have not yet been addressed, as revealed by our survey. Included were items heretofore considered too "controversial" for incorporation into guidelines, as well as items from the APA ethical framework. All APA items were evaluated as addressing ethical problems. The majority of respondents also viewed most of the "controversial" items as confronting relevant ethical problems, thereby suggesting their inclusion, in some form, in the profession's guidelines. They also appeared to favor retention of many traditional medical ethical values when functioning as a forensic psychiatrist. Clear selective discrimination existed among differing death penalty facets. Since AAPL at present does not wish to conduct its own ethics hearings, the AAPL guidelines as well as the items supported in this paper's survey would best be translated into a form consistent with the APA framework. In this way, AAPL's guidelines and also the new suggested items could readily be coordinated within the APA framework and could play a role in the APA local district branch enforcement process.

This study shows that referrals to psychiatry for evaluation for competence to give informed consent generally were made on patients who refused medical treatment. In this sample of referred patients, the only patients found to be incompetent to give informed consent were those with organic brain syndromes. No one with either schizophrenia or depression was found to be incompetent. It is possible that schizophrenic and depressed patients may generally be competent to give informed consent to medical treatment. This finding might be true notwithstanding the fact that many such patients have been found in other studies to be incompetent to consent to voluntary psychiatric treatment. For example, a patient may have delusions that others can read his mind and thoughts, but he still can understand that he needs dialysis for renal failure. Alternatively, it may be relatively rare that an emergency procedure is necessary before a patient's psychosis can be brought under control and consequently internists and surgeons themselves may prefer to wait. The significance of the results is unclear. Because of active interest in the doctrine of informed consent for psychiatric and medical patients by both physicians and attorneys and the few studies within this population, there is a strong need for more study regarding competence to give informed consent. Further study is especially important for psychotic patients for whom psychiatric consultation is not requested.(ABSTRACT TRUNCATED AT 250 WORDS)

The acquired immune deficiency syndrome (AIDS) crisis has raised many clinical and forensic dilemmas for the health-care system. Psychiatrists may encounter particular problems when evaluating and treating human immunodeficiency virus (HIV) infected patients. The authors present a case of an HIV seropositive, bipolar, intravenous drug abusing patient who participates in unsafe sexual practices to illustrate clinicolegal dilemmas involving dangerousness, involuntary hospitalization, confidentiality, and Tarasoff-like duty.