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Handbook of Forensic Psychiatric Practice in Capital Cases


What is Clinical Ethics?


‘Clinical ethics’ amounts to application of a reflective process to a clinical case, within which there are issues concerning not just what might be the outcome of different actions, and between which a choice has to be made, but what should be done. Tat is, whereas medical science is positive (describing how things are, or would be under different circumstances), clinical ethics is normative (describing what ought to be done). In simple terms, it is the ‘oughts’ of clinical practice.


Te focus of all ethics is determining what ‘rights’ and ‘duties’ are, or should be ‘in play’ and resolving conflict between competing rights, or competing duties, or between rights and duties which compete with one another.


Tere are competing ‘schools’ of ethics, that is, alternative forms of reflective process. However, the key ‘first step’ within the practice of clinical ethics lies in recognition of what is a normative, or ethical question, before then applying a reasoning process towards coming to a decision as to what to do; that is, deciding ‘what ought to be done’.


Tere is rarely, perhaps never, ‘a right answer’ to an ethical conundrum. Rather, what is at stake is coming to ‘a justifiable answer’, and doing so in a manner which makes clear the nature of the justification. Put otherwise, it is ‘biting the ethical bullet’, and doing so with ethical insight into what form of ethical justification you are applying, and into why you have decided to choose one course of action over another competing course.


Hence, achieving an ‘ethical distillation’, or understanding the details ethically, of a particular situation – including the consequences of different courses of action, plus relevant duties and responsibilities – is vital in pursuing ethical practice. What matters is process rather than outcome.


Te schools of ethics most commonly referred to within medicine are the ‘four principles’ and ‘utilitarian’ approaches (see below). Tese two approaches essentially contrast a ‘principled’ approach with comparing, but then evaluating, the total ‘impact’ on different parties of alternative courses of action.


Conflicting Duties, and Dual Roles


Ethical dilemmas arise commonly in all clinical practice, more commonly in mental health practice, but with added frequency and difficulty in forensic mental health care; they perhaps reach the peak of complexity and severity of implications in capital cases.


A core conflict arises from the fact that forensic psychiatrists commonly owe a duty, not only to the patients they assess and treat, but also to society and to the justice system. Hence, they owe a duty, not only to treat their patients, but also to protect society from the possibility of harm arising from those they treat; they may also owe a duty to the administration of justice through adopting the role of expert witness. Te former ethical conflict arises through accepting a duty both to the individual the doctor assesses and treats and a duty directed towards the welfare of others. Te latter amounts to substituting, for the usual therapeutic role and duty to a patient, the role of expert into legal proceedings, in the absence of any therapeutic role or endeavour; albeit the doctor may still feel some form of residual therapeutic duty to the individual s/he assesses.


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