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Ethical Issues in Forensic Psychiatry in Capital Cases


Medical involvement in legal process in capital cases lends itself most obviously to clinical ethical analysis in terms of a ‘principled’ approach.


Te ethical principles which are most commonly considered to underpin most medical practice (‘the four principles’) include autonomy, beneficence, non-maleficence and a duty to respect justice. And, amongst these, it is the duty to respect patient autonomy which is generally considered ‘first amongst equals’ within clinical medicine.


Te duty to respect justice can be taken either simply as ‘the duty to act fairly to people’, for example in terms of allocation of scarce medical resources between patients, or in terms of a duty to assist the state in its proper exercise formally of justice.


It will be immediately obvious that the practice of forensic psychiatry poses greater challenges to ‘ordinary accepted clinical ethical practice’, as described above, than say surgery.


Tis is made obvious by any circumstance where there is conflict between respecting patient autonomy and protecting the public. And, where a doctor acts as an expert witness s/he might appear to all but abandon ‘respect for autonomy’ in favour of a duty to assist the state in the exercise of justice. Hence, it might reasonably be perceived that, as a mental health expert giving evidence, your overriding duty is to the court, thereby potentially undermining the more usual balancing of conflicting ethical principles by doctors.


And involvement in capital cases might be seen as focusing upon the ‘unusual nature’ of forensic psychiatric practice to an extreme degree, particularly in terms of the usual injunction of non-maleficence. Tat is, in all expert witness work respect for justice essentially overrides respect for autonomy, and non-maleficence; however, appearing as an expert witness in regard to capital legal proceedings amounts to a doctor privileging justice over non-maleficence writ large.


As a result, some doctors argue that participation in death penalty proceedings amounts to ‘a step too far’ away from usual medical ethical practice and principles, through being equivalent to ‘participation’ in the process of execution, or at least in facilitating or legitimising legal process which can lead to such punishment, therefore fundamentally contravening the principle ‘doing no harm’.


One ‘partial solution’ to such a fundamental objection to appearing as an expert witness in capital proceedings lies in appearing only for the defence in such cases. However, this runs the risk of being perceived as, or even of being, partial in one’s approach to the role of expert witness. Te only escape from such a danger lies in ensuring that skills are applied fairly, as they would be clinically in a non-litigious situation, and that one is insightful into the risk of bias arising from applying medical ethical principles to an essentially legal context. Tat is, again what is crucial is process (see above).


Alternatively, some distinguish ethically between involvement within different stages of the justice process applied in capital cases, in terms of the degree of ‘remoteness’ of the doctor’s role from execution per se. Hence, assessment of ‘fitness for interview’ of a suspect in a murder enquiry might be seen as more remote from an individual being executed than assessment of ‘fitness to plead’ in a capital trial; whilst giving evidence towards determining whether a mental condition defence is available to a defendant in a capital trial might reasonably be seen as more remote from execution per se than the former two stages, but less remote than medical involvement in a capital sentencing hearing, or in assessing for fitness for execution.


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