July 6 juillet 13:45 – 17:45
(extended session)
Room NCDH–201
Chair:
Jagannathan Srinivasaraghavan
, Southern Illinois
University
There has been much discussion of the many ways doctors are
asked to be agents for social causes, such as testing pregnant women for drug
abuse to protect the fetus, or drivers in accidents to help those injured in the
crash (or their insurance companies). These are sometimes called being a dual or
double agent. This is often criticized, saying the traditional role of the
physician as an advocate for the patient is compromised.
Social activists, in contrast, are usually seen as working to correct the
inequities in society, and carry a positive connotation. But there is also a
political agenda to which each group is considered in a positive light. For
people concerned about law and order, or the rights of innocent victims, the
first group, double agents, are refusing to let their patients harm others, and
so it is akin to the second group.
In psychiatry, there are controversies about two drugs, Prozac and
Ritalin, which might be beneficially analyzed in these categories. The controversies around Prozac are well
known. I will review them briefly, focusing especially on the role of social
change. Over the past century, the expectations of work have increased
dramatically, with productivity measures becoming almost an obsession in
business and management circles. School teachers commonly work a 50-hour week,
and doctors 60-90 hours, depending upon their specialty. Could it be these
external pressures are making otherwise normal people feel inadequate? Further,
the pressure to be productive may mean less tolerance for people with an
existential or poetic nature. Aptly named, many have decided that it is better
to be prosaic. Similarly,
the rise of ADHD has occurred over the century of urbanization. One hundred
years ago most ADHD children would have had a future working on the family farm,
while only the most academically talented child from a family of five or ten
children would go to college. In contrast, now 1 or 2% of the population in
economically developed nations work on farms, over 50% go to college, and are
considered a failure if you don’t at least graduate from high school. The
ability to sit in class and memorize (whether in a textbook or on the board) are
essential, rather than optional skills. Indeed, it is often the school’s that
ask for the child to be evaluated (and medicated), not the parents.
Whether these psychopharmacological interventions are seen as helpful and
patient friendly, or overused and done primarily for the good of others, will be
the topic of my presentation, and of the discussion afterwards. Together we can
decide whether psychiatrists are being used as double agents, and whether it is
a justifiable role for them to assume.
In the 1960’s, the criteria for civil commitment shifted
from need for treatment to need for confinement based on dangerousness. With
increasing acceptance of the doctrine of informed consent, the decision making
power shifted from physicians to patients. Along with these changes, a civilly
committed person’s right to decision making, including the right to refuse
medications, came to be recognized. The right of refusal is adjudicated either
judicially or administratively. Giving patients’ autonomy and rights greater
significance than treatment considerations are models fashioned like Rogers
v. Commissioner of Mental Health (Mass 1983), using judicial review
mechanisms. Models that emphasize treatment, not just confinement, and that rely
on the principles of Rennie v. Klein (Third Circuit Court 1983), are models that utilize
administrative review panels. This lecture will highlight these two models and
variants of these models currently in operation in the United States.
Psychiatric care in Maryland is provided both voluntarily
and involuntarily in general medical and psychiatric hospitals. Severely
mentally ill patients often refuse treatment. Such patients may present a danger
to themselves or others if released without appropriate care. The law in the
State of Maryland–HG 10-708–provides for a “forced medication panel”
to prescribe treatment under these circumstances. This lecture will
outline the procedures involved in administration of medication over patients’
objection by a clinical review panel. There will be case examples to demonstrate
the working of this panel emphasizing how it is possible to safely and
successfully treat involuntary patients with forced medications in a responsible
and humane manner.
The overturning of Right to Refuse Psychotropic Medications is a function of the judicial system in the State of Illinois. There is wide discrepancy among hospitals and psychiatrists how this statute is utilized for the benefit of the patients. This presentation focuses on methods that encourage the use of court-ordered treatment in a 500-bed State hospital. Literature and clinical practice confirm that denial or delay in treatment can result in an increase in morbidity and adverse events for patients. A performance improvement project aimed at encouraging staff psychiatrists to actively pursue the option of court-ordered treatment for appropriate patients was designed. The major theme of the project was education and feedback to address the court avoidance attitude of psychiatrists. Results: In four years the number of petitions seeking court-ordered medications doubled. This project also led to a hospital wide effort to foster the theme of assertive treatment extending to other disciplines. The heightened awareness of the benefits of assertive treatment contributed to a decrease in average length of stay as well as reduced restraint usage and patient-to-patient injuries during the same period. Conclusion: Severely mentally ill patients derive benefit by early medication intervention, even if it is court-ordered. Education, support, and feedback can positively influence clinician attitudes and behaviors.
Objective: To
test whether the combined ratings of the quality of testimony of the
psychiatrist, the performance of the State Attorney and Public Defender can
differentiate between two groups of cases where the petition for medication of
psychotropic medications was granted or denied. Subjects: From 1991
to 1999, in Southern Illinois, there were 17 denials and 109 grants of petition
for administration of psychotropic medications in Union County Court.
Preliminary study involves transcripts of randomly selected six denials and
eight granted petitions.
Method: From the court
transcripts, any reference to the court decisions is deleted. An academic
forensic psychiatrist and an academic lawyer rate the content and process of
psychiatric testimony, and the performance of legal professionals on a scale of
one to four (poor, fair, good, and excellent). Results: Mean rating
of the performance of the Psychiatrist, State’s Attorney and Defense Attorney
for granted and denied petitions are noted. There were six psychiatrists, four
State Attorneys, two Defense Attorneys, and one judge involved. Conclusion:
Co-efficient of the Linear Discriminant Function suggests that the most
important variable for discrimination
between the two groups is the rating of overall performance of the
psychiatrist. The study provides opportunity to improve psychiatric testimony by
education and regular feedback.
The East Louisiana Mental Health System, Forensic Division,
is the maximum security inpatient forensic hospital for Louisiana. The
population comprises of patients who are unfit to stand trial, not guilty by
reason of insanity, permanently incompetent defendants and patients too
dangerous to be in state civil hospitals. Although judicial review
is not required to force medications, the facility has adopted procedures
to ensure that the patient receives appropriate due process when refusing
medications. When a patient refuses medications, the treating physician requests
an Administrative Review to assess the appropriateness of enforced medications.
The Medical Director reviews the patient’s hospital record, including staff
reports of the patient’s behavior and the treating physician’s
recommendations. The Director interviews the patient with a patient advocate to
determine if the patient is competent to make an informed decision regarding
medications. In order to force medication, the Director must determine that the
patient is mentally ill or
suffering from substance abuse and is dangerous to self or others, or gravely
disabled without the medication, and that
the recommended medication is the most appropriate treatment. The
presenter will discuss the data collected over the past three years concerning
outcomes of this process and factors which contribute to the decision whether to
force medications involuntarily.
In the criminal setting, psychiatrists are frequently
confronted with the issue of the right to refuse treatment. In Illinois, after a
defendant is found Unfit to Stand Trial, he is committed to a Department of
Human Services forensic inpatient facility for treatment and restoration to
Fitness. But the defendant has the right to refuse treatment. The statutes
outlining the criteria for court-ordered enforced medication also apply to the
mentally ill criminal defendants. But the issues arising from treatment refusal
by these inpatients are different to those committed for civil reasons. In Riggins
v. Nevada, the issue of enforcing treatment with psychotropic medications in
order to restore Fitness to Stand Trial was raised. Even if the defendant is
medicated for restoration of Fitness to Stand Trial, whether the medications
would affect the ability of the individual to effectively take part in the trial
has been questioned. There is a tug-of-war between the liberty interest of the
defendant and the State’s interest to expedite the trial. The case laws
addressing these issues will be reviewed. The clinical, legal and ethical
dilemmas faced by psychiatrists who work in the forensic inpatient facilities
will also be addressed.
The Supreme Court determined in the case of Ford
v. Wainwright that an incompetent defendant cannot be executed. This led to
competency-to-be-executed evaluations on death row inmates. One of the most
controversial issues in psychiatry is the participation of psychiatrist in
capital punishment. Once found incompetent to be executed, the question of the
prisoner’s right to refuse treatment comes into play. In Perry
v. Louisiana, the Supreme Court
was faced with the issue of determining whether forcibly medicating a death row
inmate in order to restore competency-to-be-executed is unconstitutional. Often
the prison psychiatrist is called upon to treat the death row inmate for
restoration of competency. Our ethical values are greatly questioned under these
circumstances, when our goals depart from treatment to relieve suffering to treatment to allow
execution. What are the clinical and ethical problems, when the prisoner refuses
treatment? The case laws addressing this issue will be reviewed, along with a
discussion of the ethical dilemmas.
Discussant: Maggie Tweddle, University of Alberta
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