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Care or custody? Ethical dilemmas in forensic psychiatry
  1. Gwen Adshead
  1. Broadmoor Hospital, Crowthorne, Berkshire

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    Ethical dilemmas in forensic psychiatry have not, on the whole, been exposed to the same degree of scrutiny as other medical topics in the medical ethical literature. In this editorial, I will hope to show that forensic psychiatric practice raises many ethical dilemmas; not only practical, but also conceptual. Indeed the level of public debate following the publication of the Fallon report1 and new proposals for preventive detention of dangerous people2 suggest that these dilemmas also belong in the political sphere. Renewed attention to this area is therefore timely.

    In this editorial, I shall provide a brief overview of the many ethical dilemmas that arise in relation to the practice of forensic psychiatry. I shall use the four principles plus scope approach3 for my analysis. I will invert the usual discussion order; reflecting perhaps the relative importance of the different principles in forensic psychiatry.

    Respect for justice

    Forensic psychiatry represents the interface of two worlds which identify and regulate deviance ie medicine and the law. Many ethical-conceptual issues in relation to psychiatry still need elucidation. For example, what counts as a mental illness, and how does mental illness excuse responsibility for criminal actions? This question is particularly difficult to answer in relation to personality disorder, and its sister concept, psychopathy.

    Respect for justice usually requires that we treat similar people in similar ways. However, forensic patients are vulnerable to exploitation and injustice. For example, mentally ill offenders are detained longer in secure settings than their counterparts who have committed exactly the same offence, but do not have a mental disorder.4 Political pressures (especially if the patient has a high media profile), and concern for victim's feelings may influence release decisions. This may do justice to the victims of violence, but at the expense of the offender patient's welfare; so …

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    • Gwen Adshead, MA(Medical Law and Ethics), is a Consultant and Honorary Senior Lecturer in Forensic Psychotherapy at Broadmoor Hospital, Crowthorne, Berkshire and St George's Hospital, London.