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Biomedical subjects

P S Appelbaum

Publications and source records attributed to P S Appelbaum.

At least 19 recordsLinked to original sources
PubMed1992

On the duty to protect: an evolutionary perspective.

Psychotherapists' duty to protect potential victims from their patients' violence has evolved in recent years toward a narrower set of obligations. This reformulation of the duty appears to us to be consistent with a sociobiological analysis of the reasonableness of compelled altruism. Altruistic behavior (e.g., rescuing a potential victim) takes place rarely in the animal world, and even among humans usually occurs only in situations in which reciprocity is likely. The Tarasoff-like duty to protect violates this sociobiological rule by requiring therapists to place the interests of an unknown victim over a known patient, and even to subordinate their own interests to the victim's. This has never been a socially tenable position. Psychotherapists appear to have escaped from this situation by avoiding potentially dangerous patients. The changes in the duty to protect have mitigated this dilemma, by moving the duty in a direction consistent with the evolutionary theory of altruism.

Adult↗
PubMed1992

Legal aspects of clinical care for severely mentally ill, homeless persons.

The problem of widespread homelessness among mentally ill persons is often attributed to changes in mental health law. In consequence, suggestions for addressing homelessness frequently involve legal interventions, including loosening of commitment standards. A review of the limited data on the relation of legal standards to homelessness suggests that the problem is not primarily a result of statutory changes or court decisions, but stems from broader social problems, including the diminution of public psychiatric services. Simple legal remedies are, therefore, unlikely to be found. Nonetheless, there may be ways in which legal initiatives can be useful in mitigating homelessness, ranging from implementation of outpatient commitment to modification of rules concerning confidentiality, to efforts to establish entitlements to psychiatric and social services.

Commitment of Persons with Psychiatric Disorders↗
PubMed1992

Forensic psychiatry: the need for self-regulation.

The shortcomings of forensic psychiatrists in the courtroom fall into two categories: failure to meet expected levels of performance in evaluation and testimony; and unethical behavior or deliberate misfeasance. Legal mechanisms for controlling the quality of testimony have been inadequate to the task. Courts rarely make use of their powers to screen expert witnesses with care; and post-hoc remedies, such as malpractice actions or charges of perjury, are almost unheard of. Psychiatry has been equally ineffective to date in responding to these problems, with educational programs usually reaching those least in need of help, and ethical codes either not addressing forensic issues or lacking powers of enforcement. Each class of problem calls for a distinct response. Inadequate performance in forensic work can be monitored and corrected by implementation of a program of peer review of forensic testimony. Preliminary attempts indicate the feasibility and utility of this effort. Unethical behavior, on the other hand, should be addressed by clear standards of forensic ethics, enforced by the relevant professional organizations. Forensic psychiatry bears the responsibility of cleaning its own house.

Dangerous Behavior↗
PubMed1991

Psychotherapist-patient sexual contact after termination of treatment: an analysis and a proposal.

Controversy over the legitimate extent, if any, of sexual contact between psychotherapists and former patients remains intense. In this paper the authors review current approaches to controlling posttermination sexual contact, offer a conceptual framework within which the problematic aspects of therapist-patient sex both during and after treatment can be understood, and develop a set of recommendations for policies that balance the goals of protecting former patients and avoiding unnecessary interventions into consensual relationships. Review of ethical, legal, and administrative controls on posttermination sex revealed considerable heterogeneity of approaches, which appeared to be based on confusion concerning the rationale for restriction. An analysis of the problems with therapist-patient sexual contact suggests four areas of concern: impaired decision making, coercion, fraud, and exploitation of a fiduciary relationship. The nature and magnitude of these problems differ in pre- and posttermination sexual relationships. The authors conclude that clarity of restrictions on posttreatment sex is important, but an absolute ban is not essential to protecting former patients. Rather, a 1-year waiting period after termination, during which even social contact would be precluded, should minimize problems and allow former patients and therapists to enter into intimate relationships. The authors discuss the advantages and disadvantages of this approach over other approaches.

Criminal Law↗
PubMed1991

A model hospital policy on prosecuting patients for presumptively criminal acts.

Evidence suggests that violence by psychiatric inpatients, especially in public-sector hospitals, may be on the rise. The authors present a model policy developed at a state hospital for deciding whether to prosecute presumptively criminal assaults by patients. The policy addresses the circumstances under which it is ethically permissible to file a criminal complaint while emphasizing the need to use clinical interventions first and to consider the clinical sequelae of prosecution. The authors also review criticisms made of the policy, which reflect opposing views that prosecution is unjustified and that the policy unduly restricts the use of prosecution. In the first six months after the policy became effective, state hospital staff considered filing charges against five patients, but no case progressed beyond the first steps in the implementation procedure.

Confidentiality↗
PubMed1990

A prospective, multicenter study of patients' refusal of antipsychotic medication.

Refusal of treatment with antipsychotic medication was studied prospectively in a sample of 1434 psychiatric patients admitted to four acute inpatient units in state-operated mental health facilities in Massachusetts during a 6-month period. Compared with a control group of patients who accepted prescribed antipsychotic treatment, the 103 patients who refused were older, of a higher social class, and less likely to have been prescribed antiparkinsonian medications. On admission, prior to refusal of medication, patients who refused were found to have significantly higher Brief Psychiatric Rating Scale scores than compliant patients and more negative attitudes regarding their hospitalization and past, present, and future treatment. Treatment refusal had negative effects on the hospital milieu and on the patient; refusers were more likely to require seclusion or restraint and had longer hospitalizations than treatment acceptors. Most refusal episodes ended with voluntary acceptance of treatment. In 23% of cases medications were discontinued. Only 18% of the sample reached formal, judicial review, and in every case that did, involuntary treatment was ordered. The policy implications of these findings are discussed.

Adult↗
PubMed1990

Neuroleptics: effects on neuropsychological function in chronic schizophrenic patients.

We have reviewed the literature from the 1950's to the present on the effects of neuroleptics on perceptual and neuropsychological function in chronic schizophrenic patients. In contrast to previous reviews, we have delineated the acute and chronic effects of neuroleptics on individual cognitive and motor tasks by drug, dose, and length of administration. To date, studies have shown that acute administration of neuroleptics impairs performance on some, but not all, tasks requiring vigilance and attention, and on some tasks requiring motor behavior. Chronic administration of neuroleptics, however, improves performance on some tasks requiring sustained attention and visuomotor problem-solving skills depending on dose and length of administration. Moreover, there is consistent evidence to suggest that chronic administration of neuroleptics in this patient population does not impair neuropsychological function independent of motor function. These findings have direct implications regarding the risk/benefit ratio and legal ramifications for the use of neuroleptics in chronic schizophrenic patients.

Antipsychotic Agents↗