Commentary: comparative forensic psychiatry, USA vs UK
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Commentary: Comparative forensic psychiatry, USA vs UK JOHN GUNN Professor of Forensic Psychiatry, Maudsley Institute of Psychiatry, London Dr Beck must be congratulated on his lucid analysis of the UK and US sys- tems of forensic psychiatry. From the UK perspective it is good to receive such unsolicited complimentary comments. Those of us working in the UK system can take some pride in the fact that there has been an effort by professionals and governments alike to create an effective forensic psychiatry profession with high standards. However, this article gives us no cause for complacency and indeed raises several important questions for both systems. As Dr Beck guesses, there are considerable variations in the standard of service offered to patients in different parts of the UK. Dr Beck, from his account, did not spend much time in Scotland, and he would have noted their much less well organ- ised and differentiated forensic psychiatry service. Scotland, for example, has no medium secure services and some patients pay a price for this. Equally it is not true that forensic psychiatry is as well regarded as, say, general psychiatry in the UK. It is not possible to take up all the points raised for discussion, so I will sim- ply deal with two broad areas: the nature of the differences between the two systems and the tricky matter of differing standards of ethics. DIFFERENCES BETWEEN THE USA AND UK Dr Beck attributes many of the differences he finds between the two countries to a difference in attitude towards public services. Whilst I would not disagree with that in broad terms, I am not sure I would emphasise it quite the way he does. He says that in the UK there is a belief that government exercises a benign influence on the lives of citizens and that agents of the Crown can be trusted to protect the interests of the individual. This is only partly true and we have had fifteen years of Conservative governments which have been trying to change the public’s mind about this, to take on attitudes that are unashamedly copies of a US approach. As with many of these matters I sus- Criminal Behaviour and Mental Health, 6, 45–48, 1996 © Whurr Publishers Ltd 45
Transcript of Commentary: comparative forensic psychiatry, USA vs UK
Commentary: Comparative forensicpsychiatry, USA vs UK
JOHN GUNN Professor of Forensic Psychiatry, Maudsley Institute ofPsychiatry, London
Dr Beck must be congratulated on his lucid analysis of the UK and US sys-tems of forensic psychiatry. From the UK perspective it is good to receive suchunsolicited complimentary comments. Those of us working in the UK systemcan take some pride in the fact that there has been an effort by professionalsand governments alike to create an effective forensic psychiatry professionwith high standards. However, this article gives us no cause for complacencyand indeed raises several important questions for both systems. As Dr Beckguesses, there are considerable variations in the standard of service offered topatients in different parts of the UK. Dr Beck, from his account, did not spendmuch time in Scotland, and he would have noted their much less well organ-ised and differentiated forensic psychiatry service. Scotland, for example, hasno medium secure services and some patients pay a price for this. Equally it isnot true that forensic psychiatry is as well regarded as, say, general psychiatryin the UK.
It is not possible to take up all the points raised for discussion, so I will sim-ply deal with two broad areas: the nature of the differences between the twosystems and the tricky matter of differing standards of ethics.
DIFFERENCES BETWEEN THE USA AND UK
Dr Beck attributes many of the differences he finds between the two countriesto a difference in attitude towards public services. Whilst I would not disagreewith that in broad terms, I am not sure I would emphasise it quite the way hedoes. He says that in the UK there is a belief that government exercises abenign influence on the lives of citizens and that agents of the Crown can betrusted to protect the interests of the individual. This is only partly true andwe have had fifteen years of Conservative governments which have been trying to change the public’s mind about this, to take on attitudes that areunashamedly copies of a US approach. As with many of these matters I sus-
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pect that economics are at least as important as other more erudite concerns.Perhaps the most significant difference between the USA and the UK is
that funding of the US public services is a low priority and health is a decided-ly two-tiered system with forensic psychiatry falling clearly in the less wellfunded, less prestigious, public system. Much of the current Conservativerhetoric in the UK about supporting the individual against the state is actuallyconcerned with attempting to copy the US two-tiered system, which is con-sidered to be less of a burden to the taxpayer.
It is my belief that the majority of the differences which have been per-ceived by Dr Beck are concerned with this economic matter. If the USA had apublic funded health care system which embraced high standards of psychi-atric care, then the niceties of differences in statute and the like would fadeinto the background. I accept that there is a greater readiness in the USA tocall upon the use of lawyers, but even here Dr Beck acknowledges that thelawyer, in psychiatric matters, is only as good as the psychiatrist who adviseshim/her. Furthermore the UK system has a good deal of intervention bylawyers within its tribunal and other appeal frameworks.
Another difference which Dr Beck spotted may be more related to hisnorth-west of England experience than to a general difference between thetwo systems. He noted that few forensic psychiatrists are involved in civilwork. Whilst it is true that much civil work is still undertaken by general psy-chiatrists in the UK, this is a pattern that is beginning to change as peoplerecognise the relationships between some civil and some criminal issues andalso in the overlap of skills required in court and in the management of chron-ic disorders. It is nice to think that Dr Beck managed to avoid encounteringthe ‘rent-a-shrink’ in the UK. This is a further reflection of his lack of contactwith civil work because, whilst such activity is largely unknown in the crimi-nal field, it certainly is an increasing problem in the more obviously financial-ly driven civil work.
One of the most noticeable differences between the US criminal systemand the UK criminal system was brought out by Dr Beck, but not perhapsemphasised as much as I feel it could be. That is the sharp division that existsin the USA between assessment and treatment. I will need to return to thisunder ‘Ethics’, but for the moment I want to indicate just how foreign it feelsto a UK psychiatrist to note that psychiatric assessments are often primarilyconsidered to be an end in themselves, or a means of informing others aboutthe patient being assessed. The average UK psychiatrist sees the primary taskof assessment as part of the general professional relationship between doctorand patient, with the patient’s needs being paramount and the result of theassessment being largely advisory to the patient. Thus assessments spill intoother functions, and the psychiatrist who sees him- or herself as acting primar-ily as an assessor outside the treatment framework is unusual. The UK publicare not, on the whole, used to an adversarial relationship with their doctorsand most people, including judges and juries, would accept that a medical
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intervention in a legal case is more likely than not to be therapeutically orien-tated, rather than punitive, albeit honest.
ETHICS
The differences in attitude towards assessment mentioned above lead to somevery strange conflicts among psychiatrists who believe they are practising thesame kind of work within the same profession. I well remember the look ofabject horror that came upon a distinguished US visitor to our hospital whenhe grasped that I was about to write a court report on a patient I had in treat-ment. He was clearly distressed at what he regarded as my totally unethicalbehaviour and inferred that I would not be allowed to practise such behaviourin the USA. There may have been an element of exaggeration, but I amunder no illusion that his view would be shared by many other forensic psy-chiatrists in the USA. The argument seemed to turn on the notion that anassessor has, above all, to be impartial and thus serve as effectively as possiblesome superior ‘client’, presumably the court in this instance. I, on the otherhand, took the view that the doctor who knew most about the patient (andthat happened to be me because I had spent more time with him) had a dutyto the patient to explain and interpret to the court, as clearly as possible, theantisocial behaviour in question. Neither I nor the patient felt it would bewrong to have other opinions also put to the court, and I certainly did notoffer to give the court anything but the fullest exposition. I did this in the fullknowledge that the court would be grateful for such assistance from the treat-ing doctor, that it is perfectly capable of taking into account the possible bias,which it would expect anyway, of the treating doctor trying to help his/herpatient as best possible, and is perfectly capable of arranging for further opin-ions to be commissioned if there seems some concern about particular issues.In other words, I thought it would be unethical to refuse to do as my patientwished and provide the report to the court.
This leads me to wonder what ethics are all about. I sometimes have a con-cern that they are not much more than trade union codes for the benefit ofpractitioners. This perhaps is over-cynical, but I cannot see that abiding, as faras possible, within the bounds of law, honesty and professional standards, it iswrong to comply with a patient’s wishes. I think at root this is a question ofdeciding who the doctor is responsible to. Now, it is never either/or, but itseems to me that every doctor always has some degree of responsibility toevery patient he/she encounters, even if the patient is not coughing up apenny and the doctor’s fee is entirely provided by some other means. Thenotion that objectivity can only be obtained from someone who does notknow the patient and will have no continuing obligation to him or her seemsto me to be misconceived.
Another stark US/UK difference relates to capital punishment. As JamesBeck notes, the role of forensic psychiatry in death penalty cases is almost
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uniquely a US concern; even South Africa has recently come into the largemajority of what Beck calls ‘industrial nations’, who now do not use it. It isstartling for Europeans to realise that psychiatrists in a huge economy on thewest side of the Atlantic are still employed to decide fitness for execution.Beck also tells us that some psychiatrists in the USA actually approve of thedeath penalty and presumably their role in it. It is startling partly because tor-ture is the one human activity that is completely outlawed by the UnitedNations Charter. It is hard to believe that the ordeals which capital-sentencedprisoners suffer in the USA fall short of this forbidden activity. All other ethi-cal problems pale into insignificance compared with this one.
Perhaps it is time for psychiatrists in all countries to join together in a con-certed effort to rid the world of this scourge. Very tough lobbying took placewithin the World Health Organisation against unacceptable practices withinthe Soviet Union. These practices have now ceased. It is difficult to knowwhether that is a direct result of the lobbying or a consequence of other politi-cal developments, but it seems likely that the adverse international opiniondid have some effect. European psychiatrists are still lobbying to effect furtherimprovements within the Greek psychiatric system. Surely no country shouldbe immune from professional pressure. The medical profession should havetenets which go beyond national standards and concerns. No country shouldbe too big and too powerful to escape justified criticism. A nation that delib-erately kills some of its citizens in cold blood is perhaps an appropriate targetfor protest and pressure from a healing profession. The difficulty may be thatUncle Sam seems a little too large to take on. He does control the budget andrule the waves, but it is difficult to believe that the persistence of the deathpenalty in the USA, with continuing medical involvement, does not have anadverse effect on forensic psychiatry everywhere.
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