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A spirited debate by four prominent psychiatrists at APA's 1997 annual meeting in San Diego last month vividly illustrates how sharply the battle lines continue to be drawn on the sensitive issue.
Forensic psychiatrists Paul Appelbaum, M.D., and Steven K. Hoge, M.D., argued that not only is it ethically permissible for psychiatrists to conduct such competency evaluations of condemned prisoners, but to refuse to do so deprives those persons of an assessment that might uncover a mental disorder that saves them from execution.
Hoge, chair of the APA Council on Psychiatry and Law and a professor at the University of Virginia, pointed out that while a psychiatrist's findings may have a detrimental effect on the prisoner, other activities such as SSI evaluations, testifying at sentencing hearings, participating in child custody battles, or even serving as an expert trial witness can cause harm yet are considered to be within the bounds of ethical medical practice.
In both forensic and research settings, ethical principles that are different from--though no less valid than--those traditional to the doctor-patient relationship guide the psychiatrist, said Appelbaum. "Truth telling and respect for the person they are evaluating" control psychiatrists' actions in these situations, and the same standards apply when they are working for the good of the justice system by assessing competency to be executed. Appelbaum is a former president of the American Academy of Psychiatry and the Law and chair of the psychiatry department at the University of Massachusetts.
Drawing a line between some practices that can cause harm to an individual and others that can have a similar end is "artificial and logically indefensible," Hoge insisted. He maintained that opponents of this form of psychiatric evaluation are using the charge of ethical breach to mask their opposition to the death penalty.
One of their debate opponents, former APA president Lawrence Hartmann, M.D., labeled Hoge and Appelbaum's position "immoral," stressing that while "there is always tension between helping patients and other social functions of medicine," participating in any form of the capital punishment process pushes the issue "beyond the ethical breaking point." When psychiatrists' actions can contribute to a person's death, their involvement is "harmful to medicine and society," he said.
Forensic psychiatrist Alfred Freedman, M.D., also a former APA president, strongly agreed with Hartmann, his debate partner. He noted that the ethical prohibitions are so clear that since the Nuremburg trials after World War II organizations worldwide have backed the principle that it is unethical for physicians to take part in proceedings that can lead to prisoner executions. No matter how advocates choose to explain their participation, doing so makes them "hangman's aides," Freedman told the standing-room-only debate audience.
"Truth and justice are worthy goals," Hartmann stated, "but when they clash with goals that are so important to my profession, I can see it damaging psychiatry in unmeasurable ways."
He refused to accept his opponents' argument that the same ethics apply to execution competency evaluations as to other forensic assessments. "I don't think it's impossible to distinguish" between competency to be executed and competency for judicial determinations with less dire consequences at stake, Hartmann said. He emphasized his belief that conducting evaluations in execution competency proceedings still equates with participation in capital punishment and cannot be justified by any ethical standard. To underscore his point, he evoked the image of psychiatrists' wearing police uniforms.
Hoge asserted, however, that ethical standards accommodating psychiatric participation in execution and other judicial proceedings are, in fact, "in the interest of persons with mental illness and serve to enhance the administration of justice. . . . Given the constitutional prohibition against execution of incompetent prisoners, psychiatric evaluation is necessary to vindicate mentally ill prisoners' rights and their interest in justice." It is a "distressing" prospect for a "caring, scientific profession to hoard its knowledge. . .when the outcome is as final as death," Hoge maintained.
In the 12 years since the U.S. Supreme Court ruled that incompetent prisoners cannot be executed, Appelbaum pointed out, three condemned inmates are alive because they were found to lack such competency following psychiatric evaluation and had their sentences commuted to life in prison.
He noted as well that in a 1990 opinion, APA's Ethics Committee stated that while it is unethical for psychiatrists to participate in an execution, that is not the case when their participation is limited to conducting a competency evaluation in which the prisoner is told of the interview's purpose and confidentiality limits, "and the opinion is rendered in keeping with existing standards."
For psychiatrists to "abandon those it is hardest to empathize with" sends the message that they are really not interested in the search for ways "to use their skills to help with the toughest populations," Appelbaum said, and will compel others in society to question the amount of trust they should invest in the psychiatric profession.
Freedman, however, insisted that if all psychiatrists resisted conducting this type of evaluation, their refusal would bring pressure on lawmakers to change capital punishment statutes so that any death row inmate found mentally incompetent would automatically have his or her sentence commuted to life without parole.
(Psychiatric News, June 20, 1997)