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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
PubMed1995

Comparison of standards for assessing patients' capacities to make treatment decisions.

OBJECTIVE: This study investigated the proportion of psychiatric and medical patients who are impaired in their decision-making abilities in relation to each of several major legal standards for determining competence to consent to treatment. METHOD: The subjects were hospitalized patients with diagnoses of schizophrenia (N = 75), major depression (N = 92), and ischemic heart disease (N = 82) and equal numbers of community comparison subjects matched on age, race, gender, education, and occupation. Three instruments measuring abilities related to the legal standards for competence were administered to each group. Impaired functioning was defined as scores two standard deviations below the means for all subjects combined or lower. RESULTS: Although similar percentages of subjects with impaired performance were found for each of the measures, different groups of patients were identified as impaired depending on the measure used. The proportion of patients identified as impaired increased when compound standards were used, i.e., when impairment was defined as poor performance on any of two or three measures. Despite previous suggestions that the legal standards might form a hierarchy of rigorousness, the data did not support this hypothesis. CONCLUSIONS: Choice of standards for determining competence, including compound standards, will affect the identity and proportion of patients classified as impaired. Clinicians should be aware of applicable standards in their jurisdictions. Use of compound standards requires independent evaluation of performance on abilities related to each relevant standard, because standards do not appear to be hierarchical. Policies relating to the characterization of persons as incompetent must be fashioned with caution.

Comprehension↗
PubMed1994

Sexual relationships between physicians and patients.

In the face of evidence suggesting that there is a substantial incidence of sexual contact between physicians of all specialties and their patients, the medical profession and the courts have not yet reached a consensus regarding appropriate responses. Some commentators, including the American Medical Association, have urged bans on sexual contact during treatment and extensive restriction of posttreatment sexual relationships. Others favor looser restrictions, particularly after termination of the physician-patient relationship. These differences in approach stem from the varying importance given the two conflicting values involved: (1) protecting patients from being harmed by unfair manipulation by physicians and (2) insulating choices about intimate relationships from intrusion by society. We propose a model for balancing these interests that would bar sexual contact during the physician-patient relationship and for a fixed period after termination; thereafter, in most cases, sexual relationships would not be proscribed. A waiting-period approach of this sort is likely to diminish most of the harms that might result from physician-patient sexual contact and may constitute a template for the resolution of similar issues elsewhere in society.

Consensus↗
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↗