Competence to Complete Psychiatric Advance Directives: Effects of Facilitated Decision Making

Psychiatric advance directives (PADs) statutes presume competence to complete these documents, but the range and dimensions of decisional competence among people who actually complete PADs is unknown. This study examines clinical and neuropsychological correlates of performance on a measure to assess competence to complete PADs and investigates the effects of a facilitated PAD intervention on decisional capacity. N=469 adults with psychotic disorders were interviewed at baseline and then randomly assigned to either a control group in which they received written materials about PADs or to an intervention group in which they were offered an opportunity to meet individually with a trained facilitator to create a PAD. At baseline, domains on the Decisional Competence Assessment Tool for PADs (DCAT-PAD) were most strongly associated with IQ, verbal memory, abstract thinking, and psychiatric symptoms. At one-month follow-up, participants in the intervention group showed more improvement on the DCAT-PAD than controls, particularly among participants with pre-morbid IQ estimates below the median of 100. The results suggest that PAD facilitation is an effective method to boost competence of cognitively-impaired clients to write PADs and make treatment decisions within PADs, thereby maximizing the chances their advance directives will be valid.     

Civil commitment in Turkey: reflections on a bill drafted by psychiatrists

Involuntary hospitalization of the mentally ill has been an issue that still remains outside the judicial system in Turkey. Despite the new Turkish Civil Code, which includes several articles relevant to involuntary psychiatric hospital admissions, there still appears to be a need for a comprehensive mental health law to address specific issues concerning civil commitment of the mentally ill. As a result of the lack of specific statutory regulation, an insufficient number of psychiatric hospital beds and limited appreciation of the safety risks involved in untreated mental illness, involuntary hospitalization remains an underutilized option by psychiatrists and the courts alike. In response to its concerned members, the Psychiatric Association of Turkey has appointed a task force to draft a proposed mental health law, entitled the "Psychiatric Patients' Bill of Rights." Although the draft suggests a model with emphasis on the right to psychiatric treatment, it also recommends close judicial oversight to prevent potential abuses of discretion by the system. However, this might present logistic problems in a country with already overburdened courts. Authors discuss the highlights of the draft within the context of Turkey's current cultural, social and judicial structure, and compare it to similar laws of other countries.     

Is it unethical to offer predictions of future violence?

An examination of the nature, foundation, and consequences of predictive testimony about future violence does not support the assertion, sometimes heard, that such testimony is necessarily unethical. Certain types of predictive testimony about future violence may have adequate scientific support. Moreover, society does not require certainty about future violence in order to restrict various liberties. Proper performance of an evaluation related to certain types of predictive testimony can provide an adequate foundation for the testimony. Finally, a consideration of the consequences of legal proceedings that restrict liberty does not support the conclusion that predictive testimony is necessarily ethically improper merely because it uses probabilities that create the potential for a significant number of false-positive legal decisions. Therefore, we would not advise psychology, psychiatry, or the courts to conclude that predictions of dangerousness as a class are unethical.This paper was supported in part by funding from the John D. and Catherine T. MacArthur Foundation Research Network on Mental Health and the Law. The authors wish to thank Alexander Greer, John Monahan, Stephen Morse, and Ed Mulvey for their helpful comments on an earlier draft.     

In the wake of Ake: the ethics of expert testimony in an advocate's world

The decision of the U.S. Supreme Court in Ake v. Oklahoma redefined the role of psychiatrists as experts in criminal cases. In addition to the expert's serving as evaluator and witness, the Court stressed the importance of the defense having a psychiatrist available to act as a consultant in the preparation and presentation of its case. This broader conception of the expert's role has raised ethical questions among psychiatrists, many of whom are concerned that their impartiality may be compromised. A careful analysis of Ake, however, demonstrates that substantial differences remain between the roles of consultant and advocate. Subtle pressures on impartial functioning will be increased, but they will not differ in kind from those operative before the decision. Several ethical issues related to the consultative role are considered and possible means of dealing with them addressed.