The ethical boundaries of forensic psychiatry: a view from the ivory tower.

At a recent meeting of sixty federal judges from around the country, one of the trial judges defined the essence of the distinction between trial and appellate judges. “Trial judges,” he said, “are in the front lines of legal warfare, they are foot soldiers involved in the bloody hand-to-hand combat. Appellate judges, in contrast, sit on a safe hill overlooking the battlefield. When the fighting is over, the appellate judge comes down from his position of safety and goes about shooting the wounded.” That is my plan of action. Forensic psychiatry is a kind of handto-hand combat, and now as never before, the troops are wounded and bloody. Now, after Hinckley, when forensic psychiatrists need encouragement, healing balms, and soothing treatment, I have come down from my ivory tower to “shoot the wounded.” But forensic psychiatrists need not be afraid, I intend only intellectual violence; like the trial judges they will survive to fight again. In fact, though wounded and bloody they are today stronger than ever. The legal assault on psychiatry of the past two decades had one consistent result: it took discretionary authority from the psychiatrist and handed it to the courts. But the courts, in order to take on this burden responsibly, require more (not less) psychiatric testimony. The more they hate us the more they need us. Whatever the reasons, forensic psychiatry seems to be flourishing. There is an array of journals, new organizations, subspecialty boards, a remarkable number of competent practitioners, and an increasingly sophisticated intellectual dialogue. In a stagnant psychiatric economy, forensic psychiatry is one of the few growth stocks. I am not a forensic psychiatrist. What has kept me out of the courtroom is my concern about the ethical boundaries of forensic psychiatry. Let me state what I think the ethical boundary problems are. First, there is the basic boundary question. Does psychiatry have anything true to say that the courts should listen to? Second, there is the risk that one will go too far and twist the rules of justice and fairness to help the patient. Third, there is the opposite risk that one will deceive the patient in order to serve justice and fairness. Fourth, there is the danger that one will prostitute the profession, as one is alternately seduced by the power of the adversarial system and assaulted by it. Finally, as one struggles with these four issues— Does one have something true to say? Is one twisting justice? Is one deceiving the patient? Is one prostituting the profession?—there is the additional problem: forensic psychiatrists are without any clear guidelines This article was originally published 25 years ago in The Bulletin of the American Academy of Psychiatry and the Law (Bull Am Acad Psychiatry Law 12:209–19, 1984). In the original publication, Dr. Stone noted: This is a shortened version of a chapter in Law, Psychiatry, and Morality: Essays and Analysis, by Alan A. Stone, MD (Washington, DC, American Psychiatric Press, Inc., 1984). Copyright 1984 by Alan A. Stone; reprinted with permission. An earlier version of the 1984 publication was delivered by Stone in a special lecture at the Thirteenth Annual Meeting of the American Academy of Psychiatry and the Law on October 22, 1982.