Forensic psychiatry: critique of a critique.

To paraphrase Mark Twain, "Forensic psychiatrists are the only psychiatrists that blush or need to." Dr. Alan Stone attempts to measure forensic psychiatry with an ethical ruler and finds it sadly short. The Hinckley trial was the most recent example that evoked yet another reexamination of the insanity defense and the role of psychiatrists in that process. Although this trial is never specifically discussed in Dr. Stone's paper, its importance as a precipitant is apparent in both the emphasis given to the insanity defense and in the search made for justification to condone psychiatric involvement in such proceedings. I believe Dr. Stone's sweeping indictment of forensic psychiatry is based partially on his narrow definition of the field: child custody and insanity defense evaluations rather than a more general consultative role to the legal system. The news media choose to highlight these cases and, therefore, psychiatrists who perform such evaluations have been most vulnerable to being depicted as "hired guns." However, employing the kind of definition Stone suggests can be very misleading as illustrated by the following examples: 1. Dr. A testifies that Mr. B is a chronic schizophrenic who is frequently delusional to a degree that has precluded his ability to work for the past ten years. Hospitalizations have occurred on an average of three times per year during the past three years. He concludes that he meets the criteria for social security disability. 2. Dr. C testifies that Dr. D was negligent in allowing a patient a home visit four days after admission precipitated by a suicide attempt. The patient had continued to express suicidal impulses to the nursing staff, but the doctor had not reviewed the chart prior to his decision. While on the visit the patient committed suicide. 3. Dr. E testifies that Mr. F does not meet the standards for civil commitment although he needs and could benefit from treatment. 4. Dr. F is employed by the U.S. Government and is asked to screen applicants for their fitness to work. 5. Dr. G, in his consultant role to the FBI, develops a psychological profile of a suspect. What do these situations have in common? First they are all situations that require psychiatric opinions within a forensic framework, that is, examinations by an expert to help resolve legal questions. Such evaluations, if they contribute to the ultimate loss of a job or incarceration of an individual, may not be "therapeutic" from the individual's perspective. Yet without the goal of doing "the best he can to ease his patient's suffering," the justification for psychiatric involve-