Abraham L. Halpern, MD

In 2005, the Board of Trustees of the American Psychiatric Association (APA) prepared a Position Statement entitled

 Psychiatric Participation in Interrogation of Detainees.

 The Statement essentially provided that psychiatrists should not participate in interrogations under any circumstances (including coercive and non-coercive interrogations), whether in military or civilian settings. The Statement was referred to the APA Assembly for approval at its November 2005 meeting.

 drastically amending the Statement, permitting psychiatrists to participate in non-coercive interrogations. The Board of Trustees reaffirmed its original Statement, and after extensive discussion and clarification of its position (eg, certain techniques used in “enhanced” interrogations that according to international and US laws constituted torture were declared to be non-coercive by some authorities

), the Assembly at its May 2006 meeting voted in favor of the Statement proposed by the board.

 Thus, Psychiatric Participation in Interrogation of Detainees became official APA policy.

I feel that an explanation is needed as to why the Assembly initially disapproved of the board’s proposed position that psychiatrists should not participate in interrogation of detainees.

I believe that a majority of Assembly members voted as they did because of the strong protestations of a substantial number of representatives-many of whom are engaged in forensic psychiatric practice in addition to their regular psychiatric activity-together with military Assembly representatives, who felt that participation in non-coercive interrogations of detainees was entirely appropriate and necessary. It is my view that the Assembly’s position has its roots in a firmly embedded conviction of most forensic psychiatrists in the United States that the rules embodied in 

The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry

 do not apply to psychiatrists when engaged in practice as forensic psychiatrists. In other words, they are not required or expected to abide by all the canons in the code of medical ethics.

This position was taken as a result of the very strong stand expounded by one of this country’s foremost experts in psychiatry and the law, Paul S. Appelbaum, MD,

 past APA president and past president of the American Academy of Psychiatry and the Law. Appelbaum’s position was forcefully endorsed by Thomas G. Gutheil, MD,

 another leading figure in forensic psychiatry. “The forensic psychiatrist,” Appelbaum writes, “in truth does not act as a physician. If the essence of the physician’s role is to promote healing and/or to relieve suffering, it is apparent that the forensic psychiatrist operates outside the scope of the role. Were we to call such a person a ‘forensicist,’ or some similar appellation, it might more easily be apparent that a different-nonmedical-role with its own ethical values is involved. . . . [P]sychiatrists operate outside the medical framework when they enter the forensic realm, and the ethical principles by which their behavior is justified are simply not the same.”

He adds, “Their functioning in the forensic setting is guided by a different set of principles.”

Thus, by sanctioning the participation of psychiatrists in non-coercive interrogations, the slippery slope of clearly unethical involvement in this regard is created. To illustrate, a policy, recommended by a past president of the American Academy of Psychiatry and the Law, under which participation by forensic psychiatrists in police interrogation of individuals who might be dangerous would not violate professional ethics, because such interrogations “are derivative of agency and efficacy, not ethics.”

 This forensic psychiatrist also states, “Police interrogation techniques not only allow but also encourage deception.”

Dr Jeffrey Janofsky captures the essence of the problem succinctly: “Police interrogators routinely use deceptive techniques to obtain confessions from criminal suspects. . . . When a psychiatrist directly uses, works with others who use, or trains others to use deceptive or coercive techniques to obtain information in police, military, or intelligence interrogations, the psychiatrist breaches basic principles of ethics.”

Dr Appelbaum11 sees the forensic psychiatrist as an “advocate of justice.”On the other hand, not only forensic psychiatrists but all psychiatrists must remain constantly alert to the danger of being drawn into unethical conduct in the service of an elusive and not infrequently unjust justice.

 It has long been recognized that in countries where misuse of psychiatry has been, and in some countries still is, rampant (eg, the former Soviet Union,

), psychiatrists justified their unethical conduct on the grounds that they were furthering the interests of their countries’ justice.

It is regrettable, but understandable, that the influential military and forensic psychiatrists in the APA Assembly would agree with and endorse the view of a renowned forensic psychiatrist that “the theoretical framework offered by Appelbaum has become a mainstay of our understanding of forensic ethics.”

 It should be recognized, however, that Appelbaum bases his entire argument that a special code of ethics is necessary for forensic psychiatrists on his mistaken belief that APA’s 

Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry

 is restricted to the physician-patient relationship in which “the physician’s role is to promote healing and/or to relieve suffering.”

We do not need a special set of ethics for the forensic psychiatrist: the principles and annotations of the ethics code

“A physician shall be dedicated to providing competent medical care with compassion and respect for human dignity and rights.”

“A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.”

“A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.”

 “Psychiatrists are often asked to examine individuals for security purposes, to determine suitability for various jobs, and to determine legal competence. The psychiatrist must fully describe the nature and purpose and lack of confidentiality of the examination to the examinee at the beginning of the examination.”

“When, in the clinical judgment of the treating psychiatrist, the risk of danger is deemed to be significant, the psychiatrist may reveal confidential information disclosed by the patient.”

Appropriate guidance to assist forensic psychiatrists in adhering to the code of medical ethics is provided in the 

American Academy of Psychiatry and the Law Ethics Guidelines for the Practice of Forensic Psychiatry 

 in stating that “the forensic psychiatrist does not act as a physician,” overlooks the fact that a large number of psychiatrists who work in prisons are also forensic psychiatrists (all forensic psychiatry fellowship programs accredited by the Accreditation Council for Graduate Medical Education must include substantial training in correctional psychiatry, and the American Board of Psychiatry and Neurology’s certification examination in the subspecialty of forensic psychiatry covers the area of correctional psychiatry).

Thus, I unreservedly disagree with Dr Appelbaum’s position that “forensic psychiatrists cannot simply rely on general medical ethics.”

 I believe the prestige of the forensic psychiatry profession will flounder if forensic psychiatrists are exempt from abiding by the time-honored principles of medical ethics.

Psychiatric Participation in Interrogation of Detainees

 Annas GJ. Unspeakably cruel-torture, medical ethics, and the law. 

 Borchelt D, Pross C. Systematic use of psychological torture by US forces. 

Interpretation of the Geneva Conventions Common Article 3 as Applied to a Program of Detention and Interrogation Operated by the Central Intelligence Agency

Senate Armed Services Committee: The origins of aggressive interrogation techniques. 

Committee Statement. Senate Armed Services Committee Hearing.

Shane S. Documents laid out interrogation procedures. 

 American Psychiatric Association. APA passes position statement barring psychiatric participation in interrogation of detainees. 

The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry.

 Appelbaum PS. The parable of the forensic psychiatrist: ethics and the problem of doing harm. 

 Gutheil TG. Forensic psychiatry as a specialty. 

Clinical Handbook of Psychiatry and the Law

 Phillips RT. Expanding the role of the forensic consultant. 

Janofsky JS. Lies and coercion: why psychiatrists should not participate in police and intelligence interrogations. 

Halpern AL, Freedman AM, Schoenholtz JC. Ethics in forensic psychiatry. 

Articles

DEBATE
In 2005, the Board of Trustees of the American Psychiatric Association (APA) prepared a Position Statement entitled Psychiatric Participation in Interrogation of Detainees

The Forensic Psychiatrist and the Code of Medical Ethics

By Thomas Szasz; New Brunswick, NJ: Transaction Publishers, 2006 154 pages  $29.95

A tremendous gap in the literary worldhas existed for 65 years and ThomasSzasz has filled it. Was VirginiaWoolf mad?

In this 30th book by Szasz, heargues convincingly that VirginiaWoolf, albeit boorish, meddling andnasty . . . a first class snob and coward,was not mentally ill. His conclusion,the product of extensive and meticulousresearch, runs counter to theopinions of most nonmedical authorsand of psychiatrists who havesuggested that Virginia Woolf wasmentally ill. He shows with abundantproof that her spurious suicidalgestures, and even the act that endedher life at age 59 in March 1941, werenot the acts of a madwoman but simplythe choice of a relentless self-dramatizer,who, in the end, was convincedthat she had a right to kill herself andthat by so doing, was committinggood, not evil.

It is unclear why Szasz devotes somany pages to his already well-knowndenunciations of psychiatry, psychoanalysis,Sigmund Freud, and fakeneuroscientists--attacks not specificallyrelated to the case of Virginia Woolf. Perhaps Szasz believes thereare some readers who are unfamiliarwith his views. But there is no doubtthat his digressive anti-psychiatryfulminations will weaken the abilityof psychiatrists to grasp readily thefact that Szasz's criticisms of psychiatryare particularly applicable to thepsychiatrists who treated Woolf. Szaszmakes clear that these psychiatrists,some highly regarded and distinguished,indeed merit condemnation.

The attacks--really diatribes--against psychiatry undermine theauthor's insightful and well-foundedviews concerning Woolf. Still, eventhe most ardent critic of Szasz's anti-psychiatryextremism must acknowledgethe comprehensive research hehas undertaken and that Szasz's criticismof Woolf's psychiatrists is nomore than warranted.

As an added bonus, we are treatedto 2 chapters entitled Appendix Iand Appendix II, in which Szaszcogently and deftly debunks the myththat creativity and genius are inextricablylinked to madness.

This is a book that I believe willbe thoroughly enjoyed by the psychiatristwho is interested in learning thetruth about Virginia Woolf. It will benecessary, however, for the readerto disabuse himself of the notion thatall of Szasz's anti-psychiatry proclamationsare wildly unwarrantedexaggerations that should be dismissedout of hand.

Dr Halpern is professor emeritus of psychiatryat New York Medical College inValhalla.

Was Virginia Woolf mad?  Thomas Szasz seeks to answer that question in his 30th book

Abraham L. Halpern, MD

Articles

The Forensic Psychiatrist and the Code of Medical Ethics

“My Madness Saved Me”: The Madness and Marriage of Virginia Woolf