Ethical issues of long-term forensic psychiatric care

Abstract

Forensic psychiatry is a subspecialty of clinical psychiatry that operates at the interface between law and psychiatry. It is concerned with patients who have a mental disorder as well as having committed an offence, often serious. Forensic psychiatric institutions are high-cost/low-volume services that impose significant restrictions upon their residents. Patients may be detained in those services against their will for lengthy periods, potentially life-long. The purpose of this detention is seen as two-fold: care and treatment for the patient and protection of the public from harm from the offender. Here we review the ethical issues around such long-term detention. We base our observations on a review of relevant literature and from focus groups with professionals working in forensic psychiatric settings. Additionally, we visited three institutions in the UK where long-stay forensic psychiatric patients receive care. A number of factors have been identified contributing to long-term stay (long-stay) in forensic psychiatric care, including organisational factors (e.g., lack of beds in less secure settings) and patient characteristics (severity of psychopathology and offending). Long-stay in a forensic psychiatric setting – which is often longer than had the patient received a prison sentence for the same offence – poses significant ethical and human rights issues, particularly when it is unclear whether the treatments offered benefit the patient and when risk management considerations may outweigh the best interests of the patient. The main topics of concern identified by our participants included “system failures”, “avoidance of warehousing”, “importance of hope”, “denial” and long-stay units and “quality of life”. Participants were concerned that the system is set up in a way that does not allow patients with complex and long-term needs to move to more appropriate, less restrictive settings and that the issue of “long-stay” is met with denial. In order to avoid warehousing and maintain hope, those we spoke to felt it was important to not give up on patients and continue to deliver treatment, almost regardless of its effect. Providing long-stay patients with a good quality of life was seen as important, though we found that the stated ambitions were not always matched by the reality of the units we visited. Despite the stated need to provide something “different” for long-stay patients, the units were nevertheless very restrictive in their approach (e.g., prohibition of sexual expression). Professionals seemed to lack a more ambitious and creative vision to create something truly distinct. We discuss possible solutions, including explicitly maximising the quality of life of those detained, limiting the time of detention to equal the sentence length of non-disordered offenders and locating the public protection function of the management of mentally disordered offenders within the criminal justice rather than the health care system. The implementation of such radical solutions, however, might be hampered by the difficulties in changing entrenched values and procedures, to the point that diverse stakeholders join together in maintaining the status quo.