The malpractice status of the use of electroshock therapy (electroencephalotherapy) has been reviewed. In about 40 years, there have been relatively few reported cases dealing with EST (EET) and professional liability. Few cases have been won, and those generally for modest amounts. However, future successful claims are expected to reflect current inflation. Certainly the limited volume of litigation would seem to raise a question as to the justification for the extent of the surcharges charged for psychiatric malpractice insurance for the administration of EST. Potential liability for EST continues to be a significant threat to the psychiatric practitioner, although drug matters, suicide, and conformance with legal standards seem a more significant area for current litigation. Those who use EST (EET) can minimize liability exposure by (1) obtaining an informed consent from the patient, (2) describing the method of treatment and possible complications to the family or patient and so noting, (3) ensuring legal authority to treat the patient who is incompetent to give consent or for whom special procedures are required, (4) treating in accordance with accepted procedures, (5) avoiding outpatient EST, if possible, (6) paying close attention to patient complaints, (7) keeping good records, and (8) not promising perfection.
Most psychiatrists have little contact with arsonists. Those who work with juvenile delinquents will have seen some adolescent firesetters, often of limited intelligence with schizoid personality or other behavior disorders. On rare occasions the compulsive firesetter, driven sexually, will engage in repetitive events and be found masturbating at the scene of a fire. Vandalism or revenge fires may be directed at schools, public buildings, and employers. Similarly, psychotic firesetters are caught in the throes of their bizarre practices—burning churches or other symbolic institutions. Many criminals show a history of adolescent firesetting. Nonetheless, psychiatrists see few arsonists. It is unclear if the arsonists seen are typical because so few are actually caught. Thus those caught may be singularly incompetent in one way or another.
As a reaction to the tradition of corruption and reward (“to the victor belongs the spoils”) in the distribution of governmental jobs, a civil service system has developed which regulates the granting of millions of such jobs. Basic qualifications are established for positions (age, education, physical size, special skills). Those eligible then take a written examination; a common practice is to allow a hiring authority to pick among the top three candidates on the basis of the test scores, allowing for some flexibility. In some jurisdictions, veterans are given an arbitrary number of points to add to test scores so that in some cases, the veteran applicant automatically will outscore the nonveteran. In the state of New Jersey [1], applicants are placed on eligible lists in the following order: (1) disabled veterans, (2) veterans, and (3) others.
The M'Naghten case and the Hinckley matter are in some ways remarkably similar. The attempted assassination of a ruling figure, the public discomfort with the insanity defense, and problems in the application of the legal rules characterized both. An explosion of media criticism occurred in 1843, as it did in 1982. The English ultimately handled the M'Naghten case in a dispassionate manner that determined Anglo-American law for more than a century and provided the basic law by which Hinckley was tried. Fears expressed in 1843 were never realized; the final chapters of the Hinckley case remain to be written.
Psychiatric and psychologic screening is pertinent in many areas in our society but currently is most relevant to police work, crucial military operations (atomic weaponry), and other areas which combine potential power with delicate judgment. At the same time, at least for police work, eligibility is open, governed by some uniformity of rules, and in many areas controlled by civil service laws. The civil service laws have the effect of providing fairness at the cost of flexibility and of preventing abuse at the cost of arbitrariness.
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