Ethical issues of long-term forensic psychiatric care

Abstract

Summary 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 highcost/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 longterm 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 to 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 * Corresponding author. Please cite this article in press as: Völlm B, et al. 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 he...

A mixed-methods study exploring the characteristics and needs of long-stay patients in high and medium secure settings in England: implications for service organisation

“…165 Unlike in other areas of medicine, patients are detained against their will, and engagement in treatment is a requisite to moving on and regaining autonomy. These issues are compounded when patients stay in such services for a long period of time, potentially longer than necessary, and this must be a considerable concern.…”

“…165 It seems clear from the situation that long-stay patients in forensic settings find themselves in that all of these principles are seriously challenged. From an ethical point of view, it is, therefore, paramount that the services provided can be truly said to benefit the patient and allow as much autonomy as possible.…”

Ageing patients in forensic psychiatric settings: A review of the literature

“…On ethical grounds, the scarcity of scientific literature currently available requires further research to help identify the needs of ageing patients and facilitate the implementation of effective treatment plans, to grant them equal opportunities to move along the care pathway. This would prevent a so‐called “Warehouse effect,” the risk for forensic psychiatric institutions to become “dumping grounds” for the ageing patients, particularly those who develop progressive conditions (eg, dementia) or who are terminally ill and may not require high security.…”

“…On ethical grounds, the scarcity of scientific literature currently available requires further research to help identify the needs of ageing patients and facilitate the implementation of effective treatment plans, to grant them equal opportunities to move along the care pathway. This would prevent a so-called "Warehouse effect," the risk for forensic psychiatric institutions to become "dumping grounds" for the ageing patients,34 particularly those who develop progressive conditions (eg, dementia) or who are terminally ill and may not require high security.On legal grounds, the United Nations Convention on the Rights of Persons with Disabilities,35 the National Service Framework for Older People36 and more recently the NICE guidelines on mental wellbeing and independence in older people37 recommend that all older people have the right to benefit from the same quality of care that is granted to younger citizens. These policies mandate that service providers adequately attend to the needs of ageing people, including those who live in forensic psychiatric settings.…”

A comparison of long‐term medium secure patients within NHS and private and charitable sector units in England

“…Although all are paid for from public funds, and are subject to similar regulation, medium and low secure services are provided within the private and charitable (PCS) sector as well as the National Health Service (NHS). Secure inpatient services are low volume, but high‐cost services accounting for 1% of the entire NHS budget and 10% of the mental health budget (Völlm, Bartlett, & McDonald, ). There are currently approximately 3,200 medium secure beds within around 70 units, about 40% of which are provided within the PCS (Rutherford & Duggan, ).…”