From posts to protection: Ethical considerations regarding forensic psychiatrists and a duty to warn based on social media.

Increasing use of social media in forensic mental health evaluations will lead to new challenges that must be resolved by forensic practitioners and the legal system. One such dilemma is the discovery of information that would typically trigger a legal duty and professional ethics obligation for mental health professionals to breach doctor-patient confidentiality to promote public safety and prevent harm to vulnerable third parties. Although the law and professional organizations offer clear guidance for practitioners in the treatment role, there is currently no clarity from the law or instruction from professional organizations on what mental health professionals should do if they discover such information during a confidential forensic evaluation. For example, a forensic evaluator may find evidence on social media of an evaluee's threats to seriously harm others, abuse of children and the elderly, or severely impaired driving. There are no clear guidelines for how a forensic psychiatrist should respond in these complicated situations. We review the legal concepts and historical evolution of confidentiality, privilege, and mandated reporter duties that forensic practitioners should consider in these legally ambiguous situations. Finally, we discuss ethics frameworks practitioners can implement to determine their most ethical course of action when faced with such dilemmas.

Ethical considerations for the use of artificial intelligence in medical decision-making capacity assessments.

The rapid advancement of artificial intelligence (AI) and machine learning are providing new tools to clinicians. AI tools have the potential to process vast amounts of data in a short amount of time, providing new insights and changing how we approach complicated healthcare problems. AI has the potential to assist clinicians in medical decision-making capacity assessments by providing additional insights to an evaluation process that currently lacks universal objective standards. However, despite the promise of AI in this setting, there remain significant concerns making it unlikely to replace human evaluators anytime soon. AI remains highly susceptible to biased inputs and thus biased decisions, raises questions about autonomy, and creates uncertainty for who is accountable for the ultimate decision of capacity. In this paper we explore these ethical considerations of using AI for capacity assessments. While we acknowledge AI may not be ready to replace physicians in determining patient medical-decision making capacity, these new technologies have significant near-term potential as a tool to screen patients, uncover physician biases, and guide next steps after a capacity determination has been made.

Late-Onset Sex Offending and the Assessment of Behavioral Variant Frontotemporal Dementia (bvFTD).

Behavioral variant frontotemporal dementia (bvFTD) is a common neuropsychiatric disorder, which is often missed or misdiagnosed by both neurologists and psychiatrists as a cause of emotional and behavioral problems. Inappropriate emotional responses and maladaptive behavior, including criminal behaviors, may be the first obvious expression of bvFTD caused by altered moral feelings, loss of empathy, disinhibition, and compulsive behavior. New onset sex offenses, including indecent exposure, sexually inappropriate comments, and unwanted sexual advances have been documented in early bvFTD. These behaviors may escalate with progressive disease and lead to harsh penalties. The presence of inappropriate sexual behaviors in older individuals with no prior history should raise concern about the presence of bvFTD in forensic examinations. In addition to the forensic examination, diagnostic evaluation requires psychological testing (including tests of social and affective cognition) and imaging studies. In sex offenders, a diagnosis of bvFTD has significant implications for risk assessments, requirements regarding supervision and management, and as evidence for mitigation. In this article, we review the neuropsychiatry of bvFTD, how the pathophysiology may contribute to sex offenses, and important psycholegal considerations for the forensic psychiatrist when evaluating bvFTD.

Voluntary intoxication, homicide, and mens rea: Past, present, and future.

Voluntary, or intentional, acute intoxication does not qualify for an insanity defense. However, in many jurisdictions, voluntary intoxication can create a diminished capacity to form a specific intent necessary for a criminal offense. This is a type of mens rea defense. Homicide provides a clear example where the absence of a required specific intent can lead to a lesser included crime that does not require that specific intent. Thereby, a mens rea defense may lessen a first-degree murder charge to a lesser degree or even manslaughter, depending on the jurisdiction. After reviewing the history of mens rea defenses and voluntary intoxication, we performed a search of LexisNexis for state statutes and case law regulating the use of voluntary intoxication in mens rea defenses, focusing on homicide-related offenses. In this article, we compare the different approaches that have developed to address this complex issue. We discuss why knowledge of these different approaches is essential to the practicing forensic examiner in relevant jurisdictions and explore developing issues in the area.

Physician, Protect Thyself: Why Psychiatrists Should Be Aware of Their Internet Presence and How to Protect Themselves.

ABSTRACT: Modern psychiatric practice requires the use of the Internet, and the current pandemic has accelerated the adoption of technology in clinics. Psychiatrists receive significant education on protecting patient privacy and medical information when using these tools. However, they receive little training regarding protecting their own personal privacy in the Internet era. Private information, often without one's knowledge, is frequently available online and accessible by patients. The work of physicians and psychiatrists creates additional unique vulnerabilities to privacy. Given the essential nature of the Internet in modern clinical practice, physicians should understand how to monitor and protect personal privacy and safety online. We provide advice to minimize vulnerability to a privacy breach, with a focus on areas unique to psychiatrists and psychiatric practice. We review the literature on physician safety online and offer guidance to get started.

Legal and Ethics Considerations in Reporting Sexual Exploitation by Previous Providers.

When a patient reports a sexual relationship with a prior provider during treatment, a psychiatrist or therapist must balance conflicting ethics principles of autonomy, confidentiality, and social justice in deciding whether to report this behavior to the proper authority. Many states have statutes regarding such reporting that are unclear or ambiguous; others lack laws entirely. We surveyed state laws and contacted state medical boards to clarify each state's position on mandatory reporting of sexually exploitive psychiatrists, specifically when the patient reveals the exploitation during treatment. Our results showed that only 5 state legislatures have explicitly addressed this matter. Of the remaining states, 18 require reporting through a patchwork of laws and policies, and the other 27 states and the District of Columbia have no laws that require reporting a colleague if a patient discloses a past sexual relationship. In this article, we examine the different approaches and considerations taken by state legislatures and medical boards in addressing this concern.