Capacity of forensic patients to consent to research: the use of the MacCAT-CR.

The ability of psychiatric patients and prisoners to provide informed consent to participate in clinical research has given rise to much debate. Forensic psychiatric patients present a particular concern regarding their competence to consent to research, as they are both patients and prisoners. The primary goal of this research was to evaluate whether, by employing structured assessments of capacity to consent to research, we could determine if this combined vulnerability leads to differences in competence from the published abilities of nonforensic psychiatric patients. Subjects deemed incapable of providing informed consent scored differently and lower than the other consent groups on three aspects of the decision-making process. Diagnosis evidenced only a slight relationship to decision-making abilities, and this difference was only in the ability to understand the basic procedural elements of the research. Psychiatric symptoms were modestly related to decision-making. Positive symptoms were associated with poorer performance on the Understanding subscale of the MacCAT-CR, and negative symptoms were associated with lowered performance on the Reasoning subscale. These results are in accord with several published studies of nonforensic psychiatric patients and suggest that concerns regarding both forensic and nonforensic psychiatric patients' ability to provide informed consent may be unwarranted, especially in patients with few active symptoms.

Sell v. U.S.: involuntary medication to restore trial competency--a workable standard?

Competency to Stand Trial (CST) evaluations are common in the U.S. criminal justice system. Of those defendants found Incompetent to Stand Trial (IST), psychotic disorders are the most common diagnoses, and active psychotic symptoms are strongly correlated with impairments in trial-related abilities. If a defendant is rendered IST because of psychosis, restoration will be unlikely without antipsychotic medication. Last term, in Sell v. U.S., the U.S. Supreme Court dealt with medication refusal in the context of competency restoration. The Court held that involuntary medication, under certain circumstances, is appropriate. This article includes a review of earlier relevant legal decisions and an analysis and discussion of the Sell decision.

Managed care and ERISA: synopsis and case law review.

Managed care organizations (MCOs) have become the predominant health care model in the United States. Through cost containment arrangements with providers, incentives for patients to pursue less costly care and reductions in the provision of unnecessary care, MCOs are more intimately involved in the delivery of health care than their former fee-for-service insurance company counterparts. However, this new role has not implied increased liability, largely because of The Employee Retirement Income Security Act of 1974 (ERISA). This article provides an overview of ERISA and a review of the important legal cases in this area, including the three most recent Supreme Court cases. Courts have struggled with interpreting ERISA, and decisions have been difficult to reconcile. Frustration with this statute and the failure of the U.S. Congress to amend it, has led to more liberal interpretations of ERISA in recent years.

Patients' rights and psychiatrists' duties: discharging patients against medical advice.

Every psychiatrist who treats voluntary inpatients has had or will have patients who leave the hospital against medical advice (AMA). Studies reveal that between 6 and 35 percent of voluntary psychiatric inpatients are discharged AMA. These patients often are acutely ill and have severe symptoms at discharge. They also, as a group, have high rehospitalization rates and worse outcomes than patients who do not leave AMA. When a mentally ill patient demands to leave the hospital AMA, a tension arises between the patient's rights and the psychiatrist's duties. These duties include those to the patient and, in many cases, to third parties. Patients discharged AMA may remain dangerous and can expose health care providers to a heightened liability risk. More importantly, because of such factors, decisions about handling the AMA discharge are more difficult than decisions about admission. This article analyzes the sources of increased liability risk posed by AMA discharges. It includes discussions of patients' rights, including the different types of voluntary admissions, and psychiatrists' duties. Malpractice litigation in this area is reviewed. The article concludes by suggesting risk-management techniques that can aid in protecting the psychiatrist while also respecting patients' rights and delivering good clinical care.

Sex offender registration and community notification challenges: the Supreme Court continues its trend.

All states and the District of Columbia have passed sex offender registration and community notification laws. While the specific provisions of these statutes vary, all have public safety as a primary goal. The authors discuss two recent cases heard by the United States Supreme Court that challenged the constitutionality of Alaska's and Connecticut's statutes. The laws were challenged as violations of the United States Constitution's prohibition on ex post facto laws and its Fourteenth Amendment guarantee of procedural due process. In both cases, the statutes were upheld. As it has found in challenges to sexually violent predator statutes, the Court emphasized that the registration and community notification schemes are civil and not criminal in nature. The article concludes with a discussion of possible implications for clinicians involved in evaluating or treating sex offenders.