Book Review
Forensic Psychiatry 
Ethical Issues in Forensic Mental Health Research Gwen Adshead, Christine Brown, editors. London (UK): Jessica Kingsley Publishers; 2003. 144 p. CDN$46.95.
Reviewer
rating*: Not recommended
Review by: Paul Fedoroff, MD
Ottawa, Ontario
This book is a compilation of seminars presented by Robert Baxter Fellows in the UK, meant to explore ethical dilemmas that challenge the “conventional” biomedical framework. Although the authors are highly distinguished, I was disappointed by the book. For example, the first chapter, by Gwen Adshead, “Do You Feel Lucky? Assessing Capacity to Consent to Research Forensic Mental Health Practice,” addresses the straw-man issue of whether capacity to consent to treatment differs from capacity to consent to research. After 24 pages, the author concludes that
arguably much of the literature on consent to research is biased, written as it is by a highly selected sample of researchers, who may stand to gain most immediate benefit from the research process (p 24).
Among the references that presumably include “biased researchers” are the Nuremburg Code (see www.hhs.gov/ohrp/references/nurcode.htm), the WHO International Guidelines for Biomedical Research Involving Human Subjects (see www.cioms.ch/frame_guidelines_nov_2002.htm), and the Fifth Revision of the Helsinki Declaration (see www.wma.net/e/policy/b3.htm).
Justine Rothwell and Carly Smith consider adolescents’ consent to participation in research. They remind us that “consent must be given freely” (p32) and that it must be obtained “before any research process can be undertaken” (p33) They point out that consent forms need to be written so that adolescents can understand them. They describe a (to my mind, somewhat ethically questionable) process whereby researchers were able to recruit more participants by being “highly visible” on the ward. They introduce a concept of “ownership of a young person’s consent” and argue that the ability to consent to research is a function of autonomy and therefore a developmental task. They conclude that
practitioners and researchers need to be aware of their perceived position of power and exercise
caution when informing interested parties about the costs/benefits of participation (p 43)
Perceived?
Christine Brown provides a chapter on “Consent and Confidentiality.” However, much of the chapter has nothing to do with research, focusing instead on consent-to-treatment issues. By criticizing studies that report dropout rates, Dr Brown implies that consent within biomedical research is an “irreversible, one-way process.” To her credit, she does argue persuasively for obtaining consent both at the beginning and end of data collection, but this in not an issue unique either to forensic mental health research or to biomedical research.
Annie Bartlett and Krysa Canvin argue that the key workers providing care to potential research participants can act in ways that are paternalistic and protective when they prevent researchers from approaching patients who are “not well enough” (quotations in original). Much of this chapter deals with the problems encountered in qualitative research.
Caroline Logan describes ethical issues in risk-assessment research. She reviews both actuarial and clinical risk assessment but does little to distinguish between clinical and research issues. She concludes that “actuarial risk assessment methods . . . promote the least ethical practice. Ethical practice must supersede psychometric purism” (p 83)
Tom Mason reviews multidisciplinary aspects of forensic mental health research. He compares multidisciplinary teams to herds but argues that “herding alone is insufficient to account for the success of the human race” (p 87). He writes that psychiatric patients have their
autonomy of thought . . . curtailed through mind-altering drugs or ‘talking therapies’, their autonomy of will is restrained through prescribing limits on their behaviours, and their autonomy of action is confined by the rules of normative standards (p 94).
He says that competing value systems “may be a source of tension within teams” (p 103). While this may be the case in teams
Dr Mason belongs to, it is not clear to me what this has to do with forensic mental health research.
Christine Brown and Gwen Adshead next turn their attention to research ethics committees (RECs). They argue that RECs may pay too much attention to the scientific merit of a study while ignoring its “moral” merit. In one of the many examples where the book completely misses the point, they argue that experiments by Nazi “researchers” were condemned because they were scientifically flawed! Other assertions include the statement that “detention, per se, has little effect on the capacity to make research decisions” (p 113) or that “the problem of consent is particularly acute in forensic research because so much is non-therapeutic in nature” (p 113). They reach the nonsensical conclusion that “the traditional biomedical disease focus in research means lack of consideration of ethical issues raised by disability and living with disability” (p 115).
The last chapter, by Jean Ruane, provides a real-life commentary about her attempts to obtain ethical approval to conduct a survey of sexual health in a secure environment. The proposal was ultimately rejected by 2 independent RECs. She wonders whether RECs should be “making judgements about the scientific validity of peer-reviewed studies” (p 130) and about “the scope of legitimate protection of subjects and when does this equate with inappropriate paternalism?”(p 130) She ultimately wonders whether her proposal was rejected owing to “a perceived threat of political sanction” She says she overcame the problem by designing an (unspecified) study that did not require scrutiny by RECs and that yielded data the quality of which “surpassed all expectations”. She does not mention whether this opinion was shared by the RECs she successfully bypassed.
In summary, this is a book that pits clinical care against research, biomedical perspectives against other health care views, and quantitative research against qualitative research. North American researchers will likely find these arguments to be quaint reminders of false dichotomies that have long been abandoned. Readers with an interest in research ethics would be better served by taking the National Institute of Health’s brief, free, Web-based course (see http://ohsr.od.nih.gov/) or by studying the Tri-Council Policy Statement (see http://pre.ethics.gc.ca).
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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