In Part 1 we explored the practical role of psychiatrists in criminal trials. Now we turn to the ethical side of the psychiatrist-defendant relationship.
There is an ethical side to the “hired gun” situation. What happens if the psychiatrist agrees to evaluate and testify for the defendant, but after evaluating the defendant the psychiatrist forms the opinion that at the time of the crime the patient knew what he or she were doing and was in control? In the doctor’s opinion, then, the defendant was guilty, and responsible for his actions. Can the defendant now say that he doesn’t want this information to be used in court?
In reality the defense attorney’s and the psychiatrist’s questioning generally goes something like this. The defendant will make the first move. The defense attorney will call a psychiatrist they know, who may be someone good or not so good. They may even be part of the pool (hired guns) I referred to earlier. This doctor will be asked to examine the client who is facing criminal charges. The less knowledgeable psychiatrist might decide right at that moment either to evaluate the defendant or not. The more knowledgeable one will first ask what the defense wants the defendant examined for, and what is the exact psychiatric legal issue they want to have explored.
The inexperienced attorney may not be prepared for that kind of question, and may ask the doctor what they mean. The doctor may say that the defense attorney is raising the question as to whether or not, at the time of the alleged event, the defendant was criminally responsible, or was acting under “extreme emotional disturbance.” Extreme emotional disturbance (“EED”) generally is interpreted to mean the emotional state of an individual who 1) has no mental disease or defect that affects accountability; 2) is exposed to an extremely unusual and overwhelming stress; and 3) has an extreme emotional reaction to it, as a result of which there is a loss of self control, and reason is overborne by intense feelings, such as passion, anger, distress, grief, excessive agitation, or other similar emotions. In short, if a person has had time to cool down and then act on their intentions to harm someone, this would not be EED.
The doctor wants to know if the defense is trying to inquire as to whether or not, when the police read the defendant his or her Miranda Rights, the defendant was competent to understand those rights, or competent to make the confession that was given. A Miranda Right is a warning given by police to criminal suspects in police custody, or in a custodial situation, before asking guilt-seeking questions relating to the commission of a crime. An incriminating statement by a suspect will not constitute admissible evidence unless the suspect was advised of his or her “Miranda rights” and made a knowing, intelligent, and voluntary waiver of those rights.
Miranda warnings developed out of the Ernesto Miranda case (1962), in which a rape suspect was arrested and taken to the police station. After two hours of questioning, he signed a written confession and was subsequently found guilty. Miranda appealed his conviction on the grounds that prior to confessing, he had not been informed of his Fifth Amendment right against self incrimination or his Sixth Amendment right to counsel.
Is the doctor concerned with whether the defendant is competent to stand trial at the moment? Is the doctor concerned with whether the defendant is competent to abide by the terms of bail and should be bailed out, or should remain in jail? Is the doctor concerned that at this time the defendant might be a danger to the community if released?
The Ehrlich case, for example, involved a mentally ill defendant in New York City. The defendant was found not responsible by reason of mental disease and defect after he killed his mother. He then cut off her head, placed it on her bed, and combed her hair so she would look neat when the police arrived. While he was in the Manhattan Psychiatric Center, members of his family complained that he was not being treated properly, and should be allowed to attend some education classes. The doctors allowed him to leave the locked ward, and he went to attend a class. As soon as he entered the class room and the attendants left, he walked out of the room and the hospital. While out, he threatened members of his family and others, and was out on the street for approximately nine days before he was rehospitalized.
The Ehrlich case and other like it are examples of the tremendous responsibility psychiatric medical professionals take on when they become involved in criminal psychiatric evaluations for the court system.
If there is a capital punishment issue (crimes that can result in a death penalty), the reason for the psychiatric examination may be to evaluate whether the defendant is competent to be executed. The common notion of the insanity defense is that there is a straightforward question of whether the defendant was responsible at the time of the crime. However, in fact there are many important issues at hand. The defendant could have been responsible at the time, and then became mentally ill because of the police arrest, and hence did not understand the Miranda warnings. The kernel of the issue is what was the mental state of the defendant at the time of the crime.
Let’s take a moment to explore the psychiatric evaluation process and the amount of time spent on each patient. In America we have a multi-layered system which may unfortunately translate into “you get what you pay for.” If you are being defended by a public defender (Legal Aid Society), they have limited funds. It is generally believed in the medical community that most doctors will not spend less than 45 minutes at the very minimum on an insanity defense evaluation (described as a psychiatric hour). This is because psychiatrists providing insanity defense evaluations need sufficient time to properly gather information; it also helps the doctor to maintain credibility in court.
Because there are wide discrepancies in how psychiatric evaluations are done, many experts believe the best solution is to look for whether or not there was any other evidence, independent of the defendant’s or police testimony. This additional evidence may help reveal what the defendant’s mental state was at the time of the alleged crime. Were there eyewitnesses? Had the person had other psychiatric help prior to the incident? It is important to mention that this type of evaluation is not confidential once a defendant chooses an insanity defense in a criminal case.
Once the event has occurred, the alleged criminal has an interest in presenting a picture that is consistent with his own interests, so mental data is important. For example, most people would ask the defendant how he or she was feeling at the time of the alleged crime. The defendant would probably give a long, drawn-out story about how he was feeling, consistent with whatever position he or she wanted to defend.
Consider this ethical dilemma. Suppose the defense psychiatrist discovers that a patient is malingering (a medical and psychological term that refers to fabricating or exaggerating the symptoms of mental or physical disorders). Should the doctor get off the case, remain as the advocate for the defendant, or go to the prosecution with information on the defendant that could work to the prosecution’s advantage?
Can a defense psychiatrist who has conducted an evaluation go over to the prosecution? The way it normally works is that the prosecution might know whether or not the psychiatrist has visited a defendant in jail. If three psychiatrists visited a defendant in jail, and the names of only two are advanced by the defense to support the claim of “not responsible by reason of mental disease or defect,” it is reasonable for the prosecutor to assume that the third psychiatrist found something that is not going to be of use to the defense; otherwise his or her name would be advanced too. The prosecutor then moves to subpoena the third psychiatrist, whose name has not been advanced by the defense. Thus he can be used as the prosecution’s witness. The psychiatrist now can agree to aid the prosecution, as it is fair game if the judge allows his testimony to be entered into court as evidence.
Now let’s take the above situation a little further. Suppose a psychiatrist is hired by the court to conduct an evaluation. There are issues of advocacy (the pursuit of influencing outcomes), when the court psychiatrist can also be the treating psychiatrist. For example, while the court psychiatrist is doing an evaluation, he or she may also be doing a scientific probe; information thus gained does not hold the kind of doctor-patient relationship of loyalty towards the patient. The psychiatrist visits the patient and explains that though he may sound like a psychiatrist and look like a psychiatrist, in this capacity he is not the patient’s doctor. What discussions go on between them will not be bound by the oath of confidentially. It will be reported to the court. At this stage a sort of distancing is suppose to take place. Often, however, it turns out that the court psychiatrist may be working as an evaluator, but is also treating the patient. This brings up the issue of whether the doctor should be treating the patient both as an evaluator and as a treating doctor, because of the issue of conflicting loyalties.
Another interesting issue concerns separate case records. This is when you have a corrections unit (a facility handling adult probation and parole matters and sometimes juvenile aftercare supervision cases from the Department of Corrections), where there is a treating psychiatrist(s), and an evaluating psychiatrist(s) on the unit. In some situations the same case record may be used. This means that as a patient, the defendant has given varied amounts of information to their treating psychiatrist that he or she would not want given to the courts. Some units try to solve this problem by having one case record presented by the evaluating psychiatrist, which goes to the courts. The evaluating psychiatrist and the court cannot see the second case record, prepared by the treating psychiatrist, which only goes towards the patient’s treatment, to make sure that there is no conflict (fact sharing between records).
Part 3 of this series will return to the hired gun issue: if the psychiatrist has been hired by the defense, should the psychiatrist say what the defense wants him to?
By: Peter Sabbagh