Steven K. Hoge

Ethics and neuropsychiatric genetics: a review of major issues

Advances in neuropsychiatric genetics hold great hopes for improved prevention, diagnosis and treatment. However, the power of genetic testing to identify individuals at increased risk for disorders and to convey information about relatives creates a set of complex ethical issues. Public attitudes are inevitably affected by the shadow of eugenics, with its history of distorting scientific findings to serve socio-political ends. Nonetheless, the growing availability of genetic tests means that more patients will seek genetic information and physicians must manage the process of informed consent to allow meaningful decisions. Patients should be helped to understand the often-limited predictive power of current knowledge, potential psychological impact, risks of stigma and discrimination and possible implications for family members. Decisions for predictive testing of children raise additional concerns, including distortions of family dynamics and negative effects on childrens self-image; testing is best deferred until adulthood unless preventive interventions exist. Pharmacogenomic testing, part of personalized medicine, may bring collateral susceptibility information for which patients should be prepared. The implications of genetic findings for families raise the question of whether physicians have duties to inform family members of implications for their health. Finally, participation in research in neuropsychiatric genetics evokes a broad range of ethical concerns, including the contentious issue of the extent to which results should be returned to individual subjects. As genetic science becomes more widely applied, the public will become more sophisticated and will be likely to demand a greater role in determining social policy on these issues.

Competence to stand trial: An overview

The legal concept of competence to stand trial has ancient roots. The history of this legal construct in Anglo-Saxon law will be reviewed. A competent defendant is a requirement of the criminal justice system because it reflects interests related to the dignity of the process, the accuracy of adjudication, and respect for the autonomy of defendants. In the United States, legal decisions have established the contours of the requirements related to competent participation in adjudication. Forensic psychiatrists have operationalized the requirements for assessment purposes. Recent decisions in the United States have expanded earlier notions of competence to include decision-making during the course of adjudication. These decisions will be reviewed. The process of clinical evaluation, the use of collateral information, and other aspects of expert opinion formation will be reviewed. In addition, the special problems posed by amnesia, pro se defendants, competence to plead insanity, and unrestorable defendants will be discussed. The use of standardized assessment tools will also be reviewed. The application to the Indian criminal justice system will be discussed.

Restoration of firearm rights in New York

The National Instant Criminal Background Check System (NICS) Improvement Amendments Act of 2007 encouraged states to create processes by which individuals who have lost their rights to firearm possession for mental-illness-related reasons could receive relief from restrictions. Over 20 states have created relief processes for this sub-group, but there still exists considerable state-by-state heterogeneity. The spectrum ranges from states that require a physicians opinion regarding appropriateness for restoration to those that rely solely on judicial proceedings without input from psychiatrists or other mental health professionals. This article reviews the restoration process in New York State, a model in which psychiatrists participate in the process of assessing whether an individuals firearm rights can be restored. It discusses the legislative background of these regulations, the specific policies and procedures governing the restoration process, and clinical considerations for the forensic evaluation.