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When Should Psychiatrists Seek Criminal Prosecution of Assaultive Psychiatric Inpatients?

Mr. Ho and Mr. Ralston are with the Department of Philosophy, Rice University, Houston, Texas. Dr. McCullough and Dr. Coverdale are with the Center for Medical Ethics and Health Policy, Baylor College, Houston. Dr. Coverdale is also with the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Send correspondence to Dr. Coverdale at the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1 Baylor Plaza, BCM 350, Houston, TX 77030 (e-mail: jhc{at}bcm.tmc.edu)

This Open Forum commentary reviews the ethical considerations relevant to the question of prosecuting assaultive psychiatric patients, with particular attention to the significance that should be attached to the arguments generated by those considerations. A comprehensive literature search was conducted incorporating the terms "assaultive patients," "ethics," "psychiatric inpatients," and "law." The literature of professional medical ethics was applied to identify relevant domains of ethical argument. Five domains were identified: fiduciary obligations of physicians to assaultive and other patients; obligations to staff members; professional virtues of compassion, self-sacrifice, and self-effacement; retributive justice; and the patient's right to confidentiality. The content of each domain is explained, and guidance is provided on how to assess the relative strengths of ethical argument within each domain. All five domains must be explicitly addressed in order to make ethically disciplined judgments about whether to seek prosecution. A distinctive feature of this ethical analysis is the central importance of the professional virtues.

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