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Ethics and Law
Forensic Psychiatry Division | CAMH Research
Ethics and Law
In this research area we explore ethics and forensic mental health, including issues around coercive care and procedural justice, relevance and impact of case law with respect to forensic mental health care (such as criminal responsibility and fitness to stand trial), and legislation on Medical Assistance in Dying (MAiD) as relevant to correctional and forensic mental health populations.
Paper Summaries
Assisted death for prisoners and forensic patients: complexity and controversy illustrated by four recent cases
BJPsych bulletin 48, no. 5 (2024): 300-305.
Roland M. Jones and Alexander .I.F Simpson
https://www.cambridge.org/core/journals/bjpsych-bulletin/article/assisted-death-for-prisoners-and-forensic-patients-complexity-and-controversy-illustrated-by-four-recent-cases/1659690EC46F94A0446743E56112E641
What’s the issue: The complexities of allowing prisoners and people in mental health facilities to choose Medical Assistance in Dying (MAiD) are discussed in this paper. Four recent cases are described which illustrate the challenges and ethical dilemmas involved.
Why it matters: Deciding whether prisoners should access MAiD based on mental illness as the sole criterion raises questions about balancing the right to self-determination against the state's duty to protect vulnerable individuals. Allowing those who have committed serious crimes to choose death also potentially impacts on victims' rights and societal perceptions of justice and care.
What’s next: While individuals should have the right to equivalence of health care, jurisdictions that are considering laws permitting MAiD for non-terminal disorders should consider where the balance between personal autonomy and paternalism should lie.
Recent publications
Procedural justice and forensic mental health: An introduction and future directions
Jack Tomlin, Sarah Markham, Ciska Wittouck, and Alexander Simpson, p.00258024231206865.
Medicine, Science and the Law, 2023
Link to Publication
Due to the involuntary nature of their treatment, patients in the forensic system often have decisions made for them. Procedural justice relates to the fairness of processes used by those in positions of authority in the forensic system. This article advocates for forensic mental health services to be provided under a procedural justice framework. This would include shared decision-making where patients are involved in developing their own treatment plans. Such autonomy and “ownership” of treatment has been shown to improve trust in the system and increase compliance — and thus promote recovery.
Examining the prevalence and forms of leveraged treatment pressure and its relationship to personal recovery: A Canadian cross-sectional study
Frank Sirotich, Samuel F. Law, Alexander I. F. Simpson, and Arash Nakhost
Community Mental Health Journal volume 59, pages1352–1363 (2023)
Link to Publication
This study is the first in Canada to examine the relationship between forms of leveraged treatment pressures and personal recovery in outpatient community mental systems. Leverage involves suggesting access to desired resources (e.g. social welfare entitlements and money) or avoidance of some undesired outcome (e.g. criminal sanctions) to encourage adherence to recommended treatment. Leverage is widespread in mental health settings. The authors found that financial leverage was associated with feelings of coercion and negatively related to personal recovery. This suggests the need for further studies to better understand the relationship between different types of leverage and recovery.
Ethical considerations regarding mental disorder and medical assistance in dying (MAiD) in the prison population
Alexander I.F. Simpson, Jason Tran, and Roland Jones
Medicine, Science and the Law. 2023;63(1):3-5.
Link to Publication
As of March 2023, modifications to Bill-C14 now allow for a mental disorder to be the sole condition for seeking Medical Assistance in Dying (MAiD). In the prison environment, where hopelessness, stigmatization of mental disorders and lack of treatment opportunities are pervasive, there may be similarities between MAiD and suicide. Furthermore, there is a concern that MAiD may be used to avoid justice, impacting victims and society more broadly. Given these considerations, there is a need for careful appraisal when incarcerated individuals request MAiD to alleviate suffering solely for mental disorders.
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