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Ethical Issues in Forensic Mental Health ResearchReview - Ethical Issues in Forensic Mental Health Research
by Gwen Adshead and Christine Brown (Editors)
Jessica Kingsley Publishers, 2003
Review by Tony O'Brien, M Phil.
Jun 3rd 2005 (Volume 9, Issue 22)

This is a slim volume covering a very specific area of research ethics: that of research in forensic mental health settings. The book is the product of a series of seminars conducted by a group of forensic researchers. In a selection of brief chapters by different authors it covers a range of issues and problems, with the individual chapters teasing out the issues in different situations. While there is no attempt to draw the different themes into a single framework, common issues emerge through the book. To some extent there is repetition; informed consent and competence are themes throughout the book, and there is rather a lot of restatement of definitions. The advantage of presenting the work as an edited collection is that each chapter can be read in its own right, and on its own merits. Overall I found the book interesting but uneven.

The first chapter covers the issue of consent and competence. Gwen Adshead outlines the important distinction between consent to treatment and consent to participation in research. Coercion in research is always potentially problematic both ethically and methodologically, and this issue is accentuated in the case of patients subject to detention in treatment facilities, especially forensic settings which may already exert a considerable coercive influence. Adshead presents views on these issues without an undue reliance on the assumed beneficent intent of researchers. She points out that much of the literature on research ethics is generated by researchers, and so requires a critical reading.   

Chapter two explores consent with adolescents in forensic settings, and begins with an outline of the notion of Gillick competence, a concept that has evolved from a House of Lords decision that age alone is an insufficient criterion for competence. Gillick competence is particularly important in forensic settings because of the multiple constraints on competence: maturity, the legal definition of 'adult', education, literacy, language, developmental delay, handicap and mental disorder. A case study provides the focus for this chapter and while the authors acknowledge that not all the concerns of adolescents or researchers are addressed, their case study does provide a nice illustration of the complexities of gaining consent in these circumstances. Statutory guardians and organizations as wells as parents may have interests other than those of the adolescent when it comes to giving substituted consent. The authors also describe the difficulties of compliance with requirements for written informed consent, when the documentation becomes so complex that it may be difficult for the proposed participant to understand.   

'Dangerous stories' (Chapter Three) outlines the limits to ownership of an individual narrative, an issue that is likely to be especially problematic when the reasons for a person's detention in a forensic setting involve actual harm to third parties. Under such circumstances publication of details of the individual's life involves the possibility of further harm to the third party, and thus challenges the often-cited notion that individuals 'own' their life stories. As author Christine Brown states, individual narratives are also relational, something that needs to be considered when publication is an aim of the researcher. I was less comfortable with Brown's assertion that such issues are beyond the scope of 'traditional biomedical ethics', although if that term is given a narrow interpretation that is probably true. But in identifying new ethical concerns for researchers, it is to those traditions that ethicists return, with new interpretations of 'autonomy' and 'beneficence'.

The chapter on qualitative research covers the usual issues such as consent, confidentiality, and anonymity and includes a recommendation for consumer involvement, a useful recommendation in forensic research generally. Risk assessment is given its own chapter, deservedly so in a discipline that owes its existence to the notion of risk. There is unfortunately little in this chapter that relates to research, although a lot about risk assessment. The emphasis on practice seemed out of place given the title of the book. Multidisciplinary research is more glossed than explored in Chapter Six. The chapter revisits ethical principles, but without much discussion on how they might be seen by different professions. Instead there is talk of an emerging profession of 'forensic practice', whatever that might be. The discussion of the impact of professional rivalries on research was more promising, but too brief.

The concluding chapters examine Ethics Committees, and while there is a specifically local flavor to this discussion, the chapters canvas problems with approval processes that are common to most settings. The outline of the committee process is followed up with a case study that exemplifies the difficulties faced by researchers in gaining ethics approval, especially when the proposed study explores a sensitive area such as sexuality. As Jean Ruane observes, sometimes the concerns for rigor and ethical propriety trump the potential benefits of research on grounds that seem hard to justify. The effect on researchers of the demands of over zealous guardians is seldom a consideration for committees.   

Overall, this book will be useful additional reading for those studying or considering research in forensic mental health. Forensic mental health care, already an area with unique ethical challenges, is likely to develop further in response to public and official anxiety about risk. Research offers a tool to provide evidence for more informed clinical practice and service delivery, as this book demonstrates, such research brings its own unique ethical concerns. Doctors in particular, especially if they have been steeped in the traditions of biological research, will find that the varied approach opens up the task of research to new ideas and insights. Other disciplines will find those ideas refreshed by the range of applications to different forensic settings.

 

© 2005 Tony O'Brien

 

 Tony O'Brien, M Phil., Lecturer, Mental Health Nursing, University of Auckland


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