Psychiatrie médico-légale. Envergure, responsabilités éthiques et conflits de valeurs

Quand une spécialité chevauche plusieurs systèmes, on ne peut traiter d’éthique sans discuter des valeurs et des règles de décision à la base de chacun de ces systèmes. Par ses multiples associations, la psychiatrie médico-légale est un archétype d’une telle spécialité ; elle opère au sein d’un ensemble de valeurs qui peuvent sembler antithétiques, voire irréconciliables en regard d’autres aspects de la psychiatrie. L’action de la psychiatrie médico-légale a pris une envergure considérable, et ses praticiens doivent adopter d’autres vues sur le monde et appliquer des règles de décision qui peuvent heurter les valeurs classiques et les considérations éthiques de la médecine (Weisstub, 1980). Après un bref historique, les auteurs passent en revue l’étendue de l’action de la psychiatrie médico-légale vue comme fondement de sa définition. Les concepts, thèmes et controverses relativement à l’éthique de cette spécialité sont examinés à la lumière des questions soulevées dans la pratique actuelle.To write about ethics in specialties that straddle the lines of multiple systems cannnot be done without discussing values and decisional rules that underlie each one of those systems. By virtue of its multiple associations, forensic psychiatry is an archetype of such specialties ; it works within a set of values that might be viewed as antithetical, even irreconcilable, with other aspects of psychiatry. The extensive scope of action of forensic psychiatry compels its practitioners to hold alternate world views and to apply decisional rules that may clash with the classical values and ethical considerations of medicine (Weisstub, 1980). In this article, following an historical précis, the authors review the scope of action of forensic psychiatry as the basis for the definition of this subspecialty. The concepts, themes and controversies pertaining to the ethical practice of this specialty will be reflected upon in the light of issues encountered in actual practice.Cuando una especialidad compete a varios sistemas, no se puede tratar de etiqueta sin discutir los valores y las reglas de decisión a la base de cada uno de estos sistemas. Por sus múltiples asociaciones, la psiquiatría medico-legal es un arquetipo de este tipo de especialidad; ésta opera en el seno de un conjunto de valores que pueden parecer antitéticos, es decir, irreconciliables con respecto a otros aspectos de la psiquiatría. La actividad de la psiquiatría medico-legal ha tomado una envergadura considerable y los que la practican deben adoptar otros puntos de vista sobre el mundo y aplicar las reglas de decisión que pueden chocar contra los valores clásicos y las consideraciones éticas de la medicina (Weisstub, 1980). Después de un breve resumen histórico, los autores revisan la amplitud de acción de la psiquiatría médico-legal vista como fundamento de su definición. Los conceptos, temas y controversias relacionados con la ética de esta especialidad se examinan a la luz de las preguntas que surgen en la práctica actual.Quando uma especialidade sobrepõe vários sistemas, não se pode tratar de ética sem discutir valores e regras de decisão que estão na base de cada um destes sistemas. Através de suas múltiplas associações, a psiquiatria médico-legal é um arquétipo de tal especialidade; ela opera dentro de um conjunto de valores que podem parecer antitéticos, ou mesmo irreconciliáveis com respeito a outros aspectos da psiquiatria. A ação da psiquiatria médico-legal tomou uma envergadura considerável, e seus especialistas devem adotar outras visões do mundo e aplicar regras de decisão que podem atingir os valores clássicos e as considerações éticas da medicina (Weisstub, 1980). Depois de um breve histórico, os autores passam em revista a extensão da ação da psiquiatria médico-legal, vista como fundamento de sua definição. Os conceitos, temas e controvérsias, com respeito à ética desta especialidade, são examinados à luz das questões levantadas na prática atual

Les droits en santé mentale au Canada : une perspective internationale

Cet article examine le statut des personnes souffrant de troubles mentaux à la lumière des instruments internationaux en matière de droits humains et évalue si les droits de ces personnes sont respectés dans le contexte canadien. Les auteurs estiment que bien que les systèmes de pays tels que le Canada garantissent des protections civiles et constitutionnelles significatives à l’ensemble de leurs citoyens, incluant ceux qui souffrent de troubles mentaux, il en est bien autrement au chapitre de l’accès aux services sociaux. Les auteurs discutent de la nécessité de corriger cette lacune. Enfin, ils estiment qu’il faut surveiller de près l’apparente dissonance entre les droits internationalement reconnus à des soins adéquats et à la protection contre la discrimination, et leur application restreinte en contexte canadien.This article surveys the status of people with mental disorders in the light of international human rights law and assesses if their rights are respected in the Canadian context. The authors recognize that although the national systems of countries such as Canada provide significant civil and constitutional protections on the positive rights of its citizens, including those who suffer from intellectual disability, the same cannot be said with respect to entitlements to the provision of social services. The authors argue that this shortcoming must be remedied. Finally, the authors conclude that it is paramount to closely monitor the apparent dissonance between internationally recognized rights to adequate healthcare and freedom from discrimination and their strict application in the Canadian context.Este artículo examina el estado de las personas que sufren trastornos mentales, en relación con los instrumentos internacionales en materia de derechos humanos, y evalúa si los derechos de estas personas son respetados en el contexto canadiense. Los autores estiman que, aunque los sistemas de países como Canadá garantizan la protección civil y constitucional significativa de todos sus ciudadanos, incluyendo a aquellos que sufren de trastornos mentales, es muy diferente en cuanto al acceso a los servicios sociales. Los autores discuten la necesidad de corregir esta laguna. Finalmente, estiman que es necesario vigilar la aparente disonancia entre los derechos internacionalmente reconocidos, al cuidado adecuado y a la protección contra la discriminación, y su aplicación restringida en el contexto canadiense.Este artigo examina o estatuto das pessoas que sofrem de transtornos mentais à luz dos instrumentos internacionais em matéria de direitos humanos e avalia se os direitos destas pessoas são respeitados no contexto canadense. Os autores acreditam que, apesar dos sistemas de países, como o Canadá, garantirem proteções civis e constitucionais significativas a seus cidadãos, incluindo os que sofrem de transtornos mentais, não é bem assim no capítulo do acesso aos serviços sociais. Os autores discutem a necessidade de corrigir esta lacuna. Finalmente, eles acreditam que é necessário observar de perto a aparente dissonância entre os direitos, internacionalmente reconhecidos, aos cuidados adequados e à proteção contra a discriminação, e sua aplicação limitada no contexto canadense

Homeward bound or bound for a home? Assessing the capacity of dementia patients to make decisions about hospital discharge: Comparing practice with legal standards

Background This article stems from a larger project which considers ways of improving assessments of capacity and judgements about best interests in connection with people with dementia admitted to acute hospitals with respect to decisions about place of residence. Aims Our aim is to comment on how assessments of residence capacity are actually performed on general hospital wards compared with legal standards for the assessment of capacity set out in the Mental Capacity Act, 2005 (MCA). Method Our findings are grounded in ethnographic ward-based observations and in-depth interviews conducted in three hospital wards, in two hospitals (acute and rehabilitation), within two NHS healthcare trusts in the North of England over a period of nine months between 2008 and 2009. Twenty-nine patient cases were recruited to the study. We also draw from broader conceptions of capacity found in domestic and international legal, medical, ethical and social science literature. Results Our findings suggest that whilst professionals profess to be familiar with broad legal standards governing the assessment of capacity under the MCA, these standards are not routinely applied in practice in general hospital settings when assessing capacity to decide place of residence on discharge from hospital. We discuss whether the criteria set out in the MCA and the guidance in its Code of Practice are sufficient when assessing residence capacity, given the particular ambiguities and complexities of this capacity. Conclusions We conclude by suggesting that more specific legal standards are required when assessing capacity in this particular context

Association study of promoter polymorphisms at the dopamine transporter gene in Attention Deficit Hyperactivity Disorder

<p>Abstract</p> <p>Background</p> <p>Attention deficit hyperactivity disorder (ADHD) is a complex neurobehavioral disorder. The dopamine transporter gene (DAT1/<it>SLC6A3</it>) has been considered a good candidate for ADHD. Most association studies with ADHD have investigated the 40-base-pair variable number of tandem repeat (VNTR) polymorphism in the 3'-untranslated region of DAT1. Only few studies have reported association between promoter polymorphisms of the gene and ADHD.</p> <p>Methods</p> <p>To investigate the association between the polymorphisms -67A/T (rs2975226) and -839C/T (rs2652511) in promoter region of DAT1 in ADHD, two samples of ADHD patients from the UK (n = 197) and Taiwan (n = 212) were genotyped, and analysed using within-family transmission disequilibrium test (TDT).</p> <p>Results</p> <p>A significant association was found between the T allele of promoter polymorphism -67A/T and ADHD in the Taiwanese population (<it>P </it>= 0.001). There was also evidence of preferential transmission of the T allele of -67A/T polymorphism in combined samples from the UK and Taiwan (<it>P </it>= 0.003). No association was detected between the -839C/T polymorphism and ADHD in either of the two populations.</p> <p>Conclusion</p> <p>The finding suggests that genetic variation in the promoter region of DAT1 may be a risk factor in the development of ADHD.</p