Ask Your Judge To Prescribe

The following hypothetical situation will be familiar to many psychiatrists working in jail setting:

You're in your clinic when you get an urgent call from a duty lieutenant. He has received an order from a judge that a newly received detainee must be evaluated promptly for suicide risk. The order mandates that the inmate be admitted to the jail infirmary, and further commands the jail psychiatrist to continue the specific combination of medications, at specific doses, that were being prescribed in free society.

You do the evaluation and discover the inmate made a rash and impulsive suicide reference in front of the judge, but that he did not intend to kill himself and had several protective factors in his favor. He did not require admission and was willing to participate in outpatient treatment within the facility. Although he arrived with several bottles of medication, none could be administered due to an institutional policy barring the dispensation of medication brought in from free society. Even without this prohibition, at least one of the medications was medically contraindicated due to the inmate's concurrent medical conditions.

You call the duty lieutenant back and advise him about the results of your evaluation.

That's when chaos breaks loose. The lieutenant refuses to house the inmate in general population because the judge ordered admission to the jail's psychiatric infirmary. If you admit the inmate, he will take up the last remaining bed. Furthermore, the infirmary nurse insists that only the free society medicine can be dispensed, against your orders and medical advice, because that's what the judge required.

There are many valid reasons why a judge would write an order like this. Obviously, there was a concern about suicide risk that the court wanted addressed. The inmate had a known psychiatric disorder and the court wanted to ensure that treatment would be provided. An order specifying a dose and frequency of medication could be written merely to ensure that medical information is transmitted to the facility. Nevertheless, the unintended consequences of an order like this are significant.

Occasionally, an inmate may convince a judge that only a court order will ensure that the “correct” medication will be prescribed, usually a medication which has economic value or abuse potential such as chlorpromazine, hydroxyzine, amitriptyline or other tricyclics, bupropion, quetiapine or even controlled substances like opioids or benzodiazepines.

When facing this situation for the first time a new correctional clinician may fear malpractice liability or being found in contempt of court. If the physician is employed by a private contractor, there may be implicit pressure to “keep the peace” and abide by the order, to maintain cordial business relations with the correctional client. The challenge for the correctional clinician is to respect the intent of the order--to perform an evaluation and offer treatment--while retaining one's independent medical judgment.

From an ethical standpoint, clinicians are bound to act in the patient's best interests under the principle of non-malfeasance. Ideally, the clinician acts in conjunction with a cooperative patient to outline available treatment options and alternatives for the patient, who then makes a treatment choice based upon his own values and wishes. Thus, non-malfeasance is balanced with respect for patient autonomy. In correctional work, one must sometimes care for patients who lack regard for their own safety and demand inappropriate or risky interventions. In this case, the ethical imperative of non-malfeasance must take priority.

Also, the principle of equivalence comes into play when an inappropriate order requires a clinician to use a scarce resource, such as an infirmary bed, in a way that would deny that resource to a more needy patient. Equivalence requires physicians to ensure that treatment resources are available for all, prioritized by patient need.

So how should a correctional psychiatrist respond to an unreasonable court order?

After exercising reasonable care and consideration, write a response to the court order and forward it through your administrative chain of command. The response should outline the reason for the evaluation, the clinical information that was available at the time of the evaluation and the pertinent information gathered from the patient interview. The response should document any treatment recommendations that were made along with the rationale behind the treatment decision, or the rationale behind any court-ordered treatments that were considered but rejected. If the inmate is demanding an inappropriate intervention, the response should document in detail any potential harms that could arise from that treatment.

While a situation like this is inherently uncomfortable and controversial, it's important to see it as an opportunity to provide thoughtful feedback to the court and to open a potentially beneficial collaboration. In future cases, a judge who knows the jail psychiatrist can be trusted to respond to a request for an evaluation and to provide competent care will be much less likely to write an unreasonable order. The court can also be a potential ally by reinforcing the rationale behind a treatment decision if an inmate complains or objects.

The American Medical Association's Code of Medical Ethics can also serve as a supporting document. The Code encourages physicians to act in the best interests of patients when making decisions about allocation of resources, and to refrain from treatments that are either unnecessary or futile.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

The following hypothetical situation will be familiar to many psychiatrists working in jail setting:

You're in your clinic when you get an urgent call from a duty lieutenant. He has received an order from a judge that a newly received detainee must be evaluated promptly for suicide risk. The order mandates that the inmate be admitted to the jail infirmary, and further commands the jail psychiatrist to continue the specific combination of medications, at specific doses, that were being prescribed in free society.

You do the evaluation and discover the inmate made a rash and impulsive suicide reference in front of the judge, but that he did not intend to kill himself and had several protective factors in his favor. He did not require admission and was willing to participate in outpatient treatment within the facility. Although he arrived with several bottles of medication, none could be administered due to an institutional policy barring the dispensation of medication brought in from free society. Even without this prohibition, at least one of the medications was medically contraindicated due to the inmate's concurrent medical conditions.

You call the duty lieutenant back and advise him about the results of your evaluation.

That's when chaos breaks loose. The lieutenant refuses to house the inmate in general population because the judge ordered admission to the jail's psychiatric infirmary. If you admit the inmate, he will take up the last remaining bed. Furthermore, the infirmary nurse insists that only the free society medicine can be dispensed, against your orders and medical advice, because that's what the judge required.

There are many valid reasons why a judge would write an order like this. Obviously, there was a concern about suicide risk that the court wanted addressed. The inmate had a known psychiatric disorder and the court wanted to ensure that treatment would be provided. An order specifying a dose and frequency of medication could be written merely to ensure that medical information is transmitted to the facility. Nevertheless, the unintended consequences of an order like this are significant.

Occasionally, an inmate may convince a judge that only a court order will ensure that the “correct” medication will be prescribed, usually a medication which has economic value or abuse potential such as chlorpromazine, hydroxyzine, amitriptyline or other tricyclics, bupropion, quetiapine or even controlled substances like opioids or benzodiazepines.

When facing this situation for the first time a new correctional clinician may fear malpractice liability or being found in contempt of court. If the physician is employed by a private contractor, there may be implicit pressure to “keep the peace” and abide by the order, to maintain cordial business relations with the correctional client. The challenge for the correctional clinician is to respect the intent of the order--to perform an evaluation and offer treatment--while retaining one's independent medical judgment.

From an ethical standpoint, clinicians are bound to act in the patient's best interests under the principle of non-malfeasance. Ideally, the clinician acts in conjunction with a cooperative patient to outline available treatment options and alternatives for the patient, who then makes a treatment choice based upon his own values and wishes. Thus, non-malfeasance is balanced with respect for patient autonomy. In correctional work, one must sometimes care for patients who lack regard for their own safety and demand inappropriate or risky interventions. In this case, the ethical imperative of non-malfeasance must take priority.

Also, the principle of equivalence comes into play when an inappropriate order requires a clinician to use a scarce resource, such as an infirmary bed, in a way that would deny that resource to a more needy patient. Equivalence requires physicians to ensure that treatment resources are available for all, prioritized by patient need.

So how should a correctional psychiatrist respond to an unreasonable court order?

After exercising reasonable care and consideration, write a response to the court order and forward it through your administrative chain of command. The response should outline the reason for the evaluation, the clinical information that was available at the time of the evaluation and the pertinent information gathered from the patient interview. The response should document any treatment recommendations that were made along with the rationale behind the treatment decision, or the rationale behind any court-ordered treatments that were considered but rejected. If the inmate is demanding an inappropriate intervention, the response should document in detail any potential harms that could arise from that treatment.

While a situation like this is inherently uncomfortable and controversial, it's important to see it as an opportunity to provide thoughtful feedback to the court and to open a potentially beneficial collaboration. In future cases, a judge who knows the jail psychiatrist can be trusted to respond to a request for an evaluation and to provide competent care will be much less likely to write an unreasonable order. The court can also be a potential ally by reinforcing the rationale behind a treatment decision if an inmate complains or objects.

The American Medical Association's Code of Medical Ethics can also serve as a supporting document. The Code encourages physicians to act in the best interests of patients when making decisions about allocation of resources, and to refrain from treatments that are either unnecessary or futile.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

The following hypothetical situation will be familiar to many psychiatrists working in jail setting:

You're in your clinic when you get an urgent call from a duty lieutenant. He has received an order from a judge that a newly received detainee must be evaluated promptly for suicide risk. The order mandates that the inmate be admitted to the jail infirmary, and further commands the jail psychiatrist to continue the specific combination of medications, at specific doses, that were being prescribed in free society.

You do the evaluation and discover the inmate made a rash and impulsive suicide reference in front of the judge, but that he did not intend to kill himself and had several protective factors in his favor. He did not require admission and was willing to participate in outpatient treatment within the facility. Although he arrived with several bottles of medication, none could be administered due to an institutional policy barring the dispensation of medication brought in from free society. Even without this prohibition, at least one of the medications was medically contraindicated due to the inmate's concurrent medical conditions.

You call the duty lieutenant back and advise him about the results of your evaluation.

That's when chaos breaks loose. The lieutenant refuses to house the inmate in general population because the judge ordered admission to the jail's psychiatric infirmary. If you admit the inmate, he will take up the last remaining bed. Furthermore, the infirmary nurse insists that only the free society medicine can be dispensed, against your orders and medical advice, because that's what the judge required.

There are many valid reasons why a judge would write an order like this. Obviously, there was a concern about suicide risk that the court wanted addressed. The inmate had a known psychiatric disorder and the court wanted to ensure that treatment would be provided. An order specifying a dose and frequency of medication could be written merely to ensure that medical information is transmitted to the facility. Nevertheless, the unintended consequences of an order like this are significant.

Occasionally, an inmate may convince a judge that only a court order will ensure that the “correct” medication will be prescribed, usually a medication which has economic value or abuse potential such as chlorpromazine, hydroxyzine, amitriptyline or other tricyclics, bupropion, quetiapine or even controlled substances like opioids or benzodiazepines.

When facing this situation for the first time a new correctional clinician may fear malpractice liability or being found in contempt of court. If the physician is employed by a private contractor, there may be implicit pressure to “keep the peace” and abide by the order, to maintain cordial business relations with the correctional client. The challenge for the correctional clinician is to respect the intent of the order--to perform an evaluation and offer treatment--while retaining one's independent medical judgment.

From an ethical standpoint, clinicians are bound to act in the patient's best interests under the principle of non-malfeasance. Ideally, the clinician acts in conjunction with a cooperative patient to outline available treatment options and alternatives for the patient, who then makes a treatment choice based upon his own values and wishes. Thus, non-malfeasance is balanced with respect for patient autonomy. In correctional work, one must sometimes care for patients who lack regard for their own safety and demand inappropriate or risky interventions. In this case, the ethical imperative of non-malfeasance must take priority.

Also, the principle of equivalence comes into play when an inappropriate order requires a clinician to use a scarce resource, such as an infirmary bed, in a way that would deny that resource to a more needy patient. Equivalence requires physicians to ensure that treatment resources are available for all, prioritized by patient need.

So how should a correctional psychiatrist respond to an unreasonable court order?

After exercising reasonable care and consideration, write a response to the court order and forward it through your administrative chain of command. The response should outline the reason for the evaluation, the clinical information that was available at the time of the evaluation and the pertinent information gathered from the patient interview. The response should document any treatment recommendations that were made along with the rationale behind the treatment decision, or the rationale behind any court-ordered treatments that were considered but rejected. If the inmate is demanding an inappropriate intervention, the response should document in detail any potential harms that could arise from that treatment.

While a situation like this is inherently uncomfortable and controversial, it's important to see it as an opportunity to provide thoughtful feedback to the court and to open a potentially beneficial collaboration. In future cases, a judge who knows the jail psychiatrist can be trusted to respond to a request for an evaluation and to provide competent care will be much less likely to write an unreasonable order. The court can also be a potential ally by reinforcing the rationale behind a treatment decision if an inmate complains or objects.

The American Medical Association's Code of Medical Ethics can also serve as a supporting document. The Code encourages physicians to act in the best interests of patients when making decisions about allocation of resources, and to refrain from treatments that are either unnecessary or futile.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.