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

Categories: Philosophical, Ethics, Psychology