Coercion in psychiatric care is often presented as a conflict between autonomy and beneficence. This framing is ethically useful, but it can obscure whether coercive care treats persons in crisis as agents who remain entitled to reasons, participation, and support. This sequential explanatory mixed-methods study examined coercion after suicide-attempt care in Caldas, Colombia. Quantitative analyses used 155 matched dyads of service users and the professionals involved in their care. Measures assessed perceived coercion, professional-reported coercive practices, stigma-related attitudes, depressive symptoms, subjective well-being, and sense of community. Qualitative analysis drew on 60 in-depth interviews with service users and professionals. Service-user perceived coercion was associated with higher depressive symptoms, professional-reported coercive practices, and authoritarian professional attitudes. Regression models explained 43.6% of the variance in professional-reported coercive practices. Interviews showed that coercion was commonly described as protection, protocol, or professional duty, with limited reference to rights, supported decision-making, or less restrictive alternatives. These findings do not establish that coercion is never justified. They suggest, more narrowly, that post-suicide-attempt coercion may be ethically defective when it bypasses reason-giving, reduces agency to clinical manageability, and normalizes paternalistic routines as beneficence. A reason-responsive account of respect clarifies why reducing coercion requires not only procedural safeguards, but also practical infrastructures for supported decision-making and non-coercive crisis care.
Leave modalities are an integral part of rehabilitation in forensic psychiatric care; however, empirical evidence on leave approvals is scarce. This study investigated the timing and reasons underlying leave approvals among 174 patients (95.4% male; mean age = 50.2 years) in resocialization units of high-security forensic psychiatric institutions in Flanders, Belgium, focusing on leave permits (up to 16 h) and leaves (up to 14 days). Analyses were conducted on the entire sample to identify general patterns, followed by latent class analysis (LCA) to group patients based on offenses, clinical indicators, and background characteristics. In total, 1012 leave permit applications and 64 leave applications were submitted. All patients had at least one leave permit application, while leave applications were recorded for only 41 patients. The first leave permits were requested after 2.8 years and approved after 3.5 years, whereas leaves were requested and approved later (4.4 and 5.2 years, respectively). Approval rates were high for leave permits (75.7%), but considerably lower for leaves (28.1%), and varied depending on the purpose and applicant. Applications initiated by institutions were far more likely to be approved (89.2-100%) than those initiated by patients or lawyers (13.3-20.9%). Latent class analysis identified four patient subgroups, revealing significant differences in approval rates across classes, but not in timing. This suggests that while institutional routines largely determine timing, approval decisions depend on patient characteristics, underscoring the need for more tailored decision-making.
The Assisted Decision-Making (Capacity) Act 2015 (ADMCA) provides a legislative basis for advance healthcare directives (AHDs) in Ireland. AHDs offer important benefits to patients, including preserving autonomy and allowing for greater control over end-of-life care. However, they can also create difficult ethical dilemmas, especially in respect of AHDs refusing basic care, pain relief and palliative symptom management. We use a hypothetical case study to interrogate how such directives should be addressed under the ADMCA and identify some uncertainties and ambiguities within the ADMCA concerning refusal of palliative care and pain relief. We argue that these dilemmas can only be properly understood by looking at the entirety of the legislative framework and not just at definitional issues around basic care. Although many ambiguities can be addressed within the framework of the ADMCA, including through consultation with the directive-maker's decision making representative, if there is one, or family members, this will not always be the case and so we have also advanced an argument that, when palliative care is refused, even if the healthcare professionals conclude that the AHD is valid and applicable, there is still a case for referral of the matter to court.
The revised Product Liability Directive (rPLD) introduces a pivotal shift in the liability landscape for healthcare professionals using artificial intelligence. While existing research often focuses on professional or regulatory thresholds, this paper highlights a critical and underexplored juncture: the moment a health institution or professional's interaction with an AI system constitutes a substantial modification, thereby transforming them from a user into a de facto manufacturer under the rPLD's strict liability regime.Drawing on the author's prior work on threshold-based liability frameworks, this paper examines how the rPLD redefines the “product” to include software and AI systems, and expands liability to any natural or legal person who substantially modifies a product outside the manufacturer's control. In clinical practice, such modifications may occur through actions such as overriding safety parameters, integrating unauthorized components, or in other manner. When these actions are not foreseen in the manufacturer's initial risk assessment, create a new hazard or increase the risk level, and are performed by a healthcare professional rather than a consumer, the health institution or professional crosses the product liability threshold, triggering strict liability for any resulting harm.The analysis situates this threshold within the broader EU regulatory ecosystem, including the AI Act, the General Product Safety Regulation, and the Medical Devices Regulation, to demonstrate how liability becomes distributed and context-dependent. The paper argues that the rPLD does not merely complement existing fault-based regimes but creates a distinct, strict liability pathway that reallocates risk to the party with the highest degree of control over the AI system's final safety configuration.
The Supreme Court's decision in Reference by the Attorney General for Northern Ireland [2026] UKSC 16 represents the most significant development in deprivation of liberty jurisprudence since P v Cheshire West and Chester Council; P and Q v Surrey County Council [2014] UKSC 19. Whilst the proceedings arose from a challenge to proposed revisions to the Northern Ireland Deprivation of Liberty Safeguards (DoLS) Code of Practice under the Mental Capacity Act (Northern Ireland) 2016 (MCA (NI) 2016), the judgment extends considerably beyond the issue of consent that formed the basis of the Attorney General's reference. Instead, it reformulates the domestic approach to determining when Article 5 of the European Convention on Human Rights (ECHR) is engaged, moving beyond an exclusively threshold-based analysis to a multi-factorial assessment of the individual's circumstances.This article examines the legal and practical implications of that recalibration for deprivation of liberty safeguards under the MCA (NI) 2016. It argues that the judgment restores proportionality to the assessment of deprivation of liberty by requiring consideration of the purpose, normality, duration and effects of care arrangements, together with the person's wishes and feelings, the presence or absence of objection, and whether the circumstances amount to confinement in the autonomous Convention sense. In doing so, the Supreme Court moves beyond the binary application of the Cheshire West acid test whilst maintaining the fundamental protections afforded by Article 5 ECHR.Drawing upon human rights jurisprudence, the reasoning of the Supreme Court and the operational realities of implementing the MCA (NI) 2016, the article considers the implications of the judgment for professional decision-making, documentation, governance and the future operation of deprivation of liberty safeguards. It concludes that the judgment does not weaken Article 5 protections but provides a more proportionate and context-sensitive framework through which they should be applied. The principal challenge now lies not in redefining deprivation of liberty, but in translating the Supreme Court's reformulated approach into consistent and legally robust practice.
Cross-national studies provide a valuable framework for examining how assessments of criminal responsibility in forensic psychiatry vary across psychiatric systems and legal contexts. This paper presents a comparative analysis of forensic psychiatric practice in Italy and Switzerland, two neighboring jurisdictions rooted in the Roman legal tradition, yet characterized by distinct trajectories in criminal law and forensic development. Particular attention is devoted to structural differences in psychiatric care, contrasting Italy's community-based model with Switzerland's predominantly hospital-centered system. The analysis further explores divergences in approaches to the assessment of recidivism risk and in expert evaluation methodologies, demonstrating how such variations reflect broader legal, institutional, and epistemological configurations. It also examines disparities in professional training, situating them within their respective cultural and practical contexts. These factors collectively shape the role of the forensic psychiatrist as an independent expert engaged in addressing complex questions concerning criminal behavior, criminal responsibility, and the interplay between psychopathology and free will within judicial proceedings. By identifying both convergences and divergences, this study underscores the value of comparative inquiry in advancing the field and contributes to ongoing efforts toward the development of more standardized international approaches in forensic psychiatry. It concludes by emphasizing the need for further research in this foundational domain, with the aim of enhancing the rigor, coherence, and cross-cultural validity of forensic psychiatric evaluations, particularly in the expertise report and assessment of recidivism risk.
The United Nations Convention on the Rights of Persons with Disabilities (CRPD) is the first human rights treaty of this century. It aims to ensure that persons with disabilities have full and effective inclusion in society and are not the subjects of discrimination. Support for the CRPD was unprecedented, attracting widespread approval from states in all regions, and achieving the highest number of signatories to a UN Convention on its opening day. Whilst most of its provisions have been welcomed, the interpretation of several key articles by UN bodies has led to some unanticipated issues of compliance with areas of the criminal justice system. In particular, it has been argued that the CRPD requires the abolition of any criminal defence which relieves or mitigates liability because of a disability. The relevant mental condition defence focused on in this article is the insanity defence. No State Party to the CRPD has shown any inclination to abolish the insanity defence due to a perception that the interpretations advanced by the UN bodies are flawed and unworkable. This article establishes that the insanity defence can be reformed in a way that is CRPD compliant without the necessity of abolition. It is proposed that the cognitive limb of insanity should be replaced by a legal rule which allows for evidence of a psychosocial disability to negate mens rea. The evaluative and volitional limbs should be replaced with a new defence which focuses on the defendant's ability to generate alternative choices.
Change isn't something new to Medicine. Since the beginning of times, Medicine has been forced to, progressively, adapt according to scientific, biological and technological discoveries as well to the social and ethical transformations. Nowadays, the evolution of Medicine points out to the gradual introduction of new supporting tools in healthcare, such as Artificial Intelligence (AI), which can be very challenging. The challenges are not the ones relate to the introduction of AI or other technological tools, per si, since that seems inevitable, but how their introduction may impact some cornerstones of Medicine Law, such as physician-patient relationship, consent and even physicians' civil liability. Summing up, we are dealing with newer challenges of even older issues. In this article, we aim to review the doctor-patient relationship, duty of information and consent and medical civil liability in the light of the introduction of AI supporting tools in healthcare.
Mental health professionals (MHPs) play important roles in providing expert opinions in courts; however, dated studies indicate that legal professionals prefer psychiatrists as mental health expert witnesses as well as mental health testimony on ultimate opinions, clinical diagnosis, and interpreting the legal standard for mental conditions. This mixed-methods study surveyed 132 judges and lawyers in the United States and Canada to examine their preferences for mental health testimony elements and MHPs as expert witnesses. Updating previous research conducted between the 1980s to 2010s, respondents were presented with 11 questions describing different elements of mental health testimonies and were asked to rate the importance of these testimonies and rank their preference for psychiatrists, psychologists or social work experts. Legal professionals preferred expert testimony on clinical diagnosis, psychological testing, and descriptive testimonies. American legal professionals considered testimony on crime statistical data related to diagnosis as more essential than did Canadians, and Canadians ranked testimony on measure of dangerousness higher. Overall, American legal professionals preferred having psychologists as expert witnesses, whereas Canadian legal professionals preferred psychiatrists. Using a qualitative reflexive thematic analysis of participants' comments on factors that contribute to a useful testimony, four themes summarized the indicators of useful expert testimony: Qualified and Engaged Experts, Relevant and Useful Information, Empirical Rigor in Testimony, and Clarity and Accessibility. Results reveal that American legal professionals are increasingly understanding the value of forensic psychologists as expert witnesses, whereas Canadians hold preferences for psychiatrists.
The specific circumstances under which autism spectrum disorder could meet the legal standards severe mental disorder (SMD; the core Swedish legal concept underpinning sentencing to forensic psychiatric care) in criminal court cases are unclear. Aim To explore which neurocognitive and contextual factors that have been emphasized in the assessment of SMD in cases of autism spectrum disorder. Method A randomized sample (N = 20) was derived from a data set of forensic psychiatric evaluations (FPEs) conducted between 2016 and 2018 on violent offenders with autism. Qualitative content analysis was used separately for offenders who did (n = 10) and did not (n = 10) meet the standard for SMD. Results A dimensional approach to autism-associated features was commonly used within SMD decision-making, including overall statements that autism was considered severe enough, or not, for SMD. Certain types of autism-associated features were more prominent in the SMD group, contributing to autism being considered more severe. Examples were very low psychosocial functioning, fixation on violence, few or rigid coping strategies, impaired central coherence/metacognition. Pronounced degree of idiosyncratic/atypical worldview, feelings of anxiety, insecurity, fear, or desperation were also emphasized in the SMD group. Degree of compulsive behavior could also be highlighted in the SMD group, particularly if it was considered associated with severe anxiety when routines were broken or certain stimulus was perceived. Emphasized characteristics in the no SMD group included antisocial traits, complex and/or vague psychopathology, substance abuse, intact reality monitoring, and the ability to integrate multiple perspectives. Discussion Degree of autism-symptomatology and global/psychosocial functional impairment were considered both in the SMD and no SMD groups' FPEs. The no SMD group was often described as not exhibiting sufficiently marked autism-functioning, a lower degree of psychiatric symptomatology in general, and a motivation for the crime which is not considered clearly related to a non-normative perception of reality due to autism. The vagueness in when autism severity was considered “sufficient” for SMD, emphasizes the importance of further in-depth studies to inform the development and implementation of standards or guidelines to support experts in their decision-making.
Therapeutic jurisprudence (TJ) highlights how legal processes and legal actors may shape the psychological experiences of those who engage with the law. This study uses TJ as an interpretive framework to examine changes in mental well-being among veterans accessing a free social welfare legal advice service. Using the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), we compared well-being scores at service entry (baseline) and follow-up. Follow-up surveys were issued after a minimum of 14 days and re-sent at approximately two-week intervals. Because completion depended on participant response, the interval between baseline and follow-up varied (median 78 days, IQR 29-179; range 10-749; n = 100). Among veterans reporting mental health challenges at baseline, WEMWBS scores increased from a median of 28.00 (IQR = 14.00) at baseline to 35.00 (IQR = 15.25) at follow-up, consistent with higher reported well-being during the service engagement period. Exploratory analyses of item-level change indicated that improvements were strongest for items relating to cognitive clarity, relaxation, cheerfulness, and managing problems, alongside smaller improvements in perceived usefulness and optimism. Items loading on Component 3 (social connectedness) did not show significant change. Future research combining quantitative and qualitative methods is needed to examine client experiences, perceived procedural justice, outcome favourability and the durability of well-being changes over time.
Islamist terrorism is a major preoccupation in France as it poses a serious threat to safety. Pre-release assessment of convicted jihadi terrorists requires high-quality psychiatric expert reports to assist magistrates in deciding on post-sentence follow-up. In the literature, the quality of psychiatric expert reports in France has been questioned. This arises from a discrepancy between the number of expert reports that are requested and the number of experts available. We studied the quality of these reports, focusing on evaluation of dangerousness and the risk of recidivism.In this novel study, quantitative and qualitative data were extracted from 100 post-sentence expert reports, 15 s expert opinions and 10 supplemental reports. These reports were taken from 100 different case files exclusively concerning Islamist terrorism-related offenses. This study was carried out in partnership with the national counter-terrorism prosecutor's office, the Parquet National Antiterrorisme (PNAT).In order to study the quality of these reports, we developed conformity scores based on the general recommendations of the French National Authority for Health (Haute Autorité de Santé, HAS). These general conformity scores concerned the recommendations for all types of expert reports, while specific conformity scores related to post-sentence reports. Lastly, we proposed a list of risk factors for violent radicalization based on the data of the literature, and these enabled us to calculate conformity scores specifically related to Islamist terrorism.The mean conformity score of the expert reports was 86.7%, with scores varying between reports. The score decreased to 82.1% if criteria specific to terrorism were included. The experts often made no reference to a classification when making a diagnosis. They were reticent to use actuarial tools or structured professional judgments to assess the risk of recidivism. Their practice in searching for criteria specific to Islamist terrorism also appeared to vary.There is a need for training and working meetings between psychiatric experts to reach a consensus on the quality of expert reports. Meetings and exchanges between experts and magistrates would help clarify their respective missions.
Bipolar Disorder (BD) is a chronic and cyclical mood disorder characterized by fluctuations between an expansive or diminished mood. In the Spanish legal framework, BD is a recognized clinical condition that may significantly modify criminal liability, potentially leading to findings of non-imputability. Methodology: A retrospective and systematic review of criminal court sentences in Spain was conducted over a 5year period (2019-2024), focusing on cases involving manic symptomatology. A total of 182 sentences were identified and analyzed to characterize the sociodemographic, clinical, and judicial variables of the defendants. Results: The sample was predominantly male (81.87%), with a high prevalence of social isolation (76.92% lacked family support). While 69.23% had a prior BD diagnosis, a significant majority were not receiving pharmacological treatment (61.54%) or psychiatric follow-up (64.29%) at the time of the offense. Most defendants had a prior criminal record (63.74%). Regarding judicial outcomes, the most frequent results were appeal dismissals (37.36%) and prison sentences (28.57%). Notably, court-ordered pharmacological treatment was applied in 6.59% of cases, while BD was considered a full exonerating factor in only 3.3% of the sample. Conclusions: The findings highlight a strong correlation between social vulnerability, treatment non-adherence, and criminal involvement in BD patients. There is an urgent need for standardized forensic protocols and interdisciplinary training to ensure that judicial measures are clinically appropriate and proportionate to the defendant's mental state.
The study analyses how courts formulate questions in orders/measures commissioning expert reports in legal-capacity proceedings, with the aim of systematising and improving such assignments. Using qualitative clustering with duplicate removal and explicitly focusing on excluding prompts that solicit legal evaluations, we identified eleven question clusters aggregated into four superordinate categories A-D: (A) identification of illnesses and medication; (B) general limitations of cognitive and motivational-volitional processes; (C) specific limitations with a predominant impact on rights and obligations; and (D) specific limitations with a predominant impact on everyday life. Drawing on this semantic structure, we proposed optimised formulations that invite experts to provide descriptive accounts of a person's condition and functioning rather than categorical "is/is not capable" judgments. The reformulation is grounded in (i) longstanding higher-court critiques in the Czech Republic of courts' passive adoption of categorical expert conclusions, (ii) the revealed thematic categories (A-D) with corrections to imprecise wording, and (iii) international frameworks emphasising supported decision-making and non-discriminatory indicators of support needs. Descriptive conclusions in expert reports better equip courts to form a qualified understanding of mental condition and functioning. Practically, we recommend structuring assignments around clearly defined semantic clusters and using model descriptive phrasings for recurrent content areas. Across two judicial regions (HK and SK), we examined 40 court assignments comprising 202 questions in total, of which 188 were substantively related to legal capacity and were retained for analysis.
This study explores the reentry needs of incarcerated individuals within a local jail, focusing on expressed needs related to mental health and its impact on one's self-reported future outlook of staying out of legal trouble. Using data from 385 participants in a Southeastern jail reentry program in the United States, self-reported reentry needs were examined, highlighting variations by race and biological sex. Using logistic regression, it was found that mental health needs negatively influenced future outlooks, while other significant needs such as housing and employment were prevalent but not as influential on future outlooks. Overall, the findings reflect the importance of integrated, gender-responsive, and culturally tailored mental health services to improve reintegration success and reduce recidivism among returning citizens.
The concept of algorithmic fairness is intricate and multifaceted, concerning the equitable treatment of individuals or groups by algorithms in data processing and decision-making. This issue not only impacts trust in algorithms but also influences societal acceptance and reliance on technology. With the growing utilisation of big data and machine learning in predictive algorithms, crime prediction software has become integral to modern policing. However, data bias within these algorithms can result in unfair outcomes, affecting policing decisions, undermining the perceived fairness of algorithmic choices and exacerbating social inequality. Current crime prediction software exhibits three primary types of bias: design bias, training bias and interaction bias. These biases are ingrained in algorithms through predictive models and materialise as feedback loops in practice. Mitigating the adverse effects of data biases can be achieved by enhancing algorithmic transparency and interpretability, enhancing dataset diversity and fairness, and optimising feedback mechanisms to guide the evaluation of future algorithmic fairness practices.
In developing countries like Indonesia, the application of mental health considerations in legal practice remains inconsistent and underdeveloped. The study explores how legal practitioners navigate cases involving individuals with mental disorders within this context. This qualitative study represents the needs assessment phase of a larger project to develop a forensic psychiatry educational module. Focus group discussions were conducted with nine legal practitioners (judges, prosecutors, and lawyers) selected based on their experience in handling mental health-related cases. Data were analyzed using inductive thematic analysis. Three overarching domains emerged: experience of handling legal cases with mental health issues, knowledge and regulatory gaps in handling legal cases with mental health issues and future directions. Legal practitioners reported difficulties in recognizing and interpreting mental disorders, conducting effective communication with affected individuals, and integrating psychiatric perspectives into legal decision-making. These challenges were further compounded by limited formal mental health training, inconsistent use of psychiatric evaluations, restricted access to mental health professionals, and gaps in translating clinical findings into legal reasoning. This study highlights a gap between advancements in forensic mental health practices in developed countries and their implementation in lowresource settings. It underscores the need for context-specific training, strengthened collaboration between legal and mental health professionals, and clearer procedural guidance to support both clinical understanding and fair trial processes.
This study evaluates the application of the DUNDRUM-2 Triage Urgency scale for prioritizing admissions to high security forensic psychiatric centers in Flanders, given forensic bed shortages and extended waiting periods. A retrospective cohort of 120 admitted patients was examined to compare DUNDRUM-2 scores of prioritized admissions with regular admissions and to assess the instrument's reliability and validity. Results indicated that prioritized patients scored significantly higher, with nearly nine out of ten displaying urgent or very urgent needs. One third of the regular patients also had urgent needs, highlighting resource allocation challenges. Psychometric analyses revealed weak internal consistency and there were scoring difficulties, suggesting limitations in applying DUNDRUM-2 within Belgium's clinical and judicial framework. Despite these limitations, DUNDRUM-2 showcased potential in enhancing transparency and accountability in decision-making processes. Recommendations include adapting the scale to better align with the Belgian context and undertaking further validation to optimize forensic psychiatric care.
Background: The Community Access Support Team is an initiative aimed at improving crisis response for people facing mental health challenges or trauma. It brings together policing, health and social care in a co-response team that offers compassionate, timely support, reducing the need for risk and emergency department visits. Co-responding has three core elements namely specialised call handling, a joint police mental health team, and a community support hub for follow-up care. This scoping review, which follows the JBI Methodological Framework, aims to explore and map the extent, range and nature of research related to co-responding and to identify gaps in existing literature. Methods: Following a search of various online databases, two independent reviewers underwent a two-step screening process on Covidence; a total of 29 papers were included for data extraction. The mapping included a review of the various models and regulatory frameworks underpinning service providers, type of interventions, outcomes and stakeholder experiences (providers, person, family). Findings: Co-response teams improved interagency collaboration and service co-ordination; they reduced jail bookings and emergency department transport. Service users felt better understood and communicated with compared to police-only responses. Police gained confidence and received more crisis training. Conclusions: Co-response teams help to improve service user care and access to community mental health services. However, there is limited evidence of the long-term cost-effectiveness, and some challenges included role conflict, staffing and data sharing issues.
