CHAPTER

16

I

t’s the early evening rush hour in New York City in

January 1998. People are waiting in a subway station for

a train to take them home, to meet friends, or to go out

to dinner. Kendra Webdale, a 32-year-old woman, is among

the people waiting at the platform. Andrew Goldstein, a

29-year-old man, comes up from behind her and pushes her

in front of an oncoming train as it enters the station. He

murdered her, as many witnesses later testifi ed. This might

seem an open-and-shut criminal case, but it’s not. Goldstein

had a 10-year history of mental illness, had been in and out

of psychiatric units and hospitals, and was diagnosed with

paranoid schizophrenia.

If Goldstein wasn’t in his “right mind” when he pushed Web-

dale, should he face a trial? And if found guilty, should he go to

jail, or perhaps be executed? Or should he be judged and treated as

someone who is mentally ill—and if so, why? Are those who commit

criminal acts dealt with differently if they are mentally ill? Moreover,

what if Goldstein had been seeing a psychotherapist and had men-

tioned that he might do something like this? Should the therapist

have reported his statement to the police? Mental health clinicians

are bound by a code of ethics and by state and federal laws. What

are the relevant ethical guidelines and laws that affect how mental

health clinicians treat their patients? These are the types of questions

that address the relationships among the law, ethics, and the reality

of mental illness and its treatment.

The laws and ethical codes pertaining to mental illness, treat-

ment, and criminal behavior by the mentally ill evolve over time. As

we shall see, even when the law is clear about the type of treatment

an individual should receive, fi nancial constraints may prevent the

individual from receiving that treatment.

In this chapter, we examine the legal and ethical issues that can

affect mental health professionals and their patients, paying particu-

lar attention to criminal actions by people who are mentally ill—the

circumstances under which they are considered insane, what hap-

pens to them when they are dangerous to themselves or others, and

whether and when they receive treatment.

717

Ethical and

Legal Issues

Chapter Outline

Ethical Issues

An Ethical Principle: The Role of

Confi dentiality

Informed Consent to Participate in Research

on Mental Illness: Can Patients Truly Be

Informed?

Criminal Actions and Insanity

While Committing the Crime: Sane or

Insane?

The Insanity Defense: Current Issues

After Committing the Crime: Competent to

Stand Trial?

Dangerousness: Legal Consequences

Evaluating Dangerousness

Actual Dangerousness

Confi dentiality and the Dangerous Patient:

Duty to Warn and Duty to Protect

Maintaining Safety: Confi ning the

Dangerously Mentally Ill Patient

Legal Issues Related to Treatment

Right to Treatment

Right to Refuse Treatment

Competence to Refuse Treatment

Mental Health and Drug Courts

The Wheels of Justice: Follow-up on

Andrew Goldstein

Clifford Alejandro