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Violence risk assessment as a medical intervention: ethical tensions

  • Ashimesh Roychowdhury (a1) and Gwen Adshead (a2)

Summary

Risk assessment differs from other medical interventions in that the welfare of the patient is not the immediate object of the intervention. However, improving the risk assessment process may reduce the chance of risk assessment itself being unjust. We explore the ethical arguments in relation to risk assessment as a medical intervention, drawing analogies, where applicable, with ethical arguments raised by general medical investigations. The article concludes by supporting the structured professional judgement approach as a method of risk assessment that is most consistent with the respect for principles of medical ethics. Recommendations are made for the future direction of risk assessment indicated by ethical theory.

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Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

Ashimesh Roychowdhury (ARoychowdhury@standrew.co.uk)

Footnotes

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Declaration of interest

None.

Footnotes

References

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42 Haque, Q, Webster, CD. Staging the HCR-20: towards successful implementation of team-based structured professional judgement schemes. Adv Psychiatr Treat 2012; 18: 5966.

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Violence risk assessment as a medical intervention: ethical tensions

  • Ashimesh Roychowdhury (a1) and Gwen Adshead (a2)
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Author Reply: Violence risk assessment as a medical intervention: ethical tensions

Ashimesh Roychowdhury, Consultant Forensic Psychiatrist and Associate Medical Director, St Andrew's Healthcare, and
21 May 2014

We thank Dr Matthew Large for his helpful comments.

We wished to respond only by clarifying that the figures in Table 2 were from a hypothetical population, based on a hypothetical risk assessment tool with certain sensitivity and specificity values. The purpose was to illustrate that, even in risk assessments with unrealistic accuracy levels, the PPV (positive predictive value) was still low, as it was greatly influenced by the base rate. Any misleading odds ratios arising from the table was not intentional and arose (perhaps ironically) by chance.

Ashimesh Roychowdhury, Consultant Forensic Psychiatrist andAssociate Medical Director, St Andrew's Healthcare, Northampton.

Gwen Adshead, Consultant Forensic Medical Psychotherapist,Broadmoor Hospital, Crowthorne, Berkshire.

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Conflict of interest: None declared

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Over-selling risk assessment

Trevor D Broughton, Consultant Forensic Psychiatrist
09 May 2014

I need to congratulate Roychowdhury and Adshead (1) on a thought provoking critique. Whilst their arguments struck a chord in exposing the flaws in risk assessment tools and their unjust application in preventative detention, I was disappointed that they didn't go further. All of these tools, structured clinical judgement included, apply population-derived data to individuals, thus painting them with the behaviour of their peers.

The central flaw of risk assessment lies in presuming causality from association. The premise in these tools that symptom severity invariably correlates to risk is demonstrably fallacious as any psychiatrist could counter-cite cases where treating the mental illness improves functional ability in patients who choose pro-criminal lifestyles.

The second problem, as previously highlighted by Szmukler (2), is their inherent determinism by casting the subject as a hapless automaton. Society is rightly critical of the boorish youth who binge drinks and getsinto fights; yet exculpates the capacitous non-compliant schizophrenic - and holds their psychiatrist vicariously liable for their violence.

Risk assessment attempts to sanitize an unpalatable fact that violence is part of the human condition, which exists independently of mental illness. Milgram (3) and Zimbardo (4) infamously illustrated this. Nonetheless, even when convicted, the non-mentally disordered offender rarely faces the sanction of possible indefinite detention. Indeed it was implicit in the debate around DSPD [dangerous and severe personality disorder] and the 2007 revisions to the Mental Health Act that Psychiatry could be manipulated into preventatively detaining risky individuals in society without the bothersome need for a trial (5).

The truth is that risk assessment has become an industry. Those devising the next "marginally-better-than-chance" tool can live off the proceeds of the copyright, training seminars and subsequent release of version 2.0. It is also politically expedient in reverse-engineering a scapegoat and providing glib platitudes that "lessons are learnt", and "something is done" in a world increasingly tilting at the reality of rareunpleasant events.

I believe that expectation regarding the prescience of risk assessment has far outstripped the reality of what it can achieve. The evidence base for risk assessment, by the authors' own conclusion, would not support its use as a diagnostic instrument; yet in clinical practice it is insidiously taking over as a priority. Criminal justice operates on a principle that is better to let 10 guilty men go free than convict one innocent. If the original question was one of ethics, surely for an exception to be made for the mentally ill is frankly discriminatory.

Furthermore, the question around the ethical principle of beneficenceremains unanswered: if risk assessment is a priority activity, what is theevidence that it improves clinical outcomes over-and-above quality standard care? I cannot offer an alternative other than to lament the fact that the Richardson Committee's Report in 1999 on transforming mental health legislation from risk- to capacity-based was never realised. We need to refocus this debate clinically by emphasising "needs assessment" over "risk assessment". Risks are unavoidable; but good quality evidence-based care should not be usurped by the latest fashionable risk assessment tool.

References:

1.Roychowdhury A, Adshead G. Violence risk assessment as a medicalintervention: ethical tensions. Psychiatric Bulletin 2014; 38:75-82

2.Szmukler G. Homicide Inquiries: What sense do they make? Psychiatric Bulletin 2000; 24:6-10

3.Milgram S. Behavioural Study of Obedience; Journal of Abnormal and Social Psychology 1963; 67:371-378

4.Zimbardo PG. (1971). The power and pathology of imprisonment. Congressional Record. (Serial No. 15, 1971-10-25). Hearings before Subcommittee No. 3, of the Committee on the Judiciary, House of Representatives, Ninety-Second Congress, First Session on Corrections, Part II, Prisons, Prison Reform and Prisoner's Rights: California. Washington, DC: U.S. Government Printing Office

5.Per Jack Straw, then Home Secretary, Hansard (HC) 15th February 1999 col 601-603

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Conflict of interest: None declared

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GMC guidance needed

Keith E. Dudleston, Retired psychiatrist
09 May 2014

Roychowdhury and Adshead should be thanked for raising the issue of the ethics of the use of actuarial risk assessment in psychiatry (1). These ethics might at first appear obvious: Medical practitioners must have an over riding duty to protect the public from serious crime. It follows thatthey must do everything possible to accurately assess the risk of such crime, including the use of these assessment instruments.However, as Roychowdhury and Adshead point out, these instruments will produce misleading results if the prevalence of the serious crime being considered, in the relevant population, is low or unknown. Indeed they point out: " A key challenge in psychiatry is that base rates [of the prevalence of serious crime] are often not known, are low and vary for different types of violence". So if doctors use these assessments they will risk wrongly identifying their patient as at high risk of committing a serious crime, and then act in a way that is not in the best interests of that patient. Such an act would of course be inconsistent with the duties of a doctor as set out by the GMC in Good Medical Practice.lt follows that while the prevalence of particular serious crimes, in various patient populations, is unknown, or is known to be low, the use ofthese actuarial risk assessments will remain unethical. As Roychowdhury and Ashhead conclude: "SPJ [risk assessment] tools used as checklists of risk factors without construction of risk scenarios or a risk management plan remains harmful and unethical practice." In my opinion psychiatrists would value guidance on this issue from the GMC.

Reference:1. Roychowdhury A and Adshead G. Violence risk assessment as a medical intervention: ethical tensions.Psychiatric Bulletin 2014; 38: 75-82.

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Conflict of interest: None declared

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Risk assessment and evidence based medicine

Matthew Large, Psychiatrist
06 April 2014

The article by Roychowdhury and Adshead starts to place violence riskassessment in the context of medical care (1). While this is welcome, their partial defence of risk assessment in general, and of structured professional judgement in particular is based on some significant distortions.

The first distortion is the gross over-estimation of the power of risk assessment to discriminate between low-risk and high-risk people. In table2 the authors present a contingency table that they imagine shows the 'potential' outcomes of a violence risk assessment. Using their tabulateddata, a diagnostic odds ratio for risk assessment can be calculated to be 81, indicating that the risk of violence in the high-risk group (50%) is hugely higher than in the low-risk group (1.2%). These figures are totallyunrealistic. In fact the diagnostic odds ratio of violence risk assessmentin replication studies was recently estimated by meta-analysis to be three! (2). Roychowdhury and Adshead overestimate the discriminating power of risk assessment by 27 times. Moreover, even an unrealistically powerful risk assessment with diagnostic odds of 16 is of little or no value because of failure to detect potential violence in the low-risk group and the large proportion of false positives in the high-risk group (3).

The second distortion relates to the underestimation of the precisionof medical tests. In fact the authors seem to have had difficulty finding any medical test with diagnostic odds that they could compare to a violence risk assessment. Instead they chose to compare two medical treatments. They argue that the high number-needed-to-treat as a result ofa violence risk assessment is acceptable in psychiatry because in cardiology the number of bypass grafts needed to prevent one fatal outcomehas been calculated to be 53 (3). However, the meta-analysis they derived this figure from compared coronary bypass surgery to angioplasty - both ofwhich are highly efficacious treatments for angina (3). In reality medicaltests that are used to diagnose conditions with serious implications for the patient are very accurate - biopsy is an excellent indicator of cancerand an angiogram a good indicator of coronary heart disease.

Despite these limitations, I support the author's general idea of viewing risk assessment as a medical procedure. I would go further, surelyviolence risk assessment should be judged by the standards of evidence based medicine.

The real questions then become:

i)are there any rational interventions that can be justified in terms of cost and benefit which might reduce violence among high-risk patients (many of whom will not be violent) and yet should not be offered to low risk patients (who commit as many or even the majority of acts of violence)? and,

ii)is there evidence that that shifting treatment resources from low-risk to high-risk people can, in any way, reduce overall levels of harm?

The answer to both these questions is no (4,5). There is no doubt that medical diagnostic tests serve as a good basis for medical treatment and that medical and surgical treatment can save lives. It is simply disingenuous to suggest that the same can be said of violence risk assessment.

References:

1. Roychowdhury, A., Adshead GViolence risk assessment as a medical intervention: ethical tensions Psychiatric Bulletin; published ahead of print March 6, 2014

2. Singh JP, Grann M, Fazel S. Authorship bias in violence risk assessment? A systematic review and meta-analysis. PLoS One. 2013 Sep 2;8(9):e72484.

3. Hoffman SN, TenBrook JA, Wolf MP, Pauker SG, Salem DN, Wong JB A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes. J Am Coll Cardiol. 2003 Apr 16;41(8):1293-304.

4. Large MM, Ryan CJ, Callaghan S, Paton MB, Singh SP.Can violence risk assessment really assist in clinical decision-making?Aust N Z J Psychiatry. 2014 Mar;48(3):286-8.

5. Wand T, Large M.Little evidence for the usefulness of violence risk assessment.Br J Psychiatry. 2013 Jun;202:468.

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Conflict of interest: Dr Large has provided expert evidence in matters relating to risk assessment.

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