Patient access to records: tonic or toxin?

The authors review their experiences in permitting psychiatric patients to read their own records. Patients are permitted to read the records with a staff member present to explain the information in the record. Copies of the records are not provided, nor is the patient always provided access to the complete record. Permitting this type of limited patient access to records has resulted in a generally positive experience for the patients, and harm has not ensued.

Dangerousness, confidentiality, and the duty to warn

The Tarasoff decision, by imposing on psychiatrists an obligation to warn the intended victim of threats made by a patient, but only under certain vaguely specified circumstances, may stampede psychiatrists into issuing such warnings to avoid possible legal liability no matter how remote the risk of harm may actually be. The authors suggest that the ill effects of such a reaction by psychiatrists--breach of confidentiality and the attendant erosion of trust and harm to the therapeutic alliance--can often be easily avoided by taking less drastic steps, some of which are illustrated by case presentations.

Tests of competency to consent to treatment

The authors describe the various tests of competency to consent to treatment used today, which include the following: 1)evidencing a choice, 2)"reasonable" outcome of choice, 3)choice based on "rational" reasons, 4)ability to understand, and 5)actual understanding. They analyze the applicability of these tests to patients' decisions to accept or refuse psychiatric treatment and illustrate the problems of ap-lying these tests by citing clinical case examples. They find that the circumstances in which competency becomes an issue determine which elements of which tests are stressed and which are underplayed.

Toward a model of the legal doctrine of informed consent

The authors draw together the disparate scholarly and judicial commentaries on consent to medical treatment to develop a model of the components in the decision-making process regarding consent to or refusal of psychiatric treatment. The components consist of the precondition of voluntariness, the provision of information, the patient's competency and understanding, and, finally, consent or refusal. They offer two models of valid consent: the objective model, which focuses on the congruence or lack of it between the patient and a "reasonable" person, and the subjective model, which focuses entirely on the patient's actual understanding.