Dileep

1

 Which of the following statements by a criminal
defendant most strongly suggests a patient is incompetent
to stand trial?
1. "I killed her because I didn't want to pay her back."
2. "I am a wizard and therefore have diplomatic
immunity."
3. "I'm fairly certain my lawyer is an alien, and I'm ok
with that."
4. "I know the difference between a felony and a
misdemeanor“
5. "I keep hearing the voice of the judge in my head saying 'be
honest.’
 
 Answer: 2
 Legal Jargon

 Plaintiff: A plaintiff is the party who initiates a
lawsuit before a court.
 Defendant: A defendant is a person or entity accused
of a crime
 Plaintiff’s attorney/Prosecutor
 Defense lawyer
Negligence/Malpractice

 To prove malpractice, the plaintiff (e.g., patient,
family, or estate) must establish by a preponderance
of evidence that (1) a doctor–patient relationship
existed that created a duty of care, (2) a deviation
from the standard of care occurred, (3) the patient
was damaged, and (4) the deviation directly caused
the damage.
 Competence

 Competence is determined on the basis of a person’s ability to make a sound
judgment—to weigh, to reason, and to make reasonable decisions. Competence is
task specific, not general; the capacity to weigh decision-making factors (competence)
often is best demonstrated by a person’s ability to ask pertinent and knowledgeable
questions after the risks and the benefits have been explained. Although physicians
(especially psychiatrists) often give opinions on competence, only a judge’s ruling
converts the opinion into a finding; a patient is not competent or incompetent until
the court so rules. The diagnosis of a mental disorder is not, in itself, sufficient to
warrant a finding of incompetence. Instead, the mental disorder must cause an
impairment in judgment for the specific issues involved. After they have been
declared incompetent, persons are deprived of certain rights: they cannot make
contracts, marry, start a divorce action, drive a vehicle, handle their own property, or
practice their professions. Incompetence is decided at a formal courtroom
proceeding, and the court usually appoints a guardian who will best serve a patient’s
interests. Another hearing is necessary to declare a patient competent. Admission to
a mental hospital does not automatically mean that a person is incompetent.
 Competence to Stand
Trial

 The Supreme Court of the United States stated that
the prohibition against trying someone who is
mentally incompetent is fundamental to the US
system of justice. Accordingly, the Court, approved a
test of competence that seeks to ascertain whether a
criminal defendant “has sufficient present ability to
consult with his lawyer with a reasonable degree of
rational understanding—and whether he has a
rational as well as factual understanding of the
proceedings against him.”
 
 A diplomat is a person appointed by a state to
conduct diplomacy with one or more other states or
international organizations.
 Diplomatic immunity is a form of legal immunity
that ensures diplomats are given safe passage and
are considered not susceptible to lawsuit or
prosecution under the host country's laws, although
they can still be expelled.
 2

 A psychiatrist agrees to prescribe medication to a patient who
receives ongoing psychotherapy from another mental health
professional. What is the psychiatrist's liability in this
treatment arrangement?
1. Liability is shared 50/50.
2. Psychiatrist retains full responsibility for the patient's care.
3. Psychiatrist is liable only for damages related to the
medication.
4. Liability is negotiated at the beginning of the treatment
agreement.
5. Psychiatrist is liable for the therapy only if he/she
supervises the other professional.
 
 Answer:2
 Split treatment

 In split treatment, the psychiatrist provides medication,
and a nonmedical therapist conducts the psychotherapy.
 Psychiatrists must do an adequate evaluation, obtain
prior medical records, and understand that no such thing
as a partial patient exists. Split treatments are potential
malpractice traps because patients can “fall between the
cracks” of fragmented care. The psychiatrist retains full
responsibility for the patient’s care in a split treatment
situation. This does not preempt the responsibility of the
other mental health professionals involved in the patient’s
treatment.
 3

 When going on vacation , a psychiatrist's outgoing
voicemail message must clarify that, in the event of
an urgent but not emergent clinical matter, a patient
should:
1. call 911.
2. find another doctor.
3. call the primary care physician.
4. call the arranged clinical coverage .
5. go to the local emergency department.
 
 Answer:3
 4

 A psychiatrist regularly blogs about various mental
health topics under the pseudonym "Dr. Empathy ."
According to the Federation of State Medical Boards, such
behavior is unprofessional because:
1. psychiatrists should not blog or engage in any social
media activities in their professional life.
2. providing psychoeducation online can establish a
doctor-patient relationship and increase liability
concerns .
3. such online activity is tantamount to advertising
which is unethical for psychiatrists.
4. The psychiatrist should make his or her identity and
credentials clear to readers of the blog.
 
 Answer:2
 
 Psychiatrists are not likely to be sued successfully if
they give advice on a radio program that is harmful
to a caller, particularly if a caveat was given to the
caller that no doctor–patient relationship was being
created.
 5

 When a psychiatrist fails to obtain informed consent
for treatment, the psychiatrist has failed to respect
which of the following core principles of medical
ethics?
1. Justice
2. Fidelity
3. Autonomy
4. Beneficence
5. Non maleficence
 
 Answer:3
 Medical ethics

 Autonomy - The principle of autonomy views the
rights of an individual to self-determination. This is
rooted in society's respect for individuals' ability to
make informed decisions about personal matters.
Autonomy has become more important as social
values have shifted to define medical quality in
terms of outcomes that are important to the patient
rather than medical professionals.
 
 Beneficence - The term beneficence refers to actions
that promote the well being of others. In the medical
context, this means taking actions that serve the best
interests of patients.
 
 Non-maleficence - Primum non nocere - "first, do no
Many consider this should be the main or primary
consideration (hence primum): that it is more
important not to harm your patient, than to do them
good. This is partly because enthusiastic
practitioners are prone to using treatments that they
believe will do good, without first having evaluated
them adequately to ensure they do no (or only
acceptable levels of) harm. Much harm has been
done to patients as a result, as in the saying, "The
treatment was a success, but the patient died."
 6

 During a session the psychiatrist tells a long-time patient, "I am moving to
another state and will not be able to see you anymore. This is our last
session. I am giving you a one-month supply of medication. Here is a letter
documenting the end of our treatment relationship: please sign here to
acknowledge it. This concludes our session." The patient independently
finds another psychiatrist and establishes care without incident. Three
months later, the patient sues the previous psychiatrist for damages, citing
abandonment. Which of the following is the best defense against medical
malpractice?
1. Patient did not suffer an appreciably bad outcome.
2. Patient filed outside the time period of the statute of limitations.
3. Psychiatrist now lives in another state and is not liable for prior activities.
4. Psychiatrist fulfilled the duty to the patient by giving 30 days of
medication.
5. Psychiatrist provided written notification of termination that the patient
signed .
 
 Answer:5
 7

 The mental competency of an elderly patient is
determined by:
1. judicial hearing.
2. psychiatric assessment.
3. neuropsychological testing .
4. petition by the spouse.
5. action by an attorney.
 
 Answer: 1
 8

 Which of the following standards of proof applies to
civil involuntary psychiatric commitment?
1. Probable cause
2. Reason to believe
3. Beyond a reasonable doubt
4. Clear and convincing evidence
5. Preponderance of the evidence
 
 Answer : 4
 Legal burden of proof

 Reasonable suspicion - Reasonable suspicion is a low
standard of proof to determine whether a brief
investigative stop or search by a police officer or any
government agent is warranted.
 Some credible evidence
 Substantial evidence
 Reasonable to believe - This standard applies only to
vehicle searches after the suspect has been placed under
arrest. The Court overruled and concluded that police
officers are allowed to go back and search a vehicle
incident to a suspect's arrest only where it is "reasonable
to believe" that there is more evidence in the vehicle of the
crime for which the suspect was arrested.
 
 Preponderance of the evidence -
 Preponderance of the evidence, also known as balance of
probabilities is the standard required in most civil cases, and
in family court determinations solely involving money, such
as child support.
 The standard is met if the proposition is more likely to be true
than not true. The standard is satisfied if there is greater than
fifty percent chance that the proposition is true.
 This is also the standard of proof used when determining
eligibility of unemployment benefits for a former employee
accused of losing the job through alleged misconduct. In most
US states, the employer must prove this case with a
preponderance of evidence.
 
 Clear and convincing evidence - Clear and convincing evidence is a
higher level of burden of persuasion than "preponderance of the
evidence".
 This standard is used in many types of equity cases, including
paternity, persons in need of supervision, juvenile delinquency,
child custody, the probate of both wills and living wills, petitions
to remove a person from life support ("right to die" cases)
 Clear and convincing proof means that the evidence presented by a
party during the trial must be highly and substantially more
probable to be true than not and the trier of fact must have a firm
belief or conviction in its factuality. In this standard, a greater
degree of believability must be met than the common standard of
proof in civil actions, which only requires that the facts as a
threshold be more likely than not to prove the issue for which they
are asserted.
 
 Beyond reasonable doubt - This is the highest
standard used as the burden of proof in Anglo-
American jurisprudence and typically only applies in
criminal proceedings and when considering
aggravating circumstances in criminal proceedings.
It has been described, in negative terms, as a proof
having been met if there is no plausible reason to
believe otherwise.
 
 Beyond the shadow of a doubt - Beyond the shadow
of a doubt is the strictest standard of proof. It
requires that there be no doubt as to the issue.
Widely considered an impossible standard, a
situation stemming from the nature of knowledge
itself, it is valuable to mention only as a comment on
the fact that evidence in a court never need (nor can)
reach this level. This phrase, has, nonetheless, come
to be associated with the law in popular culture.
 9

 Which of the following has been shown to
consistently predict positive therapy outcome in
most psychiatric disorders?
1. Therapist's qualifications
2. Therapist's contributions
3. Therapeutic alliance
4. Patient's motivation
5. Patient's ego strength
 
 Answer : 3

 This concept of therapeutic relationship was described by

Freud (1912) as "friendly affectionate feeling" in the form
of positive transference.
 It has been found to predict treatment adherence
(compliance) and concordance and outcome across a
range of client/patient diagnoses and treatment settings.
Research on the statistical power of the therapeutic
relationship now reflects more than 1,000 findings.
 10

 You are a practicing psychiatrist in a mental health clinic. Your
patient who is a 24 year old Caucasian male with diagnosed
schizophrenia reports that he is having homicidal thoughts
about his girlfriend because they were in a relationship for a
while but now she says she is no longer interested in him. He
denies current plan. He is compliant with medications and has
no past history of violence. What is your next best course of
action?
 1. do nothing
 2. notify the police
 3. notify the girl friend
 4. notify both police and the girl friend
 5. make an anonymous ad in the paper to warn the girlfriend
 
 Answer: 4
 Duty to warn and
protect

 Tarasoff I
 Tarasoff II


Prosenjit Poddar was a student from Bengal, India.He entered the University of California, Berkeley as a graduate student in
September 1967 and resided at International House. In the fall of 1968, he attended folk dancing classes at the International
House, and it was there he met Tatiana Tarasoff. They saw each other weekly throughout the fall, and on New Year's Eve she
kissed Poddar. He interpreted the act to be a recognition of the existence of a serious relationship. This view was not shared by
Tarasoff who, upon learning of his feelings, told him that she was involved with other men and that she was not interested in
entering into an intimate relationship with him. This gave rise to feelings of resentment in Poddar. He began to stalk her.

 After this rebuff, Poddar underwent a severe emotional crisis. He became depressed and neglected his appearance, his studies,
and his health. He remained by himself, speaking disjointedly and often weeping. This condition persisted, with steady
deterioration, throughout the spring and into the summer of 1969. Poddar had occasional meetings with Tarasoff during this
period and tape recorded their various conversations to try to find out why she did not love him.

 During the summer of 1969, Tarasoff went to South America. After her departure Poddar began to improve and at the
suggestion of a friend sought psychological assistance. Prosenjit Poddar was a patient of Dr. Lawrence Moore, a psychologist at
UC Berkeley's Cowell Memorial Hospital in 1969. Poddar confided his intent to kill Tarasoff. Dr. Moore requested that the
campus police detain Poddar, writing that, in his opinion, Poddar was suffering from paranoid schizophrenia, acute and
severe. The psychologist recommended that the defendant be civilly committed as a dangerous person. Poddar was detained
but shortly thereafter released, as he appeared rational. Dr. Moore's supervisor, Dr. Harvey Powelson, then ordered that
Poddar not be subject to further detention.

 In October, after Tarasoff had returned, Poddar stopped seeing his psychologist. Neither Tarasoff nor her parents received any
warning of the threat. Poddar then befriended Tarasoff's brother, even moving in with him. Several weeks later, on October 27,
1969, Poddar carried out the plan he had confided to his psychologist, stabbing and killing Tarasoff. Tarasoff's parents then
sued Moore and various other employees of the University.

 Poddar was subsequently convicted of second-degree murder, but the conviction was later appealed and overturned on the
grounds that the jury was inadequately instructed. A second trial was not held, and Poddar was released on the condition that
he would return to India.