Paul Appelbaum

Columbia University, Psychiatry, Faculty Member

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Dollard Professor of Psychiatry, Medicine & Law; Director, Division of Law, Ethics, & Psychiatry; Director, Center for Research on Ethical, Legal, & Social Implications of Psychiatric, Neurologic, & Behavioral Genetics, Columbia. Past President, American Psychiatric Association
Address: New York, New York, United States

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Paul Appelbaum

Stephen D Hart

Simon Fraser University

Ronald Roesch

Simon Fraser University

The Australian National University

Johannes Wancata

Medical University of Vienna

Mats Dernevik

University of Lincoln

Elvira Yamileth Sánchez Acosta

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Papers by Paul Appelbaum

Ethics and law continue to shape psychiatric practice and research

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Legal Issues in Psychiatric Practice

Springer eBooks, 2023

Protecting the Residency Training Environment: A Resident's Perspective on the Ethical Boundaries in the Faculty-Resident Relationship

by Marjorie Clay and Paul Appelbaum

Academic Psychiatry, 2005

On What We Have Learned and Still Need to Learn about the Psychosocial Impacts of Genetic Testing

Hastings Center Report, 2019

Since the start of the program to investigate the ethical, legal, and social implications (ELSI) ... more Since the start of the program to investigate the ethical, legal, and social implications (ELSI) of the Human Genome Project in 1990, many ELSI scholars have maintained that genetic testing should be used with caution because of the potential for negative psychosocial effects associated with receiving genetic information. More recently, though, some ELSI scholars have produced evidence suggesting that the original ELSI concerns were unfounded, exaggerated, or, at a minimum, misdirected. At least in the contexts that have been most studied, large negative impacts have not been found in the vast majority of people studied. What might explain the discrepancy between the original hypothesized outcomes and the growing impression that large negative effects appear to be few and far between? And if the original predictions of large negative psychosocial effects were simply wrong, is it time for ELSI researchers to move on? Should genetic testing be routinized, and would it be appropriate t...

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Views of internists towards uses of PGD

Reproductive BioMedicine Online, 2013

Preimplantation genetic diagnosis (PGD) is increasingly available, but how physicians view it is ... more Preimplantation genetic diagnosis (PGD) is increasingly available, but how physicians view it is unclear. Internists are gatekeepers and sources of information, often treating disorders for which PGD is possible. This quantitative study surveyed 220 US internists, who were found to be divided. Many would recommend PGD for cystic fibrosis (CF; 33.7%), breast cancer (BRCA; 23.4%), familial adenomatous polyposis (FAP; 20.6%) and familial hypertrophic cardiomyopathy (19.9%), but few for social sex selection (5.2%); however, in each case, >50% were unsure. Of those surveyed, 4.9% have suggested PGD to patients. Only 7.1% felt qualified to answer patient questions about it. Internists who would refer for PGD had completed medical training less recently and, for CF, were more likely to have privately insured patients (P < 0.033) and patients who reported genetic discrimination (P < 0.013). Physicians more likely to refer for BRCA and FAP were less likely to have patients ask about genetic testing. This study suggests that internists often feel they have insufficient knowledge about it and may refer for it based on limited understanding. They view possible uses of PGD differently, partly reflecting varying ages of onset and disease treatability. These data have critical implications for training, research and practice.

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Is there a duty to reinterpret genetic data? The ethical dimensions

Genetics in Medicine, 2019

The evolving evidence base for the interpretation of variants identified in genetic and genomic t... more The evolving evidence base for the interpretation of variants identified in genetic and genomic testing has presented the genetics community with the challenge of variant reinterpretation. In particular, it is unclear whether an ethical duty of periodic reinterpretation should exist, who should bear that duty, and what its dimensions should be. Based on an analysis of the ethical arguments for and against a duty to reinterpret, we conclude that a duty should be recognized. Most importantly, by virtue of ordering and conducting tests likely to produce data on variants that cannot be definitively interpreted today, the health-care system incurs a duty to reinterpret when more reliable data become available. We identify four elements of the proposed ethical duty: data storage, initiation of reinterpretation, conduct of reinterpretation, and patient recontact, and we identify the parties best situated to implement each component. We also consider the reasonable extent and duration of a duty, and the role of the patient's consent in the process, although we acknowledge that some details regarding procedures and funding still need to be addressed. The likelihood of substantial patient benefit from a systematic approach to reinterpretation suggests the importance for the genetics community to reach consensus on this issue.

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The physician-patient relationship in the age of precision medicine

Genetics in medicine : official journal of the American College of Medical Genetics, Jan 14, 2018

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Balancing autonomy and beneficence at the time of psychiatric discharge

Israel journal of health policy research, Jan 2, 2018

As in much of the world, mental health law in Israel has evolved over the past half-century towar... more As in much of the world, mental health law in Israel has evolved over the past half-century toward greater protection of patients' liberty and an increased emphasis on due process. Part of that process in Israel involved taking decisions about prolonged involuntary hospitalization out of the hands of treating psychiatrists and turning them over to independent review panels. Argo and colleagues examined outcomes of discharge decisions made by these panels compared with treating psychiatrists. In this brief commentary, we describe related trends in mental health law in other countries, especially the U.S., consider countervailing perspectives on the role of review panels, and suggest how the Argo et al. study might be followed up with additional research.

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Harnessing the power of fusion? A valiant but flawed effort to obviate the need for a distinct mental health law

International Journal of Mental Health and Capacity Law, 2014

When it comes to involuntary interventions, the notion that people with mental disorders should b... more When it comes to involuntary interventions, the notion that people with mental disorders should be treated identically to persons with general medical disorders has an undoubted appeal. As Dawson and Szmukler have argued previously, principles of fairness and non-discrimination would appear to be well served by basing involuntary hospitalization and treatment in both contexts on incapacity to provide consent. 2 In this commentary, I take note of some of the intellectual forebears of the Szmukler, Daw, and Dawson proposal, 3 and ask why-despite the formidable intellects that have lined up behind similar approaches in the past-they have not been adopted. I also consider some aspects of the current proposal itself, including the unresolved tensions between equal and differential treatment of persons with mental disorders, and the potential practical consequences, especially for persons with general medical disorders. 4 I conclude that the rationale for fusing two disparate bodies of law may itself be irremediably flawed, and the undesirable consequences significant.

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Reflections on the Goldwater Rule

The journal of the American Academy of Psychiatry and the Law, 2017

The APA's Goldwater Rule, precluding psychiatrists from rendering opinions to the media about... more The APA's Goldwater Rule, precluding psychiatrists from rendering opinions to the media about public figures whom they have not examined, has often engendered controversy. Here, I consider the justifications for the rule, how well they stand up to criticism, and the extent, if any, to which modifications might be called for. Although embarrassment to the profession is often cited as the basis for the Rule, it reflects more substantive concerns, including the risk of harm to living persons and discouraging persons in need of treatment from seeking psychiatric attention. The most potent criticisms of the Rule are that it discourages public education about mental illness and its effects and precludes legitimate scholarly endeavors by psychiatrists studying foreign leaders, historical figures, and others. However, there are many ways of providing education about mental illness without violating the Rule, and read properly, it should not prevent legitimate historical investigation, t...

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Beyond Googling: The Ethics of Using Patients' Electronic Footprints in Psychiatric Practice

Harvard review of psychiatry, Jan 12, 2017

Electronic communications are an increasingly important part of people's lives, and much info... more Electronic communications are an increasingly important part of people's lives, and much information is accessible through such means. Anecdotal clinical reports indicate that mental health professionals are beginning to use information from their patients' electronic activities in treatment and that their data-gathering practices have gone far beyond simply searching for patients online. Both academic and private sector researchers are developing mental health applications to collect patient information for clinical purposes. Professional societies and commentators have provided minimal guidance, however, about best practices for obtaining or using information from electronic communications or other online activities. This article reviews the clinical and ethical issues regarding use of patients' electronic activities, primarily focusing on situations in which patients share information with clinicians voluntarily. We discuss the potential uses of mental health patients...

The forensic use of behavioral genetics in criminal proceedings: Case of the MAOA-L genotype

International Journal of Law and Psychiatry, 2017

The role of behavioral genetic evidence in excusing and mitigating criminal behavior is unclear. ... more The role of behavioral genetic evidence in excusing and mitigating criminal behavior is unclear. Research has suggested that a low activity genotype of the enzyme monoamine oxidase (MAOA-L) may increase the risk for aggressive and antisocial behavior. By examining criminal proceedings in which MAOA-L genotype evidence was introduced, we explored the forensic uses of behavioral genetic science. Westlaw and LexisNexis legal databases were electronically searched for cases from 1995-2016 to identify court documents from cases involving the MAOA-L genotype. Evidence of the MAOA-L genotype was included in records from 11 criminal cases (9 U.S. and 2 Italian). In the guilt phase, genotype evidence was ruled admissible in one of two cases, and may have contributed to a conviction on a lesser charge. In the sentencing phase, genotype evidence was admissible in four of five cases, one of which ended with a lesser sentence. Five cases used genotype evidence for post-conviction appeals, two of which resulted in sentence reductions. Even when charges or sentences are reduced it is difficult to gauge the effect of evidence of the MAOA-L genotype. Genotype evidence may lack persuasive effect because the impact of the allele on a particular accused is difficult to establish.

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Effects of Behavioral Genetic Evidence on Perceptions of Criminal Responsibility and Appropriate Punishment

Psychology, public policy, and law : an official law review of the University of Arizona College of Law and the University of Miami School of Law, 2015

Demonstrations of a link between genetic variants and criminal behavior have stimulated increasin... more Demonstrations of a link between genetic variants and criminal behavior have stimulated increasing use of genetic evidence to reduce perceptions of defendants' responsibility for criminal behavior and to mitigate punishment. However, because only limited data exist regarding the impact of such evidence on decision makers and the public at large, we recruited a representative sample of the U.S. adult population (n=960) for a web-based survey. Participants were presented with descriptions of three legal cases and were asked to: determine the length of incarceration for a convicted murderer; adjudicate an insanity defense; and decide whether a defendant should receive the death penalty. A fully crossed, between-participants, factorial design was used, varying the type of evidence (none, genetic, neuroimaging, both), heinousness of the crime, and past criminal record, with sentence or verdict as the primary outcome. Also assessed were participants' apprehension of the defendant,...

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Getting Serious About Reducing Suicide: More "How" and Less "Why

JAMA, Jan 2, 2015

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Honey, I Sequenced the Kids: Preventive Genomics and the Complexities of Adolescence

The American Journal of Bioethics, 2015

How much control should individuals have over their genomic data? Although this question has been... more How much control should individuals have over their genomic data? Although this question has been extensively discussed in debates about return of genomic incidental findings (IFs), Lazaro-Munoz and colleagues consider it in another putative context: population-based preventive genomic sequencing (PGS) programs that would target rare, highly penetrant, and medically actionable genetic (MAG) conditions. The authors advocate for a "menu" rather than a "panel" approach to the management of genomic information-allowing participants greater discretion regarding genes to be analyzed-because it better resonates with prevalent notions of patients' autonomy, choice, and patient-centered decision making in medical contexts. This is an important discussion, which will likely continue. However, the article does not address the implications of either approach for minors; indeed, it does not mention minors at all. Although steering away from genomic dilemmas in minors may simplify the discussion, it misses important considerations for this substantial group of stakeholders. As genetic testing in pediatrics increases, knowledge of adolescents' genetic propensities may have substantial positive and negative impact on their life plans, identity, and other aspects of their development. Consideration of their interests in this evolving context is consistent with the increasing recognition of children, especially adolescents, as active participants in medical decision making. In this commentary, we highlight the complexities involved with the management of genomic findings of adolescents and offer possible ways to enhance their autonomous choices in such processes.

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Ethics and forensic psychiatry: translating principles into practice

The journal of the American Academy of Psychiatry and the Law, 2008

Twenty-five years ago, Alan Stone expressed his skepticism that forensic psychiatry could be prac... more Twenty-five years ago, Alan Stone expressed his skepticism that forensic psychiatry could be practiced ethically. His remarks have proven a useful goad to the field, focusing attention on the importance of an ethics framework for forensic practice. But Stone remains dubious that any system of ethics--including the "Standard Position" on which he focuses his critique--could be of much value in practice. In contrast, I suggest that Stone's pessimism is not well founded. Immanent in forensic practice itself is a reasonable set of ethics principles, based on truth-telling and respect for persons. Psychiatrists can offer reliable and valid testimony, while resisting seduction into an advocacy role. Indeed, with new structured approaches to assessment, the potential utility of forensic testimony is probably greater than ever. Though problematic behavior still exists, forensic psychiatry offers the factual background and interpretive context to allow legal decision-makers to ...

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Coping with the ethical conundra of forensic psychiatry: a tribute to Howard Zonana, MD

The journal of the American Academy of Psychiatry and the Law, 2010

As part of the Festschrift in honor of Howard Zonana, MD, this article reviews two important conc... more As part of the Festschrift in honor of Howard Zonana, MD, this article reviews two important concerns that emerged in the ethics of forensic psychiatry in the resolution of which he played critical roles. In the late 1980s and early 1990s, the question arose of what role, if any, was proper for psychiatrists to play with regard to evaluations of competence to be executed and treatment of incompetent prisoners. Dr. Zonana was a major force in developing the American Psychiatric Association's position, in which the rights of prisoners were balanced with protection of the integrity of the medical profession. He was then deeply involved in helping to persuade the American Medical Association to reject a more extreme position and to adopt this approach. Similarly, in the mid-2000s, Dr. Zonana brought to the attention of the American Psychiatric Association (APA) the participation of psychiatrists in interrogation of detainees in national security settings. The policy that he subseque...

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Consent in impaired populations

Current neurology and neuroscience reports, 2010

Impairments in patients with dementia and other disorders affecting cognition may have a negative... more Impairments in patients with dementia and other disorders affecting cognition may have a negative impact on their capacity to provide consent to treatment or to participation in research. A growing literature confirms that even patients with mild cognitive impairment may experience decrements in decisional abilities, findings that are more pronounced still in the early stages of dementia. However, most patients with mild dementia probably remain competent to provide a valid consent to treatment or research, and even some patients with moderate dementia may retain capacity in particular circumstances. Clinical evaluation of decisional competence has been augmented by structured approaches, including reliable instruments that may be used in the clinical setting. To avoid needlessly depriving patients of their right to make health care decisions, evaluations should be designed to maximize patient performance. However, when substitute consent is necessary, state laws generally provide a...

Privilege in the Federal Courts: should there be a "dangerous patient exception"?

Psychiatric services (Washington, D.C.), 2008

Although a 1996 U.S. Supreme Court decision affirmed that therapists cannot be compelled to testi... more Although a 1996 U.S. Supreme Court decision affirmed that therapists cannot be compelled to testify in federal proceedings about patients' disclosures, a footnote could be interpreted as creating a "dangerous patient exception" when there is a serious threat of harm. This column describes circuit courts' differing views about whether such an exception exists and the value of an exception. Although the footnote appears to indicate the Supreme Court's inclinations to create an exception to psychiatrist-patient privilege in some cases, opponents have made strong arguments that a dangerous patient exception would inhibit help seeking by those in whose treatment society has the strongest interest -- people who have harmed or are likely to harm others.

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Genetic Testing in Psychiatry: A Review of Attitudes and Beliefs

Psychiatry: Interpersonal and Biological Processes, 2011

The advent of genetic testing for psychiatric conditions raises difficult questions about when an... more The advent of genetic testing for psychiatric conditions raises difficult questions about when and how the tests should be used. Development of policies regarding these issues may be informed in a variety of ways by the views of key stakeholders: patients, family members, healthcare professionals, and the general public. Here we review empirical studies of attitudes towards genetic testing among these groups. Patients and family members show strong interest in diagnostic and predictive genetic testing, and to a considerable extent psychiatrists share their enthusiasm. Prenatal test utilization seems likely to depend both on parental views on abortion and the seriousness of the disorder. Parents show a surprising degree of interest in predictive testing of children, even when there are no preventive interventions available. Many persons report themselves ready to alter their lifestyles and plans for marriage and family in response to test results. Respondents also fear negative consequences, from discrimination to being unable to cope with knowledge of their "genetic fate." Empirical studies of beliefs about genetic testing suggest tests are likely to be embraced widely, but the studies have methodologic limitations, reducing the certainty of their conclusions, and indicating a need for further research with more representative samples.

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Ethics and law continue to shape psychiatric practice and research

Download

Legal Issues in Psychiatric Practice

Springer eBooks, 2023

Protecting the Residency Training Environment: A Resident's Perspective on the Ethical Boundaries in the Faculty-Resident Relationship

by Marjorie Clay and Paul Appelbaum

Academic Psychiatry, 2005

On What We Have Learned and Still Need to Learn about the Psychosocial Impacts of Genetic Testing

Hastings Center Report, 2019

Download

Views of internists towards uses of PGD

Reproductive BioMedicine Online, 2013

Download

Is there a duty to reinterpret genetic data? The ethical dimensions

Genetics in Medicine, 2019

Download

The physician-patient relationship in the age of precision medicine

Genetics in medicine : official journal of the American College of Medical Genetics, Jan 14, 2018

Download

Balancing autonomy and beneficence at the time of psychiatric discharge

Israel journal of health policy research, Jan 2, 2018

Download

Harnessing the power of fusion? A valiant but flawed effort to obviate the need for a distinct mental health law

International Journal of Mental Health and Capacity Law, 2014

Download

Reflections on the Goldwater Rule

The journal of the American Academy of Psychiatry and the Law, 2017

Download

Beyond Googling: The Ethics of Using Patients' Electronic Footprints in Psychiatric Practice

Harvard review of psychiatry, Jan 12, 2017

The forensic use of behavioral genetics in criminal proceedings: Case of the MAOA-L genotype

International Journal of Law and Psychiatry, 2017

Download

Effects of Behavioral Genetic Evidence on Perceptions of Criminal Responsibility and Appropriate Punishment

Psychology, public policy, and law : an official law review of the University of Arizona College of Law and the University of Miami School of Law, 2015

Download

Getting Serious About Reducing Suicide: More "How" and Less "Why

JAMA, Jan 2, 2015

Download

Honey, I Sequenced the Kids: Preventive Genomics and the Complexities of Adolescence

The American Journal of Bioethics, 2015

Download

Ethics and forensic psychiatry: translating principles into practice

The journal of the American Academy of Psychiatry and the Law, 2008

Download

Coping with the ethical conundra of forensic psychiatry: a tribute to Howard Zonana, MD

The journal of the American Academy of Psychiatry and the Law, 2010

Download

Consent in impaired populations

Current neurology and neuroscience reports, 2010

Privilege in the Federal Courts: should there be a "dangerous patient exception"?

Psychiatric services (Washington, D.C.), 2008

Download

Genetic Testing in Psychiatry: A Review of Attitudes and Beliefs

Psychiatry: Interpersonal and Biological Processes, 2011

Download

Novel ethical and policy issues in psychiatric uses of psychedelic substances

by William Smith and Paul Appelbaum

Neuropharmacology, 2022

Classic psychedelics and related substances have shown promising initial research results. Howeve... more Classic psychedelics and related substances have shown promising initial research results. However, they raise a number of relatively novel ethical and policy challenges in light of their psychoactive properties, their emergence from the unregulated “underground” settings in which they have been used, their rapid commercialization, and the means and speed with which they are moving from a Schedule 1 drug to legalized use. All of these issues are affected by the current limits to the evidence base on use of psychedelics. Here we survey these novel challenges, illustrating the issues raised regarding each, and offering suggestions for how to address
them.

Two Models of Legalization of Psychedelic Substances: Reasons for Concern

by William Smith and Paul Appelbaum

JAMA, 2021

In 1973, the federal government classified psychedelics as schedule I substances, rendering posse... more In 1973, the federal government classified psychedelics as schedule I substances, rendering possession illegal, even for research purposes except under tightly regulated circumstances. Although these restrictions have hindered research on the therapeutic uses of psychedelics for decades, recent studies have brought increasing attention and enthusiasm to the potential benefits of psychedelic treatment.1 Accompanying this revival of psychedelic research have been initiatives by states and localities to legalize psychedelic possession and use. Two of the most ambitious measures, in Oregon and California, take different paths to legalization. This Viewpoint reviews these initiatives and the concerns they raise by looking to the cautionary precedents involving the legalization and commercialization of other controlled substances.

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