Richard Bonnie

University of Virginia | UVa · School of Law

Youth who acquire a juvenile crime record may be at increased risk of perpetrating gun violence as adults. North Carolina and 21 other states permit young adults who were adjudicated by a juvenile court – even for some felony-equivalent offenses – to legally access firearms. Effectiveness of gun restrictions for adults with juvenile crime histories...

This position statement briefly reviews the principle of informed consent, the elements of decisional capacity, and how acute stroke may affect this capacity. It further reviews the role of surrogate decision-making, including advance directives, next of kin, physician orders for life-sustaining treatment, and guardianship. In some cases of acute s...

The authors propose a formal statutory diversion process for offenders with serious mental disorders: expedited diversion to court-ordered treatment (EDCOT). As a civil commitment proceeding accompanied by dismissal of criminal charges, EDCOT would not entail a waiver of criminal trial rights and could be invoked even if the defendant lacked trial...

Alzheimer disease and other dementias present unique practical challenges for patients, their families, clinicians, and health systems. These challenges reflect not only the growing public health effect of dementia in an aging global population, but also more specific ethical complexities including early loss of patients' capacity to make decisions...

This chapter describes the collaboration between the Institute of Law, Psychiatry, and Public Policy at the University of Virginia and the Department of Behavioral Health and Developmental Services in the Commonwealth. It is the longest running of the collaborations described in this book, having been in operation for nearly 50 years, and it involv...

The authors propose a new form of civil commitment that would benefit individuals with serious mental illness involved with the criminal justice system. This population has complex needs rooted in comorbid conditions, alienation from treatment and support systems, and poor access to care. Although many dollars are spent on costly assessments and ho...

In September 2019, physicians at a Michigan hospital declared Bobby Reyes, a 14-year-old boy, dead by neurologic criteria. Nearly 3 weeks later, they took Bobby off of organ support, despite his parents’ valiant attempts to prevent discontinuation of support by obtaining legal injunctions and seeking transfer to another facility. To provide other c...

Patients, clinicians, and hospitals have undergone monumental changes during the COVID-19 pandemic. This time of troubles has forced us to consider the fundamental obligations that neurologists have to our own individual patients as well as the greater community. By returning to our fundamental understanding of these duties we can ensure that we ar...

This chapter, which grew out of a Greenwall Foundation–funded working group of a dozen or so ethicists, lawyers, and public health practitioners, provides a rough conceptual map of the terrain of public health ethics. It examines the nature of public health and public health interventions, and it identifies a number of general moral considerations...

Although death by neurologic criteria (brain death) is legally recognized throughout the United States, state laws and clinical practice vary concerning three key issues: (1) the medical standards used to determine death by neurologic criteria, (2) management of family objections before determination of death by neurologic criteria, and (3) managem...

(Reprinted with permission from APA Resource Document, June 2018).

The still-growing US opioid epidemic lies at the intersection of two major public health challenges: reducing suffering from pain and containing the rising toll of harms associated with the use of opioids medications. Responding successfully to these challenges requires a substantial investment in surveillance and research on many fronts and a coor...

In 1998, the American Academy of Neurology published its prior position on physician-hastened death, titled “Assisted suicide, euthanasia, and the neurologist.” In that statement, the American Academy of Neurology (AAN) expressed its vigorous opposition to its members’ participation in either physician-assisted suicide (PAS) (prescription without c...

Individuals must feel free to exert personal control over decisions regarding research participation. We present an examination of participants’ perceived personal control over, as well as reported pressures and threats from others, influencing their decision to join a study assessing the effectiveness of extended-release naltrexone in preventing o...

Developmental scientists have examined the independent effects of peer presence, social cues, and rewards on adolescent decision-making and cognitive control. Yet, these contextual factors often co-occur in real world social situations. The current study examined the combined effects of all three factors on cognitive control, and its underlying neu...

In response to a number of recent lawsuits related to brain death determination, the American Academy of Neurology Ethics, Law, and Humanities Committee convened a multisociety quality improvement summit in October 2016 to address, and potentially correct, aspects of brain death determination within the purview of medical practice that may have con...

A central tenet of Anglo-American penal law is that in order for an actor to be found criminally liable, a proscribed act must be accompanied by a guilty mind. While it is easy to understand the importance of this principle in theory, in practice it requires jurors and judges to decide what a person was thinking months or years earlier at the time...

Concerns persist that individuals with substance use disorders who are under community criminal justice supervision experience circumstances that might compromise their provision of valid, informed consent for research participation. These concerns include the possibilities that desire to obtain access to treatment might lead individuals to ignore...

The ongoing opioid crisis is at the intersection of 2 substantial public health challenges: improving the treatment of pain and minimizing the harms that can arise from use of opioid medications. Recent Viewpoints in JAMA highlighted this tension. In one article, the authors emphasized that “there is no evidence that opioids are effective in chroni...

Significance Because criminal statutes demand it, juries often must assess criminal intent by determining which of two legally defined mental states a defendant was in when committing a crime. For instance, did the defendant know he was carrying drugs, or was he merely aware of a risk that he was? Legal scholars have debated whether that conceptual...

Background and aims: Criminal justice-involved individuals are highly susceptible to opioid relapse and overdose-related deaths. In a recent randomized trial, we demonstrated the effectiveness of extended-release naltrexone (XR-NTX; Vivitrol® ) in preventing opioid relapse among criminal justice-involved US adults with a history of opioid use diso...

Background: Extended release naltrexone (XR-NTX) injected intramuscularly monthly has been shown to reduce relapse in persons with opioid use disorder. Baseline factors, including patients' demographics, comorbidities and lifestyle, may help identify patients who will benefit most or least from XR-NTX treatment. Methods: Potential moderators of...

Developmental differences regarding decision making are often reported in the absence of emotional stimuli and without context, failing to explain why some individuals are more likely to have a greater inclination toward risk. The current study (N=212; 10-25y) examined the influence of emotional context on underlying functional brain connectivity o...

Unlabelled: The evolved capacity for third-party punishment is considered crucial to the emergence and maintenance of elaborate human social organization and is central to the modern provision of fairness and justice within society. Although it is well established that the mental state of the offender and the severity of the harm he caused are the...

In Reply Mr Kels highlights a confusing aspect of federal and state laws that disqualify certain people from accessing firearms. What types of involuntary mental health interventions result in a gun-prohibiting record that is reportable to the NICS? The question is difficult to answer because commitment practices vary substantially by state and loc...

Background Extended-release naltrexone, a sustained-release monthly injectable formulation of the full mu-opioid receptor antagonist, is effective for the prevention of relapse to opioid dependence. Data supporting its effectiveness in U.S. criminal justice populations are limited. Methods In this five-site, open-label, randomized trial, we compar...

An individual is typically considered an adult at age 18, although the age of adulthood varies for different legal and social policies. A key question is how cognitive capacities relevant to these policies change with development. The current study used an emotional go/no-go paradigm and functional neuroimaging to assess cognitive control under sus...

Psychiatric advance directives (PADs) are written documents or oral statements that allow adults with decision-making capacity to declare their treatment preferences and/or to designate proxy decision makers to act on their behalf should they be deemed incapable in the future of making informed choices on their own. In the U.S., the Patient Self-D...

The American Psychiatric Association, ("APA"), with more than 36,000 members at present, is the Nation's leading organization of physicians who specialize in psychiatry. APA provides for education and advocacy and develops policy through Position Statements. It promotes enhanced knowledge of particular topics relevant to psychiatric practice and pa...

The American Psychiatric Association, ("APA"), with more than 36,000 members at present, is the Nation's leading organization of physicians who specialize in psychiatry. APA provides for education and advocacy and develops policy through Position Statements. It promotes enhanced knowledge of particular topics relevant to psychiatric practice and pa...

Before the Supreme Court's 2008 decision in District of Columbia v. Heller, the American Psychiatric Association's position on gun policy reflected the strong gun control perspective championed by the nation's public health establishment. After Heller declared that an individual's right to bear arms is constitutionally protected, the APA refocused...

Extended-release naltrexone (XR-NTX, Vivitrol®; Alkermes Inc.) is an injectable monthly sustained-release mu opioid receptor antagonist. XR-NTX is a potentially effective intervention for opioid use disorders and as relapse prevention among criminal justice system (CJS) populations. This 5-site open-label randomized controlled effectiveness trial e...

Virginia appears to be the first state to commit itself to statewide implementation of psychiatric advance directives, and its experience may be highly instructive for other states. The project began with consensus building among stakeholders (2007-2009), followed by revisions to Virginia's Health Care Decisions Act (2009-2010) and designation of f...

For people with serious mental illness, research demonstrates the potential positive effects of having an advance directive with specific instructions for mental health care. The Commonwealth of Virginia has undertaken efforts to incorporate the completion of psychiatric advance directives into routine mental health services for individuals with se...

This Article empirically tests two key questions. First: How sensitive are jurors to variations in the language that delineates the criminal mental state categories? Second: To what extent do jurors assign culpability in the manner assumed by the Model Penal Code (MPC)? In prior work, we challenged numerous assumptions underlying the MPC mental sta...

Recent mass shootings have prompted a national dialogue around mental illness and gun policy. To advance an evidence-informed policy agenda on this controversial issue, we formed a consortium of national gun violence prevention and mental health experts. The consortium agreed on a guiding principle for future policy recommendations: restricting fir...

President Obama charged the Presidential Commission for the Study of Bioethical Issues to identify a set of core ethical standards in the neuroscience domain, including the appropriate use of neuroscience in the criminal-justice system. The Commission, in turn, called for comments and recommendations. The MacArthur Foundation Research Network on La...

This article, which is based on and expands on an amicus brief the authors submitted to the United States Supreme Court, first provides the moral argument in favor of the insanity defense. It considers and rejects the most important moral counterargument and suggests that jurisdictions have considerable leeway in deciding what test best meets their...

Adolescence is a distinct, yet transient, period of development between childhood and adulthood characterized by increased experimentation and risk-taking, a tendency to discount long-term consequences, and heightened sensitivity to peers and other social influences. A key function of adolescence is developing an integrated sense of self, including...

Letter

In this article, we explore the emerging and potential influence of adolescent brain science on law and public policy. The primary importance of this research is in policy domains that implicate adolescent risk taking; these include drug and alcohol use, driver licensing, and criminal justice. We describe the emerging importance of brain science in...

Objective: This study examined the predictors of actions to initiate involuntary commitment of individuals experiencing a mental health crisis. Methods: Emergency services clinicians throughout Virginia completed a questionnaire following each face-to-face evaluation of individuals experiencing a mental health crisis. Over a one-month period in...

Background: Clinicians who evaluate people having a mental health crisis recommend an involuntary action in almost 50% of the cases. This study investigates the relationship between community mental health services and involuntary actions taken by clinicians following emergency evaluations of individuals during a mental health crisis. Methods: One-...

Federal and state laws currently include categorical restrictions of gun rights for people with a history of mental health adjudication. The categorical restriction may be ineffective and discriminatory, and could be subject to constitutional challenge, but is unlikely to be eliminated altogether. An alternative backdoor solution to the problem may...

This chapter reviews the foundation for the legal concept of adjudicative competence and frames questions about juveniles' competence. The first part of the chapter develops the concept of adjudicative competence and describes its legal contours. The second part explores the question of youths' participation in criminal trials from a historical per...

In an explicit attempt to reduce physician paternalism and encourage patient participation in making health care decisions, the informed consent doctrine has become a foundational precept in medical ethics and health law. The underlying ethical principle on which informed consent rests — autonomy — embodies the idea that as rational moral agents, p...

This study examined whether lengthening the holding period for an individual experiencing a mental health crisis under a temporary detention order (TDO) can reduce the number and length of post-TDO involuntary hospital commitments. Data from the Virginia Court System were matched to the Commonwealth of Virginia Medicaid claims database for July 1,...

An innovative Virginia health care law enables competent adults with serious mental illness to plan for treatment during incapacitating crises using an integrated advance directive with no legal distinction between psychiatric or other causes of decisional incapacity. This article reports results of a survey of 460 individuals in five stakeholder g...

This study examined interventions by colleges in 2008-2009 to respond to students during mental health crises. Public (N=15) and private (N=25) four-year colleges and two-year community colleges (N=23) in Virginia were surveyed about academic policies governing responses to apparent mental health crises among students and how often they were invoke...

Individuals experiencing an emergency mental health crisis (e.g., psychosis) are typically assessed to determine needed treatment. Involuntary or voluntary inpatient psychiatric hospitalization or outpatient treatments are options for those in crisis depending upon the availability of services and other factors. A point-in-time survey of all face-t...

Most states in the U.S. have established mechanisms in community-based mental health agencies to evaluate people experiencing a mental health crisis (e.g., manic episode) to determine needed treatment. Involuntary commitment to an inpatient psychiatric hospital is one option when a person in crisis refuses treatment, often due to the nature of the...

In most states, smoking has been curtailed to some extent in public buildings, workplaces, and restaurants. The next frontier for smoke-free policies is the multiunit dwelling industry. However, the extent to which smoke-free housing currently is available is unknown. The purpose of this study was to measure the market for smoke-free housing in Vir...

Objective: This study examined interventions used by colleges to respond to students who appear to be experiencing mental health crises. Methods: All public and private colleges in Virginia (N = 64) were surveyed regarding academic policies governing responses to apparent mental health crises experienced by students and the frequency with which the...

To determine whether holding an individual suffering from a mental health crisis for a longer period under a temporary detention order (TDO) reduces the number and length of involuntary commitments.

OBJECTIVE: The right to vote can be abrogated when persons become incompetent to cast a ballot. This applies particularly to people with Alzheimer’s disease, who at some point will lose capacity. A 2001 federal court decision offered the first clear criteria (“Doe voting capacity standard”) for determining voting competence, focused on understandin...

Objective: This study examined the relationship between the availability of mental health outpatient services provided by 40 publicly funded community service boards (CSBs) and the use of inpatient mental health treatment among Medicaid recipients. Methods: Three-year data were obtained for Medicaid recipients aged 18-64 from the Medicaid claims da...

This study examined the relationship between the availability of mental health outpatient services provided by 40 publicly funded community service boards (CSBs) and the use of inpatient mental health treatment among Medicaid recipients. Three-year data were obtained for Medicaid recipients aged 18-64 from the Medicaid claims database for the Commo...

On April 16, 2007, a deeply disturbed Virginia Tech student murdered 32 fellow students and faculty and then shot himself. Less than one year later, the Virginia legislature improved the emergency evaluation process, modified the criteria for involuntary commitment, tightened procedures for mandatory outpatient treatment, and increased state fundin...

Modern democratic nations have designed electoral systems to achieve two fundamental goals: increasing enfranchisement and voting, and, assuring the integrity of the vote. Efforts to achieve these two objectives can generate a tension between them. As an example, postal voting (also called absentee balloting) has the benefit of allowing persons who...

The determinative issue in applying the insanity defense is whether the defendant experienced a legally relevant functional impairment at the time of the offense. Categorical exclusion of personality disorders from the definition of mental disease is clinically and morally arbitrary because it may lead to unfair conviction of a defendant with a per...

In recognition of Howard Zonana's contributions, I take stock of the progress of the field of forensic psychiatry over three decades. As forensic psychiatrists, you are the voice of psychiatry in the law and the interpreter of law to your colleagues in psychiatry. I offer provisional impressions of your collective accomplishments under three themes...

In the last decade, persons who have no diagnosed medical or mental health condition are increasingly seeking and utilizing, for the ostensible purpose of enhancing their memory or cognitive skills, prescription drugs that were originally developed to improve executive function or memory in persons diagnosed with disorders such as attention deficit...

Aggregated health decisions by individuals are of paramount importance to public health professionals and policymakers, especially in situations where collective participation is a prerequisite for achieving an important public health goal such as herd immunity. In such circumstances, concerted action often falls short of the common good through la...

This study examined the role of workplace mandates to chemical dependency treatment in treatment adherence, alcohol and drug abstinence, severity of employment problems, and severity of psychiatric problems. The sample included 448 employed members of a private, nonprofit U.S. managed care health plan who entered chemical dependency treatment with...

On 16 April 2007, a deeply disturbed Virginia Tech student murdered thirty-two fellow students and faculty and then shot himself. Less than one year later, the Virginia legislature improved the emergency evaluation process, modified the criteria for involuntary commitment, tightened procedures for mandatory outpatient treatment, and increased state...

This chapter illustrates how ethical analysis can be a helpful tool, along with legal analysis, to support and enrich public health decision making. It provides n overview of the complementary roles of public health ethics and law; an approach to public health ethics, including a framework to guide ethical reflection, deliberation, and justificatio...

In February 1954, President Eisenhower invited Chief Justice Warren to dinner at the White House. Among the guests were well-known opponents of school desegregation. During that evening, Eisenhower commented to Warren that "law and force cannot change a man's heart." Three months later, however, the Supreme Court handed down its unanimous decision...

This conference addresses “obstacles to development and use of pharmacotherapies in the treatment of addiction.” I will focus on the challenges of increasing use of medical agents if they are developed. Expanding the potential market for these drugs will increase the likelihood that they will be developed in the first place. My point of departure i...

The horrifying killings committed by Seung Hui Cho on the Virginia Tech campus on April 16, 2007 highlighted a growing concern about students with mental health problems on campuses across the country. Many students arrive on campus taking anti-depressants and other psychiatric medications. The American College Health Association’s Survey in 2006 i...

The gap between the number of organs available for transplant and the number of individuals who need transplanted organs continues to increase. At the same time, thousands of transplantable organs are needlessly overlooked every year for the single reason that they come from individuals who were declared dead according to cardio pulmonary criteria....

To ascertain the need for and to inform development of guidelines for voting in long-term care settings, we conducted a telephone survey of Philadelphia nursing (n = 31) and assisted living (n = 20) settings following the 2003 election. Substantial variability existed in procedures used for registration and voting, in staff attitudes, and in the es...

As neuroscience advances our understanding of addiction, a drug called naltrexone offers the possibility of treating drug offenders, particularly those on probation or parole, and helping them avoid relapse. Richard J. Bonnie, Donna T. Chen and Charles P. O’Brien examine ethical and legal concerns related to various methods of administering naltrex...

Psychiatric interventions for crisis care through the legal mechanism of civil commitments are a reality across the U.S. With a comprehensive, community-based system of adequately funded mental health services that are accessible by all and provided in the least restrictive environment, optimal service delivery is envisioned. However, there are bar...

My assignment is to comment on the Supreme Court’s 5-4 decision in Panetti v. Quarterman, holding that a delusional mentally ill prisoner who is aware that the State intends to execute him based on his conviction for a capital crime is not, based on that finding alone, competent for execution under the Eighth Amendment. In so doing, the Court rejec...

Any lawyer in a gathering of health professionals, especially physicians, can expect to be bombarded by complaints about the law of professional liability and the high cost of malpractice insurance. It is well-established, of course, that the number of medical malpractice claims significantly increased in the 1960s, precipitating the first insuranc...

The right to vote can be abrogated when persons become incompetent to cast a ballot, a particular issue for people with Alzheimer's disease (AD). This paper explores the impact of a standard for voting capacity embodied in a U.S. court decision, Doe v. Rowe. Performance on the Doe standard was assessed in 33 patients attending an AD clinic. Perform...

The starting point for this article is the possibility of improving treatment adherence by making naltrexone therapy, particularly the recently developed depot preparation, a condition of probation or parole for nonviolent opiate-addicted offenders who voluntarily agree to these conditions. (I will characterize these arrangements as "leveraged agre...

1. Preamble The purpose of this policy statement, which was approved by the Public Policy Committee of the Alzheimer’s Association national Board of Directors, is to identify steps that should be taken by federal agencies, state legislatures, election officials, staff of long-term care facilities, and longterm care residents and their families to a...

This report of the American Psychiatric Association's task force on research ethics addresses ethical issues related to the conduct of research involving human participants with mental illness. The report includes discussion of recruitment and ongoing participation of persons whose decisional capacity may be impaired and the ethical costs of catego...

Organ transplantation remains one of modern medicine’s remarkable achievements. It saves lives, improves quality of life, diminishes healthcare expenditures in end-stage renal patients, and enjoys high success rates. Yet the promise of transplantation is substantially compromised by the scarcity of organs. The gap between the number of patients on...

The right to vote can be abrogated when persons become incompetent to cast a ballot. This applies particularly to people with Alzheimer's disease, who at some point will lose capacity. A 2001 federal court decision offered the first clear criteria ("Doe voting capacity standard") for determining voting competence, focused on understanding the natur...

Approximately half the people receiving treatment in the public sector for mental disorder have experienced some form of "leverage" in which deprivations such as jail or hospitalization have been avoided, or rewards such as money or housing have been obtained, contingent on treatment adherence. We argue in this essay that framing the legal debate o...

Periodic examination of UNOS’s policies is a useful feature of an ongoing effort to assure just and equitable allocation of lifesaving organs and to avoid potential exploitation by individuals. Yet, those whom the authors seek to protect - the majority of patients on the waiting lists and fortunate recipients - are in a morally awkward position bec...