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The treatment of psychiatric disorder necessitates a speciﬁc ethical discourse in view of the speciﬁc nature of psychiatric disorder and treatment. Mental illness and its treatment are highly contextual and situated. Any consideration of the ethical dilemmas around this area necessitates broad consideration of multiple discourses in neuroscience, sociology, epistemology, and moral philosophy. In the ﬁnal analysis, the treatment of mental illness is linked intimately with notions of social justice, which forms the background to any moral agency in the ﬁeld.
Mental health and mental illness are constructs that sit at the intersection of multiple discourses – neuroscience, philosophy, sociology, axiology, linguistics, and ontology. The notion of mental illness in particular is not a uniform construct – disorders such as schizophrenia or bipolar disorder have a much more biological hue than personality disorders or sexual dysfunction. Moreover, the ontological aspects of mental illness are not uniform over time or place.
Conceptualizations of mental health and mental illness are therefore highly situated and contextualized to a place, time, culture, and community. The same can be said for the treatment of mental illness and, by extension, the related ﬁeld of psychiatric ethics.
In deﬁning “treatment” of mental illness, this section focuses primarily upon the two main forms of intervention in mental health care – psychotherapy and psychopharmacology. This is not to dismiss the importance of fundamentals of mental health such as access to social goods (education, housing, or access to opportunity), liberty, development of human capability, and potential for ﬂourishing – such “interventions” arguably transcend the scope of psychiatry, nursing, and psychology and represent a “whole of government” or “whole of community” response to mental illness.
This section will consider ﬁrst a brief history of psychiatric ethics, before examining speciﬁc dilemmas in consent, conﬁdentiality, and coercion in psychiatric treatment. The discussion concludes by considering the intersection of social justice and the treatment of psychiatric disorder.
History And Development: Background Of The Issue
From antiquity, human societies grappled with the notion of “madness.” Throughout the Middle Ages, the “insane” were considered to be demonically possessed, and many were murdered as “witches.” Before the Enlightenment, madness was deﬁned as a form of demonic possession, and those with mental illnesses were excluded from society and condemned to incarceration often involving physical restraint such as manacles or chains. Psychiatric “treatments” of this period included bleeding, purging, and blistering.
At the time of the Enlightenment, madness came to be seen as the reverse of reason. Parisian psychiatrist Philippe Pinel developed an approach to the care of the mentally ill, involving close contact with and careful observation of his patients. Pinel argued that his approach to madness (l’aliénation mentale) was to emphasize its “moral” component. For Pinel, madness needed to be seen in the context of the social and psychological factors affecting the patient. Pinel engaged in what he termed “moral treatments,” involving therapeutic conversations with patients, seeking to encourage them out of their delusional ideas. He attempted reform of the culture of asylums, choosing to involve patients in the daily life of the asylum and choosing his asylum attendants carefully. Despite their rational basis, Pinel’s psychiatric treatments were still coercive and continued to employ physical treatments such as baths, showers, opium, camphor, and laxatives.
In the twentieth century, the psychiatric profession descended into a moral vacuum under the National Socialist regime in Germany and later in the Soviet Union. In October 1939, Adolf Hitler ordered the elimination of patients, or “inmates,” of German psychiatric hospitals under the auspices of Operation (Aktion) T4. Aktion T4 was originally intended to eliminate disabled children. The subsequent “euthanasia program” resulted in the deaths of more than two hundred thousand people with psychiatric disorders, intellectual disability, brain diseases such as epilepsy, and those with histories of asoziale (antisocial) behavior. Many psychiatrists participated or cooperated in the killing process, and a number later became involved in the mass murder of millions of Europe’s Jewish population.
Psychiatrists were later involved in egregious abuses of power in the Soviet Union (USSR). From the 1950s until the collapse of Communism in 1989, politically loyal psychiatrists used diagnostic labels for political ends. Soviet psychiatrists championed numerous diagnoses such as “schizophrenia forme fruste” and “paranoia with delusions of reform.” The most infamous of these labels was “sluggish schizophrenia.” The criteria for sluggish schizophrenia included reformist delusions, characterized by the belief that improvement in social conditions can be achieved only through the reformation of attitudes. Sluggish schizophrenia also burdened the sufferer with “litigation mania,” a false belief that one’s human rights are being violated.
The Soviet Union had two networks of psychiatric hospitals. One was an ostensibly mainstream network administered by the Ministry of Health, and another comprised a network of “forensic” hospitals, administered by the Ministry of the Interior under the auspices of the KGB. In some facilities, the two groups were mixed. People were sent to forensic hospitals following orders by Soviet courts and psychiatric tribunals. Inmates often received dangerously high doses of antipsychotic medications, unanesthetized ECT, and frequent beatings or sadistic treatment by guards, nurses, and other inmates.
The World Psychiatric Association (WPA) became aware of the malfeasance of Soviet psychiatry in 1971, after receiving a document written by Vladimir Bukovsky, a dissident who had been subject to such treatment. In 1977, the WPA held its triennial congress in Honolulu and made a formal condemnation of the practices in the Soviet Union and similar abuses in other Eastern Bloc countries and South Africa under the Apartheid regime.
The 1977 Declaration of Hawaii called for the psychiatric profession to respect patient’s autonomy and an approach of beneﬁcence and non-maleﬁcence. It also addressed issues of informed consent, conﬁdentiality, and provided guidelines for forensic evaluation of psychiatric patients and involuntary treatment. There was also an obligation for psychiatrists not to “misuse” their professional skills. Particular reference was made to the use of involuntary treatment in the absence of psychiatric disorder. The USSR withdrew from the WPA in 1982 and was readmitted to the WPA in 1989 when extant inhumane psychiatric practices were abandoned under Gorbachev’s glasnost and perestroika. In 1996, the WPA updated the Hawaii Declaration with the Declaration of Madrid (WPA 1996).
Psychiatric ethics have been referred to as the “bioethical ugly duckling” (Fulford 1994). Compared to other discourses in bioethics, psychiatric ethics and ethical concerns surrounding the treatment of mental illness have tended to languish in obscurity. The fundamental ethical dilemmas that emerge in the treatment of mental illness are seem mundane compared to more technologically driven ethical quandaries, such as in molecular genetics and other areas of biotechnical research.
The treatment of mental illness arguably invites a distinct discourse. Philosopher Jennifer Radden argued that psychiatry differentiates itself from other medical specialties in the unique role of the therapeutic relationship in therapeutic outcome, the vulnerability of psychiatric patients, and the features of the psychiatric therapeutic project – deﬁned as “re-forming the patient’s whole self or character… akin to the responsibilities of raising children”(Radden 2002).
Beyond the speciﬁc nature of the psychiatric project, the nature of psychiatric diagnosis invites a speciﬁc set of concerns, particularly in regard to the value-laden and socially constructed nature of psychiatric disorder (Fulford 1999) and the potential concerns this raises in areas such as disease mongering, the misuse of psychiatric diagnosis for political or legal gain, and the relationship between psychiatric profession and the pharmaceutical industry.
Consistent with other ﬁelds of medicine or health care, the diagnostic act in psychiatry or psychology is a necessary step to a process of treatment. Debates over the limits and nature of psychiatric diagnosis have a long history, best evident in the critique of Thomas Szasz. Szasz argued that mental illness was a myth, given the contentious nature of “mind,” and that psychiatric power and coercive treatment were wrong. In recent times the controversies over each edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) have been the focus of such debates. A deﬁnitive American psychiatric nosology did not emerge until 1952, with the publication of the ﬁrst edition of the DSM (DSM-I), which listed 106 psychiatric diagnoses. In 1968, the DSM-II added further 76 disorders. The DSM-III listed 265 diagnoses. The DSM-III-R (1987) listed 292 diagnoses, and the DSM-IV (1994), 297 diagnoses. The DSM-V (2013) seems to have stabilized the alarming growth of psychiatric diagnoses, but created controversies over the creation of new disorders involving grief, behavioral disturbances in children, and the conceptualization of psychosomatic disorders.
There have been a variety of narratives addressing how the DSM appears to represent political, ﬁnancial, and guild interests of the American Psychiatric Association and related bodies. More signiﬁcantly, some critiques have argued that the DSM represents a controlling strategy in the face of diminishing health and academic resources. Apart from the critiques of the process of diagnosis, John Sadler (Sadler 2005) has articulated the aesthetic value of psychiatric diagnosis in that it provides a simpler characterization of a complex phenomena, which penetrate beneath surface appearances and is receptive to multiple contexts balanced with reducing illness complexity. In addition it forges knowledge and moral purpose into action in a way that respects the patient in diagnostic practices and is rigorous, accountable, thorough, and consistent. Despite these qualities, many diagnoses emerge out of what the patient does, not what happens to them, which create ambiguities about moral responsibility. Moreover the process of diagnosis pathologizes some experiences the patient either considers normative or values, such as the apparent creativity of mania.
Involuntary Treatment Of Mental Illness
Unlike other ﬁelds of health care, the treatment of mental illness not infrequently involves the use of coercion, but manifests as enforced psychiatric treatment under speciﬁc laws. This represents a fundamental assumption of diminished autonomy and raises some of the most troubling ethical dilemmas in the treatment of mental illness. In most jurisdictions, there are essentially three criteria in the process of civil commitment – being a danger to self, being a danger to others, or being gravely disabled.
The state’s asserted right to enforce psychiatric treatment, through detention, administration of treatment, or imposition of obligations in community care, occurs ostensibly under the rubric of parens patriae (literally translated as “parent of the nation”). This originally referred to the power of the sovereign to intervene against an abusive or negligent parent, legal guardian, or informal caretaker and to act therefore as the parent of any child or individual who is in need of protection. The original invocation of parens patriae referred to safeguarding the interests of incompetent adults.
In the light of the doctrine of parens patriae, there are two broad moral justiﬁcations for involuntary psychiatric treatment. The ﬁrst is the right to protect other citizens from harm, predicated on the “harm principle” of John Stuart Mill. The second is based upon presumption of “incapacity,” necessitating a “duty of beneﬁcence” which, in essence, represents the state providing a correction for what philosopher John Rawls described as the “natural lottery”(Rawls 1971). This latter justiﬁcation of involuntary psychiatric treatment turns upon the notion of diminished or impaired autonomy in mental illness and reﬂects a fundamentally liberal notion of justice (Robertson and Walter 2013).
English philosopher John Stuart Mill had argued in his libertarian tome, On Liberty, that the state had no right to paternalistic action over an individual, unless his or her actions were harmful to others. Mill speciﬁcally stated that potential or actual harm to self was not a ground for state paternalism. This is acknowledged as Mill’s “harm principle.” In applying Mill’s philosophy to justify paternalistic involuntary psychiatric treatment, it has been argued that the preconditions to paternalistic acts are that the individual in question is not responsible for their actions, the individual’s incompetence is about to cause harm, the act will ultimately enhance the individual’s competence and/or prevent further deterioration, and the act takes place in the least restrictive manner. One of the main problems with Mill’s arguments in On Liberty is his incapacity to delimit the idea of “harm” – his arguments seem unable to dismiss harm arising from failures in social roles, the secondary harms arising from self-neglect, and the distress of others in witnessing the consequences in this regard of radical libertarianism (Robertson and Walter 2013).
In mental health legislation, the “harm principle” is usually deﬁned in terms of the construct of “risk.” Risk is a term that has multiple meanings in different disciplinary contexts, although all approaches to “risk” attempt to apply knowledge to an area of uncertainty. The notion of “risk assessment” is a process of estimating the likelihood of dangerousness, such as completed suicide or harm to others. Epistemic discourses of risk speak to evaluative processes that estimate the probability of a negative event. The estimation of risk is subject to “bounded rationality,” i.e., the effect of particular biases inﬂuencing how such information is handled. In a culture that is averse to risk, bounded rationality is clearly more likely to favor an overestimation of risk. Applying actuarial approaches to risk in mental health is a process of passively predicting the likelihood of harmful or dangerous behavior. This is a particularly inaccurate process, given that around a quarter of all dangerous acts are predictable. The tendency to overestimate risk will therefore subject many patients to coercive psychiatric treatment unnecessarily. Mental health laws based upon risk often delay the access to treatment until the patient’s illness is so severe that risk of harm becomes the focus of clinical attention. In addition to the consequences of self-neglect, damage to reputation, ﬁnances, career, and relationships, delays in treatment lead to poorer prognosis. Moreover, by promoting risk of dangerousness as a feature of mental illness within the community, such laws promote stigma around psychiatric disorder. Risk-based mental health legislation may promote unrealistic expectations within the community in regard to a psychiatrist’s capacity to mitigate risk.
One particularly challenging ethical implication of involuntary psychiatric treatment is the obligation of the state to provide a reasonable standard of care. The level of resourcing of mental health services has declined signiﬁcantly in the postindustrial West, yet the scope of involuntary psychiatric treatment has broadened, particularly with the introduction of outpatient coercive psychiatric treatment in many jurisdictions. Beyond simple issues of fairness or the state’s duty of care, there are speciﬁc ethical dilemmas arising from the prospect of iatrogenic harm. In interrogating the state’s right to enforce psychiatric treatment, on whatever pretext, there is the reciprocal obligation of the state to provide a reasonable standard of care. There are speciﬁc ethical dilemmas for psychiatrists in the form of obligations to the patient subject to involuntary treatment. Chronic exposure to ﬁrst-generation antipsychotic medications carries the risk of drug-induced movement disorder. Medium and long-term use of second-generation antipsychotics leads to the development of obesity, dyslipidemia, diabetes, and cardiovascular disease, which create a moral obligation to ameliorate such consequences of enforced treatment.
Iatrogenic harm arising from enforced treatment with antipsychotic treatment is arguably a manifestation of Aquinas’ “doctrine of double effect” – the justiﬁcation of a well-intentioned action that causes a serious harm. In general medicine, this might be a serious complication of an operation or side effect of medication. Patients giving informed consent to medication would be appraised of potential beneﬁts and risks of that decision. The patient subject to involuntary psychiatric treatment is not able to refuse treatment. This arguably heightens the need for greater care in the use of psychotropic medication. This necessitates a more speciﬁc consideration of the patient’s best interests in terms of the risk-beneﬁt analysis underlying treatment decisions. A speciﬁc, individualized evaluation of the multiple aspects of the risk of an untreated mental illness for a particular patient is balanced against the high likelihood of iatrogenic harm coming from the enforced use of antipsychotic treatment.
The “capacity argument” for involuntary psychiatric treatment is based upon the notion that mental illness impairs the sufferer from seeking treatment through the effects of the disorder. Impairment of reason, insight, or judgment are the presumed impairments to be compensated for by such legislation. The capacity argument is limited to enforcing intervention to correct for the speciﬁc impairments of mental illness, which preclude the patient from seeking or accepting treatment. The supposition is that the person has a “right to treatment,” and the effects of the mental illness deny that right.
A precondition of this argument is accepting the premise that the fundamental impairment of mental illness is the impairment of autonomy. If one accepts the most succinct deﬁnition of autonomy is the capacity for rational self-governance, this presupposes the patient has capacity to understand and decide on questions affecting his or her welfare and preferences . Jennifer Radden deﬁned the impairment in autonomy of mental illness in terms of dispositional autonomy (Radden 2004). Radden has argued that mental illness disrupts the synchronic (or cross-sectional) component of identity. The actions of an incompetent person at one point in time will compromise their life journey by denying themselves access to treatment and by extension correction for the bad luck of Rawls’ natural lottery. Treatment of mental illness thus allows the affected person to become an equal competitor for social goods in Rawls’ well-ordered society (Rawls 1971).
This is all very well, but in Rawls’ imagined society, no one becomes psychotic. Norman Daniels (Daniels 1995) tried to address this by deﬁning health care as a distinct form of social good, which speciﬁcally corrects for the vicissitudes of the natural lottery. To Daniels, health care exists to level the playing ﬁeld for the sick and should be distributed or rationed differently from social goods. Daniels’ argument is undermined in the face of the notion that much mental illness is chronic and leads to lifelong disability. The life of fulﬁllment aspired to in Rawls’ philosophy is beyond the reach of many of those struggling with chronic mental illness.
This problem was addressed by Martha Nussbaum in Frontiers of Justice (Nussbaum 2006). Rather than Rawls’ life of autonomous fulﬁllment, Nussbaum suggests that the natural lottery should be corrected for incapacities that prevent the experience of a “life of dignity.” Nussbaum’s approach to distributive justice focuses on human capabilities, that is, what people are actually able to do and be, and a threshold level of capabilities beneath which truly human functioning is not possible. Nussbaum listed central human capabilities (such as the ability to live a normal life-span, bodily health, freedom of movement secure against assault, the use of emotion, to play, to seek a safe environment, and to participate in economic and political functioning) as essential to human dignity. Rather than rational choosers in a highly regulated game of competing for social resources to live a fulﬁlled autonomous life, the just society aims to provide those most vulnerable with a hierarchy of goods to enable them to ﬂourish through realizing lives of dignity. In the case of severe mental illness, this involves freedom from the effects of disease, freedom from the deleterious consequences of its treatment, and freedom from the socially imposed limitations of stigma and the status of second-class citizenship.
Consent To Psychiatric Treatment
The patient’s capacity to accept or refuse treatment is a fundamental assumption of autonomy in clinical care. Beyond the previous consideration of enforced psychiatric treatment, the treatment of mental illness in special groups of patients has particular ethical challenges.
Childhood And Adolescence
Childhood and adolescence are not biologically determined states. While human development is a biological entity, the status of “child” or “adolescent” is a recent social construct. Previous societies had little concern with child labor or the sexual exploitation of children. The capacity of children and adolescents to partake in rational self-governance is both dimensional and highly individualized.
As autonomy is time and task speciﬁc, there can be no uniform assumptions of autonomy in children and adolescents. The capacity for a child of eight to consent to treatment is clearly different from that of a child of 15. In most jurisdictions, neither the 8-year-old nor the 15-year-old can consent to treatment without a responsible parent or guardian. A child’s capacity to make autonomous decisions about their health evolves with their cognitive and emotional development. They have an “evolving” or “future” autonomy. Like autonomy in other settings, it is not a categorical construct, and therefore, one of the critical considerations is how decisions made by parents or guardians on behalf of the child should reﬂect the current and future wishes of the child. In this setting, the speciﬁc ethical dilemma involves balancing the complex relationship between a child’s conﬁdentiality, their capacity for consent, and the role of advocating for the child’s interests.
One of the primary ethical challenges in the management of mental illness in older people is the nuances of managing patients with evolving and permanent cognitive impairment arising from dementing illness. These dilemmas have primarily considered issues of patient competence and testamentary capacity, particularly in questions of ﬁnancial management and decisions about health care.
In this setting, autonomy requires consideration as a dimensional rather than categorical construct. One particular approach to resolve the problem has been the use of the concept of “precedent autonomy,” in which proxy decisions are made on behalf of the patient based upon extrapolation of their attitudes, decisions. and value systems prior to the onset of dementia (Dworkin 1986). The “situated embodied agent” view of older people argues that the embodiment of the person links them with their culture and their history, assisting their careers to estimate decisions on behalf of the person which assists in the notion of integrity with their life’s philosophy. Related to this area is the consideration of advance directives, or so-called Ulysses contracts, made by older patients. Considerable efforts have been made to develop models of such decisions which are contextualized to the individual person. Such approaches need to distinguish a patient’s “critical interests” (higher order aspects of one’s life such as dignity and autonomy) and their “experiential interests” (those which bring stimulation and pleasure).
Confidentiality In The Treatment Of Mental Illness
In light of the stigma associated with mental illness and its treatment, conﬁdentiality is instrumental to the therapeutic relationship in mental health care in psychiatry and hence its ethical signiﬁcance. The dilemmas around conﬁdentiality in the treatment of mental illness vary from the disclosure of information between clinicians, within families, and to employers, legal representatives, and insurers. Indeed, some of the deﬁning aspects of the therapeutic relationship in mental health care are the interests and relative entitlements of third parties with interest in the patient’s care. Such interests may be legal, ﬁnancial, actuarial, or interpersonal. The maintenance of patient conﬁdence in the treatment of mental illness has been the subject of much discussion in the light of necessary breaches and potential implications for the extension of the therapeutic obligations of psychiatrists and psychologists to third parties. Conﬁdentiality can never be absolute in the treatment of mental illness.
The pivotal instance of conﬁdentiality and the so-called duty to inform was the so-called Tarasoff Case in the United States. This 1969 case turned on the failure of a therapist working at the University of California at Berkeley to disclose the homicidal intent of his patient to the intended victim, Tatiana Tarasoff. Despite the therapist’s decision to notify campus security and the police of the threat, no action was taken and the individual murdered Tarasoff on 27 October 1969. The Tarasoff family took legal action against the Regents of the University of California for their failure to warn Tatiana of the danger. The “Tarasoff Case” highlighted the obligation of a clinician’s duty to inform someone or a third party of the risk posed by a current patient.
As a point of ethical reﬂection on the notion of the limits of conﬁdentiality in the treatment of mental illness, the Tarasoff Case highlights the dimensional nature of patient conﬁdentiality in this setting. Arguably a paradigm case, Tarasoff emphasizes the relative entitlements of third parties to information about a particular patient, particularly in light of the formulated risks posed by the patient’s illness. In jurisdictions where privacy is enshrined by law, this is apt to create signiﬁcant ethical dilemmas.
Ethical Dilemmas In Psychotherapy
The inception of the “talking cure” followed the establishment of the psychoanalytic movement in the late nineteenth and early twentieth centuries. Psychotherapy underwent major transformation in the wake of the major twentieth-century wars in Europe and later with the development in the 1970s of manualized and structured psychotherapies such as cognitive behavioral therapy and rational emotive therapy.
Psychotherapy is, in essence, a masked form of moral discourse, occupying a space around clinical medicine and medical science and values. Psychotherapy can be conceptualized as the integration of a nonreligious, yet spiritual view of life. Psychotherapy often works best when the value systems of both patient and therapist approximate each other, but not necessarily converge. As such, psychotherapy is an intensely interpersonal interaction, presenting a particular power differential between patient and therapist. Much of the focus of ethical deliberation in this setting has involved consideration of clinical boundaries.
The area of ethical boundaries in clinical practice, particularly sexual abuse of patients by their therapists, has been well outlined in the scientiﬁc literature (Gabbard 1994). Sexual abuse of patients by psychiatrists is invariably catastrophic for victims, and in some settings, such behavior has been the subject of criminal sanction or removal of the right to practice. It seems that recent attention to the phenomena appears to have reduced its severity, and attempts have been made to better identify “at-risk” clinicians and provide frameworks to detect small boundary violations before they evolve into more egregious sexual boundary violations.
Gabbard deﬁnes boundaries as simply the rules that govern the therapeutic relationship. They are the parameters that describe the limits of a ﬁduciary relationship in which one person (a patient) entrusts his or her welfare to another (a physician), to whom a fee is paid for the provision of a service. Boundaries imply professional distance and respect and explicit prohibition of sexual involvement with patients.
Gabbard is strongly of the view that all sexual boundary violations are part of a slippery slope and begin as a series of violations of the rules that are not sexual in nature. Nonsexual boundary violations include benign acts such as gifts or services, prolonging consultations, reducing or waiving fees, and self-disclosure. Gabbard sees distinct categories of sexual boundary violators. The ﬁrst group is simply those with a serious mental illness. Such therapists are grossly impaired and should suspend practice, only to return when well, and under supervision. The second group is predatory and psychopathic in character. The third is “love-sick” therapists, who are vulnerable having encountered disappointments and setbacks in life. In such a state they are susceptible to misinterpret the patient’s responses to them as amorous and submit knowingly to a self-destructive process of “masochistic surrender.”
Social Justice And Psychiatric Treatment
Just allocation of limited mental health-care resources is a global issue. Several articles in The Lancet have also implored psychiatrists to consider issues of just allocation of resources in a global setting as part of their ethical obligations (Dhanda and Narayah 2007; Herrman and Swartz 2007). This is a clear indication that one of the most important ethical dilemmas in the treatment of mental illness is advocacy. This interrogates the concept of social justice.
Robertson and Walter (Robertson and Walter 2013) have argued that social justice can be conceptualized as the successful operation of the social contract, in which rational choosers submit to a rule of law in order to enjoy the beneﬁts of a safe and well-ordered society. American philosopher James Rachels has been critical of the tradition of the social contract, seeing it as a historical ﬁction “not worth the paper it was never written on.” Rachels has also highlighted circumstances where the social contract process appears to fail (Rachels 2003):
What of those citizens, like the mentally ill, who may be incapable of rational agreement to the social contract process, yet need the protection of the sovereign?
What of those members of society who are second-class citizens and do not beneﬁt from the social contract, yet are expected to abide by it?
What if the sovereign fails in its responsibilities in enforcing the social contract?
These three scenarios represent speciﬁc moral challenges for psychiatrists and provide a framework for considering social justice in regard to their patients.
In contrast to the moral free-rider problem, i.e., those who seek to beneﬁt from the social contract without abiding by its requirements, those who cannot necessarily commit to the social contract due to mental illness present a challenge to this view of social justice.
One of the main questions over the role of psychiatrist’s and psychologist’s advocacy on behalf of their patients pertains to the limits of such advocacy. Most psychiatrists and psychologists are focused upon advocating for their individual patients, addressing the patient’s dealings with various third parties. Such advocacy is part of the second problem with the social contract tradition – that of the “second-class citizens” – who are expected to fulﬁll the expectations of the social contract, without reasonable expectation of the beneﬁts.
The third problem area deals with the failure of the sovereign – the failure to provide adequate services or when there is a failure of the sovereign to maintain law and order. This breakdown of law and order may occur as a consequence of some calamity occurring in the state, such as natural disaster or foreign invasion, or when the sovereign perpetrates oppressive violence against its citizens. These circumstances have been seen in totalitarian regimes, where widespread persecution by the state occurs. As history has shown, psychiatrists have often been a part of this persecution, as well as the victims of it, in some settings.
Patients in a culturally alien treatment setting are vulnerable in this third condition. The treatment of mental illness is highly bound to context and culture. Many patients arrive in different societies and cultures through both enforced and elective migration. Many immigrant patients, particularly those who have arrived in new settings as refugees, have complex mental health problems. There exists a need for culturally sensitive and appropriate mental health services that can provide such interventions. Moreover, in some “second world” countries, such as in North America or Australasia, patients from indigenous cultures require speciﬁc mental health services that are sensitive to complex clinical, political, and cultural inﬂuences upon the experience of mental illness and its treatment requirements.
In this section, some of the general and speciﬁc dilemmas around the treatment of mental health have been enumerated and examined. Mental health and mental illnesses are highly contextual, and therefore, the approach to treatment requires a sophistication. Discourses around this area require broad considerations of social constructionism, epistemic considerations, moral philosophy applied to the area, and sociology. The ethical treatment of mental illness requires consideration of a social and cultural context and in the ﬁnal analysis is tethered to a notion of social justice.
- Daniels, N. (1995). Just health care. Cambridge: Cambridge University Press.
- Dhanda, A., & Narayah, T. (2007). Mental health and human rights. The Lancet, 370, 1197–1198.
- Dworkin, R. (1986). Autonomy and the demented self. Millbank Quarterly, 64, 4–16.
- Fulford, K. (1994). Psychiatric ethics: A bioethical ugly duckling. In R. Gillon & A. Lloyd (Eds.), Principles of health care ethics (pp. 681–695). Chichester: Wiley.
- Fulford, K. (1999). Analytic philosophy, brain science, and the concept of disorder. In S. Bloch, S. Green, & P. Chodoff (Eds.), Psychiatric ethics (pp. 161–191). New York: Oxford University Press.
- Gabbard, G. (1994). Psychotherapists who transgress sexual boundaries with patients. Bulletin of the Menninger Clinic, 58, 124–135.
- Herrman, H., & Swartz, L. (2007). Promotion of mental health in poorly resourced countries. The Lancet, 370, 1195–1197.
- Nussbaum, M. (2006). Frontiers of justice. Cambridge, MA: Bellknap.
- Rachels, J. (2003). The elements of moral philosophy (4th ed.). Boston: McGraw Hill.
- Radden, J. (2002). Psychiatric ethics. Bioethics, 16(5), 397–411.
- Radden, J. (2004). Personal identity, characterization identity, and mental disorder. In J. Radden (Ed.), The philosophy of psychiatry (pp. 133–146). New York: Oxford University Press.
- Rawls, J. (1971). A theory of justice. Cambridge, MA: The Bellknap Press.
- Robertson, M., & Walter, G. (2013). Ethics and mental health – The patient, profession and community. Boca Raton: CRC Press.
- Sadler, J. (2005). Values and psychiatric diagnosis. New York: Oxford University Press.
- WPA (1996). World Psychiatric Association – Madrid Declaration on Ethical Standards for Psychiatric Practice. http://www.wpanet.org/generalinfo/ethic1.html. Accessed 23 Nov 2007.
- Robertson, M., & Walter, G. (2013). Ethics and mental health – The patient, profession and community. Boca Raton: CRC Press.
- Bloch, S., & Green, S. A. (Eds.). (2009). Psychiatric ethics (4th ed.). Oxford: Oxford University Press.
- Green, S. A., & Bloch, S. (2006). An anthology of psychiatric ethics. Oxford: Oxford University Press.
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