Abstract
Ethics is an inherent component of medical practice. This is in part because clinical decision making involves a social relationship, and relationships always involve ethics, and in part because the nature and meaning of illness are themselves steeped in culture and values. Although this applies no more or less to psychiatry than to other areas of medicine, some issues – most obviously, those involving consent – arise in psychiatry with particular force.
Although it is universally acknowledged that values vary across cultures, remarkably, apart from some descriptive studies within sociology and cultural anthropology, and some speculative reflections within the Marxist tradition, there has been relatively little detailed analysis of how this occurs. Even less well understood is how the cultural specificity of different moral frameworks shapes everyday clinical practice. Indeed, discussions about ethics in medicine have tended to assume the existence of a unitary philosophical standpoint that privileges a single set of values, on the basis of which universally binding protocols and conventions are supposed to be defined.
In this context Ethics, culture and psychiatry offers a welcome contribution. Although it sets itself a relatively limited task – to provide an overview of ethical perspectives prevailing in a variety of cultural settings – many important issues are raised and it should stimulate wideranging debate. The main part of the book is a series of descriptive chapters concerning the ethical features of the cultures of Arab countries, Latin America, the Western Mediterranean, Scandinavia, the United States, Sub-Saharan Africa, India, China and Japan; there are also two chapters dealing with competence and consent in psychiatric research. Although, as expected with a work of this breadth, the contributions are somewhat uneven, taken together the field is well covered.
Not surprisingly, the importance of religion arises repeatedly. For example, according to Ahmed Okasa, in Arab culture the notion of mental illness is closely linked to Islamic concepts referring not to insanity but to obstacles arising in the path to enlightenment, as a result of which the mentally ill are seen as possessed, as innovative and creative, or as dissidents. In other cultures, tensions frequently emerge between religious traditions, with their fatalistic conceptions of illness, and that of science, which seeks knowledge and cures.
Local cultural traditions may profoundly affect the understanding of illness and the ways in which doctors practise. As Julio Arboleda-Florez and David Weisstub show, in South America, ‘machismo’, or the ethos of masculinity, and traditional and mythological beliefs, such as ideas about ‘magical fright’ and ‘evil eyes’, profoundly affect the experiences of both patients and carers. According to Michael Olatawura, in sub-Saharan Africa a wife cannot give consent for medical treatment, whether scientific or traditional, without agreement from her husband, even in an emergency. Here, and elsewhere, treatment decisions are often made by community elders or by family members.
In the United States, the advent of managed care has profoundly influenced the nature and practice of psychiatry. Renato Alarcon, in a helpful analysis, argues that this development resulted from a failure by medicine to establish its own viable ethical framework; as a result, despite continued proclamations about the pre-eminent value of ‘autonomy’, under the regime of managed care the space for freedom of choice has been severely curtailed. However, the adverse effects of social change are not restricted to the United States. As Xiehe Liu shows, in recent years in China there has been a huge growth in alcohol use and related problems and major shifts in the patterns of mental illness.
Cultural traditions, demographic changes and economic pressures all deeply influence the development of social policy. Such influences may manifest themselves through the medium of public reflections on hitherto widely accepted social precepts, as in debates about the weight to be placed on welfare in Scandinavia or on individualism in the United States, or merely through pressure on resources. In some countries, these debates have focused on the roles of inpatient and community based psychiatric care; in Italy, in particular, as David Weisstub and Julio Arboleda-Florez show, this debate has been particularly intense following the mental health law reforms of 1978, which led to the closure of psychiatric hospitals, with the final balance sheet evidently still to be drawn.
Not unexpectedly, this book contains deficiencies and omissions. There is only limited discussion about the misuse of psychiatry as an instrument of state power. In spite of the implied assumption of the book as a whole that ethics cannot be spoken of in the general but only in the particular, with specific reference to local cultural traditions and practices, there is a tendency for many writers to collapse ethics into universal human rights declarations and protocols. The discussion of ethical issues in research is relatively superficial, with little evidence of an appreciation of the cultural aspects of the consent process or the multifaceted nature of competency. There is limited discussion of the role of traditional healing practices and their relationship with and impact on Western psychiatry.
In spite of this, the book should be appreciated for what it does achieve rather than for what it does not. As an addition to the ethical and cultural literature of psychiatry it will be welcome. As an aid to practitioners working in multicultural settings it will be useful, and as a treatise on the cultural variability both of needs in the field of mental health and of the impact of institutional change and therapeutic interventions it will provide an important reminder of the need for cultural sensitivity in the development of new social policies.