Abstract
I approached this review with a degree of excitement – this appeared to be an unique opportunity for psychiatrists to better understand those of a culture different from their own in an increasingly ethnically diversified society. Were my expectations fulfilled? Only partly even though the definition of culture was widely interpreted beyond ethnicity and religion. The volume is well presented in a readable format of 13 chapters of which seven are geographically based (Latin America, Scandinavia, Western Mediterranean, Japan, China, India and Sub-Sahara). The influence of religion crosses ethnic boundaries and, surprisingly, apart from Islam, is little mentioned but that is not to say that spiritual influences are ignored. All the authors are distinguished and most well known but this did not guarantee clarity of expression for some of the chapters are heavy going. Furthermore the construction of each chapter was idiosyncratic suggesting a lack of a common conceptual framework and firm editorial direction. One was left with little idea as to how one culture differed from another in its application of ethical considerations in psychiatric practice.
In the first chapter Norman Sartorius examines the origins of ethics in psychiatry explaining the role of international organisations omitting to state that the average psychiatrist has little knowledge of their activities and any input they have is through their affiliated national organisation. Sartorius then rightly directs his attention to the neglected area of ethics and national mental health programs in which there is a shift from the dyad (patient and psychiatrist) to community and mental health team. The concluding section ‘future action’ is a gem.
Overall the ‘geographically/religious’ based chapters were disappointing – some were as meagre in content as psychiatry in their region. Most would not have informed the average well-read psychiatrist attentive to the wider world about them. The fundamentals expressed in the chapter on Arab culture (i.e. a universally held belief in a supreme being and the family/society vs individual autonomy) are echoed around the world and account for much of the ethical dissonance. Examples of this are profuse but solutions regrettably few.
The second chapter, ‘The Impact of Arab Culture on Psychiatric Ethics’ is crisp and clear. The essential differences between ‘traditional’ and Western Societies is summed up in a table supported in the text by an exposition of the different concepts of mental illness. This is one of the few chapters to give practical guidance on specific issues. Asked is the basic question what is the role of ethics – psychiatric or other – in a system with negligible resources and facilities in those impoverished nations where the pockets of affluence are well served? The Western Mediterranean perspective is long on interesting philosophical concepts and tensions such as those that arise when treating ethics as a secular religion; it is short on what goes on between patient and psychiatrist. The same could be said of the other geographically based chapters with the exception of ‘Scandinavian Approaches’ which favours the purely clinical approach and problems proceeding therefrom to wider social issues. Greater interest I am sure will be aroused by the unambiguously entitled, ‘Culture and Ethics of Managed Care in the United States’ which is a brilliantly written balanced account of this phenomenon, with parts of which those with monocular vision might not agree.
The Sub Saharan chapter is almost poignant in its brevity as it tells of the struggle of psychiatry in the face of widespread organic disease and gross deprivation. The Indian experience is also short and dwells mainly on the Hindu philosophy of subjective ethics without mentioning particularly culturally based ethical concerns or analysis.
The Chinese chapter was disappointing for although it outlined the late origins and troubled development of psychiatry, it failed to identify those aspects of the traditions and beliefs of an ancient complex civilisation which will inevitably lead to ethical conflicts as globalisation proceeds. The Japanese contribution is almost as enigmatic as the country itself. It seems that ethics generally is based on Confucianism and Buddhism and in many respects is similar in approach to that of China.
The three overarching chapters stretch the definition of culture, dealing as they do with three aspects which should be of interest to any psychiatrist anywhere: research using incompetent patients; informed consent and mental health law reform. The first is a fascinating account of the historical background to one of psychi-atry's more horrifying episodes which has been more widespread than one would like to think. This chapter links up with a similar historical and medical perspective on informed consent. The last chapter on mental health law reform gets back to the main ethical issues at a macro level, addressing conflicting social-political-economic issues involved and their cultural background, which again goes back to their influence on the provision of mental health services and the question of individual rights and entitlements where these might conflict with societal and family values.
Using an heuristic template I would not recommend this volume, fascinating and clinically educative as parts of it are, even to those in our plural society who have patients of diverse cultural backgrounds. For those who have a wider interest and involvement with ethical issues it is required reading – if only because it is the first and hopefully not the only work in this area.