Abstract
“Let us bear in mind that psychiatrists have been in the forefront in helping homosexuals … It is unthinkable that homosexuals be persecuted for something over which they have no choice”
Dr Charles Socardies made this remark in 1973. The setting was an American Psychiatric Association symposium, debating the issue of ‘demedicalizing’ homosexuality. This window into a different time calls to mind the notion that “the past is a different country”. Many such confronting dilemmas, faced by psychiatrists of different eras and in different fields of the profession, are evident throughout An anthology of psychiatric ethics, recently published by Oxford University Press. Stephen Green and Sidney Bloch, whose ongoing collaboration has enriched the field of psychiatric ethics over the last few decades, have edited this encyclopaedic work. The Anthology provides nine chapters of classic papers in the field of psychiatric ethics, each prefaced by a thoughtful introductory essay by the editors.
In the first section of the Anthology, Green and Bloch provide the reader with excellent overviews of virtue, deontic, care, utilitarian and principlism approaches to ethics. For purists, illustrative biopsies of the writings of Mill and Kant are offered for examination. The recent revival of the method of casuistry in bioethics, is also addressed in the Anthology.
Apart from commonly discussed issues of the ethics of confidentiality (particularly in the ‘post-Tarasoff era’), coercive treatments and research, Green and Bloch embark on an exposé of areas that have been largely neglected in the field. Issues related to distributive justice in mental health, the ethical implications of psychiatric diagnosis and the ethical issues peculiar to special populations such as indigenous people, the elderly and children are given consideration by Green and Bloch.
The editors’ choice of articles is, at times, quite inspired. The section of the Anthology dealing with psychiatric treatments and services includes articles relating to the so-called “Osheroff exchanges”. Such provocative choice of articles has enabled the editors to create a narrative, which emerges throughout the book's chapters. In this case, Klerman's somewhat incendiary paper, “The psychiatric patient's right to effective treatment”, is juxtaposed with articles imploring psychiatrists to take a balanced approach to the rigours of evidence-based medicine, thus elevating the ethical dilemmas of clinical decision making in the mind of the reader.
The ethics surrounding the practice of forensic psychiatry has traditionally been a rich source of writing in the field of psychiatric ethics. In this section of the Anthology, Green and Bloch's main focus is the dilemma surrounding the so-called ‘double agent’ role faced by forensic psychiatrists. Green and Bloch present the views of the two main protagonists in the history of this polemic debate, Paul Appelbaum and Alan Stone. Appelbaum's “Parable of the forensic psychiatrist: ethics and the problem of doing harm” avers simply the position that the forensic psychiatrist have no concern with beneficence and non-maleficence. To Appelbaum the primary obligation of so-called “forensicists”, is the pursuit of justice. Other papers featured in this section call for a more balanced view, imploring forensic psychiatrists to partake in moral reflection upon their actions. The overrepresentation of the North American literature in this chapter is one of the few concerns I have about the selections made by Green and Bloch. This limitation, however, is not specific to the Anthology – it is a shortcoming of the field in general. Given the social and cultural context of psychiatry, there can only be particularism, rather than universalism, in psychiatric ethics.
One of the strengths of the Anthology is its attempt to address the vexed issue of distributive justice in mental health. Much of the literature in this area has come from the US experience of managed care. Green and Bloch have carefully chosen a selection of articles that provide a nuanced understanding of the dilemmas facing policy makers in mental health. Their assembly of articles by key thinkers in the field illustrates the tension between the two rival political philosophies of the West, Rawlsian liberal egalitarianism and Nozick's libertarianism. It is evident that both Rawls and Nozick failed to countenance the issue of mental health care in their writings and so the application of their ideas pertaining to the allocation of scarce health resources leads to unacceptable conclusions. If we followed Rawls’ approach to distributive justice, we would bankrupt society in an attempt to benefit the least advantaged. In adopting the alternative of Nozick's libertarianism we would condemn the mentally ill to a wretched state of abjection in the interests of limiting the interference of the state on the free exchange of resources. Other articles by writers such as Englehardt, Sabin and Daniels further grapple with this dilemma.
The Anthology is a worthwhile companion to the editors’ other significant work in the field, Psychiatric ethics. It certainly belongs in any medical or university library and would provide years of material for journal clubs. For those conducting research in psychiatric ethics, the articles and their references are a valuable source of bibliography.
In this era of stem-cells, therapeutic cloning and other dazzling biotechnologies, the comparative mundaneness of the important issues in mental health ethics has left them neglected in bioethical discourse. This is the challenge that Green and Bloch take up in the latest instalment of their oeuvre.
Michael Robertson
Sydney, Australia