Abstract
This is the introductory paper to the special issue on ethics in psychiatry. We introduce the other papers that follow and set them in a context. Inevitably, they represent only a thin slice of the work going on in psychiatric ethics. But they serve to show two unique features of this discipline. First, it has a tendency to dig deep and to make connections with other philosophical concepts. So, for example, in a number of ways the papers that follow touch on the nature of personhood. We examine this notion. Second, psychiatric ethics, because of its content and its embededness in the real world, tends to hit upon diverse and sometimes conflicting values. We introduce the idea of values-based medicine, which provides both a theoretical framework and a practical approach to the common dilemmas of psychiatric practice. The need to think deeply, but also clearly and coherently, combined with the need to engage with the hurly-burly of the world of patients, users and carers, suggests the reasons why psychiatric ethics offers a paradigm for practical ethics generally.
Psychiatric practice raises ethical issues. It would be tempting to approach such issues as if they were simply like any other difficult decisions that have to be faced in medical practice; that is, as if they were like any other issues in medical ethics. Psychiatric ethics, however, raises problems of a different kind. In this introductory paper, we shall chart the unique character of psychiatric ethics. There are two aspects to this that we wish to highlight.
First, the nature of psychiatric ethics makes immediate connections with deeper philosophical issues. As an example of this, and because of its relevance to the papers that follow, we shall consider the nature of personhood and its impact on decisions that have to be made in psychiatric practice. It was the philosopher Wittgenstein who once wrote: ‘We judge an action according to its background within human life.… Not what one person is doing now, but the whole hurly-burly, is the background against which we see an action, and it determines our judgement, our concepts, and our reactions’ [1]. We shall need a broad concept of personhood to reflect the realities of the hurly-burly of the world of practice. Second, a key feature of this hurly-burly, which we shall emphasize, is the influence of values and the way in which this influence structures our practice as it must also shape our reasoning.
The conclusion towhich we come is, if the unique quality of psychiatric ethics is that it pulls us, on the one hand, deeper into conceptual analysis (to do with the nature of personhood for instance), while, on the other hand, in the direction of the hurly-burly of shared and disputed values in the world, this is also a quality that shows how issues in practical ethics need to be approached generally. In this sense, psychiatric ethics leads the way.
The pull in the direction of conceptual analysis requires exactly the sort of logical rigour, involving coherence, consistency and clarity, that Campbell commends [2]. But he also speaks of the ‘fresh air of philosophical debate’, which comes from the diversity of moral theories and the ‘new ways of thinking’ [2] opened up by philosophy. In our terms, these ‘new ways’ and ‘fresh air’ are to be found in the ‘hurly-burly’ that makes up the background against which our judgements have to be reached.
The different aspects of philosophical analysis in psychiatric ethics are also shown by the next pair of papers in this special issue on ethics. Adshead and Sarkar [3] present arguments, very clearly, around the notions of privatewelfare (respect for autonomy) and public welfare (respect for justice) as they impinge on thinking about the role of the forensic psychiatrist. Should the forensic psychiatrist be inalienably on the side of the accused, or is it reasonable for forensic psychiatrists to regard themselves as working for fairness in the judicial system, whether or not the individual citizen's welfare is maintained? Although they give clear arguments in favour and against these different positions, the tensions inherent in clinical practice – which stem from different values clashing in the hurly-burly – mean that no particular answer seems warranted on grounds that are incorrigible.
McMillan and Gillett [4] deal with a theme pertinent to forensic psychiatry, namely moral responsibility. But their analysis shows how this notion has to be linked to broader understandings ‘of the lived experience of the individual’. Particular acts will then have a meaning within the person's narrative. Although this analysis involves using terms with clarity, for instance to do with our desires and the differences between lower order and higher order desires, it also sheds light on how our understanding of moral responsibility is relevant beyond the sphere of, for example, severe personality disorder and forensic psychiatry: it is also of importance in relation to schizophrenia, depression and anorexia [4]. Responsibility is an issue throughout psychiatric practice, where it has to be judged in context against the backdrop of an individual's life experiences and his or her ability to shape that life.
This takes us on to the final pair of papers, which both (in different ways) flesh out what it might mean to be a person. They do this through conceptual analysis – by thinking about the nature of narrative in our lives (in the case of Baldwin [5]) and by discussion of the notions of meaning and discourse in relation to the selves of people with dementia (in the case of Sabat [6]). But this analysis takes place in the context of the real world, where people must interact and be dependent; where people can be positioned, qua selves, in a positive or negative light. Here, in the hurly-burly, is the ‘fresh air of philosophical debate’ [2].
But, of course, debate is crucially public and it requires the careful use of language. This brings together the two aspects of philosophy discussed by Campbell [2]. There is no way round this: our speech must be coherent, consistent and clear. However, as Buber said, ‘in actuality speech does not abide in man, but man takes his stand in speech and talks from there’ [7]. Our nature, as spirits in the world of human discourse, means that we exist, for a thinker such as Buber, in the midst of our interactions: ‘Spirit is not in the I, but between I and Thou’ [7]. Hence, psychiatric ethics, embedded in the human world of values, must be open to the nature of this spirit of interaction: ‘It is not like the blood that circulates in you, but like the air in which you breathe’ [7].
People in the world
The first of the unique characteristics of psychiatric ethics is the way in which it makes immediate connections with deeper philosophical issues. We shall focus on the issue of personhood because of its relevance to the papers that follow. Adshead and Sarkar [3] are concerned about the person's welfare, but this is problematic precisely because the person is not an isolated atom, but is rather located in a public arena where the welfare of othersmust come into play. McMillan and Gillett [4] point to (what might be called) the deep grammar of the notion of moral responsibility, which links it to the person's thought and psychological development. The person's narrative history, his or her ‘account of lived personhood as a conscious experience’ [4], becomes relevant to our estimation of moral responsibility. This in itself suggests that we require a rich conception of what it is to be a person. Baldwin [5] fleshes this out in his discussion of narrative. He concludes: ‘Narrative… is essential in maintaining and creating our sense of Self’ [5]. Moreover, his analytical account of narrative and the connections with the self suggests something very practical, namely that – if we are to help people with mental illnesses – we must engage with them (as selves) in the re-construction or coconstruction of their lives. 1 This is exactly the work that Sabat commends elsewhere [8], while here he highlights the possibility of undermining the person's selfhood by the judgements we might make about capacity or competence [6]. Once again, the ethical issue (making the right judgement about someone's capacity to make decisions) is predicated on a deeper philosophical issue to do with our conception of personhood.
Hence, psychiatric ethics, by the nature of the questions it confronts, requires issues around personhood to be raised. We might regard this as an example of how philosophy can help clinical practice, because it sharpens the concepts that have to be used. What it is to be responsible, for instance, comes into sharper focus in the papers that follow. But then, the solution depends on wider issues relating to personhood. It becomes obvious that we require a broad notion of what it is to be a person in order to accommodate the data from the hurly-burly of real life. In this way, clinical practice contributes to philosophy [12]. Or, perhaps it would be truer to say that this is an example of how practice and philosophy come together at one and the same time: both require reflection on the realities of being a person in the world. Clinical practice that is ignorant of such realitieswould almost certainly have difficulties, if not fail; philosophy that does not square with such realities would seem simply academic and stale, without any sense of freshness.
Why do we require a broad notion of what it is to be a person?Well, for a start, being a person with schizophrenia raises biomedical questions: about the development, structure and function of the brain; and about genetics for instance. It also raises psychological questions, which in turn touch on important philosophical topics, to do with agency and the nature of reality. The notion of moral responsibility comes in here too. But then there are social questions, because of the evidence that the social and emotional environment has an impact on the person's tendency to relapse. Meanwhile, schizophrenia (like mania) raises questions about the nature of an authentic existence: why is one lived reality (the one that may seem to be more creative) in need of treatment, whereas the other (duller, flatter, more boring experience) is regarded as normal? So, schizophrenia (or bipolar affective disorder, or numerous other psychiatric conditions) raise questions that are biological, psychological, social and (in a broad sense) spiritual, in addition to the ethical issues we are already considering. A full understanding of what it is to be a person with schizophrenia, therefore, would require understanding in all of these fields.
The argument so far runs as follows:
Issues in psychiatric ethics (e.g. to do with moral responsibility) cannot be discussed fruitfully without reference to philosophical concerns about the person (e.g. about their lived narrative experience); and The notion of the person then appealed to must be broad, because the reality of the world for people is that it is a biopsychosocial world, which also involves ethical and spiritual domains.
Well, do we have a suitably broad notion of the person? It might seem that what is required here is a definition. Locke [13], in the seventeenth century, defined the person thus:
… a thinking intelligent being, that has reason and reflection, and can consider itself as itself, the same thinking thing, in different times and places; which it does only by that consciousness which is inseparable from thinking, and… essential to it.
Locke made it plain that whatwas requiredwas memory in order for the conscious states to link together to form the same person over time, which is one of the meanings of personal identity:
… as far as this consciousness can be extended backwards to any past action or thought, so far reaches the identity of that person. [13]
Thirty years later, in the eighteenth century, Hume agreed:
Had we no memory, we never should have any notion of causation, nor consequently of that chain of causes and effects, which constitute our self or person. [14]
In more modern times Parfit [15] has argued that personal identity really only amounts to psychological continuity and connectedness. In other words, a person is the same person over time only to the extent that his or her psychological states are continuous or connect from one moment to the next. This raises a threat to the possibility of personhood in people with dementia. 2 But it has been suggested that, inasmuch as Parfit's theory admits the survival of the self or person to a degree (because there are degrees of continuity and connectedness), to this extent it can be squared with the language of successive selves (in bipolar affective disorder, where the self might seem quite different over time) and multiple selves (in dissociative identity disorder) [17].
Be that as it may, the Locke–Parfit view of the person does depend on a strongly cognitive notion of what it is to be the same person over time. Other thinkers have been keen to stress alternative features of personal psychology. Thus, Harré states:
… I want to bring back the study of endeavour, conatus, striving, trying and the like. In the conditions for the use of these concepts I feel the presence of persons as agents rather than as passive passengers on a mental vehicle directed and powered by subpersonal vectors (or information-processing modules) of various kinds. [18]
Another alternative is to stress the degree to which our selfhood depends on our bodies, as Taylor suggests:
Our body is not just the executant of the goals we frame … Our understanding is itself embodied. That is, our bodily know-how, and the way we act and move, can encode components of our understanding of self and world. … Mysense of myself, of the footing I am on with others, is in large part also embodied. [19]
If we put these conceptions of personhood together with the idea that we are inevitably embedded in the human world – that is, our existence as human beings is essentially characterized by our sharing in the possibility of language – we can arrive at the notion of people as situated embodied agents [20]. How we are situated will vary from person to person, but to understand any particular person must involve understanding his or her situatedness.
Before spelling out what this means, it is important to go back a step. It looked as if what was required was a definition of personhood and we saw that one was provided by Locke. However, the idea that a definition can pin downwhat it is to be a personmay be illusory. At least, it may be that stipulating what something is by defining it is, at best, misleading and, at worst (from the ethical perspective), dangerous. This takes us back to the hurly-burly, the background against which our actions must be judged. A stipulative definition (e.g. that to be a person is to have [or to be] such-and-such) risks undervaluing the personhood of some individuals in some circumstances. An alternative route, one that pays attention to context and the possibility of difference in the hurly-burly of the realworld, is to regard the characterization of personhood as essentially open-ended.
The situated-embodied-agent view of the person allows that people can be situated in an uncircumscribable number of fields. We are situated among our families and friends, in a legal system, a community and broader society, in our interconnecting personal narratives, which include psychological continuities and discontinuities, in our cultural histories, by our moral concerns and in a spiritual field. Nothing here can be stipulated ahead of time. What each of us does, for instance with respect to our families or in response to a moral concern, helps to shape how we are situated, by shaping our lives, and in so doing we alter our standing as people among other people.
So, the argument can now be concluded:
Issues in psychiatric ethics cannot be discussed fruitfully without reference to philosophical concerns about the person;
The notion of the person must be broad;
The situated-embodied-agent view of the person is a characterization, that is, broad enough to reflect and encompass the background hurly-burly of the real world in which human beings live; and furthermore,
This broad view of the person emphasizes the extent to which decisions in psychiatric ethics inevitably change our standing as beings in the world.
Values in practice
The second unique characteristic of psychiatric ethics is the influence of values and the way in which this influence structures clinical practice. Indeed, this would be predicted by the nature of people as situated-embodiedagents. For we are unavoidably situated in a world in which there are both shared and disputed values. Negotiating values is a common feature of clinical practice. But the matter goes deeper than this. First, although the experience of value-conflict is ubiquitous in psychiatric practice (in the hurly-burly of the real world), it is not always considered that this, far from being a nuisance (or perhaps as well as being a nuisance), reflects the intellectual toughness of clinical work. It is in the nature of clinical practice that values must be negotiated. This does not solely refer to the negotiations that might have to occur with patients and their carers, or within or between clinical teams; it also refers to negotiations at the heart of practice. When, for instance, does a wheeze become asthma? Or when does blood pressure become hypertension? Such decisions are values-based as well as evidence-based.
Especially (but not exclusively) in psychiatry, symptoms and signs themselves have to be negotiated (at some level) in order to decide whether or not they are to be regarded as pathological. At what stage ought the psychiatrist to regard unhappiness as depression? The psychiatrist might have to negotiate this with the patient. But there may also have to be an internal negotiation, within the psychiatrist or within the psychiatric community (or the community at large), to hit upon acceptable (e.g. reliable and valid) criteria for saying that a particular symptom or sign is pathological. In psychiatric practice, even delusions, which carry so much clinical significance, turn out to be value-laden concepts [21]. Moreover, there is hardly any point in the whole business of psychiatric classification that does not reflect value judgements or contain evaluative notions [22].
But what are values? In the context we are considering, values reflect that which we prize or consider important in our lives. Most of us would place liberty high up in the scheme of things that we value. There are likely, however, to be some freedoms that are valued more highly than others. The freedom to walk in our neighbourhoods without harassment is probably prized more than the freedom to eat particular foods whenever we wish. Difficulties start to emerge when we consider that talk of values usually implies matters of some weight, rather than trivia. When we start to proclaim that X is something we value, X is normally a weighty matter such as friendship, or liberty itself, or health, or the right to vote, or a host of other matters covered by the term ‘human rights’. The difficulty is that these basic matters, which we prize highly enough to describe as things we value, can sometimes conflict.
In any area ofmedical practicewemight have to give up something of value in order to get better. We might value the benefits of a holiday, but recognize that treatment is required now. The holiday is cancelled because of the value we place on health. In psychiatric practice, however, precisely because values are to the fore (from the level of symptoms to the level of diagnostic categories), there is a greater chance that values will conflict. And this is most starkly shown when it comes to compulsory treatment or detention. Given the value placed on liberty (or freedom), in particular the liberty of the individual to make his or her own decisions (reflected in the principle of respect for autonomy), the decision to deprive a person of liberty ought always to be a grave one. Yet it may sometimes be highly contentious, as when themanic person has no sense of being ill. Forcible treatment, as might occur in anorexia nervosa, is another clear case where a person's (the patient's) values might be disregarded. The usual justification for compulsory detention or treatment is the suggestion that there are other things the person would value were he or she not in the grips of the disease; at the extreme, it is presumed that life would be more highly valued than the person's pathological desires. But these presumptions already contain value judgements about what the patient ought to prize. Furthermore, apart from the health and safety of the person who is deemed to be ill, which it is taken for granted ought to be valued, the safety of others (itself a value) also comes into play. So, the scope for the individual's values to be overwhelmed in psychiatric illnesses is very real.
There is considerable scope for values not to be shared in psychiatric practice. It is important, therefore, that psychiatric ethics should be open to this possibility. One of the problemswith the (so-called) four principles approach to medical ethics [23] – beneficence, non-maleficence, respect for autonomy and justice – is its implicit acceptance of a biomedical model, which takes it for granted that diagnosis is value-free. In psychiatric practice, this is not the case [21],[22]. The person with a psychotic depression, for instance, may or may not require compulsory detention; but the four principles can readily fail to account for the clinical decision that most people would be inclined to accept as correct. In fact, the four principles can either seem just too indeterminate or even so completely irrelevant as to be otiose.
As one of us has argued elsewhere [24], alternative moral theories might get it right inasmuch as they recognize the place of values, but might then get it wrong by the emphasis placed on these values. Thus, casuistry, which starts from the particularities of the individual case, and which, therefore, encourages recognition of the values involved, might nevertheless simply laud the view of the majority, over against minority views (i.e. the views of the patient), because of its tendency toward a social consensus. Meanwhile, perspectivism, which very overtly attends to the points of view of all concerned, runs the risk of a disabling relativism, where no decisions can be made, because ‘anything goes’. The difficulty is that either everyone's values count equally, or the values of the majority override those of the minority.
Luckily, there is emerging a practical approach that takes values seriously and is embedded in the hurly-burly of the real world where values are both shared and disputed. Values-based medicine (VBM) is an approach that is firmly based on theory (the first five principles of VBM), but is also practical in its manner of identifying and dealing with legitimately different values (the second five principles of VBM) [25]. It will not have escaped attention that VBM echoes evidencebased medicine (EBM). They are indeed counterparts, both arising in response to the increasing complexity of health care decisions; but whereas EBM deals with facts, VBM deals with values. In summary form (see [25] for further details), the principles are as follows:
In psychiatric practice, therefore, the background against which our decisions have to be made, the hurly-burly, is the world of shared, but often diverse and disputed, values. Psychiatric ethics has to find a practical way to negotiate these values with care. This type of careful negotiation ought to be the bread and butter of psychiatric practice. The focus on VBM, as a complement to EBM, is a way to encourage good practice. A training manual for VBM, with a range of practical exercises to support the development of the key skills of awareness of values, reasoning, knowledge and communication, has been published by the Sainsbury Centre for Mental Health in partnership with the Department of Philosophy and the Medical School at Warwick University [26]. The manualwas launched in the Summer of 2004, by Rosie Winterton (the Minister of State, with responsibility for mental health) as the basis of a number of national policy initiatives for skills training in mental health in the UK [27–29]. Values-based medicine, as a practical set of ‘tools’, complementing traditional ethics, is also being developed actively in a number of other countries around the world, with early initiatives, for example, in Belgium, Brazil, Holland, South Africa and Sweden.
Conclusions
The unique quality of psychiatric ethics is that it pulls us, on the one hand, deeper into conceptual analysis; on the other hand, it pulls us in the direction of the hurly-burly of not only shared, but also diverse and disputed values in the world. Our final point is that this way of ‘doing ethics’ might provide a paradigm for dealing with issues in practical ethics generally. There needs to be clear, coherent, consistent analysis [2], but there also needs to be an engagement with the constituencies concerned and a commitment to the sort of careful negotiation described by the theory and practice of VBM.
In the remainder of the papers in this special issue, in addition to rational analysis and clear argument, the ‘fresh air of philosophical debate’ [2] will emerge. The need to negotiate the diverse and competing values that bedevil forensic practice are plain in the paper by Adshead and Sarkar [3]. Theway in which our understanding of ‘moral responsibility’ pervades psychiatric practice and draws us to consider the ‘lived experience’ of individuals is shown by McMillan and Gillett [4]. The narrative structure of our lives and the implications this might have for our attempts to heal people whose narratives have been disrupted are clearly laid out by Baldwin [5]. And the possibility that the standing of the individual with Alzheimer's disease, as a semiotic person capable of decision-making, might be undermined is shown by Sabat [6].
In each case, the ethical issues are compounded by their connections to the broader background of empirical facts and normative issues that make up the hurly-burly of the world. Against this background we make our clinical judgements. We engage with real people who, as situated-embodied-agents, must be understood broadly. Their narratives and values must be heard properly and, through good communication, a way forward must be carefully negotiated.
Footnotes
Acknowledgements
We are grateful to Sid Bloch, whose inspiration lies behind this special section on ethics, for graciously inviting us to act as commissioning editors. We are grateful to his successor, Peter Joyce, for encouraging the process to completion. We are grateful to the other authors in this section for their kind cooperation.
1The idea of the social construction of selves is presupposed by both Baldwin [5] and Sabat [6]. This is the idea that our selfhood is created in a social way. The idea is also apparent in works elsewhere contributed to by Gillett [9], who writes in this issue too [4]. Clearly, the idea of the social construction of selves raises important issues in psychological and social theory, as well as in philosophy. It is an idea that has had both significant support and influence [10]. But it also has its critics. Thornton, for instance, while acknowledging its practical, heuristic value, suggests doubts about the possibility that it is coherent to speak of meaning being constructed by a social process such as discourse [
]; by implication, it would be hard to construct a whole self by similar social means.