It is not uncommon for business institutions to position themselves as stakeholder-caring companies or organizations. However, there is little research on conceptualizing stakeholder-caring as a component of brand image. Through a theoretical lens of brand-consumer interactions, this paper introduces a new construct—stakeholder-caring image—and proposes a model that examines stakeholder-caring’s antecedents (integrity and courtesy) and its consequence (customer satisfaction). The two antecedents—integrity and courtesy—capture intrinsic and extrinsic aspects of brand-consumer interaction practice, respectively, while the consequence (customer satisfaction) is one important behavioral (...) outcome in marketing. The proposed model was tested with Hong Kong customers (n = 296) via a systematic survey. The data were analyzed using LISREL. Several measurement and structural models were constructed to test the proposed hypotheses. The findings reveal that the effect of integrity on customer satisfaction is mediated by a stakeholder-caring image. However, contrary to the conventional wisdom, we surprisingly find that courtesy is not effective to build a stakeholder-caring image. Managerially, this research offers guidance on how to develop stakeholder-caring image and subsequently increase customer satisfaction. In addition, we discuss the nuanced distinction between a stakeholder-caring image and related brand constructs, such as “sincerity” in Aaker’s (1997) brand personality framework. (shrink)

It is evident, in the face of the COVID-19 pandemic that has physicians confronting death and dying at unprecedented levels along with growing data suggesting that physicians who care for dying patients face complex emotional, psychological and behavioural effects, that there is a need for their better understanding and the implementation of supportive measures. Taking into account data positing that effects of caring for dying patients may impact a physician’s concept of personhood, or “what makes you, ‘you’”, we adopt Radha (...) Krishna’s Ring Theory of Personhood (RToP) to scrutinise the experiences of physicians working in intensive care units (ICU) using a fictional scenario that was inspired by real events. The impact of death and dying, its catalysts, internal constituents, external factors, dyssynchrony, and buffers, specific to ICU physicians, were identified and explored. Such a framework allows for ramifications to be considered holistically and facilitates the curation of strategies for conflict resolution. This evaluation of the RToP acknowledges the experience and wide-ranging effects it has on ICU physicians. As such, our findings provide insight into their specific needs and highlight the importance of support on a personal and organisational level. Although further research needs to be conducted, the RToP could serve as the basis for a longitudinal assessment tool supported by the use of portfolios or mentorship due to their provision of personalised, appropriate, specific, timely, accessible and long-term support. (shrink)

This chapter gives an outline of the development of the human organ transplant system in Hong Kong, whose key features are a soft opt-in system and strict prohibitions on commercial dealings in human organs for transplant. It is argued that under such a system, there is a lack of incentives for either cadaveric or living organ donations and for family members to endorse deceased donation. This argument is followed by an investigation of the shortage of organ donations in Hong Kong, (...) the limited success of the government promotion to improve the number of donations, and a discussion of new alternatives for improvement that have been initiated or proposed. It is argued that the feasibility and effectiveness of these alternatives are limited and uncertain. More radical reform of the existing system in terms of honorary, compensationalist, and familist incentives is needed and they all need to be taken into consideration. (shrink)

T'ang Chün-i's early work Ai-ching chih fu-yin (Gospel of love) has been much neglected by T'ang scholars. This essay argues that this text is not a caprice, and that it marks an important stage in T'ang's life and studies. Furthermore, in the history of Chinese philosophy, it is probably the first book ever written on the philosophy of love.

Increasing the tax compliance of self-employed business owners—particularly of trade-specific service providers such as those involved in construction and repair work—remains an ongoing challenge for tax authorities. From a compliance point of view, cash transactions are particularly problematic when services are paid for on the spot, as these exchanges are difficult to audit. We present experimental evidence testing ten different policy strategies rooted in the enforcement, service, and trust/social paradigms, in a setting that allows payment either via a transaction that (...) directly reports income for tax collection purposes or in cash, where taxes are only collected on reported income. Our sample includes both a typical subject pool of students, as used in most previous studies, and non-students who are active within service industries characterised by the opportunity to engage in cash transactions. While our comparative results show that, for both student and non-student participants, interventions that rely on greater enforcement by the tax authority have the greatest effect on compliance in our cash economy setting, treatments involving cooperative elements may be similarly effective in enhancing tax compliance. Given their effectiveness, cooperative approaches should therefore be considered for addition to the policy mix if implemented at relatively low costs, making both carrot and stick approaches promising to increase compliance in an environment where cash-for-service payments offer a common benefit for small businesses and their customers from implicit collusion that enables tax evasion. (shrink)

Because of the importance of Confucian doctrines in shaping ethical business practices under Chinese leadership, revealing the roles of other Chinese ethical doctrines in modern Chinese leadership is informative. A thorough understanding of the ethical foundations of Chinese leadership is necessary for fruitful interaction with Chinese leaders, according to cultural fit theory. The present study illustrates the philosophical foundations of business management, based on dialogues with five eminent corporate executive officers. It reveals that the CEOs practice a style of Chinese (...) leadership synthesizing Confucian, Daoist, Mohist, and Legalist doctrines. The Confucian doctrines advocate benevolence, harmony, learning, loyalty, righteousness, and humility. They are the most prevalent tenets that support paternalism and collectivism. The Daoist doctrines emphasize flexibility and reversion. They bolster the leader's forbearance. The Mohist doctrines underpin thrift and working with the masses whereas the Legalist doctrines inculcate self-control and innovativeness. Hence, contemporary Chinese leadership does not rely exclusively on Confucian ethics and this reflects evolution over 1000s of years. (shrink)

Metacognitive training (MCT) was developed to promote awareness of reasoning biases among patients with schizophrenia. While MCT has been translated into 31 languages, most MCT studies were conducted in Europe, including newer evidence recommending an individualized approach of delivery. As reasoning biases covered in MCT are separable processes and are associated with different symptoms, testing the effect of selected MCT modules would help to develop a targeted and cost-effective intervention for specific symptoms and associated mechanisms. This study tested the efficacy (...) of a 4-session metacognitive training for delusions, MCTd (in Traditional Chinese with cultural adaptations, provided individually), as an adjunct to antipsychotics in reducing severity and conviction of delusions, jumping to conclusions bias and belief inflexibility. Forty-four patients with delusions were randomized into the MCTd or the wait-list control condition. Patients on wait-list received the same MCTd after four weeks of treatment as usual. Assessment interviews took place before and after the treatment, and at 4-week follow-up. There was an additional baseline assessment for the controls. Jumping to conclusions and belief flexibility were measured by the beads tasks and the Maudsley Assessment of Delusions Scale. Attendance rate of the MCTd was satisfactory (84.5%). Compared to treatment as usual, there was a greater reduction in psychotic symptoms, delusional severity and conviction following MCTd. There was a large treatment effect size in improvement in belief flexibility. Improvement in reaction to hypothetical contradiction predicted treatment effect in positive symptoms and delusions. Jumping to conclusions bias was reduced following MCTd, although the treatment effect was not significantly larger than TAU. Our results support the use of process-based interventions that target psychological mechanisms underlying specific psychotic symptoms as adjuncts to more conventional approach. (shrink)

Because of the importance of Confucian doctrines in shaping ethical business practices under Chinese leadership, revealing the roles of other Chinese ethical doctrines in modern Chinese leadership is informative. A thorough understanding of the ethical foundations of Chinese leadership is necessary for fruitful interaction with Chinese leaders, according to cultural fit theory. The present study illustrates the philosophical foundations of business management, based on dialogues with five eminent corporate executive officers (CEOs). It reveals that the CEOs practice a style of (...) Chinese leadership synthesizing Confucian, Daoist, Mohist, and Legalist doctrines. The Confucian doctrines advocate benevolence, harmony, learning, loyalty, righteousness, and humility. They are the most prevalent tenets that support paternalism and collectivism. The Daoist doctrines emphasize flexibility and reversion (e.g., the principle that the weak can defeat the strong). They bolster the leader’s forbearance. The Mohist doctrines underpin thrift and working with the masses whereas the Legalist doctrines inculcate self-control and innovativeness. Hence, contemporary Chinese leadership does not rely exclusively on Confucian ethics and this reflects evolution over 1000s of years. (shrink)

Background Care homes have been disproportionately affected during the COVID-19 pandemic. Practical challenges of enacting infection control measures in care home settings have been widely reported, but little is known about the ethical concerns of care home staff during the implementation of such measures.. Objectives To understand the ethical challenges perceived by care home staff during the early months of the COVID-19 pandemic. Research design An exploratory qualitative study. Participants and research context A purposive sample of 15 care home staff (...) in different roles and ranks in Hong Kong was recruited to take part in semi-structured interviews between June and August 2020. Ethical considerations Ethical approval for this study was obtained. Participation was voluntary and anonymous. Participants had the right to withdraw from the study at any time without reprisal. Findings Three themes were identified: unclear legitimacy regarding infection control measures, limited autonomy in choices over infection control measures and inevitable harms to residents’ well-being. While the participants expected that they would have legitimated power to implement infection control measures, they were resistant when their right to self-determination of testing and vaccination was infringed. They also felt trapped between ethical duties to protect care home residents from infection risk and the anticipated detrimental effects of infection control measures. Conclusions The findings of this study reveal tensions among the ethical obligations of care home staff in response to a public health emergency. They highlight the importance of strengthening ethical sensitivity and ethical leadership in identifying and resolving the challenges of pandemic responses. (shrink)

Background Supporting physicians in Intensive Care Units s as they face dying patients at unprecedented levels due to the COVID-19 pandemic is critical. Amidst a dearth of such data and guided by evidence that nurses in ICUs experience personal, professional and existential issues in similar conditions, a systematic scoping review is proposed to evaluate prevailing accounts of physicians facing dying patients in ICUs through the lens of Personhood. Such data would enhance understanding and guide the provision of better support for (...) ICU physicians. Methods An SSR adopts the Systematic Evidenced Based Approach to map prevailing accounts of caring for dying patients in ICUs. To enhance the transparency and reproducibility of this process, concurrent and independent use of tabulated summaries, thematic analysis and directed content analysis is adopted. Results Eight thousand three hundred fifty-eight abstracts were reviewed from four databases, 474 full-text articles were evaluated, 58 articles were included, and the Split Approach revealed six categories/themes centered around the Innate, Individual, Relational and Societal Rings of Personhood, conflicts in providing end of life care and coping mechanisms employed. Conclusion This SSR suggests that caring for dying patients in ICU impacts how physicians view their personhood. To resolve conflicts within individual concepts of personhood, physicians use prioritization, reframing and rely on accessible, personalized support from colleagues to steer coping strategies. An adapted form of the Ring Theory of Personhood is proposed to direct timely personalized, appropriate and holistic support. (shrink)

This book is a collection of articles on different aspects of university education in China since the late nineteenth century, addressing how far the ideal of modern university education, which has gradually been developed in the West since the age of European Enlightenment, was adopted or transformed by Chinese universities.

Background:Suicide remains an important cause of premature deaths and draws much media attention. However, unsafe reporting and portrayal of suicides by the media have been associated with increased risk of suicidal behavior. Current evidence suggests that media capacity-building could potentially prevent suicide. However, there are still knowledge gaps in terms of a lack of data on effective strategies for improving awareness and safe reporting of suicide-related media content. This study aims to investigate the effectiveness of a workshop conducted with members (...) of the media community on the safe reporting of suicide-related content.Methods:An interventional single-arm pre and post pilot study was conducted on a sample of the Malaysian media community recruited through purposive and snowball sampling. The media safe reporting workshop was conducted by a suicide prevention expert with a media industry background. Thirty participants completed a self-reported evaluation questionnaire on their awareness and knowledge of reporting on suicide-related media content; before and after the interventional workshop.Results:There was a significant difference between the total scores before and after the intervention, with a large effect size. Post-intervention scores were significantly improved in 8 items, namely those related to the reporting of: (i) the content of any suicide note; (ii) headlines with methods of suicide; (iii) headlines with the location of suicide; (iv) cases of suspected suicide despite the unconfirmed cause of death; (v) suicide news to cater to readers’ interests; (vi) cause of suicide; (vii) details of the location of suicide; and (viii) the negative impact to media community when reporting suicide stories. In particular, there was an improvement in the majority of items for people from the media community with no lived experience of suicidal behavior.Conclusion:The media safe reporting workshop is a potentially effective intervention for improving awareness and knowledge measures relating to safe reporting on suicide among the media community, with a more pronounced effect in those without lived experience of suicidal behavior. Limitations in the sample size, generalizability, short-term evaluation, and lack of a control group warrant future larger, longer-term controlled, and more representative studies. (shrink)

For two thousand years the Mencius was revered as one of the foundational texts of the Confucian canon, which formed the basis of traditional Chinese education. Today it commands considerable attention in current debates on "Asian values" raging in classrooms and boardrooms in both East Asia and the West. This volume, which represents the work of fifteen respected scholars of early Chinese thought and culture, is an especially timely effort to bring the Mencius under fresh scrutiny. Making use of recently (...) excavated manuscripts, the contributors approach the Mencius from novel perspectives, challenge established interpretations, and confront anew issues that continue to attract and divide students of this classic text. The famous Mencian doctrine of the "goodness" of human nature forms one main focus. Questions of context and interpretation bring into sharp relief key hermeneutical issues that surround the text. Does the Mencius present a coherent and systematically developed ethical teaching? Or should it be read as a composite work, comprising different layers of material that reflect different emphases and conflicting doctrines? Traversing contested territories and exploring new avenues of understanding, the essays presented here do not aim at settling debates; on the contrary, they afford ample opportunities for further discussion on the background, interpretation, and continued relevance of this classic of Confucian philosophy. Contributors: Roger T. Ames, Irene Bloom, A. Taeko Brooks, E. Bruce Brooks, Alan K. L. Chan, Kim-Chong Chong, Antonio S. Cua, Robert Eno, Jiuan Heng, Donald J. Munro, Ning Chen, David Nivison, Kwong-Loi Shun, Sor-Hoon Tan. (shrink)

For two thousand years the Mencius was revered as one of the foundational texts of the Confucian canon, which formed the basis of traditional Chinese education. Today it commands considerable attention in current debates on "Asian values" raging in classrooms and boardrooms in both East Asia and the West. This volume, which represents the work of fifteen respected scholars of early Chinese thought and culture, is an especially timely effort to bring the Mencius under fresh scrutiny. Making use of recently (...) excavated manuscripts, the contributors approach the Mencius from novel perspectives, challenge established interpretations, and confront anew issues that continue to attract and divide students of this classic text. The famous Mencian doctrine of the "goodness" of human nature forms one main focus. Questions of context and interpretation bring into sharp relief key hermeneutical issues that surround the text. Does the Mencius present a coherent and systematically developed ethical teaching? Or should it be read as a composite work, comprising different layers of material that reflect different emphases and conflicting doctrines? Traversing contested territories and exploring new avenues of understanding, the essays presented here do not aim at settling debates; on the contrary, they afford ample opportunities for further discussion on the background, interpretation, and continued relevance of this classic of Confucian philosophy. Contributors: Roger T. Ames, Irene Bloom, A. Taeko Brooks, E. Bruce Brooks, Alan K. L. Chan, Kim-Chong Chong, Antonio S. Cua, Robert Eno, Jiuan Heng, Donald J. Munro, Ning Chen, David Nivison, Kwong-Loi Shun, Sor-Hoon Tan. (shrink)

Essentiellement composé de photographies aériennes, Earthscape est néanmoins un ouvrage de phénoménologie. Après avoir commencé des études d’architecture, puis soutenu une thèse de doctorat en philosophie à Freiburg, son auteur, Chan-fai Cheung, qui a dirigé le département de philosophie de la Chinese University of Hong Kong, met en effet, en tant que photographe, en suspens nos appréhensions habituelles et, pour ainsi dire, naturelles de la terre ; comme l’écrit Bernhard Waldenfels à propos...

What should we do about “tainted” public commemorations? Recent events have highlighted the urgency of reaching a consensus on this question. However, existing discussions appear to be dominated by two naïve opposing views – to remove or preserve them. My aims in this essay are two-fold. First, I argue that the two views are not naïve, but undergirded by concerns with securing self-respect and with the character of our engagement with the past. Second, I offer a qualified defence of vandalising (...) tainted commemorations. The defence comprises two parts. I consider two prominent suggestions – to install counter-commemorations and to add contextualising plaques – and argue that they are typically beset with difficulties. I then argue that in some circumstances, constrained vandalism is a response to tainted commemorations which effectively adjudicates the demands of the two opposing views. (shrink)

The term, "objectionable commemorations”, refers to a broad category of public artefacts – such as, and especially, memorials, monuments and statues – that are regarded as morally problematic in virtue of what or whom they honour. In this regard, they are a special class of public artefacts that are subject to public contestation. In this paper, we survey the general ethical and political issues on this topic. First, we categorise the arguments on offer in the literature, concerning the objectionable nature (...) of such commemorations. Second, we review common political responses to objectionable commemorations. Finally, we identify fruitful areas for further philosophical inquiry on this topic. (shrink)

I review José Medina's The Epistemology of Protest: Silencing, Epistemic Activism, and the Communicative Life of Resistance, and raise some questions about the felicity, legitimacy and civility of protest.

성리학의 이기론을 체계화한 16세기 학자 율곡 이이 의 생애와 사상, 학문을 살핀 저서.

The concept of the cheng xin in the Zhuangzi claims that the cognitive function of the heart-mind is not over and above its affective states and in charge of them in developing and controlling virtue, as assumed by the Confucians and others. This joint cognitive and affective nature of the heart-mind denies ethical and epistemic certainty. Individual perspectives are limited given habits of thought, attitudes, personal orientations and particular cognitive/affective experiences. Nevertheless, the heart-mind has a vast imaginative capacity that allows (...) the open-endedness and broadening of perspectives. (shrink)

Lun heng / Wang Chong zhuan -- Feng su tong yi / Ying Shao zhuan -- Feng shi wen jian ji / Feng Yan zhuan -- Shang shu gu shi / Li Chuo zhuan -- Guan qi xia yu / bu zhao zhuan ren -- Chun ming tui chao lu / Song Minqiu zhuan -- Song Jingwen bi ji / Song Qi zhuan -- Dong yuan lu / Gong Dingchen zhuan -- Wang shi tan lu / Wang Qinchen zhuan (...) -- Zhu shi / Wang Dechen zhuan -- Wen chang za lu : bu yi / Pang Yuanying zhuan -- Mengxi bi tan : bu bi tan / Shen Kuo zhuan. (shrink)

Both Carnap and Quine made significant contributions to the philosophy of mathematics despite their diversed views. Carnap endorsed the dichotomy between analytic and synthetic knowledge and classified certain mathematical questions as internal questions appealing to logic and convention. On the contrary, Quine was opposed to the analytic-synthetic distinction and promoted a holistic view of scientific inquiry. The purpose of this paper is to argue that in light of the recent advancement of experimental mathematics such as Monte Carlo simulations, limiting mathematical (...) inquiry to the domain of logic is unjustified. Robustness studies implemented in Monte Carlo Studies demonstrate that mathematics is on par with other experimental-based sciences. (shrink)

The Humility Thesis is a persistent thesis in contemporary metaphysics. It is known by a variety of names, including, but not limited to, Humility, Intrinsic Humility, Kantian Humility, Kantian Physicalism, Intrinsic Ignorance, Categorical Ignorance, Irremediable Ignorance, and Noumenalism. According to the thesis, we human beings, and any knowers that share our general ways of knowing, are irremediably ignorant of a certain class of properties that are intrinsic to material entities … Continue reading Humility Regarding Intrinsic Properties →.

A common assumption in the selection of nonhuman animal subjects for research and the approval of research is that, if the risks of a procedure are too great for humans, and if there is a so-called scientific necessity, then it is permissible to use nonhuman animal subjects. I reject the common assumption as neglecting the central ethical issue of the permissibility of using nonhuman animal subjects and as being inconsistent with the principle of justice used in human subjects research ethics. (...) This principle requires that certain classes of individuals not be subjected to a disproportionate share of the burdens or risks of research. I argue for an extension of this principle to nonhuman animal research and show that a prima facie violation of the principle occurs because nonhuman animals bear an overwhelmingly disproportionate share of the risks of research without sufficient justification or reciprocal benefit. (shrink)

In this paper, we describe four broad ‘meta-methods’ employed in scientific and philosophical research of qualia. These are the theory-centred metamethod, the property-centred meta-method, the argument-centred meta-method, and the event-centred meta-method. Broadly speaking, the theory-centred meta-method is interested in the role of qualia as some theoretical entities picked out by our folk psychological theories; the property-centred meta-method is interested in some metaphysical properties of qualia that we immediately observe through introspection ; the argument-centred meta-method is interested in the role of (...) qualia in some arguments for non-physicalism; the event-centred metamethod is interested in the role of qualia as some natural events whose nature is hidden and must be uncovered empirically. We will argue that the event-centred metamethod is the most promising route to a comprehensive scientific conception of qualia because of the flexibility of ontological and methodological assumptions it can provide. We also reveal the hidden influences of the different meta-methods and in doing so show why consideration of meta-methods has value for the study of consciousness. (shrink)

While it is well known that Zhuangzi uses metaphor extensively, there is much less appreciation of the role that it plays in his thought-a topic that is investigated in this essay. At the same time, this investigation is closely concerned with questions about the nature of metaphor. Comparisons are made between a central metaphorical structure in the Zhuangzi on the one hand and contemporary views of the nature of metaphor by Donald Davidson and by Lakoff and Johnson on the other. (...) It is hoped that these comparisons will help to illuminate the central metaphorical structure and its role in the philosophy of the Zhuangzi. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical CommentaryChong Siow Ann, Associate ProfessorDr. G appears to experiencing symptoms of schizophrenia, which is arguably the most severe mental disorder and which afflicts about one in a hundred people. This is a psychotic disorder that causes disturbances and distortions in thinking, including neurocognitive impairments, perception and behaviour. There is no cure for this often devastating disorder. Current antipsychotic medications can alleviate some of the symptoms but it often (...) comes at a price as these antipsychotics have burdensome side effects.A feature of this disorder is anosognosia, which is a lack of awareness or “insight” that an illness is present. This lack of insight presents a particular challenge because these individuals would, as in the case of Dr. G, refuse needed treatment as they do not perceive that they are ill. This is not necessarily an all-or-none phenomenon but is rather more complex and multidimensional; there might be an unawareness or recognition on behalf of the patient that they are suffering from a mental illness, the failure to appreciate the necessity of treatment; and/or the inability to recognise and define the psychotic symptoms like unusual thoughts and hallucinations as signs of illness1 and in many instances, all three are present. It is also by no means uncommon. Studies have found that between 60% and 80% of people with schizophrenia lack awareness of their illness to varying degrees.2This phenomenon remains an enigma. Some regard it as a form of psychological defence against the harsh reality of a psychotic illness — awareness of having a chronic and devastating illness might lead to demoralisation, hopelessness and suicide.3 Recent research, however, [End Page 250] indicates that this psychological denial plays a small part, if any, and instead has found an association with certain neuropsychological and neurocognitive deficits,4 as well as functional and structural brain abnormalities in the frontal lobe of the brain.5The prevailing clinical view thus is that this is an intrinsic and organic aspect of the schizophrenic illness which has nothing to do with wilfulness but rather the incapacity to perceive the presence of the illness. Edwin Fuller Torrey, an eminent psychiatrist and executive director of the Stanley Medical Research Foundation, calls anosognosia the “single largest reason why individuals with schizophrenia and bipolar disorder do not take their medications”, and he has remarked that “to keep talking about civil liberty is illogical. Patients are anything but free when they’re at the beck and call of their own delusions”.6It is also this view that it is a product of a brain disorder that some — particularly patients — find unacceptable. At one level, it does not take into context the person’s own experiences, and at a deeper level it calls into question the conception of the self with its capacity to exercise judgements and the autonomy to make decisions.This is a perennial ethical issue in psychiatry when people with severe mental illnesses refuse treatment. This becomes a Catch-22 situation where part of the illness that needs treatment is also preventing any treatment to be given: implicit in the principle of informed consent for treatment is that the person should be aware of the nature and course of their illness and acknowledge the need for treatment. While there are laws for involuntary commitment, the bar is usually high in that there must be a clear and present risk of harm to the person or others. Alan Stone, a professor of law and psychiatry at Harvard University proposed a possible justification for involuntary treatment based on his “thank-you theory” which assumes that patients will become well and subsequently agree that the intervention was in their best interests but research suggests that only half of these patients would admit so.7One suggested mechanism is the use of advance directives — psychiatry’s version of the living will in which people can specify what sort of medical care they would like should they become mentally unwell and unable to exercise appropriate judgement. An intrinsic part of this might include a “Ulysses contract” — just as Ulysess instructed his crew to lash him to the mast of the his ship so that he could... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Underplayed Ethics and the Dilemmas of Psychiatric CareChong Siow Ann and Tamra LysaghtThe practice of psychiatry is fraught with uncertainty. The exact causes and the biological substrates underlying mental disorders remain to be elucidated; even the diagnosis of these disorders is descriptive and not based on an etiological understanding and no biological diagnostic markers have been validated. The manifestation of almost all mental disorders results from a complex interaction (...) of biological and environmental factors which encompasses the patient’s unique life history, experiences and relationship with others and the community. In the face of such uncertainties — at times extending to the types of treatment (psychiatry is generally acknowledged not be an exact science) — it has been argued that adopting a pragmatic approach is necessary.1 Accordingly, this approach necessitates high ethical standards among mental health practitioners.Some mental illnesses are associated with varying degrees and types of cognitive impairments. Others have certain symptoms like auditory hallucinations and delusions that might severely compromise the patients’ autonomy, distort their sense of reality, increase the risk of harm to themselves or others and render them incapable of making informed decisions in their treatment and participation in research.Consequently, there are issues that are particular to the provision of mental healthcare. These include the need for enforced involuntary treatment with the corollary of depriving a patient of his personal liberty even [End Page 173] though it is often justified on the grounds that it is in the patient’s best interests. However, at times, it is the legal and societal obligation of mental health practitioners to protect those who might be harmed from the patient’s action that might seem to be more pressing. In this situation of double agency, lies the tension of providing confidential care for patients and acting as “an agent of the state” where that patient’s confidentiality might be breached and his liberty infringed upon. This situation is further aggravated by the stigma that clings ever so tenaciously to those who suffer from mental disorders and where it is the norm to stereotype them as dangerous and unpredictable.Consideration of a patient’s autonomy is also challenged by characteristics that are unique to the practice of psychiatry. The prescription of certain psychotropic medications can alter how people think and feel, while psychotherapy works towards changing the patient’s views and values. The philosopher, Jennifer Radden, describes this process as “re-forming the patient’s whole self or character … akin to the responsibilities of raising children”.2 The psychotherapeutic relationship is thus particularly personal and intimate because patients are asked to provide information that often reveals their innermost feelings, fears and fantasies. This information is provided on the basis of trust and assurance of confidentiality, and with expectation of being helped.Jeremy Holmes and Gwen Adshead have elaborated on the vulnerability of patients seeking psychotherapy: they might be particularly susceptible to exploitation because their past experiences of being exploited have led to their distress and help seeking — their dependency and the extreme privacy of the therapeutic relationship make any transgression difficult to be uncovered.3 There is a calamitous combination of the “unconscious wish in the patient to be used” with the complicity of an unethical therapist seeking to fulfil his own interests.4As in any other doctor-patient relationship, the relationship between the mental healthcare practitioner and the patient is one of unequal power where the former is ascendant. While that power should be exercised to heal and to relieve suffering, it also gives the practitioner tremendous power “to harm, reject, misunderstand, or exploit patients who struggle with the experience of mental illness, which itself may generate helplessness, despair, distress, and exceptional dependence on the clinician”.5 Given the potential of doing good and harm coupled with the likelihood of being so significant in the life of the patient,6 providing care for those with mental disorders and distress is necessarily ethically exacting — arguably more so than in other medical practice settings. [End Page 174]This precariousness has led to the suggestion that ethics in psychiatry should have a special status and that the more general principles of biomedical ethics are too limited in scope to... (shrink)