Ethical issues are pivotal to the practice of psychiatry. Anyone involved in psychiatric practice and mental healthcare has to be aware of the range of ethical issues relevant to their profession. An increased professional commitment to accountability, in parallel with a growing "consumer" movement has paved the way for a creative engagement with the ethical movement. The bestselling 'Psychiatric Ethics' has carved out a niche for itself as the major comprehensive text and core reference in the field, (...) covering a range of complex ethical dilemmas which face clinicians and researchers in their everyday practice. This new edition takes a fresh look at recent trends and developments at the interface between ethics and psychiatric practice. Coming ten years after the third edition, the editors have observed several emerging aspects of psychiatric practice requiring coverage, as a result, 5 new chapters have been added, including cutting edge topics - such as neuroethics. All other chapters have been fully revised and updated. The book will continue to be essential reading for psychiatrists, psychologists, other mental health professionals, and bioethicists, as well as of interest to policy makers, managers and lawyers. (shrink)

This new edition of Psychiatric Ethics continues to serve as the most authoritative and comprehensive text on the many complex ethical dilemmas which face the clinician in everyday practice. In addition to addressing questions about drug therapy, sex therapy, suicide, and child psychiatry, among others, this up-to-date revision adds six new chapters discussing abuses in psychiatry in Japan and Nazi Germany; a conceptual analysis of what mental illness is; psychiatry as a profession; the ethical aspects of psychogeriatrics; and (...) deinstitutionalization. This book is essential reading for all mental health professionals. (shrink)

The chapter traces the history of psychiatric ethics with a focus on the emergence of autonomy and how assumptions and thresholds surrounding informed consent and decision-making capacity have changed over the centuries. Innovators like Philippe PInel and William Tuke are featured in this account of how the 'mad' and the abuses of the 'domestication paradigm' of madness eventually gave way to more humanitarian approaches of treating the 'mad', like moral treatment. The chapter closes with a brief reflection regarding (...) the limits of autonomy and the decline of paternalism in psychiatric ethics. (shrink)

Psychiatric ethics spans several overlapping domains, including the guidelines for ethical research in psychiatry, the professional ethics required in the practice of psychiatry, and a broader set of moral and ethical problems and dilemmas distinctive to, or at least magnified by, the mental health care setting. Reviewed here are selected issues arising in the last two domains, some seemingly inevitable components of mental disorder and its cultural history and others resultant from recent changes and discoveries. Even as (...) science explains and demystifies mental disorder, it is concluded, new ethical problems will continue to arise in psychiatry and certain recalcitrant problems will likely persist. (shrink)

Australia has one of the harshest regimes for the processing of asylum seekers, people who have applied for refugee status but are still awaiting an answer. It has received sharp rebuke for its policies from international human rights bodies but continues to exercise its resolve to protect its borders from those seeking protection. One means of doing so is the detention of asylum seekers who arrive in Australia by boat. Health care providers who care for asylum seekers in these conditions (...) experience a conflict of “dual loyalty,” whereby their role in preserving and maintaining the health of patients can run counter to their employment in detention facilities. Many psychiatrists who have worked in the detention setting engage in forms of political activism in order to change the process of seeking refuge. (shrink)

This book is derived from the author's Concise guide to ethics in mental health care, published in 2004. It has been revised, updated, and rewritten with new chapters, topics and data.

The Oxford Handbook of Psychiatric Ethics is the most comprehensive treatment of the field in history. The volume is organized into ten sections which survey the scope of the text: Introduction, People Come First, Specific Populations, Philosophy and Psychiatric Ethics, Religious Contexts of Psychiatric Ethics, Social Contexts of Psychiatric Ethics, Ethics in Psychiatric Citizenship and the Law, Ethics of Psychiatric Research, Ethics and Values in Psychiatric Assessment (...) and Diagnosis, Ethics and Values in Psychiatric Treatment. Written and edited by an international team of experts, this landmark book provides a powerful and compelling review of psychiatric ethics in the 21st Century. (shrink)

The on-the-ground case conference at the interface of philosophical ethics and clinical psychiatry is an innovative idea that advances pedagogy in presenting a creative approach to teaching and practicing psychiatric ethics. In the current exercise of the proposed partnership, there was a generally positive outcome. The philosopher and the psychiatrist learned from each other, were able to find norms that made their collaboration productive, and found that clinical care was enhanced. My commentary aims to help others replicate (...) this model, and preserve its virtues without its vulnerabilities.Would a mathematical logician or philosopher of aesthetics be as good of a collaborator as a moral philosopher? Probably not.... (shrink)

Book reviewed in this article: Philosophy in Medicine: Conceptual and Ethical Problems in Medicine and Psychiatry. By Charles M. Culver and Bernard Gert. Psychiatric Ethics. Edited by Sidney Block and Paul Chodoff. Man, Mind, and Morality: The Ethics of Behavior Control. By Ruth Macklin.

This title includes the following features: Presents a comprehensivediscussion of the central issues of psychiatric ethics, defining and exploringeach of these issues; Contains essential readings for each of these central issues, providing in onevolume readings that would otherwise be difficult to obtain; Includes introductory essays that provide a comprehensive overview of eachissue, efficiently and effectively organizing the reader's approach to theselected readings; Draws on the success of the well-known and respected 'PsychiatricEthics'.

In his paper, A Logic in Madness, Aaron Hauptman describes the evolving clinical picture of Mr. A, a patient with Asperger’s syndrome who presents with symptoms consistent with a major depressive episode. In his case discussion, Hauptman describes the difficulties, both conceptual and practical, faced by the clinical team in trying to help this man recover from his depression. Among these he identifies: ‘the ethics of mandated treatment, definitions of mental illness, rationality in the context of psychiatric disorders, (...) and the limitations on patient autonomy in a psychiatric inpatient setting’. In this response to Hauptman’s paper, I discuss the first and last concerns with emphasis on... (shrink)

This chapter explores four kinds of skepticism about autonomy in general and its applicability to psychiatric ethics in particular. It is argued that although there are valuable lessons to be learnt from each of these skeptical challenges, their overall contribution is best understood in terms of friendly correctives to an autonomy-centered normative and conceptual framework instead of viable alternatives to it. The first four sections each provide a logical reconstruction of a distinct skeptical line of reasoning about autonomy (...) and expand on its implications for psychiatric ethics: skepticism about personal autonomy; skepticism about autonomy as an agency concept; vulnerability-grounded skepticism about autonomy; and paternalism-friendly skepticism about autonomy. The fifth section identifies and explores the underlying presuppositions that motivate the previously discussed forms of skepticism about autonomy, and the sixth reflects on the significance of psychiatric ethics for rebutting skepticism about autonomy and developing a new, more promising positive theory. (shrink)

The essay by Potter and El-Mallakh proposes "on the ground" consultations in psychiatric ethics as a novel style of bioethics deliberation. The continual dialogue between a moral philosopher and clinician creates the opportunity for informal real-time ethical thinking as cases unfold, instead of formal ethics committee reviews and instead of the artificially simple scenarios found in much bioethics literature. The essay has important practical implications for ethics pedagogy during psychiatric training and in mental health settings (...) more generally. It also has important theoretical implications for the cross-talk between... (shrink)

In Two Minds is a practical casebook of problem solving in psychiatric ethics. Written in a lively and accessible style, it builds on a series of detailed case histories to illustrate the central place of ethical reasoning as a key competency for clinical work and research in psychiatry. Topics include risk, dangerousness and confidentiality; judgements of responsibility; involuntary treatment and mental health legislation; consent to genetic screening; dual role issues in child and adolescent psychiatry; needs assessment; cross-cultural and (...) gender issues; rational and irrational suicide; shared decision making in multi-agency teams, and the growing role of the user's voice in psychiatry. Key ethical concepts are carefully introduced and explained. The text is richly supported by detailed guides for further reading. There are separate chapters on teaching psychiatric ethics, including a sample seminar, and on writing a research ethics application. Each case history and discussion is followed by a critical commentary from a practitioner with relevant experience. Jim Birley adds a comparative international perspective on psychiatric ethics. Cartoons by Johnny Cowee provide punchy counterpoint! In Two Minds is the sister volume to the third edition of Sidney, Paul Chodoff and Steven Green's highly successful Psychiatric Ethics. In providing a bridge between theory and practice, it will be essential reading for everyone concerned with improving standards in mental health care. (shrink)

The evolution of the internet and associated social media pose novel challenges for psychiatric ethics. Issues surrounding emotional contagion, personal identity, and misinformation figure importantly among these new challenges, with important consequences for consumers of mental health services, as well as psychiatrists and other mental health professionals. The evolution of the internet and associated social media pose novel challenges for psychiatric ethics. Issues surrounding emotional contagion, personal identity, and misinformation figure importantly among these new challenges, with (...) important consequences for consumers of mental health services, as well as psychiatrists and other mental health professionals. (shrink)

Psychiatric ethics as professional and biomedical ethics -- The distinctiveness of the psychiatric setting -- Psychiatric ethics as virtue ethics -- Elements of a gender-sensitive ethics for psychiatry -- Some virtues for psychiatrists -- Character and social role -- Case studies in psychiatric virtues.

This case consultation offers three cases that illustrate a collaborative consultation model for psychiatric ethics that we have developed in outpatient clinic and in emergency psychiatry over the last 10 years. After we present these cases, we discuss three points of interest: 1) the characteristics we found to be important to our collaborative project, 2) the benefits of an integrative approach, and 3) ways that our collaborative moral reasoning developed our awareness of and sensitivity to ethical issues. We (...) end by raising some topics on which commentators could engage.Potter began working with El-Mallakh more than 10 years ago. Her impetus was that she was writing a critique of the criteria used in borderline... (shrink)

Extant business research has not addressed the ethical treatment of individuals with psychiatric disabilities. This article will describe previous research on individuals with psychiatric disabilities drawn from rehabilitation, psychological, managerial, legal, as well as related business ethics writings before presenting a framework that illustrates the dynamics of (un)ethical behavior in relation to the employment of such individuals. Individuals with psychiatric disabilities often evoke negative reactions from those in their environment. Lastly, we provide recommendations for how employees (...) and organizations can become more proactive in providing individuals with such disabilities equal employment opportunities for both access and accommodation in the workplace. (shrink)

Utilitarianism is one of the “grand Enlightenment” moral philosophies. It provides a means of evaluating the ethical implications of common and unusual situations faced by psychiatrists, and offers a logical and ostensibly scientific method of moral justification and action. In this first of our two papers, we trace the evolution of utilitarianism into a contemporary moral theory and review the main theoretical critiques. In the second paper we contextualize utilitarianism in psychiatry and consider its function within the realm of the (...) professional ethics of psychiatrist as physician, before applying it to two dilemmas faced by psychiatrists as individuals and as members of a profession. We conclude that psychiatry must search beyond utilitarianism in grappling with everyday clinical scenarios. (shrink)

Background Psychiatric electroceutical interventions (PEIs) use electrical or magnetic stimulation to treat mental disorders and may raise different ethical concerns than other therapies such as medications or talk therapy. Yet little is known about stakeholders’ perceptions of, and ethical concerns related to, these interventions. We aimed to better understand the ethical concerns of a variety of stakeholder groups (patients with depression, caregivers of patients, members of the public, and psychiatrists) regarding four PEIs: electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (...) (rTMS), deep brain stimulation (DBS), and adaptive brain implants (ABI).Methods We conducted a national survey of these four stakeholder groups, using an embedded video vignette experiment depicting a patient with treatment-resistant depression and her psychiatrist discussing the possibility of treatment with one of the four PEIs.Results Participants’ ethical concerns varied by stakeholder group, by PEI, and by the interaction of the two. The three non-clinician groups tended to have similar ethical concerns, but to differ from psychiatrists. Similar concerns were raised with regard to the two implantable technologies, DBS and ABI. Overall, there was relatively little concern about the involuntary use of PEIs, though some expressed concern about the adequacy of information provided during the consent process. There was also significant concern that patients may not receive helpful therapies.Conclusions To our knowledge, this is the first national survey that includes multiple stakeholder groups and multiple PEI modalities. A better understanding of the ethical concerns of stakeholders can help to shape clinical practice and health care policy regarding PEIs. (shrink)

Two general ethical problems in psychiatry are thrown into sharp relief by long term care. This article discusses each in turn, in the context of two anonymised case studies from actual clinical practice. First, previous mental health legislation soothed doubts about patients' refusal of consent by incorporating time limits on involuntary treatment. When these are absent, as in the provisions for long term care which have recently come into force, the justification for compulsory treatment and supervision becomes more obviously problematic. (...) Second, Anglo-American law does not normally allow the preventive detention of someone who may be dangerous but has not actually committed any crime. The justification for detaining a possibly dangerous user of mental health services without his or her consent can only be based on risk assessment, but this raises issues of moral luck. Is the psychiatrist who decides not to take out a supervision order for a possibly dangerous patient with an initial psychotic diagnosis morally at fault if that person harms someone in the community, or himself? Or is the psychiatrist merely unlucky? (shrink)

Realizing the benefits of translating psychiatric genomics research into mental health care is not straightforward. The translation process gives rise to ethical challenges that are distinctive from challenges posed within psychiatric genomics research itself, or that form part of the delivery of clinical psychiatric genetics services. This article outlines and considers three distinct ethical concerns posed by the process of translating genomic research into frontline psychiatric practice and policy making. First, the genetic essentialism that is commonly (...) associated with the genomics revolution in health care might inadvertently exacerbate stigma towards people with mental disorders. Secondly, the promises of genomic medicine advance a narrative of individual empowerment. This narrative could promote a fatalism towards patients' biology in ways that function in practice to undermine patients' agency and autonomy, or, alternatively, a heightened sense of subjective genetic responsibility could become embedded within mental health services that leads to psychosocial therapeutic approaches and the clinician-patient therapeutic alliance being undermined. Finally, adopting a genomics-focused approach to public mental health risks shifting attention away from the complex causal relationships between inequitable socio-economic, political, and cultural structures and negative mental health outcomes. The article concludes by outlining a number of potential pathways for future ethics research that emphasizes the importance of examining appropriate translation mechanisms, the complementarity between genetic and psychosocial models of mental disorder, the implications of genomic information for the clinician-patient relationship, and funding priorities and resource allocation decision making in mental health. (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)

This paper analyses ethical issues in forensic psychiatric research on mentally disordered offenders, especially those detained in the psychiatric treatment system. The idea of a 'dual role' dilemma afflicting forensic psychiatry is more complicated than acknowledged. Our suggestion acknowledges the good of criminal law and crime prevention as a part that should be balanced against familiar research ethical considerations. Research aiming at improvements of criminal justice and treatment is a societal priority, and the total benefit of studies has (...) to be balanced against the risks for research subjects inferred by almost all systematic studies. Direct substantial risks must be balanced by health benefits, and normal informed consent requirements apply. When direct risks are slight, as in register-based epidemiology, lack of consent may be counter-balanced by special measures to protect integrity and the general benefit of better understanding of susceptibility, treatment and prevention. Special requirements on consent procedures in the forensic psychiatric context are suggested, and the issue of the relation between decision competence and legal accountability is found to be in need of further study. The major ethical hazard in forensic psychiatric research connects to the role of researchers as assessors and consultants in a society entertaining strong prejudices against mentally disordered offenders. (shrink)

ABSTRACTThis paper analyses ethical issues in forensic psychiatric research on mentally disordered offenders, especially those detained in the psychiatric treatment system. The idea of a ‘dual role’ dilemma afflicting forensic psychiatry is more complicated than acknowledged. Our suggestion acknowledges the good of criminal law and crime prevention as a part that should be balanced against familiar research ethical considerations. Research aiming at improvements of criminal justice and treatment is a societal priority, and the total benefit of studies has (...) to be balanced against the risks for research subjects inferred by almost all systematic studies. Direct substantial risks must be balanced by health benefits, and normal informed consent requirements apply. When direct risks are slight, as in register‐based epidemiology, lack of consent may be counter‐balanced by special measures to protect integrity and the general benefit of better understanding of susceptibility, treatment and prevention. Special requirements on consent procedures in the forensic psychiatric context are suggested, and the issue of the relation between decision competence and legal accountability is found to be in need of further study. The major ethical hazard in forensic psychiatric research connects to the role of researchers as assessors and consultants in a society entertaining strong prejudices against mentally disordered offenders. (shrink)