Common mental health disorders are rising globally, creating a strain on public healthcare systems. This has led to a renewed interest in the role that digital technologies may have for improving mental health outcomes. One result of this interest is the development and use of artificial intelligence for assessing, diagnosing, and treating mental health issues, which we refer to as ‘digital psychiatry’. This article focuses on the increasing use of digital psychiatry outside of clinical settings, in the following (...) sectors: education, employment, financial services, social media, and the digital well-being industry. We analyse the ethical risks of deploying digital psychiatry in these sectors, emphasising key problems and opportunities for public health, and offer recommendations for protecting and promoting public health and well-being in information societies. (shrink)

The integration of digital phenotyping in psychiatry promises unprecedented insights into mental health, particularly in college settings where mental well-being is a growing concern. The COVID-19...

In this groundbreaking book, psychiatrist and ethicist Mona Gupta analyzes the basic assumptions of Evidence-based medicine (EBM), and critically examines their applicability to psychiatry. Highlighting ethical tensions between psychiatry and EBM, she asks the controversial question - should psychiatrists practice evidence-based medicine at all?

The demand for liver transplants continues to far exceed the number of available viable donor organs; hence, it is of utmost importance to determine those individuals who are best able to care for these valuable, limited resources as potential recipients. At the same time, psychiatric comorbidity is common in the course of end-stage liver disease and can be mutually complicating. This article focuses on liver transplant candidacy from a psychiatric perspective, using illustrative cases to underscore the foundational facets of medical (...) ethics that serve as the guide to these complex medical and ethical decisions. (shrink)

Psychiatric disorders present distinct clinical challenges which are partly attributable to their multifactorial aetiology and the absence of laboratory tests that can be used to confirm diagnosis or predict risk. Psychiatric disorders are highly heritable, but also polygenic, with genetic risk conferred by interactions between thousands of variants of small effect that can be summarized in a polygenic risk score. We discuss four areas in which the use of polygenic risk scores in psychiatric research and clinical contexts could have ethical (...) implications. First, there is concern that clinical use of polygenic risk scores may exacerbate existing health inequities. Second, research findings regarding polygenic risk could be misinterpreted in stigmatising or discriminatory ways. Third, there are concerns associated with testing minors as well as eugenics concerns elicited by prenatal polygenic risk testing. Fourth, potential challenges that could arise with the feedback and interpretation of high polygenic risk for a psychiatric disorder would require consideration. While there would be extensive overlap with the challenges of feeding back genetic findings in general, the potential clinical use of polygenic risk scoring warrants discussion in its own right, given the recency of this possibility. To this end, we discuss how lay interpretations of risk and genetic information could intersect. Consideration of these factors would be necessary for ensuring effective and constructive communication and interpretation of polygenic risk information which, in turn, could have implications for the uptake of any therapeutic recommendations. Recent advances in polygenic risk scoring have major implications for its clinical potential, however, care should be taken to ensure that communication of polygenic risk does not feed into problematic assumptions regarding mental disorders or support reductive interpretations. (shrink)

Ethical Considerations at the Intersection of Psychiatry and Religion aims to give mental health professionals a conceptual framework for understanding the role of R/S in ethical decision-making and serve as practical guidance for approaching challenging cases. Part I addresses general considerations, including the basis of therapeutic values in a pluralistic context, the nature of theological and psychiatric ethics, spiritual issues arising in diagnosis and treatment, unhealthy and harmful uses of religion, and practical implications of personal spirituality. Part II (...) examines how these considerations apply in specific contexts: inpatient and outpatient, consultation-liaison, child and adolescent, geriatric, disability, forensic, community, international, addiction and disaster and emergency psychiatry, as well as in the work of religious professionals, ethics committees, psychiatric education, and research. Thick descriptions of case examples analyzed using the framework of Jonson and Winslow show the clinical relevance of understanding the contributions of religion and spirituality to patient preferences, quality of life, decision making, and effective treatment. (shrink)

Pt. 1. The context -- pt. 2. Principles of ethics in psychiatry -- pt. 3. The applications of the ethical principles in psychiatric practice and research -- pt. 4. Non-medical uses of psychiatry -- pt. 5. Teaching ethics in psychiatry -- pt. 6. Conclusions and summary.

Introduction to the study : unveiling the problematic -- The evolution of madness : a journey through time -- Modernity (1890-2014 ) : a journey through time, part two -- Probing the boss text : the DSM : what? whither? how? which? -- The beast/in the belly of the beast : pinioned by paper -- The psychiatric team -- Marching to pharmageddon : psychopharmacy unmasked -- Electroshock : not a healing option -- Dusting ourselves off and starting anew.

Gupta effectively probes the methodological and ethical presuppostions of Evidence Based Medicine, and its more contestable application to psychiatry. She concludes with an endorsement of a very modest reformulation of it as one guide to practice among many.

Genealogy of the treatment model -- Expert knowledge and encounters with futility -- Treatment plans : mandatory narratives of progress -- Representative payeeships : the deep logic of dependency -- Commitment orders : the practice of consent and constraint -- Coercion, confidentiality, and the moral contours of work.

Psychiatry presents a unique array of difficult ethical questions. However, a major challenge is to approach psychiatry in a way that does justice to the real ethical issues. Recently there has been a growing body of research in empirical psychiatric ethics, and an increased interest in how empirical and philosophical methods can be combined. Empirical Ethics in Psychiatry demonstrates how ethics can engage more closely with the reality of psychiatric practice and shows how empirical (...) methodologies from the social sciences can help foster this link. -/- The book is divided into two sections. In the first section there are discussions of the possibility of empirical ethics from a theoretical standpoint and an overview of the history of empirical medical ethics in general. The second, larger section is made up of chapters, discussing specific research projects in empirical psychiatric ethics. The contributors reflect on their choice of method: how and why they combine empirical and philosophical work, and how the two approaches relate to each other. The chapters in the second part thus have two purposes. The first is to present examples of empirical ethics in psychiatry; the second is to reflect on the way in which empirical research can support ethical analysis. -/- Empirical Ethics in Psychiatry is a unique contribution to bioethics and will be fascinating reading for all those working within the field, as well as mental health care professionals. (shrink)

This paper argues that in the case of mental illnesses whose somatic bases are not known or do not exist, a promising route to understand mental illness is to see it as the lack of a patient’s engagement with some moral values that are necessary for a good human life. The paper explains how the first-person perspective, which is constitutive for mental illnesses, makes it impossible to provide an adequate, third-person explanation of the pathological. Because of its irreducible first-personal nature, (...) mental illness must be understood in terms of a moral harm to the patient, and so an integration of ethics and psychiatry is required. This view is further illustrated with A. Kępiński’s idea of psychiatry as therapy with moral values. (shrink)

When it becomes available, neuroscience-based apprehension of subjective thoughts is bound to have a profound impact on several areas of society. One of these areas is medicine. In principle, medical specialties that are primarily concerned with mind and brain are most likely to apply neurotechnological thought apprehension (NTA) techniques. Psychiatry is such a specialty, and the relevance of NTA developments for psychiatry has been recognized. In this article, I discuss ethical issues regarding the use of NTA techniques in (...) psychiatric contexts. First, I consider the notion of neurotechnological “thought apprehension,” as well as some limitations of present-day NTA applications. Next, I identify ethical priorities for its possible future use in psychiatry. The topics I explore concern key (bio)ethical issues: confidentiality, trust and distrust, consent and coercion, and, finally, responsibility. I conclude that mental health-related use of NTA entails some specific ethical concerns that deserve careful attention before introducing these technologies in psychiatric practice. (shrink)

Researchers are studying how artificial intelligence (AI) can be used to better detect, prognosticate and subgroup diseases. The idea that AI might advance medicine’s understanding of biological categories of psychiatric disorders, as well as provide better treatments, is appealing given the historical challenges with prediction, diagnosis and treatment in psychiatry. Given the power of AI to analyse vast amounts of information, some clinicians may feel obligated to align their clinical judgements with the outputs of the AI system. However, a (...) potential epistemic privileging of AI in clinical judgements may lead to unintended consequences that could negatively affect patient treatment, well-being and rights. The implications are also relevant to precision medicine, digital twin technologies and predictive analytics generally. We propose that a commitment to epistemic humility can help promote judicious clinical decision-making at the interface of big data and AI in psychiatry. (shrink)

In psychiatry, caregivers try to get free and informed consent of patients, but often feel required to restrict freedom and to use coercion. The present article develops ethical advice given by an Ethics Committee for Mental Health Care. The advice recommends an ethical ideal of shared deliberation, consisting of information, motivation, consensus and evaluation. For the exceptional use of coercion, the advice develops three criteria, namely incapacity to deliberate, threat of serious harm and proportionality between harm and coercion.The (...) article also discusses the viewpoints of the ethical advice and of the European Convention on Human Rights and Biomedicine: is the advice in agreement with the Convention and can the advice refine the guidelines of the Convention for the particular context of psychiatry? Although the Convention emphasises the autonomy of the individual patient, whereas the advice focuses on the relationships between the partners involved, the advice enjoys a complementary and supportive function in the application of the Convention. (shrink)

The introduction of the Diagnostic and statistical manual of mental disorders in May 2013 is being hailed as the biggest event in psychiatry in the last 10 years. In this paper I examine three important issues that arise from the new manual: Expanding nosology: Psychiatry has again broadened its nosology to include human experiences not previously under its purview . Consequence-based ethical concerns about this expansion are addressed, along with conceptual concerns about a confusion of “construct validity” and (...) “conceptual validity” and a failure to distinguish between “disorder” and “non disordered conditions for which we help people.” The role of claims about societal impact in changes in nosology: Several changes in the DSM-5 involved claims about societal impact in their rationales. This is due in part to a new online open comment period during DSM development. Examples include advancement of science, greater access to treatment, greater public awareness of condition, loss of identify or harm to those with removed disorders, stigmatization, offensiveness, etc. I identify and evaluate four importantly distinct ways in which claims about societal impact might operate in DSM development. Categorisation nosology to spectrum nosology: The move to “degrees of severity” of mental disorders, a major change for DSM-5, raises concerns about conceptual clarity and uniformity concerning what it means to have a severe form of a disorder, and ethical concerns about communication. (shrink)

Forensic psychiatry is pervaded by moral dilemmas. Although professionals in forensic psychiatry are trained in law and psychiatry and are certainly aware of ethical issues in the care for patients, they tend to make decisions in an implicit way and not to discuss their moral concerns or doubts. More structural attention for ethics seems to be required. In this paper, we show the value of moral case deliberation in forensic psychiatry. Moral case deliberation is a (...) specific kind of clinical ethics support in which healthcare professionals discuss a moral issue from practice in a structured way, facilitated by an ethicist or specifically trained facilitator. It is applicable to a wide array of situations in healthcare practice. In contrast to other models of clinical ethics support, such as individual consultation, the focus is on the moral experience of professionals and using a structured method to foster dialog and joint moral learning. In this paper, an example of case on a forensic ward is presented. The case shows that moral case deliberation leads to reflection on values and stimulates openness and honesty regarding uncertainties. Moreover, the deliberation provides room for new insights and creates a basis for a joint decision on how to proceed further, recognizing the tensions and difficulties involved. (shrink)

Forensic psychiatry is a particular subspecialty within psychiatry, dedicated in applying psychiatric knowledge and psychiatric training for particular legal purposes. Given that within the scope of forensic psychiatry, a third party usually intervenes in the patient-doctor relationship, an amendment of the traditional ethical principles seems justified. Thus, 47 articles, two book chapters and the guidelines produced by the World Psychiatric Association, the American Association of Psychiatry and the Law, as well as by the Royal Australian and (...) New Zealand College of psychiatrists, were analyzed. The review revealed that the ethics of correctional forensic psychiatry and those of legal forensic psychiatry do not markedly differ from each other, but they are incongruent in terms of implementation. In an effort to better understand which ethical principles apply to forensic psychiatry, a chronological review of the literature published from 1950 to 2015 was carried out. The ethics of correctional forensic psychiatry are primarily deontological. The principle of justice translates into the principle of health care equivalence, the principle of beneficence into providing the best possible care to patients, and the principle of respect of autonomy into ensuring confidentiality and informed consent. The ethics of legal forensic psychiatry are rather consequentialist. In this latter setting, the principle of justice is mainly characterized by professionalism, the principle of beneficence by objectivity and impartiality, and the principle of respect of autonomy by informed consent. However, these two distinct fields of forensic psychiatry share in common the principle of non maleficence, defined as the non collaboration of the psychiatrist in any activity leading to inhuman and degrading treatment or to the death penalty. (shrink)

One approach to the analysis of ethical dilemmas in medical practice uses the “four principles plus scope” approach. These principles are: respect for autonomy, beneficence, non-maleficence and justice, along with concern for their scope of application. However, conflicts between the different principles are commonplace in psychiatric practice, especially in forensic psychiatry, where duties to patients often conflict with duties to third parties such as the public. This article seeks to highlight some of the specific ethical dilemmas encountered in forensic (...) psychiatry: the excessive use of segregation for the protection of others, the ethics of using mechanical restraint when clinically beneficial and the use of physical treatment without consent. We argue that justice, as a principle, should be paramount in forensic psychiatry, and that there is a need for a more specific code of ethics to cover specialised areas of medicine like forensic psychiatry. This code should specify that in cases of conflict between different principles, justice should gain precedence over the other principles. (shrink)

Background and aim Child and adolescent forensic psychiatry is fraught with complex medical, legal, and social tensions. The ethical challenges this entails for inhospital treatment have hardly been investigated, and specific support for health care professionals is lacking. This study identifies ethical issues and problems in this area and develops a tool for early detection and intervention of ethical problems in clinical practice. Methods A systematic literature search and an observational study in adolescent forensics at the University Psychiatric Clinics (...) Basel are conducted. The observation data are evaluated using a qualitative content analysis. The instrument is developed based on the results using a new method. Results In the literature search, 14 valid publications were identified that mainly address ethical conflicts in legal psychiatry, such as professional role conflicts, ethical problems in diagnostics and assessment, or confidentiality issues. Empirical or empirical–normative studies are missing. In the observational study, 24 ethical issues and specific conflicts were identified. Ethical questions about moral competencies of the adolescents, the quality of treatment, the handling of rules and sanctions, and freedom and privacy are particularly common. The Instrument for Early Detection and Intervention of Ethical Problems (FIEP) contains the four core elements risk factors, indicators, intervention planning and decision-making. Conclusions Inhospital treatment in forensic child and adolescent psychiatry reveals a broad spectrum of ethical issues with specific ethical problems, which are hardly investigated in literature so far. The FIEP instrument developed here supports health care practitioners in recognizing ethical problems at an early stage and addressing them efficiently. (shrink)

The introduction of the Diagnostic and Statistical Manual of Mental Disorders in May 2013 is being hailed as the biggest event in psychiatry in the last 10 years. In this paper I examine three important issues that arise from the new manual: Expanding nosology: Psychiatry has again broadened its nosology to include human experiences not previously under its purview. Consequence-based ethical concerns about this expansion are addressed, along with conceptual concerns about a confusion of "construct validity" and "conceptual (...) validity" and a failure to distinguish between "disorder" and "nondisordered conditions for which we help people." The role of claims about societal impact in changes in nosology: Several changes in the DSM-5 involved claims about societal impact in their rationales. This is due in part to a new online open comment period during DSM development. Examples include advancement of science, greater access to treatment, greater public awareness of condition, loss of identify or harm to those with removed disorders, stigmatization, offensiveness, etc. I identify and evaluate four importantly distinct ways in which claims about societal impact might operate in DSM development. Categorisation nosology to spectrum nosology: The move to "degrees of severity" of mental disorders, a major change for DSM-5, raises concerns about conceptual clarity and uniformity concerning what it means to have a severe form of a disorder, and ethical concerns about communication. (shrink)

Ethics of Psychiatry addresses the key ethical and legal issues in mental health care. With selections by Paul S. Applebaum, Christopher Boorse, Kerry Brace, Peter R. Breggin, Paula J. Caplan, Glen O. Gabbard, Donald H.J. Hermann, Lawrie Reznek, Thomas Szasz, Jerome Wakefield, Bruce J. Winick, and Robert M. Veatch, among others, this sourcebook offers the latest research in psychiatry, psychology, advocacy, mental health law, social services, and medical ethics relevant to the rational autonomy of psychiatric patients.

This book considers coercion within the healing and ethical framework of therapeutic relationships and partnerships at all levels, and addresses the universal ...

The interface between religion, psychiatry, and ethics is often a locus for considerable controversy. This article focuses on the response of American psychiatry to religious nonconformism, and to religious conversion generally. At issue is the societal pressure against unpopular religious movements. The author argues for an ethic that conserves the freedom of religious conscience, and that guards against inquisitions in the guise of medical expertise and nosology.

Psychiatric practice is often faced with complex situations that seem to pose serious moral dilemmas for practitioners. Methods for solving these dilemmas have included the development of more objective rules to guide the practitioner such as utilitarianism and deontology. A more modern variant on this objective model has been 'Principlism' where 4 mid level rules are used to help solve these complex problems. In opposition to this, there has recently been a focus on more subjective criteria for resolving complex moral (...) dilemmas. In particular, virtue ethics has been posited as a more sensitive method for helping doctors to reason their way through difficult ethical issues. Here the focus is on the character traits of the practitioner. Bloch and Green advocated another way whereby more objective methods such as Principlism and virtue ethics are combined to produce what they considered sound moral reasoning in psychiatrists. This paper points out some difficulties with this approach and instead suggests that a better model of ethical judgment could be developed through the use of narratives or stories. This idea puts equal prima facie value on the patient's and the psychiatrist's version of the dilemma they are faced with. It has the potential to lead to a more genuine empathy and reflective decision-making. (shrink)

This book examines core issues related to legal insanity, integrating perspectives from psychiatry, law, and ethics. Various criteria for insanity are analyzed and recommendations for forensic psychiatric and legal practice are offered. Many legal systems have an insanity defense, in one form or another. Still, it remains unclear exactly when and why mental disorders affect a person’s moral or criminal responsibility. Questions addressed in this book include: Why should insanity be a component of our legal system? What should (...) be the criteria for an insanity defense? What would be the reasons for abolishing it? Who should bear the burden of proof? Furthermore, the book discusses the impact neurosciences may have on psychiatric and psychological evaluations of defendants as well as on legal decisions about insanity. (shrink)

Ethics is defined as the realm of the 'ought', the realm of conscience which postulates that Man has the freedom to carry out what he judges to be morally right. By such acts he realizes his freedom of making himself into a truer, more authentic person than he was before. A libertarian psychotherapy, based on this ethic, is outlined. Medical science (as all science) belongs to the realm of the 'is' and postulates that the phenomena which it studies follow (...) a necessary course. It is therefore deterministic. In psychiatry, allowance is made for a neurological determinism in cases in which personal freedom has been diminished or abolished by mental illness, but the determinisms of behaviour therapy and of psycho-analysis are rejected by the author. (shrink)

Background: Psychedelics are known for their powerful mental effects due to the activation of 5HT-2A receptors in the brain. During the 1950s and 1960s, research was conducted on these molecules until their criminalization. However, their clinical investigation as therapeutic tools for psychiatric disorders has revived the deontological ethics surrounding this subject. Questions arise as research on their therapeutic outcome becomes a reality. We aim to explore deontological ethics to understand the implications of psychedelics for the clinician, patient, and (...) society. Results: A total of 42 articles were considered for this review. Methods: A methodological search of psychedelic studies from 2017 to 2022 was conducted in PubMed, Scopus, EBSCOhost, and ScienceDirect to address the deontological ethics of clinical psychedelic use. Conclusion: Psychedelics need to be culturally contextualized, epistemic harm minimized and represented to ensure informed consent. Open data and commissions are needed to ensure safe and equal distribution. (shrink)

In this paper we describe the objectives of teaching medical ethics to undergraduates and the teaching methods used. We describe a workshop used in the University of Liverpool Department of Psychiatry, designed to enhance ethical sensitivity in psychiatry. The workshop reviews significant historical and current errors in the ethical practice of psychiatry and doctors' defence mechanisms against accepting responsibility for deficiencies in ethical practice. The workshop explores the student doctors' own group ethos in response to ethical (...) dilemmas, and demonstrates how the individual contributes to and is responsible for the group ethos through participation and also through nonparticipation. The student feedback about the workshop is reviewed. The Toronto Ethical Sensitivity Instrument was used to assess whether or not the workshop altered sensitivity. Compared to a control group the attenders' sensitivity was significantly increased (on Student's t-test p equals or is less than 0.002). (shrink)

Recent studies show that psychiatry residents express a relatively greater need for ethics curricula than their colleagues in other specialties. Such studies have been limited in their generalizability because they were conducted at one site. This study of 151 psychiatry residents at seven U.S. psychiatry programs aims to address that limitation. Residents were surveyed on issues pertaining to ethics and professionalism education. Participants were found to support such curricula during training and to value its relevance (...) to the practice of psychiatry. Gender differences and the influence of the “hidden curriculum” on such results merit further study. (shrink)

Se realiza una revisión bibliográfica con el objetivo de analizar los diferentes códigos éticos y deontológicos internacionales, regionales y nacionales de los que se nutre la especialidad de psiquiatría. Se concluye que el comportamiento ético se basa en el sentido de la responsabilidad individual de cada psiquiatra hacia cada paciente y en la capacidad de ambos para determinar cuál es la conducta correcta y más apropiada. Las normas externas y las directrices, tales como los códigos de conducta profesional, las aportaciones (...) de la ética y de las normas legales, no garantizan por sí solas la práctica ética de la medicina, pero constituyen un importante marco referencial. A literature review was performed with the objective of analyzing the various international, regional and national ethical and deontological codes that the psychiatry specialty feeds on. It is concluded that ethical behavior is based on the sense of individual responsibility of each psychiatrist to each patient and the ability of both to determine what the correct and appropriate behavior is. External standards and guidelines, such as professional codes of conduct, the study of ethics and legal standards alone do not guarantee the ethical practice of medicine but are an important framework. (shrink)

This paper concerns the special ethical problems in child and adolescent psychiatry which relate to the child as a developing being. Two themes are discussed--the sense of responsibility in the child, and the therapist's responsibility towards the child. As a background to understanding the former, ideas on moral and cognitive development are reviewed. The therapist's responsibility is discussed in relation to different styles of therapy and the ethical issues they raise. The article concludes with a number of suggested ethical (...) principles. (shrink)

There has been a spurt in both fundamental and translational research that examines the underlying mechanisms of the human microbiome in psychiatric disorders. The personalized and dynamic features of the human microbiome suggest the potential of its manipulation for precision psychiatry in ways to improve mental health and avoid disease. However, findings in the field of microbiome also raise philosophical and ethical questions. From a philosophical point of view, they may yet be another attempt at providing a biological cause (...) for phenomena that ultimately cannot be so easily localized. From an ethical point of view, it is relevant that the human gut microbiome comprises data on the individual’s lifestyle, disease history, previous medications, and mental health. Massive datasets of microbiome sequences are collected to facilitate comparative studies to identify specific links between the microbiome and mental health. Although this emerging research domain may show promise for psychiatric patients, it is surrounded by ethical challenges regarding patient privacy, health risks, effects on personal identity, and concerns about responsibility. This narrative overview displays the roles and advances of microbiome research in psychiatry and discusses the philosophical and ethical implications of microbiome big data and microbiome-based interventions for psychiatric patients. We also investigate whether these issues are really “new,” or “old wine in new bottles.”. (shrink)

Initiating clinical ethics support in psychiatry and maintaining its continuity appear to be easy. This is contradicted by the observed delay or lack of CESiP, e.g. ethics consultation. On the basis of a published literature search and the discussion of practical experiences over 2.5 years 10 tasks and relating challenges of initiating and maintaining CESiP are formulated and illustrated by examples. Referral to experiences is grounded on the systematic documentation of ca. 100 CESiP activities. The tasks and (...) challenges illustrate how CESiP was initiated and maintained in child and adolescent, adult and forensic psychiatry. Each example is followed by a “rule of thumb” that was found useful in our centre. Discussion: Suggestions I–III are of organisational nature, IV–X have explicit ethical content concerning the ethos or professionalism of the ethics consultant and CES practice. Their realisation requires a minimum of stability of CESiP and considerable consultancy experience. (shrink)

The aim of this article is to give more insight into what ethical challenges clinicians in mental healthcare experience and discuss with a Clinical Ethics Committee in psychiatry in the Region of Southern Denmark. Ethical considerations are an important part of the daily decision-making processes and thereby for the quality of care in mental healthcare. However, such ethical challenges have been given little systematic attention – both in research and in practices. A qualitative content analysis of 55 written (...) case-reports from the Clinical Ethics Committee. The Committee offers clinicians in mental healthcare structured ethical analyses of ethical challenges and makes a thorough written case-report. The ethical challenges are grouped into three overarching topics: 1. Clinicians and their relation to patients and relatives. 2. Clinicians and institutional aspects of mental healthcare 3. Clinicians and mental healthcare in a wider social context. Through presentation of illustrative examples the complexity of daily clinical life in mental healthcare becomes evident, as well as typical interests, values and arguments. This qualitative study indicates that difficult ethical challenges are an inherent part of mental healthcare that requires time, space and competence to be dealt with adequately. (shrink)

Cognitive and rational assessments of competence do not fully capture the way in which individuals normally make decisions. Human beings have always used stories to explain their experiences and values. Narrative ethics should be used to understand the perspective in context of a patient whose competence is in question, and so avoid a destructive clash. Psychiatry and professionals within it also have a narrative that may join with that of science, but there is no special privilege for these (...) narratives unless survival is at stake. The narrative approach should be used to try to make different stories compatible. This article examines the background to this approach, and indicates some ways in which it could be used in the specific cases addressed in the series. (shrink)