Mrs. J, a 22-year-old secretary, began to exhibit restlessness, perplexity, and remoteness from her husband, Mr. K, following the birth of her first baby 10 weeks earlier. A psychiatrist was summoned after she had visited several neighbors without obvious purpose. He found a reticent, detached woman complaining that, “They have been out to get me from the beginning,” and alluding to “world famine and starving children.” Mental status examination revealed vague, paranoid thinking but firm denial of suicidal and homicidal impulses; she was not obviously delirious. Mrs. J resisted the psychiatrist’s recommendation that she be admitted to the local psychiatric hospital. Mr. K supported her in this, insisting that he did not regard his wife as mentally ill and feared she would deteriorate if placed alongside genuinely disturbed patients.
Psychiatric ethics is concerned with the application of moral rules to situations and relationships specific to the field of psychiatry. Resolution of ethical dilemmas confronting psychiatrists, as illustrated by the above case, requires deliberation grounded in a moral theoretical framework that provides methods and justifications for clinical decision making. An outline of such theories is covered in the introductory chapter of the book. We will focus exclusively on ethical aspects of clinical practice that are especially challenging to psychiatrists and briefly offer a preferred theoretical framework to deal with them.
Conferring a diagnosis of mental illness on a person has significant ethical sequelae since the act may embody profound adverse effects, notably stigmatization, prejudice, and discrimination (e.g., limited job prospects, inequitable insurance cover). Furthermore, those deemed at risk to harm themselves or others may have their civil rights abridged. These consequences justify Reich’s (1999) call for the most thorough ethical examination of what he terms the clinician’s “prerogative to diagnose.”
Psychiatrists strive to diagnose by using as objective criteria as possible and information gained from previous clinical encounters. The process is relatively uncomplicated when findings, such as gross defective memory and life-threatening social withdrawal, strongly suggest severe depression. Other situations are not so obvious. For instance, the distress experienced by a bereaved person may incline one clinician towards diagnosing clinical depression whereas another may attribute the picture to normal grief. Expertise, peer review, and benevolence help to protect against arbitrariness and idiosyncrasy. Notwithstanding, psychiatrists must, to some extent, employ what might be termed “reasoned subjectivism.” Consequently, specified criteria in the American Psychiatric Association’s (1994) Diagnosis and Statistical Manual (DSM) IV and the World Health Organization’s (1992) International Statistical Classification of Diseases and Related Health Problems (ICD) 10 do not preclude debate about the preciseness or legitimacy of certain syndromes like attention deficit hyperactivity disorder (ADHD) and sexual orientation disturbance. Concern about the intrusion of value judgements into contemporary classifications has led to the contention that some diagnoses reflect pejorative labeling rather than scientific decisions (Green and Bloch, 2006). For example, charges of sexism were leveled against DSM-III (Kaplan, 1983) on the grounds that masculine-based assumptions shaped criteria, resulting in women receiving unwarranted diagnoses like premenstrual dysphoria (Chesler, 1972).
The issue central to this debate is whether certain mental states are grounded in fact or value judgements. Szasz (1960) took a radical position, arguing that disorders of thinking and behavior result from objective abnormalities of the brain whereas mental illness per se is a “myth” created by society in tandem with the medical profession for the purpose of exerting social control. The “anti-psychiatrist movement” (Scheff, 1966; Laing, 1969, 1970) asserted that mental illnesses are social constructions reflecting deviations from societal norms. This argument is supported by the role of values in both defining homosexuality as a psychiatric disorder and then reversing that position through a ballot among members of the American Psychiatric Association in 1973 (Stoller et al., 1973). Legitimate diagnoses necessarily combine aspects of fact and value, as Wakefield (1992) contended in his conception of “harmful dysfunction.” He viewed “dysfunction” as a scientific and factual term based in biology that refers to the failure of an internal evolutionary mechanism to perform a natural function for which it is designed, and “harmful” as a value-oriented term which refers to the consequences of the dysfunction for the person that are deemed detrimental in terms of sociocultural norms. Applying this notion to mental functioning, Wakefield (1992) described the beneficial effects of natural mechanisms, like those mediating cognition and emotional regulation, and judged their dysfunction harmful when it yielded consequences disvalued by society (e.g., aphasia or self-destructive acts). Diagnosable conditions exist when the inability of an internal mechanism to perform its natural function causes harm to the person.
Consequences of these sorts of disputes can be considerable (e.g., exposing children erroneously labeled as having ADHD to long-term dexamphetamine medication with its attendant risks) (Halasz, 2002). A related issue, so-called “cosmetic psychopharmacology,” involves the use of medication to enhance psychological functioning. As Kramer (1993) noted, fluoxetine may modulate emotions such as anxiety, guilt, and shame, raising ethical questions as to a person’s capacity to possess “two senses of self.” Psychiatric diagnosis may also mitigate legal and personal consequences of one’s actions (e.g., interpreting excessive sexual activity or kleptomania as variants of obsessive–compulsive disorder rather than wilful, chosen behaviors).
Assessing and treating patients require a working alliance and informed consent. Many psychiatric patients are in a position to understand and appreciate the nuances of treatment options, to express an informed preference, and to feel comfortably allied with a therapist in their collaborative work. When the process of informed consent is responsibly handled, particularly with reference to benefits and risks of therapeutic options, patients undergoing psychiatric treatment are in a comparable position to their counterparts in general medicine. This comparability is grounded in two concepts: competence (Lidz et al., 1984) and voluntarism (Roberts, 2002). The former covers the required criterion that the person facing choices in treatment enjoys the “critical faculties” to appreciate the implications of each course of action. Voluntarism refers to a condition whereby the process of consent is devoid of coercion and suggestion. Obviously, given that the organ of decision making is the same one that is impaired in many psychiatric conditions, profound ethical complications may ensue when seeking informed consent.
Ethical issues arise once therapist and patient embark on treatment. At the outset, the patient is bewildered, vulnerable, and distressed, while the therapist is ostensibly omniscient. Dependency bolsters the authority already vested in the therapist and may be reinforced by his divulging little about the nature of treatment, believing this would undermine the transference (irrational feelings and attitudes patients develop towards therapists), regarded by dynamically oriented schools as central to the process.
As noted above, informed consent (Beahrs and Gutheil, 2001) is one means to dispel this air of mystery. Carl Goldberg’s (1977) admirably clear model invoked the concept of “therapeutic partnership,” its cornerstone a “mutually agreed upon and explicitly articulated working plan” subject to regular review. Among its elements are identifying goals and methods to reach them, monitoring efficacy, and permitting either partner to voice dissatisfaction. Moreover, respective roles, tasks, and responsibilities are examined as necessary. The partnership does not imply an equal share of power but rather an agreement about how power will be allocated. Thus, total autonomy in the patient, whereby the patient enjoys the capacity to reflect, to decide, and to act freely, may not always be apt. A patient in the throes of an intense crisis, for instance, may lack the wherewithal to appreciate what is in her best interests. In collaboration with the therapist, she may agree to a redistribution of responsibility, assigning the latter a more paternalistic role. As the crisis wanes, so restoration of the patient’s state of autonomy occurs. The key feature of such shifts is their determination by both protagonists.
In reviewing models pertinent to informed consent in the therapeutic relationship, Dyer and Bloch (1987) proposed a fiduciary approach given its emphasis on trust and time. The therapist works to earn the patient’s trust which occurs over time and is not a one-off negotiation at the outset. The fiduciary-based relationship also enhances a sense of responsibility in the therapist, who responds to patients’ particular needs. Although autonomy in the patient is always a preeminent goal, it is not the therapist’s sole preoccupation.
Permeation of treatment by values is another ethically based feature that must be addressed since the problems for which patients seek help are bound up with the question of how they should live their lives, and therapists may impose values intentionally or unwittingly (Holmes, 1996).
Engelhardt (1973) posited that psychotherapy is about meta-ethics in that it paves the way for ethical decision making by patients; the aim is not for them to adopt a particular set of values. Indeed, the therapist avoids recommending how patients should live their lives. Instead, they are helped to reach a point where they can make their own choices, unhindered by psychological conflict and unconscious influences. Freud (1924, p. 118), also intent on promoting value-free treatment, argued that a therapist “should be opaque to his patients and, like a mirror, should show them nothing but what is shown to him.” He insisted that therapy was limited to “freeing someone from his neurotic symptoms, inhibitions and abnormalities of character” through making conscious the unconscious. However, he also pointed out an educative role, suggesting that the analyst “possess some kind of superiority, so that in certain analytic situations he can act as a model for his patient and in others as a teacher” (Freud, 1937, p. 248).
It is difficult to conceive of this hybrid role of mirror, model, and teacher as value free, even if the ultimate goal in analysis is to achieve autonomy, free of the influence of irrational forces. Therefore, if therapy amounts to ethical intervention, the question arises as to how the therapist should handle this? He or she could make every effort to minimize the ethical role, but the likelihood of succeeding is slim since unavowed values will be manifest non-verbally.
Another option is to accept the ethical intervention function but recognize this as the therapist’s “problem,” not the patient’s. The former must be aware of a potential role as moral agent and regard personal values as a factor in the encounter. The therapist should be sensitive to his or her own values and monitor any unconsciously derived impulses to influence the patient. A process of “value-testing” ensures that their intrusion is never ignored and imposition thus obviated.
A third option has the therapist declaring his or her values as a value in itself. The argument runs as follows: psychotherapy is a form of social influence; the therapist influences patients; the therapist acknowledges this state of affairs; and the therapist is “transparent” regarding the values personally espoused.
Some homosexual therapists, for example, have aligned themselves with the “gay movement” when treating homosexual patients. A distinguished psychotherapist and committed Christian, Alan Bergin (1980), has evolved a school of “theistic realism” in which the therapist shares values derived from a Judeo-Christian tradition, including forgiveness, reconciliation, spiritual belief, and love. A group of therapists who functioned in the context of apartheid South Africa not only declared their repudiation of racism but also demonstrated their support for traumatized Blacks, especially those who had been victims of detention and torture (Steere and Dowdall, 1990). Particular constituencies are being served in these three illustrations. Avowal of values can also be applied generally. A therapist may adopt an approach with all his patients in which he will strive to be transparent about his ethical attitudes on the premise that values are central in selecting therapeutic options. The corollary is unambiguous: “Therapists do not have a choice about whether they need to deal with their values in therapy, only how well” (Aponte, 1985).
The emphasis on society providing adequate resources brings us to the right to treatment where liberty is restricted. The asylum has been marked by tragic neglect of patients’ interests (Bloch and Pargiter, 2002). The overcrowded institution became little more than a warehouse. Its custodial nature persisted even after the advent of psychotropic drugs and psychosocial therapies. It took a plaintiff (Donaldson v. O’Connor, 1974; O’Connor v. Donaldson, 1975) to determine that a person committed involuntarily had the “right to receive treatment that would offer him a reasonable opportunity to be cured or to improve his mental condition.” Diagnosed with schizophrenia in 1957, Kenneth Donaldson received minimal treatment for the next decade and a half. The US Supreme Court concluded in 1975 that a patient who does not pose a danger to himself or to others and who is not receiving treatment should be released if able to live safely in the community.
The right to treatment has been revisited in subsequent judgments, predominantly in the USA (Wyatt v. Stickney, 1971, 1972). However, the right has lacked a guarantee that patients will receive effective treatment. This opens up a Pandora’s box, reflected vividly in Osheroff v. Chestnut Lodge (Klerman, 1990). The plaintiff sued a private psychiatric hospital for failure to provide antidepressants in the face of his deteriorating depression. Klerman (1990) subsequently argued that the clinician is duty-bound to use only “treatments for which there is substantial evidence” or seek a second opinion in the absence of a clinical response. Stone (1990) countered this position, which he proposed was tantamount to “… promulgating more uniformed scientific standards of treatment in psychiatry, based on … opinion about science and clinical practice.” Moreover, legal standards of care should not be established by one “school” for the whole profession, even if enveloped in science. Instead, we should depend on “the collective sense” of psychiatry, as well as use the “respectable minority rule,” namely that a relatively small group within psychiatry can legitimately develop new therapies (Stone, 1990).
As a voluntary patient, Osheroff could have refused treatment of any type as part of informed consent. His lawsuit pinpointed the institution’s alleged failure to offer him an alternative treatment in the face of his deterioration with the therapy offered. If principles of informed consent had been applied correctly, his freedom to choose one treatment over others, and to withdraw consent at any stage thereafter, should have prevailed.
The situation differs radically when the patient is committed involuntarily to hospital or community treatment. The right to refuse treatment then looms large (Appelbaum, 1988). A key event was another US legal judgment when a court ruled that detained patients had a constitutional right to refuse treatment (Rogers v. Okin, 1979; Rogers v. Commissioner of the Department of Mental Health, 1983). This coincided with changing commitment laws in many jurisdictions from criteria linked to need for treatment to those highlighting the danger posed to oneself and/or others. The ethical repercussions are profound. If psychiatrists are empowered to detain patients, is it not a contradiction if they are then powerless to offer them treatment should they refuse? The argument rests on the premise that a person sufficiently disturbed to warrant involuntary admission is axiomatically entitled to treatment, and the consulting psychiatrist suitably placed to provide it. Without this arrangement, the psychiatrist’s functions are reduced to custodial.
A countervailing argument is grounded in constitutional rights. Merely because people are committed does not mean they are incapable of participating in the process of informed consent. In the event they cannot understand or appreciate the rationale for a course of action, a form of substituted judgement should be employed thereby ensuring that rights remain prominent.
An assortment of legal remedies has emerged in response to this ethical quandary, ranging from a full adversarial process to reliance on a guardian’s decision. Appelbaum (1988) has offered a lucid account of the options and his predilection for a treatment-driven model in which patients are committed because their capacity to decide about treatment is lacking as part of a disturbed mental state. His own research demonstrates that most refusing patients voluntarily accept treatment within 24 hours (Appelbaum and Gutheil, 1979).
In another pragmatically oriented account, Stone (1981) proposed that presumption of competence is dealt with before hospitalization. Dealing with commitment and competence would obviate the problem of compulsory admission without treatment. The difficulty is the fluidity of one’s mental state. What patients think about treatment during the maelstrom of being detained may well change once they are admitted and suitably cared for.
A consensus has prevailed for generations that a proportion of psychiatric patients loses the capacity for self-determination. They become vulnerable to harming themselves and/or others, acting in ways they will later regret (e.g., a manic patient’s sexual indiscretions) and suffer from self-neglect (e.g., schizophrenic patients who are homeless, malnourished, and physically ill). What is not universally agreed is how best to deal with such vulnerable people. Society has, generally, assigned the law to serve as the vehicle to respond to the thorny issue of when and how to protect this group. However, variations in legislation and its application are legion, reflecting, in part, the ethical underpinnings of the process. Psychiatrists and society need coherent arguments concerning the moral principles we should heed. A good start is J.S. Mill’s contention, in his essay On Liberty in the 1850s, that the “only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant” (Gray, 1976) Mill’s caveat that an exception must be made in children and mentally disturbed people (i.e., “delirious” or in a “state of excitement or absorption incompatible with the full use of the reflecting faculty”) suggests they can legitimately be assisted.
Paul Chodoff (1984) has addressed the awesome question of compulsory treatment on the grounds of mental illness. He found utilitarian and deontological theories wanting and, therefore, proposed a “chastened and self-critical” paternalism, one “willing to commit to strong safeguards against abuse.” This humanism is epitomized in a concluding sentiment: involuntary treatment is not a conflict of right versus wrong but one over the right to remain at liberty against the right “to be free from dehumanising disease.” This notion of being imprisoned by illness would resonate with all psychiatrists who have treated psychotic patients.
Our account hitherto has referred to patients as a homogeneous group. Loss of critical faculties may be a unifying feature but ethical factors will vary according to particulars of the clinical state. One obvious example is suicidal behavior.
Szasz (1986) saw suicide as the act of a moral agent. The state should, therefore, not assume power to prevent self-killing although it may opt to advise for or against. This argument is libertarian, with the corollary that everyone should have the right to end their life. Szasz had, however, neglected Mill’s point that, when respecting a person’s right to liberty, a possible exception is the loss of critical faculties. This is not to aver that all suicidal behavior is the product of a disordered mind. Suicide in the wake of chronic, debilitating illness, and a long-standing commitment to euthanasia, seems rational and coherent. For example, the renowned author, Arthur Koestler, left a suicide note demonstrating that he arrived at his decision authentically and with his critical faculties intact (Cesarani, 1998).
The suicidal patient epitomizes the psychiatrist’s dilemma in having no choice but to impose treatment in various circumstances and having to declare a person’s incapacity, by dint of mental illness, to make rational judgements about what is in their best interests. Van Staden and Kruger (2003) covered this topic by highlighting its dimensions, namely the failure to understand relevant information, choose decisively between options, and accept that the need for treatment prevails. They refer to the utility of a “functional approach” in determining capacity, especially the temporal factor, so that a patient incapable of consenting at one point in their illness may well become capable at another. Ethical arguments to justify detention in a hospital can be extrapolated into the community setting. Similar restrictions on liberty lie at the heart of the moral dilemma, and the psychiatrist again has to consider patients’ competence. Munetz and his colleagues (2003) applied three ethical arguments – utilitarian, communitarian, and beneficence – concluding that all three support the application of compulsory community treatment. For more on issues related to consent and capacity, see Section 1 .
If we return to the family described at the beginning of this chapter, we can readily note how ethical challenges exist at several levels, both diagnostically and therapeutically. A combination of two ethical approaches, principlism (Beauchamp and Childress, 2001) and care ethics (Baier, 1985, 2004), can be gainfully adopted in wrestling with these challenges. Principlism (or principle-based ethics) relies on a set of well-recognized moral principles to identify and analyze ethical problems: respect for autonomy, non-maleficence (avoidance of causing harm), beneficence, and justice. The essence of care ethics is a reliance on the natural inclination of a health professional to extend care to dependent and vulnerable people and to react sensitively to such “moral” feelings as compassion, love, and trustworthiness. The approach fits well with psychiatry since its practitioners rely significantly on empathy in order to understand the wishes and needs of patients and their families.
We conclude by applying the interplay of care and principle ethics in relation to the family in the case opening this chapter. Buffeted by frightening internal forces, Mrs. J’s withdrawal and bizarre behavior since her baby’s birth point to the question of whether or not she is competent to appreciate her circumstances. Above all, can she protect her infant? Extending care to a deeply distressed woman who has lost her anchorage (as well as to her anxious husband and the vulnerable baby) directs the psychiatrist to the option of responding in accordance with the tenets of care ethics, particularly the goal of promoting trust. It remains an open question whether this means advising Mrs. J (in tandem with gaining Mr. K’s support) to enter hospital, committing her to involuntary treatment, or arranging for her rigorous supervision by family and friends. What is vital is that the psychiatrist adopts a caring posture. However, his options must be considered in the context of basic bioethical principles; for example, is respect for Mrs. J’s autonomy possible or must the psychiatrist necessarily act in loco parentis, in accordance with the principle of beneficence? And given the entitlements owing to the three participants in the scenario, what role does justice play?
A synthesis of care ethics and principlism permits sound moral reflection within an environment of emotionally based connectedness between patients and therapist. We believe this approach acknowledges and best exploits the importance of moral emotions when clinicians are presented with the varied, nuanced ethical conundrums of psychiatric practice.