Ethics of Psychiatry

These days publishers seem to be falling over themselves to put out textbooks on medical ethics. But when it comes to mental health ethics, there is far less competition. When I taught a course on "Mental Health and Morality," one book I used was Psychiatric Ethics (second edition out of print, third edition forthcoming), a collection of artciles written by psychiatrists for psychiatrists. Currently, the only collection of articles aimed at a fairly general audience is Ethics of Psychiatry, edited by Rem Edwards of the University of Tennessee in Knoxville. (It is a radically revised edition of Psychiatry and Ethics (1982).) While it is not perfect, this book is an impressive work of editorship.

There are so many issues in mental health ethics that any book on the subject is bound to leave large gaps. Furthermore, there's the question of at what level of sophistication to pitch the book. Edwards' solution to these problems is a scattershot approach. There are seven main sections of the book, with a total of 31 different readings. Each section has a short introduction and suggestions for further reading at the end. Most of the readings are articles from professional journals, but there are a few magazine articles and extracts from books. The topics covered include: the values used in psychiatric diagnosis; the medical model of mental illness; the rights and competence of people with mental illness; confidentiality between patients and health care providers; sexual relations with patients; controversial treatments; the insanity defense; and deinstitutionalization. Some articles are explanations of the obvious, such as why sex with patients is wrong. Others are simple outlines of current psychiatric practice, such as different drugs used for different for different disorders. But most are discussions of controversial moral and legal issues aimed at mental health professionals or philosophers. The majority of the readings shall be accessible to the general reader, even if some require careful study.

Especially welcome is the fact that Edwards has chosen mostly articles less than ten years old. He does include a couple of old anti-psychiatric chestnuts by Thomas Szasz and an authoritative refutation of his view by Michael Moore. I expect Szasz is included because he is still the most well-known writer criticizing modern psychiatric praxes and he still attracts quite a following (at least judging from what I have seen on some Internet discussion groups!). But I am somewhat dismayed that Szasz is still getting included: his initial work arguing that mental illness is a myth is now over forty years old, and his arguments have continued to be unsophisticated. It is striking that anti-psychiatry has not been able to come up with a more thoughtful defender of its claims. Even the article included by Szasz's follower, Peter Breggin, on the coercion of patients in a mental hospital, is more than 35 years old now.

While the anti-psychiatry tradition has tended to make broad-ranging condemnations of the mental health profession and its abuse of power, most of the other articles in Ethics of Psychiatry are more measured in their approach. It is here that Edwards' editorship is at its best: he has chosen some articles that are not well known but deserve to get a far wider readership. I was especially pleased to be introduced to Kerry Brace's 'Nonrelativist Ethical Standards for Goal Setting in Psychotherapy,' and Grisso and Applebaum's 'Is It Unethical to Offer Predictions of Future Violence?' These are both subtle and thorough articles on topics that do not get enough discussion.

As I say, gaps in such collections of articles are inevitable. The most notable gaps here are related: psychotropic drugs and the right to mental health care. There are a couple of articles on the right to refuse treatment, but maybe the most frequent question that gets asked these days about psychiatry is 'should so many people be taking psychiatric medication?' This arises especially in connection with antidepressants, anti-anxiety pills, and treatment for hyperactivity and attention deficit disorder. Having done work on this area myself, I know that part of the problem for an editor is that there is little intelligent discussion of the issues. But there have been some very thought provoking articles written in the last few years on the use of Prozac and Ritalin especially, and it is a shame that none was included here.

Maybe most odd is the lack of coverage of the ethical issue concerned with mental health which faces more families in the US than any other: coverage of mental illness by health insurance companies and the effect on the quality of health care by the shift towards Health Managements Organizations. I'm tempted to speculate this is because Ethics of Psychiatry is about substantial moral puzzles, and there the moral evaluation of the mental health HMO industry is as black and white as that of Bosnian war crimes. It's a business driven by profits, cost-cutting, bureaucracy, and stupidity, where the lowest priority is the well-being of patients. But even if my own immoderate view is true, there are still shades of gray to be discussed. For instance, is it ever ethical for a psychiatrist to lie to an HMO about a patient's condition in order to secure that patient the care she needs? Should federal government mandate parity of coverage for mental disorders and other forms of illness? Tangentially to this, is it right that mental disorders should be included in the scope of the Americans with Disabilities Act, and if so, is it also right that addictions and sexually related disorders are specifically excluded from protection under the ADA?

Looking to the future, it is likely that the one of the main preoccupations of psychiatric ethics will center on genetics. A whole host of new moral dilemmas will face us in the next century as we gain the power to control the psychological characteristics of our future children. Again, Edwards' collection doesn't address these issues. What that means is there plenty of room for more books on related topics-publishers take note! Despite its limitations, Ethics of Psychiatry is a fine introduction to morality in mental health, and is a very welcome addition to my bookshelf.