1.10.4.13 Ethics and philosophy in psychiatry

Ethics and law

• Law sets what a doctor may do and ethics asks whether it is justified, so a lawful act can still be wrong.

• A tort is a civil, not criminal, wrong arising from a duty imposed by law, for which the injured person sues for damages.

Theories of what makes an act right

Moral reasoning has three levels: ethical theories sit above the prima facie principles, which sit above rules.

Utilitarianism

• Utilitarianism, founded by Jeremy Bentham and John Stuart Mill, is the main consequentialist theory: rightness depends only on outcomes.

• The best outcome is the greatest total happiness or welfare, with each person counted equally.

• Act utilitarianism, usually linked with Bentham, judges each choice afresh by its own consequences, so a usual rule may be broken for greater happiness.

• Rule utilitarianism, linked with Mill, judges an act by the consequences of the rule it follows.

• Placing public safety above a mentally disordered offender's therapeutic interests is utilitarian reasoning, weighing aggregate benefit to the public against benefit to one patient.

Deontology

• Kant's categorical imperative is the test of deontology: act only on a maxim that can be universalised without contradiction.

• It also requires that persons are treated as ends, never merely as means.

Deontology is told from rule utilitarianism by its justification: a Kantian duty binds whatever the outcome, whereas rule utilitarianism justifies a rule by the good consequences of general compliance.

The four principles

• Principlism, set out by Beauchamp and Childress, is the biomedical ethics framework of four prima facie principles.

• Each principle binds unless outweighed by another, and none overrides by default, so they are balanced case by case. They identify conflicts but do not resolve them alone.

• Their philosophical source is W D Ross's pluralist theory of prima facie duties: several conditional duties, none ranked permanently above the others, settled by judgement in each case.

• Declining to prescribe when risk outweighs benefit applies non-maleficence, and weighing a treatment's expected benefit against its foreseen harm sets beneficence against non-maleficence.

• Paternalism is a clinician substituting their own judgement of a patient's good for the wishes, or the right to know, of a capable patient, acting for their good while setting aside their choice.

Capacity, consent and refusal

• Under the Mental Capacity Act 2005 in England and Wales, a person lacks capacity only if they cannot understand, retain, use or weigh, or communicate a decision because of impaired functioning of the mind or brain.

• Capacity is presumed and is decision-specific and time-specific, and an unwise choice or a diagnosis alone does not establish incapacity.

• An adult with capacity may refuse treatment, even treatment needed to save life. The refusal is respected and documented, not overridden by referral, assumed incapacity, repeated persuasion or forced treatment.

• Mental health legislation can authorise specified treatment despite refusal when its statutory criteria are met, and any restriction must be necessary, proportionate, the least restrictive option and actively reviewed.

• Therapeutic privilege is withholding specific information from a capable patient during consent because disclosure is judged likely to cause serious harm. It is recognised but narrow and discouraged, and concern about distress alone does not justify it.

• The Fraser guidelines on contraception for under-16s without parental involvement come from the House of Lords judgment in Gillick v West Norfolk and Wisbech Area Health Authority (1985); Gillick competence applies more widely.

• Under the Abortion Act 1967 as amended in 1990, the upper limit in Great Britain for termination on grounds of risk to the woman's physical or mental health is 24 weeks.

Emanuel and Emanuel's models of the doctor-patient relationship

Confidentiality and competing duties

• Disclosure without consent may be required by law or justified by an overriding public interest, such as serious harm, safeguarding or serious crime.

• The Tarasoff case established a duty to warn or protect an identifiable third party from a patient's credible threat of serious violence, so confidentiality gives way.

• Tarasoff did not require compulsory detention, and as a Californian ruling it does not bind UK practice.

• Double agency is a clinician's duty to a patient competing with an obligation to a third party such as the state, an employer, a court or society.

• Double agency names a general type of conflict, not one relationship pair, so before a report assessment the clinician clarifies their role, the recipient and the purpose.

Boundaries and gifts

• A doctor must never pursue a sexual relationship with a current patient.

• General Medical Council guidance allows a doctor to accept an unsolicited gift from a patient, provided it does not affect, or appear to affect, treatment, prescribing or referral decisions.

Codes of professional ethics

• The Declaration of Hawaii was partly a response to the political abuse of psychiatry in the Soviet Union.

Research ethics

• Under Helsinki, a placebo arm is acceptable only where no proven treatment exists, or for compelling methodological reasons without risk of serious harm, and post-trial provision must be addressed.

• Unlike Nuremberg, Helsinki permits research on people who cannot consent, but only with safeguards: appropriate consultation, justified risk and respect for dissent.

• Consent to research is voluntary and continuing: a participant may withdraw at any time, even after signing a consent form, without justification or penalty.

Landmark unethical studies

What counts as mental disorder

• Fulford argued that judging function to be impaired is evaluative throughout medicine, so a useful diagnostic category is not thereby value-free.

Explanation, mind and body

• Jaspers distinguished causal explanation (Erklären) from meaningful understanding (Verstehen): primary delusions cannot be understood psychologically, whereas overvalued ideas are intelligible.

• Substance dualism separates mind and body but struggles to explain their interaction, whereas physicalism regards mental states as physical and functionalism defines them by causal role.

• The hard problem asks why processing is accompanied by subjective experience.

Antipsychiatry and its critics

• Thomas Szasz, in The Myth of Mental Illness (1961), argued that mental illness is not a literal disease but a metaphor for problems in living, because disease requires a bodily lesion.

• Szasz opposed coercion, which he saw as social control, and insisted on personal responsibility.

• R D Laing held that madness can be a breakthrough as well as a breakdown, a potentially liberating and renewing voyage.

• Laing also saw madness as an understandable, even sane, reaction to a disturbed society.

• Foucault argued that psychiatric knowledge and power are intertwined.

Szasz denied that mental illness is a literal disease, whereas Laing made psychotic experience intelligible without denying the disease concept.