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An Anthology of Psychiatric EthicsReview - An Anthology of Psychiatric Ethics
by Stephen Green and Sidney Bloch (Editors)
Oxford University Press, 2006
Review by Christian Perring
May 27th 2008 (Volume 12, Issue 22)

An Anthology of Psychiatric Ethics does a wonderful job of collecting important work in the field at a reasonable price.  I used it recently as a textbook for an undergraduate course on philosophical, ethical and social issues in clinical psychology and psychiatry, and it worked well.  The book is divided into nine sections, each with a short introduction written by the editors.  The introductions survey the general area of each section and have a long list of references that could guide further research.

  1. Theoretical Foundations
  2. The Therapeutic Relationship and the Social Domain
  3. Diagnosis
  4. Confidentiality
  5. Psychiatric Treatment and Services
  6. Special Clinical Populations
  7. Forensic Psychiatry
  8. Resource Allocation
  9. Research

With over 500 pages in small font, it contains about 73 different pieces.  The font is so small that some readers may find themselves squinting at the pages.  However, it does mean that the book is relatively thorough.  The length of the book also means that there will be sections that when used as a textbook, a fair proportion of the book won't be used, especially if it supplemented by other readings and materials.  The same holds true of most textbooks.  This and following comments on the decisions of the editors should not be interpreted to mean a lack of enthusiasm for this collection, which is very welcome. 

The first section on theoretical foundations does not really do much to provide foundations.  I didn't include any of the pieces from this section in my teaching and I rarely felt that students had missed out on important information.  When some papers draw a distinction between following a set of rules or looking at the overall consequences of actions, it is straightforward to explain the distinction without appeals to highly theoretical questions.  The selections discuss virtue ethics, casuistry, Kant, Utilitarianism, principilism and the ethics of care.  This debate in meta-ethics is for the most part beside the point in most of the following discussion.  Indeed, this raises the question to what extent is this debate mostly about ethical issues.  One of the strengths of the collection is that, despite the first section, it is thoroughly interdisciplinary.  If the book were to really give theoretical foundations for the work to be done, it would need to include the bases of metaphysics, conceptual analysis, sociology, law, and political theory, as well as large portions of medicine and psychology.  Different students will bring different sorts of knowledge to a course based on this book, and, if it goes well, they can educate each other.

The second section is mainly about issues in psychotherapy: it has an extract from Freud on transference, and several discussions of exploitation of patients by clinicians.  Much of the debate here depends on how one understands the relationship between therapist and client, which is largely a matter of psychotherapeutic theory as to how therapy gives the therapist power over the client.  The basic ethical issue is relatively simple: therapists should not harm their clients.  Thus this section will be mainly of interest to students who are going to be therapists or have been in psychotherapy themselves.  They will be motivated to discuss whether hugging between therapist and patient, gifts, or payment for services in forms other than money can be appropriate.  The section does include an excellent discussion from Hastings Center Reports in 1977 on the conflict of interests of psychiatrists in the military, prisons, and psychiatric institutions, which overlaps well with the later discussion of confidentiality.

The third section on diagnosis brings together many issues under one section: the reality of mental illness, psychiatric classification, labeling theory, and the relation between mind and body.  Inevitably it is rather compressed.  It has a sample of Szasz, which students always find provocative and surprisingly appealing.  It also has Rosenhan's classic article "On Being Sane in Insane Places," which fuels the antipsychiatric fire.  On the other side are papers by Boorse and Wakefield, which overlap in their criticisms of antipsychiatry.  Wakefield's paper sets out his harmful dysfunction model as well as criticize competing views, and works well with the debate over whether homosexuality should be classified as a mental disorder.  I wished there were a more stolid defense of the psychiatric medical model in this section, by someone like Samuel Guze or Nancy C. Andreasen, to help draw the contrast between the two sides, since Boorse's approach from 1976 ends up recommending psychoanalysis as a model of what a theory of mental health should be. 

Section 4, on confidentiality, contains the standard debate over the Tarasoff decision, but also includes a nice paper on family involvement for patients with psychoses by Szmukler and Bloch, which helps to reframe the issues going beyond the standard debate.

The fifth section is the largest of the book at over 100 pages, discussing various forms of psychiatric treatment and the ethics of their use, especially when the patient does not consent to them.  It includes involuntary hospitalization, informed consent, the right to treatment, malpractice, psychotropic drug use in children, the medicalization of unhappiness, electroshock treatment, values in psychotherapy and psychoanalysis, and the place of religious values in treatment.  This is a large area, and so the editors had difficult choices to make.  I would have urged to basically take out papers concerning psychoanalysis which are largely irrelevant to contemporary clinical practice, and to include more on the role of the pharmaceutical industry in treatment trends. 

One of the shortest sections of the book should have been one of the longest, I would argue.  The sixth section on special clinical populations has 6 papers, addressing the treatment of children, people with dementia, different ethnicities and racism.  The paper by Dworkin and Dresser on dementia and autonomy work well together.  The other papers in the section are interesting.  Furthermore, there are papers in other sections, on women, children, gay and lesbian populations, that can be used in connection with this section.  Nevertheless, there is so much to be said about dealing with cultural difference in psychiatry, so much controversy about certain diagnoses, and so much about the role of gender in psychiatry, that this section is strangely bare.  My experience teaching suggests that students can especially warm to these issues, and so I would suggest that faculty using this section might want to supplement the readings with others.

The final three sections are all strong.  The section on forensic psychology of course contains some papers on the insanity defense, but it also has papers on the conflicting roles of psychiatrists when they are both evaluating criminals and judging their psychiatric needs, as well as papers on other related topics.  The section on resource allocation addresses relatively familiar questions about how to determine medical or psychiatric needs and who should receive care when resources are limited.  The final section on research covers informed consent and the ethics of some experimentation. 

This book is an outstanding resource for faculty teaching courses in this area, suitable for a wide range of different student populations, such as liberal arts undergraduates, medical students, or graduate courses in clinical psychology.  It could also be very useful for people wanting to educate themselves.  There are not many competing texts.  This collection supersedes the third edition of Psychiatric Ethics edited by Bloch, Chodoff, and Green from 1999, and is clearly more comprehensive and up-to-date than Ethics of Psychiatry: Insanity, Rational Autonomy, and Mental Health Care edited by Rem Edwards from 1997.  The editors of An Anthology of Psychiatric Ethics deserve congratulation for the success of their work.

© 2008 Christian Perring

Christian Perring, Associate Professor of Philosophy, Dowling College, New York.

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