This excellent, comprehensive and thought-provoking collection is part of the continuing series in the International Library of Ethics, Law and the New Medicine. This is Volume 45, and so there is a long, distinguished and very varied tradition in which it takes its place.
The editors make it clear from the outset that there is no such thing as "psychiatric ethics" but rather "ethics in psychiatry" and as such the volume cannot be seen as putting forward or supporting a particular approach but more entering into and generously covering the entire field of opinion and circumstance. In that sense it is a reader rather than a prescription.
Ethical principles, they say, should be used when examining research and practice – and, of course, different principles, will give rise to different conclusions. Not only will the reader find classic ethical theory being applied but, also newer considerations such as relational ethics.
It is also important to note that the contributions are self-consciously European. This again does not mean that they are monolithic or uniform but, the tradition out of which they grow is in many areas quite different to that of North America. Psychiatric practice, particularly private practice, has taken quite different trajectories in different countries. This is not to say that all European traditions are homogenous, in fact from East to West and North to South there are as many variations as could be imagined – there is an old joke that in a room with three psychiatrists there are five opinions- but there is still something European that is worthy of exploration.
The volume is divided into six parts, or more accurately five and a conclusion. There are 32 papers in total, and all the authors seem to have been given a wide scope in which to discuss the issue and debate. Some are more contentious than others but, the collection is highly readable and generally not too technical.
The first part addresses the essential context in which research and practice is carried out. Particular emphasis is placed on legislation, governance issues and some of the elements and consequences of stigma.
In the second part four significant questions are addressed in more detail; informed consent (and its shadow, acting without consent); patient autonomy (and medical decision-making); confidentiality (and sharing of knowledge); and distributive justice. These areas of concern are as old as psychiatry and, the fact that they still create dilemmas for clinicians and administrators confirms how fundamental they are to the practice world.
The third part examines assessment and treatment issues, particularly in-patient treatment, and looks at the vexed question of competence. It is the longest section and broaches some of the new issues that are presenting themselves as a result of scientific advances as well as cultural change. For example, with the advance of genetics what are the implications for counseling, or indeed legal restrictions? Could this open a new age of eugenics because it may be possible to identify genetic markers for specific illnesses or conditions? Is there a question to be balanced between individual autonomy and risk to self – and what are the clinicians' rights and responsibilities, what are the rights and responsibilities of the individual? Do responsibilities come along with rights or not?
In the fourth part the non-medical use of psychiatric practice and classification are debated. For example, the use of psychiatric diagnosis for political purposes, which may have subsided in intensity but still presents a challenge, especially in a forensic setting.
The fifth part looks at the place of ethics in the education of clinicians, and is by a considerable stretch the shortest section (except the concluding chapter). There may be a significant weakness in this part in that it has a rather limited view of practitioners and clients. Little mention is made of other professions and even less of the general role of public education and cultural shift.
The final section is simply the summary and conclusions by the editors.
Although it a large text, almost 600 closely typed pages, it is a significant addition to the literature. Its segmented structure allows for specific as well as general reading. It augments the existing literature in and will be of particular interest to North American audiences who may not necessarily appreciate the full breadth of tradition and thought.
It is to be highly recommended and would easily find a place on the book shelf of any concerned clinician.
© 2011 Mark Welch
Mark Welch PhD, British Columbia