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There are any number of important but frequently neglected research programs in biomedical ethics. Notable amongst these are projects deeply grounded in the history of philosophy as well as critical treatments of the methodological contours of the field. Fortunately the present volume, Applied Ethics in Mental Health Care: An Interdisciplinary Reader (MIT Press, 2013), edited by Dominic Sisti, Arthur Caplan, and Hila-Rimon-Greenspan, addresses another commonly overlooked topic, that of mental health – or psychiatric – ethics. Indeed, it can be argued that the multidisciplinary field of mental health is particularly deserving of ethical analysis given several of its special features. These include the relative emotional and cognitive vulnerability of mental health patients, the highly personal and confidential information involved in therapeutic encounters, and the use of the therapeutic relationship itself as an instrument of treatment (Radden, 2002; APA, 2009). And of course these attributes figure against a background of broader, quite topical issues, such as recent developments in psychiatric classification and ongoing policy debates on the funding structure of healthcare systems (including the issue of coverage parity for mental health treatment).
All of these considerations make the present volume a welcome addition to the biomedical ethics literature, as it collects some of the most interesting articles published on mental health ethics over the last fifty years or so. With an explicit focus on issues arising from care and treatment (ie. excluding research ethics), the editors have done an excellent job of including selections that are truly multidisciplinary and that cover a wide variety of research. It is organized into six sections: 'Foundational questions,' 'Capacity, coercion, and consent,' 'Violence, trauma, and treatment,' 'Addiction,' 'Mental illness and the courts,' and 'Therapeutic boundaries.' Within these sections there are articles on topics such as PTSD, personality disorder, anorexia, forensic psychiatry, and the ethics of psychotherapy. And reflecting the current state of play in biomedical ethics, there is a striking methodological diversity, with many of the contributions incorporating case material alongside others that deploy qualitative and quantitative methods, critical review, social history, and conceptual analysis.
Here I'll focus on several representative articles from the collection that also happen to touch on core issues in biomedical ethics, starting with the broad question of the role of ethical theory. Like most readers in applied ethics, this collection opens with a section that introduces the relevant issues at their most basic theoretical level. And so, for instance, there is an excellent introductory article by the historian Charles Rosenberg that describes the various factors at work over the last century and a half in setting the social boundaries of mental illness. But what is not included in this section is a selection that reviews or critiques the leading theories in psychiatric ethics (cf. Bloch & Green, 2009). This is not as conspicuous or negligent an oversight as it may seem; there are good reasons to avoid grand theorizing and this collection is clearly intended to have a predominantly applied remit. What's more, knowing how presentations of grand theory usually play out, any and all efforts to eschew the well-worn divide between deontology and consequentialism should be applauded and encouraged. In fact, the only article included that directly takes up issues in traditional ethical theory does just this, in philosopher Jennifer Radden and psychiatrist John Sadler's piece on virtue ethics.
Radden and Sadler have developed their position more fully elsewhere (Radden & Sadler, 2010); here they make a brief but strong argument for the application of virtue theory to psychiatry that is both careful in its handling of the conceptual groundwork and practical in its incorporation of case material. They focus on several aspects of virtue theory central to its use in professional education, in line with Aristotelian 'habituation' of the virtues through deliberate repetition. These include attention to the mental states that drive behavior, the heterogeneity of the virtues, associated affective elements, the partiality of virtue, the importance of role morality, inevitable temptations and weaknesses, and of course phronesis. The discussion of these features benefits from the use of case material which demonstrates how virtue ethics is especially well-suited for psychiatry given the centrality of interpersonal relations. And more generally, this approach should be commended due to the fact that attention to the moral character of practitioners is another oft-ignored aspect of biomedical ethics (despite the recent increased popularity of virtue theory in moral philosophy).
But there are also reasons for caution, as virtue-based approaches have limitations, some of which extend to the theoretical underpinnings of other work included in the collection. Radden and Sadler espouse a kind of theoretical pluralism which emphasizes the compatibility of virtue ethics with other traditions. As I've indicated, this is all to the good given the stultifying impasse between competing theories in much moral philosophy. But we do need to be careful not be overstate any apparent compatibility. For a start, it remains highly contentious as to whether competing ethical theories can truly be reconciled; not surprisingly, such debates are active and need to be directly engaged. What's more, not all theoretical strands are appropriate for certain modes of ethical reasoning. For example, as Radden and Sadler recognize, virtue ethics is better suited for educational purposes than for the formalization of professional codes of ethics. Even if we think that the virtues provide some basis for the rules and principles of other ethical frameworks, the applications and deliberations afforded by deontological and consequentialist theories arguably outstrip the resources of virtue ethics. A similar point applies to the work of many contributors to the present volume who endorse a flexible, context-sensitive ethical framework, largely consistent with the 'pragmatist' view of psychiatrist David Brendel (2006). But this approach, at least as it stands, is theoretically insufficient for a comprehensive ethics of mental health, which may at least partially explain the continuing appeal of 'principlism' (Beauchamp & Childress, 2009).
Continuing with the Radden and Sadler article, but with implications for some of the other contributions, there are additional worries about relying on a certain kind of case material. Clinical examples are often illustrative and instructional, particularly in the field of biomedical ethics where some researchers never set foot in the clinic or the lab. But like the frequent use of case reports in many of the entries, in the Radden and Sadler piece it's noticeable that what is often at stake is really a question of clinical skill rather than something necessarily moral. It seems right that all therapeutic interactions are inherently moral, but surely such a claim is by degree. Not all clinical matters rise to a level of true moral concern. As Radden and Sadler suggest, it may be that clinical skills are best viewed as virtues in the context of role morality. But generally we should avoid obscuring the distinction between ethical issues attendant to the communicative subtleties within a therapeutic relationship versus ethical quandaries on a larger scale. This may be a product of the selection of relevant cases, but questions of methodology are important. So, for example, any theory of virtue ethics also needs to accommodate – or, alternatively, explain way – the empirical findings suggesting that character traits are highly sensitive to situational factors (rather than stable dispositions).
Another topic at the core of biomedical ethics that runs through many of the collected articles is the question of autonomy. As one of the editors of the volume, the medical ethicist Arthur Caplan, notes in his article on the treatment of addiction, there has been a remarkable shift over the last forty years towards increased respect of patient autonomy and self-determination. Given this trend, though, serious ethical questions persist, and here Caplan advocates (against the trend) for the temporary mandatory treatment of sufferers of severe addiction. Interestingly, this is motivated not by consequentialist concerns but, rather, on the grounds that the compulsive nature of addiction restricts autonomy and thus that treatment is required to restore it. Caplan turns to the example of rehabilitation medicine to make the point that some patients, while retaining competence (or capacity), are unable to make the fully autonomous choice to receive treatment given obstacles inherent to their medical condition (such as despondency, and even suicidality, in cases of paralysis). Thus addiction treatment should also not shy away from using compulsory means.
Now, some of the authors included in the section on 'Addiction' would most likely disagree with aspects of this position, particularly the perennial internal critic of psychiatry Thomas Szasz and the sociologist Craig Reinarman, both of whom write critically of the social forces that shape the 'disease' model of addiction. There certainly are a number of questions one could pose to Caplan's view. But here I will only briefly comment on the more conceptual issues upon which the normative questions in part depend. Simply put, his account – and others like it – would profit from greater clarity on the relation between the notions of autonomy, competence, and coercion. According to Caplan, addiction 'literally coerces' and in doing so undermines autonomy despite the possible retention of competence. This framing is consonant with a rough understanding of autonomy as comprised of both negative (ie. no coercion) and positive (ie. capacity to reason) properties. But of course autonomy has a long and contentious conceptual history and so a lot more could be said. It would also be interesting to know what conception of competence or capacity is at work, as the relationship between capacity and mental disorder is notoriously complex. Other contributors to the volume (such as the case reports by psychologists Margery Gans and William Gunn, on anorexia, and the psychiatrist George Szmukler, on personality disorder) rely upon the influential work on capacity by the psychiatrist and medical ethicist Paul Appelbaum, who wrote the collection's foreword and also contributes an article on advance directives.
In addition, while there is definitely something to the idea that mental disorders can impinge on personal agency (as noted in Pouncey and Luken's article on the tensions between the recovery movement and forensic psychiatry), it's far from clear that coercion is the best way to understand this relation. First, there is a longstanding debate on how best to define coercion, and none of the theories are a natural fit for the agency-limiting processes involved in addiction. Second, it's important to emphasize that coercion and non-voluntariness are not co-extensive. That is, one can fail to have control of one's choices for all sorts of reasons (that have little to do with coercion per se), and the presence of coercion does not necessarily imply a lack of voluntary choice (although it often does involve constrained choice). And lastly, many of these questions are potentially empirical. It's possible that the extent to which sufferers of addiction lack the freedom to choose can be studied empirically. And while Caplan's account implies that only one type of decision-making is impaired or beyond control (that of how and when to use substances), a fuller empirical picture of the relation between global competency and addiction would be instructive. An analogue is the growing empirical literature on coercion and voluntariness, which has revealed, for example, a dissociation between legally mandated treatment and patients' perceptions of the presence of various forms of coercion.
I take all of this to suggest that there are better ways to understand the lack of behavioral control associated with addiction than by appealing to coercion. Rather boringly, the best conceptualization may simply be that of 'compulsion.' Notice that this is not a minor issue. In these debates we have a responsibility to be as clear as possible about the operative concepts; this can only improve the quality of exchange and ultimately the moral status of practice and policy decisions (clear concepts may also better serve the operationalizations used in empirical research). This is particularly true when a normative claim rests upon a conceptual stipulation. None of this is fatal for projects like Caplan's which argue that an exception to the default presumption of autonomy is justified and/or obligatory in certain circumstances. Such projects exemplify mental health and psychiatry's most serious social role, that of moral and legal arbiter. But it is particularly problematic in this case given that coercion is often thought of as an inherently moralized notion that necessarily links to ascriptions or mitigations of moral and legal responsibility. For instance, if addiction in fact coerces, then this runs up against the hotly debated question as to whether addiction undercuts criminal responsibility. And it is also a common assumption within biomedical ethics that an inability to voluntarily choose precludes the possibility of coercion, as coercion requires the overthrow of genuine decision-making. We should therefore resist arguments that simply assume non-voluntariness or lack of control in order to effectively lower the justificatory bar for infringements on autonomy (ie. if the patient is already internally coerced then it's permissible to externally coerce them).
Moving past the more conceptual and theoretical issues raised by many of the entries in this collection, one of the most interesting sections is its last, which focuses on issues having to do with boundary crossings and violations in clinical work. In this section the strength of the collection's applied approach is readily apparent. Following an entry that provides some useful conceptual ground clearing by Jennifer Radden, a handful of articles provide case examples coupled with helpful guidelines and recommendations on how to handle the often contested boundaries of therapeutic relationships. David Brendel and colleagues examine the ethics of gift-giving between patient and therapist, the psychiatrist Arnold Lazarus gives a spirited defense of the use of commonsense when setting boundaries, and professor of social work Frederic Reamer outlines the relevant boundary issues within that discipline. And breaking the newest ground for research and practice on this topic are two recent articles on the use of the internet and social media in psychiatry, by the psychiatrists Brian Clinton and colleagues and Glen Gabbard and colleagues. Both provide practical recommendations for tackling the ethical issues posed by such new technology. All of the articles in this section should thus prove useful for practitioners and ethicists who are dealing with the challenges of negotiating boundaries in the therapeutic context.
Overall this is a high quality collection that includes many interesting and important contributions to mental health ethics. No one collection can be comprehensive or entirely successful, though, and so I should briefly register some of this volume's shortcomings. As I've indicated, the collection as a whole, and several of its entries, would have benefited from more of an engagement with foundational issues in ethical theory. This was most likely a considered judgment on the part of the editors, defensible in light of the collection's foregrounding of applied matters. But the theoretical contextualization of applied matters can be quite important, and even a broadly-pitched introduction by the editors would have strengthened the collection (only brief introductions of each thematic section are provided). More of an international focus would also have improved things, as biomedical ethics increasingly takes up global issues, including in developing countries. And while probably beyond the scope of this volume, and as some of my previous commentary suggests, there is a pressing need for biomedical ethics to grapple with methodological issues. The variety of methods used in the collected articles is laudable, but while such inclusiveness is fairly standard in biomedical ethics, methodology is the subject of ongoing debate in philosophy proper. Thus we may need to turn our attention to the dynamics of the interplay between empirical and theoretical research. As I've mentioned above, a number of the more theoretical pieces would have benefited from considering prima facie relevant empirical data. And while there are instances where the extant data carries with it such a clear moral mandate that hardly any further analysis is required (as in the psychologist Rebecca Campbell's powerful article here on victims of sexual assault), more often than not the descriptive profile of an issue will call for ethical – and perhaps conceptual – critique.
American Psychiatric Association (2009). The principles of medical ethics with annotations especially applicable to psychiatry (Rev. ed.). Washington, DC.
Beauchamp, T.L. & Childress, J.F. (2012). Principles of biomedical ethics (7th Ed.). New York: Oxford University Press.
Bloch, S. & Green, S. (2009). Psychiatric Ethics. New York: Oxford University Press.
Brendel, D. (2006). Healing psychiatry. Cambridge, MA: MIT Press.
Radden, J. (2002). Psychiatric ethics. Bioethics, 16, 5, 397-411.
Radden, J. & Sadler, J. (2010). The virtuous psychiatrist: character ethics in clinical practice. New York: Oxford University Press.
© 2014 Kelso Cratsley
Kelso Cratsley, PhD, is currently a Visiting Researcher at the Brocher Foundation in Geneva