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Oxford Handbook of Psychiatric EthicsReview - Oxford Handbook of Psychiatric Ethics
Volumes 1 and 2
by John Z. Sadler, Werdie (C.W.) Van Staden, K.W.M. (Bill) Fulford (Editors)
Oxford University Press, 2015
Review by James Kow
Aug 30th 2016 (Volume 20, Issue 35)

This formidable two volume work comprises ten sections of ninety-four articles.  And these two volumes have as their  "sister volume, the Oxford Handbook of Philosophy and Psychiatry." (Eds. K. W. M. Fulford, M. Davies, R. G. Gipps, G. Graham, G. Stranghellini and T. Thorton, Oxford University Press 2015 (Hereafter PP), which has eight sections in one volume comprising seventy three articles and 1291 pages. These works are part of the Oxford series dealing with "International Perspectives in Philosophy and Psychiatry" in an inter-disciplinary manner. To assist the reader the PP has an introduction to each of its eight sections, while the former two volumes of PE has a very welcome detailed table of contents regarding each of the ninety-four articles. PP is characterized as  "we hope a cross-section of the new field" and is "primarily philosophical in focus," while PE extends this self-reflection. Other relevant works in the field include The Oxord Textbook of Philosophy and Psychiatry. Eds. B. Fulford, T. Thorton, and G. Graham. Oxford: Oxford University Press, 2006, and The Philosophy of Psychiatry. Ed. J. Radden. Oxford: Oxford University Press, 2004

Our present two volumes are as "proactive" as the Oxford TextBook was said to be. They are meant to provoke new lines of thought. Unlike the Oxford Textbook" our volumes are not case studies, but anchored, broadly speaking, in clinical encounters.

This new philosophy of psychiatry, which psychiatry presupposes does not put grand theories, but rather deals in as Okasha states in the TextBook: "the best that we can hope many small explanations from a variety of explanatory perspectives, each addressing part of the complex processes underlying "normality or disorder."

As a new mode of  research in PP experts work in scholarly exploration of diverse areas of psychiatry. As a result these volumes are not composed of summaries or introductions to different areas. Instead they present a more concrete individualistic approach in response to live issues thrown up by real cases psychiatrists have to deal with.

One must note that the notion of "Handbook" employed is a new form of presentation for philosophy and psychiatry. Oxford has furnished us with something more than an anthology, and less than a multi-volume Encyclopaedia. Just as the field of psychiatry this series on philosophy and psychiatry is a challenging work in progress. The most likely audience of readers for the volumes for PE are psychiatrists, philosophers, and those in the therapeutic field. One might best employ The Oxford Handbook of Psychiatric Ethics as a work to be perused or read for certain areas of interest.

How should these volumes be read? Let me suggest reading the volumes dipping in and out roughly in the following sequence of sections. Each reader will, no doubt, find her own way. I  will not unfairly pick out too many individual articles because that would do an injustice to those not mentioned.

To set the context read Section I "The Introduction" first. The first article by the editors "Why an Oxford Handbook of Psychiatric Ethics" justifies the rationale for the two volumes. The values-based approach is argued for immediately in article four. Follow with Section IV "Philosophy and Psychiatric Ethics" which encompasses some of the main ethics theories: principalism, utilitarianism, values, autonomy, and virtue ethics among others. Given the orientation of the volumes these theories are profiled against Sadler's "Value-based Psychiatric Ethics." After this Section 2 "People Come First" can be used to remind us of those who sought and found or did not find resolution in therapy. For an understanding of the patient's point of view we possess an article by O. Flanagan that is very informative (PP. pp. 865-888, ,and many good books by patients:  K. Jamieson on bipolar disorder  An Unquiet Mind; E. Saks on schizophrenia  The Centre Cannot Hold; A. Solomon on depression The Noonday Demon; S. Stoessel on anxiety

My Age of Anxiety; and C. Knapp Drinking: A Love Story. )

Then more specifically delve into Section IX "Ethics and Values in Psychiatric Assessment and Diagnosis." All articles in this section are indispensable. New diagnoses in psychiatry have crucially significant real world effects in creating new classifications and categorizations of human beings which ironically may only last as long as the life-time of the European International Classification of Mental and Behavioral Disorders (ICD) or American  Diagnostic and Statistical Manual (DSM) publications. The diagnosis is crucial because it is entrance into the intimate psychiatrist-patient relationship. The clinical and deeply human  encounter begins here. For this reason diagnosis is not a neutral one-off. It is on-going and open to revision with contributions by both psychiatrist and patient.

For the psychiatrist thinking about her area ethically is to enter a relationship with a patient. The process of diagnosis opens up this relationship, which is non-linear, asymmetrical, and dynamic. If evidence-based, then the evidence is not merely scientific (ratified by random clinical trials, or committees of psychiatrists (Cf DSM) but also phenomenological. And so empathy and sympathy are deeply involved in the exploration in the psychiatric setting. The difficult  question of the difference between normal and abnormal, of functional and dysfunctional has individual, familial, community, societal, and cultural dimensions. Diagnosis is in many ways a "whale" category. Who is Moby Dick and who is Ahab and who is Ishmael? Who is the voice of psychiatry and philosophy? Who?

The next section X "Ethics and Values in Psychiatric Treatment." I suggest this contains the pertinent ethical themes for the moment. The intention is to heal or cure as much as possible, secondarily to understand or explain. Issues regarding professional boundaries and pharmacology are just some of the many themes touched on here.

Next read Section VI "The Social Context of Psychiatric Ethics." I propose that this section should include the schizophrenic-like division in modern psychiatry itself. (Cf Of Two Minds: The Growing Disorder in American Psychiatry by T.M. Luhrmann; less controversially Cf E. Shorter A History of Psychiatry).  Psychiatry has mutated from the psychoanalytic to the current biomedical model which finds its aspirational expression in ICD and DSM, and in the notion that psychiatry should be like the science of internal medicine. Importantly some reflection upon the cultural context and the education of psychiatrists should be included. And one has to acknowledge that 80% of psychiatric diagnoses and treatment are carried out by primary care physicians.

Following on this, section VII "Ethics in Psychiatric Citizenship and the Law," the articles on involuntary seclusion and forensic psychiatry disclose the fine line psychiatry must walk.  An insightful wide-ranging discussion is conducted in section VIII on the "Ethics of Psychiatric Research" embracing the staple of consent, but also animal research. Penultimately, I would place section III "Specific Populations" at the end because of the particularity of the evidential groups. Nonetheless we should note that those in penal institutions–Los Angeles Holding Centre and New York's  Ryckers Island–contain the largest concentrations of the mentally ill in the America. And finally we should acknowledge the the psychiatrist who herself/himself, requires psychiatric help. Their status as Nouwen's "wounded healers" opens a bridge into deeper therapeutic relationships.

Section V on the "Religious Contexts of Psychiatric Ethics" may be premature. The section on religion needs to tackle the notion of psychiatry as a secular religion before exploring this global area. Section V is broadly sketched. What needs to be addressed head on is the replacement of religion with psychiatrists in curing/healing/making holy the human condition.. Is psychiatry subject to the criticism that it a secular religion, with a messianic, albeit minor, complex of its own? Is psychiatry a new religion, and a bourgeois one at that?

The Evidence-based approach permeates all the sections of these two volumes. But the model is more diversified by the varying content, context, and cultures by implication. All articles deal with evidence. The meaning of evidence is equivocal. Talk-evidence in a psychiatric setting is not addressed. One should note that such evidence is by report, or expression, or both.

More substantively two themes guide the approach in PE , and by implication the Oxford project in its International  Perspectives in Philosophy and Psychiatry. PE is rooted in the Anglo-American analytic approach or  Oxford school of philosophy ordinary theory of J.L. Austen. The practitioners deploy a pragmatic Wittgenstein-like toolkit to access meaning in the extremes of human behaviour.  Precision and exactitude is not necessarily desirable here for human beings are rather messy and untidy in their lives, given to incoherences that somehow cohere to get most us through if not felicitously, then at least enough.

Despite some adversions to hermeneutical  phenomenology,  PE follows Hume in a deep sense. Given the diversity of content, the subject-matter is "evidence-based," or about, I suggest, the facts. Given all the viewpoints expressed the method for PE as an ethical reflective work is value-based. PE is not only evidence-based  and value-based, but it is centrally these as its controlling principles: facts and values.

I suggest that the evidence-base is formulated utilizing as its lineage the Kraepelinian biophysical model. Psychiatry is a science. ICD and DSM seem to be lurking in the background here. The role of subjective or phenomenological evidence in its diversity including embodied consciousness is not explicitly dealt with. Since the facts do not speak for themselves we cannot simply "listen to the evidence" as is implied. There is no controlling ethical description telling us what to do to be gleaned from the evidence.

The objective or subjective facts of being human are opaque, ambiguous, contingent, and mysterious. Human beings need to be empathized with to be interpreted, and empathetically understood sympathetically. But there are always remain some who are inaccessible. So an evidence-based approach could, inadvertently) be guilty of an unintended overreach (especially if randomized controlled trials and committee define what mental illness, mental disorder etc... are.)  All these evidence-based hypotheses of psychiatry might not a thesis make.

PE does not adjudicate whether psychiatry is medical in the strong sense of hard science? Regarding randomized clinical trials (Rcts) a power curve distribution would show most people are not happy yet most likely content.  In ethics for Aristotle the average person is morally/ethically weak. This fits in with a power curve distribution. Rcts are based in part on the bell/Gaussian curve and standard deviation. This ignores fat-tails and outliers. It smooths discontinuities which human life seems to be about. But the patient group for psychiatry seem to be outliers from the mean and the median. Their's is not the standard deviation. On the contrary it is non-linear and non-standard.

The value component in PE said to be value-based indicates the value of health. But what is health? Tellingly, Aristotle uses health as a pros en equivocal in Aristotle to explain the good, or good functioning. Well-being is both non-moral and moral/ethical. This is not captured in the notion of value-based.

In consequence, what mental disease or disorder or illness is a fuzzy concept. Is it a discrete entity or part of a continuum? We have a "science" of psychiatry dealing with symptoms/effects but we have no defined causes for the effects. Psychiatry is more like pattern recognition when it comes to categorizing someone with a mental disorder.

Or what type of sign is mental disorder? There is an important place for semiotics in evidence-based psychiatry. What does it express, and is the expressive relationship best understood causally? PE presupposes philosophy, but not in foundational or coherentist terms, but rather in analytic and pragmatic terms.

One area of science left out despite two articles on it in PE is cognitive and especially affective neuroscience, psychiatry, and ethics. Neuroscience is addressed in an Oxford handbook devoted solely to neuroscience. (Cf The Oxford Handbook of Neuroscience. Ed. J. Bickle. Oxford: Oxford University Press, 2013.  618 pages).  PP noted that "The philosophy of psychiatry...for all its recent burgeoning, remains a minnow to the neuroscience whale." (p.8)

In addition greater attention needs to be paid to women as psychiatrists and patients, and to those who are mentally ill but incarcerated in penal institutions. Not doing so diverts psychiatry as it is practiced in north America and the UK into a kind of methodological individualism. The patient has to encouraged to express and "own" her mental disorder, not merely report on it. Here the methodological individualism of psychiatry discloses itself. Is the we of the therapeutic context simply the doctor and the patient, or is the family, or a group, or the community included as well? This seems to be culturally variable.

We possess evidence of clinically important impairment.  Human beings suffer real distress—emotionally and mentally. This is expressed symptomatically. But the suffering person lives in this distress. The standard in psychiatry must be the mysterious person as patient and as a subject. Is the patient the patient (passive?) or the person, individual, self, subject, or human being (active)? Who is she? It is her whoness that appears to be problematic. The individuation of the patient goes against the grain of too strong a statistical or stochastic evidence-based approach.

As a patient I recognize that no one is fully autonomous. I/We require a good (in)depency to function well. Yes psychiatry presupposes philosophical reflection–simply to recognize the limits of psychiatry. There is no treatment for being human. But there are treatments for some aspects of the human condition. Psychiatry at the points of human suffering and extremes darkly illuminates who we are. The struggle continues.

In all though, these two volumes are a welcome addition to the Oxford series in Philosophy and Psychiatry. You will find great breadth and depth here, and as the editors, know this is an on-going project in our aspiration to explore the human condition in all its forms.


© 2016 James Kow


James Kow, King's University College, London, Ontario, Canada


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