CLINICAL HANDBOOK OF SCHIZOPHRENIA

626 VIII. SPECIAL TOPICSinterests can be claimed to address patient needs. But this is conceptually problematic, becausethere is no—and probably cannot be—consensus on what a person needs to achieveand maintain a satisfactory and meaningful life and, arguably, that is so subjective that itcan only be determined by the person, mentally ill or not.Thus, client-centered mental health care, at least in the area of psychiatric rehabilitation,may not be ethically and conceptually sound in some cases. In such cases, alternativeapproaches may be required, with the recognition that forced or coerced psychiatric rehabilitationmay not be ethically acceptable with regard to achievement of goals, and tomaintenance of goals (the latter would probably require continuous and possibly increasedcoercion or force). An alternative could be a dialogical approach, where all involvedparties engage in structured dialogue to establish mutually acceptable goals in anethically sound manner (Rudnick, 2002a). Schizophrenia, with its various symptoms andimpairments, may challenge this approach, but there may be ways to overcome this challengewithin a dialogical approach by facilitating communication and accommodating forsuch psychiatric symptoms and cognitive impairments (Rudnick, 2007). For instance, impairmentsin executive functions may disrupt the ability to predict consequences of actions,and hence to discuss relevant utilitarian considerations, but cognitive rehabilitationand support strategies (Twamley, Jeste, & Bellack, 2003) may be helpful in overcomingthis challenge, therefore facilitating such dialogue with cognitively impaired individualswho have schizophrenia. Future study may explore this approach in detail.ETHICS OF CLINICAL RESEARCH IN SCHIZOPHRENIAResearch ethics is concerned with the moral principles and rules that govern the conductof scientific study involving human subjects. Clinical research is essential to further ourunderstanding of the causes of schizophrenia and the development of safe and effectivetreatments. But these ends cannot be pursued legitimately by any means. Clinical researchmust be conducted in a manner that protects the liberty and welfare interests of researchsubjects. Standards for the conduct of clinical research are set out in federal regulationsand are enforced by institutional review boards. Clinicians who conduct research, orwhose patients may be enrolled in such research by others, need an understanding of theregulation of clinical research, ethical principles and rules, and issues of special importanceto psychiatric research.The need for regulation of research by the State is often traced to unethical practicesin the past. Unfortunately, medical history is replete with examples of research that failsto take adequate account of the rights and welfare of subjects (Moreno, 2001). For instance,at the Allen Memorial Institute in Montreal, Canada, in the 1950s and 1960s, Dr.Ewan Cameron used a variety of experimental techniques on psychiatric patients, includingelectric shocks; “psychic driving,” in which taped messages would be repeated fordays at a time; and sensory deprivation. Later, experiments funded by the Central IntelligenceAgency involved the administration of LSD (lysergic acid diethylamide) to patients.The ethical failings of these experiments were multiple: informed consent was either notobtained or was inadequate; the interventions lacked a scientific basis; and patients weresubjected to serious risks.To protect research subjects, the State has established a system of oversight for clinicalresearch in which the keystone is the institutional review board (IRB). IRBs are localcommittees that review research on human subjects for ethical acceptability. IRB approvalis required for such research to be conducted. The first IRBs were federally mandatedin 1966 and, by current estimates, there are 3,000–5,000 IRBs at universities,