An Overview of Psychiatric Ethics

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08The social contract tradition in medical ethics is problematic in the setting of psychiatry. Societymay evolve certain expectations of the psychiatric profession, which are to the detriment of peoplewith mental illness. This places the psychiatric profession in a position of conflict between obligationto a patient and obligation to society in the professional social contract. The clearest example ofthis is the one of public safety. After the rare instance of a person suffering a mental illness harminganother person, society may, through its legislators or its institutions, emphasize the expectationthat psychiatrists must manage risk more effectively. Putting aside the obvious limits of this as anundertaking, this may result in the psychiatric profession being expected to act more coercively inthe treatment of people with mental illness in order to protect the public, rather than provide carefor their patients. This highlights the fundamental dilemma in the social contract tradition of ethicsapplied to a professional group – where the presumed ‘common good’ of society comes intoconflict with the interests of the patient.UTILITARIANISMIntroductionIn seeking to define the ‘good life’ many philosophers have argued that it aims to maximisepleasure, defined as the absence of pain. As the basis of moral philosophy, ethical hedonismtherefore seeks to maximise pleasure. This approach dates from antiquity and the writings ofEpicurus, who deemed:“Pleasure is our first and kindred good. It is the starting-point of every choice andof every aversion, and to it we come back, inasmuch as we make feeling the ruleby which to judge of every good thing.” 18‘Consequentialism’ is the view that the merit of any act is evident in its ultimate consequences.In the light of ethical hedonism, this was the notion that the merit of any act was the degree ofoverall utility or pleasure it generated. The method of utilitarianism was first articulated by JeremyBentham, 19 who argued that all humans were beholden to a form of hedonism, and as such amoral and political philosophy should aim to maximize pleasure. Bentham’s utilitarianism was vulgar,arguing it was “better to be a contented pig than an unhappy human”. The evolution of utilitarianismas a credible ethical theory derives from writers since Bentham, particularly John Stuart Mill 20, 21 andHenry Sidgwick. 22 The key ideas underlying the evolution of utilitarianism are summarised in Table 1.Utilitarianism has been so dominant in moral philosophy, that it could claim to be the starting pointfor all ethical considerations. 23 It is possible that there is a survival advantage for species whichpractise utilitarian approaches, where the elevation of group over individual needs may helpprimitive communities thrive. 24
Normative Ethical Theories and Psychiatry1Author Key Concepts Other issuesJ. Bentham(1748-1832)Maximising utility was to maximisethe total amount of pleasure insociety 19Higher pleasures not preferable to baseones – “pushpin is as good as poetry”Runs into the ’quantification problem’i.e. how to measure pleasureJ.S Mill(1806-1873)Cultural, intellectual, and spiritual Providespleasures are of greater value thanphysical pleasures in the eyes of a20, 21“competent judge”foundation for later formulationsof preference utilitarianism, i.e. thegood relates to satisfaction of greatestnumber of preferences. “Act” and “Rule”utilitarianism distinction later outlined byR Smart 2509H. Sidgwick(1838-1900)Outlines a method of moralphilosophy based on “UniversalHedonism” (utilitarianism) 22Sidgwick’s Ideas provide the foundationof current conception of utilitarianismand highlights some conflicts betweenpersonal and collective pleasure. Rejectsmotivations as a basis of morality, rathersees “common sense” as the basis ofethical choiceG.E Moore(1873-1958)No true conception of the ethicalgood could be formulated.Maximising “ideals”, likeaestheticism, or love preferred tomere pleasure 26Advances the notion of what is laterdubbed ’informed preferences’ andeconomic views of personal preferencesR.M Hare(1919-2002)Levels of moral thinking –Sees“practical” is utilitarian and9, 27“analytic” is more complexKant’s “Kingdom of ends” asutilitarian in spirit. 27, 28 Advances a formof utilitarianism as a method of psychiatricethics. 29K. Popper(1902-1994)“Negative Utilitarianism” as theresponsibility to prevent thegreatest amount of harm or evil 30Argument reductio ad absurdum, againstnegative utilitarianism is the so-called“pin-prick argument”, which states itwould be better to painlessly destroyhumanity than allow one person toexperience a pin-prick. 31 Also criticised byR Smart 32P. Singer(1946-)Utilitarianism requires equalconsideration of interests, whateverthe species. 33 Utilitarian ideas aform of naturalism – suppressingindividual need for that of thecollective has survival advantage 24Concept of “diminishing marginal utility”argued. Adopts a “journey model”of life, which sees validity of claim toconsideration of preferences based insentience and the stage or capacityto meet life goals. Singer’s views arepolemic and have led to heated debate,in particular over the manner in which hisphilosophy appears to validate euthanasiaand abortion 34Table 1. Key Concepts in the evolution of utilitarianismIMET AN OVERVIEW OF PSYCHIATRIC ETHICS
Page 2 and 3: ContentsForeword 02Introduction 03W
Page 4: 02ForewordMedical ethics is an impo
Page 8 and 9: 1Normative Ethical Theories and Psy
Page 12 and 13: 10The Philosophical Basis of Utilit
Page 14 and 15: It is part of a psychiatrist’s re
Page 16 and 17: 14‘Kantian’ EthicsContemporary
Page 18 and 19: 16Recent Conceptions of Virtue Ethi
Page 20 and 21: Gert described a two-step method fo
Page 22 and 23: 20Criticisms of the 4Ps Principles
Page 24 and 25: His method then applies a taxonomic
Page 26 and 27: 24THE ETHICS OF CAREBackgroundOne r
Page 28 and 29: met poorly in Rawls’ philosophy.
Page 30 and 31: moral philosophy. Foucault took the
Page 32 and 33: 2Psychiatry and Human Rights30INTRO
Page 34 and 35: hydrocephalus and other abnormaliti
Page 36 and 37: Bukovsky’s account of his treatme
Page 38 and 39: The NT Intervention also had the po
Page 40 and 41: Unrepentant, his suicide note state
Page 42 and 43: 40NOTES
Page 44 and 45: 3Applied Psychiatric Ethics42INTROD
Page 46 and 47: not be motivated by malicious inten
Page 48 and 49: 46Psychopharmacology and ChildhoodT
Page 50 and 51: able to refuse treatment arguably h
Page 52 and 53: 50i. Physical: assaults, excessive
Page 54 and 55: 52offered by defendants in the “D
Page 56 and 57: “normal” member of that culture
Page 58 and 59: Appendices56Appendix 1 - The Declar
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4. When the patient is gravely disa
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Psychiatrists and other clinicians
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In addition to the “patient’s r
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10. When obtaining informed consent
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Bibliography661. Beauchamp T, Child
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6864. Megone C. Aristotle’s funct
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70129. Stone A. The Tarasoff case a
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72194. Anderson W. The Cultivation
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74250. Freedman A, Halpern A. Forum
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76309. Healy D. The fluoxetine and
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78367. Stevens A, Price J. Evolutio
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80NOTES
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An Overview of Psychiatric Ethics

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