An Overview of Psychiatric Ethics

Normative Ethical Theories and Psychiatry1Apart from this, the ethics of care approach to ethics suffers from an inadequate analysis of theconcept of “care”, which has been argued to be “hopelessly vague”. 146 In lacking a descriptiveor normative account of morality, care-related language defines the concept of care as beingconstitutive of a moral good. This introduces a form of prescriptivism, which argues that actions aregood if they are caring. The argument suffers from a suppressed premise that care is constitutiveof an ethical good. Moreover, the prescriptive argument that ’one ought to care’ is weakened bya fallacy of ambiguity – caring about how your football team fares is not the same as care for yourfamily or patients. 147In suggesting the ethics of care are a substantive moral philosophy, Held 130 argued that it hasfive defining features. First, “the focus of the ethics of care is on the compelling moral salience ofattending to and meeting the needs of the particular others for whom we take responsibility (p.10)”.Second, the ethics of care value emotions, and appreciate emotions and relational capabilities thatenable morally concerned persons in actual interpersonal contexts to understand what would bebest. Third, the ethics of care reject the view that the more abstract the reasoning about a moralproblem, the better. Fourth, the ethics of care propose a novel conceptualization of the distinctionbetween private and public moralities and of their respective importance. Finally, the ethics of careadopt a relational conception of persons, which is in stark contrast to the rights-based approachesof modern liberal individualism.25DISTRIBUTIVE JUSTICEIntroductionUnlike criminal or “retributive” justice, “distributive” justice describes the process of the just or fairallocation of limited social goods. The World Psychiatric Association’s Declaration of Madrid (1996)states that “psychiatrists should be aware of and concerned with the equitable allocation of healthresources”. 148 Several articles in The Lancet have also implored psychiatrists to consider issues of149, 150just allocation of resources in a global setting as part of their ethical obligations.The philosopher John Rawls crafted a conception of distributive justice during his career. 151-153Rawls’ approach to justice derived from a hypothetical notion of having moral agents conceptualizean “original position”, which was pre-social and pre-historical. The participant in this social contractwould be blinded as to who they were going to be in this future society through a “veil of ignorance”.Based on these constraints, the moral agents would then define a just distribution of goods in thisfuture “well-ordered society”. Rawls believed that all choosers would operate on the assumptionthat they would end up the least advantaged person in the society and through a process of“constrained maximisation”, allocate resources accordingly. Such resources were not merely wealth,but also freedom, mobility of labour and equal access to opportunity to achieve fulfilment in life. Thisapproach to justice assumed first, all participants would act out of self-interest and, secondly, be riskaverse and conclude that assuming worst case scenarios was the safest approach. Whilst the firstassumption is reasonable, the second may not reflect how all people might approach the problem.In stark contrast to Rawls’ liberal egalitarianism was the free-market libertarian ideas of RobertNozick, 154 who averred that the only constraint the state should place on the free exchange ofresources within a society should be to ensure he legitimacy of the acquisition and subsequentexchanges of property. Libertarianism has become the dominant paradigm in post-industrialdeveloped economies and many health systems have evolved based upon the principles of suchfree exchanges of goods and services between individuals.Rawls’ Theory and Mental HealthWhilst Rawls’ contractarian method was ingenious, there are problems with what he defined as“social goods”. Rawls saw that all members of a well ordered society had equal entitlement toaccess social goods to have the opportunity to live fulfilling lives. Rawls took the Kantian view thatindividual fulfilment is a product of autonomy, or rational self-governance. As such, social goods areinstrumental in achieving this, and the just distribution of these social goods assists members ofsociety to achieve this autonomous existence. As Nussbaum points out, such an approach falterswhen we consider the situation of those whose capacity for autonomy is impaired life-long. A personwith disabling chronic schizophrenia may never be truly capable of autonomy and so their needs areIMET AN OVERVIEW OF PSYCHIATRIC ETHICS