An Overview of Psychiatric Ethics

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The NT Intervention also had the political utility of criticising the failure of state governments toprotect Aboriginal children and challenged the custom of judicial deference to local tribal law inmatters of violence in Aboriginal communities. 20236Historically, the approach to the relationship between indigenous and non-indigenous Australianswas predicated on the assumption of terra nullius. In 1992, the High Court of Australia determinedin the “Mabo” case that pastoral leases did not extinguish native title in the common law. The HighCourt found that native title was tied to the long-standing and unique relationship between theAboriginal population and the land. This decision was seen to herald a new era of reconciliation withindigenous Australia. In 1996 the terra nullius issue was resuscitated when the High Court ruled inthe “Wik” decision that competing claims between native title and pastoral leases could co-exist.The newly elected conservative government subsequently implemented The Native Title AmendmentAct 1998, which undermined much of the progress in reconciliation. A parallel cultural processemerged in the so-called “history wars”, where questions were raised about the historical accuracyof the accounts of the genocide of Aboriginal peoples in the 19th Century. 203The social and political discourse of the period from the “Wik decision” to the more recent Federalgovernment apology to the “Stolen Generations” was deleterious to the psyche of AboriginalAustralians. The alleged “black armband” view of Australian history gave credence to terra nulliusand then dwelled on the trauma of Aboriginal history, whereas the “white blindfold” view denied thisand emphasised the triumph of white settlement in Australia.Indigenous Australia continues to be a profoundly divisive theme in Australian history. There is acontemptuous and latent racist approach towards Aboriginal Australians in mainstream Australianpolitical and social discourse. Despite an intermittent and sporadic desire for true reconciliationbetween indigenous and non-indigenous Australians, there remain profound divisions within bothcommunities. Aboriginal Australia suffers from the consequences of dispossession, the trauma ofcolonization and the status of being second class citizens. Violence, social instability and appallinghealth statistics remain the challenge for indigenous Australia, yet there is no consensus on how torespond. As the Aboriginal community leader Noel Pearson noted:“There is an arc of views held by non-indigenous Australians that goes from denialto moral vanity, to acknowledgement and responsibility. For Aboriginal peoplethe arc of views goes from separatism to victimhood and to pride and principleddefence.” 204Contemporary Ethics and Indigenous Mental HealthThe ongoing situation of injustice faced by indigenous people in Australia manifests as physical andmental illness and social discord. 205 Arguably, disrespect and a sense of inferiority become physicallymanifest as immune suppression, inflammation, and acute and chronic illness. Externally, thesesocial processes emerge as substance misuse, risk-taking, violence and social discord. 205,206 It alsoindicates that for indigenous populations, physical health, mental health and social deprivation areinseparable. Whilst it is evident that indigenous people suffer common DSM psychiatric disorders, 207these are often experienced in the context of factors such as guilt or self-reproach arising from theexperience of injustice and deprivation. This profoundly influences help seeking amongst indigenouspeople, whose relationship with health care professional – from non-Indigenous society is oftencharacterised by problematic power relationships such as the political authority that governmentemployed non-indigenous health workers possess. 208 There are frequent breakdowns of orderin indigenous communities, leading to demoralization and anomie. 209 As representatives of amore powerful group in society, non-indigenous health care workers find themselves in a difficultsituation. This has created a discourse in indigenous mental health which has realised the need forculturally respectful and sensitive mental health services. 210 Aboriginal communities are based uponkinship and linkages with the natural world granting an “ontologic legitimation”, 197 poorly graspedby traditional Western models of mind and mental illness. Experience in this area indicates thatworkable approaches to indigenous mental health care require empowerment of their communityand, in particular, their health care workers in a process of what is being described as ‘deeplistening’ to the community 211 and more extensive consultation. 212
Psychiatry and Human Rights2At the time of the NT Intervention, the RANZCP issued a press statement expressing its concernat the implications of the plan which appeared to lack a long-term perspective to the issues of themental health of indigenous children and their families. 213 Doubts about the efficacy and ethicalimplications of the NT Intervention were also voiced by other medical organizations. Critics ofthe Intervention argued that its paternalistic approach was disrespectful of Aboriginal people,undermined their community leadership structures and utterly devalued their culture and communityorder, thus exacerbating the mental and physical health of this population. 214 A particularly criticaleditorial was published in the Medical Journal of Australia, stating that the NT Intervention wasmeaningless or tokenistic, if the Federal Government failed to support “any national or internationalrequirement or responsibility to recognise and acknowledge native title, cultural integrity, selfdetermination,and preservation of Indigenous knowledge and sovereignty”. 215 The AboriginalMedical Services Alliance of the Northern Territory (AMSANT) argued that the medical intervention(was) “in serious and ongoing breach of medical ethics, including National Health and MedicalResearch Guidelines, Medicare and guidelines on health screening issued by the Royal AustralianCollege of General Practice”. 216 AMSANT also expressed concern that the intervention was a “Trojanhorse”, which allowed politically motivated acts, such as scrapping the permit system and theCommunity Development Employment Program (CDEP) and the quarantining of welfare payments.Other concerns included preliminary data indicating that by late 2007, only 10% of children hadundergone medical examinations. 21737Counter to these arguments was the brutal reality of endemic violence and trauma in someAboriginal communities. Regardless of the political ramifications of taking a position on the NTIntervention, it highlights the problem of trauma experienced by indigenous patients and theircommunities.Australian Psychiatry and human rights violationsBackgroundAustralian psychiatry has an ambivalent history. Milton Lewis highlighted this by saying that the1950s Australian psychiatry was not only “divorced from the mainstream of medicine” but it wasalso “not a very highly regarded area of medical specialisation” (p 99). 218 Two historians havehighlighted that the official history of the RANZCP 219 has a tone of negative self assessment. 220Moreover, psychiatry in Australia has endured a series of scandals, either involving moral lapseson the part of individual psychiatrists resulting in sexual abuse of patients, or in one extraordinaryincident, the murder of a senior psychiatrist, Dr Margaret Tobin, by a disgruntled and paranoidcolleague in 2002. 221 More recently, a public scandal involved the failure of psychiatrists, workinginside immigration detention facilities, to identify a severely psychotic Australian citizen, CorneliaRau. As Coleborne and MacKinnon note in their history of Australian psychiatry “Psychiatry’s public‘image’ is not enhanced by media coverage of events such as the internment of Cornelia Rau in animmigration detention centre”. 220Chelmsford Psychiatric HospitalThe Chelmsford Hospital scandal involved the criminally negligent use of the discredited practice ofcontinuous narcosis or ‘Deep Sleep Therapy’ (DST). Under the direction of a psychiatrist, Dr HarryBailey, and a local general practitioner, Dr Ian Herron, DST was performed at Chelmsford from 1963until the mid-late 1980s. Patients were induced into continuous profound sedation with barbiturates,fed through nasogastric tube and administered ECT. Those who did not respond to Bailey’ssatisfaction were referred to a local teaching hospital for cingulotractotomy. Apart from severemedical negligence, Chelmsford Hospital was also culpable in its use of inexperienced nurses inthe care of such patients. Moreover, when the hospital’s medical board prohibited the use of DST,Bailey subverted the process by admitting patients under Herron’s name.After a series of complaints, a Royal Commission was established in 1988/89 222 and concludedthat, at the very least, 24 patients had died as a result of DST at Chelmsford. Another 19 patientswho had undergone DST had committed suicide within a year of their admissions to ChelmsfordHospital. Much of the agitation about Chelmsford had been by the Church of Scientology’s mainanti-psychiatry organ, the Citizen’s Commission of Human Rights. Bailey committed suicide in 1985.IMET 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 10 and 11: 08The social contract tradition in
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 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
Page 60 and 61: 4. When the patient is gravely disa
Page 62 and 63: Psychiatrists and other clinicians
Page 64 and 65: In addition to the “patient’s r
Page 66 and 67: 10. When obtaining informed consent
Page 68 and 69: Bibliography661. Beauchamp T, Child
Page 70 and 71: 6864. Megone C. Aristotle’s funct
Page 72 and 73: 70129. Stone A. The Tarasoff case a
Page 74 and 75: 72194. Anderson W. The Cultivation
Page 76 and 77: 74250. Freedman A, Halpern A. Forum
Page 78 and 79: 76309. Healy D. The fluoxetine and
Page 80 and 81: 78367. Stevens A, Price J. Evolutio
Page 82: 80NOTES

An Overview of Psychiatric Ethics

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