An Overview of Psychiatric Ethics

Unrepentant, his suicide note stated “Let it be known that the Scientologists and the forces ofmadness have won”. 223The ultimate impact of Chelmsford on the Australian psychiatric profession was the loss of adegree of professional autonomy. Much of the subsequent legislation leading to the regulation ofmedicine by external bodies has been influenced by the shadow cast over medical ethics by theChelmsford tragedy. As a direct result of the crimes by Bailey and Herron, mental health legislationin NSW now prohibits private psychiatric hospitals admitting patients on an involuntary basis,psychosurgery has been outlawed and independent tribunals now closely regulate the administrationof Electroconvulsive Therapy.38The Townsville Hospital ScandalJust as the Chelmsford scandal was resolving, another emerged in Queensland. Dr John Lindsay,the director of the psychiatric ward of Townsville Base Hospital (Ward 10B) had run the inpatientunit along the lines of a therapeutic community. By 1986, 123 complaints had been made to theTownsville Hospital’s Board about Lindsay and the care on Ward 10B. 224 These complaints includedallegations of sexual and physical abuse and gross medical negligence.In 1991, the Queensland government established a commission of inquiry. 225 The commissionreceived testimony that patients in Ward 10B were subjected to “cruel and inhumane” treatment andidentified sixty-five deaths attributable to either suicide or iatrogenic causes. Like Chelmsford, 10Baffected psychiatry in Australia:“Although (Townsville Ward 10B) suggests that problems at Townsville can be attributed to Lindsay’sdesire for innovation, and refusal to recognise mistakes, further investigation reveals that this is notan unusual problem within psychiatric practice in Australia.” 224Social Justice and mental illness in modern AustraliaIn the 1960s, the global trend to community care led to a process of deinstitutionalisation inAustralia, 218 although this resulted in those suffering mental illness being “removed from one formof incarceration only to end up in another”. 226 Subsequent years saw significant levels of divestmentof government in community mental health services and the defaulting of many services to poorlyfunded non-Government organisations. 227 In 1993, the Burdekin Report 228 estimated that aroundone in five adults in Australia suffered from some form of mental disorder, but that only about3% accessed mental health services. The Burdekin Report concluded that this was a function ofignorance and stigma in the community. This clearly presented a significant imperative for advocacyto the RANZCP. In 1993 the Australian Health Ministers’ Conference (AHMC) endorsed a NationalMental Health Strategy, facilitating the decommissioning of an institutionally focussed mentalhealth system to one that was consumer-and community-focused. 229 The RANZCP was heavilyinvolved in informing this policy, although the strategy seems to have been far less successful thananticipated. 230 Rather than seeing the blossoming of community psychiatry, Australian psychiatristshave witnessed a process of transinstitutionalisation of the mentally ill from large psychiatric hospitalsto overcrowded low cost accommodation, homelessness and, increasingly, prisons. In Australia,much like the rest of the developed world, the prevalence of psychiatric disorder is significantlyhigher in the prison population than the community, 231 inviting the critique that prisons have becomede-facto psychiatric institutions. 232 Whether this can be reasonably depicted as a failure of advocacyon the part of Australian psychiatry or not, the abject state of services for the mentally ill in Australiais a significant ethical concern for the profession.The Asylum Seeker DebateThe most recent and arguably internecine debate over advocacy involved psychiatry’s perceivedrole in regards to policies of mandatory detention of refugees seeking asylum in Australia. Whilstthe issue of border protection and treatment of asylum seekers is highly political and has figuredas a significant issue in Federal elections, 233 there is robust evidence of psychological harm arisingfrom the policy of mandatory detention, 234, 235 and indefinite periods of uncertainty about immigrationstatus. 236 As such, the policy represents a public health issue.