An Overview of Psychiatric Ethics

Applied Psychiatric Ethics3occurs as a result of an unconscious drive to seek punishment or humiliation. These are vulnerabletherapists, usually male, who typically encounter disappointments and setbacks in life. They haveoften stagnated and lost a sense of meaning. In such a state they are susceptible to misinterprettransference and countertransference for true love.Psychotherapy and ValuesAnother area of interest in this stream of psychiatric ethics has been the implications ofpsychotherapy for the autonomy of patients, particularly in regard to the imposition of the valuesof the therapist on the patient. It has been argued that in creating the “talking cure” Freud hadattempted to convert moral discourse into a scientific one. 287 Psychotherapy has been describedas a masked form of moral discourse, with allusions to a quasi-religious conception of the good 288“veering” – as Hinshelwood argued – “between being a scientific and a moral activity (p.195)”. 289Indeed psychotherapy has been conceptualised as the integration of a nonreligious but spiritualview in the pursuit of empathic understanding. 290 Psychotherapy often works best when the valuesystems of both patient and therapist approximate each other, but not necessarily converge. 288Jeremy Holmes argued, “Psychotherapy reflects and transmits the values of the prevailing culture”and “makes its own unique contribution to cultural and ethical development within our pluralisticsocieties” – through its advocacy for the inner world and self-reflection. 291 By liberating from disease,psychotherapy can be considered as enabling patients to become moral agents 292 and enhancingautonomy by encouraging self knowledge. 293 This process involves the outgrowing of infantilenarcissism and imparts values operating at an unconscious level. This necessitates an injunctionfor therapists to deliberate on how their own values affect their work. 29145Psychotherapy and Distributive JusticeThe other main theme in the psychotherapy ethics literature considers the impact of market forceson the practice of psychotherapy. As Holmes asked “is it ethically correct to prescribe the mostcost-effective (psychotherapies), thereby freeing resources for other potential beneficiaries?”(p.227). Chodoff examined the effect of the intrusion of third party payers into the patient therapistrelationship, particularly in regard to the dilemmas created by issues such as breaches ofconfidentiality and control of the provision of treatment. 294Ethics and Child and Adolescent (C&A) PsychiatryThe Concept of ChildhoodChildhood and adolescence are not biologically determined states. Whilst the concept ofdevelopment is a biological entity, the status of child or adolescent is a social construct. Green andBloch refer to childhood as a “social construction” with a “brief history” 295 in that previous societieshad little concern with child labour or the sexual exploitation of children. The capacity of children andadolescents to partake in rational self-governance is both dimensional and highly individual. As such,the conceptualization of childhood and adolescence within the context of psychiatric ethics relatesprimarily to the differentiation between children and adolescents and autonomous, self-legislatingadults.Autonomy and ChildhoodAutonomy is time and task specific. The capacity for a child of 8 to consent to treatment is clearlydifferent from that of a child of 15. Regardless, in the eyes of the law and the tenets of best practice,neither patient can consent to treatment without a parent or guardian. A child’s capacity to makeautonomous decisions about their health develops with their cognitive and emotional development,thus evolving into increased future autonomy, 296 this is significant for clinical decision making. 297 Likeautonomy in other settings, it is not a categorical process. As a consequence some of the literaturein child psychiatry has considered the viability of the construct of informed consent in childhood,and in particular how decisions made by parents or guardians on behalf of the child should reflectthe wishes of the child. 298,299 In this setting, the role of psychiatrist is one of juggling the complexrelationship between a child’s confidentiality, their capacity for consent, and their responsibility toadvocate for the child’s interests. 300 Indeed, the therapeutic relationship in child psychiatry is uniquein that it frequently casts the therapist in the role of de facto parent or authority figure. 301IMET AN OVERVIEW OF PSYCHIATRIC ETHICS