An Overview of Psychiatric Ethics

46Psychopharmacology and ChildhoodThe issue of pharmacological treatment of childhood psychiatric disorder is among the mostcontroversial in the area, however, it has received little in the way of rigorous ethical consideration.The use of stimulant medication in the spectrum of Attention Deficit Hyperactivity Disorder (ADHD)has received some attention, much of it in the form of polemic. Amongst the most recognized of thepolemics are those of Peter Breggin, 302, 303 who disputes the validity of the diagnosis of ADHD andthe evidence that pharmacotherapy actually helps. Other authors have asserted that commercialpressures brought to bear by pharmaceutical companies have influenced the evidence supportingthe use of psychopharmacology of children with ADHD. 304, 305 This speculation is given oxygen bythe controversy in the lay press over increased sales of methylphenidate for children in the USA 305and recent, albeit unsuccessful, class-litigation against the American Psychiatric Association andthe pharmaceutical company marketing methylphenidate as “Ritalin”, Novartis. 306 Amidst theemotiveness of the arguments in this area, one more balanced review of the situation has concludedthat the supposed ethical arguments against stimulant use in ADHD are not factually sound whentreatment is provided under proper psychiatric supervision. 307The other recent ethical controversy in child psychiatry has been the use of antidepressants inchildren, particularly newer agents. Like the debate over stimulants and ADHD, this area has not hadrigorous ethical consideration. The issue of newer antidepressants and the alleged over-diagnosisof depression has been the subject of writers such as David Healy, 308 who has championed theargument that the introduction of the serotonin reuptake inhibitor class of antidepressants has ledto increases in suicidal behavior in patients. 309 The scientific literature in this field indicates an overalltrend for newer antidepressants to be of benefit in childhood depression, 310 despite some legitimateconcerns about slight increase in the risk of suicidal behavior in children. 311 Most balanced reviews ofthis issue indicate that antidepressants should continue to be used in childhood depression. 312 The“safety issue” appears to be the main focus of ethical discussion, knowledge in this area is limited bythe concerns over psychopharmacological research in children. 313The Ethics of Involuntary TreatmentIntroductionOne of the most recognized ethical issues in psychiatry is that of involuntary or coercive psychiatrictreatment. 2,314-317 Access to psychiatric treatment has been defined in terms of the right to be freefrom “dehumanizing disease”, 314 whereas the other justification used is the prevention of suicide orother forms of self-inflicted harm. 315The Moral Justification of Involuntary Psychiatric TreatmentJohn Stuart Mill argued in On Liberty that the state had no right to paternalistic action over anindividual, unless his or her actions were harmful to others. Mill specifically stated that potential oractual harm to self was not grounds for state paternalism. 21Mill had argued that:“That the only purpose for which power can be rightfully exercised over anymember of a civilised community, against his will, is to prevent harm to others.”This so-called “harm principle” has been used as an argument for involuntary psychiatric treatmentof suicidal patients, in that the suicidal patient him or herself is an individual who can be harmed bytheir own actions. 318 Mill made some attempt to qualify mental illness based on his harm principle:“And even …if the consequences of misconduct could be confined to the viciousor thoughtless individual, ought society to abandon to their own guidance thosewho are manifestly unfit for it? If protection against themselves is confessedlydue to children and persons under age, is not society equally bound to afford it topersons of mature years who are equally incapable of self-government?”