An Overview of Psychiatric Ethics

Normative Ethical Theories and Psychiatry1evolution of Western societies into consumer economies, 12 the commercialization of the healthsystem and the technological advances in medicine. 7, 12 It has been argued that, in the light of suchdevelopments, the craft of medicine has evolved into a service industry in which technical skills aretraded in a market place. As such, the notions of a physician’s virtue and the Hippocratic traditionhave been lost. The scale of the practice of medicine has also increased exponentially. In developedcountries medicine has changed in one or two generations from a cottage industry toone consuming a significant portion of each country’s gross domestic product. 12Professional ethics, arguably, have three core components – specialized training and the acquisitionof specialized skills; the provision of expert assistance to those who are vulnerable and in need; andthe virtues of trustworthiness, efficacy and knowledge which ultimately enhance the common goodand aggregate well being. 13Several physicians’ organizations have jointly outlined a series of principles and responsibilities forthe medical profession, which integrate the recent influences on medical practice 14 . In this newcode, the principles of patient welfare, patient autonomy and social justice are juxtaposed with theresponsibilities of commitment to professional competence, honesty with patients, confidentiality,appropriate relations, improving quality of care, improving access to care, ensuring a fair distributionof finite resources, pursuit of scientific knowledge and maintenance of trust by managing conflicts ofinterest and professional responsibilities.Any medical practitioner abides by a social contract 14 as both a healer and professional. Professionalethical autonomy is therefore given on the understanding that professionals will devote themselvesto serving the best interests of society and will self-regulate to maintain high quality service. 1507Social Contract TheoriesHumans tend to act primarily out of self-interest. Whilst there may be many instances where peopletake action out of altruism, the strongest motivation to act for a person is out of self-regard.The English philosopher Hobbes postulated that humans were, by nature, prone to act in selfinterest.16 In Hobbes’ view, society would deteriorate to a violent state of anarchy unless regulatedby laws. Hobbes argued that everyone was vulnerable in such a “state of nature”, even the mostcanny or physically capable. In the alternate, humans could agree to abide by a covenant in whichthey would all act in a way that allowed others to go about their lives without fear of being attackedor exploited. In essence, all members of society would act out of their own self-interest to participatein an agreement in which a set of laws would create a society where no-one was allowed to actin an exploitative or violent manner. The self-interest component of such an arrangement was thateach participant would recognize that it was in their interest to have a society where they couldpursue their life’s goals in safety and harmony. The one potential pitfall in this arrangement would bethe so-called “moral free rider”, who would still act in an unconstrained manner out of self-interest,yet expect the benefits of the social contract. Hobbes’ solution to this was a powerful sovereign(or “Leviathan”), who would enforce the social contract arrangement by punishing or excludingthose persons who violated the social contract arrangement. Later social contract theorists such asGauthier have described less dramatic instances of social contract, such as the so-called “prisonersdilemma” thought experiment, in which two prisoners see a mutual advantage in not informing oneach other and therefore act out of mutual self-interest.Social contract theories have been criticized as historically inaccurate (“not worth the paper theywere never written on”), 17 as well as their implicit moral nihilism – they effectively assume the worstof humans and assert that as a species we are incapable of any form of moral responsibility.Applied to a professional context, the contractarian approach to ethics involves the assumptionthat a professional group will, primarily out of self-interest, abide by an agreed set of expectationsof behaviour and conduct. This is usually in exchange for a level of professional autonomy orself-regulation. When a profession is seen to fail in this agreement, in either a specific instance oran overall manner, society tends to respond through enacting legislation to enforce a particularchange. For example, if there are a number of instances of failure of a professional group to maintainstandards of practice, then a society’s legislators will enact laws to force the profession to introducesuch standards. In essence, the penalty for a profession’s failing to meet the expectations of thesocial contract is the loss of various components of self-regulation.IMET AN OVERVIEW OF PSYCHIATRIC ETHICS