Commentary: the alleged abuses of human rights in Chinese psychiatry

Psychiatry has a sorry legacy in the field of ethics and human rights (Welsh & Deahl, 2002). The inhumane and sometimes cruel treatment of the asylum era (Musto, 1991), not to mention the participation of psychiatrists in the holocaust (Muller-Hill, 1991) and eugenic programmes involving mass sterilisation of the mentally ill and handicapped, most notably in the USA and Scandinavia (Pappworth, 1967), have cast an indelible shadow over our profession. The Nazi atrocities gave medicine a belated ‘wake up’ call which consequently, albeit somewhat belatedly, began to take its ethical responsibilities and obligations seriously, codifying these in the 1964 Declaration of Helsinki (World Medical Association) and the 1977 Declaration of Hawaii (World Psychiatric Association, WPA), the first uniquely psychiatric code of ethics.

Despite those noble ethical ideals we are all so quick to espouse the use of psychiatry as a tool to abuse the human rights of the mentally fit, let alone those of the mentally ill, has persisted, most (in)famously in the former Soviet Union, where psychiatry was widely used as a tool to suppress political dissent (British Medical Association, 1992).

The profession's historic response to these outrages has typically been one of complacency and ‘quoplegic myopia’ (the syndrome of seeing weaknesses and deficiencies in current systems, yet becoming blind to them as soon as an alternative is proposed) (Dowie, 1994). Efforts to bring abuses of psychiatry to public awareness and galvanise a professional response have been largely thanks to the determination and efforts of a handful of indefatigable individuals.

Against this background of complacency, the Royal College of Psychiatrists can boast a proud tradition in its support of human rights. Most notably, in 1977 the College established SCOUPP — the Special Committee on Unethical Psychiatric Practices.

Reporting directly to the President and College Council and with a deliberately international perspective as its focus, SCOUPP was largely responsible for raising awareness, within the international medical community, of the human rights abuses that pervaded Soviet psychiatry, culminating in the eventual expulsion of the former Soviet Union from the WPA in 1983. With hindsight, many former Soviet psychiatrists felt that the pressure exerted by SCOUPP and the College made a real difference within the former Soviet Union to raise ethical awareness, exert effective pressure on the authorities and, more importantly, change practice.

It is sad, but perhaps not surprising, that a quarter of a century later similar allegations are now being made about Chinese psychiatry (e.g. Munro, 2000). Rising to this challenge, the College passed the following resolution at its 2001 Annual General Meeting (AGM):

‘Bearing in mind the available evidence that political dissidents in The People's Republic of China (PRC) are being systematically detained in psychiatric hospitals, we propose that the Royal College of Psychiatrists takes the following action: (1) to join with the WPA to arrange a fact-finding visit to the PRC; and (2) if this visit and other evidence confirm political abuse of psychiatry, to ask the WPA to reconsider the constituent membership of the Chinese Society of Psychiatrists; (3) to work with the WPA to provide support for those Chinese psychiatrists who are committed to ethical and evidence-based practice.’ (Royal College of Psychiatrists, 2001).

This resolution was passed at a particularly sensitive time with China (and its already questionable human rights record) very much under the media spotlight during its bid to host the Olympic Games. It was notable in the AGM that while everybody sympathised with the spirit of the resolution, many Chinese psychiatrists present at the meeting were less than enthusiastic (the third paragraph of the resolution was added at their request from the floor), believing that constructive engagement, not confrontation, was more likely to bear fruit with the Chinese authorities. They argued that pursuing a path likely to result in the public humiliation of the authorities would probably only make matters worse and that the isolation of Chinese psychiatry from the international medical community would seriously damage fragile professional relationships built up over a number of years. Moreover, expulsion from the WPA would unfairly punish the vast majority of mainstream Chinese psychiatrists, as the allegations of abuse primarily concern the police-run forensic services.

Defending human rights and ethical values is vital if we are to retain public respect and professional credibility. How this is best achieved, however, is another matter. The College and the WPA must try to avoid ‘knee-jerk’ responses that may only do further harm by simply alienating the Chinese authorities as well as isolating the majority of Chinese psychiatrists who are committed to ethical practice. The proposed fact-finding mission must be seen to be fair, open-minded and scrupulous in seeking the truth and establishing the facts, as well as giving the Chinese themselves an opportunity to respond to the allegations made against them and account for their actions. It must also disentangle fact from the rhetoric of anti-Chinese, anti-communist protest. Ultimately, whether to adopt a ‘softly-softly’ approach of constructive engagement, or a more bullish confrontational stance is a matter of political judgement and diplomacy, which psychiatrists are poorly qualified to make. It is especially important to listen to the advice of Chinese colleagues and those familiar with the country and its customs to judge where the balance should be struck.

Finally, in taking the moral high ground and condemning the practices of other countries, we should take care to get our own house in good ethical order. UK psychiatry itself leaves much to be desired (Royal College of Psychiatrists, 1996). After all, how many general psychiatrists can honestly say they would be happy for themselves (or their loved ones) to be treated in the very services where they work and which they oversee. I always felt a strong sense of irony and shame chairing meetings of the Ethics Sub-committee (the derivative of SCOUPP), where unethical behaviour overseas was regularly subjected to critical scrutiny in the comfortable surroundings of Belgrave Square, only to return to my own practice in East London, where patients (many of them compulsorily detained and lacking any sort of choice) often had to sleep on floors, in dilapidated acute admission wards with little possibility of access to psychological therapies, decent occupational therapy or any adequate provision for care in the community.

Of course we should stand up against abuses of psychiatry and unethical practice wherever it may be, and we applaud the efforts of those individuals who strive to right the wrongs of our colleagues overseas. But meanwhile, perhaps the rest of us should spend a moment reflecting on our own workaday routine and redouble our efforts to strive towards the highest ethical ideals and standards of practice that we can justifiably hold up to the world with pride, as an example of how the mentally ill should be treated in the twenty-first century.