The Oxford Handbook of Psychiatric Ethics has 10 sections, 94 chapters, 139 authors and well over 1000 pages. It is therefore a sourcebook on psychiatric ethics that is unprecedented in its scope and detail and which will likely be the standard work of reference for many years to come. The quality of contributions is generally high. The scale of this Handbook is such that it would be impossible to summarise its contents in a short review. I will therefore confine my comments on content to some general issues.
Medical ethics is widely held to rest on the four pillars of respect for autonomy, beneficence, non-maleficence and justice. It would be fair to say that the main ethical concerns discussed in this handbook are those arising in the areas of autonomy and non-maleficence. Over many years, there have been concerns in psychiatry about issues such as coercive treatment, legal detention in hospital, paternalism, medicalisation, confidentiality, boundary violations, pharmaceutical company malfeasance, financial conflicts of interest and failures to respect patient autonomy. These are extensively discussed in this book and are undoubtedly of great importance. Less well discussed are failings and shortfalls in beneficence and justice.
In relation to beneficence, underdiagnosis and undertreatment of serious mental illnesses are major causes of avoidable suffering and death. Patients suffering from the consequences of complex and severe traumatisation are often not well-served by psychiatry and may find their experience of services to be negative or even a source of further traumatisation. Such patients are often the ones who go on to describe themselves as ‘survivors’ of mental health treatment.
This is illustrated in the 11 chapters in which current or former service users describe their experiences of psychiatric care. The majority of these individuals appear to have suffered from the effects of traumatisation and their experiences of mental healthcare have been mostly negative. In contrast, Chadwick describes what sounds like a typical psychotic breakdown. He supports the medical model and describes his medication as ‘wonderfully helpful’. His treatment took place in the UK National Health Service. As an employee of the NHS, I am pleased to say that he was generally very positive and complimentary about the treatment that he received!
In an excellent chapter on intellectual disabilities, Clegg & Jones take a broader view of ethics and argue that the prevalent ethical focus on autonomy, choice and inclusion may have adverse consequences. These include ‘denial of disability’ and consequent failure to intervene when disabled people are at risk of coming to harm. It can also lead to failure to acknowledge the emotional pressures that people with intellectual disabilities impose on families and professional carers as a result of aggression and other disturbing behaviours. If these pressures are not acknowledged and dealt with, carers can end up exhausted and frustrated and standards of care can then deteriorate.
With regard to justice, there are several references in the book to the aspiration to achieve ‘parity of esteem’ between mental and physical illness. There is also a need for the resources of mental healthcare to be focused on where need is greatest and where the benefits of treatment are clear. It is almost universally the case that aspirations such as these are rarely met and it is essential, from the point of view of practical ethics, to discuss how a just distribution and prioritisation of resources can be achieved.
As nearly half of the contributors are from the USA, it may be apposite to use an example from that country. The think tank Mental Illness Policy Org has estimated that in 2014 in New York City, the American home of psychoanalysis, around 40% of adults with serious mental illnesses received no treatment at all. Of those admitted to in-patient care, only one-third were discharged to an out-patient treatment programme. As a result, many mentally ill people end up destitute and homeless or in prison.
One reason for this may be illustrated by the case of a young American woman who was admitted to our service a few years ago suffering from a psychotic illness. Her mother came over to be with her and to take her home. She implored me not to give her daughter a diagnosis of schizophrenia as this would effectively disbar her from access to private health insurance. The risk that diagnosis of a common and severe mental illness could lead to inability to gain access to high-quality psychiatric treatment is an obvious failure in the just allocation of resources. This is surely an ethical issue of the first importance. One can only hope that ‘Obamacare’ has provided a remedy.
A related issue is that only one chapter out of 94 specifically discusses the problems of service provision that arise in low- or middle-income countries, despite these being the countries where more than half of the world's population lives. As a result, the focus of this work is mainly on ‘First World’ ethical issues and not on the desperate predicaments faced by mentally ill people in many other parts of the world.
These are matters that may be picked up in future editions of this work. The editors are to be congratulated on the monumental achievement of pulling together such a range of talent in the field of psychiatric ethics. Anyone with an interest in this field will find this Handbook to be an inestimable source of knowledge and wisdom. Every medical library should have a copy on its shelves.
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