One approach to the analysis of ethical dilemmas in medical practice uses the “four principles plus scope” approach. These principles are: respect for autonomy, beneficence, non-maleficence and justice, along with concern for their scope of application. However, conflicts between the different principles are commonplace in psychiatric practice, especially in forensic psychiatry, where duties to patients often conflict with duties to third parties such as the public. This article seeks to highlight some of the specific ethical dilemmas encountered in forensic psychiatry: (...) the excessive use of segregation for the protection of others, the ethics of using mechanical restraint when clinically beneficial and the use of physical treatment without consent. We argue that justice, as a principle, should be paramount in forensic psychiatry, and that there is a need for a more specific code of ethics to cover specialised areas of medicine like forensic psychiatry. This code should specify that in cases of conflict between different principles, justice should gain precedence over the other principles. (shrink)
Chapter 9 describes and evaluates the relatively recent mental health models of the impact of trauma, and discusses the ways that traumatic events affect people, the political and cultural effects of understanding these consequences as ‘disorder’, particularly as Post-traumatic Stress Disorder (PTSD), and concludes by looking at the relevance of the concept of PTSD to forensic populations.
I am grateful to the editor for asking me to comment on this interesting article about interdisciplinary work between a philosopher and a psychiatrist, with which I found much to agree. As a medical student, I had no exposure to bioethical reasoning in medicine, and even now, I think it is the case that junior doctors in the UK have variable exposure to good quality ethical reasoning in clinical practice. I also agree that lectures are a poor way to learn (...) about ethical reasoning, especially in psychiatric practice; and I have been part of a special interest group at the Royal College of Psychiatrists that has tried to develop and enhance bioethical awareness in mental health. We do this by a) ensuring that ethical... (shrink)
We are more alike than we are different.In male prisons, the agency and antisocial mindset of violent offenders is taken seriously in the pursuit of rehabilitation. Male offenders are expected to own full agency for their cruelty and violence to others, and to explore it in supported rehabilitative group-work programs. Such programs have been shown to be highly effective for some offenders and relate to a process of engaging with a new pro-social identity and taking responsibility for leading a "good (...) life."Such programs hardly exist for violent women. Psychological services in female prisons rarely offer programs on anger management or opportunities to explore the wish to hurt or control; rather, they emphasize .. (shrink)
Ethical dilemmas in forensic psychiatry have not, on the whole, been exposed to the same degree of scrutiny as other medical topics in the medical ethical literature. In this editorial, I will hope to show that forensic psychiatric practice raises many ethical dilemmas; not only practical, but also conceptual. Indeed the level of public debate following the publication of the Fallon report1 and new proposals for preventive detention of dangerous people2 suggest that these dilemmas also belong in the political sphere. (...) Renewed attention to this area is therefore timely.In this editorial, I shall provide a brief overview of the many ethical dilemmas that arise in relation to the practice of forensic psychiatry. I shall use the four principles plus scope approach3 for my analysis. I will invert the usual discussion order; reflecting perhaps the relative importance of the different principles in forensic psychiatry.Respect for justiceForensic psychiatry represents the interface of two worlds which identify and regulate deviance ie medicine and the law. Many ethical-conceptual issues in relation to psychiatry still need elucidation. For example, what counts as a mental illness, and how does mental illness excuse responsibility for criminal actions? This question is particularly difficult to answer in relation to personality disorder, and its sister concept, psychopathy.Respect for justice usually requires that we treat similar people in similar ways. However, forensic patients are vulnerable to exploitation and injustice. For example, mentally ill offenders are detained longer in secure settings than their counterparts who have committed exactly the same offence, but do not have a mental disorder.4 Political pressures, and concern for victim's feelings may influence release decisions. This may do justice to the victims of violence, but at the expense of the offender patient's welfare; so …. (shrink)
Freely given informed consent to participation is the ethical cornerstone of research in health care. However, in mental health settings, there are many patients who lack the capacity to give such consent to participate in research. There is an abundance of guidance now available on how researchers might think about this issue and the Royal College of Psychiatrists has also recently reviewed its guidance to members about the ethics of research. In this piece, I will discuss some of the issues (...) that were raised during the revision process, and add some reflections of my own. (shrink)
Philosophy says that life must be understood backwards. But . . . it must be lived forward. . , , It is more and more evident that life can never be really understood in Time. It was a pleasure to read Jason Thompson’s serious and thought-provoking piece, and I am grateful to the editors for giving me a chance to comment. The idea that the self is revealed in narrative is a popular one among different schools of psychotherapy, both in (...) terms of technique and theory; and my response addresses both these issues in turn. As a clinician, I have always liked people’s stories. As a junior psychiatrist, I used to love the moment when I first met someone and could say to them, ‘You were born; and then what .. (shrink)
Szasz argues that the threat of harm to self or others cannot be understood as a symptom of mental illness, and that there is an irresolvable tension between the traditional medical ethical duty to heal, and any notion of a medical duty to protect the public.1 I think these are two distinct arguments which could each be the subject of extended analysis, and this commentary is of necessity limited.Professor Szasz has consistently raised concerns about the political abuse of psychiatry as (...) a way of controlling dissidence. Many of his arguments remain as cogent and unanswered as when they were first put 30 years ago. But as sympathetic as I am to some of his criticisms, it seems to me that many are too sweeping; especially the first claim that there is no such thing as mental illness, but only persons whose expressed intentions involve taking a stance which is contrary to certain social rules.I do not propose here to discuss the so called “hard” problem of consciousness—that is, exactly how brain states give rise to intentional psychological experience, or indeed, the extent to which “brain” and “mental” can be used synonymously. If we accept that mental states give rise to intentions, then different mental states will give rise to different intentions, and there is no reason not to think that there might be abnormal mental states that might give rise to abnormal intentions. The question then is what we mean by the word “abnormal”. Clearly it is possible for abnormal to be defined as “socially inappropriate”, which is Szasz’s concern. In that case, political and social dissidence is then turned into a symptom by the language of medicine, and thus becomes not a social matter, but an individual’s personal problem.But “abnormal” could be defined with reference …. (shrink)