Ajai R. Singh MD

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Psychiatric ethics: role of philosophical enquiry

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Indian Philosophical Quarterly Vol. XVll, No. 1, January 1989, p89-118.

 

 

PSYCHIATRIC ETHICS: ROLE OF PHILOSOPHICAL ENQUIRY

 

Introduction

Philosophy as such is an obscure topic for most. And philo­sophers help no less in making it more obscure by their appro­ach. This is probably one of the reasons philosophical enquiry is avoided by most professionals as well as professional journals, not· only in India1 but also on the European continent. 2 This is also the reason why it is promptly given up after a brief honey-moon by others who may otherwise profess such a bent of mind. We shall not here try to increase the confusion of either. The pluralistic thrust of the American set-up has of course encouraged discussion of ethical issues (Chavez 1964; West 1968; Braceland 1969; Halleck 1974b; Michels 1976; Redlich & Mollica 1976; Chodoff 1976; Monahan 1977; Somers 1977; Spiegel 1978; Bazelon 1978; Towery and Sharfstein 1978; Moore 1978; Karasu 1980) 3 but that has not necessarily inclu­ded resolute enquiries into its philosophical fundamentals: Traditionally the philosopher has been used to a form of language so abstruse as to intimidate even the most eager psychiatrist (Bloch and Chodoff 1984a). Of course some philosophers have made efforts to overcome this by offering practical and concrete solutions, of which Hare (1952, 1981, 1984), Warnock (1978) and Singer (1978) are notable examples. In an effort to further this, let us temper the philosopher's absolutism with the psychiatrist's utilitarianism4. We believe such a synthesis can be of benefit especially in a branch like psychiatric ethics, where absolute concepts taken originally from philosophy have to be made applicable to the exigencies of professional practice. Moreover, scientific knowledge by itself does not confer ethical sensi­tivity and 'generalization of expertise' (Veatch 1973) from scientific to moral, when exposed, is an important source of anti- professionalism (Michels 1981). At the same time when moral conflicts arise, no one-level account can solve the problem; if conflicts arise at one level, they cannot be resolved without ascending to a higher level (Hare 1984). At the intuitive level of thinking, the absolutist stance is appropriate; but it no longer remains sufficient when conflicts arise between them and/or with other circumstances. Then the critical level of thinking of the utilitarian alone can suffice. We select thereby the principles to be used at the intuitive level and adjudicate between them in cases where they conflict (Hare 1984; also Hare 1981). How­ever, both intuition and critical thinking cannot be allowed to negatively influence each other; and part of our energies have to be legitimately utilized in such prevention. A true utilitarian, therefore, is not one who simply maximises utility.  He is one who acts for the greatest good of those whose welfare he is charged with; and 'when faced with a moral decision he conti­nues to act in whichever way is best for the interests of those affected' (Hare 1984).

Philosophical exploration is 'necessary also because in the field of ethical conduct, psychiatrists must be able to do more than convey injunctions against fraudulent or exploitative actions or merely supply a code of professional etiquette (Murry 1979). A grounding in a theory of values is also required (Chodoff 1984), for which tracing of philosophical credentials becomes obligatory.

 

Code, Regulation

We shall start by asking and trying to answer certain basic questions. In this manner, we may be able to scrutinize some of our presuppositions, evaluate them, sift the proper from the improper, and lay down certain criteria for sound reasoning.

What is ethics, after all? It is the science of conduct, whether good or bad, of morals, whether moral or immoral, of propriety, whether proper or improper. If there is to be a code of ethics, it presupposes both the need and the ability to regulate conduct according to morality principles irrefutable as to their propriety. A code of psychiatric ethics means there is both the need to regulate such conduct of the psychiatric establishment5, and an acknowledgement that the bodies entrusted therewith have the ability to do so. When there is a question of ability, both competence and volition come into play. The regulating body, therefore, must be competent to do what it professes to and should have the will to carry it out. Here, conduct, which invol­ves volition and action, comes into the picture. A code of ethical conduct must therefore regulate the will to action and guide the purposiveness of that action. It must, moreover, be intimately related to action itself, to the activity of the establishment which is supposed to profess it.

Is there a need to regulate the establishment's activity? To this the consensus answer would be yes, although some die-hards may disapprove because they intrinsically fear outside interference in their affairs as they fear any accountability; accountability and scrutiny become synonymous with prosecution in their minds which arouses guilt and anxiety and a consequent avoidance behaviour that can be aggressively propelled. Is there a will to bring about such a regulation? The answer to this again is at least a partial yes. Most psychiatrists in their individual capa­city do so, or at least expect themselves to do so, and errors of omission, not necessarily born of deceit, are more common here than those of commission. Others who do not have such a will are the back sheep whose presence is inevitable in any set up; the most that can be done is minimize their importance and expose their nefarious influence. For both these, a watch-dog type of set-up is needed, comprising of members of the establish­ment all-right, but also those of other social welfare bodies, whether the establishment wills it or not. The latter's presence is rendered inevitable precisely because the establishment's objectivity is likely to be jeopardized when it has to pass judgments over faults of its own members. Whilst some errors can be almost unconsciously condoned, others may be highlighted just to side-track from certain issues or, worse, malign certain sec­tions. Patient rights advocates in social welfare organisations cannot be kept at bay for long in such a set up. This of course is in spite of howsoever much the establishment wishes to shoo them away. Growing scepticism about the sanctity of science, medicine and psychiatry means that these fields are no longer above rebuke or exempt from active moral review by their recipients, professional peers and others outside of their practice (Karasu 1980). Professional organizations and societies, psychia­try included, must invite this participation in professional designs (Michels 1981). Appropriate role for non-professionals in professional decision making has already begun in ethics review boards, licensure groups and selection committee, and will probably extend further.

Is there a need to guide the purposiveness of the establish­ment's action? Most of us would again agree, although how this is to be done would be no smaIl hurdle to cross; Again, when we talk of the need to guide activity so that it becomes purposeful, we must presume that there is the possibility that this activity can be purposeful as also that it can stray from this purpose. Now, again, in keeping an activity purposeful, interested parties must automatically get involved, and where there is also a question of prevention from straying, the role of watch dog agency that profess to prevent such an eventuality cannot but be envisioned. A code is supposed to regulate activity to make it purposeful and as long as this activity does not become censure-free, regulating bodies must define and redefine priorities and principles to nake the establishment's activity as less malevolent and as morally sound as possible.

Coming now to the question of activity, it presupposes at least two agencies: the actor and the one acted upon. The code thus, must be a guideline to the activities of the establishment as it comes in contact with the patient population on which it has to act. We know, however, it is not only these two agencies that are involved. Probably in a secondary manner at present, and we may have occasion to dispute this later, the involvement cannot be circumscribed thus. Of course one would be justified in feeling better off if it remained so, but that is another matter -­ for one thing, it is no longer practical, for another, it itself is fraught with chances of exploitation, by both the agencies involved.

To obviate the emergence of exploitation or improper implementation, certain other agencies must need enter the picture. One of them is the judiciary, with the judges, the lawyers and even the police-force playing a role. The other is legislative bodies who consider it their duty to legislate in matters of law pertaining to professional transactions. (Of course often this duty is only a subterfuge for rights, but that is another matter). Also, socio- humanitarian activists in the community, as well as others with not so honest intentions, consider it their duty to make their presence felt. ‘Critics maintain that in the interest of justice to the public it is essential that non-professional representatives also take part in deliberations about the derelictions and mis­deeds of psychiatrists ' (Chodoff 1984).

A code of ethics must, therefore, attempt to incorporate the diverse opinion of such groups. What we mean thereby is not necessarily accept their views, Rather it means minimize the chances of friction between the establishment's conduct and the over-seeing attitude of these agencies. In other words, to accept their presence. if not all their views. A code should therefore try to incorporate such barriers that safeguard the profession against unnecessary conflict with such groups. It must also try to prevent transgressions by members likely to create conflict with its clientele and their champions. It attempts to lay down, in the least complicated manner possible, what a reasonably conscientious professional should attempt, and assiduously guard against.

Two Points

Conscientiousness in a professional must be considered a virtue. But by itself it leads to difficulties. If coupled with aggressively, for example, it may lead to heroic measures in treatment which no doubt help many patients but can equally well arouse resent­ment and animosity in any number of others. It can also lead to disenchantment and guilt feelings because the best of intentions are either not implemental or when implemented arouse a negative response from the client's side; which again brings home the fact that the best of intentions need not necessarily beget the best of results, even if coupled with competence and professional expertise. Who does not know of the honest psychiatrist who makes a proper diagnosis and carries out the best treatment possible only to be hauled before the court of law for negligence or improper treatment ? Or to be involved in a tacit word by mouth campaign about his very capabilities? Or worse stilI, arouse doubts in himself about is own capacity, with reduction in his realistic vigour and zest, imperceptibly resulting in an passive acquiescence in the client’s paranoia. Do we also not know that in a case where there is no informed consent, the fact with the treatment was technically well performed and 'effected a complete cure is immaterial (Slovenko 1985, Kaplan arid Sadock l985)? Again, it is one malpractice claim under which the requirement of expert testimony can be avoided (Slovenko 1985 ). Who does not know how often the inability to get informed consent is just a means to avoid coming to decisions  likely to be painful to implement or sustain later, 'besides involving legal hassles as an ever-hanging Damocles’' sword'?

The points that come across glaringly to even a casual observer are two. Firstly, involvement of other agencies in the profession’s code of conduct has come to stay. We cannot wish it away. We cannot also minimize its influence' by either hurt resignation or aggressive rebuttal. Refer, for example, to state­ments like,' our intentions were and still are, good in this area and that, given the wherewithall, we have a lot to offer. Society's intentions, however, have been proven to be questionable and they have not given us what were need', (Rappeport 1978) 7. Michels (1981) advocates that the profession's attitude toward this trend itself be professional, an eminently suitable suggestion. If anything this influence is bound to increase, precisely because the psychiatric establishment works less with the body more with the mind. That other medical professionals also face ethical dilemmas is as clear as the fact that the psychiatrist's difficul­ties are to an extent unique because of the peculiar nature of the problems be has to come to grips with. The psychiatrist is a rather special variety of physician (Chodoff 1981). It is the mind with which he works; on which he attempts modification, over which the ideals of proper, right and good are super-imposed. He is thus in that very much greater a capacity to both influence the other and to be influenced by him, for good or for evil. Therefore, we must believe that the code will come under increasing scrutiny of its clients, social activists and the law. Forces within the establishment that select to question its credentials (Szasz 1963,1970,1974) will appear as critical of its capacities as members of the judiciary who pass strictures on the uncertainties of psychiatric diagnoses and therapy, and appear unconvinced even of the reality of psychiatric disorders. For example, some Justices in the United States appear firmly convinced that psychiatry is  akin to charlatanism and psychiatric diagnoses is no more accurate than palm-reading (Appelbaum 1984). Justice White's majority opinion compared mental hospitals unfavourably with prisons (Vitek v Jones 1980). Justice Stewart considered milieu therapy an euphemism for confinement in the milieu of a mental hospital (O'Conner v Donaldson 1975). Compare this with Szasz and the other anti-establishment writings that seek to establish mental illness itself as a myth and even identify involuntary hospitalisation with slavery (Szasz 1978). This will be more so as long as psychiatrists presume to decide questions for courts by incorporating into their medical judgments factors beyond their medical expertise (Bazelon 1978). They must then face up to the irksome cross-examination of their expertise in courts and elsewhere. They will also have to accept that a court does not feel bound by the opinion of even those psychiatric experts it itself appoints (Rappeport 1978). The trial of John W. Hinckley Jr, the would be assassin of U. S. President Ronald Reagen by a District of Columbia jury in 1982 also turned out to be a trial of law and psychiatry. The psychiatrists, and the law allo­wing their testimony, were made culprits far the unpopular verdict of not guilty by reason of insanity: 'The psychiatrists spun sticky webs of pseudo scientific jargon, and in those webs the concept of justice, like a moth, fluttered feebly and was trapped' (opinion quoted by Slovenko 1985).

 

And yet, somewhere along the line, we must also sound a word of caution. This is the second point. Influence of other agencies, especially law, on the establishment does not amount to transformation of its ethical identity to become one mainly influenced by them. Let us see what we mean thereby. Law for example, plays, an important part in the establishment’s code of conduct, especially in its application and in arbitration offer disputes. How important this is can be gauged from any worth while book on psychiatric ethics for it concentrates mainly on law and legality as applicable to the establishment. This is under­standable since the professional has to apply ethical principles in day-to-day practice and must concern himself with practicality more than its conceptual principals; and in an adversarial situa­tion an arbiter cannot but step in which is what the judicial process essentially is. It is part of professional expertise, then, to be conversant with legal intricacies. And yet we know the impro­priety of equating legality with propriety. Ethics is not to be equated with legality, or with legal rights, sanctions and privileges. Or with formulating the means of saving one's skin. It then becomes little more than a trade union, defending the parochial interests of its members against the claims of their employers, in this case the public, while the latter inevitably organize in an adversarial relation to the profession (Michel's 1981). Ethics essentially is morality in practice. And anyone who tries to excuse himself, for whatever reasons, pragmatic for survival, by means of tenuous logic or cover of legality cannot but accuse himself in the bargain. Qui s’excuse s’accuse.  For example there can be a tendency, especially amongst the medical professional so mooted in professionalism and worried about indemnity claims, to consider obtaining valid consent in various forms (by valid we do not mean those that are morally proper but those that stand in a court of law - and it is unfortunately necessary to make this differentiation) as the major, if not only, concern of ethics in medical research or practice. Legality thus gets confused with proper or improper conduct. Whilst no doubt ethics is concerned with law and legislation (as it is concerned with every issue in which conduct can possibly be involved) it is not to be considered synonymous with the legality of conduct, or be restricted within this sphere. It can of course be so at times because exigencies of practice demand an operational framework. But it cannot be limited within it. In fact, it must always keep at the back of its consciousness the belief that property of conduct must transcend legality, that the later is only an operational framework, a narrow and therefore defective one at that, we acquiesce in for want of another that encompasses all myriads of this subtle mosaic.

            It is hence improper to consider issues that fall within the purview of legal regulations or control as the only legitimate concern of medical, or psychiatric, ethics, Neither need our concepts or activities be guided or motivated solely by considerations that come in contact or conflict with the law. Unfortunately, the history of medical, especially psychiatric, ethics is so influenced to a degree that is not inconsequential. Such an attitude is more an attempt to safeguard one’s professional interests. Or, to put it more bluntly, to save one’s skin, especially in the face of compensation claims. We kid ourselves into believing it a proper implementation of ethical principles. If ethics is considered synonymous with this attitude, overtly or covertly, it only reflects our lack of understanding of what ethics conceptually involves, and shows how unethical we can be about ethics itself. This becomes more gloating when the need for the psychiatrist to make vital moral decisions is considered pervasive infiltrating every facet of his work (Bloch and Chodoff, 1984a): ‘And his task is made more complicated by the fact that most of the ethical problems he faces have not hitherto been dealt with, let alone resolved. Some problems have not even begun to receive systematic study.’ There could be an element of denial here, for psychiatric practice itself may be characterised by uncertainness and ambiguities which it constantly struggles to keep within bounds (ibid). It may signify the medical man’s search for a system of medicine allegedly free of ethical values (Szasz, 1960). Or a belief that his therapeutic activities do not, and should not, have any political consequences. Halleck (1971) believe that a psychiatrist has a political role to play, whether he is prepared to recognize it or not, and this role has significant social and ethical implications. Bloch and Chodoff (1984) agree thoroughly with this contention. This however, is a topic by itself, for which much could be said either way.

            In all our discussion till now, and further, we will be guided by what Chodoff (1984) has so succinctly put as the dilemma of psychiatry viewing. The psychiatrist has to acknowledge that his dissent, especially if stated very strongly, can harm his profession, and in addition, might confuse the public. But that does not of course mean that the psychiatrist indulge in rationalizations which enable him to ignore his true beliefs.

 

            Involuntary Hospitalization and Informed Consent.

 

            There is then the issue of involuntary hospitalization as well as informed consent. In all the meanderings of both these procedures we know the essential core involved. The dilemma is of control and forced conformity by one agency of another. The fears, not altogether unfounded, are of misuse of power when one exercises control over another’s mind. Thus involuntary hospitalization raises all the questions about who should decide such a need and under what conditions is it invariable. The consensus opinion that emerges is that law enforcing bodies alone are so empowered, the psychiatrist only acting as an ally who imparts his professional expertise, if asked for. In the case of in­formed consent, again, the establishment knows how the concept is basically defective, though that need not mean it is not a workable one in the absence of anything better. What are issues like information and consent, after· all? They cannot ever be a one-way process.  We may impart the best of information but unless grasped by the other side it cannot be supposed to arouse any reasoned consent. Both information and· consent are, in fact, two way processes. Information becomes what it is only when processed by another. Consent again becomes legitimate only if the agency seeking it carries out legitimate activities to obtain it, and. the other is in a state of mind to understand what he consenting for.

We know, however, how both these issues are efficiently side­tracked in most discussions of informed consent. We know also how the very fact that one party may make the most honest attempts to inform - and that may not be altogether without doubt - the basic difficulty is with the person supposed to be informed and in a position to give valid consent. For example, how do you gain a proper informed consent from a paranoid psychotic with most personality functions intact except for his paranoid delusions? He does not believe he is sick. He can convince the Court and the police that he is able to lead a not altogether unreasonable life, albeit with his oddities and eccentricities. And yet the close relatives, the ones with whom he stays and interacts, know the chaos that he causes in their personal relationship, the disruption of intimate bonds that results, and the decline in finer qualities and blunting of appropriate affect. Here we are faced with the difficulty of obtaining any valid consent. Will such a patient be ever certified anywhere unless he lands up markedly psychotic or commits a heinously barbaric act? Will such a person ever give a valid informed consent in spite of our best efforts? This, although each psychiatrist can vouch for the tremendous amount of social morbidity unleashed by the poison of paranoia let loose on an unsuspecting society thereby. Are we then not essentially only saving our skins by our talk of failure to obtain informed consent? Are we not shirking our responsibility by letting such individuals loose in society? This, especially when certain agencies raise the question of individual liberty, of the fundamental right to freedom of expression and movement in this context, - and the establishment responds by sheepishly taking the cover of legal helplessness and hassles. Which is quite unnecessary because every psychiatrist places high on his list the value of individual liberty and right to self-expression or self-decision, and when he suggests the abrogation of these rights, he does so not to force or coerce people into subjugation but to help them regain their earlier levels of judgments and self-expression, if not fully, at least as great a level as is possible; and help temporarily restrain them from harming these rights of others. For any social system to work, both functions are invariable. And the establishment need be defensive only if it is as unsure of its methods as its opponents and detractors make it out to be. Also we know very well that if we continue to value Iiberty so exclusively we might find ourselves taking an anti-humanistic position (Halleck 1974j; and 'the minority who suffer from psychiatric illness, will suffer if a liberty they cannot enjoy is made superior to a health that must sometimes be forced upon them' (Michels 1973). As Peele and Chodoff et al (1974) state, 'it is a perversion and travesty to deprive these needy and suffering people of treatment in order to preserve a liberty which is actuality so destructive as to constitute another form of imprisonment'. In other words, the duty of beneficence enjoins us to carry out activities for the benefit of the client and empowers us with the necessary moral guidelines, whether accepted by law or otherwise.

 

***** TYPING PG NO 102-103 NOT DONE

 

disposal can bring about  remission to a satisfactory degree in the majority of cases; and in those where remission occurs the relief and gratitude of the patient as well as his relative is the bonus of good-will on which the whole establishment rests. The difficulty is that treatment failures complain and seek redress and there is no corresponding rebuttal from the side of those who have benefited. This is but natural and is understandable. Also natural and understandable is the establishment's defensive attitude in such circumstances. But what is natural and understandable is not what is necessarily appropriate. Here again we must ascend in our thinking and critically judge for ourselves whether what we are doing is for the general welfare of our patients or not. Have we been consistently successful in some types of psychiatric problems? Have we consistently failed in certain others? And are both· these mainly related to our present expertise? In such a case, we should categorically be able to say that in 'X' type of case, involuntary confinement helps, but in ' Y' type, according to our present level of expertise, it does not. And after setting such limits, we must stick to them consistently till we have evidence to refute or modify this line of action. If our activities are directed thus, inflated and unneces­sary duelling would stop, while healthy questioning and conse­quent modification continues.

In all this the psychiatrist may sometimes have to act at personal risk, and that is part of the hazard of being a professional in this unique branch. For psychiatrists need to he alert· to the possibility that they are avoiding responsible action because it is difficult and painful (Chodoff 1984). We do not mean to say one invites trouble for oneself by being rash or over bearing. Far from it. This in fact is what has encouraged the improper control by other agencies of the psychiatrist-patient relation­ship which has caused  estrangement in both. It has even prompted agencies like a United Nations Committee to find involuntary admission unjustifiable and worthy of abolition since it is 'abused' in several parts of the world 'especially against persons who defend fundamental freedoms or exercise their human rights', (Daes 1986), for psychiatric mistreatment is a sinister abuse of scientific and medical technology and psychiatric drugs are used for torturing persons diagnosed as mentally ill (Daes 1986). What we need is neither an aggressive over-lordship nor a meek acquiescence. We need a firm commitment toward the good of both the client and the social framework in which he exists, irrespective of the constraints and the paranoia that may exist in societal agencies. By irrespective we do not sanction a steam roller aggressivity. What we rather mean is a firm, persistent commitment to certain values of professional conduct and an abiding conviction in the worth of action that follows there from. No code of conduct which condones any of these can be said to exist on morally sound principles. No sound philosophical basis, therefore, can be claimed for them, either. As Chodoff (1981, 1984) states, 'It is a hallmark of psychiatry that in a number of areas (e. g. involuntary hospitalization, the insanity defense) the psychiatrist operates as an interface between the rights of the individual and the requirements of society. On such occasions the sometimes difficult issue to be faced is whether true responsi­bility to society necessitates adherence to professional standards or to societal dictates'. And he states further, ‘a psychiatrist may find himself in circumstances when he believes that he can discharge his proper responsibility to society only by resisting its dictates if he believes that these are intolerable because they are in conflict with the ethics and values of his profession'.

To the question whether the establishment accord primacy to the dictates of professional conscience or the requirements of social conscience, the answer cannot be simple. Yet some guidelines can be definitely offered. At the ideational level, social conscience is of course supreme and all professional considerations have to be made subservient to it. But to say so is to acknowledge that this social conscience is a concrete unchangeable entity. A major part of all reformist activity must be guided by the knowledge that this social conscience is a concept, and it concept amenable to change arid modification. While professional conscience can never tear up or annihilate social conscience, it can and must, try to educate it, even modify it by legitimate means that the socio-political atmosphere of a region provides. In so doing it will probably realize the true and legitimate political role· that some of those we mentioned earlier (Halleck 1971, Bloch and Chodoff 1984a) envisage for the psychiatric establishment. For we do know that a society's concern for unorthodox ideas and behaviour amongst its members appears to be universal (Bloch 1984), whether in closed or open societies although certainly varying in degree. The political dissenters labelled psychiatrically sick is but one manifestation of this phenomenon; it probably occurs in a more ubiquitous manner than the establishment is wont to grant, and not all the popular fiction of psychiatric diagnoses as a tool to ostracize and mani­pulate can be considered baseless. For  “without the stigmatiza­tion of some acts and some people as 'abnormal' or ‘anti-social', there would be no idea of the normal, no rules to govern­ social behaviour ... it follows that people whose behaviour is labelled as schizophrenic, criminal, inadequate or otherwise anti­social provide the yardstick by which acceptable conduct is measured. Society is making use of them for its own ends, the orthodox depend on the unorthodox to define their own ortho­doxy; but the labels tend to be attached to people haphazardly. Behaviour which is seen as psychiatric disturbance in one society may be regarded as criminal in another, and simply tolerated in a third (Jones 1978).

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officers or others. The psychiatrist can be no exception. They will further have to provide channels of communication and monitoring agencies to assure the public that they are in effective control of their activities and are effectively policing their· ranks (Chodoff 1984). And for the goal of maximising mental- health, they must be unflinchingly ready to be baptised by the fire of critical, sharp and incisive scrutiny by other social welfare agencies. This appears a tall order with an establishment as wrapped up in self-protective activities as at present. But there is no reason to lament that it will not be able to rise out of ·this self-inflicted morass over a period of time. This cannot but be so in the case of a branch that has retained its healthy core amidst the most unhealthy draughts, both from without and within. One wishes the hope inherent in this dialogue matches the conviction of the establishment that must profess it. And a firm philosophical enquiry into its ethical basis should supply it some of the roots to strengthen this commitment and the convictions from which it should spring.

No doubt some psychiatrists will play a greater role than· others here. But none can escape from this role; their commitment will be advisable in at least as great a measure as is in their honest capacity. This is also to obviate the compulsions that would be otherwise entailed if present trends are any indica­tions of future portents. Even pragmatism hence demands it. Moreover, the maturity and comprehensively with which the psychiatrist tackles his patient and his branch must be trans­parently clear to the community in which he has the honour to be a professional. In this respect, the responsibility of the establishment and its individual members to promote an equit­able distribution of services through about the society, rich or poor, in private practice or in public or charitable institutions, and to as fair a level as is honestly possible becomes a pressing need

 officers or others. The psychiatrist can be no exception. They will further have· to provide . channels of communication and monitoring agencies to assure the public that they are in effective control of their activities and are effectively policing their ranks (Chodoff 1984). And for the goal of maximising mental' health, they must be unflinchingly ready to be baptised by the nre of critical, sharp and incisive scrutiny by other social welfare' agencies. This appears a tall order with an establishment as wrapped up in . self-protective activities as at present. But there· is no reason to lament that it will not be able to rise out of ·this self-inflicted morass over a period of time. This cannot but be so in the case of a branch that has retained its healthy core amidst the most unhealthy draughts, both from without and within. One  wishes the hope inherent in this dialogue matches the conviction of the establishment that must profess it. And a firm philoso­phical enquiry into its ethical basis should supply it some of the roots to strengthen this commitment and the convictions from which it should spring

 

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useful to, his own understanding of his ethical code (as well as his branch itself), sift the proper from the improper in the light of this, and hold on to the proper while getting rid of the improper. The average vigilant philosopher similarly has a role to play in that although he cannot avoid offering abstract generalizations he need also offer concrete working concepts in his ethical enquiries, since the exigencies of this situation demand it.

The difficulties in doing so are no doubt many, and will be better appreciated if we understand the basic dichotomy in the training, expertise and value orientation of the philosophical thinker and the practising professional. While the former prides himself, and cherishes, (quite legitimately perhaps), the ability to ask: resolute questions, the professional (equally legitimately) concentrates energies mainly to find answers. Hence there can be a basic, and unavoidable, divergence as much of orientation as of emphasis. When, therefore, we think of making our questions relevant to an answer seeker, as in the present situation, we must avoid any but the most operational ones, and certainly avoid those that appear armchair or ivory-tower pontifications not cognizant of applicability. For nothing puts off professionals more than this; and communication thus severed has hardly a chance to be re-established. Philosophers, therefore, will have to indulge in only such questioning as prompts, guides, even excites professionals to search for answers, even as they make them aware of the multitude of questions that remain to be answered. And it must come in this order; if reversed, communication has every chance of being severed or becoming skewed. While so ­doing, they must avoid smug generalisations or sticky hair-splitting; they must further forbear the impatience of the profe­ssional's obsession with solution seeking. Even as they do so, they must endeavour to lay the broad foundations of a solid theory of values, which is their basic philosophical concern. This

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To put it in a nutshell. The philosopher's abstract generali­ations, then, will often need to be at a minimum. Their applicable operable definitions and frame works will have to be maximised. Of course the abstract cannot but be present, but in a covert form, as an under-lying broad principle alive· to the special needs this situation; and therefore one that· does not domi­nate it, for by so doing it would only undermine its own· impor­tance.· As philosophical concepts become more understandable to those who have to implement them, they will serve the dual purpose of actualizing themselves and getting rid of needless vacuity. They will, further, become vital, and their energizing influence on professionals cannot but afford health-giving feed back.

This then is the role to which the philosophically oriented must rise; and in so doing they will only hasten their own fulfillment. For, if Plato dreamt of a 'philosopher-king', we have yet to find that commitment amongst his successors which can convert this dream into reality. The establishment itself also needs to know that a robust grounding in a theory of values and striving to lake it workable will gain for it that forward thrust which is its potential but continuously eludes its grasp. For this, some amongst its· own ranks must closely study the philosophical base of the establishment itself, as well as its ethics and the stance of the moral philosopher, (as indeed of the Social Sciences and the Humanities at large; and even of its detractors) and find paradigms useful for its own proper growth. Any dampening of vigour that results therefrom can only be over adventitious elements in the branch that have usurped positions of importance. Here, a meeting ground must first be first laid down on the basis of a consensus, particularly on the basis of the lowest common denominator, gradually working upward to encompass wider and subtler entities. For this, open-ness to critical scrutiny is a must for the establishment, as is acknowledgement of errors and activities aimed at their speedy termination. Similarly, a necessary second step is to understand rather than neglect the abstruse and acknowledge its important wherever due. The establishment can give a lead in this, for often philosophical thinkers, being only human, can be unduly pompous and, for all their declared catholicity, more dogmatic about convictions than is healthy for their own philosophizing.

Gradually, then, as barriers of communication are removed, the result will be a sound-based practicality for the professional and a living-philosophy for the philosopher. This need not only remain a hope and a dream; for ideals that cannot be practised are not worthy of being ideals. In any case, they are hardly likely to fire the imagination of professionals. This then is the challenge to both sides. This then is also our hope.

 

                                                                                        AJAI R. SINGH

                                                                                                    And

                                                                                         Shakuntala Singh

 

NOTES

1.      In India ethics has been discussed only twice in the Indian Journal Of Psychiatry (Singh 1965, Dube 1982), both well-intentioned forays . which have not spawned the interest they should have.

2. Some notable British comments have been Roth (1976) on involuntary hospitalization, Blumenfeld (1974), and Rosen & Rekers et al (1978) on ethical issues and the treatment of children, and Jones (1978) on socie­tal responsibility of psychiatrists.

3. This of course is but a representative sample; many more can be cited.

  4. We use the two terms in their widest possible connotation here, wherein absolutism is also the opposite of relativism and utilitarianism is also utility to self, here, the profession involved; this, of course, is not how Hare, 1984, would understand these terms.

5.  Unless otherwise specified, the word ‘establishment' later on in the text means ‘psychiatric. Establishment’.

6.  Words underlined are to be considered italicized.

7; Although Rappeport talks here to the juvenile justice system, it is a typical example of pique and hurt of well-intentioned exasperation. And the broader generalisation about the honesty of the establishment's intentions is implied. Society’s intentions are not proven to be questionable here, as elsewhere, precisely because its standpoint is essentially of the championing watch-dog type and must, by the very Iogic of its existence, come at times in adversarial contact with the establishment.

8.  Parenthesis added. All the Ethical Codes quoted above are from Bloch and Chodoff (1984b).

 

REFERENCES

 

Appelbaum, P. S. (1984), "The Supreme Court Looks at Psychiatry". American Journal of Psychiatry, Vol. 141: 7, pp. 827-835.

Bazelon, L. D. (1978a), "The Psychiatrist in Court". In: Controversy in Psychiatry. (Ed.) John Paul Brady and H. Keith H. Brodie, Philadelphia: Saunders, pp 909-917.

Bazelon, D. (1978b), "The Role of the Psychiatrist in the Criminal Justice System". American Academy of Psychiatry and the Law Bulletin,

      Vol. VI, pp. 139-146.

Bloch, S. (1984), "The Political Misuse of Psychiatry in the Soviet Union". In: Psychiatric Ethics (Ed:) Sidney Bloch & Paul Chodoff, Oxford: Oxford University Press, pp. 322-341.

Bloch, S. & Chodoff P. (1984a), Introduction. In: Psychiatric Ethics, (Ed.) Sidney Bloch and Paul Chodoff, Oxford: Oxford University Press, pp.1-12.

Bloch. S., & Chodolf, P. (1984b), "Appendix Code of Ethics ". In:

Psychiatric Ethics (Eds.) Sidney Bloch and Paul Chodoff, Oxford: Oxford University Press, pp 343-360.

Blumenfeld, A. (1974), "Ethical Problems in Child Guidance", British Journal of Medical Psychology, Vol. 47, Pl'. 17-26.

Braceland, F. J. (1969), "Historical Perspectives of the Ethical Practice of Psychiatry", American Journal of Psychiatry, Vol. 126, pp. 230-237.

Chavez, I. (1964), "Professional Ethics in our Time", Journal of the American Medical Association, Vol. 190, pp. 226-231.

Chodoff, P. (1976), "The Case for Involuntary Hospitalization of the Mentally III", American Journal of Psychiatry, Vol. 133, pp. 496-501.

Chodoff, P. (1981), The Responsibilities of Psychiatrists to Society. In: Law and Ethics in the Practice of Psychiatry, (Ed.) Charles K. Hofling, New York; Brunner I Mazel, pp. 225-238.

Chodoff, P. (1984), "The Responsibility of the Psychiatrist to his Society". In; Psychiatric Ethics (Ed.) Sidney Bloch and Paul Chodoff, Oxford: Oxford University Press, pp. 306-321.

Daes, E. I. (1986), Principles, Guidelines and Guarantees for the Protection of Persons Detained on· Grounds of Mental III Health or Suffering from Mental Disorder, New York: United Nations.

Dube, K. C. (1982), "Morals in Medicine", Indian Journal of Psychiatry, Vol. 24, I, pp. 8-14.

Foot, P. (1967), Theories of Ethics (Ed.), Cambridge, Massachusetts: Harvard University Press.

Halleck, S. (1971), The Politics of Therapy, New York: Science House, p. 13.

Halleck, S. L., (1974a), "A Troubled View of Current Trends In Forensic Psychiatry", Journal of Psychiatric Law, Vol. 2, pp. 135-157.

Halleck, S. L., (1974b), "Legal and Ethical Aspects of Behavioral Control", American Journal of Psychiatry, Vol. 131, pp.381-387.

Hare, R. M. (1952), The Language of Morals, Oxford: Oxford University Press.

Hare, R. (1981), Moral Thinking: Its Levels, Method, and Point, Oxford: Oxford University Press.

 

Hare, R. (1984),  "The Philosophical Basis of Psychiatric Ethics ". In:

Psychiatric, Ethics (Ed.) Sidney Bloch and Paul Chodoff, Oxford: Oxford University Press, pp. 31-45.

Jones, K. (1918),"Society Looks at the Psychiatrist ", British Journal of Psychiatry, Vol. 132, pp. 321-332.

 

Kaplan,H. I., and Sadock B. J. (1985'), "Forensic Psychiatry". In:

Modem Synopsis of Comprehensive Textbook of Psychiatry/ IV, IV Ed. Baltimore: William and Wilkins, pp. 887-898.

Karasu, T. T. (1980), "The Ethics of Psychotherapy", American Journal of Psychiatry, Vol. 137: 12, pp. 1502-1512.

Levine, C. (1979), “Ethics and Health Cost Containment: Report from Hasting Center Conference", Hasting Center Report, Vol, 9, pp. 10-17.

Michels, R. (1973), " The Right to Refuse Psychotropic Drugs", Hastings Center Report, Vol. 3, pp. 10-11.

Michels, R. (1976),  “professional Ethics and Social Values". International Review of Psychoanalysis, Vol. 3, pp. 377-384.

 

Michels, R. (1981), "The Responsibility of Psychiatry to Society". In:

Law and Ethics in the Practice of Psychiatry (Ed.) Charles K. Hoffling. New York: Brunner / Mazel, pp. 239-251.

Monahan, M. (1977), “John Stuart Mill on the Liberty of the Mentally III", American Journal of Psychiatry, Vol. 134, pp. 1428-1429.

Moore, R. A. (1978), "Ethics in the Practice of Medicine: Origins, Functions, Models and Enforcement ", American Journal of Psychiatry, Vol. 135, pp. 157-162.

Murray, G. B. (1979), "Ethics at the Crossroads ", Psychiatric Annals, Vol. 9, pp. 21-28.

O’Conner V Donaldson (1975), 422 US 563.

Peele, R., Chodoff P., and Taub N. (1974), "Involuntary Hospitaliza­tion and Treatability: Observations from the District of Columbia Ex­perience”, Catholic University Law Review, Vol. 23,pp. 744-753.

Rappeport, J. R. (1978), "The Psychiatrist and Criminal Justice: From Police Investigation to Prisoner Rehabilitation ". In: Controversy in Psychiatry, (Ed.) John Paul Brady and H. Keith, H. Brodie, Phila­delphia: Saunders, pp. 918-932.

Redlich, F. and Mollica A. (1976), "Overview: Ethical Issues in Con­temporary Psychiatry", American Journal of Psychiatry, Vol. 133, pp. 125-126.

Rosen, A. C., Rekers, G. A., and BentIer, P. M. (1978), " Ethical Issues in the Treatment of Children ", Journal of Social Issues, Vol. 34, pp. 122-136.

Roth, M. (1976), "Schizophrenia and the Theories of Szasz", British Journal of Psychiatry, Vol. 129, pp. 317-326.

Singer, P. (1979), Practical Ethics. Cambridge University Press.

Singh, H. (1965), "Psychiatry, Ethics and Religion", Indian Journal of Psychiatry, Vol 7: 4, pp:278~286.

Slovenko, R. (1985), "Law and psychiatry". In: Comprehensive·Text­book of Psychiatry/IV, IV Ed., (Eds.,) H.I. Kaplan and B. J. Sadock, Baltimore: Williams &. Wilkins, pp. 1960-1990.

Somers, A. R. (1977), "Accountability. Public Policy and Psychiatry", American Journal of Psychiatry, Vol. 134, pp. 959-965.

Spiegel, R. (1978), Editorial: On Psychoanalysis Values and Ethics, Journal of the American Academy of Psychoanalysis, Vol. 6, pp. 271-273

Szasz, T. S. (1960), "The Myth of Mental Illness ", American Psycho­logist, Vol. 15, pp. 113-118.

Szasz, T. S. (1963), Law, Liberty and Psychiatry: An Inquiry into the Social Uses of Mental Health Practices, New York: Macmillan.

Szasz, T. S. (1970), The Manufacture of Madness: A Comparative study of the Inquisition and the Mental Health Movement, New York: Harper and Row.

Szasz, T. S. (1974), The Myth of Mental Illness: Foundation of a Theory of Personal Conflict. New York: Harper and Row.

Szasz, T. S. (1978), "Under any circumstances - No". In: Controversy in Psychiatry, (Ed.) John Paul Brady and H: Keith, H. Brodie, Phila­delphia: Saunders, pp. 965-977,

Towery, O. B., and Sharfstein S. S. (1978), " Fraud and Abuse in Psychiatric Practice", American Journal of Psychiatry, Vol. 135:1, pp. 92-94

Veatch, R. M. (1973), “Generalization of Expertise''; Hastings Center Studies, Vol. l, pp. 29-40.

 

Vitek V. Jones, (1980), 445 US 480.

Warnock, M. (19'18), Ethics Since 1900, Oxford: Oxford University Press.

West, L. T. (1968), "Ethical Psychiatry and Biological Humanism", American Journal of Psychiatry, Vol. 126: 2, pp. 226-230.

 

 

 

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