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Mental Disorders and Genetics: the Ethical Context
  1. Christopher Howard
  1. Consultant Psychiatrist, 152 Harley Street, London W1

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    Nuffield Council on Bioethics, London, Nuffield Council on Bioethics, 1998, 116 pages, £20.

    The moral climate of our society has changed. Management has replaced consensus. Acquisition of riches has replaced personal achievement. Orders have replaced encouragement. Blame has replaced empathy. The effect of this on psychiatrists is that, through the requirements of the Mental Health Commission and the sanctions of inquiries at all levels, what they do and how they do it is prescribed and monitored and threats of sanction in event of failure are no longer remote instruments of last resort. The creation of such a climate requires individuals and bodies who are prepared to adopt and promote these values and lay down the rules. Individuals and bodies who predated the changes are adept at modifying their values and approaches for large numbers of reasons, some no doubt good but others probably bad. It is hard not to find these changes reflected in this book.

    The Nuffield Council on Bioethics is a worthy organisation, funded jointly by the Medical Research Council, the Nuffield Foundation and the Wellcome Trust. Its self-proclaimed purpose is to make moral pronouncements, fulfilling some of the role occupied in another age by prophets. The membership of the council itself is impeccable as is the membership of the committee which produced this particular report. Despite this pedigree I found this report disappointing—too politically correct, too full of clichés and lacking philosophical analysis.

    In the introduction, for example, we are told: “Mental disorders place a heavy burden on individual sufferers, on those who care for them and on society at large”. Two basic ethical requirements are identified for the evaluation of genetic research: “the limitation of harm and suffering to humans (even to all sentient animals) and the maintenance of respect for human beings and human dignity”. Anyone who might find the last of these criteria a little philosophically opaque can read on and learn that: “Respect for persons is shown by treating others as persons who can make their own decisions and lead their own lives; it is expressed in action and procedures that give weight to personal autonomy and integrity, to human (including patients') rights, and to the obligation of doctors and researchers to seek informed consent, to preserve confidentiality, to respect privacy and to communicate effectively with patients”.

    One is left wondering if anyone on the committee has ever seen a nurse trying to stop a patient throw hot tea over staff.

    We move to the more technical parts of the book and are reminded that mental disorder “is not an exact term”. We are then given some examples of accumulating genetic knowledge of varying degrees of specificity, in terms of phenylketonurea, Huntington's disease, Alzheimer's disease and attention deficit-hyperactivity disorder and are reminded of the importance of environmental factors.

    There follows a section on clinical applications which on my reading appears to contain an undiscussed assumption of the feasibility of finding physical markers for altered states of mind. There are empirical and logical sides to this issue. The latter goes undiscussed. In what possible sense could it be said of someone that he or she had schizophrenia if his or her state of mind were unaltered when some putative future genetic test was positive? Whenever this book gets close to an interesting question it ignores it. There is much discussion of genetic counselling and a presumed requirement that this can only be done by super-experts, a further example of a lack of contact with clinical reality. Quite why a practising clinician cannot discuss these matters with patients under his care is not discussed. I have little doubt that most genetic counselling for common psychiatric disorders is done in this way with good effect.

    The discussion of consent to genetic testing and impaired capacity is again somewhat clichéd. In the course of this discussion a point is made which seems to me absurd. It is stated with regard to withdrawal from a research programme that the participant “should also understand the implications of his or her withdrawal including a possible contribution to misleading research findings. Although this may risk the appearance of coercion, withdrawal is a serious problem and a competent participant is unlikely to be harmed or unduly pressurised by a properly given explanation of the situation.” Rain is a problem if you play cricket but scarcely an ethical issue.

    This book intends to summarise issues, set out in comprehensible form the factual background and make recommendations. While it is possible to extract from the verbiage what is of importance in these areas and while the recommendations, by and large, are unexceptional (perhaps because of their vagueness and generality), its goal could have been achieved with half the wording. This would have left space to examine those concepts which sound good but are, on close inspection, elusive and difficult to penetrate with philosophical light.

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