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S Bloch, P Chodoff, S Agreen, Oxford, Oxford University Press, 1999, 531 pages, £65 (hb) £34.50 (pb).
When receiving this book to review, I was irresistibly reminded of those advertisements for washing powders, which are described as “new and improved”. Drs Bloch and Chodoff have made an important contribution to the literature on medical ethics since the first edition of their book was published in 1981. As conceptual and practical thinking has developed in mental health services, so the ethical dilemmas too have multiplied; and so one might expect a new and improved edition of Psychiatric Ethics to address these.
A welcome addition is the chapter by Fulford, who has written extensively in the area of the conceptual aspects of mental disorder and their implications for ethics. This might have been an appropriate starting chapter, and many of the chapters could have done with similar conceptual analyses, aimed at trying to get at the heart of the real ethical tensions. For example, in the chapter on confidentiality, there seemed to me to be little attention to the discussion of principles or concepts underlying the dilemmas, although there was detailed information about all the possible situations in which psychiatrists can breach confidentiality.
Another valuable addition is a chapter by Glenn Gabbard about boundary crossings and violation in psychiatry. This is an area which is well discussed in the American psychiatric literature and is shamefully neglected in mental health practice in this country. This neglect may reflect a lack of a code of ethics for psychiatrists in the UK: their American and Australian counterparts do not suffer from such a lack. In chapter 6, Bloch describes the development and use of ethical codes, and the difficulties and advantages thereof. Although there is always a danger that such codes will be reified into something unhelpful, the experience of Australian and American colleagues seems to be that they can assist in ethical decision making.
One advantage of having a code of ethics as part of a professional identity may be to keep the question of ethical practice to the fore in daily clinical discourse. Otherwise there is a danger that ethics in psychiatry, and particularly ethical violations in psychiatric practice, may tend to become focused on extreme cases and located outside the daily world. A good example of this is given in chapter 10. George Reich's chapter on the Use and abuse of psychiatric diagnosis reviews the history of the misuse of psychiatric diagnosis in the Soviet Union, but makes absolutely no mention of the potential misuse of diagnostic labels (whether wittingly or unwittingly) in other settings common to Western psychiatry; such as in relation to women and individuals from ethnic minority groups.
There is much to provoke, stimulate and admire in this book. I wish that I could have written Jeremy Holme's chapter on Ethical issues in psychotherapy which sensitively and thoughtfully outlines the practical issues of consent and confidentiality in psychotherapeutic practice. Merskey's chapter about brain treatments is typically provocative; for example, making a link between brain surgery and cosmetic surgery. Here again I felt the lack of a conceptual analysis, particularly in relation to the connection between brain and mind; this weakened the chapter. I accept that it would be impossible to review the literature on the connection between mind and brain in a single chapter, but some discussion of the different views might have been relevant in relation to the discussion on the merits or otherwise of psychosurgery.
As in previous editions, I found the chapter on research frustrating. What I missed was an analysis of the question of competence to consent to an interaction, or experience, which is essentially altruistic and for other people's benefit. There could have been a very interesting discussion of what it is to be competent to be altruistic at any time, and whether in fact this is quite a sophisticated capacity, including as it does the capacity to gamble (as would certainly be true in many placebo trials of new medication). The ethical problems of research ethic committees really require a whole chapter in themselves; possibly for the 4th edition? Other possible contributions for future editions include the views of users of psychiatric services, more discussion about the ethic of care in psychiatry and psychotherapy; and perhaps a chapter on virtue ethics in relation to professional boundaries and boundary keeping.
These criticisms should be taken as an indication of the edition's capacity to stimulate thought about difficult issues. Everyone who bought earlier editions can benefit from buying the newest one. Although the editors have focused on ethical issues in psychiatry, this book is, none the less, a useful book for other mental health professionals to refer to. I can safely say that the new edition of Psychiatric Ethics is definitely improved and would make a valuable addition to any library, whether personal or professional.