The ethics of psychiatry

The ethics of psychiatry is one of the areas of medical ethics where the overlap between medical ethics and philosophy of medicine is largest. This is illustrated by two papers in the current issue of the JME.

Charlotte Blease discusses whether it is “… ever right to prescribe placebos to patients in clinical practice?” in the context of prescribing for patients with severe depression (see page 13). Would such prescriptions for instance amount to morally problematic deception? In an intricate analysis she points out that the answer to the question depends on a range of complex conceptual distinctions that will be familiar to scholars in philosophy of medicine. One very significant issue that is raised is that well-being is not synonymous with a realistic assessment of oneself or one's circumstances. Most of us who are not depressed have positive illusions about ourselves and this may even be indicative of psychological health. It may therefore be a legitimate goal of treatment for depression to engender such positive illusions in patients. But that seems to point to a perhaps unavoidable role for deception in this context and to the fact that the issue of placebo use cannot be settled decisively just by pointing out that it involves deception.

Thornton and Lucas discuss the ‘Recovery model’ for mental health (see page 24). The recovery model is often put forward as an alternative to a biomedical model, but the precise content of the recovery model and its theoretical commitments are rarely made explicit. In their analysis the authors clearly show that a recovery model cannot be posited without taking on some commitments of a more philosophical kind, for instance relating to the conceptualisation and understanding of (mental) health and illness. As they make clear their purpose is not primarily to argue for one particular recovery model but to outline the options. They do however show that the most natural way to understand the recovery model for mental health does commit one to seeing mental health as “…an essentially normative or evaluative notion.”

Measuring spiritual well-being

The well being of healthcare professionals in general and in relation to their work is important. It is clearly important for themselves, but it may also be important for the effective functioning of healthcare teams and for good doctor patient relationships. Fang et al argue that well-being has many aspects and that one of these is spiritual well-being which they define as “… a sense of meaning and purpose in life, faith and comfort with existential concerns.” (see page 6).

Based on qualitative interviews, focus groups and a comprehensive survey of the literature the authors developed the Physician's Spiritual Well-Being Scale (PSpWBS) which they then proceeded to validate in Taiwan and Australia. The results show that the scale is internally consistent and that it contains four domains: “physician's characteristics; medical practice challenges; response to changes; and overall well-being.”

Etzioni on communitarian bioethics

Communitarian approaches to bioethics are increasingly popular, but how should we understand communitarianism? In the important paper by Amitai Etzioni he distinguishes between two types of communitarianism according to how needs of patients are prioritised in relation to the needs of the community (see page 17). In ‘authoritarian communitarianism’ the needs of the community always takes precedence, whereas in ‘responsive communitarianism’ the “…starting point is that we face two conflicting core values, autonomy and the common good, and that neither should be a priori privileged and that we have principles and procedure that can be used to work out this conflict but not to eliminate it.” The paper argues, not surprisingly that responsive communitarianism is the preferable version of communitarianism. It further provides more concrete suggestions concerning how the responsive communitarian can and should handle situations of conflict between individual and community interests.

A rare treat

It is rare that a paper in the JME is so short that it can be re-published in extenso in the Concise Argument, but in this issue there is a rare exception. We bring it here partly to encourage others to submit equally good, short material.

One little life in Kenya“Daktari, come!”I arrive just after Baby. No pulse, no breathing. Wait! Yes there is!Press, press, breathe… I keep it up, he gasps, a life here in my hands.Minutes become hours. Do I stop? Continue? Is this futile?Not to me - not to him.Pressing on, three long hours.So slowly, life returns.William E Cayley Jr