Johnstone, Brian

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The Linacre QuarterlyVolume 54 | Number 1 Article 132-1-1987[Book Review of ] Psychiatric Ethics, by Brian V.Johnstone, edited by Sidney Bloch and PaulChodoffBrian JohnstoneFollow this and additional works at: http://epublications.marquette.edu/lnqPart of the Ethics and Political Philosophy Commons, and the Medicine and Health SciencesCommonsRecommended CitationJohnstone, Brian (1987) "[Book Review of] Psychiatric Ethics, by Brian V. Johnstone, edited by Sidney Bloch and Paul Chodoff," TheLinacre Quarterly: Vol. 54 : No. 1 , Article 13.Available at: http://epublications.marquette.edu/lnq/vol54/iss1/13BOOK REVIEW Psychiatric Ethics by Brian V. Johnstone, C.SS.R. Edited br Shine I' Bloch and Paul Chodo/{ (Ne ll ' York: Ox/iml Uni,'ersitl' Press, 1985), "iii + 368 pp. $12.95. This collecti on of 17 essays was fir st published in 198 1. and is now mad e availab le. with corrections. in paperback. The ed itors document the gro wing interest of psychiatrist s in the ethical foundations of their work. as evidenced by the vol ume of lit era ture o n thi s subj ect. The increased inte rest in et hi cs has bee n sparked. in a s pecial way. by th e medi ca l consumer mo ve ment and the civil libe rties approach to men tal illness. The psyc hiatric professio n has res ponded. for exa mple. at the 1977 World Psychia tri c Associatio n. where t he Dec laration of Ha wa ii was formu lated. An a ppendi x pr ov ides a useful co ll ection of codes of e thics. including the Declaration of Hawa ii. The perspecti ve within whic h the co ll ec ti on is conce ived is set by th e historica l o utline contributed by Da vid Musto. This author a rgu es that we a re at a peak of conflict over the rol e of psychia try in modern soc iet y. Essentia ll y the conflict is between an att it ude which accorded psyc hiatry a great dea l of co ntro l o f the destinies of persons. and powe rful move me nt s see king to limit that co ntrol in the name of persona l au tonom y and rights . A central ques ti o n concerns th e pro pe r po int at wh ich these limits s hould be drawn. The one essay on ethical th eory is that by R. M. Hare who defends a form o f rule utilitari a ni sm . He di st ingu ishes two levels of e thical thinking. The first is th e intui ti ve leve l. at wh ich leve l prima/cll'ie duties and principles have their place. Our intuiti o ns info rm us that we ha ve duties to others: for example. to te ll the truth. to protec t innoce nt life . However. these intuiti ons a re not se lf-justifying. To provide a justifica tion for the intuiti o ns. we must move to the second level. At thi s leve l we ca n argue. fo r exa mple. that a person who has s uch di spositi o ns (to te ll the truth. to protect life) is muc h more lik e ly to do . on the who le. what is best. than someone who d oes cos t benefi t a nal yses on eac h parti cular occas ion . O ne who mak es suc h ca lcul at ions wou ld lack time or informat io n to mak e th e m adequately and would probab ly cook th c results to suit his own convenience. Thus. adhere nce to suc h in tuiti ons or dispositions can be just ifi ed o n th e basis of th e ir utility. In the case o f conflict s betwee n duties. for example. bet ween the dut Yfio reli eve pain and the dut y to prese rve life. we cannot reso lve th e d iffic ult y bv a ppeals to intuitions. but must mo ve to the second leve l of e thical reasoning. For exa mple. a pysc hiatrist has duties to hi s / her patient a nd also duti es to respec t the inte rests of other members of society. On th e seco nd critical le ve l of thinking. o ne should be impartia l to a ll those affec ted by our ac tions. But th e interest s of a ll. considered im partiallv. will be li ke ly to be bett e r served if psychiatrists absorb the principle to do the best o ne ca n for one's own patie nt. T hi s is beca use the re la tionship bet wee n psychiatri st and pa tient has immense utilit y. and th e destruction of this relationship is like ly to do much more harm than good. This argu ment does not seem to be a dequate. How do we det ermine th a t th e re lati onship between psychiatris t a nd patient. give n prio rit y ove r the re lationsh ip of the psyc hiat r is t to a ll concerned. will ha ve greater utilit y than the re la tion ship of the psyc hiatrist to a ll conce rned. give n pri o rit y over the rela ti o nship to a patient') The o nl y answer Hare provides seems to be that. under the press ured ci rcumsta nces of act u~1 dec ision-mak ing. we would lack time. information and perhaps virtue. to make an adequate assess ment of utilit y in respect to all co ncerned. Ha re argues that if the psyc hiatris t follows the principle o f doing what is best for hi s her patient. this wi ll be producti ve of great utilit y and more utilit y than wou ld be produced by mo re complex a nd probabl y se riously flawed calc ula tions of cos t benefit for a ll. On th e critica l level. howe ve r. gi ve n time and access to m ore info rmati on. we ca n make 92 Linacre Quarterly satisfactory assessments of the latter kind of utility. However, it is not clear how, at this level, we determine what is to count as benefit and cost. In other words , how do we determine what is good for patients and for all concerned? Is this to be done by intuition? Hare explicitly rejects intuition on the critical level of ethical rejection. Is it to be done by a further calculus of utility at a higher leve l again? This would leave us with the same problems again on this level of reflection. Further, if there is no clear way of determining what is to count as good on the critical level of reflection , it is difficult to see how reasoning at this level can provide any lldequate resolution of conflicts . However, the major concern of the book is not with ethical theory, but with the concrete issues and dilemmas which arise in the practice of psychiatry. The significant contribution of the volume is in the judiciously selected range of topics covered. These are the social dimension (David Mechanic); the ethical aspects of diagnosis (Walter Reich); psychotherapy (Toksoz Karasu); drug treatment (Gerald Klerman and Gail Schechter); physical manipulation of the brain (Harold Merskey); sexuality and sex therapy (John Bancroft); suicide (David Heyd and Sidney Bloch); involuntary hospitalization (Louis McGarry and Paul Chodoff); confidentiality (Jerome Beigler): ch ild psychiatry (Philip Graham); forensic psychiatry (Jonas Rappeport) ; psychiatric resea rch (John Wing) ; as well as ethical training in psychiatric ethics (Robert Michels) and the social responsiblit y of the psychiatrist (Paul Chodoff). A final chapter by Sidney Bloch is concerned with the political misuse of psychiatry in the Soviet Union. All but three of the authors are psychiatrists (the others being professors of philosophy and of social work). The articles provide valuable information on the state of psychiatry, its current internal disputes and its interaction with soc ia l policy and law. The authors. as would be expected, address the ethical issues from the perspective of psychiatric professionals. This provides a dimension of considerable importance to non-psychiatrists, including students of ethics. It brings clearly to the fore how the conflicts appear to those who actually have the conflicts. The conflicts are dealt with frankly and perceptively. In a chapter on the responsibility of the psychiatrist , one of the editors, Paul Chodoff. argues that accountability obliges the profession to be clear about what it is, what it does, its ab ilities and limits, and to make a reasonable amount of this information avai lable to the interested public. Such an exercise of accountability is a guiding concern of this collect ion. This raises an acute difficulty, as psychiatrists are not in agreement about these matters. Indeed , as Chodoff writes, psychiatry is at present involved in an identity cris is. The differences are frankly acknowledged by the authors. At the same time, the reader may well wonder whether she or he is being provided , in all cases, with a sufficient range of current opinion. For example, the account of leucotomy given in the chapter on the physical manipulation of the brain, is more favorab le than that given by some other authors. A more general question is suggested by one of the contributors (t:lavid Mechanic). Psychiatrists work with models of the human person, which have broad eth ical implications for all aspects of their craft. What are the models of the human person implicit in the diverse modes of contemporary psychiatry? Here further questions arise which would be the proper concern of philosophical and theological ethics. But such questions could not be adequately framed without the contribution of psychiatrists themselves , such as those provided in this collection. T he collection is a va luab le resource both for spec ia lists in psychiatry and for all who are concerned with study and teaching in the field of ethics. February, 1987 - Brian V, Johnstone, CSS,R, The Catholic University of America 93 

[Book Review of] \u3cem\u3ePsychiatric Ethics\u3c/em\u3e, by Brian V. Johnstone, edited by Sidney Bloch and Paul Chodoff

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[Book Review of] \u3cem\u3ePsychiatric Ethics\u3c/em\u3e, by Brian V. Johnstone, edited by Sidney Bloch and Paul Chodoff

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