CONCEPTUAL BASES OF PSYCHIATRY FOR THE PERSON

 

Values and Ethics: Perspectives on Psychiatry for the Person

 

(Bill) K.W.M. Fulford DPhil FRCP FRCPsych a, George N. Christodoulou MD PhD FRCPsych FICPMb, and Dan J. Stein PhD DPhil FRCPCc

 

a Emeritus Professor of Philosophy and Mental Health, University of Warwick, Editor, Philosophy, Psychiatry and Psychology and Special Adviser for Values-Based Practice, Department of Health, London, UK

b Emeritus Professor of Psychiatry, Athens University and Honorary President, Hellenic Psychiatric Association

c Professor and Chair of the Department of Psychiatry and Mental Health, University of Cape Town, South Africa

 

Keywords

Compulsory treatment, ethics, values, value-based practice

 

Accepted for Publication: 19 January 2011

 

 


Introduction

 

A key challenge for person-centred psychiatry is to combine the generalised findings of objective science with responsiveness to the diverse values of each individual patient [1].  There are two main ethical resources for responding to this challenge, substantive and analytic [2]. 

 

 

Substantive ethics

 

Substantive ethics aims to define ‘the right values’ guiding practice, to provide substantive answers to ethical dilemmas. 

 

1) Utilitarianism

 

Utilitarianism is based on balancing utilities, ‘the greatest good of the greatest number’.  This has been widely adopted in relation to questions of rationing: the QALY (Quality Adjusted Life Year), for example, is based on utilitarianism.

The QALY, however, also illustrates a key limitation of utilitarianism for person-centred psychiatry. Based as it is on majority views, this measure arguably prejudices minorities [3].

 

2) Deontology

 

Deontology is concerned with defining duties, rights and responsibilities that are absolute.  In practice, few duties are truly absolute: truth telling, for example, however important, sometimes really does have to be balanced against utilities (for example, if telling a patient the truth is likely to result in that patient killing someone). 

Nonetheless, deontology balances utilitarianism in person-centred psychiatry by protecting the rights of the individual. 

 

3) Principlism

 

As a basis for deciding ‘what is right’, principlism defines what are called ‘prima facie principles’ that combine elements of both deontology (attention to important rights and duties) and utilitarianism (attention to context).

The idea is that ethical dilemmas arise from tensions arising between two (or more) principles each of which is prima facie important in its own right and which then have to be balanced according to the particular context [4].

There have been attempts other than principlism to integrate different substantive perspectives.  Of particular relevance to mental health, are attempts to describe moral reasoning as a special case of reasoning in general.  This ‘naturalistic’ approach may conclude that substantive ethics as a whole – insofar as it relies on only a single or few overarching values or concepts of human flourishing, and given the diversity of our needs and practices – cannot be a sole resource for ethics [5]. 

 

 

Analytic ethics

 

Analytic ethics focuses not on substantive ethical issues but rather on the meanings of the terms in which ethical issues are presented.  Analytic ethics is thus similar to logic and mathematics, i.e. it is concerned with correct standards of reasoning as a basis for answering problems rather than with the answers to problems as such.

This is one of the advantages of a position that emphasizes moral reasoning as a particular case of reasoning in general - it allows an assessment of the extent to which there are universal aspects of moral reasoning.  Although our needs and practices may be diverse, we can still weigh up different moral arguments in a reasonable way, for example in the way we approach particular clinical cases [6].

An important current example of analytic ethics is philosophical value theory [7] which is the basis of a new skills-based approach to working with values called values-based practice [8,9].  Philosophical value theory focuses on the relationship between facts and values [10] and is thus directly relevant to the challenge noted at the start of this article of reconciling generalised scientific findings (‘facts’) with the unique values of each individual.

 

 

Bringing analytic and substantive ethics together: the example of compulsory treatment

 

Compulsory treatment offers a particularly sharp challenge to person-centred psychiatry: by definition, such treatment is directly against the wishes of the person concerned and the dangers of abuse in practice are all too evident [11].

 

 



 

 

Figure 1

 

 


These dangers were the focus of a Code of Practice [12] recently published in the UK to support a revised Mental Health Act.  The Code of Practice includes a set of Guiding Principles that were incorporated into supporting training materials as a way of combining substantive with analytic ethics [13].

The approach is shown diagrammatically in the Figure. Thus, the Guiding Principles, consistently with their status as prima facie principles, may conflict.  For example, the ‘purpose principle’, which covers aspects of safety, may conflict with the principle of ‘respect’, which includes respect for the patient’s wishes.  This is exactly the kind of situation, then, in which values-based practice can be used to support balanced decision-making according to the particular circumstances of each individual case.  Values-based practice, therefore, combined with the substantive ethics represented by the Guiding Principles, provides a basis for a person-centred approach to compulsory treatment [14].

This ‘balancing’ approach illustrates the wider point that it is always important to investigate carefully the different moral arguments used in any particular clinical case.  Different metaphors, for example, may be used to frame different positions on psychiatric intervention, and these require careful balancing in order to reach optimal clinical decisions [6].

 

 

Conclusions

 

In this article we have outlined two main kinds of ethical resource for person-centred psychiatry, substantive ethics and analytic ethics; we have noted a naturalistic perspective which views moral reasoning as just one case of reasoning in general; and we have illustrated how different ethical resources can be combined with the example of compulsory treatment. 

There are many other resources, both theoretical and practical, that we have not been able to cover in this article.  Virtue theory, for example, is important for education.  In addition to ethics, moreover, the focus of this article, the new philosophy of psychiatry [15] as a whole represents a rich conceptual resource for a psychiatry that, to return to the challenge that opened this article, is both firmly science-based but also genuinely person-centred.

 

 

References

 

[1] Christodoulou, G., Fulford, K.W.M. and Mezzich, J. (2008) Psychiatry for the Person and its Conceptual Bases. International Psychiatry, Vol 5:1, pp 1-3.

[2] Warnock, G.J. (1967) Contemporary moral philosophy.  London and Basingstoke: The Macmillan Press Ltd.

[3] Crisp, R., (1994) Quality of Life and Health Care. Chapter 13 (pps 171 – 183) in Fulford, K.W.M., Gillett, G. and Soskice, J. eds.  Medicine and Moral Reasoning. Cambridge: Cambridge University Press.

[4] Beauchamp, T. L. and Childress, J. F. (2001) Principles of biomedical ethics. 5th edn. Oxford University Press: New York.

[5] Johnson, M. (1993) Moral Imagination:  Implications of Cognitive Science for Ethics.  Chicago, IL:  Chicago University Press.

[6]  Stein, D.J. (2008) Philosophy of Psychopharmacology:  Smart Pills, Happy Pills, and Pep Pills.  Cambridge:  Cambridge University Press.

[7] Hare, R.M. (1952) The language of morals.  Oxford: Oxford University Press.

[8]  Fulford, K.W.M. (1989, reprinted 1995 and 1999) Moral Theory and Medical Practice. Cambridge: Cambridge University Press.

[9] Woodbridge, K., and Fulford, K.W.M. (2004) ‘Whose Values?’ A workbook for values-based practice in mental health care.  London: The Sainsbury Centre for Mental Health.

[10] Putnam, H. (2002) The Collapse of the Fact/Value Dichotomy and other Essays.  Cambridge, Mass., and London, England: Harvard University Press.

[11] Peele, R. and Chodoff, R. (2009) Involuntary Hospitalization and Deinstitutionalisation. Chapter 12 In Bloch, S., and Green, S.A., (eds.) Psychiatric Ethics (4th Edition).  Oxford: Oxford University Press, pp 211-228.

[12] Department of Health (2008) Draft Code of Practice: Mental Health Act 1983.  Laid before Parliament pursuant to Section 118 of the Act on 7th May 2008.  London: Department of Health.

[13] Care Services Improvement Partnership (CSIP) and the National Institute for Mental Health in England (NIMHE) (2008) Workbook to Support Implementation of the Mental Health Act 1983 as Amended by the Mental Health Act 2007.  London: Department of Health.

[14] Fulford, K.W.M., King, M. and Dewey, S. (forthcoming) Values Based Practice and Involuntary Treatment: A new training programme in the UK.  Advances in Psychiatric Treatment. Geneva: World Psychiatric Association.

[15] Fulford, K.W.M., Thornton, T., and Graham, G. (2006) The Oxford Textbook of Philosophy and Psychiatry.  Oxford: Oxford University Press.