The Professional Context - The Psychiatrist
What are we talking about?
The mental illness of King George III (1738-1820) is commonly said to have helped to focus public and political attention on the problems of the mentally ill (Bewley, 2008). The hypothesis that this illness was due to porphyria may well be a myth (Peters, 2009). The king was under great strain following the loss of the American colonies, particularly as he had insisted that the American war be extended to prevent further protests over British taxes. Following serious bouts of illness, he became permanently deranged in 1810 and his son then acted as regent.
Although famous physicians failed to treat the king successfully during his first illness in 1788-9, Francis Willis, on the other hand, become celebrated for curing and mastering the king’s madness. The king was not excused standard treatments of the time from Willis, such as restraint in a straightjacket and blistering of the skin. His intervention met with opposition from other physicians. They minimised his reputation by pointing out that he had been ordained as a priest before practising medicine, and that he apparently gained financially from taking upper class lunatics into his private asylum even before obtaining his medical degrees.
Noteworthy complaints from other physicians included that Willis allowed the king to read King Lear and to shave himself with an ordinary razor (British Medical Journal, 1914). However, such gentler methods and greater liberty seemed to have gained the confidence of the king. A traditional anecdote is that, when asked what he would have done if the king had become violent with the razor, Willis replied that he would have controlled him with his gaze. The regime at his asylum involved manual work in the stables and fields of the estate. These patient labourers were dressed in coats, waistcoats, breeches, stockings and powdered wigs.
Mental health services have developed since Willis’ time, particularly through the replacement of asylum provision by community care. However, the ethical environment of his psychiatric practice may not be that dissimilar from the present day. Psychiatry manages madness on behalf of society, and it therefore has a tendency to exaggerate its authority for control, as illustrated by Willis’ belief in the dominant power of his gaze. How to manage risk, such as the question of who is responsible if an incapable patient harms himself because he has access to a shaving razor, is a particularly modern, central concern. Justifications are still made for custodial practice, including the need for sedation and seclusion, even if the straightjacket is no longer in regular use in developed services.
However much it may at times wish that it could, psychiatry cannot escape its social role. Its authority for compulsory detention and treatment is legitimated in the Mental Health Act. Its power is also kept in check by provisions within the Act, such as appeal against detention, which are designed to protect patients’ rights. There has always been a tension between restraint and freedom in psychiatric practice. There may be good intentions but practice easily slips into paternalism, as reflected by putting patients into unnatural dress at Willis’ asylum.
What I want to do in this chapter is explore some of these ethical issues for psychiatrists raised by this anecdote, not in a comprehensive way, but, in particular, to highlight the extent to which treating people as objects may have ethical implications for psychiatric practice. I acknowledge the subtleties and complexities of behaving ethically in practice, rather than assume that it is always easy to do what is right for patients. Nonetheless, it is not my intention to avoid the need to make judgements about professional behaviour.
From asylum to community care
To set the role of psychiatry in context it is important to understand its history. Modern psychiatry has its origins in the state provision of the asylums. In the UK, the first was opened in Nottingham in 1812. The Lunacy and County Asylums Act 1845 made it mandatory for each borough and county to provide adequate asylum accommodation at public expense for its pauper lunatic population. Despite the emphasis on asylum provision, there always was some turnover of patients in the asylum and boarding-out of chronic cases and trial discharge played a role (Bartlett & Wright, 1999).
Doctors have always had a key part in the asylums and in psychiatric care in general. Even at the Retreat in York, opened by the Quaker and layman, William Tuke, in 1796, the original superintendent was a retired medical practitioner, although he died after 2 months. The Retreat was famed for its humane treatment of patients, using "reason and kindness" to create a management regime which minimised the use of restraint. However, it was not set up, as such, to challenge the medical profession, whose role has always been key. The original superintendent was replaced by an apothecary, and there was a visiting physician who attended the Institution several times a week from when it opened (Tuke, 1996).
The Asylum Journal of Mental Science was first published in 1855 by authority of The Association of Medical Officers of Asylums and Hospitals for the Insane, which had been formed in 1841. The Royal College of Psychiatrists now publishes this journal as the British Journal of Psychiatry.
Voluntary admission was only possible after the Mental Treatment Act 1930. Even then, application needed to be made in writing to the person in charge of the hospital. The Mental Heath Act 1959 set the foundations for modern psychiatric treatment and made informal admission the usual method of admission.
Although asylums initially may have been built with good intentions, they quickly became overcrowded institutions. The motivation for the rundown of the traditional asylum, or ‘dehospitalisation’, was because of ethical factors - what has been called the "dismay and disgust with the old asylum system" (Clark, 2005). I prefer the term ‘dehospitalisation’ to ‘deinstitutionalisation’, as patients are often still cared for in smaller, semi-institutional settings, and in that sense not completely deinstitutionalised.
Scandals about poor care in psychiatric hospitals were a powerful motivator for community care (Martin, 1984). The peak of the mental health population in the UK and USA was the mid-1950s and later in other Western countries (Goodwin, 1997). A World Health Organisation report (1953) recognised that the hospital needed to become more of a therapeutic community. After this time, the doors of the old asylums started to be unlocked.
What most concerned the critics of the asylums were the effects of cutting people off from the wider society, making them apathetic, submissive and lacking in initiative and interest. Custodial care may compound peoples’ mental health problems. As the numbers of people reduced, the traditional asylum became increasingly irrelevant to the bulk of mental health problems. This does not mean that the same institutionalising pressures do not affect modern community practice and I will take up this issue further when I discuss the ethical problems inherent in professional relationships and other aspects of community services.
What are the ethical problems of psychiatry?
Mental health professionals face the challenge of dealing with people who may be in a vulnerable and desperate state. The potential intimacy of relationship, which is easily exploited, can mean that professionals may gratify their own needs, such as sexual and financial needs, rather than really be motivated by helping others.
For example, in a nationwide survey of american psychiatrists, 7.1% of male and 3.1% of female respondents admitted to sexual contact with their own patients (Gartrell et al, 1986). These high figures show that sexual prohibition in mental health therapy and care, although an absolute moral and ethical standard, is clearly an issue that needs to be considered in the training of doctors. At the beginning of their training, 25% of medical students were found to be prepared to contemplate that intimacies with patients may be acceptable if there existed genuineness of feeling between the two parties (Kardener, 1974).
Furthermore, financial ties, in particular, between the pharmaceutical industry and academic psychiatry, provide personal as well as institutional income, creating a conflict of interest that pervades mental health practice. The drug companies pay "key opinion leaders", whose job includes writing journal articles and speaking at medical education meetings. For example, Joseph Biederman, professor of psychiatry at Harvard Medical School and chief of pediatric psychopharmacology at Harvard's Massachusetts General Hospital, has influenced psychiatric practice to the extent that children as young as two years old are now being diagnosed with bipolar disorder and treated with a cocktails of drugs, many of which are prescribed "off licence". Through Congressional investigations by Senator Charles Grassley, it has been disclosed that Biederman received $1.6 million in consulting and speaking fees between 2000 and 2007 (Angell, 2009).
While sexual contact and financial exploitation may be the most extreme forms of boundary violation, much other professional behaviour may take advantage of the dependency of the patient on the doctor and the inherent power differential. It may not be surprising that an antirational approach is taken to dealing with the problem of illness. The wish is for a simple, quick, cheap, painless, and complete cure. However, in these circumstances, the ethical responsibility of doctors is not to make grandiose claims and not to play up to ideas that they are magically omnipotent (Sharaf & Levinson, 1967).
The mainstream claim, that mental disorders can be entirely explained in neurobiological terms, has been justified by the argument that an emphasis on impersonal brain mechanisms eliminates feelings of guilt or shame in those with psychiatric disorders, as well as avoiding the tendency to blame individuals, such as parents, for causing the problems (Glannon, 2008). However, by focusing on the brain rather than the person, biological psychiatry may reduce any sense of personhood and agency. There are, therefore, ethical implications of believing that everything we do is at the will of the brain. Reducing mentally ill people to the need to rectify a neurochemical imbalance in the brain misdirects attention away from the difficult task of understanding the reasons for their problems This is particularly the case with psychosis, which is difficult to understand and empathise with in a rational way.
In Paradise Square in Sheffield, there is a plaque commemorating the translation of Philippe Pinel’s seminal work A treatise on insanity by Dr D.D. Davis in 1806 (Jenner & Kendall, 1991). The original was published in french a few years earlier. Pinel was clear that mental illness was a psychological problem and that psychiatry focused on "lesions of the functions of understanding". I mention the case of Pinel to emphasise that there has always been a psychosocial approach in psychiatry, right from its modern foundations.
Pinel’s approach was called "traitement moral", which was translated as moral treatment, meaning psychological, in the sense of ‘through the emotions’, not moralising, treatment. He viewed case histories of asylum inmates with understanding and respectful kindness, although he was still determined to break any resistance of patients (Weiner, 1992).
There has always been a tension between custodial and therapeutic practice in psychiatry. Jean Baptiste Pussin, the director of the Bicêtre, a public hospice for men near Paris, where Pinel worked as "physician of the infirmaries", first replaced iron shackles with straightjackets in 1797 (Weiner, 1979). Pinel followed Pussin’s example 3 years later at the Salpêtrière, the public hospice for women, where he then served as physician-in-chief. Pussin used repressive measures but claimed he controlled patients without mistreatment. The idea of Pinel as the liberator of the insane has become fixed in two well-known paintings, entitled "Pinel orders the chains removed from the insane at Bicêtre" by Charles Muller, dated 1849, and "Pinel frees the madwomen at the Salpêtrière" by Tony Robert-Fleury, painted as late as 1878.
Pinel was sceptical about the aetiological importance of brain changes in mental illness. His psychosocial perspective was the basis for his humanitarian intent. The theoretical model of mental illness held by professionals can have implications for their ethical practice. However, this does not mean that I do not recognise that psychiatrists with different theoretical orientations cannot treat patients ethically and with kindness. For example, Vincenzio Chiaguri (1759-1826), although having a somaticist, different understanding of mental illness from Pinel, expected patients to be treated with respect. He outlawed chains as a means of restraint, even before Pinel, in 1793, at Santa Dorotea, the hospital he directed before moving to the Bonifazio in Florence (Gerard, 1997).
Can psychiatrists ever escape their history?
When King George III relapsed in 1801, Willis’ sons treated him. The following epigram became well-known:-
The king receives three doctors daily –
Willis, Heberden, and Baillie:
Three distinguished clever men –
Baillie, Willis, Heberden:
Doubtful which more sure to kill is
Baillie, Heberden, or Willis.
There can be disastrous consequences of investing faith in the omnipotence of doctors. Therapeutic zeal has led to the justification of all sorts of groundless, and sometimes damaging, if not lethal, medical interventions. Doctors should not exploit patients, but abuse may well be endemic in psychiatric practice. Psychiatry may not easily be able to escape this unethical history. This predicament may be related to its tendency to emphasise physical treatment.
Medical emphasis on physical treatment
Medical authority has had an influential, if not dominant, role in mental health practice. As mentioned above, there has always been a range of views within the profession. Although the majority view has been to focus on somatic treatment, the psychosocial emphasis on the mind has also always been present, as we saw with the example of Philippe Pinel. Nonetheless, the somatic perspective has led to the development of various physical treatments over the years.
For example, hydrotherapy was used to treat disturbed patients by using baths of different temperatures, and packs, which meant wrapping patients in sheets and blankets. The theory was that a well-equipped hydrotherapy outfit could reduce the use of mechanical and chemical restraint.
Dorothea Buck-Zerchin (2007), who was sterilised without consent in 1936 at a Hospital for Nervous and Mood Diseases in Germany, described the treatment she received there. This included "buckets of cold water poured over our heads, with lengthy baths in a tub covered with a canvas that bore a stiff high collar in which my neck was fixed for 23 hours … Rest was given with wet packs ... A wet pack meant to be bound into cold, wet sheets so tightly that one could no longer move at all. From our body temperature, the sheets would become first warm and then hot. I would cry out in rage at this senseless restraint in these hot sheets."
Buck-Zerchin does not describe her state of mind at the time. Presumably her treatment was intended to help control her disturbance. The "sharp end" of psychiatry still includes control and restraint, seclusion and forced injections. Maybe it is better to see these interventions as a failure of treatment, rather than as treatment itself.
Another example of physical treatment is insulin coma therapy, which was seen as a means of bringing psychiatry closer to mainstream medicine. Patients were put into a hypoglycaemic coma through administration of dangerously large doses of insulin in a special insulin unit. They were then lifted back to consciousness with a sugar solution. The treatment was used for 2 decades until the 1950s when clinical trials questioned its effectiveness (Bourne, 1953).
Electroconvulsive therapy - ECT - is the only somatic therapy still in general use. It involves giving patients an epileptic fit through administering electric shock to the head. It is now used with a short-acting anaesthetic and muscle relaxant, but not when first introduced. Initially it was used for schizophrenia, but now for psychotic depression.
Surgical intervention may not be the most obvious treatment for mental disorder. Looking at its development in a little more detail may help us to understand what the enthusiasm for physical treatments in psychiatry is all about. We may think some physical treatments sound excessive, but the motivation has been to intervene in what is seen as a desperate situation.
Lobotomy or operating to partially separate the frontal lobes from the rest of the brain was thought to take the "sting" out of mental disorder, by removing disabling fear (Freeman & Watts, 1950). Walter Freeman (1895-1972), an American psychiatrist, developed the transorbital or "ice pick" lobotomy, by performing the operation by accessing the frontal lobes through the eye socket. As far as he was concerned, this was a minor operation and he toured the country performing several operations in a day, even in public (El-Hai, 2005). Aggressive treatments are justified by the apparent results, and the damage they cause is overlooked.
Less well known is the phase of surgery on other parts of the body that preceded that on the brain itself. Henry Cotton (1876-1933), an eminent and notorious American psychiatrist, believed that the cause of mental illness was the systemic effects of largely hidden chronic infections (Scull, 2005). Septic foci, therefore, must be searched for and eradicated. Particular attention was paid to removing the teeth and tonsils.
Even if many people were sceptical about the causal connection, Cotton argued that detoxification was none the less beneficial, and that patients were relieved when they found that their mental condition was the result of poisoning by infection. Cotton's theory of focal infection may have met its demise because of the drastic, and not infrequently fatal, operation of colectomy, the removal of the colon.
We may think we are now protected from the dangers and blindness of wish-fulfilling expectations in the era of the randomised controlled trial. However, simplistic and biologically reductionist accounts of mental disorder, which underpinned the work of Cotton, still sustain modern pharmacotherapy. For example, it is commonly said that psychotropic medication corrects chemical imbalances in the brain. This theory is as much without proof and requires as much faith and self-deception as that of Cotton.
Perhaps we can learn from our sense of outrage about the damage caused by the overenthusiastic physical treatments of the past. I think the lesson is that even a psychosocial understanding of mental illness, if it is to be influential, needs to have a strong ethical foundation.
What is the point of psychiatric medicine?
Psychiatry diagnoses and treats mentally ill people. I want to look briefly at the specific ethical implications of both diagnosis and treatment, in particular the use of medication.
In everyday practice, moving on too soon to making a diagnosis can foreclose understanding of a person's problems. ‘The answer’ has not necessarily been found by giving a single-word label for a person’s difficulties. Most psychiatrists assume that there are discrete entities that correspond to the different psychiatric diagnoses. In reality, there may be no absolute differentiation between normality and mental illness. Furthermore, there is considerable overlap between different diagnoses.
It is important not to reify a psychiatric diagnosis by regarding it as an entity of some kind. Diagnosis can easily become the first step in the objectification of a person, with obvious ethical implications. Speculating about the biological basis of mental illness, and the supposed biochemical imbalance or other brain abnormality behind it, is a myth. The biomedical diagnostic process is self-protective and may avoid dealing with the difficulties of understanding the meaning of a person’s problems. At least potentially, the ethical implication is that it reduces persons to their brains.
Doctors do not just prescribe medication in their treatment of patients. Of course, their relationship with patients and how they interact with others involved with patients also have an influence. However, medication is the particular aspect of mental health treatment most associated with doctors, although supplementary prescribing has now been extended to UK nurses and pharmacists (Avery & Pringle, 2005).
Medication is often prescribed in life crises. When people are desperate they will accept almost anything that is proposed to help them. Medication reinforces defensive mechanisms against overwhelming anxiety. Expectations alone that medication will produce improvement may themselves produce apparent benefit. In other words, placebo effects can be powerful.
Ethical implications of the use of medication arise because of bias in clinical trials, leading to data being interpreted in a more positive way than it should be. The degree to which psychotropic medications are merely placebos with side-effects is rarely considered (Fisher & Greenberg, 1997). However, the extent to which this is true has ethical implications because of the, at least potential, exploitation of patients.
The problem of relying on placebo is that it may prevent patients from dealing with their problems and create a dependency and vulnerability to discontinuation reactions. Because people believe in the drug, taking it becomes a habit. Any change threatens an equilibrium related to a complex set of meanings that their medications have acquired. People often stay on medication, maybe several at once, even though their actual benefit is questionable. It can be more of a problem than it is worth to stop medication.
As I have said, medication is not the only treatment used by psychiatrists. At the other end of the spectrum of psychophysical treatment, there are also ethical implications of the use of psychological therapy. Psychoanalysis, for example, at times, has been deterministic in its scientific understanding of human nature, with the potential to objectify people as much as medication treatment. The ethical implications of focusing on the person need to be considered for all psychiatric treatments.
What are the ethical challenges inherent in professional relationships?
Psychiatrists work in teams and form just one of the professions providing mental health health services. Organisational factors also have ethical implications for their practice.
In particular, as I outlined above, the political context now focuses on community care, rather than hospital provision. The rundown of the traditional psychiatric hospitals tapped into an anxiety about loss of control of the mentally ill in the community. In particular, a central concern of UK mental health policy has become public safety due to homicides by psychiatric patients. There is an independent inquiry into every such case (Buchanan, 1999). The effect of these inquiries has been to introduce an ever more rigid and bureaucratic interpretation of the Care Programme Approach and risk assessment, despite the difficulties of showing that any deficiencies in this regard are in fact related to outcome (Szmukler, 2000).
More generally, our modern identity is expressed in the "Risk Society" (Beck, 1992). We find it difficult just to accept that things we do not want to happen have happened.
As expectations of what can be achieved have risen, our increasingly technological society switches blame onto services provided by society that it thinks should have prevented the misfortune.
The ethical implications of these institutional pressures are that professional behaviour may not necessarily be in the interests of patients, because it becomes more important for professionals to defend themselves against criticism. There is a problem about being too risk averse. Psychiatry learnt this lesson when it opened the doors of the traditional hospital. Patients did better and regained some independence outside the bureaucratic control of the hospital. The worst kind of administrative behaviour restricts initiative. The danger is that the fear that things may go wrong in mental health services distracts us from the task of how to make things better for people (Cooper, 2001). We may become too defensive in protecting ourselves from litigation and other threats of blame. We are in danger of repeating the worse institutionalising excesses of the asylum in the community.
We need to recognise the inherent uncertainty in clinical practice. However much we may wish it were the case, guidelines and procedures cannot eliminate clinical judgement in the management of patients. We need to be able to trust professionals to act ethically to obtain the best quality care based on our own expertise as patients.
In these circumstances, it is important that doctors do not abuse their authority. This applies in relation to other professional groups, as much as patients, in that medical attitudes should not dominate over the validity of other professional views. Sometimes, defensiveness about biomedical attitudes can create an authoritarianism that can cause harm to practice. Psychiatrists need to encourage an open culture where problems are discussed in a fair manner.
I have outlined the practice of psychiatry looking at it from an ethical point of view. Psychiatry may believe it is based on scientific principles, but it cannot escape its basis in values. Making decisions about how mentally ill people should be treated is inevitably an ethical matter.
The history of psychiatry demonstrates that the mentally ill have not always been well treated. Their rights and dignity need to be defended. This applies as much in modern community practice as it ever did in the asylums.
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