- Putting Minds TogetherCommentary on the Interface of Ethics and Psychiatry
I am grateful to the editor for asking me to comment on this interesting article about interdisciplinary work between a philosopher and a psychiatrist, with which I found much to agree. As a medical student, I had no exposure to bioethical reasoning in medicine, and even now, I think it is the case that junior doctors in the UK have variable exposure to good quality ethical reasoning in clinical practice. I also agree that lectures are a poor way to learn about ethical reasoning, especially in psychiatric practice; and I have been part of a special interest group at the Royal College of Psychiatrists that has tried to develop and enhance bioethical awareness in mental health. We do this by a) ensuring that ethical issues are embedded in the curriculum for the postgraduate qualification, b) developing and publicizing a Code of Ethics for Psychiatrists, and c) regularly offering seminars and clinical bioethics workshops to trainees. In this way we hope that seniors and juniors can learn together about ethical dilemmas in practice and what underpins the different ways that professionals 'see' ethical dilemmas and solutions.
I was particularly fortunate as a junior psychiatrist to have studied medical law and ethics at a masters level, and to have met and worked with Professor Bill Fulford, whose work on values based practice in mental health has been influential practically as well as at a level of policy in British psychiatry (Fulford, 2008). I have also had experience of jointly working with a philosopher to carry out research on moral reasoning in patients with mental disorders (Glover, 2014), which enabled me to appreciate how this type of joint working can broaden psychiatric horizons and understanding.
I have also learned from my experience of teaching bioethics to multidisciplinary groups for professionals working in mental health. First, I have learned to begin the learning process by acknowledging that everyone who comes to the seminars is already an ethical reasoner, although they may not have realized this! So initial sessions start by opening awareness of different ethical perspectives and processes, naturally using clinical vignettes and encouraging participants to bring dilemmas from their own clinical experience. It is central to this process to consider an aspect of experience or appraisal that they have not considered before, especially in terms of individual identity, culture, ethnicity, and values. [End Page 191]
Second, there are often initial conceptual struggles in the group that relate to the use of mental health law to address an ethical dilemma, for example, the 'right' answer must be the legal one; and we spend some time unpacking why law is different from ethics. As in case 3 (David), it is vital to discuss and explore how the role of law in mental health has operated historically and in different countries. For example, there are salutary lessons to be learned from studying the role of psychiatrists and nurses in the killing of their patients in 1930s Germany—killing that was sanctioned by law.
The next conceptual struggle relates to policy and procedures, where there is often hopeless confusion about what 'the policy says' and what a 'good' ethical decision might be. The case of Eleanor (case 2) is a good example of an ethical dilemma that is rarely discussed in medical training: namely, resource allocation, and especially the resource of time. Proper amounts of time are essential for good quality medical and bioethical reasoning, but hospital policies and procedures rarely acknowledge this, with heavy consequences. Eleanor's case is a reminder that all emergency room physicians are controllers of access to hospital beds; they routinely turn away people who need admission for safety and sanity reasons, not because they do not see the human need, but because it does not seem ethically justifiable to offer an inpatient bed to someone who does not need inpatient treatment, thus depriving a later patient who does need it. In the UK, there is a similar lack of discussion about resources, and a similar confusion of procedures about access with ethical decisions about allocation. In relation to mental health, there are complex decisions to be made...