Ethics of Psychiatry: Insanity, Rational Autonomy, and Mental Health Care
Reflecting a renewed emphasis on ethics in medical curricula nationwide, Rem Edwards has brought together a group of prominent, and often controversial, writers in his most recent text. Ethics of Psychiatry takes a hard and skeptical view of the values inherent in diagnosing mental illness, highlighting the intrusion of unrecognized and unappreciated social influences on the medical model.
Featuring careful thinkers in ethics and medicine like Robert Veatch, James Drane, Glen Gabbard, Howard Zonana, and Paul Appelbaum, the text begins with Thomas Szasz's classic 1960 "myth of mental illness" paper, with a critical response by Michael Moore. Edwards himself follows with his 1981 paper defining mental illness as a failure of "rational autonomy," a philosophical construct that avoids some of the pitfalls of various medical definitions.
Had the remainder of the text followed this contrapuntal style of developing major themes in the ethics of psychiatry, an important contribution to the literature would have resulted. Regrettably, the subtle antipsychiatric tone of the early sections begins to insinuate itself more insistently as the book develops. The use of language like "creeping medical imperialism and totalitarianism" (from Edwards, page 51) and statements like "Competency hearings degenerate easily into farces" (page 175) or "Psychiatry remains the greatest threat to the civil liberties and the mental integrity of individual citizens" (Peter Breggin, page 424) do much to sap the credibility of some important criticism.
A review of historical views of alcoholism and homosexuality reminds practitioners to remain humble in their scientific certainty, and Paula Caplan's well-known indictment of gender bias in diagnosis is both painfully accurate and written with sardonic flair. But the overplayed criticism of electroconvulsive therapy (ECT), a mainstay of antipsychiatric calumny, is again betrayed by comments such as "It also appears that older people are more at risk for ECT than younger people, although the reasons are not clear" (page 361). How an author, here a master's-level occupational therapist, can justify such statements in the face of elderly patients' differing physiology, lesser tolerance for medication side effects, and greater risk for drug-drug interactions is testament to the overall unevenness of this work.
Yet the fault is not with this author alone. Further information on psychoactive drugs offered by the editor is essentially no more than a list of side effects, laying the foundation for a thinly disguised assault on somatic therapies.
Application of the medical model to value-laden areas such as aggression, hyperactivity, and sexual "aberrancy" carries with it enormous responsibilities. The social impact of medicalizing behavior is indeed problematic, as Edwards demonstrates. But to offer indiscriminate criticism without adequate rebuttal does not do justice to ethics or psychiatry.
Application of the medical model to value-laden areas such as aggression, hyperactivity, and sexual "aberrancy" carries with it enormous responsibilities. The social impact of medicalizing behavior is indeed problematic, as Edwards demonstrates. But to offer indiscriminate criticism without adequate rebuttal does not do justice to ethics or psychiatry.
Dr. Candilis is associate director of the office of ethics and assistant professor of psychiatry at the University of Massachusetts Medical Center in Worcester.
