Ethics, Culture, and Psychiatry: International Perspectives
The late George Engel, M.D., acknowledged author of the biopsychosocial paradigm for health and illness, once commented to me, "Physicians should not only 'do no harm,' but they should also 'do good.'"
Attention to ethics is one way we can advance what is good for our patients, our profession, and our society. This book, Ethics, Culture, and Psychiatry, not only shows us how ethics and the practice of psychiatry are intertwined but also illustrates the variation of the theme around the world. To explore how ethics, culture, and psychiatry are interrelated in different cultures, the editors of this volume invited contributors from around the globe to discuss their views.
The book is divided into two sections. The ten chapters of section 1 cover the subject of ethics and psychiatry in various parts of the world, with most chapters devoted to specific countries. Section 2, which contains three chapters, addresses some "overarching issues" of ethics. One of these is informed consent, a concern that grew out of policies such as forced sterilization and experiments on human subjects committed in Nazi Germany in the name of medicine during World War II. One chapter discusses mental health law reform from the international perspective. An appendix contains the Declaration of Madrid of the World Psychiatric Association, which sets out ethical guidelines for the practice of psychiatry.
The chapters in section 1 suggest that attention to the issue of ethics for the practice of psychiatry is increasing, in both the developed and the developing countries of the world. Nevertheless, there is considerable variation in the extent to which ethical codes are promulgated in the different countries. For example, in the Scandinavian countries the medical profession has a long tradition of advancing human rights, so strong ethical codes are in place and medical ethics is taught in all Scandinavian medical schools.
In a chapter on sub-Saharan Africa, where countries must face the reality of poor allocation of resources to health care and psychiatry, the author points out that it is difficult to adhere to the ethical guideline of providing the best treatment available for mental illness, including rehabilitation, as called for by the Declaration of Madrid. The subject of culture and psychiatry is well discussed in the chapter on the People's Republic of China, but the chapter contains no discussion of ethical issues.
In the chapter on culture and ethics in the United States, the author notes that the U.S. medical profession is increasingly hard-pressed to set its own professional ethical standards and conditions at work. This state of affairs is the result of the penetrating influence of managed care practices that threaten the quality of care while attending to the bottom line of cost. Psychiatrists in the United States are increasingly being challenged to pay more attention to preserving the sanctity of the doctor-patient relationship, to informed consent, to maintaining full fidelity to the patient's concerns, and to the integrity of information entered into the medical record.
Ethics, Culture, and Psychiatry will heighten attention to ethical practices among psychiatrists and all other mental health professionals. Despite the unevenness of the discussion across chapters, this book is worthwhile reading for anyone who seriously wants to heed Dr. Engel's admonition to "do good" through the provision of high-quality mental health care.
Dr. Gaw is medical director of long-term care for mental health and of the mental health rehabilitation facility of the Department of Public Health of the City and County of San Francisco.
