Ethics in managed care

The current era of managed costs and care create ethical dilemmas based on economic constraints and incorporation of principles of distributive justice. Traditional ethical concerns related to confidentiality, conflicts of interest, double agentry, and honesty are complicated by interference in the doctor-patient relationship caused by intrusive utilization management. National health reform must take these issues seriously to ensure that the cure promised by such reform efforts is not worse than the disease. The challenge for psychiatrists is to adapt to these constraints without losing sight of traditional ethical medical positions. If the ethics become diseased, then no cure may exist at all.

The ethics of e-mail communication in psychiatry

In both medicine and science, practice has historically preceded ethical scrutiny and legal regulation. Recent examples include the debates over stem cell research and cloning. The technology existed and was in the initial stages of study prior to the sounding of alarms by ethicists and lawmakers. The same state of affairs has occurred with the use of electronic (E)-mail in psychiatric practice. The convenience and possibilities of E-mail have already entered into the practice of physicians without pause to consider the ethical implications: specifically, those related to privacy and confidentiality. The authors do not discuss the more questionable uses of the Internet such as physician prescribing to patients they have not evaluated face to face. In this article, the authors confine their discussion to situations in which E-mail communication is used as an adjunct to ongoing face-to-face meetings.

Genetic counseling for psychiatric disorders

Like other medical conditions, some psychiatric disorders are inherited, whereas others are not. Human genetics research is moving at a rapid pace. Genes for over 450 genetic disorders have been cloned and many disease-causing mutations have also been identified. The explosion of this new knowledge has created many new exciting opportunities in the diagnosis of these heritable disorders. The rapid pace of gene discovery will aid the identification of susceptibility genes for psychiatric disorders. Indeed, we can look forward to answers to many clinical and research questions. These are some of the gifts that the expanding field of human genetics research will continue to bring to medical science. However, as genetic tests for the detection of psychiatric disorders become available, many ethical, legal, and social implications will need to be considered. In this article, we review the principles of genetic counseling for psychiatric disorders, as well as the social and ethical dilemmas that genetic testing may bring. Although medical and scientific advances may bring many gifts, we should approach this new knowledge with caution, as one of the gifts may be a Pandora's box.

Demoralisation, depression and desire for death: problems with the Dutch guidelines for euthanasia of the mentally ill

OBJECTIVE

Given the recent publication of Dutch guidelines for euthanasia of the mentally ill, our aim in this paper is to review the clinical role of the psychiatrist in assessing patients who seek euthanasia or physician-assisted suicide.

METHOD

Three areas are examined that are informative of the role of the psychiatrist in assessing patients who desire death: recent surveys of psychiatrists' attitudes, empirical and clinical studies, and treatment issues.

RESULTS

Demoralisation and depression emerge as pertinent clinical issues worthy of psychiatric intervention. The role of the psychiatrist is complex and includes issues of assessment, systems, countertransference and treatment.

CONCLUSIONS

Dutch guidelines for physician-assisted suicide in the mentally ill generate serious concern given the uncertainty of prognosis, potential range and variability of outcome of treatments of suicidality and the boundary violations that are involved for the psychiatrist. The guidelines have the potential to dangerously alter the practice of psychiatry and should be condemned.

Involuntary psychiatric interventions: a breach of the Hippocratic oath?

In this article the author argues that involuntary psychiatric interventions are inherently dangerous and potentially harmful to their subjects, thus challenging the Hippocratic ethical principle of "first do no harm." Damages arising from coercion in common clinical situations are analyzed, as well as the motives of psychiatrists for persistently promoting an expansion of involuntary interventions. Alternative strategies to coercion are explored.

Responsibility and education

Ethical assumptions of psychiatry training and practice in a postmodern society, and of values and their linked beliefs have become important to search for and to acquire if a psychiatrist is to work in an informed, safe and helpful manner. These educational themes have particularly impacted on mental health services in the past 12 months and are reflected in the publications, including several editorials, reviewed. It is unsurprising that this literature is not evidence based in a restricted sense; but instead the area reviewed is within the field of opinion, purpose of regulatory bodies, and the influence of the public through user groups and the ballot box.

[The frontiers of 'abnormality': psychiatry and social control]

The article examines some of the main aspects governing psychiatry's role in the Brazilian political and social context at the close of the nineteenth century and beginning of the twentieth. It analyzes certain themes - civilization, race, labor, fanaticism, political dissent, sexuality - that were emphasized by specialists in their construction of a very broad notion of 'mental illness'. Through the analysis of texts produced by psychiatrists and legal experts (including dissertations written at the Faculdade de Medicina do Rio de Janeiro, reports from the Serviço de Assistência a Alienados, and works and articles by specialists), the relation between the psychiatric definition of the frontiers of 'abnormality' and efforts to implement new strategies of social control is discussed.

On the Szaszian argument

The Szaszian argument claims that psychiatry is a rhetorical enterprise aimed at providing justification for involuntary treatment. Such treatment, the argument holds, is just when provided to those suffering from demonstrable brain lesions, but it is unjust in cases of "mental illness" because such "illnesses" lack objective histopathology and are therefore fictional. It is here argued that this distinction is irrelevant to the morality or immorality of involuntary treatment, since such treatment inevitably rests on a subjective determination of competency or dangerousness, which is not rendered substantially more objective by the criterion of histopathology. The Szaszian argument subscribes to a naturalistic fallacy in this regard, which leads it to inconsistencies in its philosophy of mind.