Alan Saunders: Hello and welcome to The Philosopher's Zone. I'm Alan Saunders.

This week we're looking at ethics, and in particular we're looking at the ethics of a particular profession, psychiatry.

I don't know whether the professional ethics of psychiatry are more urgent or more complex than those of other professions, but it certainly seems like that. Psychiatrists cannot think of their subjects in purely mechanical or instrumental terms, and they're very much people talking to people.

Well to talk to us about this, I'm joined now by Dr Michael Robertson, Director of Psychiatry at the Royal Prince Alfred Hospital in Sydney, and clinical lecturer in Psychological Medicine at the University of Sydney. Michael welcome to The Philosopher's Zone.

Michael Robertson: Thank you, Alan.

Alan Saunders: Michael, do you think there is something special and particular about the ethical constraints under which psychiatrists operate?

Michael Robertson: Well it actually relates to a problem that's emerged in medical ethics generally, in that medical ethics have been swallowed up by biomedical ethics. So bioethicists are much more interested in stem cells. And as a result, psychiatric ethics has fallen well off the radar screen. It's been described by Bill Fulford, a British psychiatrist, as 'the bioethical ugly duckling'. There is something distinct about psychiatric ethics because of the nature of the psychiatric patient. If you were to consider the ethical dilemmas a cardiologist, or a paediatrician might confront, there are inputs from the patient or the patient's family that means they're able to make their own decisions, this concept of autonomy. Psychiatric patient, by definition, suffers a condition that diminishes or repairs their autonomy, and as a result there is a need for a separate discourse in ethics in psychiatry.

Alan Saunders: So what are the four principles?

Michael Robertson: Well, the four principles are the principles of respect for patients' autonomy, beneficence, which is the obligation to do good, non-maleficence, which is the obligation to not do bad, and justice. Now this has become the dominant paradigm in medical ethics, and essentially the four principles function by trying to articulate an ethical dilemma, and establishing is there a prima facie conflict between two principles. Now to give you an example in psychiatry, if we were looking at the issue of involuntary treatment, that is to say, somebody being hospitalised and treated against their will. The two principles that come into conflict are firstly the principle of autonomy, that is, the patient's right to choose for him or herself, versus the principle of beneficence, which is the obligation to do good. So, in the act of involuntarily hospitalising someone you have this conflict if the patient does not want to be treated. And so this tension exists. And the four principles approach is useful and it helps articulate or perhaps make concrete these very complicated dilemmas. But that's where the utility ends, because there is really no guide as to how to resolve this dilemma. One can just wrangle about the nuances of either principle, but when it comes to actually making the decision, there isn't a clear guideline, and this is in fact a problem with most of the grand ethical theories thus applied to psychiatry.

Alan Saunders: This is obviously not unique to psychiatry. I mean if you're dragging somebody unconscious from a car crash and you're going to operate on them, you're not having regard to that person's autonomy because they're unconscious, but you are exercising beneficence, but you would say would you, that these issues are more acute in the field of psychiatry?

Michael Robertson: I think they're made more complicated by this issue of the impairment of autonomy for most of the patients that these dilemmas become relevant for. There are many conditions that psychiatrists may attend to where you would argue there isn't any impairment of autonomy, where people make an informed choice, they can self-govern. Whereas people with psychotic disorders or very severe disturbances of mood or cognition are deemed to be incapable of making these kinds of determinations for themselves. And so the principle of autonomy is in a sense, it's hamstrung in a lot of these prima facie debates. And that goes against the current of a lot of the literature in the four principles, because whenever you read or talk to advocates of this approach about the prima facie conflict, it usually appears that autonomy wins every time. So autonomy has emerged primum inter pares of the four principles.

Alan Saunders: First among equals.

Michael Robertson: That's correct, yes. And as a result when you're looking at these quandaries applied to psychiatric practice, you're really approaching with one of the four principles, the one that usually wins, quite hamstrung. So it's as if the favourite's been nobbled in these debates. So the problem with the four principles applied to psychiatry really is the problem of autonomy.

Alan Saunders: Now we have four principles here, autonomy we've talked about, beneficence, it's fairly easy to see what that is, it's doing good; non-maleficence is not doing bad. What about justice? Where does that come into it, and what's the difference in this context between justice and the other principles?

Michael Robertson: Well it's been argued that beneficence and non-maleficence appear to be indistinguishable, I mean doing good and not doing bad, don't appear to be in different categories.

Alan Saunders: Well you could be non-maleficent by not doing anything.

Michael Robertson: Well potentially you could also act maleficently by standing by and watching something bad happen. The problem with justice is that it's a very socially constructed notion. Notions of justice in the liberal West are obviously quite distinct both in time in terms of history and also in geopolitical settings. So our sense of justice for example, somebody who is traumatised in the workplace, would need to be compensated for that trauma and perhaps access health care. That may not be justice in another setting. So the idea of these four principles, in particular justice having some sort of universalism, that does need to be questioned, because what is beneficent acts and what are just acts really require a consideration of the context.

Alan Saunders: And if we turn back to autonomy, that again can be culturally specific.

Michael Robertson: It's quite a unique situation to the West where autonomy becomes the primary focus of these principles, and in cultures such as Japan, to approach the patient separately from the family would be to undermine the entire fabric of that person's interpersonal world. So autonomy is very much an ethno-centric or Western focused concept.

Alan Saunders: There are also other qualities that we might look for in psychiatric care, aren't there? There's compassion, there's humility, always a difficult thing to ask of a clinician, but there's humility, fidelity, trustworthiness, respect for confidentiality, veracity, prudence, warmth, sensitivity and perseverance. You can't reduce it to just four principles, can you?

Michael Robertson: Not at all. What you've described there would be best considered virtues, and the notion of the virtuous physician is by no means a new one. The problem with virtue ethics, this approach that goes back to Aristotle's Nicomachean Ethics, and finds more contemporary expression in writers like Pellegrino, talks about what are the desirable characteristics or qualities of the character of a psychiatrist or of a physician. The problem with this is again, you can aspire to have these qualities, but you become quite elitist because if you talk about higher order virtues, not working on weekends or charging fees would be considered not virtuous, because they sort of self-sacrificing, selfless practice of psychiatry or medicine would dictate that you shouldn't place your families or your own needs above that of your patient, which is clearly untenable. And if you look at our current problems retaining medical workforces, if we become elitist in desiring all of these personal qualities, it does become problematic.

The other issue about virtues is who's to decide what virtues are needed?

Alan Saunders: So the problem here is that virtue ethics tells you what it is to be a virtuous person, but it's not sufficiently focused on a professional virtue.

Michael Robertson: No, although there are two quite useful approaches from virtue ethics that I try to encourage my junior colleagues to read. The first is the Aristotlean notion of the golden mean. That is the mean between the extremes, one considers two extreme acts, or extreme views of an act, and then tries to achieve a balance between them. The philosopher John Rawls talks about achieving some sort of equilibrium in reflecting upon why we act the way we do. If you were to look at the history of human rights abuses in relation to psychiatry, the euthanasia project for want of a better phrase, in which German psychiatrists murdered 70,000 of their patients, 40,000 of which occurred after the Germans surrendered in April, so you have this awful historical notion that German psychiatrists created the technologies for the final solution. You also have this awful notion that the first Commandant of the Treblinka death camp was a psychiatrist.

Alan Saunders: Now I want to come on shortly to the question of the abuses of the psychiatric profession, but before we go onto that, let's look at the object or perhaps we should say the subject of psychiatric extension. Now the object of science is to explain phenomena by means of general laws, but it could be said that the object of psychiatry is perhaps something else, it's not that sort of explanation; it's understanding, and understanding has clear ethical components.

Michael Robertson: What we've seen in certainly since the 1990s, the so-called Decade of the Brain, has become a dominance of the biomedical or neuroscientific discourse with regards to psychiatry, and again, we start to lose sight of this issue of personhood. And it then talks to a very fundamental distinction between mental states and brain states, and of course the dominant paradigm in psychiatry at the moment is that it's an applied form of neurology. And we have a lot of social agency occurring around that phenomenon, but there is this very discordant or inchoate group of ideas that try to comport themselves as a profession. So coming back to this idea of understanding the patient's experience, it's something that is occurring almost in contrast to the discourse in psychiatry at the moment and I think one of the more important ethical issues that has yet to really achieve any attention, has been this respect for personhood, and understanding the individual experience rather than trying to categorise as a psychiatric diagnosis, or conform to a particular scientific model.

Alan Saunders: If we think about the ethics of the profession rather than this rather particular notion of personhood, we might want to think in terms of a universal morality, to which psychiatrists are subject, just as the rest of us are, but there are problems here. You mentioned Nazi Germany, and there were plenty of people in Nazi Germany, psychiatrists and others, who thought that they were acting according to universal moral principles.

Michael Robertson: This really relates to a critique of all Western ethics, post-Enlightenment Western ethics. You have a moment of existential crisis at the time of the Second World War, you have so much human rights abuses perpetrated by doctors and psychiatrists in particular, that we've had a separate doctors' trial in Nuremberg as against the war crimes trial. And you have a question asked, How could this happen? There has to be something universal about this, there is a crime against humanity, this is the first time this term occurs, there is something universally wrong with what happened. But over time, and since the Nazi era, we've seen a couple of circumstances where psychiatric ethics have come into sharp focus, and in particular during the period of the Soviet Union where you have Soviet psychiatrists participating in a process of political suppression using psychiatric diagnosis. And the arguments offered by psychiatrists in the Soviet Union, and I might add even today, there's still a real lack of remorse in some of the older Russian psychiatrists I've talked to, is that there is a necessary social process that's being fulfilled by psychiatrists. And so this idea of universalism in psychiatric ethics is challenged by the fact that you can only understand the ethics of a psychiatrist in the social context. Now by no means am I saying what happened in the Soviet Union was right or needed to be tolerated, but we do see quite different views of psychiatrists in different cultures and in different settings. And there's a communitarian philosopher named David Bell who contrasts universalism from particularism, universalism being that there are universal truths that we must uncover, applied to psychiatry, but particularism being the contrary view that there are no universal truths, you can only socially construct moral truths within a particular social and cultural context. So I think this idea of universals and psychiatric ethics does require some reflection, because the people who set the agenda tend to be those of the liberal West, and those ideas, as we've spoken about, autonomy is not always the primary concern of some cultures.

Alan Saunders: You mentioned the Soviet Union, Michael, can we see the same thing going on in China with their treatment of members of the Falun Gong sect?

Michael Robertson: What has happened is that the Chinese Psychiatric Association has argued for the existence of a so-called qigong-related mental disorder. And they argue that this particular condition is endemic to Falun Gong and that these people have a potentially dangerous form of psychiatric disturbance that can threaten the fabric of society, and anything up to 40% of forensic hospitalisations, that is, people who are placed in secure psychiatric hospitals in China, are actually related to Falun Gong. In fact the camps have a special name; they're called angkhangs, which is centres of peace and harmony. It's almost Orwellian in nature. And what we're seeing again is a repeat of what happened in the Soviet Union, the construction of a psychiatric diagnosis for the means of political suppression. Now unfortunately, most of China's human rights record tends to be a source of obliviousness on the part of the West, because of trade relations and because of the place that China has, and so this situation's been handled in a very different way from the way the Soviet situation was handled in the 1970s. The Soviet Union was expelled from the World Psychiatric Association, and they were obviously repudiated in their approach, whereas in China it's not so clear. And one of the arguments that's been made is that it may well be that qigong-related mental disorder is a so-called culture bound syndrome, that it is something that does exist in China, that those who suffer from it may in fact be a danger and they require treatment. And of course from the point of view of a person in the liberal West to a psychiatrist watching this occur in my own time is incredibly alarming. But from the other point of view one has to make an argument, almost a morally relative argument, that, well, you can only understand this is you are working within the Chinese setting. And so this idea of the use of psychiatric labels for political purposes is something that sadly is not confined to China but certainly quite reminiscent of what happened in the Soviet Union, and I think also reflects a very problematic relationship that we have with places like China.

Alan Saunders: All of this reminds us that psychiatry is no longer a cottage industry. Like any profession it's big business, it also has links with government policy, so does this involve a change in the ethics of the profession?

Michael Robertson: If you were to think about professional ethics, they are in essence, contractarian. They reside on a negotiated agreement between a group in society and the society itself. So a profession is defined as a particular group who possess skills and knowledge and secondly, they apply that knowledge in a beneficial way for the greater good. The contractarian aspect of this is: what is the definition of the beneficent way; what is the greater good that's being served, and is it a universal, in terms of history and culture, or is it something that is very contextualised to the time? To give you an example of the 1930s psychiatry in this country where we had the mental hygiene movement as being the dominant paradigm, which is to say that mental disorders are something that can be identified and excluded from the community and we have a very strong tendency towards eugenics. One could argue that in the 1930s the greater good as defined at the time, was served by preventing people with mental illnesses from having children and trying to eliminate this from the community, as you would smallpox or any other infectious agent. And of course that is anathema to us now. We spoke earlier about virtues. To essentially see professional ethics as being a contractarian arrangement tends to deny us any form of moral agency, and I think that's fairly bleak when you think about caring for people.

Alan Saunders: Also, contracts depend upon negotiation, but between whom is the negotiation going on here, given that the subject of psychiatric care in many cases as we've already said, lack autonomy.

Michael Robertson: That's a critique of social contract theory that goes back to Hobbes who says the social contract is -

Alan Saunders: This is the 17th century we're talking about.

Michael Robertson: - the social contract is not worth the paper it was never written on. And so you have I think quite an important point, is that we say, well there is this assumption of a contract between a professional group who advocate on behalf of their patients and society. But I don't remember being invited to a negotiation; it's almost as if these things evolve somewhat tacitly over time. Certainly again, when you talk about mental health legislation, there are periods of consultation and views of a sort, but when it actually comes to what is this collective good for which you are applying your skills, there isn't a sort of forum where this is negotiated, and so the interests of those who perhaps are least able to advocate, our own patients, are not necessarily represented in that process.

Alan Saunders: What about the problems which the patient faces. We're talking about clinicians; we're talking about health and illness, but is that necessarily the model that we need here, given that some of them may simply have moral or existential problems.

Michael Robertson: Well that talks to the issue of psychiatric diagnosis and what they are. It has been argued that psychiatry is stretched between medicine and the moral, and a number of the critiques of Freud's work was that it was really a moral discourse disguised as a scientific one. So a lot of what I would see in my clinic, for example, relates to social problems that people who have certain vulnerabilities will experience. Now I can think of two people I saw recently. One chap came into my office who told me that he had a microchip implanted under his nose and that that was controlling his thinking and what-have-you, and of course that obviously is quite a distinct example of someone who was in real trouble psychiatrically. But then another chap came in and essentially asked for a Centrelink certificate, you know, a form so that he could access the pension because he claimed that his depression was so disabling that he was unable to function and his life had obviously been very difficult, and I felt quite sorry for this chap. But the whole involvement I'd had with him was that me giving him a label which would have some sort of social utilities so he could achieve a social benefit. And I think the second case is a clear example of what you're talking about, where there is a lot of social agency required of psychiatry, and it's where we start to step out of this medical model that we like to comfort ourselves as working within. And that's where the ethics get quite slippery, because how far can one go on behalf of one's patient. You know, if somebody is existing almost as a second-class citizen, how politically active one must be as a psychiatrist to aid one's patient.

The problem is what are the limits of this? And some of the research I'm conducting at the moment is looking at descriptive ethics, that is to say what are the values that my colleagues have when it comes to particular situations, and there is no consensus as to what are the reasonable limits of involving oneself practically. I have spoken to people who have gone to the extent of driving their patients to the Salvation Army depot to pick up clothes; I've spoken to other people who say that we have absolutely no business doing that, and in fact we politicise the profession and we diminish it in doing it. So you have again, this rather inchoate group of ideas that one particular person acts more on their individual moral sensibilities and another is more beholden to a professional class of ethics, and I don't know who's right, or if there is a right and where does this start or end; what are the reasonable limits, and I think that that is going to be a very difficult thing to try to define or enshrine in a code of conduct. You can't have in the Australian and New Zealand College of Psychiatrists Clause 4B, 'Thou shalt not drive thy patient to the Salvation Army depot'. And we've certainly seen other instances in recent times where there's been quite a fracture with the profession about how far we should go as a group in regards to particular groups in society.

Alan Saunders: The caricature of Freudian psychoanalysis which we've all seen in many a cartoon, particularly in The New Yorker because New York is where there are so many Freudian psychoanalysts, is the patient's on the couch, the psychoanalyst is at the head of the couch, taking notes but not actually looking the patient in the face. But ultimately I suppose in this profession, you are engaged in face-to-face encounters with people. That must make a difference.

Michael Robertson: It does, and one philosopher resonates with me and that's Emmanuel Levinas, who wrote of the ethic of the face, and how one's engagement with the other was mediated through this contact, or this kind of encounter with the face. And I think that's quite true, that one can speak dispassionately or objectively about patients, but when you actually are engaged in this very human interaction, it is a very different experience from the abstract discussions one might have about the ethics of this or that.

Alan Saunders: Well Michael Robertson, thank you very much for that far from abstract discussion about the ethics of your profession. Thank you very much for joining us.

Michael Robertson: Thank you for having me on, Alan.

Alan Saunders: Dr Michael Robertson, is Director of Psychiatry at the Royal Prince Alfred Hospital in Sydney, and a clinical lecturer in Psychological Medicine at the University of Sydney. The show is produced by Polly Rickard with technical production this week by Timothy Nicastri. I'm Alan Saunders, and I'll be back next week with another Philosopher's Zone.