Abstract
This modest publication is an educational tool whose stated aim is to guide psychiatric residents through the everyday ethical issues they face and it should be judged in this context. Although based on the American Psychiatric Association (APA) Principles of Medical Ethics with annotations especially applicable to psychiatry it resonates sufficiently well with the College Code of Ethics (2nd edition) to be of potential value to psychiatric trainees in Australia and New Zealand. The elegant introduction immediately draws attention to a fundamental difference in the way ethical issues and complaints are dealt with in the US as compared to that of our own college. APA branch committees act as complaints bodies with powers of investigation. The eleven chapter headings that follow are no doubt selected on the unparalleled experience of the APA Ethics Committee. It is assumed that experience in Australia and New Zealand would be similar but there is only one published paper on the subject when the College Ethics Committee acted as a de facto complaints committee [1].
Chapter 1 on boundary violations and crossings rightfully emphasizes the social and psychodynamic framework and gives as much space to more frequent and less dramatic non-sexual transgressions as to those of a sexual and more sensational nature – in particular financial, physical contacts, influencing, autonomy and gifts, whether material or of insider knowledge. The chapter on child and adolescent psychiatry naturally focuses in a systematic manner on the obvious and not so obvious modifications of ethics necessary in this field especially in the face of changing societal structures, values and social demography. At the other end, the obvious ethics of the geriatric (not the psychogeriatric) population are dealt with in a practical but restricted chapter in that there are several crucial areas ignored such as testamentary capacity, living wills and euthanasia.
Involuntary hospitalization deals well with the arguments for and against, together, but not as well, with the related topics of paternalism, enforced treatment and the right to refuse. It offers little practical guidance and given the wide variations in mental health law even within Australia, New Zealand and the US, that is understandable.
The more subtle impositions on patients' freedom through the medium of restricted clinical freedom through managed care not only has a chapter to itself but receives prominence in nearly all the other chapters, indicating how deep this iron of bitterness has entered the soul of psychiatry in the US. Fortunately, we have been spared the worst but the menace of corporate medicine and bureaucratization of health delivery systems are waiting in the wings. This chapter is worth reading for the principles and practices it enunciates. The confidentiality chapter is not clearly linked to the preceding chapter.
Somewhat repetitively, gifts receives a chapter all to itself. It is especially practical in dealing with gifts from industry which appears to be a greater problem in the US than here. However, it fails to mention the subtle and seductive gifts of special knowledge. Intraprofessional responsibilities are dealt with in the setting of fraud and deception with only a passing reference to other forms of professional misconduct. The ethics of emergency care in forensic psychiatry are less culture bound and practically informative. The chapter on consultation and second opinion I can only describe as strange, mercifully short and an invitation for patients to join the ‘Splitters Guild’. The appendix with its ‘principles with annotations’ gave me the opportunity once again to compare it with our own College code, which of course was originally based on that of the APA. Without being unduly chauvinistic I believe our code states the principles and annotations with greater clarity and range. A major disappointment in the primer is that it failed to deliver on its promise of clinical vignettes; they only featured in three chapters, all of which were the better for it.
Do I recommend this volume to the trainee in our system? – the answer is a reluctant no, for although readable, much of it beyond the principles and some of the annotations do not apply in our Australia and New Zealand. However, trainees do need a reference volume and of course Psychiatric ethics [2] is the choice, backed up by the more practical Ethical decision making in therapy practice [3], which although not specifically written for psychiatric trainees nevertheless covers most of the ground. But first of all, trainees must be as familiar with the College Code of Ethics as the Lord's Prayer (or its ecumenical equivalent).