Attention to psychiatric clinical ethics as a subdiscipline may alleviate one of the main causes of human suffering and socioeconomic burden
Laura W Roberts
Clinical ethics is a discipline that seeks to translate scholarship into meaningful ways of understanding and alleviating human suffering. The most basic goal of clinical ethics is to improve patient care [51
], and the methods and knowledge harnessed by this discipline derive from the fields of clinical medicine and bioethics, biomedical and social sciences, health policy, philosophy, humanities, law, theology, and, more recently, population and information sciences. Through its focus on interactions and effects - between clinicians and patients, between social policies and systems of care delivery, between scientific discoveries and society - clinical ethics values differing perspectives and is inherently relational. Informed by clinical experience, conceptual analysis, and empirical evidence, clinical ethics is about beneficent, practical wisdom in a world knotted with suffering.
In characterizing the 'future directions in clinical ethics' 10 years ago, Singer and his colleagues [53
] defined three requirements for the maturation of the field: strengthening of the field's conceptual and research base; pursuing the 'professionalisation' and standardization of clinical ethics expertise and training; and enriching the interpersonal communication skill set of clinical ethicists. In their update [1
], those authors define a much broader array of challenges for the future.
They identify research issues, including improved funding opportunities for clinical ethics studies, greater integration of ethics data into 'mainstream' scientific and clinical knowledge, and more rigorous and more diverse inquiry. In teaching, they articulate insights echoed throughout the education literature, such as the need for Internet-based and adult-centred learning methods, greater focus on the 'informal curriculum' and character development in medicine, and augmenting our capacity to teach and evaluate ethics knowledge and skill. With respect to ethics consultation and committees, they argue for greater representation of clinical ethics within the fundamental processes of health care organizations and for more systematic study of clinical ethics interventions and clinical outcomes within systems. Finally, they suggest that the principal task ahead is to address the profound bioethics issues, primarily health care inequities, which we now face on a global level. However, they do not emphasize the challenges that face subdisciplines. Psychiatric clinical ethics as a subdiscipline has an entire universe of difficult questions that are yet to receive attention.
Psychiatric clinical ethics is a small field that is evolving in parallel with its parent discipline. As in clinical ethics, psychiatric clinical ethics seeks to help patients, specifically people with mental illness or combined physical and mental disorders. Psychiatric clinical ethics work is multidisciplinary, respectful of diverse perspectives, and focused on understanding the relations between people, systems, and phenomena. It is enriched by theory, substantiated in data, and revealed through experience.
With only a handful of established scholars, our capacity for research and education in psychiatric clinical ethics has been modest in comparison with the development of clinical ethics in internal medicine. Nevertheless, using the criteria outlined by Singer et al
, indications for progress within the area of psychiatric clinical ethics are good. The US National Institute of Mental Health [54
] identified studying the ethics of research involving people with mental illness as a priority area for funding. Similarly, the Ethical, Legal, and Social Implications Program of the National Human Genome Research Institute [55
] has defined psychiatric genetic issues as a critical domain for study. The number of psychiatrists who are engaged in ethics inquiry has grown in recent years, as have the number of publications in mainstream psychiatric journals on ethics topics [56
]. Systematic, rigorous work by psychiatrists, such as Appelbaum and co-workers [58
], from related disciplines over the past 2 decades has made a profound contribution to our understanding of informed consent and decisional capacity. Psychiatric educators have been engaged in developing innovative ethics training and in addressing professionalism issues in medical curricula at several institutions in the USA [61
]. Furthermore, psychiatric ethicists and practicing psychiatrists have been long recognized for their contributions in ethics committees and organizational leadership, and in providing expertise in ethics and clinical decision-making through consultation-liaison services [65
Despite these encouraging signs, the challenges encountered in psychiatric clinical ethics are considerable. As has been noted by the World Health Organization, the Surgeon General in the USA, and psychiatry leaders internationally, mental illnesses are among the top diseases in the world in terms of human suffering and socioeconomic burden [70
]. These prevalent and severe illnesses are poorly understood, however, and people with mental illness and their families are often gravely stigmatised and prejudicially treated [73
]. Mentally ill populations of all ages and ethnic backgrounds are underserved within current systems of care in rural and urban settings, both in developed and developing countries [76
]. Medical education gives insufficient attention to psychiatric topics, particularly across intersecting age, sex, and cultural spectra, especially given their prevalence in clinical practice [79
]. Public policy related to mental illness treatment and research has been a curious mixture of valuable insight and misapprehension [81
]. Interestingly, despite these regressive pressures, research into neurobiological, clinical, genetic, and epidemiological aspects of mental illness has generated extraordinary advances and new moral dilemmas in recent years [83
]. Consequently, psychiatric clinical ethics as a subdiscipline has an entire universe of important, difficult questions that are yet to receive systematic study [83
]. There are few areas so replete with human anguish and so worthy of our attention.
Over the past decade we have witnessed the substantive development of the field of clinical ethics. In canvassing this extraordinary scholarly discipline, based primarily in internal medicine, Singer et al may have omitted one of the most important contributions clinical ethics has made: it serves as a well-spring for sustained ethics scholarship that seeks, in parallel with its parent discipline, to enhance the care and well-being of people with serious illnesses across diverse fields of medicine.
Laura Weiss Roberts is supported in part by a grant from the National Institute of Mental Health: 1K02AI01738-01.