The gender-affirming model of care is incompatible with competent, ethical medical practice

OBJECTIVE

To examine the compatibility of gender-affirming care with the principles and practices of psychiatry.

CONCLUSIONS

The assumption that there is no pathology involved in the development of gender diversity is a necessary precondition for the unquestioning affirmation of self-reported gender identity. Cases where psychosis is the undeniable cause of gender diversity demonstrate this assumption is categorically false. To protect this false assumption, gender-affirming guidelines forbid the application of the core psychiatric competencies of phenomenology and psychopathology to the assessment of gender diversity. They substitute the political goal of expanding personal liberty for the evidence-based medicine processes of clinical reasoning, rendering them incompatible with competent, ethical medical practice.

Ethical perspectives regarding Euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium

INTRODUCTION

Previous research has explored euthanasia's ethical dimensions, primarily focusing on general practice and, to a lesser extent, psychiatry, mainly from the viewpoints of physicians and nurses. However, a gap exists in understanding the comprehensive value-based perspectives of other professionals involved in both somatic and psychiatric euthanasia. This paper aims to analyze the interplay among legal, medical, and ethical factors to clarify how foundational values shape the ethical discourse surrounding euthanasia in both somatic and psychiatric contexts. It seeks to explore these dynamics among all healthcare professionals and volunteers in Belgium.

METHODS

Semi-structured interviews were conducted with 30 Dutch-speaking healthcare workers who had encountered patients requesting euthanasia for psychiatric conditions, in Belgium, from August 2019 to August 2020. Qualitative thematic analysis was applied to the interview transcripts.

FINDINGS

Participants identified three pivotal values and virtues: religious values, professional values, and fundamental medical values encompassing autonomy, beneficence, and non-maleficence, linked to compassion, quality care, and justice. These values interwove across four tiers: the patient, the patient's inner circle, the medical realm, and society at large. Irrespective of their euthanasia stance, participants generally displayed a blend of ethical values across these tiers. Their euthanasia perspective was primarily shaped by value interpretation, significance allocation to key components, and tier weighting. Explicit mention of varying ethical values, potentially indicating distinct stances in favor of or against euthanasia, was infrequent.

CONCLUSION

The study underscores ethical discourse's central role in navigating euthanasia's intricate landscape. Fostering inclusive dialogue, bridging diverse values, supports informed decision-making, nurturing justice, and empathy. Tailored end-of-life healthcare in psychiatry is essential, acknowledging all involved actors' needs. The study calls for interdisciplinary research to comprehensively grasp euthanasia's multifaceted dimensions, and guiding policy evolution. While contextualized in Belgium, the implications extend to the broader euthanasia discourse, suggesting avenues for further inquiry and cross-cultural exploration.

Comparing the World Psychiatric Association and European Psychiatric Association Codes of Ethics: Discrepancies and shared grounds

BACKGROUND

Codes of ethics provide guidance to address ethical challenges encountered in clinical practice. The harmonization of global, regional, and national codes of ethics is important to avoid gaps and discrepancies.

METHODS

We compare the European Psychiatric Association (EPA) and the World Psychiatric Association (WPA) Codes of Ethics, addressing main key points, similarities, and divergences.

RESULTS

The WPA and EPA codes are inspired by similar fundamental values but do show a few differences. The two codes have a different structure. The WPA code includes 4 sections and lists 5 overarching principles as the basis of psychiatrists' clinical practice; the EPA code is articulated in 8 sections, lists 4 ethical principles, and several fundamental values. The EPA code does not include a section on psychiatrists' education and does not contain specific references to domestic violence and death penalty. Differences can be found in how the two codes address the principle of equity: the EPA code explicitly refers to the principle of universal health care, while the WPA code mentions the principle of equity as reflected in the promotion of distributive justice.

CONCLUSIONS

We recommend that both WPA and EPA periodically update their ethical codes to minimize differences, eliminate gaps, and help member societies to develop or revise national codes in line with the principles of the associations they belong to.Minimizing differences between national and international codes and fostering a continuous dialogue on ethical issues will provide guidance for psychiatrists and will raise awareness of the importance of ethics in our profession.

Commentary: the ethical challenges of machine learning in psychiatry: a focus on data, diagnosis, and treatment

The clinical interview is the psychiatrist's data gathering procedure. However, the clinical interview is not a defined entity in the way that 'vitals' are defined as measurements of blood pressure, heart rate, respiration rate, temperature, and oxygen saturation. There are as many ways to approach a clinical interview as there are psychiatrists; and trainees can learn as many ways of performing and formulating the clinical interview as there are instructors (Nestler, 1990). Even in the same clinical setting, two clinicians might interview the same patient and conduct very different examinations and reach different treatment recommendations. From the perspective of data science, this mismatch is not one of personal style or idiosyncrasy but rather one of uncertain salience: neither the clinical interview nor the data thereby generated is operationalized and, therefore, neither can be rigorously evaluated, tested, or optimized.

[Physician-assisted death in psychiatry]

In recent years, more patients with psychiatric disorders are receiving physician-assisted death (PAD). In the Netherlands, since more than 25 years psychiatric suffering is seen as a legitimate reason for PAD, but an additional independent assessment is required. Scarce empirical research shows that patients who receive PAD on the basis of psychiatric suffering have long-standing and complex complaints. Among these patients, depression and personality disorders are relatively common. The ethical justification of PAD for patients with psychiatric disorders has been the subject of debate for decades. Decisions about competence and the irremediability of suffering are challenging and for many authors reason enough to reject PAD based on psychiatric suffering. Others regard the exclusion of all patients with mental disorders as unjust. Empirical research and ethical consideration are needed for better founded considerations and a more widely supported practice concerning patients with a mental disorder who request PAD.

Psychosis, vulnerability, and the moral significance of biomedical innovation in psychiatry. Why ethicists should join efforts

The study of the neuroscience and genomics of mental illness are increasingly intertwined. This is mostly due to the translation of medical technologies into psychiatry and to technological convergence. This article focuses on psychosis. I argue that the convergence of neuroscience and genomics in the context of psychosis is morally problematic, and that ethics scholarship should go beyond the identification of a number of ethical, legal, and social issues. My argument is composed of two strands. First, I argue that we should respond to technological convergence by developing an integrated, patient-centred approach focused on the assessment of individual vulnerabilities. Responding to technological convergence requires that we (i) integrate insights from several areas of ethics, (ii) translate bioethical principles into the mental health context, and (iii) proactively try to anticipate future ethical concerns. Second, I argue that a nuanced understanding of the concept of vulnerability might help us to accomplish this task. I borrow Florencia Luna's notion of 'layers of vulnerability' to show how potential harms or wrongs to individuals who experience psychosis can be conceptualised as stemming from different sources, or layers, of vulnerability. I argue that a layered notion of vulnerability might serve as a common ground to achieve the ethical integration needed to ensure that biomedical innovation can truly benefit, and not harm, individuals who suffer from psychosis.

Should euthanasia and assisted suicide for psychiatric disorders be permitted? A systematic review of reasons

BACKGROUND

Euthanasia and assisted suicide (EAS) based on a psychiatric disorder (psychiatric EAS) continue to pose ethical and policy challenges, even in countries where the practice has been allowed for years. We conducted a systematic review of reasons, a specific type of review for bioethical questions designed to inform rational policy-making. Our aims were twofold: (1) to systematically identify all published reasons for and against the practice (2) to identify current gaps in the debate and areas for future research.

METHODS

Following the PRISMA guidelines, we performed a search across seven electronic databases to include publications focusing on psychiatric EAS and providing ethical reasons. Reasons were grouped into domains by qualitative content analysis.

RESULTS

We included 42 articles, most of which were written after 2013. Articles in favor and against were evenly distributed. Articles in favor were mostly full-length pieces written by non-clinicians, with articles against mostly reactive, commentary-type pieces written by clinicians. Reasons were categorized into eight domains: (1) mental and physical illness and suffering (2) decisional capacity (3) irremediability (4) goals of medicine and psychiatry (5) consequences for mental health care (6) psychiatric EAS and suicide (7) self-determination and authenticity (8) psychiatric EAS and refusal of life-sustaining treatment. Parity- (or discrimination-) based reasons were dominant across domains, mostly argued for by non-clinicians, while policy reasons were mostly pointed to by clinicians.

CONCLUSIONS

The ethical debate about psychiatric EAS is relatively young, with prominent reasons of parity. More direct engagement is needed to address ethical and policy considerations.

Integrating Genomics into Psychiatric Practice: Ethical and Legal Challenges for Clinicians

Psychiatric genomics is a rapidly growing field that holds much promise for improving risk prediction, prevention, diagnosis, treatment selection, and understanding of the pathogenesis of patients' symptoms. The field of psychiatry (i.e., professional organizations, mental health clinicians, educational institutions), however, needs to address numerous challenges to promote the responsible translation of genomic technologies and knowledge into psychiatric practice. The goal of this article is to review how clinicians currently encounter and use genomics in the clinic, to summarize the existing literature on how clinicians feel about the use of genomics in psychiatry, and to analyze foreseeable ethical and legal challenges for the responsible integration of genomics into psychiatric care at the structural and clinic levels. Structural challenges are defined as aspects of the larger system of psychiatric practice that constitute potential barriers to the responsible integration of genomics for the purposes of psychiatric care and prevention. These structural challenges exist at a level where professional groups can intervene to set standards and regulate the practice of psychiatry and genomics. Clinic-level challenges are day-to-day issues clinicians face when managing genomic tests in the clinic. We discuss the need for action to mitigate these challenges and maximize the clinical and social utility of psychiatric genomics, including the following: expanding genomics training among mental health clinicians; establishing practice guidelines that consider potential clinical, psychological, and social implications of psychiatric genomics; promoting an integrated care model for managing genomics in psychiatry; emphasizing patient engagement and informed consent when managing genomic testing in psychiatric care.

[From empathy to commitment, the ethical approach in psychiatry]

Ethical questioning and reflection are a requirement for the psychiatric caregiver, a particular discipline which is both clinical and political. Ethics is a safeguard that allows the professional to refocus on the core of their profession. It is not synonymous with morality and is situational. It is a combat sport against oneself and against those who reduce the patient to a human-machine to be repaired.

Person and ethics of a psychiatrist during National Socialism: Friedrich Meggendorfer (1880-1953)

Evaluation of sources not previously considered makes it possible to describe Friedrich Meggendorfer's role as a National Socialist university psychiatrist. Relevant archive material and literature were both assessed. The gene-hygiene affinity promulgated by Meggendorfer was based on his own scientific interests, early academic influences, and also positive reinforcement from his career choices. His application of scientific knowledge in the legitimization of National Socialist jurisdiction reflects a dark facet in Meggendorfer's life. One can also criticize his ethics in failing to use his eugenics expertise to stop 'euthanasia'. Future studies into the history of the ethical aspects of Nazi psychiatry should benefit from the setting up of criteria for the collection of biographical data. This would render comparisons and contrasts fairer and more stable.

[Psychiatry and bioethics: a critical relationship, an incentive to reflect]

In the western world, especially in Italy, also legal attention to bioethical aspects is increasingly taking on importance in the debate at the medical, political and public level. In this debate, Psychiatry, as a scientific discipline closely integrated with the human and cultural, is underrepresented, little questioned on the many psychopathologal issues closely related to ethical aspects on complex themes. Against this background, Rivista di psichiatria, always keen to these topics, is designed to be a very special space for discussion with all the experts involved in mental health.

The inherent jurisdiction of the Irish High Court: Interface with psychiatry

The term "inherent jurisdiction" refers to a set of default powers, usually not set out in statute, which enables a court to fulfil its roles. We discuss recently reported cases where such power has been exercised by the Irish High Court and what this means for psychiatrists in practice. These cases demonstrate that (a) the Irish High Court can be involved in decision-making where there is a lacuna in mental health legislation and a lack of mental capacity; (b) when a minor has been placed by the Court in a specialist facility in the UK and then attains the age of 18 years, decisions can be based on mental capacity but not on preventative detention on the basis of risk; (c) complexities arise when definitions of mental disorder vary between jurisdictions, especially when the Court orders involuntary detention in a case where statute would not ordinarily allow this; and (d) the appropriate route to seek decision-making for adults with mental incapacity is through Ireland's "Ward of Court" process, although, on the face of it, this seems to be contrary to the approach taken in other cases in which inherent jurisdiction was used. Overall, while it is reassuring for state health services that they can seek to approach higher courts in respect of decision-making in complex cases, some of these decisions raise important ethical questions for psychiatrists who may be asked to treat patients detained under their care who may not have a treatable mental illness as their condition falls outside of mental disorder within Irish legislation. We recommend that clear guidance is made available to psychiatrists in light of these judgments, particularly as there is likely to be a reconsideration of cases where Irish patients are placed in the UK given the UK's planned departure from the EU.

Euthanasia and physician-assisted suicide for patients with depression: thought-provoking remarks

Euthanasia and medical assistance in dying entail daunting ethical and moral challenges, in addition to a host of medical and clinical issues, which are further complicated in cases of patients whose decision-making skills have been negatively affected or even impaired by psychiatric disorders. The authors closely focus on clinical depression and relevant European laws that have over the years set firm standards in such a complex field. Pertaining to the mental health realm specifically, patients are required to undergo a mental competence assessment in order to request aid in dying. The way psychiatrists deal and interact with decisionally capable patients who have decided to end their own lives, on account of sufferings which they find to be unbearable, may be influenced by subjective elements such as ethical and cultural biases on the part of the doctors involved. Moreover, critics of medical aid in dying claim that acceptance of such practices might gradually lead to the acceptance or practice of involuntary euthanasia for those deemed to be nothing more than a burden to society, a concept currently unacceptable to the vast majority of observers. Ultimately, the authors conclude, the key role of clinicians should be to provide alternatives to those who feel so hopeless as to request assistance in dying, through palliative care and effective social and health care policies for the weakest among patients: lonely, depressed or ill-advised people.

Education versus screening: the use of capacity to consent tools in psychiatric genomics

Informed consent procedures for participation in psychiatric genomics research among individuals with mental disorder and intellectual disability can often be unclear, particularly because the underlying ethos guiding consent tools reflects a core ethical tension between safeguarding and inclusion. This tension reflects important debates around the function of consent tools, as well as the contested legitimacy of decision-making capacity thresholds to screen potentially vulnerable participants. Drawing on human rights, person-centred psychiatry and supported decision-making, this paper problematises the use of consent procedures as screening tools in psychiatric genomics studies, particularly as increasing normative emphasis has shifted towards the empowerment and participation of those with mental disorder and intellectual disabilities. We expound on core aspects of supported decision-making, such as relational autonomy and hermeneutic competence, to orient consent procedures towards a more educative, participatory framework that is better aligned with developments in disability studies. The paper concludes with an acknowledgement of the pragmatic and substantive challenges in adopting this framework in psychiatric genomics studies if this participatory ethos towards persons with mental disorder and intellectual disability is to be fully realised.

Ethical Discourse of Psychiatrists About Gender Identity and Sexual Orientation: A Qualitative Study

OBJECTIVE

In Turkey, the studies that aim to elaborate on the experiences of people with gender identities and sexual orientations incongruent with social norms are limited both in bioethics and in psychiatry. The general aim of this study is to provide a deeper understanding about the value based problems related to the gender identity and sexual orientation of the patients who seek medical advice in psychiatry practice. In this study, psychiatrists' discourse on gender identity and sexual orientation is discussed from an ethical perspective based on their experiences in providing healthcare to LGBT individuals.

METHOD

In-depth interviews with 35 Psychiatry residents and specialists were conducted in the context of a qualitative field study. The data received from in-depth interviews were evaluated using the thematic content analysis method.

RESULTS

The raw data received from the in-depth interviews with psychiatrists were analyzed and the themes and the contexts were derived. Discrimination, LGBTs access to healthcare services, counselling practice, beneficence, non-maleficence, being empathic, self-improvement, communicating with the family and interaction with LGBTs are the main themes that emerged. These main themes were handled within the contexts of providing healthcare services, professional responsibility of the psychiatrists, physician-patient/client and family relations. The relationship between the themes and the contexts were interpreted from an ethical perspective.

CONCLUSION

The results of the study show that in the absence of comprehensive and adequate education on gender identity and sexual orientation, psychiatrists may tend to adopt scientifically debatable METHODS in diagnosis, observation and treatment of LGBT patient/ counselee.

Humane treatment versus means of control: coercive measures in Norwegian high-security psychiatry, 1895-1978

This article analyses the use of coercive measures in two national institutions for high-security psychiatry in Norway - Kriminalasylet (Criminal Asylum) and Reitgjerdet - during the period 1895-1978. Historical study of coercion in psychiatry is a fruitful approach to new insight into the moral and ethical considerations within the institutions. We approach the topic through a qualitative study of patient case files and ward reports from the institutions' archives, as well as a comprehensive quantification of the coercive measures used. The data show shifting considerations of humane treatment and changes in the respect for human dignity in the institutions' practices. They also show that technological developments, such as the introduction of new psychopharmaceuticals, did not necessarily lead to higher standards of treatment.

Coercion in psychiatry: is it right to involuntarily treat inpatients with capacity?

Psychiatric inpatients with capacity may be treated paternalistically under the Mental Health Act 1983. This violates bodily autonomy and causes potentially significant harm to health and moral status, both of which may be long-lasting. I suggest that such harms may extend to killing moral persons through the impact of psychotropic drugs on psychological connectedness. Unsurprisingly, existing legislation is overwhelmingly disliked by psychiatric inpatients, the majority of whom have capacity. I present four arguments for involuntary treatment: individual safety, public safety, authentic wishes and protection of autonomy. I explore these through a case study: a patient with schizophrenia admitted to a psychiatric hospital under the Mental Health Act 1983 after an episode of self-poisoning. Through its discussion of preventative detention, the public safety argument articulates the (un)ethical underpinnings of the current position in English law. Ultimately, none of the four arguments are cogent-all fail to justify the current legal discrimination faced by psychiatric inpatients. I conclude against any use of involuntary treatment in psychiatric inpatients with capacity, endorsing the fusion approach where only psychiatric patients lacking capacity may be treated involuntarily.

Ethical dangers of facial phenotyping through photography in psychiatric genomics studies

Psychiatric genomics research protocols are increasingly incorporating tools of deep phenotyping to observe and examine phenotypic abnormalities among individuals with neurodevelopmental disorders. In particular, photography and the use of two-dimensional and three-dimensional facial analysis is thought to shed further light on the phenotypic expression of the genes underlying neurodevelopmental disorders, as well as provide potential diagnostic tools for clinicians. In this paper, I argue that the research use of photography to aid facial phenotyping raises deeply fraught issues from an ethical point of view. First, the process of objectification through photographic imagery and facial analysis could potentially worsen the stigmatisation of persons with neurodevelopmental disorders. Second, the use of photography for facial phenotyping has worrying parallels with the historical misuse of photography to advance positive and negative eugenics around race, ethnicity and intellectual disability. The paper recommends ethical caution in the use of photography and facial phenotyping in psychiatric genomics studies exploring neurodevelopmental disorders, outlining certain necessary safeguards, such as a critical awareness of the history of anthropometric photography use among scientists, as well as the exploration of photographic methodologies that could potentially empower individuals with disabilities.

Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Crisis?

Involuntary psychiatric commitment for suicide prevention and physician aid-in-dying (PAD) in terminal illness combine to create a moral dilemma. If PAD in terminal illness is permissible, it should also be permissible for some who suffer from nonterminal psychiatric illness: suffering provides much of the justification for PAD, and the suffering in mental illness can be as severe as in physical illness. But involuntary psychiatric commitment to prevent suicide suggests that the suffering of persons with mental illness does not justify ending their own lives, ruling out PAD. Since both practices have compelling underlying justifications, the most reasonable accommodation might seem to be to allow PAD for persons with mental illness whose suffering is severe enough to justify self-killing, but prohibit PAD for persons whose suffering is less severe. This compromise, however, would require the articulation of standards by which persons' mental as well as physical suffering could be evaluated. Doing so would present a serious philosophical challenge.

[Open-door psychiatry and community mental health work]

In connection with the UN Convention on the Rights of Persons with Disabilities, mental healthcare concepts increasingly focus on the prevention of violence and coercion. Hospital care with an open-door policy is linked with a reduction in violence and coercive measures. The authors describe a specific therapeutic milieu aiming to promote social resources and to reduce institutional exclusion. Open-door policies can be extended to and tied in with outreach community mental health work. Model projects according to § 64b of the German Social Code (SGB V) on interdisciplinary care enable flexible needs-based care including home treatment for severe mental illness.

Agency, embodiment and enactment in psychosomatic theory and practice

In this paper, we examine some of the conceptual, pragmatic and moral dilemmas intrinsic to psychosomatic explanation in medicine, psychiatry and psychology. Psychosomatic explanation invokes a social grey zone in which ambiguities and conflicts about agency, causality and moral responsibility abound. This conflict reflects the deep-seated dualism in Western ontology and concepts of personhood that plays out in psychosomatic research, theory and practice. Illnesses that are seen as psychologically mediated tend also to be viewed as less real or legitimate. New forms of this dualism are evident in philosophical attacks on Engel's biopsychosocial approach, which was a mainstay of earlier psychosomatic theory, and in the recent Research Domain Criteria research programme of the US National institute of Mental Health which opts for exclusively biological modes of explanation of illness. We use the example of resignation syndrome among refugee children in Sweden to show how efforts to account for such medically unexplained symptoms raise problems of the ascription of agency. We argue for an integrative multilevel approach that builds on recent work in embodied and enactive cognitive science. On this view, agency can have many fine gradations that emerge through looping effects that link neurophenomenology, narrative practices and cultural affordances in particular social contexts. This multilevel ecosocial view points the way towards a renewed biopsychosocial approach in training and clinical practice that can advance person-centred medicine and psychiatry.

Pink and blue: the role of gender in psychiatric diagnosis

Why are the diagnostic criteria of some psychiatric disorders standardised by gender while others are not? Why standardise symptom questionnaires by gender but not other personal characteristics such as ethnicity, socioeconomic class or sexual orientation? And how might our changing attitudes towards gender, born from scientific research and changing societal narratives, alter our opinion of these questions? This paper approaches these dilemmas by assessing the concept of diagnosis in psychiatry itself, before analysing two common approaches to the study of psychiatric diagnosis; the naturalist and constructivist views. The paper assesses the relative merits and significance of each, before turning its attention to the nature of gender and its relevance to psychiatry. The paper introduces a framework to approach gender-based diagnostic bias and concludes by drawing a distinction between qualitative and quantitative standardisation, arguing that gender standardisation of psychiatric diagnoses is ethically justified in the former but not the latter.

Dualism and its place in a philosophical structure for psychiatry

It is often claimed in parts of the psychiatric literature that neuroscientific research into the biological basis of mental disorder undermines dualism in the philosophy of mind. This paper shows that such a claim does not apply to all forms of dualism. Focusing on Kenneth Kendler's discussion of the mind-body problem in biological psychiatry, I argue that such criticism of dualism often conflates the psychological and phenomenal concepts of the mental. Moreover, it fails to acknowledge that there are different varieties of dualism, and so overlooks the important metaphysical insights of contemporary dualist philosophers. I argue that while the neuroscientific research underpinning biological psychiatry challenges the traditional dualism of René Descartes, it does not pose any problem for the more modern dualism of David Chalmers. It is possible to take seriously the scientific claims of biological psychiatry while holding that this latter form of dualism is true. This has implications for the positioning of the mind-body problem in psychiatry. While the "easy" problem of explaining psychological processes is relevant to the aims of biological psychiatry, psychiatrists need not worry about the "hard" problem of consciousness.

Do Community Treatment Orders in Psychiatry Stand Up to Principalism: Considerations Reflected through the Prism of the Convention on the Rights of Persons with Disabilities

Compulsory psychiatric treatment is the norm in many Western countries, despite the increasingly individualistic and autonomous approach to medical interventions. Community Treatment Orders (CTOs) are the singular best example of this, requiring community patients to accept a variety of interventions, both pharmacological and social, despite their explicit wish not to do so. The epidemiological, medical/treatment and legal intricacies of CTOs have been examined in detail, however the ethical considerations are less commonly considered. Principlism, the normative ethical code based on the principles of autonomy, beneficence, non-maleficence and justice, underpins modern medical ethics. Conflict exists between patient centred commentary that reflects individual autonomy in decision making and the need for supported decision making, as described in the Convention on the Rights of Persons with Disabilities (CRPD) and the increasing use of such coercive measures, which undermines this principle. What appears to have been lost is the analysis of whether CTOs, or any coercive measure in psychiatric practice measures up against these ethical principles. We consider whether CTOs, as an exemplar of coercive psychiatric practice, measures up against the tenets of principalism in the modern context in order to further this debate.

Contributory injustice in psychiatry

I explain the notion of contributory injustice, a kind of epistemic injustice, and argue that it occurs within psychiatric services, affecting (at least) those who hear voices. I argue that individual effort on the part of clinicians to avoid perpetrating this injustice is an insufficient response to the problem; mitigating the injustice will require open and meaningful dialogue between clinicians and service user organisations, as well as individuals. I suggest that clinicians must become familiar with and take seriously concepts and frameworks for understanding mental distress developed in service user communities, such as Hearing Voices Network, and by individual service users. This is especially necessary when these concepts and frameworks explicitly conflict with medical or technical understandings of users' experiences. I defend this proposal against three objections.

Alternatives to War Within Medicine: From Conscientious Objection to Nonviolent Conflict About Contested Medical Practices

When we figure medical practice as warfare, an individual clinician may be either a dutiful combatant or a conscientious objector. The rhetorical structure of this choice means that clinicians may exercise their consciences by loyally joining or disloyally exiting the medical ranks' battle against disease. But there are alternatives to loyalty and exit, and within psychiatry, these alternatives have transformed clinical services. In the 1970s, gay activists successfully resisted the American Psychiatric Association's characterization of homosexuality as a mental illness. In the 1940s, Mennonite nonresisters created the Mennonite mental health movement as a noncoercive alternative to standard psychiatric care. These gay activists and Mennonite volunteers opened communal alternatives to violence. When clinicians pursue nonviolent conflict about contested medical practices, they practice with the integrity that develops out of engaging in moral dialogue. Medicine becomes something more than a war in which individuals serve or to which they object: instead, it becomes a prudential set of practices that advance through principled disagreements and that expand the imagination of clinicians as they respond to the vulnerability of the people they meet as patients.

Self-admission in psychiatry: The ethics

Self-admission to inpatient treatment is a novel approach that aims to increase agency and autonomy for patients with severe psychiatric illness and a history of high utilization of inpatient care. By focusing on brief, preventive hospital admissions in times of increased risk of relapse, self-admission seeks to reduce the need for prolonged episodes of inpatient treatment. Participants are generally satisfied with the model, which is not surprising given that self-admission programs allocate a scarce resource-hospital beds-to a select group. However, the patients targeted by these programs are not necessarily those in most need of hospital admission, which may compromise the commonly accepted 'principle of need' in allocation of public healthcare resources. In light of the current lack of consistent evidence of the usefulness and cost-effectiveness of the model, several aspects need to be further studied in order to guide any large-scale implementation of self-admission in psychiatry.

Psychopathy Treatment and the Stigma of Yesterday's Research

The psychiatric diagnosis of psychopathic personality-or psychopathy-signifies a patient stereotype with a callous lack of empathy and strong antisocial tendencies. Throughout the research record and psychiatric practices, diagnosed psychopaths have been predominantly seen as immune to psychiatric intervention and treatment, making the diagnosis a potentially strong discriminator for treatment amenability. In this contribution, the evidence in support of this proposition is critically analyzed. It is demonstrated that the untreatability perspective rests largely on erroneous, unscientific conclusions. Instead, recent research suggests that practitioners should be more optimistic about the possibility of treating and rehabilitating diagnosed psychopaths. In light of this finding, concrete ethical challenges in the forensic practice surrounding the psychopathy diagnosis are discussed, adding to a growing body of research that expresses skepticism about the forensic utility of the diagnosis.

Leadership Analysis and Political Psychology in the 21st Century

The election of President Trump has led to interest in his mental health and has resulted in heightened scrutiny regarding the American Psychiatric Association's Goldwater Rule, with its prohibition on opining psychiatrically on the mental health of public figures whom one has not examined in person. This article highlights the historic, methodological, forensic, and ethics challenges regarding psychiatric approaches to leadership analysis, and how these can offer policy makers options regarding national security decision-making.

[How human rights can guide german psychiatry]

The concerns and recommendations of the UN "Final Remarks" on the first German State Report are substantiated by up-to-date health reporting data. Their "recommendations" are substantiated by evidence-based care models and supplemented by additional content from the Special Rapporteur's report of 2017 as visions for German psychiatric care, thus demonstrating the path of psychiatry determined by respect for human rights and social inclusion. The avoidance of coercion through traumainformed treatment and the development of complex outpatient treatment structures through the models of open dialogue and the recovery approach are seen as the focus of a paradigm shift. The awareness that in today's psychiatry, especially through deficient structures, human rights violations are committed that could be avoided, should contribute to the determination for the necessary changes.

Should DBS for Psychiatric Disorders be Considered a Form of Psychosurgery? Ethical and Legal Considerations

Deep brain stimulation (DBS), a surgical procedure involving the implantation of electrodes in the brain, has rekindled the medical community's interest in psychosurgery. Whereas many researchers argue DBS is substantially different from psychosurgery, we argue psychiatric DBS-though a much more precise and refined treatment than its predecessors-is nevertheless a form of psychosurgery, which raises both old and new ethical and legal concerns that have not been given proper attention. Learning from the ethical and regulatory failures of older forms of psychosurgery can help shed light on how to address the regulatory gaps that exist currently in DBS research. To show why it is important to address the current regulatory gaps within psychiatric DBS, we draw on the motivations underlying the regulation of earlier forms of psychosurgery in the US. We begin by providing a brief history of psychosurgery and electrical brain stimulation in the US. Against this backdrop, we introduce psychiatric DBS, exploring current research and ongoing clinical trials. We then draw out the ethical and regulatory similarities between earlier forms of psychosurgery and psychiatric DBS. As we will show, the factors that motivated strict regulation of earlier psychosurgical procedures mirror concerns with psychiatric DBS today. We offer three recommendations for psychiatric DBS regulation, which echo earlier motivations for regulating psychosurgery, along with new considerations that reflect the novel technologies used in DBS.

Film Psychotherapy in the 21st Century

Psychotherapy is commonly depicted in films. Films, then, help to inform the public about the nature of psychotherapy and psychotherapists. Although much has been written about the portrayal of psychotherapy in films, there has been little empirical investigation of films from the 21st century. The current study provides a systematic investigation of the portrayal of therapists and therapy in films released between 2000 and 2013. Trained volunteers coded films with characters identified as psychotherapists. Data are presented for ratings on 22 films in which therapist characters appeared on screen for at least 15 minutes. Therapists were predominantly Caucasian, male, and between ages 40 and 60 years. Their most common characteristics were generally positive-intelligent, caring, knowledgeable, and compassionate. More than half were portrayed as unethical, and more than one-third as manipulative. Therapists were also commonly shown as touching clients in some way, disclosing client information without permission, and becoming involved in social relationships with clients. In addition, it was often unclear whether clients benefitted from their engagement in therapy. The observed portrayals raise serious concerns about their potential impact on viewers. Viewers may be discouraged from seeking help and may have increased vulnerability to exploitation because of a lack of understanding of what is appropriate and inappropriate therapist behavior.

[A relational ethical model for the assessment of decision-making competence in psychiatry]

Nowadays, partly due to legislation, decision-making competence is playing an ever-increasing role in psychiatry. So far, however, there are no clear criteria for evaluating the actual competence of the procedure.<br/> AIM: To develop a relational ethical model, including criteria and methodology, which can be used to assess and enhance decision-making competence mainly from a relational and ethical perspective.<br/> METHOD: Combination of a review of the literature and ethical reflection. First of all, a limited study was made of the literature relating to the concept of and criteria for decision-making competence. On the basis of the literature and relational ethical reflection, ten criteria were developed for decision-making competence and a method was devised for assessing the procedure.<br/> RESULTS: The criteria that have to be satisfied can be summarised as follows: the persons involved must understand the information, and must be able to apply it to their own situation. They must be able to gain insight into their own situation and be able to weigh up the available options, and be able to estimate consequences for themselves, as well as for others. They must be able to motivate choices in a sensible and comprehensible manner without being subject to coercive influences coming from internal and external sources. Participants' choices should be motivated on the basis of their own personal values. The decision-making competence is assessed and enhanced by giving a score to the individual criteria and by making an overall evaluation. This is achieved by a dialogue including all the persons involved: the care seeker (as far as possible), close relatives and the care-providers.<br/> CONCLUSION: The persons involved can attain greater objectivity by exchanging views orally on the ten proposed criteria for decision-making competence.

Clinical judgment, moral anxiety, and the limits of psychiatry

It is common for clinicians working in psychiatry and related clinical disciplines to be called on to make diagnostic clinical judgments concerning moral anxiety, which is a kind of anxiety that is closely bound up with decisions individuals face as moral agents. To make such a judgment, it is necessary to make a moral judgment. Although it has been common to acknowledge that there are ways in which moral and clinical judgment interact, this type of interaction has remained unacknowledged. This raises questions as to the nature and limits of psychiatry-particularly concerning the extent to which psychiatric discourse ought to incorporate moral discourse, and the role of the clinician as an expert in identifying problematic anxiety.

The Patient-Psychiatrist Relationship on the Axis of the Other and the Same

The patient-psychiatrist relationship is a cornerstone of psychiatric professionalism and ethics. We discuss this topic along the axis of the Other and the Same, concepts defined by continental philosophy. The self of Anglo-American philosophy is typically described in individualistic terms. Individualism, autonomy and ideal self are valorized within the current model of care. These characteristics belong to the Lacanian Imaginary Order, which is the core of narcissism. Patients may yearn for another model of interaction. For Levinas, ethics should not involve a search for perfectionism and accomplishment but responsibility toward others. Ethics is, according to him, rooted in the calling into question of one's Sameness by the other's Otherness. The question of hospitality and of the welcoming of Otherness is central to his thought. Derrida further asks whether hospitality is not an interruption of the self. Hospitality may thus become a fundamental way of re-thinking clinical practices. A relationship to the Other as an-other is characterized as of Euclidian-type, establishing borders between the self and the Other, whereas a relationship to the Other as same is characterized as of fractal-type, emphasizing similarities between self and other as same and obliterating boundaries. Winnicott's object-relating versus use of object and Buber's I-you and I-it relations are also examined along the axis of Sameness and Otherness. Since psychiatric clinical practice requires to our view adequate and adaptive to and fro movements along this axis, the two forms of relating to the Other are discussed both theoretically and through a clinical case presentation.

Global mental health, autonomy and medical paternalism: reconstructing the 'French ethical tradition' in psychiatry

In the last few decades, the definition of deontological ethics, a well-identified ethical territory in psychiatry, has been the object of increasing concerns. This has been the case in France, where claims of a specific ethical tradition in psychiatry have accompanied the institutionalization of psychiatric ethics and the perceived globalization of an Anglo-American model of mental health care. This study traces the history of the 'French ethical tradition in psychiatry' and its relationship with establishing institutional spaces for ethical decision-making. The 'ethical tradition' thus conceived proves to be functional in terms of preserving the threatened identity of French psychiatry. Nevertheless, this movement also pinpoints impasses that transcend the French context and may provide valuable resources for ethical reflections on mental health on a global scale.

A Study of the Discussions on Psychiatry of Korea in the 1960s and 1970s* - From Mental Hygiene to Modern Psychiatry

This study is to review the emergence of new psychiatrists, scientific rationalization, and popular internalization to reorganize the formation process of modern psychological medicine system. Unlike eugenic psychiatry from the Japanese Colonial Era, the social conditions and contexts forming autonomous system of psychiatry of Korea in the 1960s and 1970s have been concentrated. The discussion approach has been tried to secure two perspectives-treatment and criticism-at the same time and to expand the time and scope of study through the extensive texts such as newspapers, magazines, books, advertisements, and others in the 1960s and 1970s. Through formation of subject, rationalization, and popularization, this study has surveyed the characteristics of psychiatry in the 1960s and 1970s to accentuate complicated conditions and kinetic steps to systemize psychiatry as scientific field to promote treatment of patients by deviating from mental hygiene approaching national mental health from cleanliness and removal. The characteristics are summarized as follows. First, as the ethical models of good doctors, medical paternalistic doctors, and non-authoritarian symmetric doctors have been proposed as good psychiatrists by new medical specialists with experience of globality, a new subject emerges. However, there has been illegalization process of unlicensed medical practitioner excluded by the regulatory authority called "clearness." Second, the rationalization of psychiatry has been accelerated through the dispute of enactment of Mental Hygiene Law, segmentalization of concept of mental illness, and scientific characteristics. Especially, the disputes over enactment of Mental Hygiene Law focused on criminalization of mental patients brought a result to regulate the patients as the target of humanistic treatment and potential criminals at the same time. Third, popularization of psychiatry has embraced invisible mental illness into popular daily life through visual measure called medicine advertisement, and through the discussion about social neurosis, a new paradigm for diagnosis of Korean society has been proposed. Moreover, by focusing on autobiographical works with voices of patients, this article reveals a new doctor-patient relationship.

Reflections on the Goldwater Rule

The APA's Goldwater Rule, precluding psychiatrists from rendering opinions to the media about public figures whom they have not examined, has often engendered controversy. Here, I consider the justifications for the rule, how well they stand up to criticism, and the extent, if any, to which modifications might be called for. Although embarrassment to the profession is often cited as the basis for the Rule, it reflects more substantive concerns, including the risk of harm to living persons and discouraging persons in need of treatment from seeking psychiatric attention. The most potent criticisms of the Rule are that it discourages public education about mental illness and its effects and precludes legitimate scholarly endeavors by psychiatrists studying foreign leaders, historical figures, and others. However, there are many ways of providing education about mental illness without violating the Rule, and read properly, it should not prevent legitimate historical investigation, though some clarification of the Rule on this point might be helpful. Even psychiatrists who seek to aid policymakers in dealing with international or domestic threats should not find that the Rule interferes with their efforts. On balance, the Goldwater Rule continues to be an important underpinning of ethical behavior by psychiatrists.

A Resident Perspective on the Goldwater Rule

Section 7.3 of the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry, more commonly known as the Goldwater rule, admonishes psychiatrists to avoid offering professional opinions about public figures in the absence of an in-person evaluation. To our knowledge, no peer-reviewed articles have been published considering resident perspectives on the Goldwater rule. Furthermore, we have found little published guidance that deals specifically with teaching the Goldwater rule in a general residency curriculum. We propose that residency programs should incorporate a brief (one hour) but thoughtful discussion of the Goldwater rule into their general curriculum. We recommend that such a didactic hour should introduce arguments for and against the rule in its present form. Covered topics could include whether there should be exceptions to the rule, whether the rule is defensible on ethical grounds, and what contexts exist in which psychiatric opinions can be rendered without personal examination. We hope to make the case that a more nuanced exploration of the Goldwater rule could help open a door to discussions that would foster the growth of a mature professional identity.

Interpreting the Goldwater Rule

Section 7.3 of the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry (the so-called Goldwater Rule) provides guidance on the ethics of making psychiatric comments about public figures who have not been interviewed and have not given consent. I argue that the wording of Section 7.3 is ambiguous, and I document disagreement over the scope of the rule and consider the implications of this disagreement. If one reads Section 7.3 narrowly, as banning media comments without interview and consent, but allowing such comments in institutional settings, then the general principle articulated in the text and often repeated in the media begins to appear insubstantial. If one reads Section 7.3 broadly, then the work of psychiatrists in the courts, in government agencies such as the Central Intelligence Agency, in insurance companies, and in the academy becomes ethically problematic. I trace the American Psychiatric Association's own interpretation of Section 7.3 and conclude that the APA has advocated a narrow reading. I assert the need for an integrated theory of psychiatric ethics for settings where interview and consent are absent. Such a theory, articulating why comments in institutional settings are ethical, but comments to media are not, may reduce public confusion and provide a basis for revising Section 7.3.

Psychiatric Genomics and Mental Health Treatment: Setting the Ethical Agenda

Realizing the benefits of translating psychiatric genomics research into mental health care is not straightforward. The translation process gives rise to ethical challenges that are distinctive from challenges posed within psychiatric genomics research itself, or that form part of the delivery of clinical psychiatric genetics services. This article outlines and considers three distinct ethical concerns posed by the process of translating genomic research into frontline psychiatric practice and policy making. First, the genetic essentialism that is commonly associated with the genomics revolution in health care might inadvertently exacerbate stigma towards people with mental disorders. Secondly, the promises of genomic medicine advance a narrative of individual empowerment. This narrative could promote a fatalism towards patients' biology in ways that function in practice to undermine patients' agency and autonomy, or, alternatively, a heightened sense of subjective genetic responsibility could become embedded within mental health services that leads to psychosocial therapeutic approaches and the clinician-patient therapeutic alliance being undermined. Finally, adopting a genomics-focused approach to public mental health risks shifting attention away from the complex causal relationships between inequitable socio-economic, political, and cultural structures and negative mental health outcomes. The article concludes by outlining a number of potential pathways for future ethics research that emphasizes the importance of examining appropriate translation mechanisms, the complementarity between genetic and psychosocial models of mental disorder, the implications of genomic information for the clinician-patient relationship, and funding priorities and resource allocation decision making in mental health.