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Empirical Ethics in Psychiatry
Am J Psychiatry 2009;166:119-120. doi:10.1176/appi.ajp.2008.08050741
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edited by Guy Widdershoven, John McMillan, Tony Hope, and Lieke van der Scheer. New York, Oxford University Press, 2008, 254 pp., $59.95.

Three of the four editors of Empirical Ethics in Psychiatry are trained in philosophy, and one (Hope) is trained in psychiatry. As self-professed “traveling companions” in researching the ethical actualities of the field of psychiatry, the editors lament the continued lack of engagement between most ethics theorists, typically theologians and philosophers, and ethics “observers,” namely social scientists. Such silence is concerning because those most harmed by this are patients, families, and clinicians, since they, by necessity, must work through the ethical complexities and hazards of illness. To help reduce such harms, this book has three goals: first, to persuade ethics theorists and specialists that social scientists can help increase understanding of mental health, illness, treatment, and care; second, to explain what empirical ethics is; and third, to demonstrate how empirical ethics contributes effectively to psychiatric services, be they at the individual client-professional or program level.

The first four chapters, each by different authors, comprise Section 1, which is intended to explain “empirical ethics” and establish its theoretical and practical validity for clinical practice. Empirical ethics conscientiously combines normative analysis (i.e., what should be) with a systematic collection of data (i.e., what is). Prepared for the challenge of the naturalistic fallacy (i.e., “ought” cannot be derived from “is”), the authors rebut it satisfactorily. And rather than just appeal to knowledge of and familiarity with qualitative research and its usefulness for healthcare, the authors invoke philosophers John Dewey, Hans-Georg Gadamer, and Aristotle to help legitimate empirical ethics. Aristotle’s epistemological concept of phronesis connects wisdom to everydayness, context, and systems, all of which typify contemporary psychiatric practices. Dewey’s pragmatics emphasizes striving for realizable outcomes that are accompanied by individual commitment, solidarity, and hope, each of which is clearly important to healthcare. Psychiatry is amenable to Gadamerian hermeneutics because the latter focuses on meaning, in terms of interpreting interactions and activities relative to a group or community’s traditions and history, and on dialogue, in terms of understanding diverse experiences and world views. Additionally, meaning, perspectives, and traditions lend themselves to empirically studying people as individuals and group members.

Each of the 11 chapters of Section 2 describes a study (or studies) about an important ethical dimension or complexity of mental health care. These chapters help demonstrate the value of empirical ethics to psychiatry: greater understanding of ethics as something lived by the person with the psychiatric problem, his family, and community as well as something practiced by the psychiatrist, her team, hospital/clinic, and the profession itself. The studies are about competing notions of good clinical care (Chapter 5); dissimilar definitions of mental disorder among various health professions (Chapter 6); types of familial responsibility in caring for family members with dementia (Chapter 7); types of moral reasons families use to justify their care of relatives with dementia (Chapter 8); ways advance directives can retain or lose their validity (Chapter 9); types of implicit and explicit guides in treatment decisions (Chapter 10); efficacy of different physician-client relationships in treating Prader-Willi syndrome (Chapter 11); divergent roles of those involved in psychiatric advance directives (Chapter 12); reasons women with anorexia give to refuse life-saving interventions (Chapter 13); criminal offenders’ abilities to reason morally (Chapter 14); and reasons why the decision making of seniors is not preceded by competency assessments by clinicians (Chapter 15).

To demonstrate the relevance of empirical ethics for psychiatry, let me summarize two of the eleven research chapters. In chapter 5, the author tackles a common occurrence: patients who do not want to be moved from a psychiatric hospital to the community. Such patient refusal seems antithetical to hospitals’ efforts over the past decade to replace practices reflecting custodial care of the “mentally ill” with practices reflecting rehabilitative care of individuals living with a mental illness. Pols evaluates two familiar paradigms for today’s individualized care: promoting patient independence versus honoring their preferences. She concludes that both paradigms unintentionally overlook an important value that can help explain the reluctance of hospitalized patients to move into the community. The study discussed in Chapter 15 responds to the recent Dutch Civil Code, which includes guidelines for valid healthcare decisions by patients and professionals. Since competency (or “capacity” in many jurisdictions) is essential to informed consent, Welie is surprised by her initial study of two geriatric/psychogeriatric wards wherein the clinicians did not assess patients in terms of their competency for decision making. This finding prompts Welie to revisit the Code to see whether any exceptions are countenanced. The author uses a systematic apologetic approach to try to legally and ethically defend professionals who do not assess their patients. In support of insightful and skillful psychiatric practice, both chapters demonstrate the usefulness of researching everyday practices in terms of their explicit-implicit and coexisting- conflicting ethical dimensions and then critiquing them in terms of their defensibility or lack thereof.

Traditionally, the field of ethics has involved two subareas: theoretical ethics and applied ethics. Empirical Ethics helps bridge these two ways, as successfully argued in the book. The shortcomings of the book are few, yet noteworthy. Section 1 would have benefited by including a political theorist, such as Foucault, as part of the theoretical justifications. This is critical for mental health and addiction care, given the significant role and impact of governments as protector versus controller, judiciaries as punisher versus liberator, and societal discrimination. A study of individuals coping with substance use/abuse disorders should have been a part of Section 2 in order to be more reflective of the typical practice of psychiatrists and related professions. Additionally, a reader might feel he is “left hanging” because there is no conclusion that synthesizes the eleven studies or reconnects them with the main points of Section 1. Nevertheless, the book accomplishes its three goals handily, and thereby constitutes a valuable contribution to psychiatric ethics.

+Book review accepted for publication June 2008 (doi: 10.1176/appi.ajp.2008.08050741).

+Reprints are not available; however, Book Forum reviews can be downloaded at http://ajp.psychiatryonline.org.




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