Ethics, Culture, and Psychiatry: International Perspectives

As psychiatry emerges from the Decade of the Brain engulfed by almost daily developments in neuroscience, it is easy to forget that ethics is at the heart of all medical practice. Rapid scientific developments can obscure the more important role of ethics. The editors of this volume are to be congratulated for recognizing and fulfilling an obligation to the field.

Psychiatric ethics suffers from the fact that ethical values differ among cultures. That which is highly valued in one setting may not be highly valued in another. The editors have addressed this problem by inviting experts from different cultural backgrounds to present culturally relevant material. It often seems to the practitioner of psychiatry that ethical practice is simple—just do the right thing! Reading these chapters is humbling in that it becomes quite clear that what is the right thing in one culture is not in another. This does not mean that there are no generally agreed-on fundamentals, but there are many, many important variations.

The editors reserve some chapters for specific topics such as informed consent. These specific areas are complex, and the authors do an excellent job of presenting the material in a measured and thoughtful, as well as thought-provoking, fashion. The reader will leave this volume not only better informed but also stimulated to reflect on these important issues.

An example may help to illustrate the complexity of the problems faced. In many parts of the West it is considered unethical to perform a placebo-controlled trial if there is in fact an effective treatment. Recently, an HIV trial was to be conducted in Sub-Saharan Africa, where the problem of AIDS is pandemic. The investigators wished to find out if significantly lower than usual doses of retroviral medications would be more effective than placebo. If in fact this were true, the cost of treatment could be markedly reduced. Was it ethical to withhold the treatment from the placebo control group? Are the potential results of sufficient importance to override these concerns? Clearly, thoughtful individuals could differ in their conclusions. There will always be a tension between the rights of the individual and the rights of the group.

There is one issue that is omnipresent in the volume but never resolved. Is there a universal, unchanging Code of Ethics—whether God-given or arrived at by human consensus—or is there an evolving code that varies as a function of time and place? Students of ethics disagree on this question, yet its importance is real. Perhaps the best resolution is to recognize that there are components of a universal Code of Ethics that will be applied differently in different settings as a function of culture and resources but that other components will vary dramatically over time.