Ethics in Psychiatry (eBook)

Acknowledgement 6
Contents 7
Contributors 10
Introduction 13
Part I The Context 17
1 Societal Framework of Psychiatry 18
1.1 Society and the Individual 18
1.2 Society and the Mentally Ill Individual 20
1.3 Conclusion 23
References 23
2 Stigmatisation of People with Mental Illness and of Psychiatric Institutions 26
2.1 Introduction 27
2.2 Defining Terms 27
2.2.1 Stigma 27
2.2.2 Ignorance: The Problem of Knowledge 29
2.2.3 Prejudice: The Problem of Negative Attitudes 29
2.2.4 Discrimination: The Problem of Rejecting and Avoidant Behaviour 30
2.2.5 Structural Discrimination 30
2.3 Global Patterns of Stigma 31
2.4 Stigmatisation and Human Rights in Psychiatric Institutions 34
2.5 Conclusion 41
References 42
3 Economical Framework of Psychiatric Care 48
3.1 Introduction 49
3.2 Ethical Framework for the Mentally Ill 49
3.3 The Economical Framework of Psychiatry 51
3.3.1 Four Models for Access to Mental Health Care 51
3.3.2 The Birth of Evidence Based Psychiatry 52
3.3.3 Evidence Based Guidelines 54
3.3.4 Policy Decisions Based on Cost Effectiveness 55
3.4 Moral Implications and Ethical Pitfalls: Ethical Aspects of Standardisation of Psychiatric Care 56
3.4.1 Equity Versus Restriction of Resources for the Mentally Ill 56
3.4.2 Guideline Versus Autonomy of the Patient 57
3.4.3 Managed Care: Interference in the Patient--Physician Relationship 58
3.4.4 Marketing Strategies of Pharmaceutical Companies: Interference with Treatment Strategies 59
3.4.5 Interference with Treatment: What Can the Psychiatrist Do Against It? 59
3.5 New Developments 60
3.5.1 The Autonomous Patient: New Developments and Ethical Controversies 60
3.5.2 Patient Preference as a Concept Incorporated in Research 61
3.5.3 The Contribution of the Patient to Society as a Factor: Return to Work as Treatment Result 62
3.6 Ethical Arguments 62
3.6.1 Micro Level 63
3.6.2 Meso Level 63
3.6.3 Macro Level 64
3.7 Summary 65
References 66
4 Conflicts of Interest 70
4.1 Introduction 71
4.2 Financial Conflicts of Interest in Psychiatry 72
4.2.1 Prevalence 72
4.2.2 Disclosure 73
4.2.3 Scientific Societies and the Drug Industry 73
4.2.4 Clinical Practice Guidelines and the Pharmaceutical Industry 73
4.2.5 Attendance to Drug Sponsored Scientific Events and Prescription of the Sponsor's Medication 74
4.2.6 Pharmaceutical Sponsorship and Clinical Trial 74
4.2.7 Data Ownership 75
4.2.8 Marketing and Advertising 75
4.2.9 Ghostwriting 76
4.2.10 Implications of Conflicts of Interests 76
4.2.11 Operational Proposals 78
4.3 Non Financial Conflicts of Interest 82
4.4 Conclusions 84
References 85
5 Between Legislation and Bioethics: The European Convention on Human Rights and Biomedicine 88
5.1 Locating the Convention on Human Rights and Biomedicine 89
5.2 Context of and Background to the Convention on Human Rights and Biomedicine 91
5.3 Content of the Convention on Human Rights and Biomedicine 93
5.3.1 Article 3: Equitable Access to Health Care 94
5.3.2 Article 5: General Rule re Consent 95
5.3.3 Article 6: Protection of Persons Not Able to Consent 95
5.3.4 Article 7: Protection of Persons Who Have a Mental Disorder 96
5.3.5 Article 9: Previously Expressed Wishes 96
5.3.6 Article 10: Private Life and Right to Information 97
5.3.7 Articles 15--17: Scientific Research 98
5.3.8 Article 28: Public Debate 99
5.4 Influence of the Convention on Legislative Mechanisms 100
5.4.1 Country-Based Patient Rights Legislation 100
5.4.2 The Challenge of Harmonization 101
5.4.3 European Court of Human Rights 103
5.5 The Broader Terrain 104
5.5.1 What Is the Relationship Between Human Rights and Bioethics? 104
5.5.2 Can Rights Undermine Ethics? 106
5.5.3 What Is the Relationship Between Biomedicine and Society? 107
5.6 Conclusion 108
References 109
6 Ethics Committees for Clinical Research -- The West-European Paradigm 112
6.1 Introduction 112
6.2 Legal Basis of Research Ethics Committees 113
6.3 Scope 116
6.4 Responsibilities of Research Ethics Committees 117
6.4.1 Scientific Quality 117
6.4.2 Legal Aspects 118
6.4.3 Ethical Acceptability 120
6.4.4 Relation to Authorities 121
6.5 Legal Binding Force of RECs Decisions 121
6.6 System of Appeal 121
References 122
7 Clinical Ethics Committees and Ethics Consultationin Psychiatry 123
7.1 Introduction 123
7.2 Clinical Ethics Committees in Psychiatry 126
7.3 Clinical Ethics Consultation and Psychiatric Consultation Services 127
7.4 Structures 128
7.5 Implementation 129
7.6 Duties and Responsibilities 131
7.6.1 Clinical-Ethical Consultation for Individual Cases 131
7.6.2 Development of Guidelines 133
7.6.3 Training and Advanced Training Workshops and Seminars 134
7.6.3.1 Training for Specific Professional Groups 134
7.6.3.2 Ethics Café/Ethics Salon 135
7.6.3.3 Ethics Day 135
7.6.3.4 Hospital Newspaper 135
7.6.3.5 ''Ethics Ring Folder'' 135
7.6.3.6 External Training Courses 136
7.7 Professionalisation 136
7.8 Outlook 137
References 138
Part II Principles of Ethics in Psychiatry 140
8 Ethical Principles in Psychiatry: The Declarations of Hawaii and Madrid 141
8.1 Ethical Principles: Declarations, Codes, and Law 142
8.1.1 Normative Principles in Ethics and Law 142
8.1.2 Ethical Principles and the Socio-Cultural Context 142
8.2 The Declaration of Hawaii 143
8.3 Steps for a Revision of the Declaration of Hawaii 144
8.4 The Declaration of Madrid 145
8.5 Societys Reaction 145
8.6 Reflections of a Clinician 148
8.7 Perspectives 148
References 149
9 Informed Consent in Psychiatric Practice 150
9.1 Introduction 151
9.2 Components of Informed Consent in Practice 151
9.3 The PatientPsychiatrist Relationship as the Context of Informing the Patient 152
9.4 Procedures: Informing the Patient Why? What About? How? When? And by Whom? 153
9.4.1 Why? 153
9.4.2 What About? 154
9.4.3 How? 154
9.4.4 When? 155
9.4.5 By Whom? 155
9.5 Informed Consent and Ethical Conflicts 155
9.6 Conclusion 157
References 157
10 Advance Directives: Balancing Patient'sSelf-Determination with Professional Paternalism 158
10.1 The Case 158
10.2 Changing Values and Wishes: The Old and the New Person 160
10.3 Models of Advance Care Documents and Directives 161
10.3.1 Episodically Compromised Patients 162
10.3.2 Permanently Compromised Patients 162
10.3.2.1 Community Based Standard 162
10.3.2.2 Provider Based Standard 163
10.3.2.3 Dispositional-Preference Standard 163
10.3.2.4 Precedent Autonomy 164
10.3.2.5 Ulysses Contracts 164
10.3.2.6 Proxy Model 164
10.4 Narratives and Other Methods to Establish Value-and-Wish Profiles 164
10.4.1 Ulysses Contracts 165
10.4.2 Negotiations 165
10.4.3 Narratives 165
10.5 Balancing Paternalism and Self-Determination 167
References 169
11 Confidentiality 171
11.1 Introduction 172
11.2 Ethical and Legal Foundation 172
11.2.1 Principles 172
11.2.2 The Ethical Basis of Privacy and Confidentiality 173
11.2.2.1 Ethical Justifications 173
11.2.2.2 Ethical Boundaries to Confidentiality 174
11.2.3 The Legal Basis of Privacy and Confidentiality 174
11.2.3.1 Privacy and Confidentiality in Law 174
11.2.3.2 Legal Boundaries to Privacy and Confidentiality 176
11.2.3.3 Country Specific Legislation and Their Commonalities 177
11.2.4 Vulnerability 178
11.2.4.0 The nature of vulnerability 178
11.2.5 Balanced Decision-Making 179
11.3 Good Practice in the Protection, Uses and Disclosure of Patient Identifiable Information 179
11.3.1 Protection, Use and Disclosure of Patient Information -- General Considerations 179
11.3.1.1 Patient Consent 180
11.3.1.2 Circumstances Where a Patient Is Unable to Consent 180
11.3.1.3 Disclosure to Protect Interests that Override the Patient's Right to Confidentiality 181
11.3.1.4 Disclosure After a Patient's Death 181
11.3.1.5 Patient Access to Their Healthcare Records 181
11.3.2 Protection, Use and Disclosure of Patient Information for Their Healthcare 182
11.3.2.1 Keeping Patients Informed 182
11.3.2.2 Consent to the Use and Disclosure of Patient Information 182
11.3.2.3 Clinical Audit 182
11.3.2.4 Disclosure to a Patient's Carers 183
11.3.2.5 Multidisciplinary and Inter-agency Working 183
11.3.2.6 Dual Roles and Obligations 184
11.3.3 Protection, Use and Disclosure of Patient Information for Healthcare Purposes Not Directly Related to Their Healthcare 184
11.3.3.1 Secondary Uses 184
11.3.3.2 Keeping Patients Informed About Secondary Uses 184
11.3.3.3 Consent for Secondary Use or Disclosure of Confidential Patient Information 185
11.3.3.4 Maintaining Information in a Form Which Protects the Identity of the Patient 186
11.3.4 Obligations and Justifications for the Disclosure of Patient Identifiable Information for Purposes Not Related to Their Healthcare 186
11.3.4.1 Legal Obligations to Disclose 186
11.3.4.2 Justifications to Disclose 187
11.3.5 Security of Patient Information 188
11.4 Conclusion 188
References 189
12 Justice in Access to and Distribution of Resources in Psychiatry and Mental Health Care 190
12.1 Introduction 191
12.2 Necessary Care 192
12.3 Solidarity 195
12.4 Allocation on the Basis of Need 196
12.5 Outcome-Oriented Approaches 198
12.6 Cost-Effectiveness in Mental Health Care 200
12.7 Evidence-Based Medicine 202
12.8 Conclusion 204
References 204
Part III The Applications of the Ethical Principles in Psychiatric Practice and Research 206
13 Ethics of Diagnosis and Classification in Psychiatry 207
13.1 Introductory Remarks About Diagnosis and Classification 207
13.2 Description of Psychopathological Phenomena 209
13.3 Formulating Psychiatric Diagnoses 209
13.4 Value Conceptions in Psychiatric Classifications 210
13.5 Culturally Specific Diagnoses 210
13.6 The (Psychiatric) Illness Concept 211
13.7 The Consequences of Psychiatric Diagnosis and Classification for the Individual Person 212
13.8 Illness and Ill Being 213
References 214
14 Competence Assessment 216
14.1 Definition of Competence 217
14.2 Areas of Competence 218
14.2.1 Informed Consent 218
14.2.2 Advance Directives 220
14.2.3 Testamentary Competence 221
14.2.4 Driving Competence 221
14.3 Factors Affecting Competence 222
14.3.1 Physical Factors 222
14.3.2 Mental Factors 224
14.4 Problem of Undue Influence 225
14.4.1 Social Environment of the Testator 226
14.4.2 Factors of Potential Influence 227
14.4.3 Context of Capacity Assessment or Making the Will 227
14.5 Structured Assessments of Competence 228
14.6 Conclusion 230
References 231
15 General Overview of Ethical Issues in Psychiatric Treatment 234
15.3 Development of Therapeutic Interventions Through Research 237
15.4 Therapy and Research: The Therapeutic Misconception 239
15.5 Conclusion 240
References 240
16 Prevention and Early Treatment 242
16.1 The Prevention Paradigm 243
16.2 Cost-Benefit Estimation of Early Risk Assessment 250
16.3 Cost-Benefit Estimation of Early Intervention 255
16.4 Cost-Benefit Estimation of Prevention Research 260
16.5 Conclusion 264
References 264
17 Ethical Implications of Psychopharmacotherapy 270
17.1 Introduction 271
17.2 Practice: Clinical Applications of Established Treatments 271
17.2.1 Short-Term Medication 272
17.2.2 Long-Term Medication 273
17.2.3 An Example: The Application of Antidementive Drugs 274
17.2.3.1 Ethical Analysis 275
17.2.4 Conclusion 277
17.3 Research: Clinical Trials of New Interventions 278
17.3.1 Need for Research 278
17.3.2 The Example of Placebo-Controlled Clinical Trials 278
17.3.2.1 Pros 279
17.3.2.2 Cons 280
17.3.2.3 Specific Applications 281
17.3.3 Conclusion 282
References 284
18 Ethical Problems in Psychotherapy 287
18.1 Introduction Treatment Errors and Ethical Problems 287
18.2 Specific Ethical Implications of Treatment Difficulties and Errors 288
18.2.1 Diagnosis and Determination of Indication 288
18.2.2 Treatment Planning 289
18.2.3 Informed Consent 290
18.2.4 Concluding a Psychotherapeutic Treatment 291
18.2.5 Surrounding Economic Conditions 292
18.3 Ethical Requirements of the Therapist 293
18.3.1 Different Standards in the Profession of Psychotherapists 293
18.3.2 Professional Discretion and Protection of Intimacy 293
18.3.3 Difficulties in the Psychotherapeutic Practice 294
18.3.4 Misbehaviour of the Psychotherapist 295
18.3.4.1 Exploiting Behavior 295
18.3.4.2 Acting Out One's Own Needs 296
18.3.4.3 Violating the Rule of Abstinence -- Sexual Misuse 296
18.3.4.4 Acting Out One's Own Need for Dominance 297
18.3.4.5 The Patient as the Therapist's Own Object in the Regulation of His Narcissistic Balance 298
18.3.4.6 The Narcissistic Overrating of the Chosen Treatment Method 298
18.3.4.7 Value Concepts and Ideologies 299
18.4 Ethical Consequences for the Therapeutic Practice 301
References 301
19 Neuromodulation ECT, rTMS, DBS 304
19.1 Introduction 305
19.2 Misleading Criteria 305
19.2.1 Invasiveness 305
19.2.2 Identity 306
19.2.3 Early Psychosurgery 307
19.3 Ethical Criteria for Psychiatric Neuromodulation 307
19.3.1 ECT 308
19.3.1.1 Benefits of ECT 308
19.3.1.2 Potential Harms of ECT 309
19.3.1.3 Respecting the Patient's Preferences in ECT 310
19.3.1.4 The Ethical Problem of ECT Undertreatment 311
19.3.2 rTMS 311
19.3.2.1 Benefit of rTMS 312
19.3.2.2 Potential Harms of rTMS 313
19.3.2.3 Respecting the Patient's Preferences in rTMS 314
19.3.2.4 rTMS in the Future 314
19.3.3 DBS 315
19.3.3.1 Benefit of DBS 316
19.3.3.2 Potential Harms of DBS 317
19.3.3.3 Respecting the Patient's Preferences in DBS 318
19.3.3.4 Portraying 'DBS Miracles' to the Public 319
19.4 Conclusion 319
References 320
20 Coercive Measures 326
20.1 Preliminary Remarks 327
20.2 Compulsion 327
20.2.1 Involuntary Hospitalization and Inpatient Treatment 328
20.2.2 Compulsion in the Community ) Involuntary Outpatient Treatment )IOT) 329
20.2.3 Patients' Retrospective Attitudes to Compulsion 330
20.3 Coercion: Threats and Offers 331
20.3.1 Offers Versus Threats 331
20.3.2 Deception 332
20.3.3 Exploitation 332
20.3.4 Unwelcome Predictions 332
20.4 Inducements 333
20.4.1 Inducements in Mental Health Services 333
20.4.2 Problematic Inducements 333
20.5 Justifications for Coercive Interventions in Mental Health Care 334
20.5.1 A Framework Applicable Across the Whole Range of Interventions 334
20.5.2 A 'Capacity-Best Interests' Framework 335
20.5.3 The Protection of Other Persons 337
20.6 Reducing the Need for Coercive Interventions 338
20.6.1 Involving Patients in Treatment Decisions 338
20.6.1.1 Advance Statements 339
20.6.1.2 Crisis Cards 339
20.6.1.3 Joint Crisis Plans 339
20.6.1.4 Psychiatric Advance Directives 340
20.6.2 Interventions Aimed at Reducing Coercive Interventions on Hospital Wards 341
20.7 Conclusions 342
References 342
21 Ethics of Deinstitutionalization 346
21.1 Deinstitutionalization 347
21.2 Beauchamps Ethical Grid Extended 349
21.3 Ethical Drivers for Deinstitutionalization in Europe 351
21.4 Ethical Issues in Deinstitutionalized Mental Health Care 355
21.4.1 Rehabilitation and Recovery 356
21.4.2 Assertive Outreach 358
21.4.3 Community Treatment Orders )CTOs) 359
21.5 Reinstitutionalisation 360
21.6 Case History 362
21.7 Conclusions and Outlook 363
References 364
22 Ethical Issues in Forensic and Prison Psychiatry 367
22.1 The Dual-Role Dilemma in Forensic Psychiatry 368
22.2 European Perspective 368
22.3 The Role of a Forensic Psychiatrist 369
22.3.1 The Forensic Psychiatrist as Expert Witness 369
22.3.1.1 Ethical Issues 370
22.3.1.2 Practical Aspects of Forensic-Psychiatric Assessments 371
22.3.2 Risk Assessment 373
22.3.2.1 Ethical Issues 373
22.3.3 Forensic-Psychiatric Treatment 374
22.3.3.1 Ethical Issues 375
22.4 Prison Psychiatry 376
22.4.1 Principle of Equivalence 376
22.4.2 Ethical Issues 377
22.4.3 Consent to Treatment 379
22.4.3.1 Compulsory Treatment 380
22.4.4 Confidentiality 380
22.5 Research 381
References 382
23 Treatment of Substance Dependence 385
23.1 The Ethical Dimensions 386
23.1.1 The Ethical Basis 386
23.1.1.1 Consequential Ethics 386
23.1.1.2 Human Rights 386
23.1.1.3 Medical Ethics 387
23.1.2 Societal Values at Stake 388
23.1.2.1 Citizen's Obligations 388
23.1.2.2 Public Safety, Public Order 388
23.1.2.3 Socio-Cultural Acceptability of Behavior 388
23.1.3 Personality Values at Stake 389
23.1.3.1 Self-Fulfilment and Needs Satisfaction 389
23.1.3.2 Self-Responsibility and Freedom of Choice 389
23.1.3.3 Self-Limitation of Pleasure Seeking Behavior 390
23.2 Treatment of Substance Dependence Ethical Aspects 390
23.2.1 Substance Dependence ? Disorder or Misbehavior? 390
23.2.1.1 The Medical Concept 390
23.2.1.2 Medicalisation of a Social Problem? 391
23.2.1.3 Medical Versus Moral Treatment 392
23.2.2 Principles of Treatment in an Ethical Perspective 393
23.2.2.1 A Hierarchy of Objectives 393
23.2.2.2 Cure or Care? 393
23.2.2.3 Tailoring Treatment to Individual Needs 394
23.2.3 Public Health Interventions Versus Individual Care 394
23.2.3.1 Coverage of Treatment Needs 394
23.2.3.2 Cost-Effectiveness of Interventions 395
23.2.3.3 Risk Reduction 395
23.2.4 Motivation, Neglect, Coercion 396
23.2.4.1 Motivation for Change as a Prerequisite for Treatment 396
23.2.4.2 Accessability and Affordability of Treatment 397
23.2.4.3 Quasi-compulsory and Compulsory Treatment 397
23.2.5 The Case of Agonist Maintenance Treatment 398
23.2.5.1 Rationale and Origins 398
23.2.5.2 Results and Availability 399
23.2.5.3 Concerns and Limitations 400
23.3 Implications and Recommendations: A Final Statement 400
References 400
24 Dementia and End-of-Life Decisions: EthicalIssues -- A Perspective from The Netherlands 405
24.1 Introduction 406
24.2 Dementia, End of Life, and Ethics 406
24.3 Respecting the Individual 407
24.4 End of Life Decisions 408
24.4.1 A Philosophical Framework for End-of-Life Decisions 408
24.4.2 Non-Treatment Decisions 409
24.4.2.1 Forgoing Artificial Nutrition and Hydration 409
24.4.2.2 Refusal of Treatment by Patient or Representative 410
24.4.2.3 Medically Futile Treatment 410
24.4.3 Intensified Alleviation of Symptoms 411
24.4.4 Palliative )or Terminal) Sedation 411
24.4.5 Active Termination of Life on the Request of the Patient 412
24.4.5.1 Hopeless/Interminable Suffering 414
24.4.5.2 Unbearable/Unendurable Suffering 415
24.4.6 Ending Life Without Request of the Patient 416
24.5 Advance Directives 416
24.5.1 Empirical Data on Advance Directives 417
24.5.2 Dementia, Advance Directives and Personal Identity 418
24.5.3 'Actual' and 'Hypothetical' Decisions 419
24.6 How to Decide: Making Decisions for Persons with Dementia 420
24.7 In Conclusion 420
References 421
25 Ethics of Research with Decisionally Impaired Patients 425
25.1 Introduction 425
25.2 Basic Ethical Conflicts of Conducting Research on People 426
25.3 Basic Legitimising Factors for Conducting Research on People 426
25.3.1 Benefit for Present Patients and Groups of Patients 427
25.3.2 Risk Mitigation for Future Patients 428
25.3.3 Minimal Risk as a Protective Measure 428
25.3.3.1 The Risk of ?Daily Life? as a Parameter? 429
25.3.3.2 The Term ?Mere Inconvenience? as an Alternative? 430
25.3.3.3 The Minimal Risk as a Relational Term 430
25.3.4 Duty of Solidarity of Decisionally Impaired Patients? 432
25.3.5 Violation of Human Dignity? 435
25.4 Conclusions 437
References 438
26 Ethical Concerns in Carrying Out Surveys of PsychiatricMorbidity 440
26.1 Introduction 441
26.2 Ethics Committees 442
26.3 Sampling 443
26.3.1 Coverage 443
26.3.2 Principles of Sample Selection in Psychiatric Survey Research 444
26.4 Informed Consent 444
26.5 Ensuring that Consent Is Informed 445
26.5.1 Sending an Advance Letter Followed by an Interviewer Visit 447
26.5.2 Opting-Out in Response to a Letter 447
26.6 Content of the Advance Letter 448
26.6.1 The Title of the Survey 448
26.6.2 Pledge of Non-disclosure 448
26.7 On the Doorstep 448
26.8 Conducting the Interview 449
26.8.1 Sampling of Individual Within the Household or Interviewing All Household Members 449
26.8.2 Competence of the Selected Respondent to Give Consent 449
26.8.3 Competence of the Selected Respondent to be Interviewed 450
26.8.4 Use of Proxy Informants 450
26.8.5 Asking Sensitive Questions 451
26.8.6 Requests for Help 451
26.8.7 Follow Up Interviews by Clinically Qualified Professionals Such as Psychologists and Psychiatrists 451
26.8.8 Requests to Change or Destroy Part of the Interview 452
26.9 Effect of Survey Participation 452
26.9.1 Effect on the Survey Respondent 452
26.9.2 Safety of Interviewer 453
26.9.3 Effect on the Interviewer 453
26.10 Confidentiality of Respondents Answers 454
26.10.1 Questions Relating to Suicide 454
26.11 Psychiatric Morbidity Survey Data 454
26.11.1 Anonymisation and Confidentiality 454
26.12 Preventing Disclosure from Published Data 455
26.13 Surveys on the Mental Health of Children 455
26.13.1 Revised Pledge of Confidentiality 456
26.13.2 Child Consent Form 456
26.13.3 Cases of Abuse 456
26.14 Psychiatric Morbidity Surveys Among Elderly People 457
26.15 Psychiatric Morbidity Surveys Among Prisoners 458
26.15.1 Type and Place of Interviews 458
26.15.2 Confidentiality 458
26.15.3 Safety 458
26.16 Psychiatric Morbidity Surveys Among Homeless People 459
26.17 Psychiatric Morbidity Surveys Among Samples Identified Through Health Services 459
26.18 Conclusions 459
References 460
27 Genetics Ethical Implications of Research, Diagnostics and Counseling 462
27.1 Introduction 463
27.1.1 Hopes and Expectations 464
27.1.2 Fears and Challenges 464
27.2 The Genetic Background 467
27.2.1 Variation Within the Human Genome 467
27.2.2 Genetic Mechanisms, Simple Modes of Inheritance 468
27.2.3 Multifactorial Inheritance 469
27.2.4 Genotype--Phenotype Relationship 469
27.2.5 Chromosome Disorders 470
27.2.6 The Future of Genetic Diagnostics 471
27.3 Genetic Counseling 471
27.4 Important Opinions on the Ethics of Psychiatric Genetics 472
27.5 Ethical Issues in the Application of Genetics to Mental Disorders 472
27.5.1 Genetics as a Diagnostic Tool 473
27.5.2 Predictive Diagnosis 473
27.5.3 Genetic Testing in Children 474
27.5.4 Examination of a Child in the Interests of a Healthy Relative 475
27.5.5 Prenatal Diagnosis )Amniocentesis, Chorionic Villous Biopsy) 476
27.5.6 Genetic Screening in Newborns and Children 477
27.5.7 Screening for Late Onset Genetic Disorders 478
27.5.8 Heterozygosity Screening 478
27.5.9 'Over the Counter' Genetic Testing 479
27.5.10 Unexpected Findings 480
27.6 Research in Psychiatric Genetics 481
27.6.1 Biobanks 481
27.6.2 Prospective Cohort Studies at the Population Level 482
27.6.3 Systematic Disease-Oriented Genetic Research -- The Danish Paradigm 483
27.6.4 Experience from Iceland 483
27.6.5 The Opinion of the General Population and Patients with Mental Disorders 484
27.7 Outlook and Conclusions 484
References 485
Part IV Nonmedical Uses of Psychiatry 488
28 Political Abuse of Psychiatry 489
29 Abuse of Psychiatry for Political Purposes in the USSR: A Case-Study and Personal Account of the Efforts to Bring Them to an End 491
29.1 Introduction 492
29.2 Why Was Soviet Psychiatry Abused Politically 494
29.3 The Campaign Against Soviet Political Psychiatry 497
29.4 The International Community Becomes Involved 498
29.5 The WPA World Congress in Honolulu 501
29.6 The Soviets Leave the WPA 502
29.7 Secret Negotiations 503
29.8 The Soviets Return to the WPA While the Country Disintegrates 505
29.9 The Soviet Lesson 507
29.10 Conclusion 508
References 508
Documents 509
30 Neuro-Enhancement 510
30.1 Preliminaries 511
30.1.1 Conceptual Questions 511
30.1.2 A Short History of the Recent Enhancement Debate 512
30.2 Foreseeable Neuro-Enhancement Options 514
30.2.1 Pharmacological Means 514
30.2.1.1 Cognition: Wakefulness, Learning, Memory and Attention 514
30.2.1.2 Mood and Emotion 516
30.2.2 Technical and Surgical Means 517
30.3 Ethical Issues 517
30.3.1 Enhancing Oneself: Individual and Social Aspects 518
30.3.1.1 Risks and Benefits: Medical and Otherwise 518
30.3.1.2 Autonomous or ?Latently? Coerced Use of Neuro-Enhancement? 519
30.3.1.3 Arguments from Naturalness, Virtue or the Good Life 520
30.3.1.4 Unfairness in Access or Fairness in Compensation? 522
30.3.1.5 Authenticity, Self-Control, and Cheating? 523
30.3.2 Enhancing Others: Special Aspects 524
30.3.2.1 Enhancing Children 524
30.3.2.2 Neuro-Enhancement as a New Domain for Physicians? 526
30.3.3 Neuro-Enhancement as an Issue of Research 527
30.4 Conclusions 527
References 528
Part V Teaching Ethics in Psychiatry 532
31 Teaching Ethics in Psychiatry 533
31.1 Introduction 534
31.2 The Teacher as Moral Agent 534
31.2.1 Self-Awareness and Personal Reflection 534
31.2.2 Conflicts of Interest in Education 535
31.2.3 Transference and Counter-Transference 536
31.2.4 Teachers as Role-Models 536
31.3 Content, Process and Ethics Education 537
31.3.1 Contents of Ethics Education 537
31.3.2 The Significance of Emotion in Ethics Education 538
31.4 Multiple Methods in Ethics Education 538
31.4.1 Adoption of a Multiplicity of Methods 538
31.4.2 Clarity of Textbooks Versus Confusing Reality 539
31.4.3 The 'Ethics Road Show' 539
31.4.4 Humanities and the Arts 540
31.5 Conclusion 540
References 541
Part VI Conclusions and Summary 544
32 Summary and Conclusions 545
1 545
2 547
3 547
4 548
Index 549