Date Released: 2000
Page Count: 248
Isbn10 Code: 0880489995
Isbn13 Code: 9781585628285
From The New England Journal of Medicine The Declaration of Madrid was approved by the General Assembly of the World Psychiatric Association in 1996 as a set of principles and guidelines on ethical issues relevant to psychiatry. In Ethics, Culture, and Psychiatry, a distinguished international panel of contributing authors offers a compendium of discussions of the applicability of the declaration's standards and guidelines in a variety of social contexts. Although this book discusses ethical pitfalls specific to the field of psychiatry, it is broadly relevant to various clinical disciplines. Chapters not only review the ethical principles governing clinical practice with respect to the individual patient and his or her associated community but also explore the moral imperatives to attack the social roots of mental illness and to advocate the equitable distribution of resources. The book amply demonstrates that some overarching ethical standards apply universally to the practice of psychiatry, whereas other ethical standards governing the patient-doctor relationship are specific to the cultural and historical situation. Indeed, the pedigree and development of the ethical standards outlined in the book suggest the influence of local social values, as well as biotechnological advances. A prime example is the evolution of the notion and practice of informed consent, detailed in a fascinating chapter by Jochen Vollmann. By providing numerous examples of cultural contexts that seriously challenge the applicability of a universal code of ethics, the book calls into question the "one-size-fits-all" standard implied in the Declaration of Madrid. Specifically, the authors explore the variability in appropriate standards of patient autonomy, informed consent, and confidentiality given diverse historical and cultural contexts. Indeed, this book contains many interesting chapters about culturally particular ethical challenges: the "double agentry" inherent in managed care in the United States, the Japanese expectation that in many instances the patient should not be "burdened" with diagnostic information and choices of therapies, and the nearly inflexible insistence on patient autonomy in Denmark, which sometimes undermines optimal access to treatment for the mentally ill. The authors describe a spectrum of cultural attitudes toward personal agency in health care decision making, ranging from extreme support of patient autonomy (e.g., in the United States and in Scandinavian countries) to a more family-centered approach (e.g., in sub-Saharan African countries, where, by custom, a woman may need her husband's permission to follow medical advice). Indeed, it will become clear to the American reader that our own emphasis on autonomy is peculiar to European and American cultures. In many other regions, the family -- not the patient -- has considerable authority over decisions about health care. Unfortunately, the authors miss the opportunity to explore fully the complex dilemmas posed when the interests of the patient and his or her community or family conflict. For example, it is suggested that a patient be given the opportunity to "choose" between patient-centered and family-centered approaches to decision making, but it is quite possible that patients would not feel sufficiently empowered to advocate for themselves in cultures that discourage independent behavior. In such a situation, if the family chooses a treatment that puts the welfare of the family above that of the patient, the clinician may be confronted with the dilemma of whether to support the interests of the family or those of the patient. Such conflicts involving the resources of the community, the needs of the family, and the well-being of the patient surely present themselves frequently in culturally pluralistic societies such as ours. Readers with expertise or interest in the social sciences will be disappointed that many of the cultural analyses lack sophistication and fail to draw on the vast medical-anthropologic literature on clinical encounters in a variety of cultural settings. In particular, there is little discussion of how the therapeutic goals of Western biomedical psychiatry may interact or, indeed, conflict with those of folk medicine and popular health care practices. The book's greatest shortcoming is that no synthesis of the common ground and divergent ideas is offered at the end, nor does the reader gain sufficient direction in applying this wealth of information to clinical practice. The thorny issues that are raised remain unresolved. This is a discussion well worth continuing; perhaps a sequel by the same scholars will feature its next iteration. In an increasingly multicultural society, most clinicians in the United States routinely encounter many of the ethical dilemmas probed in this book. They will, no doubt, find the content of this edited work compelling and thought-provoking reading that is broadly relevant to clinical practice and research. Anne E. Becker, M.D., Ph.D. Copyright © 2001 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS. Review "[T]his is a book that will be food for thought as international ethics in psychiatric practice is debated in the future."-- "Journal of Clinical Psychiatry 62:8, ", "August 2001"
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