The importance of perspectives, alongside principles and casuistry, has been emphasized by the Oxford psychiatrist and bioethicist, Tony Hope, as a key feature of the practice skills model of medical ethics. (35> Ethical reasoning, applied to clinical problem solving in everyday practice, depends on those involved understanding each other's perspectives. This in turn requires sound communication skills. However, communication skills without ethics can be used as readily for bad purposes as for good. Hence the inseparability of ethics and communication as key practice skills.
The significance of perspectives particularly in psychiatric ethics follows directly from psychiatry's inherent diversity of values. In high-tech physical medicine, where differences of values are limited mainly to issues of treatment choice, autonomy means patients 'having a say' in how they are treated. The diversity of values involved in psychiatric diagnosis means that autonomy in psychiatry must be extended to include patients having a say also in how their problems are to be understood. (We owe this clear way of making the point to Dr V. Y. Allison-Bolger.) This is no mere theoretical concern. There is growing evidence, from patients themselves and from the social sciences, of the extent to which the values of users of services—patients and carers—may be different from and conflict with those of providers (36> (see Chapter...!,! and ChapteL2.6,2). Value differences are also important in transcultural psychiatry, (3Z> in relation to religious experience, (38> in the organization and delivery of services/39' and, not least, in researches
The practice skills model is not a consumer model of medical ethics, however, substituting patient hegemony for the traditional authority of doctors. Where values differ no one perspective should take precedence. Instead we should seek a balanced view. This is crucial in psychiatry since many of our deepest ethical questions arise in situations in which patients 'lack insight' (as in involuntary treatment). There is no easy route to achieving the required balance of perspectives. Good communication is essential. So too are the insights offered by patients' narratives and by the social sciences. There is also a key role here for the multidisciplinary team. It is true that conflicts of models within multidisciplinary teams may sometimes be highly disruptive clinically (see Ch.ap.teL1.10.:1), but in the practice skills model the different perspectives represented by members of the multidisciplinary team can make a central contribution to achieving the balance of values which is essential to good practice in psychiatry.
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