The functions of codes

The development of codes in the history of medicine in part reflects their importance in promoting good practice. Some codes have been a direct response to scandals: Perceval's Principles resulted from an unseemly battle among doctors for the control of patient referrals in the Manchester Infirmary; the Nuremberg Statement was formulated in the aftermath of Nazi medical crimes. But codes also have positive functions.

• Protecting and promoting the profession George Bernard Shaw famously described professions as 'conspiracies against the laity.' A professional code may be self-serving—a charter for restrictive practices, protectionist rather than protective. For a profession to function effectively, however, it must be cohesive and collegial. A code which sets out its members' obligations one to another can contribute substantially to achieving this goal. Such codes need not be wholly inward looking. Most codes have emphasized medicine's tradition of commitment and dedication; some call for 'whistle blowing' in appropriate circumstances; and the Declaration of Madrid, adopted by the World Psychiatric Association in 1996, expressly endorses a role for patient empowerment. The protective function of codes has become increasingly important in the international context. Doctors working in oppressive regimes have been supported in their resistance to abusive practices by appeals to internationally accepted codes of practice such as the Declaration of Helsinki.

• Self-regulation A second function of codes is to enhance high standards of practice. Professions are characterized, in part, by a corpus of specialized knowledge and skills, not readily available to others, and offered to a dependent, sometimes vulnerable clientele. (6) To the extent, therefore, that it takes an expert to judge expertise, a degree of self-regulation is essential. But this can become incestuous and must be balanced by external monitoring. In French psychiatry, for example, it took the introduction of a new law to persuade doctors to follow their own code on the requirement to obtain informed consent from their patients/7) Similarly, where bad practice becomes the norm, self-regulation may reinforce it: the abuse of psychiatry to suppress dissent in the former USSR was promoted by leaders of the psychiatric profession.(8) The international context is again important here. As Jim Birley, a former President of the Royal College of Psychiatrists, has put it, an 'open society' is essential if abuses arising in closed systems—whether political, cultural, or administrative—are to be prevented/9)

• Promoting ethical practice It is sometimes argued that an explicit ethical code is unnecessary, implicit disciplines (such as career prospects) and a shared ethos being sufficient to maintain standards. As we have seen, history contradicts this, with codes often appearing as a direct response to a collapse in standards. What kind of codes will best promote good practice varies with circumstances, however. They have therefore differed widely in form and content, ranging from statements of aspirational principles to detailed practice guidelines. The latter are important especially in education and training. The code of the Royal Australian and New Zealand College of Psychiatrists combines general principles with detailed annotations on specific problem areas such as confidentiality and informed consent.(19 Codes also vary in ethical structure. Some are virtue-driven, emphasizing character traits which support good practice. Others are duty-based, prescribing specific responsibilities and obligations.

Codes thus have several functions in psychiatric ethics. These, furthermore, overlap and support each other. For instance, an educational quality is critical if codes are to enhance practice; without adequate standards, self-regulation can degenerate into self-protection; and self-protection ultimately damages the profession.

There are, however, important aspects of psychiatric ethics on which codes are silent. Notable among these are the ethical dimensions of diagnosis. Concepts

The neglect of diagnosis in psychiatric ethical codes is a direct result of their derivation from medical codes. In most areas of medicine, ethical issues are confined largely to problems in management (e.g. treatment choice, resource allocation). Ethical principles of care and competence always apply to the process of diagnosis, of course. But in physical medicine, especially in the 'high tech' areas with which bioethics has been mainly concerned, the disease concepts on which diagnosis is grounded seem straightforwardly scientific in nature. In psychiatry, by contrast, there are a number of important prima facie connections between our diagnostic concepts and ethics.(H,12>

• The ethical justification for involuntary psychiatric treatment turns directly on a diagnosis of mental disorder. This is reflected in mental health law on involuntary treatment which requires, in addition to a risk element, the presence specifically of a mental disorder (see Chap,t§rJ.,:6).

• In criminal law, similarly, the insanity defence, that someone who has committed an offence is not morally responsible for their actions, that they are 'mad not bad', is based on a diagnosis of mental disorder (usually psychotic).

• A number of differential diagnoses in psychiatry involve a moral dimension. The most notorious illustration is the distinction between psychopathic personality (a medical concept) and delinquency (a moral concept). Other medical/moral differential diagnoses include hysteria/malingering and alcoholism/drunkenness.

• Some of the worst abuses of psychiatry, in which it has been used as a means of social control, have been driven by misuses of its diagnostic concepts. In the former USSR, for example, political and other dissidents were often locked away in psychiatric institutions on the basis of 'delusions of reformism'. (8)

These prima facie links between diagnosis and ethics, although more obvious in the case of psychiatry, occur in all of medicine. The psychiatric 'mad not bad' as an excuse in law, for example, reflects the fact that illness in general implies loss of responsibility (an 'off work' certificate mandates sick leave, for instance). The difference between psychiatry and the rest of medicine in this respect is thus one of degree. Nonetheless, the greater prominence of the connections between diagnosis and ethics in psychiatry has led some to regard mental disorder as intrinsically different from physical disorder. In its most extreme form this view underlies antipsychiatric theory according to which mental illness should not be thought of in medical terms at all but solely in moral terms.

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