Psychiatry requires a greater knowledge of
ethics than many other medical specialties. Its practice is keenly sensitive to
cultural nuances and the prevailing socio-political milieu. Consequently, the
World Psychiatric Association developed, in 1996, the Declaration of Madrid – a
broadly prescriptive code of ethics intended to guide psychiatric practice.

This book arose from that project. It is an
edited collection of opinions from an international selection of prominent
psychiatrists. The essays thus cover a range of different cultural perspectives
on ethics and psychiatry. Descriptions of psychiatric differences across
cultures are well handled and manage to avoid the cataloguing of culture-bound
syndromes! With varying degrees of success, most authors also grapple with
ethical relativism, although they do not generally address the formulation of
the Declaration of Madrid.

A number of the chapters in this collection
stand out. Okasha’s comparison of the influence of family and religion on
psychiatry in Arab culture is excellent. Using culture as a starting point,
Okasha examines a communitarian ethics in which family decision-making
supersedes personal autonomy. Similarly, Arboleda-Flórez and Weisstub summarise
cultural differences in Latin America, addressing illness meaning and illness
behaviour, and the cultural expression of values in modulating these. Both
chapters acknowledge the generality of such comments, subsuming many
heterogeneous populations.

The historical background of the rise of
managed care empires in the USA is discussed well by Alarcon, with an
examination of the effects of cost-containment on the ethics and practice of
psychiatry. Chapters on psychiatry in China and Japan provide good
epidemiological information and particularly interesting explanations of the
understanding of mental disorder in these cultures. Both chapters, however,
conspicuously lack any comment about the political abuse of psychiatry (China)
and the history of appalling treatment of inpatients (Japan).

The final section of the book provides two
chapters by German authors, on informed consent and research on incompetent
patients. Both of these chapters draw on an extensive literature in German,
much of which is untranslated, although Hans-Martin Sass has disseminated some
of this material previously. The strength of these chapters is in illustrating
the evolution of policies underpinned by ethical principles but influenced by
contemporaneous cultural attitudes. The final chapter takes a more global
overview and addresses mental health law reform in the light of human rights,
modern economies and changes in mental health policy in the last fifty years.

This collection of essays is a fascinating
overview of the influences on psychiatry in many countries. It does not have a
cohesive focus, and it does not answer any questions, notably that of ethical relativism.
The content is at times inconsistent in quality. It doesn’t have a great deal
to do with the Declaration of Madrid. But what it does do is link up recent
history, disparate cultures, and the changing ethical terrain in which
psychiatry is located, and provide a provocative and stimulating picture of
psychiatry at the turn of the century.

It is strongly recommended to those with an
interest in psychiatric ethics, although with qualification. Most of all, it is
recommended to mental health professionals and medical students as a resource
for teaching, and as a book to dip into at random. Used in this way, it will
provide much food for thought, and a delightful escape from daily exigencies.

© 2002 Danny Sullivan

Danny Sullivan graduated in
medicine in Australia in 1994. He has since completed a Masters Degree in
Bioethics and a Masters Degree in Medical Law. He is training in psychiatry at
the Maudsley Hospital and Institute of
Psychiatry in London, UK, and remains an Honorary Research
Associate of Monash University.

Categories: Ethics, MentalHealth

Tags: Cross-Cultural Resources, Psychiatry