Rights and responsibilities of the psychiatric profession
Limits of Psychiatry
3rd Medical Faculty, Charles University of Prague, and Psychiatric Center, Czech Republic
Psychiatry is meant to treat suffering individuals - patients. However, aberrant behaviour may be caused also by influences that are properly studied by social sciences. Psychiatry is confronted by the challenge to define the border between the processes treatable by medical discipline and those that should be the focus of regulation by legal, social, educational and counselling policies of the society. The necessity to set the legal rules for involuntary treatment satisfies the need and the requirement of the society. Consequently, the society has to take responsibility for it in a political and legal act. Psychiatry as a branch of medicine, and other scientific and social disciplines, have to collaborate to provide sufficient information for policy makers.
Key words: psychiatry; human rights; ethics
Psychiatrie má sloužit k léčbě nemocných lidí. Nicméně poruchy chování mohou být způsobeny také vlivy, které jsou odpovídajícím způsobem studovány sociálními vědami. Psychiatrie se musí vyrovnat s nárokem na definici hranic mezi tím, co spadá do medicíny a tím, co by mělo být regulováno legálními, sociálními a poradenskými nástroji společnosti. Nezbytnost zákonných pravidel pro nedobrovolnou léčbu uspokojuje potřebu té společnosti, ze které vychází. Společnost za ně nese v právním a politickém smyslu zodpovědnost. Psychiatrie jako součást medicíny má spolu s jinými vědními a sociálními obory spolupracovat a poskytovat tvůrcům politiky dostatečné informace.
Klíčová slova: psychiatrie; lidská práva; etika
Talking about abuse of psychiatry one should ask why just psychiatry among all medical disciplines is subject to being abused and misused by political power. Although this paper does not address the phenomena of abuse of psychiatry directly, it contributes indirectly to the answer on this question.
The limits of privileges and influence of any institution in the society are set by its purpose. Also science is limited by its purpose and also by its accepted definition. For example, medieval scholastics is not a science by modern standards. Any discipline that fails to test hypotheses must fight hard for a scientific status like psychoanalysis. Lack of scepticism revealed in acts of faiths instead of logical structure of inferences from axioms exclude some old fashioned sciences like theology from the authoritative company of modern sciences.
Psychiatry has two aspects:
1. It is a practical medical discipline employed to diagnose and treat mental disorders.
2. It is a medical science, which investigates the origins, the course and the outcome of the mental illness.
Psychiatry as a practical medical discipline
Psychiatry, as a practical medical discipline, treats suffering individuals. They either enter a therapeutic alliance with a psychiatrist, because they recognise their need to be treated or they are referred to his services involuntarily according to the rules of the society. These rules are set to protect the individuals who are incapacitated by an illness to the extent that prevent them from looking after their own benefit. There is a clear legal distinction between those who seek and accept the treatment and those who cannot do so because of a mental disturbance. Diagnosing patients is the necessary step for a meaningful treatment of mentally ill , and consequently it should not be done on anyone who does not seek the treatment or who, according to legal rules, has to be treated involuntarily. There is a vicious circle here: only these who are treated because of mental illness (that must be diagnosed first) are legitimate subjects for the application of psychiatry as a medical discipline. Who is responsible for the decision on the presence of mental pathology? Obviously, it should be also psychiatry in its capacity as a medical discipline. However, aberrant behaviour may not be the outcome of a mental disturbance. It may be caused by factors that are properly studied by social psychology, sociology and other social sciences. As some aberrant behaviour can be falsely attributed to individual pathological processes, instead to undesirable responses to social conditions and misguided psychological developments, it seems advisable that psychiatry defines the border between processes treatable by medical discipline and those that should be the focus of manipulation and regulation by legal, educational and counselling policies of the society.
As long as the goal of the psychiatric treatment is considered the state of psychological and social well being, the obligations for psychiatry are obviously greater than a medical discipline can fulfil.
Psychiatry should set limits to medical explanations of phenomena like, e.g., criminality, violence, cult addiction, terrorism, parapsychological phenomena, witchcraft and various healing practices. It should not assume full responsibility in regulating these phenomena, and providing their complete expert explanations.
Psychiatry as a medical discipline relies on the authority of medicine that is associated with the help to a suffering and deserving individual. If this source of authority is obscured in psychiatry, the discipline will be blamed to serve as a social tool for controlling undesirable phenomena and practices. It has already happened in the antipsychiatric movement. It is in the best interest of psychiatry, that it reflects universal ethical concerns of medicine rather than the social anxiety of a particular culture. The necessity to set the legal rules for involuntary treatment originates in the need of the society and the society has to take responsibility for it in a political and legal act.
Psychiatry and other scientific and social disciplines have to collaborate to provide sufficient information for policy makers.
There is one more concern that needs to be addressed. It deals with a tacit though misleading assumption of omnipotence on the part of psychiatrists. There is a lot of literature concerning the decision trees and algorithms for starting psychiatric treatment. The studies attempting to define the limits in duration of the treatment are conspicuously rare. Maybe that the question whom and when not to treat deserves more attention. The ethics of restraint is undeservedly underestimated in comparison to the ethics of intervention.
Psychiatry as a medical science
Medical science provides theoretical knowledge and models necessary to understand human disease and cure it effectively. Psychiatry as a medical discipline accumulates the knowledge on the relationship of biology and psychopathology. It investigates the brain and its relationship to human experience and behaviour. Psychiatry in this capacity may help to understand the instances in which undesirable social phenomena (addictive behaviour, cultism, terrorism, some kinds of violence etc.) are associated with biological or psychological patterns recognised as a source of psychopathology and lead to disability and/or dysfunction.
It will be necessary to clarify the role of social psychiatry at this point. Social psychiatry also has theoretical and practical aspects. It is concerned with social influences on human mental health. It is a discipline that allows psychiatrists to understand the relationship between the manifestation, course and outcome of the mental disturbance and social factors. It can provide partial social explanations for psychiatric phenomena; it cannot provide psychiatric explanations for social phenomena.
Psychiatry can provide explanation to the extent in which mental illness participates on socially undesirable behaviour and phenomena. It cannot explain the undesirable social phenomena as a mental illness of sorts, let alone offer an effective treatment for them. However, in its capacity as a medical science it can provide an expertise in finding a relationship between psychological and neurobiological processes.
Because of its methodological limitations that make the observation of behaviour and the evaluation of experience the main sources of knowledge on mental disturbance, psychiatry is mistaken for the science studying experience and behaviour. Instead, psychiatry studies a diseased person at all levels (from molecules to complex social relationships) in the context of the analysis of experience and behaviour.
In setting the limits of psychiatry as a medical discipline, it is necessary to clarify the co-responsibility of psychiatry as only one “expert-discipline” among many, who share the role of helping society to control socially aberrant behaviour and explain it.
Psychiatry is not a social service. It does not provide expertise in taking care of the helpless people if the helplessness is the effect of social factors rather than a disease process. Psychiatry is not a psychological counselling service for the unhappy, unfortunate, weary and dissatisfied. It may tell them that their plight is not a disease but a human condition. Perhaps psychologists may be the right professionals to seek for help.
Psychiatry is subject to abuse by political power due to its special position among medical disciplines and its overlap with social sphere. Once its original purpose is obscured, psychiatry takes responsibility far beyond its scope, and may acquire political aspects that it must not have in a democratic state. We should carefully guard the border of psychiatry to prevent its abuse in future.