Requests by patients or their families for treatment which the patient's physician considers to be "inappropriate" are becoming more frequent than refusals of treatment which the physician considers appropriate. Such requests are often based on the patient's religious beliefs about the attributes of God (sovereignty, omnipotence), the attributes of persons (sanctity of life), or the individual's personal relationship with God (communication, commands, etc). We present four such cases and discuss some of the basic religious tenets of the three Abrahamic faith (...) traditions as they relate to such requests. We suggest that religious reasons for requesting "inappropriate" treatment are "special" and deserve serious consideration. We offer guidance to assist clinicians and clinical ethicists as they attempt to resolve these conflicts, emphasising the importance of understanding the religious beliefs of the patient/surrogate and suggesting the assistance of a religious interpreter. We suggest open discussion with patients and families of both the clinical situation and the theological basis for these requests. We also suggest that clinicians use additional religious doctrines or principles from patients' own traditions to balance the reasons behind the requests. We conclude that most persistent requests for "inappropriate" treatment should be honoured. (shrink)

Savulescu maintains that our paper, which encourages clinicians to honour requests for "inappropriate treatment" is prejudicial to his atheistic beliefs, and therefore wrong. In this paper we clarify and expand on our ideas, and respond to his assertion that medicine, ethics and atheism are objective, rational and true, while religion is irrational and false.

Artificial intelligence is set to transform healthcare. Key ethical issues to emerge with this transformation encompass the accountability and transparency of the decisions made by AI-based systems, the potential for group harms arising from algorithmic bias and the professional roles and integrity of clinicians. These concerns must be balanced against the imperatives of generating public benefit with more efficient healthcare systems from the vastly higher and accurate computational power of AI. In weighing up these issues, this paper applies the deliberative (...) balancing approach of the Ethics Framework for Big Data in Health and Research. The analysis applies relevant values identified from the framework to demonstrate how decision-makers can draw on them to develop and implement AI-assisted support systems into healthcare and clinical practice ethically and responsibly. Please refer to Xafis et al. in this special issue of the Asian Bioethics Review for more information on how this framework is to be used, including a full explanation of the key values involved and the balancing approach used in the case study at the end of this paper. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:THE UNITY OF THE VICES JONATHAN JACOBS Oolgate University, Hamilton, New York JOHN ZEIS Oanisius Ooilege, Buffalo, New York W:E SOMETIMES describe someone 1rus "just plain,, ' ' • • 0 " ' ' • • mean, or Just plam d1shonesit, orr JUSt pJam unw." Or we say" thaJt wrus ·a just plain ·stupid thing rto do.," G~a:liizing from tlhese and lik!e descriiptions, we can ask, are there any (...) "just plain" vices? By this I mean, are :amy vices pure, 1e.g., can rthere he Cl'lllelty hut nort injustice or in!t:Jempertance, intemperance hut no!t a £ailill'e orf pmctical wisdom, cowardice but not intemperance or injustice, and so on? Is therie perhaps a unity of the vices? Is each ;a col'l'IU!ption thrat involves the coITUpiting ctontriburtion of the othe'l'IS? If there is,a, run:iity of the vicies, then 1be:inig ra vicious individual is Il!Ort siinply 1a ma!bter o:f failing :across the dimensioill of one or rrunothe.r 1 Cihaa:iae1becisltic. ]t ms tan extensi,ve diaiilure, 1a unified (:if l[JIOrt toit.al) failure, even if it is most evident 1and preVialent in one or another •specific respecit. 'f1his iis not to isay thrut.theiie is just one vice,.any moil'!e 1than '!Jo.endorse the unity of it.he virtues is to reduce tth:em to Ollle. There.are many woes OOlld many virrbues, eaiCh respeotively h!ruving to do with dillemnt 1and variously!l'le1aibed crupacirties, motives, emotions, and tiiaiits. Yet, rut least with respect to the virtues a good caise can be mrude :that they.are unified, aind thrut ·AnisbotLe was oorrreot in concluding that practical wisdom :and viWtues of cha;riacter mum occur st quite 1 s1tably, even if '1llolt happily. In any case, we ail"e in 1 to:tal ag.rteemelllt with Geach when he 1sayis 1that ithaJt "If 1a man's ha1bit of sound moml judgme1J11t is virtiiafod anyiwhere, then :it is at risk eVierywhere; but not all dangel"s issue in disa1sit1e'f!s." 3 But 1thes1e dis1as!ters arie aV1eTted r.not because of,any moml str1ength of characil:er 1 th:ait the agent 1truly ihas bUJt heca:us1 e of a me11e inc1ilJJaition tues. 'Ilhe former may he very :firm ox srtable. Mo11eover the n:aituil'ally vi11tuous rindividual may giener1a1ly no1t he oornfused or.impeded maction by "b.ar:d easies" or nnvelty. Alt times he rmay, 1and lthien me may find his re1sourroes iinoompe1be!I1t O'I.' unoel 'l:Ja1in in 1bhreir direetives. Hut the main rpo:inlt of co111iCT'last is thait mo11al virtues 11eflieot 1a 1evel of 1agency wh1oh involves undersitanding 1and self-determin1ation engiaged 1 to t:hat undersltanding, 1a 1leviel tihJait tis 1ruhsen1t foom iinc1ination-grounded action. Na,tu11a1l vri:r1tues 1a1rie ll101t to he despised, 1 and 1aclts :thait fLorw 1f110m 1tJhem 1are not w:iithout moml Wiortlh. But, using the fangiuiage of Fr1a:nk£u:rt, mom1l virtues are oha1racter]s,tios thait refiecrt second order volitions.5 The aiotis: thait flow fil1om them •are not H11e reis:ult of ways one just hrupens to be. And the undeil'-,starnding involvred in moml vrntues makes mo'ral misdireotion 1 1es;s li1"ely. Again, mnswder suoh t.lrings rus mis1applied oomprussfon, or paiti:errce, whioh can involve u1mairness 1and imprudence. P1 errharpis it.is heoausie rbhe mo:rial V1mtueis rare unified that it is 1so hard to rbe 1good. They invo1vie a complex reperrto:We of judgmenits, d1sposi!tiorrs, and moti¥es. No one of them can he oomp1ete on its own, and wie c1an't oome to have 1 tJhem simply 1hy decis1on. One oan til.'y rbo he move coumgeous bU1t caill't ibring it rubout meriely hy init1emal eommanid. Self-imposrutiion in5 In " Freedom of the Will and 'The Concept of a Person," H. Frankfurt writes, "Someone has a desire of the second order when he wants simply to have a certain desire or when he wants a certain desire to be his will. In situations of the latter kind, I shall call his second-order desires "secondorder volitions" or " volitions of the second order." Now it is having... (shrink)

High degrees of uncertainty and a lack of effective therapeutic treatments have characterized the COVID-19 pandemic and the provision of drug products outside research settings has been controversial. International guidelines for providing patients with experimental interventions to treat infectious diseases outside of clinical trials exist but it is unclear if or how they should apply in settings where clinical trials and research are strongly regulated. We propose the Professional Oversight of Emergency-Use Interventions and Monitoring System as an alternative pathway based (...) on guidance developed for the ethical provision of experimental interventions to treat COVID-19 in Singapore. We support our proposal with justifications that establish moral duties for physicians to record outcomes data and for institutions to establish monitoring systems for reporting information on safety and effectiveness to the relevant authorities. Institutions also have a duty to support generation of evidence for what constitutes good clinical practice and so should ensure the unproven intervention is made the subject of research studies that can contribute to generalizable knowledge as soon as practical and that physicians remain committed to supporting learning health systems. We outline key differences between POEIMS and other pathways for the provision of experimental interventions in public health emergencies. (shrink)

Between 1860-1920 a number of distinguished Scottish theologians grappled with the problems of reconciling a biblical faith with current philosophical and theological trends. Alan Sell has selected eight of these: John Kennedy of Dingwall ; Robert Flint ; John Caird ; A. B. Bruce ; James Iverach ; James Orr ; D. W. Forrest ; and James Denney. The book is not only of historical interest; many of the issues confronted by these scholars are also of contemporary interest. Professor James (...) Torrance comments: 'This study is invaluable in keeping alive the authentic tradition that Scotland has produced great theologians,... but perhaps supremely in the period covered by this eminently readable book.'. (shrink)

Background We aimed to examine the ethical concerns Singaporeans have about sharing health-data for precision medicine and identify suggestions for governance strategies. Just as Asian genomes are under-represented in PM, the views of Asian populations about the risks and benefits of data sharing are under-represented in prior attitudinal research. Methods We conducted seven focus groups with 62 participants in Singapore from May to July 2019. They were conducted in three languages and analysed with qualitative content and thematic analysis. Results Four (...) key themes emerged: nuanced understandings of data security and data sensitivity; trade-offs between data protection and research benefits; trust in the public and private sectors; and governance and control options. Participants were aware of the inherent risks associated with data sharing for research. Participants expressed conditional support for data sharing, including genomic sequence data and information contained within electronic medical records. This support included sharing data with researchers from universities and healthcare institutions, both in Singapore and overseas. Support was conditional on the perceived social value of the research and appropriate de-identification and data security processes. Participants suggested that a data sharing oversight body would help strengthen public trust and comfort in data research for PM in Singapore. Conclusion Maintenance of public trust in data security systems and governance regimes can enhance participation in PM and data sharing for research. Contrary to themes in much prior research, participants demonstrated a sophisticated understanding of the inherent risks of data sharing, analysed trade-offs between risks and potential benefits of PM, and often adopted an international perspective. (shrink)

Recent developments in stem cell research with the creation of three-dimensional structures that resemble preimplantation embryos highlight the problems in regulating the uncertainties of emerging...

Cell and tissue-based products, such as autologous adult stem cells, are being prescribed by physicians across the world for diseases and illnesses that they have neither been approved for or been demonstrated as safe and effective in formal clinical trials. These doctors often form part of informal transnational networks that exploit differences and similarities in the regulatory systems across geographical contexts. In this paper, we examine the regulatory infrastructure of five geographically diverse but socio-economically comparable countries with the aim of (...) identifying similarities and differences in how these products are regulated and governed within clinical contexts. We find that while there are many subtle technical differences in how these regulations are implemented, they are sufficiently similar that it is difficult to explain why these practices appear more prevalent in some countries and not in others. We conclude with suggestions for how international governance frameworks might be improved to discourage the exploitation of vulnerable patient populations while enabling innovation in the clinical application of cellular therapies. (shrink)

Precision medicine (PM) aims to revolutionise healthcare, but little is known about the role religion and spirituality might play in the ethical discourse about PM. This Perspective reports the outcomes of a knowledge exchange fora with religious authorities in Singapore about data sharing for PM. While the exchange did not identify any foundational religious objections to PM, ethical concerns were raised about the possibility for private industry to profiteer from social resources and the potential for genetic discrimination by private health (...) insurers. According to religious authorities in Singapore, sharing PM data with private industry will require a clear public benefit and robust data governance that incorporates principles of transparency, accountability and oversight. (shrink)

In this paper, I argue that we can get surprisingly far in vindicating common intuitions about population ethics without assuming that the well-being of those we could create gives us moral reasons for or against creating them. According to the account I sketch, rather than generating procreative reasons, facts about our potential offspring’s well-being serve as normative background conditions—they enable, disable, or modify the strength of independent reasons we might have to procreate. It is unclear whether the account can capture (...) everything many of us want to say about population ethics. But whatever the answer, the point remains that background conditions are a powerful and underappreciated tool in population ethics. (shrink)

Human embryonic stem cell research has generated considerable discussion and debate in bioethics. Bioethical discourse tends to focus on the moral status of the embryo as the central issue, however, and it is unclear how much this reflects broader community values and beliefs related to stem cell research. This paper presents the results of a study which aims to identify and classify the issues and arguments that have arisen in public discourse associated with one prominent policy episode in the United (...) States: the 2004 Californian Stem Cell Research and Cures Initiative. The findings show that public discourse about Proposition 71 is characterised by a broader range of issues than those usually addressed in scholarly publications and public policy documents. While attention to the moral status of the embryo is an important issue in stem cell research, making it the main focus of public discourse has a polarising effect. This also limits opportunities to identify shared values, understand how political alliances are forged, and develop social consensus. Implications for future research and policy are discussed. (shrink)

In 2016, the Office of the State Coroner of New South Wales released its report into the death of an Australian woman, Sheila Drysdale, who had died from complications of an autologous stem cell procedure at a Sydney clinic. In this report, we argue that Mrs Drysdale's death was avoidable, and it was the result of a pernicious global problem of an industry exploiting regulatory systems to sell unproven and unjustified interventions with stem cells.

Although Levinas did not write about The Merchant of Venice, recent scholarship has explored Levinasian themes in the play. However, most of The Merchant instantiates not Levinasian ethics per se, but the cultural and other forces that work against ethics. In particular, theodicy, which Levinas sees as morally scandalous, is deployed by Christian characters to justify their ill-treatment of Shylock. A surface reading of the play would suggest that it is structured around clear binaries, with Christian “mercy” juxtaposed to legalistic, (...) vengeful Jewish “justice.” However, a more nuanced reading, particularly one informed by Levinas’s philosophy, reveals ways in which Shakespeare seems to call these distinctions into question, and uncovers two genuinely ethical moments in the play: Shylock’s “Hath not a Jew eyes?” speech, and his implied, biblically informed critique of the treatment of slaves by Christians in Venetian society. (shrink)

Over the last decade, stem cell research has generated an enormous amount of public, political and bioethical debate. These debates have overwhelmingly tended to focus on two moral issues: the moral status of human embryos and the duty to care for the sick and vulnerable. This preoccupation, especially on the question of moral status, has not only dichotomized the debate around two fundamentally incommensurable positions, it has come at the cost of other important issues largely being ignored. In highlighting some (...) of the bioethical and regulatory deficiencies of this fixation, we draw on recent developments in the experimental use of autologous adult stem cells to argue for a more inclusive approach to the ethical issues surrounding stem cell research. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Ethics CommentaryTamra Lysaght, Senior Research FellowThe case scenario reflects the dilemmas frequently faced by researchers who discover incidental findings in the course of their studies. Indeed, the literature suggests that the prevalence of incidental findings in neuroimaging research is common,1 and a recent meta-analysis found that such findings increase significantly with age.2 Thus, given the age of the study population and increased likelihood of co-morbidities, it is puzzling that (...) the research team did not anticipate the possibility of finding an anomaly. Even more puzzling is that the reviewing IRB did not detect this omission and require that the team build a plan into the research protocol for managing incidental findings. Following international recommendations,3 such a plan would have likely included protocols for obtaining consent in dealing with an incidental finding, a procedure for evaluating the clinical relevance of the finding, and arranging for suitable follow-up care if necessary.Nevertheless, the research team, not having obtained consent to disclose an incidental finding to the participant, or not, must decide whether to break protocol and contact the participant with information that could have serious health implications for his or her health, especially if the observed lesion turns out to be cancer or some other life-threatening neuropathology. Any decision to break the research protocol should be made in consultation with the approving IRB. The principal investigator, Dr. M, who is ultimately responsible for the ethical conduct of this study, has a number of factors to consider when making this decision. First and foremost, Dr. M will need to weigh up the risks and benefits of disclosing the findings to this 72-year-old [End Page 283] research participant who is presumably already experiencing cognitive impairments, if not early stage symptoms of dementia.Numerous international scholars agree that disclosure of incidental findings should rely on the net beneficence to an individual research participant.4 Specifically, Wolf et al. argue that there should be a strong net benefit for disclosing an incidental finding, such that the information reveals a condition that is likely to be either life-threatening or grave and can be avoided or ameliorated through an intervention. In such instances, the researchers have an ethical obligation to disclose the findings and potentially follow up with clinical care. However, if there is only a net possible benefit, such that the condition is not life-threatening but may be grave or serious and cannot be avoided or ameliorated, then investigators may consider other factors, such as the respect that is owed to research participants and their needs and preferences for information about their health and well-being. Where the condition is not likely to be serious, researchers are not compelled to disclose an incidental finding.In determining the seriousness of an incidental finding, a specialist with expertise in assessing the clinical significance of MRI scans is needed to examine the participants’ images.5 In this instance, Dr. M has a neurologist on the research team who has detected the lesion but is unable to ascertain its clinical relevance without further investigation. The reasons why follow-up information is required is not detailed in the case scenario, but may have arisen because the scans were taken for research purposes and may not be clinically validated for diagnostic purposes — a possibility given the aims of the study (i.e., to elucidate the transition of minimal cognitive impairment to dementia, not brain tumours). For whatever reason, the detected lesion is only a suspected incidental finding that may or may not be life-threatening or grave. Thus, the net benefit to the participant in disclosing this unclear finding is harder to judge.Assuming that the lesion is a serious or life-threatening condition, the team may consider whether it can be avoided or ameliorated with an intervention. The cognitively impaired, although still mentally competent, participant is 72 years old and may respond poorly to a neurosurgical intervention if the diagnosis of a tumour or malignancy is confirmed. The physical and emotional distress of such a procedure may exacerbate the existing cognitive impairments, reducing the net benefit ratio of the disclosure. Indeed, the team should consider the impact that the disclosure... (shrink)

Demands for improved access to innovative therapies have prompted a discourse that claims patients have rights to access treatments that may be of benefit, even if evidence that demonstrates safety and efficacy is lacking. This rights-based discourse is grounded in accounts of autonomy and assertions claiming that the state ought to not interfere with the free choices of patients and clinical decision-making. In this essay, we scrutinise these arguments to defend the ethical and legal permissibility of interference in contexts where (...) the uncertainty of benefit and potential for harm creates vulnerabilities that undermine patient capacity for self-determination. In support of this argument, we draw on two theoretical approaches to explore the limits of autonomy in innovative contexts and analyse the legal bases of the rights-based discourse. We then apply this analysis to the case example of stem cell transplantation as an innovative treatment for multiple sclerosis. (shrink)

A prevailing issue in clinical research is the duty clinicians have to treat or prevent the progression of disease during a study that they are conducting. While all clinical researchers have a duty of care for the patients who participate in clinical research, intervening at the onset or progression of disease may skew results and have a negative impact on the scientific validity of a study. Extreme examples of failures to intervene can be found in the Tuskegee syphilis study and (...) in an attempt to determine if cervical smears were an accurate predictor of cancer, which was uncovered by the Cartwright Inquiry. However, the issue arises in all research where delay in intervention can cause harm. A current study in Singapore is investigating the significance of an ‘ultra-high risk’ state that may constitute the prodromal phase of psychosis. This project called ‘The Longitudinal Youth at Risk Study’ is potentially contentious because it is recruiting young people who are identified as being ‘at risk’ of developing psychosis. In this paper, the decision to offer treatment to all participants as well as a fast track for those who are assessed to have developed serious mental illness into treatment is discussed. It is argued that this approach is ethically justified because of the duty of care that is owed to research participants, and suggests that the principle of equipoise may be used to guide intervention decisions in other clinical research protocols. (shrink)

Martin Buber, Franz Rosenzweig and Emmanuel Levinas are three of the most prominent Jewish philosophers of the 20thcentury. This paper looks at the different understandings each author offers of intersubjectivity and authentic self-hood and questions the extent to which for each author God plays a role in interpersonal relationships.

This article examines the process of one institution’s efforts to develop an educational academic integrity seminar through an ethnographic study approach. The educational program developed allowed the institution to transition from a punitive sanctioning system to an educational one. The institution cultivated cross-campus partnerships to develop the program. Both quantitative and qualitative data revealed that students had a positive experience attending the program and found it useful. This article serves as a framework for institutions to utilize when building their own (...) educational-based academic integrity on-campus seminar and sanctioning program. (shrink)

This paper explores some aspects of the concept 'logic' and its relation to moral voice, and argues that Menssen uses it too narrowly in her respone to Orr's "Just the Facts. Ma'am" and the work of Carol Gilligan. Grounded in the work of the later Wittgenstein, it is argued that formalized logic misses much of natural logic: the concept of 'moral talk' is developed to theorize Gilligan's ethic of care; it is argued that this form of moral deliberation is not (...) argumentation in the formal sense; and the relationship between logic and epistemology is explored through the consideration of moral talk as a language-game which is woven into gendered forms of life. Finally, it is argued that the notion of a universal logic is the product of an oppressivc patriarchal culture and should not be defended by feminists. (shrink)

One common feature of debates about the best metaphysical analysis of putatively lawful phenomena is the suspicion that nomic realists who locate the modal force of such phenomena in quasi-causal necessitation relations between universals are working with a model of law that cannot convincingly erase its theological pedigree. Nancy Cartwright distills this criticism into slogan form: no God, no laws. Some have argued that a more plausible alternative for nomic realists who reject theism is to ground laws of nature in (...) the fundamental dispositional properties or “pure powers” of physical objects. This article argues that for all its advantages over deflationary and rival realist accounts, a pandispositionalist account of law cuts against the commitment to metaphysical naturalism that its supporters almost always presuppose. It then examines and rejects a Platonic version of this account before elaborating and advancing a theistic alternative that is more theoretically powerful and more metatheoretically parsimonious. In slogan form: no God, no powers. (shrink)

Cost-effectiveness analysis suggests that a society should allocate its health care budget in order to achieve the greatest total health for its budget. However, in ‘rescue’ cases, where an individual’s life is in immediate peril, reasoning in terms of cost-effectiveness can appear inhumane. Hence considerations of cost-effectiveness and of rescue appear to be in tension. However, by attending to the division of labour in medical decision making it is possible to see how cost-effectiveness analysis and rescue-style reasoning are commonly combined (...) in an ethically acceptable fashion. (shrink)

Clinical ethics is a relatively new discipline within medicine, generated not so much by the Can we . . . ? questions of fact and prognosis that physicians ...

Writing about loneliness has been a struggle in the midst of the pandemic. Characterized by loneliness, isolation, anxiety, and fear, the COVID-19 pandemic is an exceptionally challenging time. At various points while navigating this loneliness project amid a particularly lonely time, we lamented the seeming futility of it all. A main goal of developing a Feminist Loneliness Studies in this introduction is to understand the ways that systems of oppression – white supremacy, settler colonialism, anti-queer bias, misogyny, neoliberal capitalism, and (...) so on – create our lonely world. To date, there remains no comprehensive feminist analysis of the structural conditions that both produce and intensify experiences of loneliness. We aim to remedy this gap. That is, we seek to address what a Feminist Loneliness Studies can contribute to understanding the complexities of this complicated emotion. For example, what is the unique loneliness of the feminist killjoy who calls out, or calls in, existing forms of queerphobia, racism, and sexism? What does it mean to be a politicized person and how does that result in both alienation and isolation? What might the relationship be between white supremacy and loneliness? How is loneliness both individual and systemic, and what is the relationship between the two? What distinctive forms of loneliness are created by ableism, sanism, neoliberalism, capitalism, globalization, and the gig economy? Ought loneliness be avoided at all costs? What are the ethics of loneliness? In our introduction to this special issue, we unpack and theorize the potential perils and generative possibilities offered up by this profound emotion. Establishing a Feminist Loneliness Studies provides us with the space we need to begin addressing and comprehending loneliness. (shrink)

Precision medicine is an emerging approach to treatment and disease prevention that relies on linkages between very large datasets of health information that is shared amongst researchers and health professionals. While studies suggest broad support for sharing precision medicine data with researchers at publicly funded institutions, there is reluctance to share health information with private industry for research and development. As the private sector is likely to play an important role in generating public benefits from precision medicine initiatives, it is (...) important to understand what the concerns are and how they might be mitigated. This study reports outcomes of a deliberative method of citizen engagement in Singapore that asked whether sharing precision medicine data with private industry would be permissible, and if so, under what circumstances. Findings from this citizens’ jury suggest sharing with industry would be permissible under certain conditions that are set out in nine recommendations. Implications of the recommendations and their underlying assumptions for policy decision makers are discussed. This study aligns with prior international studies which found conditional acceptance for data sharing with private industry, a public benefit requirement, specific reluctance to share with insurance companies and an emphasis on accountability and transparency to demonstrate trustworthiness. However, our results differ from prior studies in that opt-in consent did not dominate the deliberations as jurors were able to set it aside as an assumed prerequisite for participation in a precision medicine programme. (shrink)

It seems intuitive to the believer that God intended through instruction in the Law to define morality, intended to lead humankind to “the right and the good.” Further, God's love for humankind, exemplified by the incarnation, atonement and teachings of Jesus, and empowered by the Holy Spirit, should lead to a better world. Indeed, the Christian worldview is a coherent and valid way to look at bioethical issues in public policy and at the bedside. Yet, as this paper explores, in (...) a pluralistic society such as the United States, it is neither possible nor desirable for Christians to try to force their views on others. Still, it is obligatory for Christians to stand up and articulate their views in the public square. We should try to persuade others using either prudential or moral arguments. While we must be willing to live with “the will of the people,” at the same time, we must not be intimidated into accepting the position that our voice is not valid because it has a religious basis. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Underplayed Ethics and the Dilemmas of Psychiatric CareChong Siow Ann and Tamra LysaghtThe practice of psychiatry is fraught with uncertainty. The exact causes and the biological substrates underlying mental disorders remain to be elucidated; even the diagnosis of these disorders is descriptive and not based on an etiological understanding and no biological diagnostic markers have been validated. The manifestation of almost all mental disorders results from a complex (...) interaction of biological and environmental factors which encompasses the patient’s unique life history, experiences and relationship with others and the community. In the face of such uncertainties — at times extending to the types of treatment (psychiatry is generally acknowledged not be an exact science) — it has been argued that adopting a pragmatic approach is necessary.1 Accordingly, this approach necessitates high ethical standards among mental health practitioners.Some mental illnesses are associated with varying degrees and types of cognitive impairments. Others have certain symptoms like auditory hallucinations and delusions that might severely compromise the patients’ autonomy, distort their sense of reality, increase the risk of harm to themselves or others and render them incapable of making informed decisions in their treatment and participation in research.Consequently, there are issues that are particular to the provision of mental healthcare. These include the need for enforced involuntary treatment with the corollary of depriving a patient of his personal liberty even [End Page 173] though it is often justified on the grounds that it is in the patient’s best interests. However, at times, it is the legal and societal obligation of mental health practitioners to protect those who might be harmed from the patient’s action that might seem to be more pressing. In this situation of double agency, lies the tension of providing confidential care for patients and acting as “an agent of the state” where that patient’s confidentiality might be breached and his liberty infringed upon. This situation is further aggravated by the stigma that clings ever so tenaciously to those who suffer from mental disorders and where it is the norm to stereotype them as dangerous and unpredictable.Consideration of a patient’s autonomy is also challenged by characteristics that are unique to the practice of psychiatry. The prescription of certain psychotropic medications can alter how people think and feel, while psychotherapy works towards changing the patient’s views and values. The philosopher, Jennifer Radden, describes this process as “re-forming the patient’s whole self or character … akin to the responsibilities of raising children”.2 The psychotherapeutic relationship is thus particularly personal and intimate because patients are asked to provide information that often reveals their innermost feelings, fears and fantasies. This information is provided on the basis of trust and assurance of confidentiality, and with expectation of being helped.Jeremy Holmes and Gwen Adshead have elaborated on the vulnerability of patients seeking psychotherapy: they might be particularly susceptible to exploitation because their past experiences of being exploited have led to their distress and help seeking — their dependency and the extreme privacy of the therapeutic relationship make any transgression difficult to be uncovered.3 There is a calamitous combination of the “unconscious wish in the patient to be used” with the complicity of an unethical therapist seeking to fulfil his own interests.4As in any other doctor-patient relationship, the relationship between the mental healthcare practitioner and the patient is one of unequal power where the former is ascendant. While that power should be exercised to heal and to relieve suffering, it also gives the practitioner tremendous power “to harm, reject, misunderstand, or exploit patients who struggle with the experience of mental illness, which itself may generate helplessness, despair, distress, and exceptional dependence on the clinician”.5 Given the potential of doing good and harm coupled with the likelihood of being so significant in the life of the patient,6 providing care for those with mental disorders and distress is necessarily ethically exacting — arguably more so than in other medical practice settings. [End Page 174]This precariousness has led to the suggestion that ethics in psychiatry should have a special status and that the more general principles of biomedical ethics are too limited in scope to... (shrink)