This study investigated the relationship between concussions and medication adherence among 247 adults experiencing homelessness in Oklahoma City, Oklahoma, who were prescribed medication for a psychiatric disorder. Participants were asked whether they had “ever experienced a blow to the head that caused a concussion,” and medication adherence was measured by asking participants whether they had taken their psychiatric medication yesterday. The data were analyzed using univariate and multivariable logistic regressions. Results showed that more than (...) half of the sample had a concussion history, and homeless adults with a concussion history had higher odds of non-adherence to psychiatric medications compared with those who reported no concussion history [OR = 2.13 ]. Findings suggest that medication non-adherence is associated with incurred concussions. Raising awareness among service providers of the relationship between traumatic brain injury and medication adherence may increase efforts to improve adherence in this underserved population. (shrink)

With improvement in medical services in the last few years, there has been a constant rise in the geriatric population throughout the world, more so in the developing countries. The elderly are highly prone to develop psychiatric disorders, probably because of age related changes in the brain, concomitant physical disorders, as well as increased stress in later life. Psychiatric disorders in this population may have a different presentation than in other groups and some of psychopathologies might be mistaken (...) for normal age related changes by an unwary clinician. Therefore the need of the day is to train psychiatrists and physicians to better recognize and manage mental disorders in this age group. (shrink)

Physicians are frequently consulted by people with physical symptoms that, after having ruled out an "organic" pathology, we suspect they are related to the most frequent psychological conditions in the usual consultation: the various forms of reaction to severe stress (Acute Stress Reaction and Adjustment Disorder, from ICD 11), "functional" pathologies, burn out syndrome, and anxiety disorders, especially Generalized Anxiety Disorder, with or without associated depression. They are usually given a brief explanation about these problems and how they affect their (...) health, given a brochure, or suggested a website with information. And then they are encouraged to visit a mental health practitioner. But there are some challenges to this seemingly simple scenario:Not all patients are ready or willing to hear that their health problem might be related to their life or emotions. Many are strongly influenced by mind-body dualism. Others have an intuition that such a relationship exists but bringing that to consciousness is not an easy process, because it can awaken emotions that are difficult to handle. This is quite frequent in people suffering chronic anxiety (DSM-5 Generalized Anxiety Disorder) who prefer to consult medical providers rather than psychologists (Wittchen H. U. et al. 2002), because they do not consider their constant and excessive worry to be related to their discomfort. In their worrying they are hoping for a straightforward solution. Often these patients ask th... (shrink)

Background Medical aid in dying (MAID) is legal in a number of countries, including some states in the U.S. While MAID is only permitted for terminal illnesses in the U.S., some other countries allow it for persons with psychiatric illness. Psychiatric MAID, however, raises unique ethical concerns, especially related to its effects on mental illness stigma and on how persons with psychiatric illnesses would come to feel about treatment and suicide. To explore those concerns, we conducted several (...) focus groups with persons with lived experience of mental illness.Methods We conducted three video-conference-based focus groups involving adults residing in the U.S. who reported a prior diagnosis of any psychiatric illness. Only participants who reported thinking that MAID for terminal illness was morally acceptable were included. Focus group participants were asked to respond to a series of four questions. Groups were facilitated by a coordinator who was independent of the research team.Results A total of 22 persons participated in the focus groups. The majority of participants had depression and anxiety disorders; no participants had psychotic disorders such as schizophrenia. Many participants strongly favored permitting psychiatric MAID, generally on the basis of respect for autonomy, its effects on stigma, and the severe suffering caused by mental illness. Others expressed concerns, typically related to difficulties in ensuring decision-making capacity and to the risk that MAID would be used in lieu of suicide.Conclusions Persons with a history of psychiatric illness, as a group, have a diverse array of views about the permissibility of psychiatric MAID, reflecting nuanced consideration of how it relates to the public perception of mental illness, stigma, autonomy, and suicide risk. (shrink)

Selective serotonin reuptake inhibitors’ wide use, combined with the blurry limit between health and psychological illness, have led neuroscientists, clinicians and ethicists to envision the possibility of these medications’ use in non-clinical populations. This prospect has evoked ethical debates, which have often ignored the findings of the empirical literature. In this context, an evaluation of the empirical evidence for SSRIs’ personality enhancing effects is needed. The present paper examines SSRIs’ effects on healthy personality, including the Five Factor Model traits Neuroticism (...) and Extraversion, as well as some of their facets: Angry Hostility, Impulsiveness, Vulnerability, Warmth, Gregariousness and Assertiveness. The review encompasses investigations in healthy humans, human clinical populations, as well as relevant animal studies. Emerging data raise the possibility that SSRIs, when used by people without a currently diagnosable mental disorder, may reduce some facets of Neuroticism, especially Angry Hostility. On the other hand, very limited support exists for an SSRI-driven change in other Neuroticism facets, such as Impulsiveness, in healthy humans. An increase in Extraversion is possible, but currently available evidence is only indirect. Future research is needed, both to clarify methodological ambiguities in existing studies, and to answer unaddressed questions, such as ones of the stability, predictors, moderators, dose- and context-dependency of the effects. (shrink)

Predictive genetic testing for susceptibility to psychiatric conditions is likely to become part of standard practice. Because the onset of most psychiatric diseases is in late adolescence or early adulthood, testing minors could lead to early identification that may prevent or delay the development of these disorders. However, due to their complex aetiology, psychiatric genetic testing does not provide the immediate medical benefits that current guidelines require for testing minors. While several authors have argued non-medical benefits may (...) play a crucial role in favour of predictive testing for other conditions, little research has explored such a role in psychiatric disorders. This paper outlines the potential non-medical benefits and harms of psychiatric genetic testing in minors in order to consider whether the non-medical benefits could ever make such testing appropriate. Five non-medical themes arise in the literature: psychological impacts, autonomy/self-determination, implications of the biomedical approach, use of financial and intellectual resources, and discrimination. Non-medical benefits were prominent in all of them, suggesting that psychiatric genetic testing in minors may be appropriate in some circumstances. Further research needs to empirically assess these potential non-medical benefits, incorporate minors in the debate, and include normative reflection to evaluate the very purposes and motivations of psychiatric genetic testing in minors. (shrink)

Medical assistance in dying, which includes voluntary euthanasia and assisted suicide, is legally permissible in a number of jurisdictions, including the Netherlands, Belgium, Switzerland and Canada. Although medical assistance in dying is most commonly provided for suffering associated with terminal somatic illness, some jurisdictions have also offered it for severe and irremediable psychiatric illness. Meanwhile, recent work in the philosophy of psychiatry has led to a renewed understanding of psychiatric illness that emphasises the role of the relation between (...) the person and the external environment in the constitution of mental disorder. In this paper, I argue that this externalist approach to mental disorder highlights an ethical challenge to the practice of medical assistance in dying for psychiatric illness. At the level of the clinical assessment, externalism draws attention to potential social and environmental interventions that might have otherwise been overlooked by the standard approach to mental disorder, which may confound the judgement that there is no further reasonable alternative that could alleviate the person’s suffering. At the level of the wider society, externalism underscores how social prejudices and structural barriers that contribute to psychiatric illness constrain the affordances available to people and result in them seeking medical assistance in dying when they otherwise might not have had under better social conditions. (shrink)

This article offers a critique and reconstruction of the concept of medicalization. Most researchers describe medicalization as the redefinition of social problems as medical concerns, and track its spread by the proliferation of disease language and diagnostic categories. Forensic psychiatry and disorders like psychopathy are often cited in these debates. I argue that focusing on discourse overlooks how medical language can justify or mask non-medical practices and outcomes, and lead researchers to identify medicalization where it has not occurred. Building on (...) other critiques of medicalization and recent studies of medical and legal expertise, I propose an alternative conception based on conditions for the performance of medical practice and other forms of expert labor. I distinguish the participation or intervention of medical practitioners from the medicalization of expert practice and identify several institutional factors that facilitate the latter. I illustrate this approach using a critical historical case: the first adult penal psychiatric clinic in the United States, founded by the eminent psychopathologist Bernard Glueck at New York’s Sing Sing Prison in 1916. Glueck’s extensive writings reveal little evidence of medicalization: psychopaths were largely defined and diagnosed according to penal rather than medical criteria, and they received additional punishment rather than treatment. A review of recent research confirms that psychopathy remains primarily a penal rather than medical condition. I conclude that focusing studies of medicalization on practice rather than discourse clarifies the concept and avoids reifying the notion of a medicalized society. (shrink)

In a recent Response published in the Journal of Medical Ethics,1 Buturovic provides two criticisms of my argument in ‘Is the exclusion of psychiatric patients from access to physician-assisted suicide discriminatory?’2 First, Buturovic argues that my argument effectively ‘erases the distinction between healthy adults and patients (whether somatic or psychiatric) essentially implying that PAS [physician-assisted suicide] should be available to all, for all reasons or, ultimately no reason’ (Buturovic,1 pg. 1). Second, Buturovic argues that opening the doors to (...) medical assistance in dying (MAID) for psychiatric patients could have a number of undesirable implications. In particular, Buturovic highlights the potential negative implications for relations of trust in medicine—psychiatry in particular—along with potential effects on the rate of organ donation. I would here like to respond to these two criticisms. In short, my response to Buturovic’s first argument is that the slope is not nearly as slippery as Buturovic suggests. The reason for this is that the plausibility of Buturovic’s argument rests on a significant misinterpretation of my argument, along with an important equivocation in her own. Buturovic argues that, under the three criteria that I propose for the provision of MAID—sufficient decision-making capacity, demonstrated treatment resistance, and a lack of substantially negative implications for existing standards of psychiatric treatment and research—the provision of MAID for trivial reasons, even no reason at all, is justifiable. The main problem with this argument is that I propose no such positive criteria. My argument is that none of the three arguments addressed in my previous paper are sufficient to justify the exclusion of any and all psychiatric patients from access to MAID. I do not claim, in other words, that any individual …. (shrink)

Some jurisdictions that have decriminalized assisted dying exclude psychiatric patients on the grounds that their condition cannot be determined to be irremediable, that they are vulnerable and in need of protection, or that they cannot be determined to be competent. We review each of these claims and find that none have been sufficiently well-supported to justify the differential treatment psychiatric patients experience with respect to assisted dying. We find bans on psychiatric patients’ access to this service amount (...) to arbitrary discrimination. Proponents of banning the practice ignore or overlook alternatives to their proposal, like an assisted dying regime with additional safeguards. Some authors have further criticized assisted dying for psychiatric patients by highlighting allegedly problematic practices in those countries which allow it. We address recent evidence from the Netherlands, showing that these problems are either misrepresented or have straightforward solutions. Even if one finds such evidence troubling despite our analysis, other jurisdictions need not adopt every feature of the Dutch system. (shrink)

In this paper, I explore the links between liberal political theory and the evaluative nature of medical classification, arguing for stronger recognition of those links in a liberal model of medical practice. All judgments of medical or psychiatric "dysfunction," I argue, are fundamentally evaluative, reflecting our collective willingness or reluctance to tolerate and/or accommodate the conditions in question. Illness, then, is "socially constructed." But the relativist worries that this loaded phrase evokes are unfounded; patients, doctors, and communities will agree (...) in the vast majority of cases about what counts as illness. Where they cannot come to agreement, however, we are faced with precisely the sort of dispute about values and ways of life that the institutions of the liberal state are designed to accommodate. I accordingly sketch a model of medical practice, based loosely on Jürgen Habermas's political theories, designed to maximize both our awareness and our understanding of these disputes. (shrink)

This paper explores a grey area of psychiatric practice and, as with other challenging practices, the law is called upon to navigate conflicting legal issues. In particular, this paper explores the covert administration of medication: the concealment of medication in food or drink so that it will be consumed undetected. Rights-based approaches support nuanced understanding of the practices. Few policies, protocols or guidelines govern the practice in Ontario's psychiatric settings. While covert medication is understood to (...) have “something to do” with rights, there is confusion about how those rights play out on the ground. Institutional silences underlie and reinforce the practice. Most pressing, the covert administration of medication warrants an overt discussion, including of its impact on the rights-experience of persons in psychiatric settings. (shrink)

Limitations on reproductive decision making, including forced sterilization and involuntary birth control, raise significant ethical challenges. In the United States, these issues are further complicated by a disturbing history of the abuse and victimization of vulnerable populations. One particularly fraught challenge is the risk of teratogenicity posed by moodstabilizing psychiatric medications in patients who are incapable of appreciating such dangers. Long-acting reversible contraception (LARC) offers an intervention to prevent pregnancy among individuals who receive such treatments, but at a cost (...) to their reproductive autonomy. This article examines the ethical issues involved in the use of involuntary LARC for patients on teratogenic psychiatric medications (TPMs) and argues that such an approach can only be justified as a last resort after a careful consideration of the alternatives and an assessment of potential risks and benefits. (shrink)

Patients with mental illness, and depression in particular, present clinicians and surrogate decision-makers with complex ethical dilemmas when they refuse life-sustaining non-psychiatric treatment. When treatment rejection is at variance with the beliefs and preferences that could be expected based on their premorbid or “authentic” self, their capacity to make these decisions may be called into question. If capacity cannot be demonstrated, medical decisions fall to surrogates who are usually advised to decide based on a substituted judgment standard or, when (...) that is not possible, best interest. We propose that in cases where the patient meets the widely accepted cognitive criteria for capacity but is making decisions that appear inauthentic, the surrogate may best uphold patient autonomy by following a “restorative representation” model. We see restorative representation as a subset of substituted judgement in which the decision-maker retains responsibility for deciding as the patient would have, but discerns the decision their “truest self” would make, rather than inferring their current wishes, which are directly influenced by illness. Here we present a case in which the patient’s treatment refusal and previously undiagnosed depression led to difficulty determining the patient’s authentic wishes and placed a distressing burden on the surrogate decision-maker. We use this case to examine how clinicians and ethicists might better advise surrogates who find themselves making these clinically and emotionally challenging decisions. (shrink)

Medicalization was the theme of the 29th European Conference on Philosophy of Medicine and Health Care that included a panel session on the DSM and mental health. Philosophical critiques of the medical model in psychiatry suffer from endemic assumptions that fail to acknowledge the real world challenges of psychiatric nosology. The descriptive model of classification of the DSM 3-5 serves a valid purpose in the absence of known etiologies for the majority of psychiatric conditions. However, a consequence of (...) the “atheoretical” approach of the DSM is rampant epistemological confusion, a shortcoming that can be ameliorated by importing perspectives from the work of Jaspers and McHugh. Finally, contemporary psychiatry’s over-reliance on neuroscience and pharmacotherapy has led to a reductionist agenda that is antagonistic to the inherently pluralistic nature of psychiatry. As a result, the field has suffered a loss of knowledge that may be difficult to recover. (shrink)

In their book Culver and Gert define irrational action in the context of medicine and psychiatry. This definition is used to define other key concepts including Malady. It is argued that their definition provides neither a necessary condition nor a sufficient condition for an action to be irrational in this context. Keywords: rational, irrational, reasons CiteULike Connotea Del.icio.us What's this?

On January 11, 2024, the United Kingdom (U.K.) Supreme Court rendered its judgment in _Paul v Royal Wolverhampton NHS Trust_, restricting the circumstances in which “secondary victims” can successfully claim for damages in clinical negligence cases. This ruling has provided welcome clarity regarding the scope of negligently caused “pure” psychiatric illness claims, but the judgment may well prove controversial. In this article, I trace the facts and opinion from the majority and also discuss an important dissenting opinion. I then (...) reflect on what the ruling means for psychiatric illness claims by secondary victims, and more broadly on the implications for clinical negligence law. I suggest that while much-needed clarity has been injected in this area of the law, it is difficult, reading the majority of the Supreme Court’s emphasis on the restricted scope of a medical practitioner’s duty, to envision a scenario in which secondary victim could ever succeed in a clinical negligence context. (shrink)

Psychiatric examinations in official institutions of the Brazilian government include examinations of individual convicts – some of whom are highly dangerous – carried out by court decision. These individuals are taken handcuffed under police escort from penitentiaries to the examination site. In most Brazilian states, medical examiners or experts adopt the basic procedure of asking the police officers to remove the handcuffs from the convict for the examination to be carried out. This article analyzes, from the bioethical standpoint, the (...) behavior of 49 forensic psychiatrists in eight Brazilian states in relation to procedures adopted as protection measures against any possible danger posed by their examinees. In the context of a developing country, where sophisticated protection means are not available, the practice of keeping convicts handcuffed during such examinations is compared to other measures and more advisable alternatives are discussed from the ethical standpoint. Considering the dilemma between showing minimum respect for the autonomy of examinees and ensuring the security of examiners, the need to adopt equitable procedures based on the recognition of the different needs of examiners and examinees is addressed. (shrink)

During the Nazi regime (1933–1945), more than 300 000 psychiatric patients were killed. The well‐calculated killing of chronic mentally ‘ill’ patients was part of a huge biopolitical program of well‐established scientific, eugenic standards of the time. Among the medical personnel implicated in these assassinations were nurses, who carried out this program through their everyday practice. However, newer research raises suspicions that psychiatric patients were being assassinated before and after the Nazi regime, which, I hypothesize, implies that the motives (...) for these killings must be investigated within psychiatric practice itself. An investigation of the impact of the interplay between the notes left by nurses and those by psychiatrists illustrates the active role of the psychiatric medical record in the killing of these patients. Using theoretical insights from Michel Foucault and philosopher Giorgio Agamben and analyzing one part of a particularly rich patient file found in the Langenhorn Psychiatric Asylum in the city of Hamburg, I demonstrate the role of the record in both constructing and deconstructing patient subjectivities. De‐subjectifying patients condemned them to specific zones in the asylum within which they were reduced to their ‘bare life’‐ a precondition for their physical assassination. (shrink)

Research suggests that people tend to overweight arguments accompanied by neuroscientific terminology, which is dubbed as the seductive allure of neuroscience explanations (SANE) in the literature. Such an effect might be of particular significance when it comes to physicians and mental health professionals (MHP), given that it has the potential to cause significant bias in their understanding as well as their treatment approaches toward psychiatric symptoms. In this study, we aimed to test the SANE effect among Turkish medical students, (...) and assess its uniqueness by comparing it with a discipline that still maintains an important role in contemporary psychiatric training in Turkey: psychoanalysis. 109 medical students with a basic level of knowledge of psychiatry and clinical neuroscience were asked to rate the credibility of explanations of differing quality (good vs. circular) for psychological phenomena, followed by three types of information: none, neuroscientific (SNI) or psychoanalytical (SPI). Our findings showed that SNI significantly increased the judged quality of explanations for both conditions with the effect being more prominent for circular explanations. On the other hand, SPI had no effect on good explanations but enhanced the judged quality of circular explanations in a level comparable to that of SNI. For the first time, the SANE effect was replicated among medical students and provided preliminary data in favor of a similar effect for psychoanalytically oriented information. (shrink)

Some jurisdictions that have decriminalized assisted dying exclude psychiatric patients on the grounds that their condition cannot be determined to be irremediable, that they are vulnerable and in need of protection, or that they cannot be determined to be competent. We review each of these claims and find that none have been sufficiently well-supported to justify the differential treatment psychiatric patients experience with respect to assisted dying. We find bans on psychiatric patients’ access to this service amount (...) to arbitrary discrimination. Proponents of banning the practice ignore or overlook alternatives to their proposal, like an assisted dying regime with additional safeguards. Some authors have further criticized assisted dying for psychiatric patients by highlighting allegedly problematic practices in those countries which allow it. We address recent evidence from the Netherlands, showing that these problems are either misrepresented or have straightforward solutions. Even if one finds such evidence troubling despite our analysis, other jurisdictions need not adopt every feature of the Dutch system. (shrink)

Purpose Medical students receive a varying amount of training in medical ethics and are expected to navigate clinical ethical dilemmas innately. There is little literature on attempts to navigate ethical dilemmas experienced during early clinical experiences and whether current curricula prepare students for these dilemmas. This study explores the different ethical dilemmas experienced by medical students on their third-year clerkships and analyzes the factors, sources, and resolutions proposed by them.Methods From 2016 to 2018, third-year medical students completed a written assignment (...) to describe, analyze, and reflect on a clinical situation in which they experienced an ethical dilemma. They identified specific ethical dilemmas present, potential preventative and aftermath solutions, and reflected on their professional development from their experience. The research team utilized applied thematic analysis to identify themes and patterns in the data. A thematic matrix was utilized to examine similarities and differences across medical students.Results Of the 162 reflections, 144 (88.9%) students indicated an ethical dilemma that included issues related to autonomy and beneficence. Of these, 116 (71.6%) students found the two ethical principles in direct conflict. Students identified three common sources of this conflict: lack of communication; unclear understanding of clinical policies regarding family authority and psychiatric capacity; and medical negligence. Lastly, students suggested different solutions for dealing with and preventing this conflict.Conclusion Our findings suggest that an overwhelming number of students face ethical challenges when confronted with medical situations that raise conflicts between autonomy and beneficence. Their recommended solutions reveal an appeal among students to have tools and strategies in place to ease the need to make difficult decisions. Medical students might be better served by learning about the complexities of ethical decision-making and the likelihood of experiencing moral distress when they feel an inability to implement what they envision as the best solution. (shrink)

The article [Title], written by [AuthorNames], was originally published electronically on the publisher’s internet portal on [date of OnlineFirst publication] without open access.

This article describes the ethical dilemmas encountered by the authors while conducting qualitative research with psychiatric patients as participants. The ethical conflicts are explored in terms of the principles of personal autonomy, voluntariness and awareness of the purpose of the study, with illustrations from the authors’ research experience. This study addresses the everyday life of psychiatric nursing in a psychiatric hospital as described by patients, nurses and nursing students. The data were collected in a university hospital in (...) northern Finland, using videotaped observations and recorded interviews. Although no definitive resolutions are proposed to the conflicts, the article endeavours to enhance awareness of the ethically perplexing situations possibly encountered by researchers during a study process. The institution where the study was conducted has a Research Board entitled to resolve ethical questions. The Ethics Review Committee of the Medical Faculty at the University and the Research Board of the University Hospital’s Department of Psychiatry reviewed and accepted this research plan. They also recommended solutions to some specific ethical problems that occurred in the course of the study. Moreover, some ethical dilemmas required further study and debate during the process. (shrink)

In mental health policy, a central ethical dilemma concerns involuntary outpatient commitment (OPC), which aims to treat vulnerable individuals with serious mental illness who decline services. The first concern regards whether coercive services undermine the quality of clinical interactions within treatment, particularly as it relates to psychiatric medication use. The second concern is the unexamined role that OPC, and coercive psychiatric programs more broadly, play in the broader landscape of social welfare policy. To examine these concerns, the (...) purpose of this dissertation is to analyze how the management of psychiatric medications in involuntary outpatient services is undergirded by (a) provider and client interpretations of psychiatric medication effects and (b) moral discourses related to coercion and client autonomy. To achieve this aim, I examined data from a team-based ethnography that consisted of 1000 hours of participant observations and 56 semi-structured interviews with 20 clients, 21 providers, and 12 client family members with diverse backgrounds. I analyzed how medication compliance was discussed, monitored, and enforced in an involuntary outpatient program. My analysis demonstrates that medications were interpreted as a technology to control clinical symptoms (clinical control) though, particularly among clients, were also viewed as a method to control client mental experiences, behavioral expression, and autonomy (social control). Providers believed that medications were a necessary component of services (compulsory compliance) and could reduce client vulnerability to violence victimization and perpetration related to clinical symptoms (medicating vulnerability). To address client noncompliance, providers employed several strategies that I categorized as client manipulation. These strategies included providers, family members, and court officials strategizing ways to undermine client autonomy without clients’ knowledge (concealed collusion), deceiving clients into believing that medications were mandated when they were not (performing coercion), and minimizing the role of client consent and preferences in decision-making processes (circumventing consent). These findings demonstrate the pervasive role of manipulation to gain client medication compliance in OPC, which I named institutional coercion. They also highlight that the broader moral justifications for manipulating clients relate to their status as structurally vulnerable in their community settings and a growing relationship between the erosion of the welfare state and psychiatric coercion. (shrink)

Psychiatric Medicine has been accused justly of making its diagnoses on the patient's report of symptoms and the physician's subjective observations of the patient. The main problem has been the lack of reliable data compounded by the stigma of a mental diagnosis. More recently, third-party pressures have become an added threat to objectivity. New knowledge of brain function, especially neurotransmitters, and more specific and effective medication have made the need for accurate diagnoses more acute. Psychiatry has responded by (...) frequent and often controversial changes in its diagnostic criteria. Much of the controversy stems from a lack of accurate measurements to validate the diagnoses, thereby allowing for differences of opinion of a highly subjective nature. The problem is complicated by the chronic, but irrational, belief that there is a separation between mental and somatic illness. Keywords: calibration, diagnoses, objective vs. subjective, stigma, third-party CiteULike Connotea Del.icio.us What's this? (shrink)

Battle lines have been drawn over involuntary treatment. On one side, there are those who oppose involuntary psychiatric treatments under any condition. Activists who take up this cause often don't acknowledge that psychiatric symptoms can render people dangerous to themselves or others. They also don't allow for the idea that the civil rights of an individual may be at odds with the heartbreak of a caring family. On the other side are groups pushing for increased use of involuntary (...) treatment. These proponents are quick to point out that people with psychiatric illnesses often don't recognize that they are ill, which (from their perspective) makes the discussion of civil rights moot. They may gloss over the sometimes dangerous side effects of psychiatric medications, and they often don't admit that patients, even after their symptoms have abated, are sometimes unhappy that treatment was inflicted upon them. In Committed, psychiatrists Dinah Miller and Annette Hanson offer a thought-provoking and engaging account of the controversy surrounding involuntary psychiatric care in the United States. They bring the issue to life with first-hand accounts from patients, clinicians, advocates, and opponents. Looking at practices such as seclusion and restraint, involuntary medication, and involuntary electroconvulsive therapy--all within the context of civil rights-- Miller and Hanson illuminate the personal consequences of this controversial practice through voices of people who have been helped by the treatment they had as well as those who have been traumatized by it. The authors explore the question of whether involuntary treatment has a role in preventing violence, suicide, and mass murder. They delve into the controversial use of court-ordered outpatient treatment at its best and at its worst. Finally, they examine innovative solutions--mental health court, crisis intervention training, and pretrial diversion--that are intended to expand access to care while diverting people who have serious mental illness out of the cycle of repeated hospitalization and incarceration. They also assess what psychiatry knows about the prediction of violence and the limitations of laws designed to protect the public. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Deflating Psychiatric ClassificationClaudio E. M. Banzato (bio)Keywordsnosography, comorbidity, utility, pragmatismSystems of classification bring order into the world. They are a key part of the informational working infrastructure of the world we inhabit (Bowker and Star 1999). Thus, much of the human interaction hinges on these ordering—pattern identifying and creating—systems. Formal or informal, standardized or ad hoc, visible or invisible, enforced or optional, there are a myriad of classifications (...) we necessarily live by.Typically, classifications convey representations of states of affairs to make interventions on them feasible and, to some extent, predictable. In other words, classificatory systems and schemes try to confer intelligibility to the world. By succeeding in such task, they may provide rational grounds to human operation on reality (toward the most diverse ends). This account fully applies to medical classifications, which struggle to sort out all kinds of diseases, ailments, complaints, and sufferings that can possibly be targeted by medical interventions. This means classifications are instrumental to the ends pursued by medicine, quintessential modificatory activity. In sum, classifications are cognitive tools devised to build up knowledge by making relevant distinctions, which may prove helpful to guide human action.By working well, classifications eventually tend to become invisible. They end up looking just natural, as if they were carved by nature itself. But indeed purpose is the touchstone here. Even if a given class of objects fully qualifies as a 'natural kind' and necessary and sufficient criteria for class membership can be definitely established, it does not entail that it constitutes the best way to classify these objects irrespective of the context. Peter Zachar (2002) offers a compelling example from natural sciences, the utmost practical importance of distinguishing between hydrogen and its isotopes (hydrogen, deuterium, and tritium). In this case, the classificatory thrust stretches beyond the shared atomic number. In his words, "A crucial factor in recognizing them as distinct is that they are used in distinct activities and practices. We get a better neutron bounce with heavy water or D2O. Deciding what aspects of internal structure are important therefore cannot be isolated from external factors." (p. 220)In contemporary psychiatry, diagnostic classification has been center stage for several reasons. But before addressing them, however, a brief historical detour is necessary. Back in the nineteenth century, putting forward a new classification of mental diseases was taken somewhat as a token of psychiatric proficiency according to the witty remark by the French physician and publicist Philippe Buchez: "Upon believing that they have [End Page 23] completed their studies, rhetoricians will compose a tragedy and alienists a classification" (Berrios 1999, 152). By the middle of the twentieth century, many psychiatric classifications (based on diverse principles and underlying theoretical orientations) were still used across the world. The British psychiatrist Erwin Stengel (1959), in his influential report on classification of mental disorders, pointed out that the issue of difficulty of communication was then the order of the day for psychiatry, because it was widely perceived as one of the most serious obstacles to the progress in the field.The broad, worldwide survey carried out by Stengel made it clear that classifications of all shapes were used in different contexts, but they were seldom appealing outside the boundaries of the respective centers that generated them. Such diversity of classifications reflected not only different functions or purposes they were meant to serve, but also the role played by the history of a given problem within a particular medical tradition and cultural background. Thus, Stengel's aims for an acceptable statistical international classification were relatively modest: it should simply ground epidemiological work.Stengel's stance on classification was frankly pragmatic and utilitarian. He understood well the difficulties posed by the 'disease entity' assumption in psychiatry and asked the straight question: "Firstly, what do we classify in this field? Are we classifying diseases or people?", to which he offered a compromised answer: "It may be said that the material the psychiatrist has to classify consists neither of diseases nor of people but of a variety of disorders or reactions, a material which does not readily lend itself to classification" (Stengel 1959, 612). For him, the pursued agreement on the... (shrink)

Although informed consent for treatment has become a cornerstone principle of psychiatric care, the process of diagnosis has remained largely in the hands of the physician alone. While the conferring of a psychiatric diagnosis has historically not been considered a form of medical intervention, the potential impact of a diagnosis for any particular patient may be substantial. This article explores the challenges involved in balancing respect for patients with the physician’s duty of truth-telling and clinical accuracy.

In lieu of an abstract, here is a brief excerpt of the content:Psychiatric Comorbidity:More Than a Kuhnian AnomalyPeter Zachar (bio)Keywordscomorbidity, classification, epidemiology, differential diagnosis, personality disorderDr. Aragona's article in this issue of Philosophy, Psychiatry, & Psychology makes some important points regarding the relationship between comorbidity rates and the classification system currently used in psychiatry. Particularly persuasive is his claim that observed patterns of comorbidity are, in important respects, consequences of the structure of the classification system. I am not convinced, (...) however, that comorbidity is best conceptualized as an artifact of the taxonic structure of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). Instead, I suggest that the use of dichotomies such as true versus artifactual should be used with caution when psychiatric classification is being discussed.In contrast with the artifact hypothesis, I argue that the phenomena covered by the term "comorbidity" are real, expectable features of the psychiatric domain. They are not the phlogiston and luminiferous ether of psychiatry. I am skeptical of the notion that high comorbidity rates as a whole can be understood as Kuhnian anomalies, or that there is a crisis, or that after a period of revolutionary science a new paradigm would eliminate these 'anomalies.' In short, high rates of comorbidity in psychiatry will not simply disappear once scientists develop a better nosological paradigm. High levels of comorbidity can, however, be both lowered and provided a better, evidence-based conceptual framework.Many Conditions, One OrganIn general medicine, comorbidity conventionally refers to the simultaneous occurrence of two independent disease processes or distinct clinical entities, such as heart disease and liver cancer (Feinstein, 1970; Jablensky 2004). The presence of one disease is supposed to affect the other in such a way that the co-occurrence of the two has implications for prognosis and treatment.Comorbidity in psychiatry is a broader concept, referring to a variety of conditions that overlap in multiple ways. The different kinds of overlap are amenable to detailed empirical analysis (e. g., Klein and Riso 1993; Neale and Kendler 1995). Depressive reactions to primary disorders, attention deficit symptoms associated with mania, panic attacks in the context of severe borderline personality disorder, substance abuse disorders among psychopaths, histrionic dynamics combined [End Page 13] with narcissistic personality traits, and emergent conditions such as schizoaffective disorder are all distinct types of comorbidity. The kinds of overlapping conditions just listed are sometimes termed psychiatric comorbidity. Also important is comorbidity between psychiatric disorders and general medical conditions as is studied in behavioral medicine and health psychology. The crisis, if there is one, is a crisis of comorbidities.The heart disease and liver cancer type of comorbidity as independent organ systems being affected is ruled out a priori in psychiatric comorbidity proper. In psychiatry, "psychopathological disease processes" can all be expected to affect a single organ, namely the brain or, more likely, affect the different systems that are tightly integrated in the brain. The tight integration can make putative comorbid psychiatric disorders difficult to disentangle.It is a widely held consensus that causes, not organ systems, are what matter in comorbidity. In this tradition, Dr. Aragona claims that in general medicine shared symptoms between two diseases (such as fever and fatigue) are not a problem because the diseases are differentiated with respect to etiology; in psychiatry, however, where syndromes are differentiated by a description of symptoms only, symptomatic overlap is a problem.Is descriptive psychopathology, therefore, a root cause of the "crisis of comorbidity" and should it be abandoned in favor of etiological classification? Unfortunately, forcing psychiatric nosology to conform to an etiological paradigm is unlikely to resolve the problem of psychiatric comorbidity. As noted, the problem is one of distinguishing between the different etiological disease processes that are affecting tightly integrated systems in the brain. The brain as a whole is a multilevel, dynamic, and open system, which has an ecology (Zachar 2000). As argued by Kendler (2005) and Schaffner (2002, 2008), it has not thus far, and may never be fully possible to segregate causes and their associated psychiatric disorders into parsimonious etiological packages. In the ecology of neuroscience, causes and effects tend to merge in a continuous series of common pathways.It would be foolish... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Psychiatric Hospitalization—Bridging the Gap Between Respect and ControlPaul P. ChristopherIntroductionThis issue of Narrative Inquiry in Bioethics offers varied and somewhat unique perspectives on the experience of psychiatric hospitalization. This commentary highlights a number of salient themes that emerge from reading these essays and attempts to explore how they relate to the broader academic literature on psychiatric hospitalization, particularly with regard to ethical considerations. In reading these (...) narratives, each several times, I was repeatedly struck by the courage required of the authors, both to share their stories publicly and to endure the challenges that the writing process no doubt demanded of them—revisiting and suspending themselves in deeply emotional and, at times, traumatic experiences in order to share the most compelling narrative. Their hard work clearly paid off—the stories are at once intimate and indelible. Still, in many instances, I found myself wanting to know more; to enter the story and sit with the individual through these events; to ask what they were thinking or feeling in a particular situation; to see and hear the world in which they found themselves. Such is the nature of good story telling—the reader, left with the lingering vision created in his mind, turns over the last page, eagerly hoping for more.Narrative ThemesI. Loss of Autonomy or ControlPerhaps the most notable theme had to do with the loss of control or freedom that followed from hospitalization. On first consideration, it may seem odd that this issue appears so often since patient autonomy constitutes one of the fundamental principles of medical ethics. Only under specific circumstances—e.g., when there is a risk of imminent harm—may autonomy be curtailed, and even then only to the extent that is minimally necessary. Yet, as these narratives highlight, there are a multitude of ways in which psychiatric hospitalization engenders actual or perceived restrictions in freedom (Newton-Howes & Mullen, 2011).Consistent with prior research (Goodwin et al., 1999), many of the authors describe a fear or the actual experience of not being able to leave the hospital freely, even when the admission seems to have been voluntary. For example, one writer worries, “I was so afraid that if I ever went ‘in,’ I would never get ‘out’... I thought I would never taste freedom again... alive.” Another describes:When it came time for my possible discharge they told me that I might not get discharged because I was ‘acting up the previous evenings.’ My anxiety level at this point went through the roof. The only reason I was discharged was because my father knew some politicians. If not [End Page 29] for him I would have been a patient there for perhaps years and my life would have been ruined.A third gives this example: “When I asked to sign the form to leave after three days, [the psychiatrist] told me if I did that she would have me committed.” Another writer fears not having any control of how the psychiatrist might approach the treatment: “... I was totally vulnerable... would the doctors blame me, drug me, shock me, kill me?”Somewhat surprising, however, was the fact that so few of the narratives take issue with the decision to hospitalize. This omission is especially striking in light of the fact that prior reports consistently note that a substantial minority (up to nearly half) of voluntarily admitted patients nevertheless experience their admission as coerced (Bonsack & Borgeat, 2005; Hiday et al., 1997; Katsakou et al., 2010; Rogers et al., 1993; Sheehan & Burns, 2011). Because many of these narrators had been hospitalized more than once, the relative absence of expressed resistance to being hospitalized seems strange, particularly when earlier hospital experiences or their aftermath are often described as negative. For example, one individual characterized the time after being released from the hospital as, “My sense of self was questioned. I felt as if I lost my soul.” Another put it this way:When I got out of the private hospital, I felt like my soul had been ripped out of me. I felt like I had a gaping hole in the center of my body... I felt psychically raped, dazed, and confused.Given these... (shrink)

Various types of health settings use clinical ethics committees (CEC) to deal with the ethical issues that confront both healthcare providers and their patients. Although these committees are now more common than ever, changes in the content of ethical dilemmas through the years is still a relatively unexplored area of research. The current study examines the major topics brought to the CEC of a psychiatric hospital in Israel and explores whether there were changes in their frequency across nearly three (...) decades. The present paper reports on a thematic analysis of the written verbatim transcripts from 466 ethical topics brought to the CEC between the years 1991 and 2016. The following major topics related to ethical dilemmas were identified: confidentiality (30%), patient autonomy (23%), health records (14%), dual relationship (12%), allocation of resources (11%), inappropriate professional and personal conduct (9%), and multicultural sensitivity (1%). Topics related to confidentiality increased significantly over the years, as did inappropriate professional and personal conduct. In addition, the analysis showed that the content of the ethical cases and the resolutions suggested by the CEC also varied over the years. In conclusion, although most ethical topics have remained relatively stable over time, the discourse around them has evolved, requiring a dynamic assessment and reflection by the mental health practitioners serving as members of a CEC. (shrink)

Weight-gain in psychiatric populations is a common clinical challenge. Many patients suffering from mental disorders, when exposed to psychotropic medications, gain significant weight with or without other side-effects. In addition to reducing the patients' willingness to comply with treatment, this weight-gain may create added psychological or physiological problems that need to be addressed. Thus, it is critical that clinicians take precautions to monitor and control weight-gain and take into account and treat all problems facing an individual. In this review, (...) we examine some of the key issues surrounding weight-gain in individuals suffering from mental disorders for contemporary practitioners in community clinics. We describe some factors known to make certain patients more susceptible to treatment-induced weight-gain and mechanisms implicated in this process. We also highlight a few psychological and pharmacological interventions that have proven effective in weight management. Importantly, we provide critical steps for management and prevention of weight-gain and related issues in the clinical practice of psychopharmacology. (shrink)

The author analyses how debate over the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders has tended to privilege certain conceptions of psychiatric diagnosis over others, as well as to polarise positions regarding psychiatric diagnosis. The article aims to muddy the black and white tenor of many discussions regarding psychiatric diagnosis by moving away from the preoccupation with diagnosis as classification and refocusing attention on diagnosis as a temporally and spatially complex, as well as (...) highly mediated process. The article draws on historical, sociological and first-person perspectives regarding psychiatric diagnosis in order to emphasise the conceptual—and potentially ethical—benefits of ambivalence vis-à-vis the achievements and problems of psychiatric diagnosis. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Democratizing Psychiatric ResearchRecognizing the Potential and the Limits of Experiential ExpertiseThe author reports no conflict of interests.First, I want to express my gratitude for such thoughtful and generative responses to the manuscript "Why Democratize Psychiatric Research?," which has been in development for several years and is the product of much reflection that has taken place in academic, advocacy, and interpersonal contexts. I am delighted to see such (...) insightful engagement with the piece and to have a chance to respond to both Drs. David Crepaz-Keay and Sam Fellowes here. Given that the authors raise such different questions within their commentaries, I consider each in turn.In his illuminating commentary, Crepaz-Keay makes three important points in response to the epistemic and ethical reasons I lay out as justifications for democratizing efforts in mental health research. First of all, Crepaz-Keay warns that there is "more subjectivity across much of medicine" than in the picture I've painted, and that we might do better to focus on this shared territory, taking up the goal of democratization across all of medicine, rather than risk "othering" psychiatry as uniquely subjective. In this way, Crepaz-Keay emphasizes, mental health service user researchers might "become leaders in progressive medical thinking."I appreciate this call to emphasize the ways in which the importance of subjective experiences cuts across all of medicine and to learn broad lessons from the pioneering participatory work that has been accomplished in the domain of mental health. I agree that much of medicine suffers from a focus on the objective to the neglect of the subjective, and wonder if this focus can sometimes create a distinct kind of worry in territories in which objective measures are widely available. Consider the focus on reducing the size of a tumor at all costs that can sometimes obscure important considerations related to what a good end of life might look like (Gawande, 2014). Particularly [End Page 143] within the process of determining what is worth measuring within research (and what is worth treating within clinical contexts), patient voices are essential to making an informed and beneficial decision. I agree with Crepaz-Keay here—this point applies to all realms of medicine.In contrast, I think other kinds of risks arise in domains in which objective measures are not widely available and therefore subjective reports of patients make up an essential part of any diagnosis or assessment. Another area I often think about is placebo studies, and in this space, stereotypes related to 'real' suffering and 'real' healing circulate widely (Friesen, 2019b). Largely, these stereotypes tend to support the importance and reality of that which occurs at the level of the physical or biological and take much less seriously suffering or healing which is thought to be located 'all in the head' (Friesen & Dionne, 2022). These biases also cut across medicine, influencing which patients are seen as trustworthy, dramatic, or worthy of one's compassion. I would argue that they show up especially in the setting of mental health care and research, in part because of the lack of objective measures and physiological explanations. A psychiatrized patient often has nothing physical or objective to point to with regard to their suffering, and so may be at the whim of a provider in relation to whether they are likely to be believed or discredited. As such, we must be especially alert to the unique risks that arise when evidence for suffering comes in a subjective form, and how efforts toward democratization might help reduce such risks.Second, Crepaz-Keay offers an essential intervention in relation to the importance of anti-racism within participatory practices in psychiatry. Although I do make mention of the lack of representation of racialized communities in participatory psychiatric research in discussing the important role that values play in the development of psychiatric knowledge, Crepaz-Keay accurately points out that this point related to representation is cross-cutting, and highly relevant to several of the other reasons I offer for why psychiatry research ought to be democratized. I am grateful for this invitation to look more broadly at how the exclusion of some voices from participatory efforts might apply across... (shrink)

The scientific investigation of mental disorders is an invigorating area of inquiry for philosophers of mind and science who are interested in exploring the nature of typical and atypical cognition as well as the overarching scientific project of ‘carving nature at its joints’. It is also important for philosophers of medicine and bioethicists who are concerned with concepts of disease and with the development of effective and ethical treatments of mental disorders and the just distribution of mental health services. Philosophical (...) worries surrounding mental health and its care have recently extended beyond the bounds of academia, becoming a vigorous topic of debate in a variety of public domains in the wake of the publication of the most recent revision of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition , the psychiatric classification system used by mental health professionals in the USA, and increasingly, by those around the world.The DSM-5 lists mental disorders according to the observable symptoms presented by patients. It is designed for pragmatic use across a variety of settings to accomplish several tasks: to facilitate clinical treatment, to provide clear criteria of eligibility for various administrative and policy related purposes ), and primarily, to further scientific research into mental disorder aetiology. Although designed to meet the needs and interests of various stakeholders , the recently revised manual has not fully satisfied any of them. This failure challenges the assumption that a single manual …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:'Psychiatric Dasein'Christopher Heginbotham (bio)Fulford and Colombo's pioneering work (2004)in linguistic analysis offers valuable insights and 'deconstructs' the often inter-related concepts of mental disorder and treatment. Their paper describes a combined philosophical and empirical research program developed to study "the role models of disorder in the community care of people with long-term schizophrenia" (2004, 130). They claim that the approach supplies a key explanatory insight into the nature of (...) the problem presented by models of disorder, a characterization of models, contributions to research design, a theoretical framework—a 'models-grid,' and a basis for turning theory into practice. These claims are not unreasonable in the context of the specific objectives of the research design, but do not necessarily cover everything of importance in the way models are used to describe mental disorder. In particular, this brief response proposes the need to develop an understanding of psychiatric Dasein—mental disorder as presented in the world.Fulford and Colombo are surely right in their claim that representations of mental disorder are high-level concepts not dissimilar to other high-level concepts such as time. These are concepts that we seem to have little difficulty using in day-to-day practice but have great difficulty defining. In their discussion of this point, they suggest that little progress has been made in relation to models of mental disorder over the previous fifty years, that there is a considerable volume of theoretical literature that has had little impact on practice.This assertion does not appear to do justice to the significant progress that might be argued to have occurred in psychoanalytic theory, psychodynamic therapy, and other metapsychological developments of the last fifty to one hundred years. Many of these developments have changed markedly our perceptions of mental disorder. Some treatments, it is true, may not have direct relevance or applicability to serious psychotic behavior, although that is contentious; there are psychoanalytic psychotherapists working with people with schizophrenia who would claim success. Recent developments in cognitive-behavioral therapy allied to other treatment modalities, such as careful use of low-dosage medication, have had therapeutic impact in enabling people with schizophrenia to 'manage their voices' and to understand the complex nature of their own thought processes.Fulford and Colombo also suggest that after this half century of work much of the development of practice has been largely abortive. Is this correct? It is true that we continue to struggle with an understanding of what we mean by mental disorder, which is made much worse, as the authors say, by the multiplicity of definitions of mental illness, models of mental disorder and practical approaches to treatment and management. Multidisciplinary and multi-agency developments of the last twenty years especially have, on the one hand, been a powerful approach to recognizing the multifaceted nature of mental disorder, but, on the other, have tended to a potential fragmentation of effort that has undermined [End Page 147] the necessary focus on the needs of the individual patient.Threefold ExpansionIt is here that perhaps an addition or expansion can be made to Fulford and Colombo's approach. That addition is, to borrow a phrase used by Hilary Putnam for the title of one of his books, a 'three fold cord.' The term comes originally from Ecclesiastes 4.12: "..a threefold cord is not quickly broken." (Putnam subtitles his book, Mind, Body and World, echoing, probably unintentionally, Heidegger's threefold structure of 'Being-In' [Dreyfus 1991. 163]).First, there have been many attempts 'informally' to understand the interplay of differing mental disorders in the operation of multidisciplinary teams. The development of community mental health teams and more recently Crisis Resolution and Out-Reach teams has required staff from varying professional backgrounds and agencies to find some common ground and to negotiate across their various professional, philosophical, and nosological boundaries. These negotiations have not been easy. A first element of the threefold expansion may be to incorporate (or strengthen) an organizational and group dynamic in the model (see, for example, de Board 1978; Hinshelwood 1987)Second, theoretical and practical work by professionals trained in psychoanalytic disciplines have sought to understand the nature of multidisciplinary community provision for people... (shrink)

Medical interventions are usually categorized as “invasive” when they involve piercing the skin or inserting an object into the body. Beyond this standard definition, however, there is little discussion of the concept of invasiveness in the medical literature, despite evidence that the term is used in ways that do not reflect the standard definition of medical invasiveness. We interviewed psychiatrists, patients with depression, and members of the public without depression to better understand their views on the invasiveness of several (...) class='Hi'>psychiatric electroceutical interventions (treatments that involve electrical or magnetic stimulation of the brain) for the treatment of depression. Our study shows that people recognize several kinds of invasiveness: physical, emotional, and lifestyle. In addition, several characteristics of therapies influence how invasive they are perceived to be; these include the perceived capacity of an intervention to result in harm; how localized the effects of the intervention are; the amount of control retained by the person receiving the intervention; how permanent its effects are perceived as being; and how familiar it seemed to participants. Our findings contribute to a small literature on the concept of invasiveness, which emphasizes that categorizing an intervention as invasive, or as noninvasive, evokes a variety of other normative considerations, including the potential harm it poses and how it compares to other potential therapies. It may also draw attention away from other salient features of the intervention. (shrink)

Objective—In Switzerland, as in some other European countries, medical doctors may breach patient confidentiality and report to police authorities any patient who seems prone to automobile accidents or traffic violations. The aim of this study was to see if those patients reported to authorities actually represent a higher risk than drivers not reported to the police.Design—This study was designed following a case-control study comparing the characteristics of a group of psychiatric patients who were reported to authorities for preventive purposes, (...) with the characteristics of another group of people who had disorders that were noticed at the time of an accident or traffic violation.Results—The results show that medical doctors tended to report male patients, patients with a low level of education, and patients with a severe psychiatric background. The subjects of the control group, who had often been involved in accidents or committed traffic violations in the past, did not possess these characteristics.Conclusions—The breach of medical confidentiality by doctors in reporting to authorities patients who are allegedly at risk is ethically questionable as long as the evaluation of driving performance does not rely on objective bases. (shrink)