Foreword

Now, well into the twenty-first century, medicine seems to be humanizing itself, and this in two ways. First, there has been a recent spate of books by physicians and surgeons confessing to their own fallibility and showing genuine concern for their patients and bitter regret about their own mistakes. This concern and regret has always been there, but it has only recently taken literary form. Secondly, it is increasingly acknowledged that the humanities, including especially literature and philosophy, can actually contribute to the science of medicine and to the therapeutic process itself in the understanding of the human being who is the patient. The conceptual interface between philosophy and psychiatry has long been a subject of fruitful exploration at an academic and theoretical level; but it is only recently that the part philosophy should play in the day to day practice of psychiatry has been highlighted.

This timely book exemplifies the relevance of one branch of philosophy to psychiatric practice, namely moral philosophy. This innovation has been part of the radical change in psychiatry over the last twenty-five years, a change that has, among other things, involved a change in the relationship between doctor and patient. (I cannot, I fear, bring myself to refer to them as ‘service provider’ and ‘service user’, however misleading the word ‘patient’ may seem in some of its connotations.) The image of the patient flat on the couch, with the doctor standing over him, directing and dominating the dialogue is long out of date. The patient, with his own set of values (albeit not fully articulated), his own unique character and preferences, virtues and vices, is at least as important as the doctor. There is a growing recognition that, in psychiatry, the doctor does not know best. After all, whether in diagnosis or therapy, the patient has privileged access to his own particular mental suffering. Moreover, it is not just the doctor but the community within which the patient has to try to live, that is to say other people, who must be engaged with.

Many familiar problems in moral philosophy appear in these essays: questions about freedom and responsibility; about the effect on our reaction to people’s behavior of judgments about mental capacity; questions about the extent to which society is entitled to intervene to change the behavior of others, however eccentric (the central question raised by John Stuart Mill’s seminal essay, On Liberty); questions about the extent to which rationality is a guide to conduct. But some of the moral problems that arise in psychiatric practice are genuinely new. Chief among these is the problem of confidentiality, a concept once as central to a psychiatrist’s ethic as to that of the priest. But now the almost incredibly swift growth and extent of the social media seems to have blown this concept out of the window. A revaluation of values appears to be essential. This topic is thoroughly explored in the following essays, and light is cast, especially by the articulation of the problems.

There cannot of course be total consistency, either of content or of style among contributions from so many hands. Some of the most revealing essays are from patients or former patients, especially in their engagement with guilt, remorse, regret and similar value-laden ideas.

There will be an enormous amount to be learned from this collection of essays. Its publication is much to be welcomed.

Baroness Warnock

House of Lords

February 2015