The preface to this book offers a powerful reminder of the capacity of doctors - and psychiatrists in particular - to participate in cruelty. The authors’ subject is Irmfried Eberl, but they argue that in focusing on one man, we have insight into the moral agency of many. And the relationships between individuals and others - be it professional groups, issue-oriented organisations or society - are the dominant theme in this title. Whether it is in the reframing of ‘the virtuous psychiatrist’ as the ‘virtuous citizen’ or in arguments for what the authors describe as ‘the moderate communitarian position’, this is a work that attends to context and connectedness.
The first section of the book offers a sound review of ethical theories which might be somewhat pedestrian were it not for careful attention to the particular context of psychiatry and the inclusion of approaches that have not traditionally informed discussion of medical ethics, for example ‘common morality theory’. The authors maintain the thread of their argument throughout this section, exploring the notion of the social contract, concepts of justice, the relevance of communitarian ethics and delineating the social construction of moral agency, to propose that psychiatry is uniquely situated in medicine and therefore in its ethical discourse.
Section two is somewhat curious and less satisfying. It comprises five chapters focusing on a specific dimension of psychiatry. The choice of involuntary treatment is expected, but the focus of the other chapters is less predictable. Although innovative approaches are refreshing, the motivation for dedicating chapters to neoliberalism and popular culture is unclear. There is much to admire in this part of the book, but the overall effect is uneven, with some parts feeling too specific whereas others seem too broad and unfocused. More significantly, the coherence of argument diminishes in this part of the book compared with the careful lucidity of the preceding section.
The final part references more explicitly the authors’ central premise, namely that the psychiatrist is a moral agent whose work creates particular ethical questions. Competing moral claims are analysed with reference to power, sociopolitical context and epistemological preferences with deftness and unusual accessibility. Yet, the structure is problematic and there are some unusual inclusions that dilute the impact of the analysis at the expense of apparently disparate glimpses into particular countries, regulatory systems or types of patient. I found myself craving a concluding chapter to pull together the ideas and arguments.
This is an interesting book and it contains some important ideas, but too often those ideas are overshadowed by the disjointed structure. It seems like a text that is seeking to serve too many audiences. I would have welcomed a more selective approach to the material allowing for a deeper engagement with the questions set out in the preface. Much of the discussion of ethical theory is well-trodden territory. The analytic contributions that are original and most interesting risk getting lost in the range of material crammed into the book. Clarity of purpose is not helped by the structure, which I found difficult to navigate. When I finished, I was left with the sense that these are authors who, in keeping with their interest in multiple roles and conflicting obligations, have been caught between the preferences and expectations of different readers. As a result, this is a book that itself reflects what it is to be in a quandary.
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