The heart of psychiatry

Craddock et al's ¹ attempt to define the core expertise of psychiatry is timely and welcome, but disconcertingly incomplete. Ethics, history and philosophy are no less central to the psychiatrist's craft. We have, after all, chosen to care for the only organ in the body that can vote.

Ethical issues arise all over medicine, but in psychiatry they abound. Issues of agency, belief and capacity, daily juggling the paradox of coercion and compassion, define much of our practice. No other branch of medicine has an entire legal statute devoted to it.

History is just as crucial. Ideas of illness, suffering and disease change constantly with the values and wisdom of the times and awareness of the progress of ideas over time is essential to the refinement of our practice. Medicine privileges us with a chance to study this within a living system of art and science, 3000 years in the making.

The importance of these skills is evident in doctors’ relationship with society. Upon qualification, we receive honorary doctorate for nothing more than a bachelor degree (not unlike an increasing number of psychological therapists). Our title acknowledges that we have chosen to go where others fear to tread; severe mental illness is one of the most perplexing matters of all.

An omission of these issues from any definition of our craft may explain the difficulties that psychiatry apparently faces today. ² Much of the concern about mental illness over the past two decades has centred on the ethics of coercion in risky cases and transgressions of the indefinable border between illness and ‘healthy’ distress. Psychiatry, practised properly, with its unique ability to evaluate past and present; brain, mind and body; culture, danger and bus pass ³ brings a clarity to these debates that none can rival.

This view appears anathema in a culture that places such heavy emphasis on consensus and certainty. The measures, goals and guidelines that abound in modern practice are symptoms of this. Against such apparent certainty, more subtle - and far more important - values become ever harder to define, but we omit them from our accounts at our peril. These are cynical times and, as Oscar Wilde reminded us, a cynic is someone who knows the price of everything and the value of nothing.