East Asian Arch Psychiatry 2015;25:143-5

Editorial

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Psychiatry is one medical specialty where psychiatrists have a legal responsibility to assess and manage risk on behalf of the society and community within which they practise. This includes the ability to provide social control and take patients’ liberty away and forcefully treat them against their will within a legal framework that has been approved by society. In this Editorial, we comment on medical social control and the human rights of psychiatric patients.

Medical social control has been said to emerge from medicine as an agent of social control¹ as evidenced by the sick role. Subsequently, sociologists such as Freidson² and Zola³ have argued that medicine has taken on jurisdictional control over anything labelled as illness. The challenge lies in the fact that doctors deal with disease more often and rarely with illness. It is entirely possible that definitions of deviant behaviour are set by society but medicine as a profession incorporates these into diagnostic and classification systems. An example of this is homosexuality that for a long time was considered a mental illness. Following the Stonewall riots in New York in 1969,⁴ there was pressure on the psychiatric profession to remove homosexuality from the DSM-III⁵; once this was done, millions of people ceased to be classified as mentally ill. There is no doubt that psychiatry has often been responsible for an increased medicalisation of normal human emotions. Until recently at least the medical profession was able to control doctor- patient interactions,⁶ the advent of the internet and the relative ease of gaining access to information has tipped the doctor-patient balance towards patients. This may have shifted some of the control away from the profession.

Medical control of deviant behaviour may have led to medicalisation of deviance.^7-9 Conrad⁹ defines medical social control as the way in which medicine wittingly or unwitting- ly attempts to secure adherence to social norms (which are defined by society) through the use of medical means to minimise, eliminate, or normalise deviant behaviour. Conrad⁹ also questions why there has been perhaps limited effort to analyse the types of medical control. He argues that defining what is health and related advice to remain healthy becomes a type of medical social control. He points out that both psychiatry and public health are modes of social control and include psychotherapy. Public health also operates as a control agent by setting and enforcing health standards in the workplace, home and community, as well as by other actions such as isolation of the sick individual and immunisations. The growth of technological interventions and medicine adds yet another dimension to medical social control.

Conrad⁹ argues that psychoactive medication under the influence of pharmaceutical companies is a form of medical social control. The context of individual suffering needs to be considered. When an individual is suffering from psychotic depression — not eating or drinking — withholding antidepressants or even electroconvulsive therapy is unethical. How does one square this circle?

Human Rights

There are many human rights frameworks that are accepted and used widely. In theory, these rights should be universal, but in practice they are not. Human rights for psychiatric patients take on an even more urgent prominence. Brody¹⁰ noted that the patients’ rights movement’s assault on organised psychiatry is embedded in self-help organisations. The power and prestige of medicine in general as a profession and psychiatry in particular and the perceived elitism may make them feel distant from human rights frameworks.

The psychiatrist-patient interaction is interpersonal, but takes place in the context of the social contract and social expectations. The impact of social deprivation on mental health has been described by Brody¹⁰ as a psychiatric deficit that is difficult to separate from a social deficit.

The diagnostic categories must be contextualised properly. Munk-Jørgensen et al¹¹ have demonstrated that of 380 available diagnoses in Denmark (from 2001 to 2007), only 4.2% have been used. This limited use of the remaining diagnoses does not automatically mean that they are of no or limited use, rather they relate to genuinely rare conditions. Aetiological, diagnostic, and therapeutic models of mental functioning are often related to definitions of reality and reality testing and shaped by language.¹⁰ Thus human rights have to be seen in this context and the social context must be applied accordingly. Patient involvement in decision-making is an important step. Brody¹⁰ cautions us that since treatment is a continuing process, competency should not be considered a one-off event. He urges us to remember that arguing for the autonomy of a mentally incompetent person without support in a hostile or uncaring environment is increasingly considered a legal as well as an ethical error. Basic human rights to privacy, autonomy, dignity, etc are universal and should not be abandoned because an individual has a psychiatric disorder.

Social Justice

Ventriglio and Bhugra¹² have argued that social justice guides people to create institutions that serve the individual and society for the good. Social justice inculcates personal responsibility and social responsibility for the betterment of society as a whole. It can be used in a culturally relativist way, depending upon societies, their social norms, values and attitudes to eliminate social inequalities that may cause mental illness: patients see food, employment, housing, income and high-quality service as their own requirements.

In conclusion, social justice can be used to deliver health justice where patients receive the required treatment, and to develop and encourage the capability to be healthy across the entire population. Social justice and human dignity go hand in hand.

Medical Profession and Medical Social Control

Conrad⁹ points out that sometimes medicine acts as an agent of social control by collaborating with other agencies, for example, with social services in the identification and management of child abuse and with the police in domestic abuse, gun-shot abuse or other similar activities. Psychiatrists who work within the judicial system to approve a defence of insanity or mental capacity bring yet another dimension to medical social control. Institutionalisation itself is a form of medical social control, but the shift to a community setting may have become a form on institutionalisation as well. Home treatment teams may be seen as another form of medical social control. Medical ideology that promotes this practice could be construed as a form of medical social control.

Conrad⁹ also notes that the medical profession does not always have control. Other interested parties in society do, but they will abrogate their responsibility to the medical profession. Medical ideology then becomes the dominant control, itself controlled by the medical profession. The other form of medical social control is embedded in medical technology, the prerogative of medicine. The medical monopoly may not be exhaustive, but it certainly is influential. The medical profession must perform several roles if they are to maintain their professionalism. First and foremost, they must serve as an advocate for their patients and for those who care for patients with mental illness. Second, they must take on the mandate for ensuring that medical ideologies are transparent and medical technology, when applied, is within the ethical, legal, and human rights framework.

Medical social control in the hands of medicine has to be balanced against medicine as a profession and the professionalism that is embedded in its values and expectations. There have been recent observations and concerns about the de-professionalisation of medicine (and psychiatry in particular¹³).

How does the psychiatric profession balance these two completely opposing values and expectations? We believe that the framework provided by human rights in the context of social justice for those with mental illness should be the target of new action plans in psychiatry. These should focus on providing to patients the treatment they need to improve outcome and recovery. As previously argued,¹² we emphasise that social justice can and indeed should be used to develop and encourage the capability to be healthy for the entire population.

Conclusions

The social context of psychiatric practice and the social contract between psychiatrists as a profession and society has to be in the context of an ethical and human rights framework. This approach allows for the protection of human rights of patients who may be vulnerable. Accordingly, the profession must look into training and curricula that include ethical and human rights aspects of clinical management. The power embedded in medicine and psychiatry, especially in the context of technology and ideology, needs to be understood and explained in a transparent way so that society can take account of this while clinicians look at risk assessment and risk management.

Antonio Ventriglio, MD, PhD
(Email: a.ventriglio@libero.it)
Department of Mental Health, Regione Marche, ASUR, Area Vasta 2, Jesi (AN), Italy
Department of Clinical and Experimental Medicine
University of Foggia, Foggia, Italy
Dinesh Bhugra, FRCP, FRCPE, FRCPsych, FFPH, MPhil, PhD
Institute of Psychiatry, Psychology & Neuroscience
King’s College London
London, UK
President, World Psychiatric Association

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