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Abstracts: Ethics, History and Mental Disorder

Dr Len Smith (Centre for the History of Medicine, Birmingham)
Running to Stand Still?: Managing Insanity in the Late Eighteenth and the Late Twentieth Centuries


My perspective on the consideration of ethical issues in relation to mental disorder stems from historical enquiry in the context of having worked as a practitioner in the mental health field over a period of more than thirty years. I am inclined to argue that, although there have been many apparent changes in the way that mental disorder has been managed over the last two and a half centuries, the key ethical concerns and dilemmas remain rather similar.

In the late eighteenth century insanity was clearly considered to be a disease whose origins were intimately connected with other physical disease processes. Its treatment consequently fell within the realms of medicine. Most ethical considerations were, therefore, largely determined by those of the medical professions. In contemporary mental health practice, psychiatrists remain the dominant professional group, and medical-based ethics continue to be at the fore-front. However, as the hegemony of psychiatry has been increasingly challenged by other professional groups, aspects of their ethical formulations have begun to become influential.

One of the emergent key principles in the treatment and management of mental disorder in the eighteenth century was that the patient had to be separated from family and friends, removed from the ‘exciting causes’ of his malady and, ideally, placed in some form of specialist facility. Sequestration had therapeutic rationales, whilst also creating a legitimated spatial and social boundary between the sane and the stigmatized. Comparable considerations have remained at the core of psychiatric practice since the 1970s, albeit that they have been tempered by the phenomenon of ‘care in the community’ and allegedly pioneering developments like ‘home treatment’.

A perennial ethical dilemma centres on the inter-face between public responsibility and private practice. Commercial considerations have, to varying degrees, always impacted on provision of services. The late eighteenth century witnessed a growing sophistication in the nature of private provision, both within public lunatic hospitals and in the mushrooming of the private madhouse sector. This brought with it a growing tension between the ethics of medical practice and those of the market-place. On the contemporary scene this tension is equally evident, with the presence of private psychiatric hospitals and the re-emergence of the private madhouse under the guise of care home or nursing home for people with mental health problems.

Complex ethical issues have been apparent in the determination of access to services according to social background. Two hundred years ago the nature of service received was likely to be dependent on rank within the social hierarchy, with a clear differentiation of what might be accorded to private, charitable, or pauper patients. In recent and current practice, although social class remains an issue, the most significant paradigm is that of ethnicity. The consistently reported research which demonstrates not only a considerable over-representation of black people within the psychiatric system, but a markedly higher proportion who are compulsorily detained, raises profound ethical concerns.

The greatest ethical conflicts, however, have tended to surround the question as to what constitutes the essential purpose of care and management of the insane. Historians have identified the ongoing tension between the promotion of practices conducive to curative treatment and the perceived need to protect the public from the behavioural excesses of mad people. This fundamental dilemma, and the ethical considerations that it engenders, remains as relevant at the dawn of the twenty-first century as it did at the dawn of the nineteenth.