This article reviews contemporary issues in telepsychiatry and telepsychotherapy. The authors examine ethics within a larger social context, particularly access to care and cost of care. They consider the evolving scientific validation of telepsychiatry and the ethical significance of telepsychiatry in various practice settings. They also focus on the doctor-patient relationship, assessments, and provision of psychiatric treatments such as medication management and psychotherapy. The authors consider concerns about malpractice liability and medicolegal constraints on telepsychiatry. They do not address artificial intelligence in virtual mental health care, nor online communications outside the clinical encounter (eg, social media, email).

BACKGROUND:Case reports are valuable tools that illustrate and analyze practical scenarios, novel problems, and the effectiveness of interventions. In psychiatry they often explore unique and potentially stigmatizing aspects of mental health, underscoring the importance of confidentiality and informed consent. However, journals' guidance on consent and confidentiality for case reports varies. In 2013, an international expert group developed the CAse REports (CARE) Guidelines for best practices in case reports, which include guidelines for informed consent and de-identification. In 2016, the Committee on Publication Ethics (COPE) issued ethical standards for publishing case reports, calling for written informed consent from featured patients. METHODS:Using a cross-sectional approach, we assessed the instructions for authors of 253 indexed psychiatry journals, of which 129 had published English-language case reports in the prior five years. Our research identified and evaluated journals' use of COPE and CARE guidelines on informed consent and de-identification in case reports. RESULTS:Among these 129 journals, 84 (65%) referred to COPE guidelines, and 59 (46%) referenced CARE guidelines. Furthermore, 46 (36%) required informed consent without de-identification, 7 (5%) required only de-identification, and 21 (16%) required both, specifying consent for identifying information. Notably, 40 (31%) lacked informed consent instructions. Of the 82 journals that required informed consent, 69 (85%) required documentation of consent. CONCLUSION:A decade after the publication of expert guidance, psychiatry journals remain inconsistent in their adherence to ethical guidelines for informed consent in case reports. More attention to clear instructions from journals on informed consent-a notable topic across different fields-would provide an important educational message about both publication ethics and fundamental respect for patients' confidentiality.

Abstract This chapter from Vice and Psychiatric Diagnosis defines the introductory problems and foci of interest of the book. The chapter describes the philosophical-analysis steps used, and then provides numerous illustrations of the methods of analysis. ‘Vice’ as used here refers to wrongful or criminal-conduct experiences and behaviors. Vice-laden disorders differ from conventional illness concepts in that the latter lack immoral or criminal conduct in their descriptions and diagnostic criteria. The ways vice-laden concepts find their way into Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases diagnostic categories are described, with examples of particular disorders such as Conduct Disorder, Antisocial Personality Disorder, and Paraphilic Disorders, among others. Having made the case for the appearance of vice concepts in these categories, the next chapter is introduced.

Stein et al1 provide a state-of-the-art summary of the philosophy-psychiatry field that centers around the mind-brain-world triumvirate. They do an astounding job summarizing 30 years of activity in the field, culminating in a present-into-the-future consideration of embodied cognition. Here I look forward in a different direction. Borrowing the internalist/externalist distinction from historiography, externalist philosophy of psychiatry might be paraphrased as a social philosophy of psychiatry. Externalist philosophy of psychiatry would consider the role of the social and cultural world in shaping conceptions of mental illness and its treatments. It would consider social phenomena as environmental contributors to the complex causalities that converge on psychopathological phenomena. It would reconsider concepts of free will in terms of structural features of the human organism alongside the structural features of our increasingly complex social environment. It would draw upon philosophy of technology, social epistemology, metaphysics, political philosophy, and philosophical anthropology in placing clinical diagnosis, research and theory into sociocultural contexts. Through understanding these social contexts, we can find new clarity in the mental health project. I can make these abstract generalizations more vivid by considering some examples from our current, and rapidly changing, era. I mention very briefly three areas ripe for development by social philosophers of psychiatry: the engulfment of clinical activity by electronic medical records; the role of domination by the State in mental health; and the psychopathology of artificial intelligence (AI). Back in 1977, Heidegger2 introduced the concept of "enframing" to the then-developing philosophies of technology. "Enframing" involves the tendency of technologies to appropriate resources for their own purposes, forming a "standing reserve" of resources increasingly remote from human goals. Heidegger's thinking helped to found the now-familiar philosophy of technology tropes such as "technologies solve problems which in turn generate new problems, requiring new technological solutions". This recursive expansion of technological imperatives can be seen playing out in clinics around the world through electronic medical records. Psychiatric training directors are already noting the deterioration of interviewing and diagnostic skills when young trainees are driven to checking box after box of clinical findings, being "enframed" into the metaphysical structure of those records, and missing the big narrative picture of the patient. What made "enframing" toxic for Heidegger was that technologies change the way we think, as in the above-mentioned check-box interviews. Fortunately, philosophers of technology have been working on this set of problems for a while, and philosophers of psychiatry can find a rich literature. The response to digital "enframing" has already begune.g.,3. The archeologist/anthropologist team of D. Graeber and D. Wengrow4 reconsider world history with a particular interest in the origin of social inequity and the origin of the State (e.g., government). As social scientists, they have access to and can interpret archeological and anthropological sciences freed from the limits of written text "traces". By studying cultural artifacts, they can provide evidence about the diversity of community living over the millennia. One of their major insights is the common threads that constitute domination of people by other people – e.g., social control. They identify three factors that are apparent singly, doubly or triply in virtually all the cultural forms of dominated communities: control of violence, control of knowledge, and control by charisma. Control of violence refers to the people who are authorized to apply violence to others, whether war-making or managing crime (as just two examples). Control of knowledge has to do with the people controlling what counts as truth and knowledge. Control by charisma has to do with the persuasiveness of the would-be empowered group; the ability to bring believers/followers into the fold. The authors note that the most successful domination occurs when all three factors of the triad are seized. They also note that the means to capturing the three factors are not determinative; one can have democratic, imperial or fascist dominations, for example. I need not detail the relevance of these concepts to our current world situation, but I can point to their relevance to the social philosophy of psychiatry. We have seen the rise of populist authoritarian rule over the past decade – the charisma element. We have witnessed the loss of confidence in "elites" – scientists, professors, philosophers, intellectuals and doctors. More importantly, talk of "post-truth" and the transformation of public lying from vice to virtue is eroding our prior forms of the domination of knowledge. Control of violence is also being shaken worldwide, as social media enable the challenging of conventional mechanisms of violence control (policing, the courts, civil liberties, rule of law, subordination) through familiar tropes such as #Icantbreathe, #metoo, and the unprecedented January 6 storming of the US Capitol building. For philosophers of psychiatry, the range of tasks deriving from these social changes is huge. Some are simple to conceive: how do clinicians communicate around these phenomena? Others are definitional: how many people must believe something before a false belief is not a delusion? Still others are insidious: what counts as mental health in a post-truth world where confidence in State institutions is diminishing? In recent months we have witnessed the explosion of AI technology proffered by the major info-tech companies. We have also witnessed gushing enthusiasm as well as apocalyptic worries from many users and commentators. Somewhere in-between these social reactions resides the systematic appraisal of these systems as they evolve. We have seen how human biases are entrained in AI, leading to perpetuation of bias in later use5. We have also seen both absurd and frightening results of natural language devices when asked ordinary questions6. Social philosophers of psychiatry can envision the development of looping effects of human-AI deviant interchanges online and worry about the social consequences. Some examples of inquiries in this area point to treating deviant AI responses as psychopathology analogues7. Others consider using AI tech as explanatory models of human psychopathologies and tools for therapeutic developments8. We can also envision the engagement of AI into disputes about medical and other misinformation in the social media environment, thus connecting psychopathology of AI to social-domination theory described above. Some preliminaries of this work have appealed to a "father" of philosophy of psychiatry: K. Jaspers9. All this potential work is wide open, deep and important.

Abstract This chapter from Vice and Psychiatric Diagnosis picks up the thread from the parallel history of morality and madness from Chapter 4 and examines more closely the response of American colonists to madness and wrongful conduct, continuing through the development of US asylum doctors and Psychiatry proper, continuing on up to the turn of the twenty-first century. The eighteenth and nineteenth centuries witnessed the development of the concept of social deviance, addressing needy others which were, in various ways, unable or unwilling to conform to the standard social expectations of the time. These groups included ‘madpersons’, thieves, vagabonds, drifters, orphans, unwed mothers, and increasingly, as medical care developed, intellectually disabled people and demented elderly people. The needs posed by social deviance, amplified by industrialization and urbanization, led to social welfare programs in general, and asylums, psychopathic clinics, jails, prisons, jails, schools for delinquents, and constituting the diverse social welfare institutions familiar to us today. These institutions ultimately became funded primarily by governments, dependent upon the will of the polity for their successes and failures. The ambivalence of the public about social welfare institutions is described and applied to the contemporary issues of the vice/mental disorder relationship.

Abstract This chapter from Vice and Psychiatric Diagnosis pulls diverse strings together from the prior chapters, to gain a more holistic understanding of the vice/mental disorder relationship (VMDR). The concept of folk-metaphysical assumptions introduced in Chapter 3 is elaborated to illuminate our confusing and complex sociocultural responses to vice and mental illness. The division of cultural ownership of vice/sin/crime for religion and criminal law, discussed in Chapters 4 and 5, and the appropriation of illness, mental or physical, by science and medicine in the post-Enlightenment era, sets the stage for tracking the metaphysical confusions exhibited in contemporary Western culture. This insight is coupled to the standard accounts of the VMDR from Chapter 3, to propose an alternative, more coherent account, a ‘rehabilitation’ account, which is described and employed to address the VMDR as well as the larger problem of incoherent social welfare efforts exhibited in the contemporary United States.

Building a culture of conceptual inquiry in psychiatric training requires the development of conceptual competence: the ability to identify and examine assumptions that constitute the philosophical foundations of clinical care and scientific investigation in psychiatry. In this article, we argue for the importance of such competence and illustrate approaches to instilling it through examples drawn from our collective experiences as psychiatric educators.

Abstract This third chapter from Vice and Psychiatric Diagnosis opens with a philosophical review of the structure and limitations of contemporary diagnostic classifications for mental disorders, namely the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases classifications. Having presented these basics, the chapter then considers the examples of vice-laden mental disorder categories described in Chapter 2 and considers the conceptual reasons why ‘vice-laden behavioral syndromes’ in general have not been considered consistently as candidates for classification as mental disorders proper. The DSM is described as embodying a default cultural morality, and the chapter explores this iconography using several cultural tropes: the virtue/vice subtext of the DSMs, the perspective of ‘common morality’, the critique of the DSMs from the positive psychology field, and the ‘seven deadly sins’ of Roman Catholic moral theology. Vice-laden syndromes are also considered as reflecting problematic conceptual and criteria-set issues. The chapter concludes with a review of how vice-laden categories are handled in the mental health literature, considering a ‘coincidental’ account, a ‘medicalization’ account, ‘moralization’ account, and a ‘mixed’ account.

Introduction to the 30th Anniversary Issue of Philosophy, Psychiatry, & Psychology John Z. Sadler (bio) This issue marks the 30th anniversary of Philosophy, Psychiatry, and Psychology (PPP). All of us at the journal are grateful to our authors, readers, editors, and publishers for enabling this landmark. To commemorate this event, I invited our Founding Editor and Chair of the Advisory Board, K.W.M. "Bill" Fulford to write a brief essay, along with our panel of smart and industrious senior editors. Their instructions were simple: 500 words on PPP past, present, and/or future. These essays appear in the pages to follow. As Editor-in-Chief, I write about PPP's early commitments as a scholarly journal, situate these in the history of academic publishing, and muse over our current moment. Bill Fulford briefly discusses the early years of the journal in his essay. My perspective emerges from an editor's perspective. As co-editors in the early years, Bill and I were committed to an international authorship with comparable editorial oversight. We wanted to build a journal that would equally recognize clinical science and practice and philosophy, maintaining the rigor of each field. We saw philosophers and mental health practitioners as equal partners, collaborators, innovators, and educators. More important, PPP was intended to offer up the best criticism of the mental health and related fields. The scattershot history of scholarly editing has identified several functions of the editor over the centuries following Gutenberg's invention of the printing press in the mid-1440s. The earliest editors took liberties with the language of the Bible, trying to make it more accessible to the public; the printing press permitted fast and inexpensive reproduction. Not surprisingly, this popularizing of the Bible led to praise as well as outrage. The printing of other scholarly works followed quickly. In 1470, only about 25 years after the invention of the printing press, Niccolo Perroni called for Pope Paul II to censor Andrea Bussi's edition of Pliny the Elder's Natural History, an anthology of then-ancient writings about the natural world. This marked the first recorded instance of censorship of a more-or-less secular scholarly work (Monfasani, 1988). In the ensuing centuries, "editors" initially were the popularizers, and later the gatekeepers of texts worth (and not worth) reading. In the [End Page 1] ensuing centuries into the present, editors have been venerated both as defenders of good reading and reviled as censors or intellectual selfaggrandizers. The current moment, in my view, represents a crisis in the history of editing and editorship. Digital communications have liberated communications worldwide. However, this liberty has come at the cost of colossal amounts of material not worth reading and an explosion of divisive, destructive discourse. Even worse, internet "trolls" on social media have moved bullying out of the schoolyard and into international cyberspace. Determining what is worth reading has moved away from a cluster of (hopefully) responsible editors to anyone who wants to go to the small effort of silencing others through online harassment and even violent threats. Such cyberbullying does not eliminate elitism, but instead substitutes a toxic online "elite" without principle other than self-promotion and the alienation of others. Our contemporary online culture has yet to figure out how to shape what is, and is not, worth reading. My wish and intent for the future of PPP is to maintain and grow our place of rational, deliberative, and open discourse, even in the face of such disruptive cultural change. John Z. Sadler John Z. Sadler, MD, is the Editor-in-Chief of PPP. He is the Daniel W. Foster, MD, Professor of Medical Ethics at the University of Texas Southwestern Medical Center, as well as a Professor of Psychiatry there. He has been a PPP editor since its inception. Reference Monfasani, J. (1988). The first call for press censorship: Niccolo Perotti, Giovanni Andrea Bussi, Antonio Moreto, and the editing of Pliny's Natural History. Renaissance Quarterly, 41, 1–31. Google Scholar Copyright © 2023 Johns Hopkins University Press

The clinical practice of psychotherapy is saturated with ethics and moralities. Having an Oxford Handbook of Psychotherapy Ethics seems a necessity in a contemporary world where visions of the good seem up for grabs; subject to whomever shouts the loudest and the most often. The quiet exchanges behind (typically) closed doors, which consider what the good is for the patient, what it means, and how to secure it, seem more crucial than ever. The Oxford Handbook of Psychotherapy Ethics aims to provide the most comprehensive reference textbook of psychotherapy ethics; to offer benchmark chapters as go-to guides for a wide variety of practitioners, scholars, policymakers, and patients; to address conceptual, philosophical, cultural, and religious perspectives while also addressing everyday practice concerns; and to identify areas of ethical consensus and convention, while identifying unresolved issues as well as identifying new, problematic areas needing further analysis and research.

Influences of chronic homelessness on patients' conceptions of bodily integrity can conflict with clinicians' recommendations about clinically indicated interventions, such as dialysis or amputations. This article considers such conflict by drawing on a capabilities-based model to reframe health care as shared between a patient and clinical team.

Phenomenon:Metonymy refers to the substitution of the name of an attribute or adjunct for the name of the object or person being described. In medical contexts, this may involve referring to a person as a disease, body part, or other health-related noun. In this study, we explore the use of metonymy in medical students' reflective writing. Approach: Using content analysis, we identified all usages of metonymy in a sample of 802 medical student reflective essays. We analyzed them for associated themes and used the Fisher's exact test to compare frequencies of clinical ethics themes that occurred in the essays with metonymy to those without metonymy. Findings: Metonymy was used 60 times in the essays. The uses were grouped into thematic clusters of substance abuse (n = 27), illness (n = 9), body part (n = 4), clinical status (n = 6), reproductive health (n = 5), challenging clinical situations (n = 6), and other thoughts on patients as people (n = 3). Several ethical themes associated with essays using metonymy (p < .05): moral distress, substance abuse, adequate treatment, jumping to conclusions, awakening, and pain. Insights: Metonymy was relatively uncommon, and some students explicitly described the practice as dehumanizing to patients. Even so, metonymy did present in a variety of forms and was used most frequently to describe individuals with substance use disorders. Essays involving metonymy were more likely to describe a scenario that elicited moral distress in the students, which may indicate that metonymy occurs more frequently in some troubling situations.

OPINION article Front. Psychiatry, 14 July 2020Sec. Public Mental Health Volume 11 - 2020 | https://doi.org/10.3389/fpsyt.2020.00665

Objective Substance abuse in the context of the opioid crisis presents a major public health concern. Despite some evidence that medical students’ attitudes towards substance use disorders worsen during medical school, very few studies have examined how students’ early clinical experiences with substance use disorders shape their views of this clinical population. This study uses student reflective essays to explore these formative educational experiences. Methods Using content analysis, the authors analyzed a collection of 802 medical student reflective essays written during core clerkships (excluding Psychiatry), coding for ethical and professional themes as well as descriptions of substance use disorders. In addition to the qualitative identification of themes, the authors used chi-square analysis to determine which themes had statistically significant associations with substance use disorders. Results Fifty-three essays described patients with substance use disorders. The most common substances described were opioids ( n = 25), alcohol ( n = 18), and cocaine ( n = 11). There were five themes statistically associated with substance use disorders ( p < 0.05): (1) adequate treatment, (2) pain, (3) difficult patient, (4) jumping to conclusions, and (5) malingering. Conclusions In the sample, students found the treatment of pain to be a significant ethical challenge related to substance use disorders. In considering a comprehensive educational plan, medical educators may need to consider educational venues outside of the Psychiatry clerkship to address substance use disorders.

The idea that mental disorders are value-laden means that they harbor action-guiding meanings and are subject to praise or blame. This domain of values includes a specific kind of value—vice—which describes wrongful, immoral, or criminal thought or conduct (e.g., antisocial personality disorder, pedophilia, conduct disorder, intermittent explosive disorder). Vice-laden mental disorders are problematic because they imply that (1) psychiatrists police antisocial conduct; (2) vice-laden disorders contribute to stigmatizing mental illness; and (3) they generate incoherent social policy and programs that both intrude upon and neglect the “served” population and community welfare. With this background, this chapter addresses the ethical, practical, and political implications of these conditions; presents four models of normative content in vice-laden mental disorders (i.e., coincidental, moralization, medicalization, and mixed); assesses their “pros” and “cons” for public policy; and concludes with considerations for psychiatric and public policy in addressing social problems associated with vice-laden mental disorders.

Little discussion has appeared in the literature regarding the ethical and value considerations when clinicians select a psychotherapy modality (e.g., CBT, psychoanalytic therapy, family systems, etc.) and format (group, individual, couple, family, systems) to offer to clients before formal treatment negotiations begin. This chapter offers a virtue-ethics framework to consider these ethics and values issues in psychotherapy modality/format selection, and embeds this virtue-ethics framework in a series of seven clinical factors to consider when doing modality/format deliberations. Karl Jaspers’s principles of clinical interpretation (hermeneutics) provide an illustrative framework for the thinking process in making modality/format decisions. The interactions between the seven factors to consider in modality/format deliberations and the eight relevant clinician virtues provide for numerous, but brief, clinical examples of how the factors, the virtues, and clinical hermeneutics combine to provide for conscientious psychotherapy modality/format deliberations.

Abstract Purpose: Moral distress occurs when one identifies an ethically appropriate course of action but cannot carry it out. In this conceptualization, medical students may be particularly vulnerable to moral distress, but the literature on moral distress in medical trainees remains sparse. Method: Using content analysis of 802 reflective essays written by third-year medical students, the authors analyzed for the presence of moral distress and other ethical themes. The authors then used chi-squared analysis to determine which ethical themes were statistically associated with moral distress. Results: Two hundred and seventy-four (34%) of the essays included student descriptions of moral distress. The most frequent theme in the moral distress essays was “role of the medical student” in the training hierarchy, and this reached a statistically significant association with moral distress (χ2=15.19, p < 0.001). Statistically significant associations (p < 0.05) were also found with moral distress and themes related to an “ethical disagreement with supervisor,” “insensitive care,” “disputes,” “abuse,” “poverty,” “medical errors,” and “transplant ethics.” Essays discussing the “doctor–patient relationship” or observations of a “job well done” were statistically less likely to involve moral distress. Conclusions: Moral distress is a common occurrence in medical students, particularly related to medical students’ role in the training hierarchy or other difficult interpersonal and clinical interactions. In our sample, moral distress was described less often in the presence of positive role models.

Tuesday, December 10, 2019; noon to 1 p.m.; Room D1.602. Corruption in Clinical Research. John Z. Sadler, M.D., The Daniel W. Foster, M.D. Professor of Medical Ethics, Distinguished Teaching Professor, Professor of Psychiatry & Clinical Sciences, The University of Texas Southwestern Medical Center.

Understanding how institutional review boards/research ethics committees (IRBs/RECs) perform risk/benefit assessment is important to help improve their function. In environmental ethics, uncertainty about potential outcomes and the precautionary principle play important roles in regulatory oversight but have received little attention in the context of human research ethics. We carried out an empirical study to gain insight into uncertainty by asking IRB/REC members about confidence in their risk assessments immediately after discussion of new protocols under review. Based on 12 meetings carried out by four IRBs/RECs over a 6-month period, we found a robust, inverse relationship between risk and confidence. As risk increased, confidence decreased. We detected different patterns of consensus between different IRBs/RECs and their members. Our study introduces a novel and relatively easy to implement approach to begin to understand IRB/REC decision making in real time that can be used within or across institutions.