Conferring a diagnosis of mental illness on a person has profound ethical sequelae since the process may embody substantive adverse effects, notably stigma, prejudice, and discrimination (e.g. limited job prospects, inequitable insurance coverage). Furthermore, those deemed at risk to harm themselves or others may have their civil rights abridged. These consequences justify Reich’s⁽⁴⁾ call for the most thorough ethical examination of what he terms the clinician’s ‘prerogative to diagnose’.

Psychiatrists strive to diagnose by using as objective criteria as possible and information gained from previous clinical encounters. The process is relatively straightforward when findings such as gross memory impairment and life-threatening social withdrawal strongly suggest severe depression. Other situations are not so obvious. For instance, the distress felt by a bereaved person may incline one clinician towards diagnosing clinical depression whereas another may construe the picture as normal grief. Expertise, peer review, and benevolence combine to protect against arbitrariness and idiosyncrasy. Notwithstanding, psychiatrists must, to some extent, apply what might be termed as ‘reasoned subjectivism’. Thus, specified criteria in the American Psychiatric Association’s (APA) DSM-IV⁽⁵⁾ and the World Health Organization’s ICD-10⁽⁶⁾ do not preclude debate about the preciseness or legitimacy of syndromes like Attention Deficit Hyperactivity Disorder (ADHD) and sexual orientation disturbance. Concern about the intrusion of value judgements into contemporary classification has led to the contention that some diagnoses reflect pejorative labelling rather than scientific decisions. For example, charges of sexism were leveled against DSM-III⁽⁷⁾ on the grounds that masculine-based assumptions shaped criteria, resulting in women receiving unwarranted diagnoses like premenstrual dysphoria.⁽⁸⁾

The issue central to this debate is whether certain mental states are grounded in fact or value judgements. Szasz⁽⁹⁾ takes a radical position, arguing that disordered thinking and behaviour are due to objective abnormalities of the brain whereas mental illness per se is a ‘myth’, created by society in tandem with the medical profession in order to exert social control. The ‘anti-psychiatrist movement’^(10,11) posits that mental illnesses are social constructs, reflecting deviations from societal norms. This argument is supported by the role of values in both defining homosexuality in the past as a psychiatric disorder, then reversing that position, in the case of American psychiatry through a ballot among members of the APA in 1973.⁽¹²⁾ Legitimate diagnoses necessarily combine aspects of fact and value, as Wakefield⁽¹³⁾ avows in his conception of ‘harmful dysfunction’. He views ‘dysfunction’ as a scientific and factual term, based in biology, which refers to the failure of an internal evolutionary mechanism to perform a natural function for which it is designed and ‘harmful’ as a value-oriented term which covers the consequences of the dysfunction deemed detrimental in socio-cultural terms. Applying this notion to mental functioning, Wakefield describes beneficial effects of natural mechanisms like those mediating
cognition and emotional regulation, and judges their dysfunction harmful when it yields effects disvalued by society (e.g. self-destructive acts). Diagnosable conditions occur when the inability of an internal mechanism to perform its natural function causes harm to the person. DSM-IV⁽⁵⁾ rightly emphasizes that mental disorders should not be diagnosed solely by reference to social norms. The deterioration of functioning by which schizophrenia is (partly) defined under Criterion B, or the norm violations of antisocial personality disorder, must therefore be, in DSM-IVs phrase, ‘clinically significant’. What this amounts to, then, is that a negative value judgement is insufficient to diagnose. The repercussions of these issues can be considerable, (e.g. exposing children erroneously labelled as ADHD to long-term medication with its attendant risks).⁽¹⁴⁾ A related matter, so-called ‘cosmetic psychopharmacology’, involves the use of medication to enhance psychological functioning. As Kramer⁽¹⁵⁾ notes, fluoxetine may modulate emotions like anxiety, guilt, and shame, raising ethical questions regarding a person’s capacity to possess ‘two senses of self’. Psychiatric diagnosis may also mitigate legal and personal results of one’s actions (e.g. interpreting excessive sexual activity as a variant of obsessive-compulsive disorder rather than as wilful).

Some of the worst perversions of psychiatry, in which it has been deployed as a form of social control, have been driven by misuse of its diagnostic concepts. In the former Soviet Union, for example, thousands of political, religious, and other dissidents were committed to psychiatric hospitals on the basis of ‘delusions of reformism’ and other similar tainted concepts.⁽¹⁶⁾

Assessing and treating patients require a working alliance in conjunction with informed consent. Many psychiatric patients are in a position to understand and appreciate the nuances of treatment options, to express an informed preference, and to feel allied with a therapist in the task. When the process of informed consent is responsibly handled, particularly with reference to benefits and risks of therapeutic options, mentally ill people are in a comparable position to their counterparts in general medicine. This comparability is grounded in two concepts—competence⁽¹⁷⁾ and voluntarism.⁽¹⁸⁾ The former satisfies the required criterion that the person facing choices in treatment has the ‘critical faculties’ to appreciate the implications of each course of action. Voluntarism refers to a state in which the process of consent is devoid of any form of coercion. Obviously, given that the organ of decision-making is the same one that is impaired in many psychiatric conditions, profound ethical complications may ensue when seeking informed consent.

Other issues also present themselves in this context; these have been conveniently examined as a series of rights—to treatment, effective treatment, and refusal of treatment—and involuntary treatment.