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Clinical and moral uncertainty in psychiatry: the problem of scarce resources
  1. Len Doyal1,
  2. Lesley Doyal2,
  3. Daniel Sokol3
  1. 1
    Queen Mary, University of London, London, UK
  2. 2
    University of Bristol, Bristol, UK
  3. 3
    St George’s School of Medicine, University of London, London, UK
  1. Correspondence to Professor Len Doyal, Queen Mary, University of London, London, UK; l.doyal{at}qmul.ac.uk

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For many years, Len Doyal taught ethics and law to fourth year medical students at the end of their psychiatry rotation. While competent in psychiatric diagnosis and pharmacology, these students were less able to answer basic questions about the conceptual foundations of psychiatry. What is a mental illness? What are the similarities and differences between psychiatry and other areas of medicine? And how do these differences impact on moral and legal dilemmas in clinical practice?

Doyal would ask students whether they had ever experienced depression, anxiety, paranoia, confused thought patterns, phobias and so on. Of course, all of them had and were usually willing to give examples. The question then arose as to when such common symptoms of psychiatric distress become indicators of serious mental illness. One good answer is when the symptoms are so severe and of such duration that the autonomy of individuals is significantly impaired. They lose capacity to protect themselves from specific types of serious emotional harm and suffering.1

Clinical uncertainty

Serious mental illness can cause extreme damage to lives and to life chances. It can negatively affect how individuals perceive themselves, how they are perceived by family, friends and colleagues, and their potential for long term relationships and fulfilling employment. Further, the emotional consequences of this stigma can in turn increase the severity of the mental disorder itself. Not surprisingly, this social feedback mechanism increases concern among psychiatrists about the potentially harmful effects of a misdiagnosis.

The possibility of misdiagnosis has always been a matter of some concern to psychiatrists, given the lack of independent confirmation of many of their diagnoses (for example, through blood tests, x rays or identifiable lesions). The Diagnostic and statistical manual (DSM) continues to be a primary tool for making sense of symptoms. Successful use of the DSM relies on correlating …

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