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60 A.B.A. J. 1521 (1974)
Psychiatry and the Dilemmas of Dual Loyalties

handle is hein.journals/abaj60 and id is 1523 raw text is: Psychiatry and the Dilemmas of Dual Loyalties by Jerome J. Shestack The psychiatrist, particularly if employed by an institution, is faced with many problems of conflicting interests and dual loyalties. It is time for psychiatrists and lawyers to co-operate in examining these conflicts, for many involve legal rights. This will be one of the tasks of the new American Bar Association Commission on the Mentally Disabled. ONE OF THE MOST difficult tasks for any pro- fession is introspection. The legal profession has yet to scrutinize the pathology of Watergate, which in- volved an extraordinary number of lawyers in egregious corruption of the rule of law. The medical profession has yet to examine the phenomenon of the widespread abuse of medicare-shoddy treatment and extensive gouging of the government that makes peer review in- evitable. Architects have not yet explored the preva- lence in their profession of complicity in cheap, unaes- thetic construction that makes the face of urban America look like cooky molds of dreary reinforced concrete that another generation will painfully have to clear away. So it goes. Introspection is painful, and professions one and all tend to erect elaborate defenses and rationales rather than face the anguish of self-probing. Perhaps one might have expected a higher degree of introspection from psychiatry. After all, introspection is the psychiatrist's stronghold. The psychiatric profes- sion nonetheless has largely ignored a condition within itself that challenges its methodology and affects the very credibility. This condition is the conflict of interest- the dual loyalties-that psychiatrists often face when they try to use their skills to serve both the traditional one-to-one, doctor-patient relationship and the institu- tions for which they work. So long as the psychiatrist acted in the traditional one-to-one relationship, representing only the individual who freely sought his counsel, this problem did not arise. But today the psychiatrist is an influential force in powerful institutions of our society-the judicial sys- tem, the educational system, the defense establishment, the correctional system, and other social institutions. The enhanced role of the psychiatrist in these institu- tions raises serious questions as to his conflict of interest or double agent role. Can the psychiatrist be both the agent of his patient and of the institution that employs him? Put in simple terms, whom is the psychiatrist sup- posed to represent? The very question challenges psychiatric methodology in a variety of institutional settings. Before considering some of these settings, however, it may be useful to de- scribe an archetypal illustration of the problem and the dangers that may flow from it. The example is found in the Soviet Union, where psychiatric method- ology has become so subservient to institutional goals as to destroy the medical model and undermine the free practice of psychiatry. In the Soviet Union today there are hundreds, per- haps thousands, of mentally healthy dissenters, students, writers, artists, and intellectuals who have been con- fined to mental institutions for disagreement with official policy. Their confinement is without trial, generally without legal counsel, and without even the various ele- ments of due process the U.S.S.R. offers to criminals. Political Dissenters Are Forcibly Committed British and American psychiatrists who have visited Soviet mental institutions also have affirmed that politi- cal dissenters are forcibly committed on the basis of psychiatric determinations that would be quite unaccept- able in the United States or the United Kingdom. Docu- mentation of these conditions has been supplied by such human rights organizations as the International League for the Rights of Man, by Soviet scientists Andrei Sak- harov and Valcry Chalidze, and by other members of the Moscow Human Rights Committee who have ad- dressed appeals on behalf of confined dissidents to the United Nations, to the World Psychiatric Organization, and to the International Congress of Psychotherapists. Why have Soviet psychiatrists chosen to participate in a process that seems so ethically and morally repre- hensible? One explanation is ideological-that Soviet psychiatrists have a deep belief in the Soviet system, in which the state symbolizes truth and stability; those who deviate from or dissent from the norms of the state are ipso facto mentally ill. Viewed from this ide- ological base, the psychiatrist may not be venal. Even from that viewpoint, however, the psychiatrist's accept- ance of the state's definition of deviance indicates at least complicity in the process of controlling social de- viance for nontherapeutic purposes. December, 1974 0 Volume 60 1521

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