Since its very establishment as a social practice, medicine has been fraught with ethical dilemmas. Moral custom, religious belief, and legal norm have been the guiding tools for dealing with them. Ancient medicine assumed that physicians are helpers of Nature and should follow its mandates, medieval practices relied heavily on Christian conceptions about the beneficent goods provided by God, and modern times saw the emergence of scientific facts as the fundament and raison-de-etre of any legitimate healing practice. Thus, different concepts of health and normality, different evaluations of the role of physicians and medicine, and different conceptions of social ordering have prevailed at one time or another. Yet, the fundamental basis of medicine, its being a secular formulation of suffering, pain, and illness and of the means of their alleviation, has remained invariant throughout the centuries.
Psychiatry, as a branch of medicine, is influenced by the different views and conceptions about art and science dictated by culture. In no other field, however, the positivistic distinction between fact and value has been more ambiguous and more difficult to sustain. Psychological normality, deviance, mental illness, therapies of all kinds, are more sensitive to the fundamental structure of values prevailing in society than other concepts related to health and well-being. The role of psychiatrists has been associated with that of spiritual counsellors and confidents, as well as with that of scientists detached from any sentiment or feeling aside from the concern with the health of their patients and clients. Psychiatry is probably the least biological of the branches of medicine and at the same time the most sensitive to scientific developments in the fundamental sciences. Being both applied neuroscience and philosophical reflection, most ethical debates acquire within its boundaries a particular character, one that makes them more difficult to articulate or to handle.
As in other fields of medicine, the essentials of ethical thinking in psychiatry have been of a normative or regulatory type. Declarations have been published which emphasize the duties of the professionals toward their peers and their patients. This deontological stance has been chacteristic of most written codes and has been reinforced by special international documents related to the participation of psychiatrists in torture, their relationships with political power, and their rights and duties. Historically relevant, as for scientific investigation in general, was the lesson provided by Third Reich psychiatry, with its emphasis on human experimentation without subject consent and its aspiration to eradicate psychiatric illness through elimination of persons.
In the general formulation of the moral obligations of psychiatrists, the role of professional associations has been fundamental. Most national societies have presented codes of ethics which their members should follow, and the Declaration of Madrid, issued by the World Psychiatric Association in 1996, set the stage for many documents to follow. Another important line of development relates to the protection of human rights, of which patients' rights are but a special case, helping to reform psychiatric services throughout the world, as exemplified in several documents.
However important these developments are, the evolution of philosophical reflection, the practical needs of regulation in practice and research, and public awareness of rights and duties have led to the development of a new form of applied ethics which has come to be known as bioethics. Presented as a form of global ethics concerned with the impact of science and technology on human affairs and the moral obligations of humankind to the environment and the biosphere, it has been expanded to cover issues related to equity of access to health care, autonomy of patients in decision making, forms of beneficence which are not paternalistic, and analysis of harm and risk in research and therapy. It is not the contents, however, but the style of reasoning and debate which more essentially characterizes modern medical bioethics. Through the creation of social institutions, such as committees and commissions, a procedural emphasis in ethical analysis has been established, using dialog as a tool for decision making in matters of therapy, research questions, resource allocation and in those limits to medical action imposed by aging and death. Bioethics goes beyond the traditional deontological quest for righteous actions on the part of professionals and departs from the highly abstract reasoning of philosophical ethics. It is an openly dialogical form of discourse which does not lead to a conflict with established medicine but to a more horizontal practice, patient-centered in the area of health care, and subject-centered in research. Bioethics takes into account the diversified nature of moral convictions in contemporary democratic societies and the character of 'moral strangers' of the members of different groups seeking ways to overcome unjust differences and to impulse a humane application of the technosciences to the welfare of mankind.
Under this new dialogical spirit, ethical (now bioethical) reflection has to deal, as ever, with the obligations of the professionals towards their peers and clients, but at the same time accord these the right to express their needs and wishes, to articulate societal demands for health and improvement and to provide insights into issues of justice and resource allocation. The problems facing psychiatry today are shaped by the emergence of dilemmas created by science and technology but not solvable by them. Genetic testing has reached limits of prediction not envisioned a few decades ago, posing threats to privacy and confidentiality not hitherto encountered, chemical interventions on thought and feeling render controllable processes which give practitioners powerful tools. Responsible management and control of the means for reducing the burden of mental disease all over the world, but particularly in the poorest regions, should permit an analysis of what is ethically as well as economically sustainable. Research in psychiatry, while increasing and refining generalizable knowledge, should respect human dignity and the rights of individuals.
Psychiatry, as other branches of medicine, faces several dilemmas. The emergence of new professions and the demands of society threaten to reduce the ability of its practitioners and leaders to shape their future. Public accountability restricts traditional paternalistic forms of practicing psychiatry or posing research questions. The influence of the market and industry introduces forms of rationality which have to be reconciled with the traditional scientific, therapeutic, or altruistic goals of the profession and its quest for knowledge based on the empirical sciences.
The (bioethical) declarations of the future will have to tackle these issues. They will have to recognize the changing character of the social scenarios in which psychiatry evolves, its many actors, the many interests which converge on mental health, on scientific research and on the oldest of all human demands: the welfare of mankind aided by reason and virtue. The challenging future of psychiatry and its bioethical underpinnings are rich food for thought and for the exercise of moral imagination.