Sidney Bloch and Paul Chodoff made an important contribution to the literature on medical ethics when the first edition of Psychiatric Ethics was published in 1981. No doubt the publication of the first (and in 1991, a second) edition have helped to encourage the development of interest in the area of psychiatric ethics, and since then there has been a large increase in the number of books published addressing ethical dilemmas in psychiatric practice. There has also been a considerable increase in academic interest, with new courses that look specifically at the relationship between philosophy and psychiatry, especially in the field of ethics. However, developments in knowledge and changing social practice pose new and different ethical dilemmas. What then is new about this third edition of Psychiatric Ethics?

Two chapter additions are particularly welcome. Professor Fulford addresses some of the conceptual aspects of mental disorder and the ethical implications for practising psychiatrists. Our understanding of different types of mental phenomena as symptoms, rather than simply experience, not only underpins psychiatry as a medical identity, but also justifies coercive interventions in the name of beneficence. Although sometimes it may seem obvious that there is such a thing as a mental disorder, which psychiatrists treat, Fulford reminds us that there is still much conceptual work to be done on what constitutes a disorder. There is a sense in which developments in neuropsychiatry make this more rather than less difficult. The presence of a brain abnormality may or may not ‘explain’ a patient's subjective mental experience, and Fulford discusses different types of mental disorder and the various sorts of explanation that may account for them.

Another new chapter also reflects changes in psychiatric practice and new tensions for the professional identity of psychiatrists. This is by Glenn Gabbard, on boundary violations in psychiatric practice. Awareness of this difficult area of psychiatric malpractice has grown over the past 10-15 years and has rightly been taken up as an issue for all mental health practitioners. Gabbard has published extensively in this area and he is well placed to offer a review of the literature and sophisticated thinking about boundary setting and maintenance. He raises questions about what patients can expect from psychiatrists and psychotherapists, and, perhaps more specifically, what it is that patients actually consent to when agreeing to come for psychotherapy. This chapter is particularly timely in the light of increasing interest (in the UK at least) in the formal regulation of psychotherapists.

Boundary violations, especially those of a sexual or financial nature, are clearly examples of psychiatric malpractice, which itself could be understood as a type of ethical failure. I was disappointed not to find in the third edition any discussion of racism and sexism in psychiatry as examples of malpractice. For instance, George Reich's chapter, on ‘the use and abuse of psychiatric diagnosis’, reviews the history of the misuse of psychiatric diagnostic labels in the former Soviet Union. However, he makes no mention of the potential for harmful use of diagnostic labels (whether wittingly or unwittingly) in Western psychiatry; for example, the question of gender or racial bias in relation to diagnoses in ordinary psychiatric practice. Over the past 2 or 3 years, there has been increasing interest in the question of racial bias within the practice of medicine generally, and there is no reason to think that psychiatry can be excluded. Indeed, English data consistently indicate that patients from some ethnic subgroups are overrepresented among detained patients, especially in secure settings. There is also continuing evidence that the use of some types of personality disorder diagnosis varies depending on the gender of the patient. Recent debates about the inclusion of certain types of personality disorder in DSM-IV and DSM-V have included discussion about the question of gender-role bias. This type of concern reflects the issue raised by Fulford about what constitutes a disorder.

The editors have encouraged authors to update their chapters from the previous edition, and some new authors have been invited to revise previous work. The content of earlier editions of Psychiatric Ethics was always uneven, and some of the old frustrations remain. The chapter on forensic psychiatry is biased towards American practice in so far as it concentrates on the ethical issues faced by clinicians who act as expert witnesses. There has been considerable debate in the American literature about the extent to which psychiatrists who act as forensic experts in criminal courts are acting medically, rather than forensically. Some authors have argued that expert witnesses do not have the same medical duty of care to those they examine that they have to those they actually treat.

Although this issue is of interest, focusing only on psychiatrists as expert witnesses omits the ethical dilemmas faced by clinicians in ordinary psychiatric practice dealing with the daily management of patients who are dangerous to others. The extremely complex problem of whether there is a duty to protect the public, and its accompanying question of whether such a duty could or should override any duties to the patient are not considered. This is surprising, given that since the second edition appeared a large amount of published research has addressed the relationship between violence and mental disorder, begging the question about the role of psychiatrists in the prevention of violence by their patients.

Some states in the USA have addressed this issue legally by developing Tarasoff-type legislation that mandates doctors to both warn and protect possible victims, but such legal strategies do not address the ethical question about the duty of care to the patient. Often this question is framed in the context of the duty of patient confidentiality and when it is justifiable to breach this in the interest of others. However, I would suggest that the ethical dilemma is broader than this because it raises questions about the role of psychiatrists as public servants who might be seen as having a primary duty to prevent patients from behaving badly to others. Again, this question might be framed differently for those psychiatrists who work in private practice alone (as perhaps is common in the USA) and for those who are employed by a public health service (such as in the UK). It seems a pity that a book of this quality does not address this very practical question in a more detailed way.

Another weakness, in the chapter on ethical issues in psychiatric research, is the absence of analysis of what it might mean for a patient to be competent to volunteer for research. Real ethical concerns are generated by the need to carry out research into disabling conditions that impair capacity to give consent to participate in that research. Since the last edition in 1991 there have been considerable developments in research into different types of dementia and neurodegenerative diseases, especially the treatment of Alzheimer's disease. The question “Who can consent to what, and on whose behalf?” could and should be explored in more detail. For example, some of the MacArthur studies on competence to consent to treatment suggest that diagnostic label alone will not tell you much about a patient's capacity to make competent decisions to accept or refuse it. Patients' competence to consent is affected not only by their mental state, but also by the way in which they are given information and the environment in which consent is requested.

If this is true of consent to treatment how much more true must this be in relation to consent to participation in research, where the person is not necessarily a patient at all, but in fact a volunteer? A key factor that distinguishes research from treatment is that the patient is not always the primary beneficiary of the intervention, and may in fact not benefit at all, either now or in the future. One of the difficulties with the literature on ethics and mental health research is that dilemmas tend to be written about from the point of view of researchers, who are naturally concerned that research should not stop because patients lack capacity to consent to participate in it. A blanket ban on research participation by incompetent subjects would certainly seem to be rather rigid. A more sophisticated approach, which looks at the capacity to consent to research as a fluctuating characteristic (like the capacity to consent to treatment), would perhaps do justice to the complexities of this area. This is particularly so at a time when user views about treatment in psychiatry are increasingly being sought and used in the planning of care.

For the fourth edition I would urge the editors to commission some analysis of the problems faced by research ethics committees, whose participation in the research process affects not only the involvement of possible subjects, but also, increasingly, which areas of mental disorder are approved for study and which are not. Other possible contributions include something about the views of the users of psychiatric services, and how differences between users and deliverers of mental health services can be reconciled. Such a discussion could also be placed in the context of an analysis of the ethical dilemmas posed when different members of a clinical team take different ethical perspectives and come to different ethical conclusions. Lastly, it would be useful to have some discussion of resource allocation for psychiatric treatments. The ethics of resource allocation is discussed often in general medicine, but rarely in psychiatry.

Overall, the quality of the book is high, and I would recommend its purchase. Anyone who bought an earlier edition could benefit from buying the newest one, and I would certainly suggest it as an addition to a psychiatry library. My critical comments should be taken as an indication of how stimulating I found this book and how many ideas it gave me about my own ethical practice and that of psychiatry in general.