Stephen A. Green

Ethics and The Pharmaceutical Industry

Objective: Relationships between the pharmaceutical industry and the medical profession enhance the potential for physicians to become involved in conflicts of interest. Whether or not these rise to a level that violates standards of medical ethics depends on the degree to which they detract from the quality of health care and its cost, the objectivity of research, and the professions integrity. This paper explores those issues from two perspectives – the micro-level of the medical profession and the macro-level of society. Conclusions: Practices and policies that affect varied aspects of the interaction between the pharmaceutical industry and the medical profession – such as education, research and marketing – are discussed. The reader is asked to reflect on the ethics of issues raised; the author offers suggestions for mitigating conflicts of interest and, in turn, the potential for unethical medical care.

The ethical limits of confidentiality in the therapeutic relationship

The author explores the moral underpinnings of psychiatric confidentiality in an attempt to define its ethical limits. Knowledge of this standard assumes growing importance as third party incursions into the patient-therapist dyad become increasingly common in day-to-day practice. The APAs AIDS policy on confidentiality and disclosure is offered as an illustrative example of the professions ability to successfully translate moral deliberation into clinical policy.

The process of reviewing peers

Drawing on experiences as a Physician Advisor to the Office of Quality Assurance of the American Psychiatric Association, the author discusses process interactions endemic to peer review and presents recommendations for facilitating this necessary professional activity.

Psychiatry: Past, Present, and Prospect

ONE of the most important conclusions derived from recent work on brain metabolism is the constancy of the cerebral blood supply. This has been clearly shown by Lennox (1936) and Lennox and Leonhardt (1931) in a large group of subjects. Gibbs, Gibbs, and Lennox (1935) have also found that sleep has little effect upon the blood supply of the brain, while Gibbs, Lennox, and Gibbs (1934) have shown that epileptic attacks do not result from a change in the total blood flow. Mental work, however, caused a small increase in the cerebral blood flow, due probably to a dilatation of the cerebral vessels (Lennox and Leonhardt, 1931). The evidence so far seems to indicate that, within limits, a constant rather than a rich supply of oxygen is necessary for the normal functioning of the brain. The object of the present series of experiments was to ascertain whether increased intracranial pressure, as produced by intracranial tumour, has any effect on this constant cerebral blood flow. It appeared that raised intracranial pressure might possibly exert an effect on the large venous channels, thus causing a partial obstruction to the venous outflow and thereby slowing the cerebral circulation. A series of experiments was first performed on a group of unanesthetized human subjects, the results of which indicated that in some cases intracranial tumour did have such a slowing effect. The investigations were then carried further, using cats with artificially produced tumours, in an endeavour to confirm the results obtained in man with neoplastic tumours.

An ethical argument for a right to mental health care.

The author reviews moral arguments supporting a right to medical care, as well as empirical data concerning the effects of mental illness on society, and explores their relevance to a rights-based claim to mental health care. He concludes that there is ample ethical justification for a right to mental health care, given the obvious benefit it would convey to individuals and to society at large. He believes that this compelling moral claim should be translated into health policy.

A case of bipolar disorder and typhoid fever

Many medical disorders present with psychiatric symptoms. Teasing out what is caused by the medical problem and what is underlying psychopathology can be a tremendous challenge. We report the case of a young man with no documented past psychiatric history that developed symptoms consistent with bipolar disorder with mood-congruent psychotic features as well as typhoid fever. In this report, we summarize the biological, psychological, and social underpinnings of this rare and interesting case.