Obviously by any professional standard this is unacceptable on ethical and clinical grounds. The family cannot insulate psychiatrists from their own independent medical decisions about the need for hospitalization, medication and other treatments. Nonetheless, perhaps the best way to continue the dialogue with Chinese psychiatrists might build on this issue of the role of the family in involuntary mental health care treatment. In the Western world, mental health statutes and policies have come to assume that the family has a disqualifying conflict of interests that threaten the "identified" patient's autonomy. On the other hand, our laws and policies were formulated in contexts where it was assumed that less restrictive alternatives were available, that there were government programs to provide a safety net of care, and these policies were advanced in sociocultural contexts where the traditional patriarchal family was itself being challenged. In a society like China, where for hundreds of millions of people there is no less restrictive alternative and the only safety net is the family, it may be necessary to reconsider the assumptions that have guided the legal reforms of mental heath law in the West. If, in China, families are by custom/tradition allowed to have an important role in these decisions, then future dialogue with our colleagues might focus on the standards psychiatrists should adopt and regularize for evaluating family decisions and exploring conflicts of interest. Furthermore, Chinese psychiatrists need to formalize their own independent medical criteria for involuntary hospitalization and treatment. The development of some such uniform clinical and medical criteria might be another basis for constructive dialogue with our Chinese colleagues. The importance of developing such medical and psychiatric criteria in China is particularly compelling, since in many provinces there is no legal infrastructure of courts and lawyers on which psychiatrists, psychiatric patients and their families can rely.
Some human rights advocates distrust all psychiatrists and all psychiatric treatments and therefore urge that strict legal safeguards be in place everywhere. The WHO recently proposed a model Mental Health Statute for all nations of the world that implements this agenda and ignores the important role of the family in traditional societies. And the WPA's own Declaration of Madrid on psychiatric ethics leaves little room for the family to participate in decisions about a patient's treatment. There are many psychiatrists, human rights advocates and lawyers who have an almost missionary zeal to impose a Western-style mental health statute on all the provinces of China. Putting aside the monumental allocation of resources necessary to create the essential infrastructure of lawyers, judges and courts where none now exist, it is by no means clear that the individualistic, legalistic values favored in the West should be imposed on one of the largest populations in the world, undercutting the traditional values that have sustained the people of China for centuries.
A dialogue that respects China's traditional values and that helps Chinese psychiatrists to develop and regularize their own clinical standards for diagnosis and involuntary treatment seems to me a first step in the path of progress. It now seems realistic to suggest that in the future, ethical issues resulting from economic, not ideological issues will become central. Such a dialogue may prove instructive to those of us in the West who can--with an open mind--examine our own economic situation and reconsider the traditional role of the family in formulating our own mental health laws and policies. But the most important message I bring back from China for my psychiatric colleagues is that we should resist the impulse to make the struggling profession of Chinese psychiatry a target of opportunity for human rights advocates whose real political grievances are with the Chinese government. Psychiatrists in China need and want our help; their failings and virtues seem to be no different than our own.
Dr. Stone is the Touroff-Glueck Professor of Law and Psychiatry at Harvard Law School.