ethical issues inchildandadolescent psychiatry · j7ournalofmedicalethics, 1987, 13, 5-11...

J7ournal ofmedical ethics, 1987, 13, 5-11

Ethical issues in child and adolescentpsychiatryJonathan Green and Anne Stewart Booth Hall Children's Hospital, Manchester andPark Hospital, Oxford, respectively

Authors' abstractThis paper concerns the special ethical problems in childand adolescent psychiatry which relate to the child as adeveloping being. Two themes are discussed - the sense ofresponsibility in the child, and the therapist's responsibilitytowards the child. As a background to understanding theformer, ideas on moral and cognitive development arereviewed. The therapist's responsibility is discussed inrelation to different styles of therapy and the ethical issuesthey raise. The article concludes with a number ofsuggestedethical principles.

IntroductionSpecial ethical problems in child and adolescentpsychiatry relate to the nature of the child as adeveloping being, with changing morals, cognitionsand emotions, and as a dependent being, reliant onadults - whether parents or professionals. This paperwill confine itself to two main themes; namely 1) thechild's sense of personal responsibility, initiallyminimal but developing, and 2) aspects of thetherapist's responsibility towards the child.The theme of responsibility in children raises issues

such as their ability to decide for themselves to say noto treatment, or to differentiate between right andwrong at particular ages. The complexity of thesubstrate for emerging responsibility and theimplications that this has for assessment, are mattersthat this paper will seek to explore. The responsibilityof health professionals, on the other hand raisesquestions about the focus oftheir responsibility - to thechild as an individual, to the family as a whole, to theparents, or sometimes to society. It also raisesquestions about the particular choice of therapeuticmodel and the way it is applied and evaluated, as wellas the ethical difficulties associated with multiplemodels of treatment.

I. Responsibility in the childFrom a developmental viewpoint the emergence of a

Key words

Child psychiatry; adolescent psychiatry; therapy; ethicalissues; moral development; cognitive development.

quality such as a sense of personal responsibility willdepend on underlying maturation in cognitive areasand moral reasoning. The relevant concepts in thesetwo fields are summarised below.

COGNITIVE DEVELOPMENTThe age ofseven provides a watershed in logical aspectsof cognitive development. In the Middle Ages, it was atseven that the Catholic Church recognised thebeginning of the age of reason, and children were firstsent to the court as pages and to the guilds asapprentices at the same age. Similarly, in Englishcommon law, the age of seven became the threshold ofcriminal intent. Further, it is around this age inPiaget's description ofcognitive development (1) that achild is first able to appreciate and perform logicaloperations. Before seven, Piaget describes the child'scognition as 'pre-logical' with little adult idea of causeand effect; relationships between objects and eventsare seen as contiguous; the child, when asked why thesun moved across the sky, might answer 'because it ishot'. Ideas are based primarily on immediateperception and for that reason tend to be intuitive andinconsistent over time. The child's world at this time isfundamentally egocentric. After seven years ideas arestill based primarily on concrete external perceptionsand objects. However, they can be manipulated in themind now, according to the logical operationsdescribed by Piaget, which allow for the organisationand working through of hierarchies, orders ofsuccession, and the combination of different classestogether. There is also an awareness of symmetricalrelations, so that logical inferences can be workedbackward as well as forward.By the age of nine to ten, adult notions of cause and

effect are well established, and the child's egocentricityhas begun to give way to an awareness of other people'spoints of view, and of being involved in a social world.From the age of twelve or so, the grasp of purelyabstract ideas becomes firmer, and these can bemanipulated according to the more complex operationsof propositional logic. This enables the adolescent toidentify and begin to produce general laws fromindividual events, and to be self-reflective in thought.An important aspect of Piaget's theory is that this

last stage of 'formal operations' may only be reached

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6 Jonathan Green and Anne Stewart

for any child in certain particularly practised areas, andthat in some children the stage of formal operationsmay not be reached in any area of thinking. Thinkingcontinues to be done with any of the developmentalmodes previously described and a regression from'higher modes' may well occur under emotional orphysical stress.Whereas Piaget sees cognitive development as

basically biologically determined, although facilitatedby social and environmental factors, later cognitivetheorists have seen thinking more as a culturallydetermined activity, and thus with much moreplasticity and variability in its development. Bryant (2)sees the child as being potentially logical long beforethe age of seven years under the right circumstancesand Vigotsky and Luria (3,4) see cultural patternsembodied in the adult language surrounding the youngchild as having an important effect on the formalstructure of the developing thought. This notionimplies that different cultural conditions can give riseto very different basic thought processes, and thisopens the way for important studies of the influence ofclass, culture and education on cognitive development.

MORAL DEVELOPMENT

a) Cognitiveldevelopmental theories

The major influence in this area was Piaget's book,Moral_judgement ofthe Child, (5). He suggested that aschildren mature they pass inevitably through two mainstages ofmoral thought - the stage ofmoral realism andthe stage of moral relativism, with the transitionbeginning at the age of seven to eight years. Before thisage, a child's behaviour is egocentrically determinedand based on specific rules; morality is one ofconstraint rather than co-operation. There is a belief inimminent justice and acts are judged in inflexible termsrather than taking into account motives and intentions.After the age of seven to eight, there emerges a moregeneral conception of right and wrong. There is moreco-operative play and the child begins to see that rulesare not just dependent on adult enforcement orarbitrary factors but can be based on mutual consent -the children themselves can have a part in them. By theage of eleven or twelve years there has been a shift froma moral code which is primarily a response to externaldemand to a moral code based on internal standards.Kohlberg (6) later developed these ideas. He suggestedthere were three main stages ofmoral development: thepre-moral stage where motivation is governed bythoughts of reward and punishment; the morality ofconventional rule conformity, where motivation isgoverned by anxiety about disapproval, and themorality of self-accepted moral principles. Kohlberg,and to some extent Piaget, did take into account socialand intellectual influences. These are seen to impede oraccelerate rates of development but do not change theessential nature of the stages. It is the maturationalprocess which is emphasised.

b) Psychoanalytic theoriesFreud formulated the idea of the super-ego,developing as a result of weakness of the infantile ego(7). This takes place at the end of the phallic period,age five to six years. The oedipal complex is at its peak,and fear of punishment from parents by the frustratedchild, and the need for affection and protection, forcethe child to accept parental demands and to internalisethem. The stronger the feeling of hostility to theparent, the stronger will be the super-ego orconscience. Later analysts came to see the conscienceas a more constructive force.

c) Learning theoriesIn these theories, moral behaviour is seen as the netresult of a pattern of learned behaviours accumulatingthrough childhood. In 1976, Eysenck (8) suggestedthat individual differences in moral behaviour may beattributed to genetically determined variation incortical arousal levels, producing variable rates ofsocial conditioning.A number of researchers have looked at factors

affecting moral development, particularly social andfamily influences. Liu (9) in 1950 compared a group ofAmerican children in one district in New York; hefound significantly different moral standards whichrelated to different cultural influences. Hardeman (10)looked at the relationship between moral reasoning andconceptual ability. She found a positive correlationbetween scores on Piagetian conservation tests andscores on a moral reasoning interview schedule, andconcluded that conservation ability is a necessary butnot sufficient condition for ensuring a mature level ofmoral reasoning. The relationship between maturity ofmoral concepts and actual moral behaviour has alsobeen looked at. Grinder (11) found little support forPiaget's idea that as children advance towards maturemoral judgement, their behaviour will also change. Hefound that the process of maturation that underlieschanges in children's understanding ofmoral conceptsis relatively independent of the processes by whichthey learn to apply concepts of morality to their ownbehaviour: social pressures from the immediateenvironment were very important. While moralunderstanding does not necessarily lead automaticallyto moral behaviour it is a necessary precondition for it.

RESPONSIBILITY AND DEVELOPMENT

The Piagetian and other developmentalist theoriesseem to imply that a child's capacity for responsibilitycan be precisely determined. In practice therelationship of these developmental processes to moralunderstanding, and moral behaviour, is not alwaysdirect. Moral behaviour may not necessarily reflectmoral understanding or even developmental level;other factors or pressures in the immediate situationmay be equally important. The developmental theoriesoffer, however, a background to the understanding of



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Ethical issues in child and adolescent psychiatry 7

responsibility. An understanding of oneself as agent ofone's behaviour would be unthinkable without thecapacity for concrete operations or understanding ofcause and effect. The development of non-egocentricthought during the stage of concrete operations wouldbe a pre-condition for early understanding ofoneself aspart of a social group, and the appearance of formaloperations is necessary for an appreciation of ethicalprinciples acting across specific situations. Similarlythe change in moral thought from moral realism tomoral relativism also seems to be necessary for adevelopment of a sense of responsibility. But added tothis must be the vagaries of ego development, and inparticular the mechanisms of defence such as denialand projection which can act against acceptingresponsibility at any stage and may mean that suchunderstanding in crucial areas may take years to come.

Personal accountability and social responsibility inlaw may be fairly straightforward, but are notoriouslyslippery when psychological mechanisms for theirabsence are considered. Clearly the developmentalsubstrate for responsibility is complex and variable,with educational, cultural and social as well asmaturational determinants. This produces a level ofcomplexity and uncertainty in the assessment ofresponsibility in children and there is no method ofanyrigour for doing this apart from trained intuition.

ADOLESCENT PSYCHIATRY

Whatever notions of developing responsibility may bedesirable for psychological considerations, withinadolescent psychiatry particularly doctors have to actwithin a framework of the law. The following areexamples of legal cut-off points:

1. A child under ten cannot be charged with a criminaloffence;

2. A child aged ten to thirteen can be charged with acriminal offence, but it must be proved that heknew his actions were wrong;

3. A child aged fourteen is assumed in law to beresponsible for his acts;

4. A child aged sixteen is able to refuse treatment;5. A child aged sixteen to eighteen can no longer be

put into care unless he consents;6. A child aged seventeen is subject to the full process

of the law;7. A child aged eighteen can vote.

Psychological development of responsibility isobviously not as clearcut as this, yet we may have towork within this framework. The relationship ofauthority, for example, between therapist andadolescent will necessarily change throughout theteenage years, especially as the adolescent reachessixteen when treatment can be legally refused.Information supplied by the Children's Legal Centre(12) indicates that even under this age, if a youngperson is old enough to understand the nature oftreatment and its implications his or her consent is

needed in preference to the parents', although ideallythere should be both.A further and related issue is that of confidentiality,

which is highlighted by the Gillick case. The Court ofAppeal (13) in December 1984 decided that 'the rightsand duties of parents are paramount unless overruledby the courts except in emergency'. Thus it was mademandatory for doctors to seek parents' permission inprescribing the contraceptive pill to girls undersixteen, with implications for other forms of treatmenttoo. In October 1985 the House of Lords (14,15) by aclose majority ruled that doctors can in certain casesprescribe the contraceptive pill to girls less than sixteenwithout parental consent. As Lord Scarman said'parental right yielded to the child's right to make hisown decisions when he reached sufficientunderstanding and intelligence to be capable ofmakingup his own mind'. General Medical Council (GMC)Guidelines make it clear that it is the doctor's duty tomake this judgement on a child's maturity and actaccordingly (16). This issue is particularly pertinentbecause adolescents differ so enormously in theiremotional, moral and cognitive maturity, making itcrucial for the doctor to have a well-trained sense ofthedevelopment of responsibility. After the age of sixteenneither the doctor nor the parent nor the local authoritycan override the consent or refusal of adolescentsunless they are incapable of expressing their views. Infact only invasive treatment by drugs, ECT etc, arecovered in this legal framework (11). Milieu therapy,psychotherapy, behaviour therapy, occupational andfamily therapy are not, although enforced milieutherapy may be covered by common law on assault.Even though not covered in law children's consent forthese latter measures should perhaps be sought,maturity permitting.The notion of responsibility includes an idea of

accountability for behaviour. The difficulty in judgingthis kind of responsibility is highlighted in thefollowing example:David is a fifteen-year-old boy with a long history ofnon-attendance at school, trouble with the law, andbeing on the fringe of drug-taking. He took anaccidental overdose of illicit drugs and was admitted toITU with respiratory failure. His parents already haveone child in care but are trying hard with David to setdown limits for him, and have made repeated efforts toget him back to school. David himself claims that theschool makes him anxious and unhappy. The drug-taking had given him a sense of security with his peerswhich had been missing at home and at school. A caseconference is held about him. It seems that his parentshave been neglectful in their care and are beingprosecuted in their failure to get the boy to school. Theboy himself says he cannot go to school because he feelsso anxious there. How much of his problem is judgedto be 'disorder', how much parental failure, how muchsituational, and how much his responsibility, willgreatly colour management decisions in such a case.Perhaps part of management should be to try to



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generate or encourage an increased sense ofresponsibility in him.

This example highlights the problem of responsibilityin practice; a clinician or team is likely to come to anassessment of a child's degree of responsibility throughpersonal contact and discussing his or her behaviourwith others. This assessment clearly contains asynthesis of information about many of the layers ofstage development and personal circumstancediscussed earlier - mixed inevitably with the clinician'sown projections and prejudices. Analysis of andreflection on the parameters involved would help toimprove this intuition.

II. The responsibilities of therapistsIn preparing this paper, it soon became apparent howelusive ethical issues often were, and particularly howmuch easier it seemed to be to see the ethicaldimensions and problems in theories and therapieswhich one does not adhere to as opposed to those onedoes. Perhaps there is something in the nature oftheoretical systems and practice in child psychiatrythat is responsible for this 'transparency' of the ethicaldimensions in positions adhered to by any particularpractitioner. Theory and practice can come to form aclosed system ofexplanation and action applicable overa wide area of behaviour. Most practical situations inchild psychiatry allow enough room for manoeuvre forone of a number of possible explanatory systems andresulting treatments to be employed. Thus involved intheir theory, therapists will rarely feel at a loss: indeedthey may be personally identified with their theoreticalposition and passionately confident in the resultingaction, which seems intuitively right. The uncertaintyand conflict is more likely to occur betweenpractitioners of different types of therapy, and ofcourse most types tend to cement their identity bybecoming organised and codified and more or lessinward-looking. Conflicts of interest or ethicalproblems which might remain invisible if consideredwithin the bounds of a particular theoretical system,become more obvious when the practice oftwo systemsis contrasted. Although these issues are naturallycommon to adult as well as child psychiatry, they areperhaps particularly pointed in work with children,due to the dependent and relatively malleable nature ofthe child.

INDIVIDUAL THERAPY

Children in long-term individual psychotherapy entera relationship with an adult of a peculiar intensitywhich is likely to take on a 'parental quality', at least forthe child. According to their theoretical lights,therapists will have different ways of seeing this roleand the nature of its benefits. But the way therapistsbehave is related to the kind of changes they hope topromote in their patients; and although these mayseem self-evident to the therapist, it is inescapable that

values and attitudes are being transmitted. Ifthe valuesand attitudes of the child's parents are fundamentallydifferent, the stage is then set for confusion in the childand dilemmas regarding the management. At theextreme these dilemmas can involve professionalsacting legally to remove children from their parents'influence (and this legal sanction underlying atherapist's position will naturally make many parentswary from the outset). In a milder form the dilemmascan make progress in therapy most difficult and it is inrecognising this that many therapists will only take onchildren if the parents are in general understandingand in agreement with the implicit attitudes in thetherapy. However, this is neither always practicablenor fully practised (and what is one's ethical positiontowards the children thereby not treated?).Between professionals the issues here are thrown

into even sharper relief by the attitude that a family orsystems therapist would have towards the individualproblem. Individual therapy would be based on aconcept of intrapsychic maturation and the belief thatsuch maturation could take place in the therapyrelatively independent of the child's environment. Fora family therapist the child's problems would, on thecontrary, be seen as symptomatic of a more widely-based disturbance in family relationships. Thetherapist's behaviour is in accord with this theory: heor she will engage the whole family. Individualtreatment then, for many family therapists, can be seenas unacceptably symptomatic: not tackling the 'real'problem. To illustrate the problems that can be posedfor individual therapy:Susan, is a girl in early adolescence in individualpsychotherapy. The therapist feels the treatment isgoing well. This immature, passive, fragmented girlseems to be gaining a sense of herself and becominghappier and more purposeful in her life. Occasionallythe parents are seen and on one occasion the father says'Since our daughter has been in therapy with you shehas been drifting away from us, she is no longerinterested in talking to us as parents, she seems only towant to go her own way. Our family is breaking up andbecause of itmy wife is threatening to take an overdose.I blame you for this happening!'

The way in which a therapist responds to this challengefrom a parent depends on a theoretical or ethicalposition concerning questions of whether individualgrowth takes precedence over family integrity, and towhat extent individual change is possible without achange in the whole family system. At what age canchildren, or adolescents take responsibility for theirown life to the extent of going a different way fromtheir family, and at what age would it be appropriate toencourage this?

Examples of the way therapists' behaviour ismodified by theoretical assumptions could bemultiplied indefinitely. Autistic children, for instance,referred to various centres within mainstream childpsychiatry can expect very differing treatments. In



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some centres the child would be felt to have anextremely fragile ego with a severe and very earlydeficit in personality development. The treatmentwould be predicated on the greatest caution andslowness in initiating contact for fear ofoverwhelminghis fragile defences (17). Other theories, however, seethe issues differently, as disturbed conceptualdevelopment and socially avoidant behaviour, and onetreatment advocated within this theoretical model hasbeen an intrusive approach to break through theavoidance (18). A highly stressful programme ofbehaviour management and sometimes forced holdingdespite the child's protestations until there isrelaxation, is undertaken. Management styles couldnot be more different.

FAMILY THERAPY

Family therapy has grown up over the last two or threedecades and seems to avoid some of the ethicalproblems involved in individual therapy, but bringswith it ethical problems of its own. Firstly, there maybe a blurring of responsibility. The therapist relates toan 'organism', the family, rather than to individualsand may not see himself as directly responsible for eachfamily member. The identified patient may improvebut other children may be affected adversely by theprocess, or the parent's marriage may suffer. Morecrucially, the traditional and even statutory duty ofchild-care professionals to act as advocate of, and in thebest interests of, the child can be badly compromisedby a systems viewpoint. Some of the recent tragicdeaths of children 'at risk' appear from reports to beattributable as much to an exclusively family viewpointas to neglect or oversight. It is important to be aware ofhow subtly yet profoundly a therapeutic focus on afamily as a unit can alter the perception ofan individualchild's predicament or needs. Individual therapistshave long been aware of how the patient can become'overvalued' by the therapist (therapeuticcommitment, like love, can be blind): the same canclearly happen with families. The danger of treatingthe family as an 'organism' can so easily be that itshealth and intactness is gained at the expense of anindividual child's. It is a delicate balance which needsa flexible viewpoint.Can family therapy be harmful? In some sessions,

parents may be encouraged to express negative feelingsabout the child or to each other. Such ventilation maylead to a raised level of expressed emotion generally inthe family. Some research indicates that expressednegative emotion in parents when the child is aroundthe age of three is an important predictor of laterbehaviour disturbance (19). Family therapy can denythe individual his or her rights and autonomy. Ifa childis not given the opportunity to express throughts orfeelings privately, without the rest ofthe family, familytherapy may actually decrease the individual child'sresponsibilities and whole areas of difficulty may notbe discovered. Furthermore the family system may beunbalanced during treatment to an extent which is

intolerable or unacceptable to the particular culture ofthat family and their immediate social environment.Finally, in strategic family therapy, issues concerningthe therapist's notions of truth come into question.The use ofparadox may require a kind ofdishonesty onthe part of the therapist which may be confusing to thefamily and eventually morally undermining to thetherapist.

III. DiscussionIn the second part of this paper, ethical problemsarising out of different theoretical perspectives in childpsychiatry have been emphasised, and it may be feltthat there has been an under-emphasis on broad areasof agreement which would exist amongst mostprofessionals about how to treat children, and also onthe increasing basis of scientific data which is availabletoday. That there is of course such a broad area ofagreement is thrown into focus by considering othermodes of adult/child relationship, and attitudestowards children. Lloyd de Mause's historical analysisof these different modes (20) is a useful clarificationeven though the historical sequence and theoreticalunderpinnng might be debatable (Table 1). Therapistsfrom varying persuasions would find common groundin general attitudes towards children, which wouldprobably fall within the 'socialising', 'helping', andperhaps 'intrusive' modes. They would also be inagreement in seeing other modes as pathological andfamilies practising them as in need of help. Althoughfew families in reality would practise any of thesemodes in pure form the socialising and helping modeswould probably represent the ideal today. Elements ofother modes can be seen in society today and form animportant part of child psychiatric practice.The theme of the first part of this paper was the

emerging sense of responsibility in the child,dependent as that is on mental maturation, and howthis affects the way clinicians act. This theme clearlyarises out of typical concerns of the socialising andhelping modes: the identification of the particularnature and special needs of the child of differing ages,and the adult concern to adapt to these and facilitatematurational processes. However, despite thismeasure ofagreement, which might be expected acrossa wide spectrum ofapproaches within child psychiatry,important differences do exist. Although differenttheoretical perspectives may address themselves todifferent levels of reality and thus not necessarily bemutually exclusive, they can in practice have verydifferent practical consequences for action, which doraise ethical issues. How then are clinicians in childpsychiatry to develop ethical ground-rules to cope withthe profusion of frameworks of understanding andtreatment which are each largely closed and self-confirming? Would it for instance be possible or evendesirable completely to open up these theories totesting? Their strength and indeed therapeutic effectmay to some extent depend on their closedness. Interms of therapy, there is clearly a dialectic here



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between the need for the therapist to hold strong,consistent (and hence somewhat closed) therapeuticideas, and the need for both therapist and theory to beopen to change and reality confrontation. In our viewthis dialectic is inevitable in that it reflects thedynamics of a healthy ego. A saying attributed toGandhi illustrates this paradox: 'I wish all the doors ofmy home to be open to the winds of different opinion,but not to let them blow me offmy feet'.One ofthe prime experiences in psychotherapy is the

patient's contact with such a 'healthy' ego, and thetherapist will, in the therapy, create such an ego out ofhis or her own capacities as a person supplemented andenriched by theory as necessary (a particular kind ofego, this 'therapeutic ego' certainly, but one that apatient can increasingly trust in and work with). Thetheory then, as well as the person of the therapist, willneed to have this quality of clear identity combinedwith openness.There is little likelihood that explanatory systems in

psychiatry will ever be wholely scientifically testable ina Popperian sense; they could only do this by ignoringsuch huge areas of reality as to be impossibly limited ina clinical setting (this is not to say that the specificityand the efficacy of the explanatory models should notbe rigorously investigated). The suggested ethicalprinciples of therapists' responsibility which follow,therefore, assume a background of diversity in boththeory and practice which exists now and which islikely to remain.

1. Therapists have a responsibility to discuss the range ofpossible treatment options andfrom this agree a 'contract'for treatment.Such issues as the merits of individual versus familytherapy, length of treatment, and what might beexpected ofparticipants could be discussed, along witha realistic appraisal of the likely outcome.2. There may be limitations to therapy with a family whohold very different assumptions from the therapist aboutchild rearing, and which they do not wish to change.There is obviously an important boundary here atwhich a particular family's assumptions may be sosocially deviant that the law must come into force.However, this is a different matter from the purelytherapeutic issues.3. There needs to be a balance between the therapeuticstrength ofa relatively closed system oftheory, and the needto be open to reality testing by means ofdiscussion betweensystems and, crucially, by audit oftreatment outcome.The same would apply within an individual treatment:the need for a consistent approach being balancedagainst a constant appraisal of its effectiveness, andnew needs emerging in the client.4. In training, the personal development of the therapistshould be as important as the development of his or hertheory.Therapists have a personal responsibility to developinsight into their motivation and attitudes in relation totheir work and choice of theoretical position, for itwould be wrong if such a position was merely an

TABLE 1

Modes of parent/child interaction seen historically (Lloyd de Mause 1974)

INFANTICIDE MODE Antiquity - C4th ADParental anxieties typically resolved by killing the child.

ABANDONMENT MODE C4- 13thParents escape from the dangers of their own projections by abandoning the child.

AMBIVALENT MODE C14-17thChild a container for projections, but can be 'moulded into shape'.

INTRUSIVE MODE C18thParents feel safe to come closer to their children with empathy. Wish to understand their minds, controltheir will. Birth of paediatrics.

SOCIALISATION MODE C19 - mid-20thEmphasis on training rather than conquering. Growth by Guidance. Includes Freud's and Skinner'stheories.

HELPING MODE C Mid-20thParents serve child, facilitate internal development by supplying all need. No external discipline or habitformation.



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elaboration of their own defences or internal conflicts.5. The ethics of much of the therapeutic work in childpsychiatry is situational and personal and should berecognised as such.Formal training in some form of analytic ethics wouldbe very appropriate in preparation for work in thisfield.6. Therapists need to evaluate carefully the emerging senseof responsibility in the child and how this interacts withtheir responsibility as therapists and the responsibilities ofparents, adapting their therapeutic stance accordingly.

AcknowledgementsThis paper arose out of a series of seminars on ethicalissues in psychiatry, held at the Department ofPsychiatry in Oxford. We are grateful to Dr SidneyBloch for encouraging us to present this topic, and toDr William Parry-Jones for his very helpful commentsin the early stages of preparation.

Jonathan Green MA (Cantab) MB BS MRCPsychDCH is Senior Registrar, Department ofChild PsychiatryBooth Hall Children's Hospital, Manchester. AnneStewart BSc MB BS MRCPsych DCH is SeniorRegistrar, Park Hospital, Oxford.

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