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effects, but also considerably safer than its pharmacological counterparts, particularly in the age group to which Dr Wallace is referring. Yet in spite of this presumably because it looks unpleasant - it is subjected to much more stringent controls than drug therapy. While I agree with Dr Wallace that guidelines need to be produced for such circumstances, it seems that to do this via the auspices of an Act will only serve to augment an already over-legislated area. A method of circumventing this aspect of the problem which has had some success in England is the publication of a Code of Practice to accompany the Act. My own suggestion as to how to manage these issues in the absence of any guidelines are basically to come to a clinical decision as to the reason why informed consent cannot be obtained. If a person is able to give consent, i.e. he understands the nature of his illness and the likely benefits and risks of the treatment offered, along with the risks of not having treatment - but refuses to give it, this is a matter of individual choice and should not be subject to interference from either doctors or the courts. If consent cannot be obtained because the above tests cannot be applied, i.e. if the person’s clinical condition prevents the obtaining of consent, then this is a clinical decision and should be managed accordingly. Within the present framework, this means the patient must be committed - as would be the case for any form of treatment - but I would dispute Dr Wallace’s argument that this is for “purely legal” reasons. The decision to treat against a person’s will when he is unable to give consent by virtue of his illness, i.e. committal, must always be a clinical one, and, as such, must be made by doctors in consultation with carers. While the “stigma of committal” is a real problem, we must not allow this to interfere with our patients’ right to the best care and treatment available.

Definitions and defining responsibility Paul Dignam, Modbury, South Australia: In the older nosologies under which I first studied psychiatry the terms “character neurosis” and “symptom neurosis” served to highlight the possibility of interaction or continuity between personality and illness. DSM-111 sought to clarify the relationship by establishing separate axes. This stratified model has real value in conceptualising diagnosis and organising treatment, but reifies a distinction that is far from

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proven, and seems even to be fading as time passes: witness the various studies linking social phobia and avoidant PD, affective disorders and borderline PD, obsessive-compulsive disorder and personalty, and of course schizotypal PD and schizophrenia, to name a few. This is hardly surprising considering the complex and overlapping origins of both personality and disorder. In this context, recent discussions by Parker [ 11and Bartholomew [2] about the Gary David case make me wonder why we argue nosologically about an Axis I/II distinction that is clearly arbitrary in our present state of knowledge. The reason of course is that we have allowed a legal definition of mental illness to intrude on a clinical one and to define collectively three quite separate issues: are the patients liable for the behaviour; who is responsible for their management; and will they respond to treatment. Although the issues could apply to all the PD’s, debate typically centres around the borderline or antisocial patient. Although most psychiatrists would accept some responsibility for managing such patients in crisis, many would be reluctant to undertake an ongoing commitment (responsibility), would question its value (treatability), and would hold the patient accountable for all his actions, in or out of crisis (liability). (According to strict DSM-IIIR, such patients would rarely even earn an axis I label as their crisis symptoms are “just” part of their ongoing pattern of maladaptive response to stress; others escape from this bind by invoking micro-psychotic episodes and superimposed depressions.) Whilst research can give us some guides as to treatability (and there are some grounds for optimism here) the area is quite contentious: Bartholomew castigates Parker’s therapeutic nihilism, but his own reference to the possibility of psychotherapists in the prisons, intuitively sound though it appears, is, to my knowledge, quite unproven. For the issue of responsibility for management this is quite critical, for if the psychiatrist has nothing to offer by way of treatment, and the patient remains dangerous to the community, he must surely be contained by experts in that field. Is this fair? Within the existing criminal justice system it depends on whether we hold the patient liable for his actions - able to form intent: the law looks to us to address the intra-psychic aspects of this and it would be regrettable if we could get no further than an argument about axis I and I1 and enough operational criteria. One would hope instead that courts, legis-

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lators and psychiatrists alike might concentrate on the best compromise or novel solution rather than arguing technicalities. In this context new Acts and new categories of institution do not seem so ludicrous. The paradox of course is that for many patients in this category treatment seems able to proceed only when the patient is regarded as if he were responsible for his actions. Thus do we avoid the regression and acting out that accompanies a more permissive approach, but perhaps thereby arbitrarily exclude a group of patients who simply cannot operate in this framework. It is, after all, nigh on a century since Freud pointed out that we are not the masters of our conscious behaviour that we pretend to be. In a recent paper Morstyn [3] quotes Gigerenzer et al’s critique of the uses of inferential statistics, to protect us from “the oppressive responsibilities that every exercise of personal judgement entails”. therapeutic success seems often to lie in being able to take this responsibility, living with our patients on the knife edge of suicide, knowing inevitably that some will die, but not interfering. Some would argue the ethics of this. Where third parties are at risk there is a different responsibility which we should still share, saying that the person must be kept secure regardless of DSM code.

References 1. Parker N. The Gary David case. Australian and New Zealand

Journal of Psychiatry 1992; 25:37 1-374. 2. Bartholomew AA. The Gary David case (letter). Australian and New Zealand Journal of Psychiatry 1992; 26: 134- 135. 3. Morston R. the quantum of meaning: an approach to the paradox of self-observation. Australian and New Zealand Journal of Psychiatry 1992; 26:287-294.

SOUTHWEST HEALTH REGION

(FUU TIME PERMANENT) Applications are invited to fill the position of Consultant Psychiatrist to lead a multi-disciplinary psychiatric team based in the City of Bunbury. Considerationwill be given to applications from Registrar’s in their elective year. The successful applicant will be involved in the planning and development of Psychiatric in-patient services and the general expansion of out-patient services in the region. Bunbury is situated on the coast some 180 kilometres south of the Perth metropolitan area. The city has a population of approximately 27,000 and is host to Edith Cowan University and a wide range of recreational and sporting facilities. This appointment offers a unique opportunity to work and reside in one of the fastest growing regions in WA. Duties: The successful applicant will be responsible for the: clinical management of a multi-disciplinary psychiatric team comprising nursing and allied health staff. Medical, psychiatric and physical welfare of patients under his or her care. Provision of advice to the Regional Director on service delivery matters. Ilualifications and Experience: Eligible for registration with the Medical Board of Western Australia. Eligible for Fellowship of the Royal Australian and New Zealand College of Psychiatrists (or equivalent). Conditions of Service: Applicable to Western Australian State Public Hospitals Medical Practitioners’ Award 1987. Salary Range: Level 1 ($68,242-$83,646) or Level 2 ($85,769- $90,400) depending on experience. General: Accommodation may be available on a short term basis. A motor vehicle will be provided for business purposes. Right of Private Practice and availability arrangements negotiable. Enquiries: Mr Russell McKenney, Regional Director (097) 91 0500 or Mr Paul Aylward (097) 91 0512. Applications: A Standard Application form and Job Description Form, which includes the selection criteria, can be obtained by telephoning (097) 91 0512. Applications must address the selection criteria and are to include the names of two professional referees. Applications to the Regional Director, South West Health Region, Level 8, Bunbury Tower, 61 Victoria Street, Bunbury, Western Australia, 6230. Closlnp Date: 30 October 1992.

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Definitions and defining responsibility.

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