Responsibility is an everyday word and an everyday concept, but for psychiatrists it poses special problems; firstly in relation to the behaviour of patients, especially when this is of an antisocial character, and secondly, even more closely and personally, in relation to our own responsibility in the everyday practice of psychiatry. I wish to discuss particularly the problems posed by situations in which psychiatrists apparently fail in their responsibilities, and I am thus attempting to link our own situation with that of our patients. In both situations, whether a patient has committed an offence or whether a psychiatrist is accused of failing in his job, the assessment largely turns upon deciding whether the lapse can be ascribed in some way to a mental disorder or to a personal ‘failure.’ To put it bluntly—is he mad or bad? Perhaps regrettably, a factor taken into account in making this decision is not only what has happened but what might happen as a consequence of this decision; that is, punishment or treatment, especially if one or the other might lead to the most serious long-term consequence, the permanent loss of employment.
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