Medical ethics is in crisis and psychiatry is not exempt. This is so because the pluralism of contemporary democratic society results in disagreement about what is morally acceptable and because there is no consensus on the best theories and methods for determining this. Bloch & Green (Reference Bloch and Green2006) address this problem and suggest a solution by proposing the combination of two established ethical approaches - principlism and care ethics. Their attempt is laudable but the result may be lacking.

Perhaps the most important flaw is that care ethics is riddled with problems (Reference RudnickRudnick, 2001) that may not be adequately resolved by combining care ethics and principlism. For instance, care ethics encourages an overly paternalistic approach by practitioners, which is illustrated by the parent-child model of physician-patient interaction, as presented by many care ethics proponents. In addition, care ethics may be philosophically redundant, as it may be reducible to more veteran ethical approaches such as virtue ethics and casuistry (case-based ethics), which are also notoriously problematic.

If care ethics is not satisfactory as part of an ethical framework for psychiatry, what could be a better alternative? A promising and relatively novel approach is dialogical ethics, which may need to be combined with justice or fairness considerations (Reference RudnickRudnick, 2002). This approach accepts moral pluralism but utilises sound procedures and processes of dialogue among all parties involved to address ethical problems satisfactorily. Dialogical ethics may be well suited to highlighting and addressing some of the more special problems of psychiatric ethics. For instance, dialogue with patients may sometimes pose special challenges in psychiatry, as it requires particular communication skills and cognitive abilities that may sometimes be deficient in people with mental illness. This deficiency could be addressed by remediation and accommodation strategies, as well as by substitute decision-making (which would also be required to engage in dialogue to address the given ethical problem). Be that as it may, a reconsideration of the ethical framework of psychiatry is needed.