ABSTRACT
The mental illness of King George III (1738-1820) is commonly said to have helped to focus public and political attention on the problems of the mentally ill.1 The hypothesis that this illness was due to porphyria may well be a myth.2 The king was under great strain following the loss of the American colonies, particularly as he had insisted that the American war be extended to prevent further protests over British taxes. Following serious bouts of illness, he became permanently deranged in 1810 and his son then acted as regent. Although famous physicians failed to treat the king successfully during his first illness in
1788-9, Francis Willis became celebrated for curing and mastering the king’s madness. The king was not excused Willis’s standard treatments of the time, such as restraint in a straightjacket and blistering of the skin. His intervention met with opposition from other physicians. They minimised his reputation by pointing out that he had been ordained as a priest before practising medicine, and that he apparently gained financially from taking upper-class lunatics into his private asylum even before obtaining his medical degrees (see Chapter 3). Noteworthy complaints from other physicians included that Willis allowed the king to
read King Lear and to shave himself with an ordinary razor.3 However, such gentler methods and greater liberty seemed to have gained the king’s confidence. A traditional anecdote is that, when asked what he would have done if the king had become violent with the razor, Willis replied that he would have controlled him with his gaze. The regime at his asylum involved manual work in the stables and fields of the estate, with the patient labourers dressed in coats, waistcoats, breeches, stockings and powdered wigs. Mental health services have developed since Willis’s time, particularly through the replace-
ment of asylum provision by community care. However, the ethical environment of his psychiatric practice may not be that dissimilar from the present day. Psychiatry manages madness on behalf of society, and it therefore has a tendency to exaggerate its authority for control, as illustrated by Willis’s belief in the dominant power of his gaze. How to manage risk, such as the question of who is responsible if an incapable patient harms himself because he has access to a shaving razor, is a particularly modern, central concern. Justifications are still made for custodial practice, including the need for sedation and seclusion, even if the straightjacket is no longer in regular use in developed services. However much it may at times wish that it could, psychiatry cannot escape its social role. Its
authority for compulsory detention and treatment is legitimated in the Mental Health Act. Its power is also kept in check by provisions within the Act, such as appeal against detention, which are designed to protect patients’ rights (see Chapters 23-27). There has always been a tension between restraint and freedom in psychiatric practice. There may be good intentions
but practice easily slips into paternalism, as reflected by putting patients into unnatural dress at Willis’s asylum. In this chapter I want to explore some of these ethical issues for psychiatrists raised by this
anecdote; not in a comprehensive way, but to highlight the extent to which treating people as objects may have ethical implications for psychiatric practice. I acknowledge the subtleties and complexities of behaving ethically in practice, rather than assume that it is always easy to do what is right for patients. Nonetheless, it is not my intention to avoid the need to make judgements about professional behaviour.
