Welcome all to the December edition of the Binational Section of Philosophy and Humanities in Psychiatry.

It is with respect that we acknowledge the Aboriginal and Torres Strait Islander peoples as the Traditional Owners, Custodians, and First Nations of Australia, and Māori as tangata whenua and Treaty of Waitangi partners in Aotearoa New Zealand.

In this edition we invite reading on ethics, poetry, literature and art – the essence of our section which we hope will enrich your practice of psychiatry.

We have a reflective article on the moral dilemmas and ethical challenges that faced psychiatrists in the recent NSW workforce crisis by Trevor Ma.

Next, we are delighted to have an unpublished contribution by the well-known and award-winning Australian poet Andy Jackson. Andy is a disabled poet who speaks of difference and embodiment and who is truly inspiring.

Psychiatrist Anne Buist reflects with fascinating insights into the process of writing her novel and the value of such writing for psychiatry and the general public.

We are also providing an overview of articles from Australasian Psychiatry covering the last year or so that may be of particular interest to SOPH section members as compiled by Ben Vialle.

Finally, our SOPH art review.

The last six months have also been a productive time for our section. We were well represented at the RANZCP Congress with a Symposium on Consciousness, ethics and creativity - Expanding the boundaries of modern psychiatry as chaired by Dr Andrew Howie with speakers philosopher Professor Tim Bayne, poet and psychiatrist Dr Jennifer Harrison and ethicist Dr Nicole Vincent. The feedback was excellent. We also had contributions on Moral Distress by Dr Trevor Ma and on Representations of Mental Illness in the Arts by Dr Lieu-Chi Nguyen.

We are also planning a webinar in February 2026 on: Philosophy - Why philosophy now for psychiatrists. This will be a presentation by leading UK Philosopher and Psychiatrist Professor Bill Fulford, author of the Oxford Handbook on Philosophy and Psychiatry with a discussion to be chaired by Dr Temi Metseagharum. Not to be missed.

More information will be available in December.

As always contributions and feedback are greatly welcomed.

Dr Susan Lutton
Editor/Chair, Bi-national SOPH Committee

Psychiatry at the Crossroads: 
Moral reflection in the aftermath of mass resignation. 

 Dr Trevor Ma
A resigned NSW psychiatrist.

When doctors protest there are serious repercussions on the lives of people throughout the health system, and it invariably attracts scrutiny as to whether their actions are right or wrong. The psychiatry workforce crisis that unfolded in New South Wales (NSW) over the past year did just this and produced difficult decisions for everyone involved. The recent Industrial Relations Commission determination marked a crossroads in the journey for system reform. It is also an opportunity to reflect on the moral decisions made, those we still need to make and to potentially navigate a reasoned path for future psychiatrists who follow.

Moral dilemmas occur when we are asked to compromise between conflicting moral values. Deciding to stop treating your patients or resign from your life’s work is deeply personal and forced many of us to examine our values in the face of moral complexity. Through this deliberative process, we appealed to a variety of theories and principles of moral philosophy to ground our moral judgements and guide the rightness and wrongness of our actions.

Beauchamp and Childress’ principlist account of biomedical ethics permits weighing and balancing of principles such as non-maleficence (not harming or injuring patients) and beneficence (preventing and removing harm and protecting the rights of patients)1. The most prominent moral argument against doctors participating in strike action is the risk that withholding and withdrawing care from sick patients would result in preventable human suffering. Doctors who justify overriding this obligation only do so in exceptional circumstances. For many NSW psychiatrists, this was the belief that wage increases or subsequent mass resignation, as a last resort, was the only alternative to fixing the structural failings of a broken mental health system actively causing harm to patients.

Some doctors appeal to a utilitarian argument in justifying their protest action as morally permissible – by accepting some initial harm to current patients or cost to the system, if it is to maximise the total benefits of the population through effective reforms and improve patient outcomes into the future. Psychiatrists argued that wage increases, for example, would be an effective use of public funds to correct the entrenched problems of recruitment and retention that were impacting on patient care in an unfair and uncompetitive market.

The state also appeals to a utilitarian argument but claims that conceding to wage increases for one group of clinicians would result in fiscal collapse of a system with scarce resources and thus detract, more broadly, from the total benefits of the entire public health system. Furthermore, the state appeals to the “slippery slope” argument – the unintended risk of other similarly qualified doctors descending into civil disobedience and demanding wage increases.

In this light, the NSW government appealed to the principle of distributive justice – the fair allocation of resources; and claimed that the system was not broken, and that psychiatrists were pursuing an ideal form of justice which was simply unattainable (the perfect being the enemy of the good). The tension was whether the expected (versus actual) outcomes claimed by each party would ever be realised.

Could a special case be made for the public mental health system being in crisis? In comparison to the burden mental illness in the community, psychiatrists claimed the system had suffered from years of government under-spending. More concerningly, was that this unfair allocation of resources, was not accidental, but rather a form of systemic discrimination and blatant neglect for least well off in society. Patient and carer testimonials appealed to these experiences and represented their voices in the debate. Psychiatrists, as advocates, felt they now had a moral obligation to act against the social norms which ascribed a lower moral worth to their patients.

Virtue ethics guides doctors to act in accordance with virtues of honesty, integrity and to act in good faith; and to avoid vices such as greed and self-interest. Critics of mass resignation could argue doctors, as clinical leaders, should display virtues more akin to prudent seamanship, where their primary responsibility is to ensure the safety of all patients (passengers) and colleagues (crew). Were NSW psychiatrists’ abandoning the so-called sinking ship, whilst still attempting to rescue it from their lifeboat?

Doctors can have a special relationship with their patients – they are people they know and committed to caring for – in doing so, they act as caring agents. This concept of our patients having “identified lives” meant that some psychiatrists, who supported and participated in the collective protest action, ultimately chose not to resign and withdraw care from their patients. These were patients in their clinics or wards, whom they identified more closely with, rather than future statistical patients who were moral strangers to them. Kant’s deontology asks us to act with fundamental respect for humanity – this requires treating humanity as an end always, and never merely as a means. In any collective bargaining standoff both parties, the state and doctors, could be criticised for holding sick and powerless patients at ransom as an innocent third-party.

Many NSW psychiatrists described experiencing moral distress from their work, leading to compassion fatigue and burnout. Systemic under-funding had placed greater constraints on psychiatrists from doing what they knew was right for their patients; and when alarms bells were raised, they felt their voices were not being taken seriously. Psychiatrists could no longer maintain the status quo of being powerless in a system that was harming patients and staff.

Doctors are also not immune to acting upon emotional intuition and other cognitive biases. Collective agency is what enables the power for change to occur, and whilst it garners strength in numbers and moral support, any group dynamics can influence our moral reasoning. From a social psychology perspective, group think can jeopardise our adherence to moral deliberation where doctors may act against their best moral judgement in preference for emotional intuition with post-hoc moral reasoning.

NSW psychiatrists are now at a crossroads. With some, but not all wage demands met in the pay dispute, will those resigned psychiatrists return to the public mental health system, or is it too little too late? What have been the impacts of protracted negotiations, and will each party hold onto their end of the deal and fulfil their ethical obligations to patients and the profession? Only time will tell, but examination of the diversity of moral reasons appealed to throughout the crisis and valuing philosophical thinking, will help guide us towards the right ethical conduct now and into the future.

1.     Beauchamp TL, Childress JF. Principles of biomedical ethics, 8^th ed, Oxford University Press, 2019; 219.

Poetry by award winning Australian poet Andy Jackson

We are privileged to have a submission of an unpublished poem by the award-winning Australian poet Andy Jackson

Andy Jackson is a poet, essayist, and lecturer in creative writing at the University of Melbourne. His latest poetry collection Human Looking won the ALS Gold Medal and the Prime Minister's Literary Award for Poetry. Andy's poems are included in the anthologies Versus Versus: 100 Poems by Deaf, Disabled & Neurodivergent Poets (Bloodaxe, UK, 2025) and Every Place on the Map is Disabled (Northwestern University Press, USA, 2026). He is a co-editor of Raging Grace: Australian Writers Speak Out on Disability (Puncher & Wattman 2024), and he writes and rests on Dja Dja Wurrung country.

Weathering

you begin to suspect you are already stone
each day a weight that does not shift with rest
with time alone or a fistful of supplements

                      thoughts become rubble, then a puff of dust
                      but the job offers keep coming, requests
                      for support, for words with heft or heat

as you sleep, a pebble drops into your chest
day, random avalanches in your actual heart
a sedimentary need to be prone, quiescent

            it hurts to mineralise, a constant furnace and settling
            your only life hack, chronic endurance
            your five-year plan, the welcoming of moss

not trending or even relevant but weathering
because stones, you know, don't lack feelings
they absorb them, are pure compressed existence

                        it's a gift and a theft, this falling into earth
                        let it all accrete – work, memory, healing
                        life, seismic, is building your resume of loss
                        this slow erosion, your bedrock calling

The power of fiction

  Psychiatrist Dr Anne Buist
Professor of Women’s Mental Health, University of Melbourne, Austin Health  

When my partner’s novel, The Rosie Project, featuring an autistic hero, was published in 2013 we were swept into a world tour that included a launch with actors dressed as lobsters, televised readings and a meeting with Bill and Melinda Gates. But, what was ultimately more exciting and important was that it was part of the wave of changing representations of and attitudes toward neurodiversity.

And I began to wonder, could a novel do the same for mental illness? I have spent nearly forty years seeing patients and giving talks; but have reached far fewer – and a different demographic of – people who would read a bestseller (The Rosie series has sold over seven million copies in forty languages).

Graeme shared my enthusiasm for the idea and the co-written Menzies Mental Health series was born. The Glass House was published in 2024; it follows psychiatry registrar Hannah and her colleagues at the beginning of their training journey (a lot like my own journey, especially in draft one). While the story is told from a clinician’s perspective – really unusual for mental-health novels – we also follow three patients from the acute ward, and get a taste in each chapter of another patient’s journey, in the style of a TV medical series.

The book got positive reviews, topped the independent bestseller charts and sold well enough that our publisher commissioned two sequels. In The Oasis, published earlier this year, Hannah, moves to the community clinic. The General Hospital, due out March 2026, sees her working in consultation-liaison.

All three books highlight the tensions between psychiatry, hospital administration and general medicine; between patient autonomy and clinical responsibility; and between care and cost.

We had positive feedback from clinicians, many of whom felt that their stories had not been told before (and one publisher turned us down on the basis that such stories should only be told from a patient perspective.) Pat McGorry and Jayashri Kulkarni offered blurbs for the cover and Bob Adler suggested to me that The Glass House was a must read for all trainees.

But our target audience was the wider public.

Last year we visited four hundred bookshops around Australia, doing over a hundred events—not to my usual audience of GPs and MCHN’s, but to avid readers, mental health workers…and those with mental health issues and their families. A colleague felt inspired to print T-shirts with a quote from our book—our patient’s problems so complex, our treatments so crude, ourselves so human—and there is feedback that still rings in my ears:

I didn’t think I could read on because it was too close to home…but I did and it was part of my healing process.
It helps me make so much more sense of the admissions my son has had (for schizophrenia).
Recommended reading…from a bookseller whose daughter had died of anorexia nervosa.

Psychiatrist Dr Alberto Veluso

Australasian Psychiatry

Overview of articles of potential interest to Section members

                Compiled by Dr Benjamin Vialle                       

In case you missed these articles Ben has compiled a brief listing of readings you may find yourself wanting to read or re-read.

We hope we may be able to expand this overview to other relevant journals for the future.

Australasian Psychiatry 2024-25:

Bioethical implications of cosmetic psychiatry: Distributive justice versus utilitarianism
M Weightman & A Amos 2024 (32.5)

Weightman and Amos reflect on cosmetic psychiatry as described by Lugg a year earlier (Vol 32, Issue 1 - in a piece that itself may be of philosophical and historical interest to Section members!). They highlight an argument from distributive justice (i.e. cosmetic psychiatry is unjustified use of scarce psychiatric resources) and a more theoretical utilitarian counterargument (i.e. society at large might benefit from enhancing the performance of the gifted).

Moving away from cosmetic psychiatry and toward eudaimonic psychiatry
B Daugherty 2025 (33.4)

Daugherty engages with that same Lugg paper, and the Weightman & Amos response above. It suggests a “eudaimonic psychiatry for all”, using the Aristotelian notion of flourishing.

The wounded healer: The history and implications of lived experience in mental health care
S Taylor 2024 (33.3)

In this exploration of the role of clinicians’ own lived experience of mental illness, Taylor includes a historical view of significant contributors to psychiatry whose work appears coloured by their experience, highlighting Klein and Bowlby.

Failures in care – The value we place on being human – Part 1
JD Little, M Burt & C Sanderson 2025 (33.3)

The authors offer this first-of-two-parts as an exploration of how a dedicated care facility can become a place of abuse. They discuss the Lake Alice Child & Adolescent Unit, and other historical examples.

Podcasts killed the radio star: A potted history of broadcasting in psychiatry
M Weightman, E Miller, F Wilkes & A Amos 2024 (32.6) 

Here, Weightman et. al. reflect on the emergence of psychiatry podcasts in Australia and New Zealand, and in doing so looks back on some of psychiatry’s history in audiovisual media, from Freud and Winnicott to Dr Phil and New Zealand’s The Nutters Club.

Medical education and creative writing: Poetry and how it can assist trainees in developing psychiatric formulation skills
V Kumar 2024 (32.4) 

Dr Kumar describes the influence of the poetry of RANZCP ‘Foundation Fellow’ Dr Ainslie Meares, and how the poetic voice and creative writing can be a helpful vehicle for the curiosity and empathy required for more sophisticated formulation.

A suicide in a Russian novel
S Pridmore 2024 (33.2)

In a brief piece that may be of interest to bookish Section members, Pridmore offers a reflection on suicide as presented in Turgenev’s Virgin Soil (1877).

SOPH ART SELECTION

Art reflecting hidden suffering and trauma

Landscape with the Fall of Icarus by Pieter Bruegel ca 1560

It is easy to miss the image of tragedy in Pieter Bruegel’s painting – just as in life we often don’t see the suffering around us. Indifference, ignorance or maybe we just don’t look, even within our own selves.

Bruegel the Elder (ca.1525 -1569) was a painter known for his landscapes of every-day life. Think of his return of the hunters looking down on their village in the winter snow. But in this particular landscape of spring, of life, with a peasant peacefully ploughing his field, a shepherd looking to the skies, another fishing in the waters while boats are passing, Bruegel has added a moment of tragedy, of death, unobserved by all three figures.

He has included, hidden in his painting, the Fall of Icarus. He has drawn on the mythological tale of Icarus who flew too close to the sun after he and his father, Daedalus, escaped from the prison where they had been held by King Minos. They escaped when the Daedalus, ever the craftsman, made makeshift wings from feathers and wax. 

Daedalus cautioned Icarus about flying too close to the sun, but like all children and overexcited, he did not heed the caution. The wax melted from the sun’s heat and Icarus fell into the sea.

The narrative chosen by Bruegel is reportedly based on the Roman poet Ovid’s Metamorphoses (8 CE), which features the Icarus story. But with some differences. In Ovid’s description, the three men, the fisherman, the ploughman, and shepherd, all look up at the sky at the two flying figures, but in Bruegel’s painting, Icarus is drowning, and the three men appear emotionally detached from what is happening.

This indifference to the suffering of Icarus was explored in the poem Musée des Beaux-Arts (1938) by W. H. Auden, who was inspired by the Icarus tale and the Landscape with the Fall of Icarus painting when he visited the Musées Royaux des Beaux-Arts. 

                 About suffering they were never wrong,
                 The Old Masters: how well they understood
                 Its human position; how it takes place
                 While someone else is eating or opening a window or just walking
                    dully along

                 How, when the aged are reverently, passionately waiting
                 For the miraculous birth, there always must be
                 Children who did not specially want it to happen, skating
                 On a pond at the edge of the wood:
                 They never forgot
                 That even the dreadful martyrdom must run its course
                 Anyhow in a corner, some untidy spot
                 Where the dogs go on with their doggy life and the torturer's
                    horse
                 Scratches its innocent behind on a tree.

                 In Brueghel's Icarus or instance: how everything turns away
                 Quite leisurely from the disaster; the ploughman may
                 Have heard the splash, the forsaken cry, 
                 But for him it was not an important failure; the sun shone
                 As it had to on the white legs disappearing into the green
                 Water; and the expensive delicate ship that must have seen
                 Something amazing, a boy falling out of the sky,
                 Had somewhere to get to and sailed calmly on.

Similarly, in 1960, poet William Carlos Williams (1883 -1963) was also inspired by the Bruegel painting Landscape with the Fall of Icarus and the indifference to tragedy. He highlights the energy of Spring, the year was awake tingling, only mentioning Icarus at the end as, a splash quite unnoticed this was Icarus drowning.

Nor can we ignore another famous painting of Icarus by the artist Matisse.

The Fall of Icarus 1943

It appears in Jazz his collection of paper cut outs. With their stunning and intense colours (which Matisse later described as "vivid and violent tones"), the rhythmic juxtapositions of forms, and the ostensibly joyous subjects, Jazz is nevertheless thought to be haunted by a deep sense of danger, loss, and dread. It was begun during World War II, when Matisse himself was recovering from illness, was preoccupied by death and had fears for his family. His Icarus is thought to have multiple connotations, including that of Matisse himself.  It recalls a figure who has been killed, either through gunshot, symbolized by the red circle on his chest or, from what Matisse said himself, " it seems that the splashes of yellow—suns or stars if you want to be mythological—were exploding shells in 1943."

Surrealist writer Louis Aragon, who knew Matisse well, writes : “The red heart, the brightest point in the picture, comes forth from within the deepest part of the picture, the breast of Icarus. It is so luminous it seems that a hole had been bored into space through the black and blue—coming to pure, intense light. That light within his heart seems to come from within the center of the universe. Could this be why Matisse, as artist, felt this was “the closest thing to an autobiography?” He said, “It is through the human figure that I best succeed in expressing the nearly religious feeling that I have towards life—that deep gravity which persists in every human being.”

Bruegel, Auden, Matisse have all contemplated the myth of Icarus; an unobserved tragedy and death, the experience of the other, or of self, that we chose to not know. A reminder of trauma in everyday life and how it can sit silently in our patient’s histories. And should we not also think of Daedalus, described as “grief stricken”, a father powerless, as he watches the fall of the son.

Alicia du Plessis,  Landscape with the Fall of Icarus – Pieter Bruegel a Deep Dive.
Art In Context 25 July 2023
Aragon, L., Matisse a Novel. (1972)
Rackow, M., The Joyous Drama of Outline and Color: or, Icarus by Henri Matisse   
Terrain Gallery with reprint from Journal of the Print World 2025
Icarus, plate VIII from the illustrated book "Jazz”
https://www.metmuseum.org/art/collection/search/337069

Next edition

Keep in touch and any contributions to the newsletter (articles, news, reading, films or photographs) much appreciated and wanted!

Contact: Dr Sue Lutton
suelutton@iinet.net.au