This case raises two important issues in relation to psychiatric practice. The first is specific to the immigration detention setting; the second applies across the range of psychiatric practice. The detention experience causes significant psychiatric disturbance. In many cases, previously well patients have been driven mad by the detention experience. In the case of Amil, events that occurred before detention would have contributed to his psychiatric disturbance. Nevertheless his severe distress and suicidal intent will have been exacerbated by the toxic detention environment in which he has been living. Whilst there is considerable evidence of the damage done to detainees by the detention environment [2], there is no evidence that psychiatric interventions can be therapeutic within this environment. Therefore, in order to pursue his responsibilities towards his patient, Dr Smith must redirect his energies from providing therapy for Amil (drug or otherwise) to advocating for his removal from the dangerous environment which can be confidently predicted to intensify his psychiatric disturbance.

Some psychiatrists doubt the appropriateness of taking on the role of advocate. Yet our ethical obligations appear to be reasonably straightforward. We must do our best to ensure that our patients are protected from adverse environmental circumstances, and this obliges us to notify possible child abuse, and to take a stance against domestic violence. Legal support for an advocacy role for psychiatrists has been provided by the Australian Federal Court. In his judgement in the case of S v Secretary, Department of Immigration & Multicultural & Indigenous Affairs, Justice Finn noted:

professionals ... are called upon to, and do, make professional and impartial judgments in relation to their area of expertise notwithstanding that they entertain strong, even passionate views about the subject matter of their judgment or of the context in which it is to be made;

and

In the proceedings before me the Commonwealth has sought to paint these doctors as advocates of a cause and to impugn their professionalism in consequence. In my view, the lack of professionalism has been demonstrated by others [1].

The case of Amil and Dr Smith raises a second ethical issue that is relevant to both custodial and non-custodial psychiatry. Within psychiatric practice, emphasis on suicidal risk can lead to a failure to implement the least restrictive available and appropriate treatment. Too often patients are admitted to hospital at cost to their autonomy and sense of mastery in the belief (perhaps correct) that this will reduce their risk of suicide. The guiding principle seems often to be to lessen the risk of litigation rather pursuing the best interests of the patient. Suicide is not the only risk that our patients face. We must balance the low probability (suicide even amongst psychiatric patients is not common) of a tragic event against the high probability of lesser harms.

For Amil, it is almost certain that harms will result from solitary confinement and intrusive observation. These forms of ‘care’ are likely to resonate with his mistreatment in his country of origin and will be exacerbated by the teasing he could realistically expect in immigration detention. In dealing with potentially suicidal patients the psychiatrist must take a population health perspective, seeking to benefit the greatest number of patients and see to it that the least suffer. For an individual, suicide is a greater harm than humiliation and torture. For a group of such patients the potential death of one may be an acceptable risk to take for the greater good of many. This does not constitute a licence to be reckless about suicidal risk but it does dictate that we must be critical in balancing the risk of suicide with other more likely harms. For this reason, it is reasonable for Dr Smith to decide to respect Amil’s request for confidentiality.