Intended for healthcare professionals

Head To Head Maudsley Debate

Does the emphasis on risk in psychiatry serve the interests of patients or the public? Yes

BMJ 2013; 346 doi: (Published 12 February 2013) Cite this as: BMJ 2013;346:f902
  1. John F Morgan, consultant psychiatrist
  1. 1Leeds and York Partnership NHS Foundation Trust, United Kingdom
  1. Correspondence to: Yorkshire Centre for Eating Disorders, Seacroft Hospital, Leeds LS14 6UH, UK jmorgan{at}

Identifying patients who are likely to harm themselves or others has become central to psychiatry. John Morgan argues that though the methods are flawed, identifying risk is essential, but Matthew Large (doi:10.1136/bmj.f857) thinks we should focus on the wider harms that patients may experience

In a biblical failing to understand sensitivity and specificity, King Herod applied demographic factors to kill all male children near Bethlehem, wishing to avoid losing his throne to a newborn king. The Massacre of the Innocents provides a potent example of inadequate predictive value of risk assessment categorisation, with sex and age failing to detect a rare outcome. Likewise, emphasis on risk in psychiatry has gone wrong, and psychiatrists baulk at playing Herod.

But medicine is risky business. Assessment and communication of risk permeates orthopaedic examination of a knee and psychiatric examination of mental state. Both orthopaedic surgeon and psychiatrist systematically elicit signs and symptoms, with due knowledge of pathology, making judgments about diagnosis, treatment, and prognosis based on awareness of risks. Our social function as doctors requires that we accept emphasis on risk in psychiatry. Psychiatric risk assessment processes are flawed, misdirected, and innumerate, but risk remains a fundamental component of psychiatry, as in all medicine.

Imperfect system

However, worst practice …

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