A number of scholars have criticized contemporary bioethics for its focus on what have been called the “neon issues”—end-of-life care, genetic technology, and resource allocation—rather than on the far less dramatic but much more common dilemmas of everyday practice, such as obtaining adequate informed consent for treatment, respecting confidentiality and privacy, and maintaining sound but reasonable boundaries in the therapeutic relationship.1-3 From the “searching and fearless” fourth step of Alcoholics Anonymous to the rigorous spiritual exercises of the Jesuits, many spiritual traditions have proposed a regular and deliberate period of introspection as an effective means of increasing the understanding of and responsiveness to ethical conscience and conduct.
Closer to our medical home, the Working Group on Promoting Physician Personal Awareness of the American Academy of Physician and Patient has recommended a curriculum of 4 core topics—physician beliefs and attitudes, feelings and emotional responses in patient care, challenging clinical situations, and physician self-care—as a means of promoting personal awareness, improving physician-patient communication, and enhancing personal satisfaction.4 This group described its innovative program as “calibrating the physician,” which suggests that the stresses and conflicts of modern medical practice can insidiously and relentlessly wear away the fabric of our idealism and empathy. This often unwonted and unnoticed creeping cynicism in medical students is brilliantly termed “ethical erosion.”5 Yet this deformation of values and virtues is even more subtle, powerful, and enervating for practicing physicians who may have less resilience, more external pressures, and fewer supports than trainees.
In this column I invite readers from all mental health disciplines who are struggling to provide compassionate and competent care in this ever more demand-rich and resource-poor environment to join me in an exercise I call the “ethics inventory.” This inventory is based on the American Psychiatric Association’s The Principles of Medical Ethics: With Annotations Especially Applicable to Psychiatry.6 Any of the professional statements from the major behavioral health professions could be selected, and all would cover essentially the same common ground. As a psychiatrist, I will use the ethics code that governs my own specialty to emphasize the personal responsibility that each clinician should take for his or her own moral attunement.
In keeping with the individual nature of the inventory, there are no set rules. A few guidelines may optimize the exercise, however.
• First, choose a period when you are consistently involved in clinical work in which to observe your own actions and attitudes: a day- or week-long period of observation makes tracking easier.
• Second, because memory is notoriously biased and faulty, keep notes in a journal or by dictation of incidents and impressions that are related to your clinical interactions to serve as seeds for the later internal gristmill.
• Third, when reviewing the events, exercise your best therapeutic technique on yourself! Be open and yet honest, find areas for growth rather than faults to blame, focus on self and not others in regard to responsibility and change.
• Fourth and finally, choose 1 or 2 aspects that need ethical alignment from your inventory, and give some thought to the precipitating and perpetuating factors that underlie the problematic approach. Develop some simple and obtainable strategies to do things differently the next time you are confronted with a similar situation.
To help organize the inventory, the American Psychiatric Association ethics principles are adapted and summarized in the Table and are paired with some trigger questions and examples to facilitate reflective probing.
Let me admit outright that when I have performed this ethics inventory I repeatedly fall short of my own expectations and of the professional standards that I seek to impart in my writing and teaching. Like any good neurotic, when I review the results, my initial reactions are painful guilt and a precipitous drop in self-worth. So that the potential reformative energy of the inventory is not dissipated in useless self-flagellation, I try to remind myself that the ancient meaning of the word sin in Greek, hamartia, is “missing the mark.” In the Hebrew Scriptures, according to biblical scholar John McKenzie, the word sin “signifies not merely an intellectual error in judgment but a failure to attain a goal” often through nonaction.7 When I reflect on my own answers to the inventory, I find that omissions are far more frequently responsible for my failure to meet my professional objectives than are commissions.
Medical boards and news stories feature the most flagrant violations of ethical standards. As Hannah Arendt showed the world, however, there is a “banality of evil” that is neither blatant nor particularly disturbing unless one reflexively analyzes it.8 Neglect more commonly underlies our moments of moral mediocrity than negligence. As we progress in our careers, we are all prone to develop haphazard and hapless habits, such as allowing fear of lawsuits to dictate the care of suicidal patients, being too careless with the handling of patient information, and becoming indolent in staying up-to-date on the latest therapeutic information. Deficient self-knowledge may be an occupational hazard of mental health professionals in particular, precisely because there is so much emphasis on the internal states of the patient and our ability to enter his or her mental world.
Yet the success, and indeed, safety of our exploration of the darker recesses of the human psyche depend on our own psychological acumen and astute observation—abilities that require discipline and vigilance if they are not to grow dull or deformed. Only intentional, courageous, and committed ethical self-assessment can enable us to recognize our own weaknesses but even more saliently to use these insights to reorient our clinical practice toward the original and laudable goal we set out to achieve whenever we began the journey to be a healer: caring for our fellow human beings.
1. Braunack-Mayer AJ. What makes a problem an ethical problem? An empirical perspective on the nature of ethical problems in general practice. J Med Ethics. 2001;27:98-103.
2. Hicks N. Public health, public policy and “neon” issues in ethics. Med J Aust. 1985;143:104-107.
3. Roberts LW, Geppert CM, Bailey R. Ethics in psychiatric practice: essential ethics skills, informed consent, the therapeutic relationship, and confidentiality. J Psychiatr Pract. 2002;8:290-305.
4. Novack DH, Suchman AL, Clark W, et al. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997;278:502-509.
5. Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development. Acad Med. 1994;69:670-679.
6. American Psychiatric Association. The Principles of Medical Ethics: With Annotations Especially Applicable to Psychiatry. Arlington, VA: American Psychiatric Association; 2006.
7. McKenzie JL. Dictionary of the Bible. New York: Macmillan; 1965.
8. Arendt H. Eichmann in Jerusalem: A Report on the Banality of Evil. New York: Penguin; 1964.