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Ethics and Virtues in Clinical Psychiatry

Ethics and Virtues in Clinical Psychiatry

Psychiatry is guided by the principles, ideals, and ethical codes applicable to all biomedical practice; these principles and prescriptions are necessary, but they are not sufficient.1,2 The additional ethical demands result from psychiatry’s distinctive practice and stem from the nature of the psychiatric disorder, the state of medical science about that disorder, cultural attitudes toward it, and aspects of the practitioner’s mandated and customary roles. Together, these features indicate the sort of additional ethical attention called for. It is one associated with the cultivation of virtuous traits, or virtues—the persisting positive personal qualities, such as integrity and kindness, attributed to character.

In virtue-based ethical systems, people’s selves or characters are at the center of moral assessment, providing the ultimate normative justifying reason for acting, and living, well. (It is not discussed further below, but virtue ethics is also associated with the human flourishing, or eudemonia, involved in psychiatric treatment goals.)

Many virtues are called for in the practice of psychiatry, including ordinary moral qualities. The virtues associated with everyday life may be insufficient for psychiatry, which calls for special virtues as well as more of the ordinary ones. The following case-based dialogues (with inner monologue in italics) illustrate some virtues required in psychiatric practice.

Patient vulnerability and practitioner temptation

This is the 12th session with a 30-year-old woman in treatment for anxiety.

Veronica (smiling seductively): Dr Scott—may I call you Kevin? Dr Scott sounds so formal. . . . I forgot it’s daylight savings, and I think I’ve missed the last bus. You live out in the western suburbs, don’t you? Could you give me a lift, just this once?

Dr Scott: Er . . . (It’s a rainy night, perhaps I should make an exception? She’s so naive, she could get into trouble . . . I’m drawn to her, watch out . . . She feels her only worth is in her appearance, has to flirt . . .) I’m afraid that’s not a wise idea.

Dr Scott is tempted, but he shows self-knowledge and restraint when he reminds himself that this boundary should not be crossed. And in recognizing the pattern that connects Veronica’s flirtatiousness to her diminished self-esteem, he exhibits gender sensitivity.

The almost unequalled vulnerability of many people with severe psychiatric disorders is readily accommodated by the holistic moral psychology of virtue-based ethics, within which each virtue is understood in terms of a particular, opposing temptation (or vice) that it counters. Best-known of the temptations that virtues serve to combat in psychiatry are sexual, but they also include exercising power or seeking personal advantage at the patient’s expense in other ways. Quite apart from its transference implications, the private encounter with a vulnerable patient in which intimate details are discussed, and the utmost candor demanded, offers considerable opportunity for unethical behavior. This is recognized in the rules governing therapeutic boundaries, wherein much behavior that is permitted in other medical settings is proscribed.

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