Kevin V. Kelly, MD

A few decades ago, ethics was widely understood in the professions to be a synonym for etiquette; it described the consideration that members of a profession showed to each other. More recently, it has come to refer to the rules governing the relationship between a professional and a client or patient. 

However,  ethics as a branch of philosophy has a broader, subtler and, perhaps, more interesting meaning. It refers to the study of values, and considers such questions as which acts (or states, or traits) are considered good, and how judgments about goodness are made. Formulated in this way, ethics may appear too abstract or too removed from clinical experience to be of much interest to the practicing mental health professional. In reality, these considerations are central to ordinary practice, and recent developments in the field may compel us to recognize this fact.

The everyday practice of psychiatry is full of value-laden decisions, as well it should be. As a therapeutic endeavor, and a branch of clinical medicine, psychiatry is appropriately committed to the value of health and opposed to illness. When pressed on the question of professional values, psychiatrists will often argue that the only value they promote is health, and claim that professional neutrality with respect to all other values relieves them of the need to consider ethics in the philosophical sense. This position assumes that the meaning of health is self-evident-a questionable proposition in many areas of medicine, and clearly a mistaken one in psychiatry.

Under the banner of promoting health, psychiatrists may, unselfconsciously, introduce a wide range of personal, social or political values into clinical practice. Anyone who has been through medical and psychiatric training knows that these experiences, while highly useful for their appropriately limited purposes, do not confer any unusual moral authority or make one an expert on how people should run their lives. 

As investigators and healers of the mind (or, as some would even say, of the soul), psychiatrists are all too easily tempted to opine about what constitutes healthy attitudes and behaviors, and to cloak these subjective opinions in the mantle of medical authority. The risk of making such well-intentioned errors is compounded by the fact that both our patients and the public routinely invite us to do so. As psychiatrists, we are often asked to answer questions about everything from how much sacrifice an individual patient should make for the sake of loved ones, to whether the state should restrict access to abortion. These questions may involve issues of psychiatric illness or well-being, but they clearly involve other values as well, values on which we have no more expertise than the ordinary citizen. For us to accept the flattering invitation to offer expert answers to them is not only a conceptual but also a countertransference error.

Psychoanalysis, more than other branches of psychiatry, has devoted self-conscious attention to the question of value judgments, because it has given more rigorous consideration to the meaning of neutrality. A thoughtful discussion of this topic by Robert Michels, M.D., and John Oldham, M.D. (1983), distinguished the individual analyst's personal values from those that analysts as a demographic group are likely to hold, and from those that might inhere in the process of analysis itself. These authors identified the core values inherent in analysis as individuality, rationality and balance; others might add to this list such ideals as curiosity, relatedness and responsibility.

General psychiatry, by contrast, has given systematic thought to its own value judgments only in a few areas, usually those where psychiatric categories are invoked in public debate about social or political issues. Thus in the profession's discussions of such topics as the insanity defense, the diagnostic status of homosexuality and masochism, or the abuses of psychiatry in the former Soviet Union, we have recognized the value judgments inherent in our own categories and practices. Outside these areas, we have too easily colluded with the public in the fiction that our categories embody only medical or psychological wisdom, free of social or moral judgments.

A vignette may illustrate how value-laden questions appear in routine clinical practice. A 55-year-old man consulted me because of dissatisfaction with his work. He was not clinically depressed, but was interested in using psychotherapy to explore his unhappiness. Before long it became clear that the problem stemmed from his difficulties with aggression; his work was such that any decision he made was likely to offend someone, and the risk of doing so left him paralyzed. His aversion to giving offense was understandable in the context of his early experience with an angry, belligerent father, and this understanding brought him some satisfaction but no relief. 

Based in part on my reading of such literature as Listening to Prozac by Peter Kramer, M.D. (1993), I suspected that this long-standing trait, which the patient understood as part of his character, might respond to antidepressant treatment. Intrigued, the patient agreed to a trial of fluoxetine (Prozac) at 20 mg/day. Within a month he noted some decrease in his work-related distress, and we agreed to try a higher dose. 

At 40 mg/day, he observed that he still thought about whether someone might be angered by his decisions, but was able quickly to remind himself that this risk was an inevitable part of his job, and to proceed efficiently. At 60 mg/day, he noted still greater comfort at work and in social situations. A few weeks later he commented with mild alarm that he had found himself making remarks that he knew might offend people. He described these remarks as true and important, but the sort of thing he would never have said in the past. He wondered aloud whether the medication had gone too far, and acknowledged, when asked, that he hoped I would answer that question for him. 

With further discussion and experimentation, we agreed that the medication had allowed us to establish a pharmacotechnology of aggression, placing him anywhere along a spectrum from timid to abrasive, simply by titrating the dose. But the question of where he wanted to be on this spectrum, or where he "should" be, or where the optimally healthy position was located, could not be answered by pharmacology.

Furthermore, the central question in this situation regarding how much aggression is appropriate, or how much consideration should be given to others' feelings, could not be answered by medical or psychiatric authority. The question is inescapably one of social and moral values, about which a psychiatrist should not presume to offer an expert opinion. The fact that mental health professionals often do so is evidenced by the popularity of the term "assertiveness." This category is used to make aggression sound more palatable, and implies not only that some degree of interpersonal aggression is appropriate and healthful, but also that it is possible to locate the boundary between appropriate assertion and inappropriate aggression on the basis of something other than the individual therapist's idiosyncratic convictions.

The example of a patient whose aggression was apparently mobilized by medication suggests an intriguing paradox. As the case illustrates, the use of pharmacologic agents to modify what were once considered character traits requires us to examine our assumptions about which character traits are desirable. To the extent that general psychiatrists have thought about value judgments in the past, they have considered these issues to be part of the "soft stuff" of psychiatry, related more to the psychotherapy of problems in living than to the pharmacologic treatment of mental illness. Now, advances in the "hard science" of psychopharmacology may call attention to the central importance of rigorous thinking about the supposedly soft science of psychiatric ethics.

Kramer's 1997 book Should You Leave? demonstrates that this process of rethinking is already underway. The title is somewhat misleading, as most of the book consists not of the psychiatrist's hoped-for answer to the patient's question about whether to leave an unsatisfying relationship, but of Kramer's thoughts about the significance of the patient's asking the question, about the psychiatrist's basis for answering it, and about the assumptions concerning intimacy and autonomy that would necessarily be involved in the act of giving advice about such a question. 

As the author demonstrates, the categories of intimacy and autonomy, like the category of aggression in the example above, designate social and moral values as well as states of psychiatric health or dysfunction. Presumably, psychiatrists and lay persons alike would all agree that some measure of intimacy along with some measure of autonomy, and some measure of aggression along with some measure of compromise, are desirable for a fulfilling and psychologically healthful life. But the question of how much of each is optimal is one that goes well beyond psychiatric expertise.

This is not to say that psychiatrists should not give advice about such matters. Patients often come to us asking not for esoteric expertise, but for common sense, because they find themselves, or believe themselves, unable to use that essential tool for everyday living. Furthermore, a psychiatrist's experience with many individuals over many years in difficult life circumstances may confer greater wisdom than does the usual range of ordinary life experience.

Kramer's clinical examples demonstrate that his awareness of the ethical implications of giving advice does not prevent him from doing so, often quite freely. The crucial point is simply that we should be aware of when we are making decisions or giving advice on the basis of scientific evidence or professional expertise, and when we are doing so on the basis of ordinary human experience or ethical judgments. When a patient asks for advice based on common sense or moral judgment, it may be appropriate to give it, but it is also advisable to wonder why the patient requires it and to avoid the narcissistic pitfall of claiming greater authority than one has.

Similarly, when the public asks psychiatric professionals for advice about matters that involve moral values as well as scientific evidence, we should be careful to observe the limits of our expertise and to refrain from commenting on moral questions. We can provide information about the mental processes of a murderer, or about the likely psychological effects of permitting homosexual marriage, or about the results of day care for children of welfare mothers, but we should not comment as a profession on the moral questions regarding what extent people are responsible for their actions, of how society should view the institution of marriage or of whether welfare recipients should be required to work.

The impulse to give moral advice is a powerful one, and it can be frustrating to observe all these limitations. However, there is consolation to be found. If we cannot, as a profession, dictate which virtues our patients or our society should rank highest, we can at least make such judgments about ourselves. My vote for the single most important moral trait that a psychiatrist should have goes to the virtue of humility. The psychiatrist should bring an attitude of respectful awe to our field (which, after all, encompasses all of human mental functioning), appreciate the limits of our ability to understand and to influence such complex systems, and recognize the narrowness of our expertise and the danger of claiming authority beyond it. In short, the psychiatrist who practices with humility is the one who will do the least harm, and therefore in the oldest and truest sense will practice most ethically.

Kramer PD (1993), Listening to Prozac. New York: Viking.
 

Kramer PD (1997), Should You Leave? New York: Scribner.
 

Michels R, Oldham J (1983), Value Judgments in Psychoanalytic Theory and Practice. Psychoanalytic Inquiry 3:599-608.

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A few decades ago, ethics was widely understood in the professions to be a synonym for etiquette; it described the consideration that members of a profession showed to each other. More recently, it has come to refer to the rules governing the relationship between a professional and a client or patient.

Author | Kevin V. Kelly, MD

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