Diligence

Jul 25, 2016

There are striking parallels between the work of the Supreme Court justices and that of psychiatrists.

From the Editor

My personal highlight at this year’s APA annual meeting in Atlanta was listening to Supreme Court Justice Stephen Breyer’s presentation. His remarks focused on explaining the Court’s process of decision-making: how it decides what cases to hear and then how the justices arrive at a decision.

The processes Justice Breyer outlined were impressive for the attention to the questions of law that he said were the primary determinants of whether a case was accepted, and for the thoroughness of the consideration at every step of the process. I won’t try to repeat the details of his description, but he has written about this and it’s worthwhile reading.

Of particular interest were his descriptions of his own views of the Supreme Court’s role and the approach he takes when considering a case. He clearly believes that interpretations of the law cannot help but be contextually based. What he described in this regard included both the personal life and educational experiences of each justice as well as the sociocultural milieu of the American-and global-societies at the time a case is decided.

Also see:

Psychiatry: Then and Now

When asked to comment on how he would have decided an important case that was adjudicated before the Civil War, he said it was an impossible hypothetical to answer. The reason he couldn’t answer, he said, is because he would somehow, impossibly, have to ignore everything he knows now about the law, his own developmental experiences, and the cultural milieu in which he has lived, and try to magically transport himself to being whatever person he would be in his role in that time and place. He’s clearly not an “original intent” strict constructionist.

Whether you agree with his perspective and decision-making philosophy, in the 90 minutes we heard him speak and answer questions, one could not help but be struck that he and the other justices all approach their task with incredible diligence. He acknowledged there will likely never be a decision about a critical legal question that is met without some criticism. And we know sometimes that criticism is extremely harsh. Justice Breyer saw this criticism as simply part of the territory when interpreting the law, about which there is often passionate dispute. In this regard, it was surprising to hear him highlight the fact that a very large percentage of cases under review are decided unanimously by the Supreme Court. Those cases, of course, are rarely the ones highlighted in the daily news.

As I was listening, I kept thinking about the parallels between the work of the justices on the Supreme Court and that of psychiatrists. Like them, we are often faced with the need to make a decision-in our case about diagnosis, treatment, or etiology-for which there is no perfect or unanimously agreed-upon answer. But we approach each patient with diligence, looking to use all our knowledge and skills to make the best possible decisions we can. And there is no lack of criticism when it appears to someone we’ve made a wrong decision.

Moreover, as in Justice Breyer’s view, our decisions are influenced by who we are as people, our own experiences, and our own sociocultural milieu. In this regard, of course, Freud’s emphasis on the value of self-awareness when engaging with patients seems right on the mark. The more we understand our own perspectives, biases, and hot-button emotional issues, the more effectively we can listen to and understand our patients, he argued. And that core recommendation has informed psychiatric practice for over a century.

On the other hand, when I was a resident, involuntary hospitalizations were supported legally if they were due either to imminent danger of harm to self or others and/or that the nature of the illness was such that it substantially impaired the ability of the person to care adequately for oneself.

We’ll keep trying to make the best possible decisions with our patients, even knowing we can’t ever be perfect and may be harshly criticized for our failings.

While the legal language in many states is unchanged, the courts’ interpretations of acceptable reasons for involuntary hospitalization now are confined to imminent self-harm or harm to others. And, as we and others look back at the history of many psychiatric treatments, there is often unanimity of opinion about what at the time were considered reasonable clinical practices, but which now seem morally and ethically appalling.

So, as I’ve considered Justice Breyer’s remarks over the ensuing weeks, I’ve thought more and more about these parallels. Of course, we continue to try to learn more and to provide better and better experiences for those who come to us for help. I have no doubt, though, that much of what we consider state-of-the-art care today, just as many current legal precedents, will be viewed as more or less primitive in a few decades and replaced by something else.

Even my most closely held belief, that at its critically important heart the practice of psychiatry requires a close therapeutic relationship with our patients, may be seen to be unnecessary with the rise of the coming advances in artificial intelligence technology (see or read the play Marjorie Prime for a preview). But until then, and even then, in spite of all the criticism that may come our way, we’ll continue to be diligent.

We’ll keep trying to make the best possible decisions with our patients, even knowing we can’t ever be perfect and may be harshly criticized for our failings. In this regard I’m reminded of Robert Browning’s poem “Andrea del Sarto,” in which his famous line reads: “Ah, but a man’s reach should exceed his grasp, Or what’s a heaven for?”

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