Ethics and Virtues in Clinical Psychiatry

March 12, 2014

Case-based dialogues illustrate some virtues required in psychiatric practice.

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.

Symptoms bring distinctive challenges

Sam’s wife has recognized a returning mania and brings Sam to Dr Ping.

Dr Ping: What seems to be the issue, Mr Durgin?

Sam: It’s not me, Doc-she brought me in here for nothing, the meddling woman. . . . But since I’m here, let me tell you about this important project. . . .

Dr Ping:(He’s not ready to confront the situation yet. Based on previous episodes, he’s not dangerous and an alliance can be established. We need to build more trust.) So, everything is OK then? What’s this new thing you’ve been working on?

The patient’s denial that the problem lies within himself must be negotiated with care. Extraordinary imagination and also great patience are demanded from practitioners who work with a patient’s misapprehensions about symptoms. This cannot be hurried: Dr Ping envisions how it seems from his patient’s perspective and avoids confronting Sam’s denial until he has established some rapport.

Psychiatric disorders frequently affect the agency, mood, and reasoning capabilities widely believed to constitute a person’s core self or identity. Moreover, patient attitudes toward symptoms are often ambivalent, and complex, communicative capabilities are compromised (when psychosis is present, for example). These capabilities are especially critical in this case because the words, behavior, and history of the patient provide the sole, or the decisive, evidence of disorder.

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Psychiatrist as moral arbiter

Returning from a college reunion, Dr Feldman has impulsively set up a Facebook page to share pictures of himself (relaxing and clowning around with the family dog). The following day, his granddaughter points out that he has disregarded privacy settings, and the uploaded pictures are available for all to see. Aghast, Dr Feldman envisions outsiders, including his patients, discovering them and hastily resets his page to limit access to these personal images.

In belatedly attending to the impression he imagines these images might make on his patients, Dr Feldman shows concern over appearances (or propriety) that had been forgotten in his eagerness to share his life with friends and family. The temptation here was to give in to impatience and ignore the foreseeable consequences of his actions.

The psychiatrist’s distinctive expertise has ethical implications. Concerning the traits of voluntariness, rational autonomy, and competence, practitioners’ decisions have societal consequences that are both practical (eg, involuntary seclusion and treatment, and culpability) and symbolic.

Voluntary action, rational autonomy, and competence are cherished attributes and core moral and political values, principles, and ideals that imbue the healing project with ethical significance when adopted as treatment goals. Those who administer these ethically based policies and opine about, uphold, and even foster such values have the status of a moral arbiter from a societal perspective, although this is not a welcome attribution. Their situation is, arguably, ethically weighty and calls for not only great fairness and integrity, but also the kind of attention to and care about appearances, or propriety, that is expected of other moral arbiters (eg, judges).

Data protection dilemmas

Ms Long had been referred by her company’s personnel department for an assessment of mental health after an office row that she apparently instigated; rapport has been established over 3 sessions.

Ms Long: The “efing” manager, he’s the one: makes trouble all the time. . . . I’d like to give him what’s coming to him, arrogant creep. I could strangle him, right there in front of everyone.

Dr Watts:(A credible threat? More likely a fantasy; she’s mad at that guy and sounding off. If I put it in her record, she’d lose her job.) I’d like to understand this better. Let’s meet again tomorrow, so I can hear more about the way this guy makes trouble for you.

Dr Watts’s decision to maintain confidentiality until the next day is weighty. If Ms Long’s “fantasy” and “sounding off” are more than that, a person’s life may be at risk. Such responsibility calls for the careful, judicious balancing associated with the practical judgment that, following Aristotle, is known as the virtue of phronesis.3

Comprising the likelihood that confidentiality will be breached together with the likely harm resulting from that breach (in stigma and discrimination, for example), the patient’s “privacy stakes” are very high and call for comparably heightened attention to confidentiality. In addition, however, the practitioner must decide when public safety (danger to others) or the patient’s own care and protection (danger to himself or herself) dictate that confidentiality be breached.

Psychiatric controversy

Kyle, a 17-year-old boy, has been referred for assessment of possible dysthymia by the family physician; Kyle’s T-shirt reads “Mad and Proud.”

Dr Sanchez: What seems to be the trouble?

Kyle (smirking): You tell me. My mom figures you know what’s going on in my mind.

Dr Sanchez: Can you tell me how you feel about school, friends?

Kyle: I feel fine, I am fine. This psychiatry stuff is all bull. Show me a blood test that says something’s wrong!

In assessing Kyle’s condition, Dr Sanchez must both acknowledge his opinions and deal with their challenge to her own raison d’être. The term “groundedness” indicates a staunch confidence in one’s role and conviction about one’s professional ideals. Along with groundedness, Dr Sanchez, and all practitioners working within a cultural context of controversy and skepticism, will need greater tact and empathy than would be required in doctor-patient relationships that possess an unquestioned, shared, and stable acknowledgement of each person’s role and expertise.

Controversies over mental disorders and their treatment cover the status of diagnostic categories and research claims, particular treatment modalities, uses of coercion, the causes of disorders, even whether psychiatric conditions involve dysfunction or disability-all confronting and potentially infringing on the psychiatrist’s identity in ways rarely encountered elsewhere in medicine.

Virtues as inner, and affectively grounded, states

Brought to the hospital by her sister, Mrs Brown is a frail, 82-year-old woman locked in a state of melancholic depression, her second episode in 1 year.

Dr Gallo: The pills I gave you, did you keep taking them?

Mrs Brown (nods slowly): Did no good . . . nothing works.

Dr Gallo: There are other ways we can approach this. I’m not going to give up on you.

Mrs Brown sighs, wearily nods again, eyes downcast. Silence. Dr Gallo is calm, quiet, and attentive, and he leans toward her. Three minutes pass, and Mrs Brown looks up.

Dr Gallo (with a warm smile): I’m not saying it will be easy, but-we’ll lick this.

In showing genuine feeling for Mrs Brown’s distress, Dr Gallo adopts the personally effaced yet acutely attentive attitude toward the patient known as “unselfing.”2 He also recognizes the value of silence, and in both demeanor and words he conveys the clinically effective trait of hopefulness.

Character and virtues centrally involve inner states, and this fits the healing medium of psychiatry, where the conduct involved in treatment is often imperceptible from the outside and even observable responses are subtle: for example, attentive listening, carefully chosen words, quiet demeanor, and calm body language.

Among inner states, feelings are seen as antecedents, preconditions, and constitutive ingredients of virtues, and this emphasis on feelings also accords with psychiatric practice, where affective states and traits are especially important. In addition to the knowledge, skill, and attention to detail with which practitioners must approach their patients, compassion, empathy, and caring are called for. The practitioner must feel the right way (as well as communicating that feeling). Indeed, the alliance that is essential to effective practice is widely believed to depend on such responses. These are not mere gut reactions-rather, they resemble the carefully regulated and habituated feelings associated with traditions of virtue ethics (which include the right time, about the right things, toward the right people, for the right end, and in the right way).

Virtue ethics

The applicability of virtue ethics to psychiatry leaves 2 outstanding questions: can virtues be taught, and why are “virtues” ethical, rather than clinical, traits?

When as young adults practitioners are taught the ethos and ethics of psychiatry, basic moral-emotional education has been achieved. Much of the task is thus one of strengthening and reinforcing virtues already present, rather than inculcating them de novo. Moreover, what are called virtues comprise a heterogeneous collection of states and traits; many are elements (eg, imagination and attention) in everyday informal and formal learning. With the use of these elements, virtues are enhanced and deepened. (Discussion of ethical dilemmas and efforts to stimulate the imagination with role play, works of fiction and film, journal keeping, and similar forms of self discovery and monitoring have been shown to be effective.)

A tenet of professional ethics is that clinical skills may be virtues as well. Thus, when professional roles generate additional ethical demands, any trait that is conducive to the goal or good of a practice may acquire the status of a moral virtue.4 Practitioners whose responses are not only right, but an expression of their underlying character, manifest clinical skills that are also moral virtues.

Disclosures:

Dr Radden is Professor of Philosophy Emerita at the University of Massachusetts in Boston. She reports no conflicts concerning the subject matter of this article.

References:

1. American Psychiatric Association. The Principles of Medical Ethics With Annotations Applicable to Psychiatry. Washington, DC: American Psychiatric Press; 2013.

2. Radden J, Sadler J. The Virtuous Psychiatrist: Character Ethics in Psychiatric Practice. Oxford, UK: Oxford University Press; 2010.

3. Aristotle. Nichomachean Ethics. Irwin T, trans. Indianapolis, IN: Hackett Publishing; 2000.

4. Oakley J, Cocking D. Virtue Ethics and Professional Roles. Cambridge, UK: Cambridge University Press; 2001.