The Ethics Inventory

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.

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