Abstract
Jennifer Radden has suggested that, because of its unique practice, a ‘unique ethics’ for psychiatry is necessary [1]. Radden's ‘unique ethics’ is based on the three characteristics which she claims are unique to psychiatry; the therapeutic relationship, the characteristics of the psychiatric patient and the goals and purposes of the therapeutic enterprise itself. Further, she suggests that an ethics for psychiatry must go beyond the ‘principles of bioethics that are applicable to all fields of medicine’. Her arguments in support of the unique nature of psychiatric practice are sound. However, to then claim that it follows that a ‘unique ethics’ for psychiatry is also required is not entirely convincing. A more plausible explanation for how ethically sensitive mental health care is enacted in practice is better served by exploring whether existing methods of philosophical ethics can adequately account for the accepted uniqueness of psychiatric practice.
The explanation, which will be argued for here, remains sensitive to ethical impartiality, the partialist demands of professional health care practice and the role-related nature of professional practice. Consistent with Radden's aims, the claims presented are intended to contribute to the development of a better understanding of ethical dimensions of mental health practice. Unlike Radden, the focus is not on the ethical differences between psychiatry and other specialties/professions, but toward similarities. What is stressed is the influence that the virtue of phronesis (practical wisdom) has on clinician decision-making and judgement.
Claims for a unique ethics for professional practice
Claims for separate or ‘unique ethics’ for particular professional practice areas are not new. Such claims have often been generated because of concerns about the ethics of health care professional partialist and impartialist behaviours. There have been claims for a unique role as a ‘patient advocate’ from nursing, claims for a ‘separate ethic’ for medicine, and suggestions that it is nurses who are able to provide ‘partialist caring’ while it is medical practitioners who ‘impartially cure’. It has even been suggested that it is predominantly female nurses who act in patients partialist interests, focusing on the importance of individual ‘caring relationships’, while predominantly male medical practitioners act impartially with a primary interest in meeting ‘justice needs’ and following certain ‘rules and principles’. Such claims do have some merit.
Probably the most well known view about a unique ethics for medical practice is articulated by Edmund Pellegrino and David Thomasma who in A philosophical basis of medical practice went so far as to propose that, the special nature of the doctor-patient relationship should be the source of the canons of professional medical ethics, complementing or even replacing a rights ethic [1]. Their contention is based on the notion that health is the most important end result in medicine. In a later work For the patient's good: the restoration of beneficence in health care [2], Pellegrino and Thomasma developed their ideas further, claiming that a medical ethic underpins an ethic of loyalty to the patient, social obligations, compassion, and the characteristics or virtues that should govern a healing relationship. Accordingly, they claim that there are four major ways in which medicine possesses a particular or unique ethical character. These are in relation to the public promise, mutual valuation, role-specific duties and condition of freedom that practitioners participate in. Public promise relates to the process of accreditation that society bestows upon those who practice medicine. The medical practitioner is expected to act in the best interests of others. Mutual valuation is considered important because as health and/or healing is considered a moral value, the ethical character of the doctor-patient relationship arises partly through mutual recognition or valuing of this by patient and doctor. The third way that illustrates the unique character of the medical relationship is particularly interesting and rests on the duty of the ‘doctor qua doctor’. Pellegrino and Thomasma consider this to be the deontological basis of professional ethics encompassing the fourth of their conditions, freedom. Above all, Pellegrino and Thomasma recognize the distinctive role-related nature of medical ethics. Others have done so too.
More recently, Paul Komesaroff has claimed that the medical relationship is so distinctive or particular that even the discipline of bioethics itself is unable to provide an adequate day-to-day account of decisionmaking in medicine or substantial guidance for medical practice. In part, Komesaroff's so-called ‘microethical’ account of medical practice is best summarized in this statement.
‘Ethics’ is what happens in every interaction between every doctor and every patient.
He further suggests that clinical practice consists of an accumulation of infinitesimal ethical events ethical analysis should chart the topography of the medical lifeworld, as it exists in its concreteness, its fluidity, and its temporal unpredictability. By this means, we can seek to reveal the structure and dynamics of the clinical interaction and, in particular, to explicate the actual processes involved in clinical decision-making. As the so-called traditional theories in bioethics cannot do this there needs to be a refocus from the ethical to the microethical [3].
This idea is really not new and Kantians, virtue theorists and utilitarians all argue that the so-called traditional theories do in fact recognize the microethical and partialist relationship elements of clinical practice. A person who prefers to act from an impartialist utilitarian perspective, for example, may not necessarily discount the importance of caring at the day-to-day level of practice. Such a notion is evidenced in R.M. Hare's suggestion for ‘two-levels of moral thinking’, where a practitioner acts intuitively in day-to-day practice and is also able to reflect critically away from the pressures of practice; where there is time for considered reflection on the challenges, dimensions and dilemmas of clinical practice [4]. The point to be made is that in relation to medicine, the so-called microethical focus is another attempt to establish a unique ethics for medicine.
A distinct ethics for medicine claim is arguably most clearly articulated by Larry Churchill. It is Churchill who, in the often cited paper, Reviving a distinctive medical ethic [5], rejects the idea that, in relation to clinical actions, medical practitioners act only from an obligation to obey state statutes or with reference to general citizenship, by drawing on personal, even idiosyncratic convictions. According to Churchill it is more likely that the medical practitioner acts consistent with rationales that might appeal to professional ethics and not just in relation to personal motivations for action. Accordingly, the medical practitioner acts from a rationale that might appeal to a professional ethic that is vocationally centred and specific to the activity of medicine itself. Such an ethics is related to, but also distinct from, other rationales. Churchill appeals to a role specific duty incurred precisely out of one's status and function as a medical doctor. The context is not just others per se, but specifically those patients that a medical practitioner is in a particular relationship with. Churchill proposes that the moral distinctiveness of medicine allows for an effective orientation from which to understand the interactions and ethics of medical practice. He claims that several things are provided by a distinctive professional ethic. The first is critical distance (a perspective from which to view general, cultural, moral trends, the law and one's personal convictions). Second, a distinctive ethic is necessary so consumers and medical doctors know what the practice of medicine means (in this sense, to have an ethic is essential to what it means to have a profession). To be a professional is to be engaged in one's work patterns and to see those patterns as constituting a source of nourishment over time. Right conduct is a central point of orientation for professional life. This is an interesting view and Churchill is right to connect the ethical responsibility of a medical practitioner in this way. The appeal to vocational responsibility and subjective connection is important. The medical practitioner is connected and engaged in subjective partialist relationships with patients.
It is into this discourse that Radden's even more focused claim for a unique ethics for the medical speciality of psychiatry comes. Like other claims for unique medical ethics it is not hard to generally agree with most of what Radden says about the uniqueness of the psychiatrists role (although where psychiatric and mental health social workers, nurses, and others working in the mental health care area fit is unclear, e.g. what is the difference between the psychotherapeutic relationship that a psychiatrist has with a patient and the psychotherapeutic relationship that a nurse or social worker has with a patient?). It is, however, possible to accept the reality of the unique nature of the psychiatrist's role but reject the idea of ‘separate ethics’ per se. It seems more plausible to encompass such claims for ‘professional uniqueness’ within a broader vision of what it means to be an ethically sensitive health care professional. The challenge is to articulate an ethical understanding that respects the context of the role-related nature of psychiatric practice (or indeed any professional practice), which also connects the professional with what one may call a ‘wider sense of what it means to be an ethically sensitive human being’. Such an ethical understanding should respect the uniqueness of different professional roles, but at the same time share a common foundation, or core characteristic, from which to base ethically sensitive agency.
Ethically sensitive mental health care practice
Much of the debate about a ‘separate ethics’ for particular areas of practice has come about because of perceived dissatisfaction with the way that different ethical theories account for the realities of practice. This dissatisfaction is to some extent understandable and it is important to acknowledge that the ethical analysis of professional practice is in reality much more complex than a simple division of ethics into the subject's main methods. However, given that it is so well accepted that there are basically three main theories or methods of philosophical ethics, the obvious place to continue this discussion is by way of a brief outline of these methods. It will be shown that the so-called traditional ethical theories can have at least some relevance to analysis of the realities of health care and particularly mental health care practice.
The three key ways of thinking about morality that have dominated the moral landscape in recent years are,
consequentialism, which emphasizes good results as the basis for evaluating human actions; Kantian ethics, which focuses on ideas of universal law and respect for others as the basis for morality; and virtue ethics, which views moral questions from the standpoint of the moral agent with virtuous character or motives [6].
Consequentialism developed from Utilitarianism, which is underpinned by the assumed pre-eminence of impartiality. John Stuart Mill (1806–1873), who claimed that maximizing happiness is of central importance to moral agency, identified utilitarianism as
The creed, which accepts as the foundation of morals, Utility, or the Greatest Happiness Principle, holds that actions are right in proportion, as they tend to promote happiness, wrong as they tend to produce the reverse of happiness. By happiness is intended pleasure, and the absence of pain; by unhappiness, pain, and the privation of pleasure. (U.2.2) [7].
Utilitarianism is seen as being a theory that is ‘consequentialist’ as it is a theory that focuses on outcomes and consequences of action. Thus, a particular action is considered to be right or wrong depending on the balance of good and bad consequences of that action. The theory requires that the ethical agent ought always to strive to maximize value over disvalue (or the least possible disvalue if only undesirable results may be achieved) [8].
Alternatively, Kantianism developed from the writings of Immanuel Kant (1724–1804) who claimed that the ultimate foundation for morality is goodwill. For Kant, if a moral system is to be justified, it must be based on the motivation to act in a way that is consistent with what is good. Thus, goodwill is individual intention to act from a position of goodwill. Outcomes are of much less importance. For example, a social worker may be very good at identifying persons problems, but if she is using her abilities to take advantage of vulnerable individuals by encouraging them to give her money for ‘safekeeping’, when in reality she is using the money for her own ends, then she is not acting from a position of goodwill. In this instance the finely honed skills of the social worker are used for the wrong reasons. Other examples are the scientist who is brilliant at his work but uses his gifts for evil and the political leader who achieves fine ends but is ruthless in the cost he is willing to impose on others in order to carry out his plans [9]. The point is that if one is motivated by a Kantian conception of the goodwill then there is an internal connection between goodwilling and right action. Moreover, only actions done from duty have moral worth. It is in actions done from duty that allows the goodwill to come forward. Thus, the Kantian cycle is completed. The Kantian approach to morality has influenced the development of well-known biomedical principles such as autonomy, beneficence, non-maleficence and justice.
In contrast, influenced by the early writings of Aristotle (384–322 BC), virtue theory or ‘virtue ethics’ has been described as a term of art which was initially introduced to identify an approach in normative ethics that emphasized the virtues or moral character of people, in contrast to ethical approaches that emphasize duties, rules or the consequences of certain actions [10]. When compared to consequentialism or Kantianism, virtue ethics represents a significant change of emphasis. For a virtue ethicist the focus is primarily on the ethical agent's character instead of solely on the agent's actions.
Much has been written about the relevance that all three methods have to ethical analysis in psychiatry [11]. For example, consequentialist theory has encouraged considered reflection on the outcomes of psychiatric care including concepts of disease, diagnosis and social dimensions of care. Kantian theory has encouraged reflection on ethical principles that should underpin and guide care, on patient autonomy and processes of informed consent. Reflection on what virtue theory can offer to practice has led to consideration about what characteristics psychiatrists and mental health professions ought to have. Now, in relation to Radden's claim for a separate ethics for psychiatry, it is the third of these three methods that Radden seems to be arguing from. Interestingly, this is not the only position one can develop from virtue ethics. Indeed it has been suggested that virtue ethics itself should not be viewed as a completely separate approach to ethics, but may instead serve to give further meaning to Kantian and consequentialist methods [12]. While this proposition will not be considered in detail here, being aware of this line of thought opens one to possible ways to develop answers to the questions addressed in this paper. Is there really a need for a separate ethics for psychiatry? How can existing philosophical ethics be relevant and important to practice? The contention is that plausible answers to these questions can be articulated. First, it is helpful to accept that it is the role-related nature of health care practice that determines clinician responses, and that these responses are underpinned by an agent's acculturated sense of the virtue of phronesis – the virtue that Aristotle claimed was the most important [13].
The role-relative nature of health care practice
On television some years ago, Sir Lawrence Olivier was talking about being an actor. An interviewer had asked about the nature of acting (it may have been Michael Parkinson). After a few seconds Sir Lawrence answered using a story about Dustin Hoffman's acting preparation for a scene from the film Marathon Man as an analogy. In the scene the character played by Hoffman is physically and psychologically fragile due to being terrorized by some rather unsavoury people. The character played by Hoffman has not slept for several days. In preparation for the role Hoffman decided it would be useful to not sleep for several days himself. He claimed that this allowed him to be able to easily identify with the character's distress because to a large extent he was experiencing similar physical and psychological fragility. Olivier dramatically paused after telling the story. He then stated that he had shared some important advice with Hoffman. In a puzzled tone and to great effect he claimed that at the time he had said to Hoffman, ‘Dustin… Why don't you try acting?’ The implication is that an actor is in a role that requires skills, knowledge and technique. It is useful for actors to immerse themselves in a role to get the sense of how to respond in a situation as the character that is being played would. However, if actors actually become the character they are playing then they are no longer an actor playing a role. The same is true in health care. A health care professional may be motivated by a general intention to treat patients in some ways similar to how one may treat a friend, but the health care professional does not actually become a friend of a patient. Thus, the analogy about the nature of acting is similar to the role-related nature of therapeutic relationships. Accordingly, the health care professional engages in role-relative therapeutic relationships with patients. The good health care professional has academic knowledge, practical clinical skill and an attitude of commitment to patients. It is plausible that, these different attributes are integrated and actualized by the virtue of phronesis. Understanding how phronesis influences role-related ethically sensitive ethical practice is therefore the key to further understanding moral wisdom and agency in health care.
Phronesis and practical moral wisdom
Moral wisdom can be identified as a human psychological capacity to make sound judgements about what we should do when seeking answers to difficult moral questions. The judgement is made in the light of our conception of a good life, but it concerns the evaluation of both the actions that exemplify the conception and the conception itself. Moral wisdom is thus sound judgement involving the application of knowledge of good and evil to the evaluation of both the means and the ends constitutive of good lives [14]. It is a character trait that different people possess to different degrees, but insofar as we aim to have a good life, reason dictates that we should aim also at developing moral wisdom, because it is indispensable to living such a life. This is why moral wisdom is a morally important character trait, hence a virtue [15]. It was Aristotle who equated moral wisdom with phronesis. Aristotle was aware that the inability to think and act value-rationally could seriously impair the social and physical existence of individuals, communities and societies.
In the Nicomachean Ethics, Aristotle discusses the interdependence of phronesis and the virtues of character [16]. Aristotle focused, in particular, on three such virtues: episteme, techne and phronesis. The terms episteme and techne are still with us as epistemology and technology, while phronesis is not so common [17]. This in itself is probably an indication of what society currently values. Despite the loss of a common appreciation of the significance of the virtue of phronesis, this virtue really is, as Aristotle suggested, the most important. Phronesis is related to value-rationality and praxis. For Aristotle, praxis is voluntary or goal orientated action, and also includes authentic action for its own sake. As such, the concept has much to offer to the exploration of the dynamic complexities of ethical dimensions of clinical encounters. Aristotle begins his discussion of phronesis thus,
Regarding practical wisdom we shall get at the truth by considering who are the persons we credit with it. Now it is thought to be the mark of a man of practical wisdom to be able to deliberate well about what is good and expedient for himself, not in some particular respect, e.g. about what sorts of thing conduce to health or to strength, but about what sorts of thing conduce to the good life in general. This is shown by the fact that we credit men with practical wisdom in some particular respect when they have calculated well with a view to some good end which are one of those which are not the object of any art. It follows that in the general sense also the man who is capable of deliberating has practical deliberation … (VI 5 1145a–1145b) [17]
The concept of practical wisdom is inseparable from the notion of character. In Aristotelian thought it is practical wisdom that integrates the different ends of character, refining and assessing them, and ultimately issuing in all considered judgements of what is best and finest to do [18, 19]. Thus, phronesis requires experience and common sense. Aristotle also considered phronesis as not only the skilful, clever discovery of means for meeting specific tasks, not only as an awareness of what is practical, of how to realize incidental goals, but as the sense for setting the goals themselves and taking responsibility for them. The concept of phronesis thereby acquires, and this is what is important, a substantive determination. This concept does not denote a merely formal capacity, but rather includes at the same time a further determination, namely its field of application [20]. Phronesis requires an engagement with the dialogues and experience of the practical, which is why health care professionals are able to apply it and mental health clinicians could give many instances from practice that support Aristotle's ideas.
An understanding of the concept of phronesis has significance for the development of any claim about the philosophical dimensions of meaningful and therapeutic relationships in health care. As well as acknowledging the importance of the practical and technical it is possible to argue for a sense of health care practice that is not primarily driven by technical skills but instead by a sense of what it is to be moral. This is not an entirely new idea. Moral knowledge is not a matter of purely observing and knowing something. To know something morally is a requirement to act in a certain way with regard to that knowledge. Therefore, what matters is not only what we know but also what we are [21]. For instance, in relation to the philosophical dimensions of law, there has been attention given to the importance of practitioner character and phronesis. Anthony Kronman in The lost lawyer has argued for a conception of the good lawyer who acts from an Aristotelian perspective [22]. Kronman sees practical wisdom as a procedural and substantive virtue. Viewed procedurally, it is a method or technique for deliberating whose exercise is consistent with different outcomes. Viewed substantially, he sees the dispositions that constitute the core of practical wisdom as the ones a person needs to live in friendship with themselves and in relationship with others in a blend of integrity and political fraternity. The virtue of phronesis is the key. Consider how Hans-Georg Gadamer describes phronesis:
Understanding is a modification of the virtue of moral knowledge. It appears in the fact of concern, not about myself, but about the other person. Thus it is a mode of moral judgement. We are obviously speaking of understanding when, using this kind of judgement, we place ourselves in the concrete situation in which the other person has to act. The question here, then, is not of a general kind of knowledge, but of its specification at a particular moment. This knowledge also is not in any sense technical knowledge or the application of such. The person experienced in the world, the man who knows all the tricks and dodges and is experienced in everything there is, does not as such have the right understanding which a person who is acting needs; he has it only if he satisfies one requirement, namely that he too is seeking what is right, i.e. that he is united with the other person in this mutual interest… Once again we discover that the person with the understanding does not know and judge as one who stands apart and unaffected; but rather, as one united by a specific bond with the other and understands the situation with him… We say that someone has insight when they make a correct judgement. A person with insight is prepared to accept the particular situation of the other person, and hence is also most inclined to be forbearing or to forgive. Here again it is clear that it is not a technical knowledge [23].
It is within such an appreciation of the notion of phronesis that an answer to how health care professionals deal with the demands of practice will become clear. It is phronesis which facilitates the combination of the right technique at the right time and results in right ethical action and outcome. The ethical agent acts from a relevant virtue based on what phronesis tells them to do. For instance within therapeutic relationships it is clinician or ‘practitioner judgement’ about when to enact ‘ethical partiality’ and/or ‘ethical impartiality’ which is at the core of ethically sensitive health care practice. Attention is placed on the role of the ethical agent, the character of the inner moral life, and on the patterns of commitment, passion and conduct that comprise professional practice. It is the health care professionals acculturated sense of the virtue of phronesis that influences ethically sensitive decision-making. For instance, a humanistic psychotherapist may choose to act with empathy, congruence and/or with positive regard in different ways in different situations. It is her experience of being in the profession that has assisted her to internalize an understanding of what it means to be a therapist. She has internalized a way of acting as a therapist. Thus, it is phronesis which guides her as she develops particular relationships. The therapist is able to reason well in a practical way. Likewise, a good psychiatrist acts from the virtue of phronesis. The psychiatrist aims at producing good mental health, knows what good mental health is and knows which specific actions to take to produce good outcomes. The psychiatrist can recognize particulars, has understanding, experience and can read an individual situation right. She can draw on previous experience and is continually enhancing that understanding in the light of each particular situation [14]. If other good health care professionals, within their unique practice setting, act in similar ways, then they too possess phronesis. It is therefore clear that, ‘unique’ practice areas are informed, and can be analysed, by ‘non-unique’ ethics.
Conclusion
Radden is right. The presence of the three elements, the therapeutic relationship, the certain characteristics of the psychiatric patient and the goals and enterprises of the therapeutic enterprise itself, serve to make psychiatry very different from other branches of medicine in terms of the ethical demands it places on practice. (Whether there are such marked differences between other mental care professions such as social work and mental health nursing gives rise to other interesting questions for future analysis). However, these different ethical demands do not necessarily indicate the need for a so-called ‘unique ethics for psychiatry’. The uniqueness of the role-related nature of psychiatric practice can flourish within a model of ethical understanding where aspects of consequentialism and Kantianism are informed by a practical understanding of virtue ethics where phronesis is central. The interpretation can be applied to most areas of health care practice. Different professions do have unique characteristics, however, claims for unique ethics for each different profession is unnecessary. Philosophical ethics can be articulated in ways that have meaning and application for all. Thus, the psychiatrist, like other health care professionals, is connected to a wider sense of what it means to be an ethically sensitive human being. The uniqueness of different professional roles are respected, but at the same time a common foundation from which to base ethically sensitive agency is also acknowledged. Exactly how, in practice, the possession, or absence of phronesis will or will not help, matters in particular cases remains a challenge to be further analysed on another occasion.
Footnotes
Acknowledgements
My thanks to Justin Oakley for comments.