Abstract
In his challenge to my claim that psychiatry imposes distinctive ethical requirements on its practitioners, Andrew Crowden has situated psychiatric ethics within a broader frame, concluding that it is medicine and healthcare, not psychiatry, which call for a distinctive or unique ethics [1], [2]. One theme, which I hope I summarize accurately, is that the partialism central to the ethics of the doctor-patient relationship and absent from impartialist frameworks such as Utilitarianism and Kantianism can be provided through the Aristotelian virtue of phronesis or practical wisdom. Once medical ethics is understood to involve the cultivation and application of phronesis, a virtue applicable to all health care settings, it will be unnecessary to call for an ethics distinctive to psychiatry.
Crowden's discussion of phronesis, and his related references to professional roles, each invite further development, and will be my focus. That said, however, let me briefly comment on some parts of my own discussion which have led, apparently, to a misreading by Crowden.
Features of the mental health care setting, I had argued, introduce special ethical considerations which are perhaps more usefully placed within the virtue ethical framework than within other frameworks. I did not wish to suggest that no part was left for other ethical systems, however: a deontological framework will be essential in codifying the minimally acceptable conduct in the relationship between psychiatrist and patient, for example, if only for purposes of professional censure.
A second apparent misunderstanding concerns the relationship between the several different reasons adduced, by myself and others, for the view that medicine and or psychiatry require a distinctive ethics. One set of reasons has been noted above: the partialist nature of medicine seems to conflict with the impartialism of ethical frameworks such as Utilitarianism and Kantianism. Other reasons pick out other features of the practice of medicine such as the role-specific duties traditionally ascribed to doctors, the moral goal of medical practice, the place of medicine in the broader society, and the interaction between doctor and patient.
That this set of reasons amply supports the claim for a separate ethics unique to medical practice seems to me incontrovertible. However, from the fact that medicine has a unique ethics and one, moreover, which governs psychiatry as a medical specialty, it does not follow that the practice of psychiatry may not also have features making additional ethical demands. Just as the doctor qua professional, will be obligated in certain ways, so the psychiatrist (as doctor and as professional) may be required to respond to a nested set of ethical obligations, each compatible, and increasingly more role-specific; and that, indeed, is the picture I attempted to portray. If not alone then at least in their cumulative distinctness, certain features of the typical therapeutic relationship, psychiatric patient, and therapeutic enterprise, serve to distinguish the practice of psychiatry. These features impose ethical demands on psychiatrists over and above the demands placed upon them by their status as doctors, professionals and, for that matter, citizens.
Since the presence of a unique medical ethics does not seem to preclude a unique psychiatric ethics, I will not here defend those ideas further, except to say that they may not extend to other mental health care professionals as readily as Crowden supposes. Their medical knowledge, privileges in relation to psychopharmacology and, most importantly, the power vested in them by society to treat and commit against the wishes of the patient, distinguish psychiatrists from other professionals providing mental health care, and to the extent that these features frame psychiatric ethics, a distinctive ethics for psychiatry will not be applicable to the provision of mental health care more generally understood, for all that compelling similarities of purpose and practice unite psychiatry, clinical psychology, psychiatric social work and mental health nursing.
The aspect of Crowden's discussion which is most interesting to me is the claims he makes about and for the notion of the psychiatrist's and doctor's professional role. But let me first comment on the virtue of phronesis. Appealing to Gadamer and other thinkers, Crowden emphasizes the way this virtue will be called for in any doctor-patient relationship. However, the difficulty of making his case, whether for the usefulness of phronesis in psychiatric practice or in medical practice more generally, is that phronesis is useful everywhere in practical life. It is a kind of meta-virtue, whose importance is at least assured in any setting where a client interacts with a provider of professional services, be it dentistry, accountancy, or law. At most then, the thesis must be that phronesis is necessary to, and is particularly helpful in, the practice of medicine – a claim apparently requiring support.
Appeal to professional roles allows Crowden to propose that while psychiatry requires its practitioners to adopt unique professional roles, it is unnecessary to derive from that the conclusion that psychiatry enjoys its own distinctive or unique ethics. He prefers to emphasize not these differences of role but instead the ‘common foundation… from which to base ethically sensitive agency’, that is, the virtue of phronesis and its influence on decision-making in health care settings.
Whether or not psychiatrists' distinctive professional roles can be said to constitute a distinctive ethics seems something of a verbal quibble. They do impose distinctive moral imperatives, at any rate. But how that is done, and whether the language of roles is, as Crowden and others suppose, deeply apt, helpful, and without dangers in this context, are questions I would like to explore more fully.
Lawrence Olivier's advice to Dustin Hoffman (‘Why don't you try acting?’) may not go down well with the method acting crowd; what Crowden draws from it seems right for stage actors though: ‘if actors actually become the character they are playing then they are no longer an actor playing a role.’ However, Crowden goes on to compare stage actors with those adopting professional roles. A health care professional he notes, ‘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 the patient.’ Thus, ‘the analogy about the nature of acting is similar to the role-related nature of therapeutic relationships.’
The aptness of the analogy between theatrical and professional roles is my first concern. Stage actors adopt many parts in many plays and, as a function of this, their roles are not in any permanent way part of their identity; moreover, to perform those parts they abide by rules, but not moral rules. In everyday life off the stage, the flavour of inauthenticity which attaches to ‘he's (just) acting’, ‘she's playing a part’, ‘more histrionics’, suggests we might find a stronger analogy; and indeed, there are analogies which even capture the ‘friend-but-not-a-realfriend’ aspect Crowden ascribes to the health care professional. Some of the more permanent roles we inhabit are familial: parental roles, sibling roles, offspring roles, and so on. To a greater and lesser extent these familial roles have the two characteristics absent from stage roles which were noted above. They confer or even constitute identity, and they generate role-specific moral and ethical obligations. In addition, just as the therapist role is in certain respects like, and in other respects quite unlike, friendship, so it is true of parent-child relationships, for instance, that they (though for different reasons) have this ‘friend-like’ status.
Using this more apt comparison between familial and professional roles, I want to raise some difficulties about the so-called role morality implicit in this emphasis on professional roles. Strong role morality asserts that what is morally permissible or even morally required by, for instance, a professional role is not necessarily required and sometimes is not even permitted on the ‘broadbased’ morality applicable to the rest of the society [3], [4]. Even if some action conflicts with the moral rules expressing broad-based morality, role morality for the doctor is dictated by the goal of maintaining or restoring the patient's health.
Because there is no more consensus over the warrant for strong role morality than there is over the values and rules of broad-based morality, uncontroversial examples of this kind of divergence are not easy to frame. A simplified case which derives from controversies in forensic psychiatry might be that in which a doctor is bound to treat the wounds of a fleeing convict before, or even instead of, assisting in the convict's capture [4], [5]. Broad-based morality would dictate that the convict must be caught; professional role morality would dictate that he must be treated.
Less controversially, role morality also refers to more, not less, stringent obligations than those dictated by broad-based morality. These obligations are compatible: the demands of weak role morality never override, they only add to, the dictates of broad-based morality. Thus, for example, weak role morality may forbid consenting sexual relations between unmarried, adult doctors and their unmarried, adult patients, even though broad-based J. RADDEN 117 morality permits sexual relations between consenting, unmarried adults.
The above distinction allows us to see that strong role morality aside, a distinctive professional ethics will impose additional rules of conduct nested within the obligations imposed by broad-based morality. Anything stronger than this weak role morality, I would suggest, will likely be so controversial that it will not without extraordinary additional justification serve the purpose of delineating professional ethics, whether in psychiatry or health care.
Drawing attention to the way in which the professional inhabits a role forces us to notice some ethical tensions around professional practice, tensions arguably magnified in the mental health care setting. We saw earlier that outside of the theatrical context, merely acting a part is associated with acting without authenticity, or without the sincerity and wholeheartedness usually deemed appropriate: indeed, ‘merely acting’ suggests something close to intentional deception practised for ignoble reasons. But if the analogy with parental roles is apt, as I think it is, then – except when participating in amateur theatricals – it can be no more possible for a doctor to merely act the part of doctor than it is for a person who is a parent to act that part. and of a person who is a mother, we want to insist, it is not that she acts being a mother, she is a mother. By analogy, this doctor does not act being a doctor, she is a doctor.
Is it even possible to merely act either part? Not usually, perhaps, but there is one notable exception. When the new role is first thrust upon them, through training programs in the one case, and the birth or adoption of a child in the other, the fledgling doctor or mother, respectively, may have to ‘act’ the part, enacting the role without an accompanying sense of authenticity (‘this is not really me’, they might even feel, or ‘I hope no-one sees through me’).
This suggests that the identity-conferring aspect of roles which would allow the response ‘this is me’ (or the corresponding tacit, identity presumption), is something acquired with practice. Rather like the acquisition of virtues on the Aristotelian model, the role of doctor will become identity-conferring and the role inhabited, rather than merely acted, through a gradual process of practice. Adopting the conduct and or virtues of the ethical doctor may have to precede feeling like a doctor.
The contrast between inhabiting and acting a role is one with particular bearing on psychiatric practice. In psychiatric practice professional ‘boundaries’ are observed and maintained with self-conscious vigilance. The practitioner's persona manifested through carefully controlled responses has long received heightened attention within psychiatry because it is widely accepted that aspects of the practitioner's way of communicating and presenting herself are importantly instrumental in therapeutic effectiveness. Healing depends on the success of the relationship or alliance, and in developing, protecting and fostering that alliance, the therapist wields her self or persona almost as an instrument, on analogy with the surgeon's scalpel.
If, with most in psychiatry, we accept the causal model of healing underlying these assumptions, we will also accept as an implication of those assumptions that the patient ‘believes in’ the therapist, that is, attributes certain traits to the therapist. This means that the patient's belief about the presence of traits X, Y and Z and not, notice, the presence of traits X, Y and Z, will affect the outcome of treatment. Yet this invites a puzzle. If the therapist wields her persona on analogy with the surgeon's scalpel, we should expect skilfully feigned traits to be as useful as real ones in promoting effective practice. The appearance of honesty, pretended sympathy, a superficial display of warmth, and so on, should be sufficient. Adopting a persona and feigning traits will result in practice whose effectiveness is only limited by the therapist's skill.
I want to explore this problem or tension within psychiatric practice by asking three questions: first, why would this be morally problematic? Second, could it actually happen? and finally, what does it tell us from the point of view of constructing a professional ethics?
Why would this be morally problematic, if the goal of treatment is achieved? Two answers immediately present themselves. First, the patient is manipulated and deceived. This conduct contravenes even Kantian rules on how we can treat other people. Moreover, and this is my second answer, such feigning and pretending will corrupt the character of the therapist, adding to it the vices of deception, hypocrisy and dishonesty.
Could this actually happen? In non-therapeutic settings, it is perhaps less likely to; there, people often can discern underlying, and real, character and are able to challenge insincerity and pretence. But the artificialities of the setting magnify the psychiatric patient's disadvantage, providing little access to the cues by which we usually discern real from feigned responses and ‘read’ another person's character. The patient cannot know the therapist fully because psychiatric engagement is restricted by the rigorous ‘boundaries’ of therapeutic procedure (themselves apparently required by the patient's other vulnerabilities, especially to exploitation). Finally, interaction with mentally disturbed patients is often distorted by the patient's misapprehensions about others due to delusions, projections and other deficiencies of social awareness and response. Such deficiencies will serve to limit the patient's capacity for knowing the therapist's true character or identity. Undeniably these features of the therapeutic engagement impose additional ethical responsibilities on the practitioner. But they also make it possible for character to be feigned rather easily in the mental health care setting.
The answer to my third question – what does it tell us from the point of view of constructing a professional ethics for psychiatry? – should now be apparent. We must recognize a place for virtue. We want the therapist to be sympathetic, not merely to adroitly feign sympathy. We want sympathy to be part of her character and identity. By adopting standard Kantianism we would be able to explain one of the two reasons why this practice was unethical: manipulating and deceiving the patient, even for her own good, is contrary to treating her with appropriate respect. But to explain the second reason why this practice is unethical, the fact that it corrupts the character of the therapist, we need something more. An evaluation of the character of the therapist as distinct from her responses and their effects on the therapeutic outcome and on the patient herself requires us to make reference to virtues and character; and whatever our differences, Crowden and I share a conviction that without virtuous practitioners psychiatric practice could not be ethical practice.
Further reading
To the extent that Kantianism or even Utilitarianism can be adjusted to make room for virtues and the importance of character, I do not mean to exclude them. Thus, Indirect Consequentialism, which evaluates actions on the character from which they derive, or Herman's character-focused Kantianism might be approaches which worked as well. See Herman B. The Practice of Moral Judgement, Cambridge, MA: Harvard University Press, 1993.
For an illuminating discussion of the application of virtue ethics to the professional setting, the reader is directed to William May's writing: May WF. The virtues in professional practice. In: Fulford KWM, Gillett GR, Soskice JM, eds. Medicine and moral reasoning. Cambridge: Cambridge University Press, 1994. Of particular importance to the issue of virtues in psychiatric practice are Dyer AR. Ethics and psychiatry: toward a professional definition. Washington DC: American Psychiatric Press, 1988 and Fraser A. Ethics for Psychiatrists Derived from Virtue Theory. Lecture delivered at the Fourth International Conference on Philosophy and Mental Health, Florence, Italy, August 2000. Other valuable work in this area, not cited by Crowden, includes: Oakley J, Cocking D. Virtue ethics and professional roles. Cambridge: Cambridge University Press, 2001; and Candilis PH, Martinez R, Dording C. Principles and narrative in forensic psychiatry: toward a robust view of professional role. Journal of the American Academy of Psychiatry Law 29; 201:167–173.