Living the Questions: Cases in Psychiatric Ethics

The past several years have been a time of radical change in the economic, technological, social, and political landscape of our country. These developments, of necessity, affect education in all its forms-including continuing medical education. Increasingly, the print medium is becoming an endangered species and previously unimagined modes of information transmission, such as blogs, RSS feeds, and podcasts, have emerged as common forms of communication. The exponential growth of medical knowledge and the increasingly rapid pace of scientific discovery have made it nearly impossible for the print medium to keep abreast of new developments. The Internet has therefore become crucial as a source of up-to-date information to ever more intellectually overwhelmed clinicians. It is no wonder that many in medicine regard the Internet and its electronic affiliates with periodic ambivalence despite their enormous potential to catalyze adult learning.¹

Many practitioners experience a version of shell shock from this information explosion-at least in part because missing in the flood of facts is any discussion of higher purpose or deeper meaning, especially for the practice of psychiatric medicine. Ethics and humanities are the areas of contemporary medicine that most often foray into the neglected territory of meaning and purpose, striving to interpret and apply the ancient tenets of professionalism for a brave new world of neuroethics, genetics, and pandemics.

We invite you listen to this podcast, in which ethicist and psychiatrist Cynthia Geppert, MD, PhD, tackles the ethical considerations when a patient asks you to pray along. Click here to review the case and listen to the podcast.

Yet, these “neon” issues² are far removed from the everyday practice of mental health practitioners struggling with the more prosaic challenges of maintaining high-risk patients, providing good-quality care in an ever more constrained and fragmented system, and keeping their own ideals of psychiatry as a profession and a vocation alive against mounting pressures to transform it into a business or simply a “job.”

Over the decade that I have taught, written, and worked as a clinical ethicist and humanistic educator, I have become convinced that clinicians have a hunger for ethical education in values and virtues that is at least as strong as their thirst for scientific learning. Bhugra³ conducted a brief survey of 66 British psychiatrists regarding professionalism and found that 94% resoundingly believed that professionalism is important in modern-day clinical practice. Those surveyed identified the internal and external threats to the practice of our specialty, including loss of auton-omy and self-regulation, pharmaceutical companies, and policy-dictated changes in service delivery and training. While this is a small survey and not a random sample of psychiatrists in the United Kingdom, there is no indication that the findings would not generalize to the majority of American psychiatrists.

Here, too, the abundance of scientific and clinical data is in stark contrast to the poverty of relevant, accessible resources available for ethical counsel, professional guidance, and humanistic renewal. Clinicians who do not have easy access to academic medical centers or major ethics institutes may not have the time or training to track down the ethics literature, professional codes, or literary works that could help illuminate their dilemmas, structure their responses, and support their decisions. In response to this unmet moral need, a number of medical journals and newsmagazines have added regular features addressing ethical and professional issues. It is at this juncture that the World Wide Web returns this time as an effective ally in the search for salience, ironically precisely because it allows readers to have a real-time and interactive relationship with publications.

During my time as a columnist at Psychiatric Times, I have received many thoughtful e-mails and letters in response to my columns, most often when the topics related to ethical or humanistic themes. Frequently, these missives contained requests for additional resources or a sharing of experience, or they included questions about the subject. While it was my privilege to send a response to each reader who had taken the effort to write me, I often wished I could continue the conversation and connect the community of our readers in a wider circle of mutual edification.

Thanks to Ronald Pies, MD, editor in chief of Psychiatric Times, and to Susan Kweskin, editorial director, I now have the opportunity to fulfill that wish. This year as one aspect of the remodeling of our PT Web site, we will feature a new electronic feature called Living the Questions. The title is taken from a poem:

. . . I would like to beg you dear Sir, as well as I can, to have patience with everything unresolved in your heart and to try to love the questions themselves as if they were locked rooms or books written in a very foreign language. Don’t search for the answers, which could not be given to you now, because you would not be able to live them. And the point is to live everything. Live the questions now. Perhaps then, someday far in the future, you will gradually, without even noticing it, live your way into the answer.

-Rainer Maria Rilke, in Letters to a Young Poet

The title is chosen to convey several messages about the intention of the feature: to provide a forum in which readers can submit ethical and humanistic questions they are living everyday. Should you pray with a patient who asks you to do so? What do you do if a patient comes to your clinic intoxicated and insists on driving home? Should you discharge a patient who is not acutely suicidal but who is still very depressed at the behest of utilization review?

The feature will live the questions in the sense that it will not provide pat or ready answers like an ethical cookbook with a stock of recipes. Instead it will explore the variety of reasonable resolutions and will offer a semi-structured process of thinking through contemporary professional problems that confront us all. In addressing readers’ queries, I will draw on clinical research and empirical ethics as I have always done in my columns and also on a broader array of philosophical, religious, and literary sources. The aim of the responses will not be so much to transmit knowledge as to convey wisdom.⁴ When inquiries lie outside my area of expertise, masters of those fields will be invited to offer their insights. To further animate this Socratic dialogue in cyberspace, brief commentaries on current or common ethical or humanistic concerns will be posted on www.psychiatrictimes.com. These will also be available as podcasts for readers who enjoy walking or driving meditations.

Recently, Academic Medicinepublished an article on the primacy of neuroscience for the educational horizon of psychiatry.⁵ Several accompanying commentaries underscore the need for the teaching of psychiatry to encompass not just the disciplines of the brain but also those of the mind.⁶ My colleague, Ron Pies, MD, would also add to this disciplines of the soul. It is my hope that Living the Questions will be such an inclusive arena and will advance the cause of the integrative specialty of “Encephiatrics” he pioneered.⁷

References:

References

1. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-learning in medical education. Acad Med. 2006;81: 207-212.
2. Hicks N. Public health, public policy and “neon” issues in ethics. Med J Aust. 1985;143:104-107.
3. Bhugra D. Professionalism and psychiatry: the profession speaks. Acta Psychiatr Scand. 2008;118:327-329.
4. Edmondson R, Pearce J. The practice of health care: wisdom as a model. Med Health Care Philos. 2007;10:233-244.
5. Reynolds CF 3rd, Lewis DA, Detre T, et al. The future of psychiatry as clinical neuroscience. Acad Med. 2009;84:446-450.
6. Healy D, Mangin D. The once and future psychiatry. Acad Med. 2009;84:418-420.
7. Pies R, Geppert C. Psychiatry encompasses much more than clinical neuroscience. Acad Med. 2009;84: 1322.