Psychiatrist Time to Know Thyself

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I think ethics is always there; it's not always a very thoughtful or reflective ethics.

-Peter Singer

March is National Ethics Awareness Month and though it generally focuses more on business and compliance than health care ethics, I was thrilled when the editorial staff at Psychiatric Times™ invited me as the Ethics section editor to examine the relevance of the month for psychiatric ethics. The purpose of the month-long observation is to provide, “Atime for all individuals and organizations to reflect on the ethics they adhere to and how they can improve upon them.”¹

Neon Issues and Everyday Ethics

One of the important aspects of National Ethics Awareness Month is its emphasis drawn from management and leadership on the neglected domain of everyday ethics.² Academic bioethics is often preoccupied with what have been called “neon issues,” such as ethical conflicts at the beginning and end of life, and resources allocation.³ The translation to psychiatric ethics might be the contemporary controversies about medication assisted death and involuntary commitment, and mental health disparity. Indeed, one of the unique contributions of Psychiatric Times™ is as host for the debates of thought leaders on these high-level contemporary public policy questions.

Professor Braunack-Mayer found that for general medical practices, these controversies did not map well onto the ethical dilemmas of general practice in Australia.⁴ The same could be said of psychiatry in America. Given the rich variety of mental health professions, some readers may rarely directly encounter the “neon issues” in their everyday work. Conversely, some among us may have struggled so long and hard for the primacy of patient welfare against the hegemony of profit and indifference that they have become demoralized and resigned to being unable to move the behemoth of bureaucracy. For many of our colleagues, their main ethical experiences occur in the quotidian conundrums of everyday practice.

Etiquette and Ethics

Regrettably, the values conflicts of day-to-day caring for patients are too readily dismissed as matters of mere etiquette without realizing that in the history of Western medicine, ethics is inextricably intertwined with that of professional etiquette.⁵ In a society where lack of civility is increasingly decried and even basic decency as a core value of the culture is denied, we can do far worse than trying to be kind, respectful, and generous in routine encounters with our patients, their families, our colleagues, and fellow citizens.

However, the best of manners is not enough to endow us with the moral virtues and empower us with the ethical principles to meet the multitude of challenges that mental health practitioners face in the office, clinic, and hospital. Etiquette is about being nice; ethics is about being good, and often this fundamental distinction is conflated. It is nice of a “provider” to try and satisfy patient’s needs. In this performance measure driven health care system, if we also can fulfill patient’s wants, we may well get a glowing endorsement. It is good of a professional to decline to prescribe a benzodiazepine or stimulant to a patient with a history of a substance use disorder without a comprehensive differential diagnosis, prior trials of more evidence-based agents, and a favorable risk/benefit analysis even if the patient becomes enraged, fires us, and puts a terrible rating on the Internet.

Reflecting, Learning, and Spreading Ethical Awareness

Recognizing the difference between these 2 scenarios requires discernment, a more philosophical rendering of the ethical awareness the month of March marks. Ethical awareness is as the renowned psychiatric ethicist Laura Roberts has taught us is a skill like interviewing and prescribing that can be learned and must be practiced.⁶ The champions of National Ethical Awareness Month recommend 3 essential activities to develop the skill: (1) reflect on ethics, (2) learn about ethics, and (3) spread ethical awareness. Each of these can be adapted and adopted to everyday ethics of mental health care.

In the house of medicine, we are the acknowledged masters of biopsychosocial awareness; our training and temperament attune us to detect and respond to the vast subtlety, intensity, and diversity of human emotion, thought, and behavior. Our chosen field is suffused with the stuff of ethics although to identify, analyze, and resolve the tensions between autonomy and nonmaleficence, confidentiality and safety in individual cases takes study and effort.

Table 1. Mini Cases Illustrating Ethical Issues

As prompts for reflection, Table 1 lists some mini cases illustrating ethical issues that commonly arise in everyday mental health practice.

Learning more about ethics in general and psychiatric ethics can help clinicians to recognize more easily, more deeply consider, and more soundly decide how to manage these everyday ethical dilemmas. Table 2 lists some useful resources.

Table 2. Ethics Resources

Concluding Thoughts

Finally, professional development of ethical awareness is a community activity: open inquiry, respectful questioning, and a shared search for deeper understanding strengthen ethical decision-making. If you raise an ethics issue, you are likely to find (a) you are not alone, and (b) colleagues are grateful you brought up the concern. If you are privileged enough to teach and mentor others, among the greatest gifts you can pass onto them is the lifelong habit of ethical awareness. Reflection, learning, and sharing are all essential. Without each of these stages, even the wisest practitioner will mistake emotional response for reasoning, abandon the hard work of thinking in favor of following guidelines slavishly, and exchange the dogma of data for the unique uncertainty of the person. Philosophy professor Anthony Weston reminds us that not only in March, but in all the days of our lives, ethical awareness is our task and calling. “So ethics asks us to think carefully, even about feelings that may be very strong. Ethics asks us to live mindfully, to take some care about how we act and even how we feel.”⁷

Dr Geppert is a professor in the Department of Psychiatry and Internal Medicine and director of ethics education at the University of New Mexico School of Medicine in Albuquerque. She is the lead ethicist for the western region and director of education, Veterans Administration National Center for Ethics in Health Care, and an adjunct professor of bioethics at the Alden March Bioethics Institute of Albany Medical College. She serves as the ethics editor for Psychiatric Times™.

References

1. National Ethics Awareness Month-March 2023 United States. National Today. Accessed February 18, 2023. https://nationaltoday.com/national-ethics-awareness-month/

2. Rion M. Everyday Ethics: Putting Values into Action. Resources for Ethics and Management; 2002.

3. Adashek JJ, Subbiah V, Westphalen CB, et al. Cancer: slaying the nine-headed Hydra. Ann Oncol. 2023;34(1):61-69.

4. Braunack-Mayer AJ. What makes a problem an ethical problem? An empirical perspective on the nature of ethical problems in general practice. J Med Ethics. 2001;27(2):98-103.

5. Patuzzo S, Goracci G, Ciliberti R. Thomas Percival. Discussing the foundation of Medical Ethics. Acta Biomed. 2018;89(3):343-348.

6. Roberts L, Hoop J, Dunn LB, Geppert CMA. An overview for mental health clinicians, researchers, and learners. In: Roberts LW, Hoop JG, eds. Professionalism and Ethics Q & A Self-Study Guide for Mental Health Professionals. American Psychiatric Publishing; 2008.

7. Weston A. A Practical Companion to Ethics. Oxford University Press; 1997.