An Overview of Psychiatric Ethics

Normative Ethical Theories and Psychiatry1In terms of “duties”, one might take the view that codes of ethics are prescriptive duties and, assuch, are Kantian in spirit. The proscription of the exploitation of patients, whether it be sexual,financial or in research settings, is clearly relevant to the third formulation of the CategoricalImperative. The principles of the RANZCP codes of ethics are arguably maxims of action formulatedin the light of the first and third formulations of the Categorical Imperative. Such duties guide actionin all circumstances, without regard to contextual factors. The devil is in the detail of the notionof what is a “universal law”. For a law to be truly universal is to assert that any psychiatrist at anytime would accept such a fact. Prescriptive duties such as RANZCP Code of ethics Principle #2– “Psychiatrists shall not misuse the inherent power differential in their relationships with patients,either sexually or in any other way” or #6 “Psychiatrists shall not misuse their professional knowledgeand skills” rely on a question-begging argument as to what the term “misuse” means. These aresurely the most relativistic of all injunctions, relying on value judgments as to what the core conceptof “misuse” means. Whilst a different category from the charges that Kantian obligations to dutygave oxygen to the projects of “dutiful ethnic cleanser(s)” 69 like Eichmann, the idea that the maximsspecified in codes of conduct like the RANZCP’s are truly timeless and universal are problematic.In the 1930s, when ’mental hygiene’ was the dominant paradigm in psychiatry, would thesterilisation of mentally ill people in order to eradicate mental illness from the population beconsidered a misuse of knowledge? As it has been claimed “the past is another country. Theydo things differently there”. 7015VIRTUE ETHICSVirtue in AntiquityMost people understand virtue as a quality of moral excellence. In antiquity, the four cardinal virtueswere courage, temperance, justice and prudence. The concept of virtue, or rrrrrrrrrr(arete), is clearlyarticulated in Aristotle’s Nicomachean Ethics 71 as “a settled disposition of the mind determining thechoice of actions and emotions, consisting essentially in the observance of the mean relative to us…as the prudent man would determine it.” (Book II, Ch. 6). Aristotle had made a study of great men ofhis time and attempted to define what it was that made them great. He concluded that the definitivecharacter of mankind was the capacity for reason, and so the “ratiocentric thesis” of the good lifewas central in Aristotle’s thought. Happiness, or rrrrrrrrrrrrrrrr (eudaemonia), was found in the lifeof rational excellence. The Aristotelian concept of virtue is a habit of choosing the golden meanbetween the extremes. In the case of justice, for example, the mean lies between being excessivelygenerous or forgiving and being excessively harsh or austere. As such, the habit of choosing thegolden mean is a form of dialectic reasoning in that the synthesis of an action or thought arisesfrom the tension between two alternate views.Phronesis as a Substantive Ethical ModelThe habit of finding the mean requires prudence or “phronesis” (practical wisdom) beingconceptually prior to the other virtues. In other words, the virtuous individual possesses thejudgment to find the mean and the practical ability to apply it. Phronesis can be seen as havinga number of components: 72i. The citation or acknowledgement of specific ethical principles where appropriate;ii. The integration of past experience into the present situation;iii. The capacity to argue by analogy from paradigm cases to particular ones;iv. The capacity to ‘paralell-process’ other issues to guide moral inquiry by e.g. psychodynamicimplications; andv. The capacity to combine all four aspects to formulate a mode of praxis.Applied to psychiatry, virtue involves an integration of its goal (telos) and the use of skills (techne),to achieve it. The virtuous psychiatrist possesses practical wisdom to find the right actions, in thespecific role of alleviating suffering of the ill. Munson had highlighted this distinction, to some degree,in the separation of science and medicine: science and the knowledge it created was instrumental,rather than intrinsic to, the telos of medicine. 73IMET AN OVERVIEW OF PSYCHIATRIC ETHICS