An Overview of Psychiatric Ethics

16Recent Conceptions of Virtue EthicsMore recent incarnations of virtue theory have provided useful points of reflection. Hannah Arendtobserved the trial of Adolf Eichmann*, the architect of the Holocaust, and realized the “banality” ofhis evil related purely to the failure to reflect upon the nature of his actions and his mindlessly servileattitudes to duty. 74“Except for an extraordinary diligence in looking out for his personal advancement,(Eichmann) had no motives at all… He merely, to put the matter colloquially, neverrealized what he was doing” (p.114)Arendt’s later development of the concept of virtue distinguished the virtues of individual life andthat of the world of action (viva activa). 75 For Arendt, the public and private spheres were distinct,the former moving beyond pure self-interest. 76 This revision of virtue ethics clearly occurs in thecontext of the totalitarian excesses of the twentieth century and raises an issue that is pertinent tocontemporary psychiatric ethics – can the psychiatrist be truly virtuous without taking part in thepublic or political sphere?The virtue ethics of Alisdair MacIntyre 77-79 further develop the concept of the socially situated,contextualized virtue. In Athenian society, the concept of the ‘good’ – rrrrrrrrrrrr ‘(agathos – goodangel)’ – related to how a man discharged his allotted social functions within the community, orpolis. As such, the measure of the virtue of a man was his functioning as a successful citizen. Inancient Athens, this involved political action. To hold on to this as the archetype of virtue risksanachronistic versions of the moral philosophies, which are “overwhelmingly the creation of deadwhite-maleheads of household, including some slaveholders and misogynists”. 80 This has been aparticular focus of MacIntyre’s arguments about the limits of all moral philosophies; that they aresituated within a particular culture at a specific point in history. MacIntyre’s solution is to emphasizethe parts of human existence which are universal, such as birth and death, and the establishment ofcommunity, or what the feminist philosopher Martha Nussbaum refers to as “non-relative virtues”. 81As such, MacIntyre sees it as inconceivable that friendliness, courage and truthfulness would not bevalued in any society at any historical point.MacIntyre’s concept of practical wisdom integrates virtue, telos, techne and arete. He considers“practices”, which are the exercise of human excellence in the pursuit of a collectively defined good.MacIntyre holds that in Greek ethics we begin with society where evaluative language is tied to theconcept of a socially established role. He argues that ethical questions “about ourselves and ouractions depend(s) on the kind of social structure of which we are a part (p.91)”. 82 In MacIntyre’s view,“bricklaying is not a practice; architecture is. Planting turnips is not a practice; farming is (p.188)”. 77Applied to psychiatry, the practice of the virtuous psychiatrist is the pursuit of expert knowledge,sound judgment and the other components of clinical skill and the application to the conceptionof a collective good.The Virtuous PsychiatristApplied to biomedical ethics, various authors and professional groups have provided checklistsof desirable virtues in physicians, often extrapolated from the four classical virtues. Beauchampand Childress 40 listed compassion, discernment, trustworthiness, integrity and conscientiousness.Engelhardt 83 listed tolerance, liberality and prudence as virtues required of a physician. Pellegrinoprovided a hierarchy of physician virtues, with the most sublime necessitating such selflesssupererogatory acts that they could not be sustained by even the most devoted physician. 84Indeed, the main critique of virtue ethics as a moral philosophy in psychiatry is that it seems tohave impractical expectations of individuals and places the individual amidst a potentially disablingpsychodynamic process of identification with the idealised ethical superman. 7 Radden outlined thevirtues necessary of a psychiatrist 4 (Table 2).* Adolf Eichmann was an Obersturmbannfuehrer (Lt Colonel) in the SS in Nazi Germany. In 1942 he coordinated the Wannseeconference, where the so-called “Final Solution to the Jewish Question” was resolved. Eichmann was tasked with coordinatingthe deportation and mass murder of millions of European Jews. After the war, he fled to Argentina where he lived under an alias.Mossad agents kidnapped him in 1960. He was taken to Israel, where he was tried and convicted of crimes against humanityand then hanged. The philosopher Hannah Arendt watched the trial and then published her reflections on the case in her nowfamous book Eichmann in Jerusalem.