The Virtuous Psychiatrist: Character Ethics in Psychiatric Practice
For a painfully long time, psychiatrists have been vilified in the media for everything from minor transgressions to egregious violations of our professional standards, most notably in the sexual misconduct scandals of the late twentieth century and more recently in the allegations of direct involvement in torturing enemy combatants during secret interrogations. Studies have surveyed lapses in medical ethics and found them committed in a variety of contexts, including among practitioners who are narcissistic, lonely, substance abusing, greedy, or even naive. The American Psychiatric Association has responded by promoting ethics education for its members, revising its procedures for complaint adjudication, and embarking on a major revision of its code. Given this attention to psychiatric ethics, what does this particular book add to the literature and would the Journal audience benefit from a close read?
The authors, an academic philosopher (Radden) and psychiatrist (Sadler), boldly assert their foundational belief that “the emphasis on character and moral psychology in a virtue theory significantly augments our understanding of the ethical demands of psychiatric practice” (p. 3). Their position contrasts sharply with the traditional framework for psychiatric ethics that relies on adherence to the duties of the role of physician and to the rules of professional behavior. Medicine has long justified its special place in society by its altruistic goal of striving to achieve positive consequences for patients. Ethical analyses have accordingly explored the core values of patient autonomy and rights, physician beneficence and nonmale?cence (doing good and not causing harm), and justice. The focus of ethical investigations has been on the actions of physicians toward patients with regard to inappropriate conduct that could result in sanctions after a complaint has been filed.
Radden and Sadler endorse a radically different approach that starts with the moral character (virtues) of psychiatrists rather than with their behavior. They believe that virtues can be cultivated and character traits altered, especially in training programs with good role models and by habituation. Further, salient factors, such as gender, race, class, and ethnicity, are seen as inescapably tied to self-identity (characterization). In this construct, effective clinicians are those who are morally good. The authors do not offer a practical means to measure virtue apart from behavior. Further, I have difficulty imagining how an ethics hearing panel can successfully assess an accused psychiatrist's character or moral health, especially since the patient's complaint may pertain to one specific action, such as a boundary crossing, which itself is hard to establish given that so much psychiatric care occurs in a closed room with only the psychiatrist and patient present. Surely we would not welcome our ethics committee colleagues probing the internal psychological processes of our members (beware of the nonvirtuous unconscious).
The authors are talented writers who can inspire virtue in its many manifestations (trustworthiness, propriety, empathy, warmth, and respect). They occasionally infuse jargon (phronesis, aretaic, supererogatory, and unsel?ng), and to my eye their gender-sensitive ethics for psychiatrists seems to evince a sociopolitical agenda that may undermine therapeutic neutrality. At the risk of quibbling, I would have preferred consideration of the many recent contributions of Paul Appelbaum and Laura Roberts, who are leading authorities in psychiatric ethics, rather than a vague reference to the 1995 Comprehensive Textbook of Psychiatry. As a future project, Radden and Sadler could expand their scope and explore the virtuous professional organization (i.e., Should the Association accept pharmaceutical advertising in its journals?) and the virtuous medical center (i.e., Should the hospital deliver charity care in the face of deficits?).
The final chapter presents case studies that reassuringly find psychiatric virtues in practitioners, trainees, and supervisors during the course of their ordinary clinical work. One may wonder which occurred first, good virtue or good behavior, or perhaps these psychiatrists were inherently virtuous without self-awareness, much as Moliere's character was delighted to learn that he had been speaking prose all his life without knowing it. Even so, this is an ambitious and provocative text whose thesis deserves the consideration of our field.
