The Psychiatrist and the Moral Life
John Peteet, MD, Associate Professor of Psychiatry, Harvard Medical School
Many individuals struggle in treatment with the moral aspects of their problems, such as whether it is right to divorce, how much to sacrifice for an aging parent, or whether to forgive a childhood abuser. To these familiar situations most clinicians could add many others which raise questions about our role in patients' moral lives. Should therapists express concern about seemingly unconflicted behavior of patients that harms themselves and/or others - for example, engaging in unsafe sex with random partners, abusing substances or neglecting responsibilities to children and partners? How can we address the conviction of some patients that they deserve to suffer – for example, the abuse survivor whose deeply rooted sense of shame drives her to continue cutting herself? Can a therapist hope to help a young patient trying to comprehend fairness after receiving a diagnosis of cancer?
Psychiatrists inevitably become involved in patients' moral lives, but are often uncertain on what legitimate basis we can proceed. How can we avoid offering treatment that is incomplete because important value-laden areas are left untouched, or inappropriate because it is guided by our own personal values?
Two perspectives can help to frame a clinician’s approach to the moral aspects of their work:
One is an understanding of normal moral functioning. The superego is a valuable concept because it helps clinicians to trace interpersonal influences on the functioning of conscience, but it accounts less well for the role of moral reasoning, emotions and beliefs in achieving moral goals. Likewise, most models of moral development have focused on moral emotions or reasoning rather than on areas of most interest to clinicians, such as character development or ways of dealing with moral failure. Viewed broadly, the moral life depends on the capacities to perform six basic tasks: Individuals have to:
develop moral commitments
make moral decisions
implement moral plans
assess their behavior
deal with moral failure
develop morally admirable character traits, or virtues.
A second perspective understands psychiatry, like medicine, to be a moral discipline. Psychiatry is a scientific discipline in investigating disease and humanistic in investigating the experience of the patient. It is moral in being altruistically committed to patients' best interests. Psychiatry encourages health related values such as care, respect and responsibility. It depends on the clinician's moral character (1). And good psychiatry is concerned with the patient as a whole person, including his moral functioning. These broad considerations have specific implications for the roles a clinician has in caring for the patient, charting a course of treatment, addressing moral resistances, dealing with moral failure, and leading by example (2).
Two case examples will illustrate the implementation of these perspectives in engaging the patient’s moral struggles and the spiritual life in which their commitments are grounded.
References
Psychiatrists inevitably become involved in patients' moral lives, but are often uncertain on what legitimate basis we can proceed. How can we avoid offering treatment that is incomplete because important value-laden areas are left untouched, or inappropriate because it is guided by our own personal values?
Two perspectives can help to frame a clinician’s approach to the moral aspects of their work:
One is an understanding of normal moral functioning. The superego is a valuable concept because it helps clinicians to trace interpersonal influences on the functioning of conscience, but it accounts less well for the role of moral reasoning, emotions and beliefs in achieving moral goals. Likewise, most models of moral development have focused on moral emotions or reasoning rather than on areas of most interest to clinicians, such as character development or ways of dealing with moral failure. Viewed broadly, the moral life depends on the capacities to perform six basic tasks: Individuals have to:
develop moral commitments
make moral decisions
implement moral plans
assess their behavior
deal with moral failure
develop morally admirable character traits, or virtues.
A second perspective understands psychiatry, like medicine, to be a moral discipline. Psychiatry is a scientific discipline in investigating disease and humanistic in investigating the experience of the patient. It is moral in being altruistically committed to patients' best interests. Psychiatry encourages health related values such as care, respect and responsibility. It depends on the clinician's moral character (1). And good psychiatry is concerned with the patient as a whole person, including his moral functioning. These broad considerations have specific implications for the roles a clinician has in caring for the patient, charting a course of treatment, addressing moral resistances, dealing with moral failure, and leading by example (2).
Two case examples will illustrate the implementation of these perspectives in engaging the patient’s moral struggles and the spiritual life in which their commitments are grounded.
References
- Radden J, Sadler J. The Virtuous Psychiatrist: Character Ethics in Psychiatric Practice. Oxford University Press, 2010.
- Peteet JR. Doing the Right Thing: An Approach to Moral Issues in Mental Health