The moral content of psychiatric treatment
Re: Setting limits to moral content in psychiatry |
10 November 2009 |
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Steve Pearce,
Consultant Psychiatrist
Oxfordshire and Buckinghamshire Mental Health NHS Foundation Trust,
Hanna Pickard
Send letter to journal:
Re: Re: Setting limits to moral content in psychiatry
steve.pearce{at}obmh.nhs.uk Steve Pearce, et al.
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Virtue and the good of the patient
We want to thank Gray and Cox (1) and Bakiyeva (2) for their
positive contributions to the position we develop in our
article (3). We are also grateful to Foreman (4) for his
critical analysis, which gives us the opportunity to further
clarify our position.
Foreman is correct that no one would assert that being a
mafia don is symptomatic of a mental disorder. But, as
Bakiyeva points out, some of the psychological traits that
may be present in such a person are constituents of mental
disorders, even if they do not on their own justify
diagnosis, e.g., aggression, callousness, lack of empathy or
lack of remorse. By treating these traits, psychiatrists
thus both improve the mental health of the patient and
increase their capacity for virtue. Of course, Foreman is
right that we can imagine a case where effective treatment,
say, for impulse control, can be put by a person to immoral
ends: the mafia don may choose to become more calculating in
his cruelty. But that does not affect the basic point of our
article, which is that there is a range of psychiatric
symptoms which in themselves constitute or are typically
associated with failures of virtue, and whose treatment
therefore involves the development of moral skills in the
patient.
Foreman is also correct that psychiatry’s primary concern is
the good of the patient. But, as Aristotle said, man is a
social animal: for many patients, it is not possible to lead
a good life without healthy, meaningful social relationships
and functioning. Virtue facilitates this. Effective
treatment of the patient will benefit their relationships
and functioning in society as a whole. That is good for the
patient. In many cases, there may also be a derivative good
for society. But that is not itself the aim of psychiatry.
Recognizing the moral content of psychiatric treatment does
not alter the fundamental point that our first duty is to
our patients. We thus agree entirely with Foreman that
psychiatrists should not participate in social
interrogation. But we do not accept that our position
invites them to.
1. Gray AJ, Cox J. Psychiatry as a moral science. (e-
response, published online, Br J Psychiatry on 28 October
2009)
2 Bakiyeva LT. Psychiatry, happiness and virtue. (e-
response, published online, Br J Psychiatry on 28 October
2009)
3. Pearce S, Pickard H. The moral content of psychiatric
treatment. Br J Psychiatry 2009; 195: 281-2.
4. Foreman, D. Setting limits to moral content in psychiatry
(e-response, published online, Br J Psychiatry on 22 October
2009)
Declaration of interest: none.
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The moral content of psychiatric treatment
Psychiatry as a moral science. |
28 October 2009 |
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Alison J Gray,
Consultant Psychiatrist
University of Birmingham, School of Psychology, Edgbaston, Birmingham, B13 8DL, UK.,
John Cox
Send letter to journal:
Re: Psychiatry as a moral science.
graya{at}bham.ac.uk Alison J Gray, et al.
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We agree with Pearce & Pickard that psychiatry is a moral value-
laden medical science and we applaud their call for psychiatry to
acknowledge that all medical practice has to do with promoting human
flourishing and helping people to optimise their quality of life.
In other areas of medicine, for example orthopaedics, it is usually
easy to see what promotes flourishing, a fractured hip is self-evidently a
bad thing and needs replacement.
However in psychiatry the right course of action may be much more
difficult to see; for example a patients marriage is struggling and they
are attracted to a new partner. Should they stay in the marriage or move
on; should they prioritize fidelity and commitment or self-fulfillment?
Although psychiatrists are unlikely to give direct advice about the
right course of action, they will form an opinion of what is right and
this will influence what they say and what questions they ask next; the
patient will know if their doctor approves or not.
‘How then should we live?’ is one of the fundamental questions, which
we all have to consider and form our own values. Being aware of our values
will help to prevent conflict with service users who may hold different
values and assumptions about the world (1).
Virtue ethics gives a useful structure for considering what is right,
there has been considerable development in this area since Aristotle(2).
The virtue of Compassion is currently being focused on by many spiritual
leaders as a universal human value and is regarded as a core professional
attribute (3).
The traditional religions also have many resources and spiritual
practices which can help in the development of the virtues, help answer
the question ‘How then should we live?’ and to give the motivation and
power to live more virtuous lives.
In DH consultation paper ‘New Horizons’ (4) mental health
professionals are urged to consider these existential issues such as
‘meaning and purpose’-as well as promoting ‘well –being’. Assistance from
Moral philosophy, ethical reasoning and comparative religion may therefore
facilitate this key CPD agenda - and is particularly pertinent for post-
modern contemporary psychiatrists working in multi faith communities.
1. Woodbridge K, Fulford B. Whose value? A workbook for values-based
practice in mental healthcare. London: Sainsbury Centre for Mental Health;
2004
2. MacIntyre A. After Virtue: a study in moral theory
Duckworth 3rd Edn (revised) 2007.
3. http://charterforcompassion.org/ last accessed 17.10.09
4.
http://www.dh.gov.uk/en/Healthcare/Mentalhealth/NewHorizons/index.htm last
accessed 17.10.09
360 words
Alison J Gray, University of Birmingham, School of Psychology,
Edgbaston, Birmingham, B13 8DL, UK. Email: graya@bham.ac.uk
John Cox, University of Keele, Institute of Psychiatry, London, and
University of Gloucestershire UK.
DOI: Alison Gray is a consultant psychiatrist, in training to be an
ordained Anglican minister.
John Cox, no interest to declare.
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The moral content of psychiatric treatment
Psychiatry, happiness and virtue |
28 October 2009 |
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Liliya T. Bakiyeva,
Psychiatric Core Trainee
Oxford School of Psychiatry
Send letter to journal:
Re: Psychiatry, happiness and virtue
liliya.bakiyeva{at}gmail.com Liliya T. Bakiyeva
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I would like to thank Pearce and Pickard for their edifying and
thought-provoking editorial on the moral content of psychiatry (1). The
authors state that "psychological interventions can lead to the
acquisition and development of moral motives, skills and understanding",
and therefore that the proper concern of psychiatry should be "helping
patients to be more virtuous".
The first, instinctive, reaction that the editorial will elicit in
the reader is likely to be one of doubt and dismissal. The authors
address these feelings in their succinct analysis of the possible reasons
for our failure to acknowledge the moral underpinnings of our specialty:
the historical perspective and the moral relativity. Another possible
reason is purely semantic. The authors' premise is that virtue is
necessary for happiness (eudaemonia). Yet, if we substitute "happy" for
"virtuous" to argue that "the proper concern of psychiatry should be
helping patients to be more happy", we would somehow feel more at ease.
This is interesting, since the word "happiness" is as value-laden as the
word "virtue", and may be no less controversial. For example, a man may
be happy molesting his young daughter, or a young boy may be happy
torturing and killing pet animals. We would agree that it is our
professional duty to help these patients to be more virtuous, even if
being virtuous is incompatible with their immediate subjective happiness.
Furthermore, it could be argued that, while limiting these patients
immediate subjective happiness, we work towards increasing their ultimate
potential for eudaemonia, by helping them to reduce or eliminate their
maladaptive behaviours. Perhaps, a balance could be stricken by stating
that "the proper concern of psychiatry should be helping patients to
achieve personal (i.e., subjective) happiness while guided by objective
virtues".
David Foreman (2) expresses his concerns with Pearce and Pickard's
views and illustrates his point with a reconstruction of the authors'
vignette. In his scenario, a recovering alcoholic becomes a Mafia don. I
do not have enough practical experience in psychiatry to form an opinion
on the likelihood of such an event taking place, given the deleterious
consequences of heavy alcohol misuse on the person's cognitive abilities
and organization skills, and I believe that is not the key issue in the
discussion. There may not be a diagnostic category corresponding to
"Mafia don" in either ICD-10 or DSM-IV, but the personality traits common
in gangsters of any type, such as callousness, lack of empathy,
aggression, impulsivity disregard to and violation of others' rights are
certainly terms used in both classification systems as diagnostic criteria
for personality disorders. If we could only administer SCID-II to the
Godfather, I am sure we would have ended up with a formal diagnosis!
The issue of moral content of psychiatry is a very important - and a
rather neglected one. I thank Pearce and Pickard for bringing the issue
forth for debate.
Potential conflict of interests: I am trainee within the same Trust
that employs one of the authors of the editorial (S.Pearce).
References:
1. Pearce S, Pickard H. The moral content of psychiatric treatment.
Br.J.Psychiatry 2009; 195: 281-2.
2. Foreman, D. Setting limits to moral content in psychiatry (e-response,
published online, British Journal of Psychiatry on 22 October 2009)
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