The Importance of Learning Ethics for and from Psychiatrists: A Teacher–Trainee Reflection

Teacher-Trainee

It is our privilege to be invited to write a commentary on the "Interface of Ethics and Psychiatry: A Philosophical Case Consultation on Psychiatric Ethics on the Ground." The article presents an innovative collaboration between a philosopher and a psychiatrist reasoning together through the ethical aspects of three clinical cases. The case consultation also offers a unique opportunity to reflect on the teaching of psychiatric ethics in clinical settings. This commentary explores those areas of the article from the perspective of a teacher and trainee whose mentoring relationship is grounded in their shared interest in philosophy and psychiatric ethics.

Teacher

A quick search on PubMed and Google Scholar confirms my own clinical impression from performing hundreds of ethics consultations over decades. In comparison with medicine and surgery, ethics consultation has been relatively underused and studied in psychiatry, especially in the out patient and emergency psychiatry settings these authors examine. Most of the clinical work and academic literature on psychiatric and ethics consultation comes from my own specialty home of consultation-liaison psychiatry, that is, psychosomatic medicine (Preisman, 1999). It is non–mental health professionals especially in inpatient settings who request many of these consults. And although my colleagues and I have shown that psychiatrists play a leading and important role on ethics committees and ethic consultation services (Geppert & Cohen, 2006), it is somewhat ironic that role has not historically extended widely to their own species and terrain.

It is not for lack of need or I suspect want on the part of psychiatrists and other mental health professionals that ethics consultation is not more frequently used. As this philosophical case consultation shows, perhaps no domain in health care is as replete with ethical concerns as psychiatry. The authors suggest what I think is a sound thesis. They claim that part of the explanation for the underuse of consultation lies in psychiatry's constrained social mandate to involve, or even defer, to the law in so many ethical decisions. Most seasoned teachers of ethics will recognize, "What does the law say?", as a common, understandable but at times constricting, refrain from medical students and residents. But psychiatry, unlike either medicine or surgery, really has little choice in the matter; we are in a very real sense coerced to factor in legal considerations in much of our ethical deliberation.

As the authors of this article underscore, the centrality of the law also likely contributes to a tendency of psychiatric residents to believe—usually because this is how they have been taught—that medical ethics begins and ends with the Georgetown Mantra. And although we are certainly not alone in medicine in our relative overreliance on these four principles, the very nature of psychiatry as elementally about the human condition makes this reliance even more misguided. These authors mention care ethics as a much-needed corrective to the principlist direction and Professors Radden and Sadler (2010) have made a persuasive case for the primacy of virtue ethics in psychiatry.

But the poverty of ethical theory in psychiatric training is only part of the problem this "on the ground integrative approach" identifies. Even more critical is by whom and in what training settings psychiatric ethics content is taught. I recall a discussion with my own ethics teacher and pioneer in clinical ethics Richard Zaner, PhD, when the very first MD/PhD programs in philosophy and bioethics were being developed. He asked whether it is better to "teach a philosopher clinical medicine or a physician philosophy?" Obviously, both options are salutary and the combination as the article suggests may be optimal. But I will admit to agreeing with Dr. Zaner then and now that the ideal is to have at least some physicians with formal ethics and philosophy training. Part of the reason the philosopher in this case consultation could be integrated into the clinic not only without disrupting, but enhancing treatment, was her dedication to not just studying the science, but also getting practical experience in the art.

There are other compelling arguments for dually...