Principle and Practice in Psychiatric Ethics Consultation: An Opening for Interdisciplinary Dialogue

The essay by Potter and El-Mallakh proposes "on the ground" consultations in psychiatric ethics as a novel style of bioethics deliberation. The continual dialogue between a moral philosopher and clinician creates the opportunity for informal real-time ethical thinking as cases unfold (and hence when the problems are small), instead of formal ethics committee reviews (once the problems become larger) and instead of the artificially simple scenarios found in much bioethics literature (see Chambers, 1999). The essay has important practical implications for ethics pedagogy during psychiatric training and in mental health settings more generally. It also has important theoretical implications for the cross-talk between bioethics and medical anthropology: the topic of the following commentary. The authors explore several points of tension between high order ethics reasoning and the realities of ordinary clinical work. Viewed through an interdisciplinary lens (bioethics and social science), the essay sheds new light on the unavoidable friction between ethical principles and everyday practice.

The essay first lays out the relational grounds for this experimental mode of ethics consultation: the personal virtues of competence, concern for the patient, and open-mindedness, as well as the interpersonal skills of trust and the non-defensive engagement with the other. Potter and El-Mallakh then model a type of dialogue between ethicist and clinician that will help work through a core problem in the teaching and practice of psychiatric ethics. The problem is easily stated: the principles of mainstream U.S. bioethics (respect for persons, beneficence, and justice) are so general that they do not, in themselves, provide sufficient guidance about applying them in specific cases. Let us explore precisely how real-time collaboration might address the problem, that is, how it might minimize the danger of a categorical mismatch between 1) abstract universal norms and 2) onthe-spot ethical decisions that are both culturally shaped and supremely pragmatic.

The authors mention Fins's critique of principlism (2013), but a more extensive treatment of the topic comes from the work of social scientists summarized in Brodwin (2013, pp. 1–26). Many anthropologists and sociologists maintain that the abstract values and systematic argumentation that define principlism simply do not resonate with how clinicians actually encounter ethical problems in the flesh. For example, clinicians discern what counts as an ethical problem not by drawing on high order moral philosophy, but by reacting in the moment to, inter alia, patients' objections, limited resources in the workplace, and other institutional constraints and contradictions. Clinicians articulate the ethical stakes of care in specific cultural idioms framed by their own biographies, training, and occupational loyalties. From this standpoint, they resort to universal principles and norms only after the fact; that is, only after they have already struggled with their ethical concerns in entirely other terms that are locally embedded and culturally conditioned.

To be sure, social scientists sometimes overextend their critique of principle-based bioethics. They easily forget that principles are meant explicitly to rub against the grain of everyday practice and to provoke clinicians to think anew about their cultural commitments and institutional loyalties. The interdisciplinary bickering is unfortunate, because at some level bioethicists and medical social science have a shared mission: to ferret out and nurture the moments of moral contemplation that emerge in the midst of treating patients (compare Sayer, 2011). In this light, Potter and El-Mallakh make some intriguing suggestions that call for a complementary social science perspective.

In case 1, for example, the ethicist queried the psychiatrist about his decision to accept gifts from Kathleen, an outpatient with bipolar illness. The two interlocutors eventually agreed that 1) the psychiatrist's original decision to accept the gifts grew out of his Egyptian background and 2) such a decision is ethically inappropriate in a U.S. clinic (Kathleen is presumably not rom a community with norms about gift giving parallel to those of her psychiatrist). The authors here confirm the anthropological notion that ethical decisions have cultural roots. They also—perhaps unknowingly—confirm another enduring anthropological insight. Across human cultures, gift relationships serve as vehicles of self-expression and social recognition...