Aims, Methods, and Resources for Ethics Training

We are pleased with the thought-provoking discussion that our article has stimulated. All of the discussants agree that the state of education and infusion of ethical principles and practices into psychiatric decision making is currently suboptimal. The ethical questions raised by the discussants, writ large, have been analyzed, reduced to a seemingly manageable 'core,' or expanded to capture nuance and subtlety, and it is invaluable for clinicians, patients, and others to explore them together.

In modern times, where the prevailing Western ethical theories were developed, the aim of ethics was to do the right thing. For example, we ought to aim to maximize overall usefulness based on consequences of actions, or to do one's duty according to the moral law. These ethical systems still are deeply influential despite widespread recognition that they do not resonate with many people. Some arguments that address the metaphysical question of whether there exists a right answer for every ethical problem are more persuasive than others, and this is often the way of philosophy; as Bertrand Russell writes, 'the value of philosophy must not depend upon any supposed body of definitely ascertainable knowledge to be acquired by those who study it. . . .The value of philosophy is, in fact, to be sought largely in its very uncertainty' (Russell, 1912).

Uncertainty is not a bad state to be in, Russell argues. Asking questions for which there are no definitive and certain answers is invaluable because the activity of engaging in them can 'enlarge our conception of what is possible, enrich our intellectual imagination and diminish the dogmatic assurance which closes the mind against speculation' (Russell, 1912). This does not reduce to ethical relativism, however, as Code argues (1991), some answers or solutions are better than others, but to reach better ethical answers, we need to know well—be epistemically responsible—as well as ethically attuned. Furthermore, we need to create an inclusive group of people in discussions (philosophically trained ethicists are not the only people with valuable perspectives and skills). Doing ethical reasoning alone runs a greater risk of bias, and inclusion of diverse people in discussions can increase the possibility that we can come up with better ethical response. The people engaged in ethical discussions should, when feasible, include the patients themselves. This is one of the tenets of the current medical model of "collaborative care" (Katon, Unutzer, Wells, & Jones, 2010). Patients' involvement in the decision making and implementation of care clearly improves outcome (van der Voort et al., 2015). Involvement of the patient in treatment discussions also may reduce the ethical conflicts that the clinician experiences. For example, it seems clear to us that it is vital to involve a patient in discussions when they are being offered nonstandard treatments that include substances of abuse (methylphenidate and ketamine) owing to their having a particularly resistant episode of bipolar depression that had failed multiple treatment attempts, including electroconvulsive therapy. The ethical strain on the clinician of whether or not to offer such treatments is reduced by including the psychiatric patient in decision making. Of course, it still is possible to have a discussion that is limited, ethically speaking. One could, for example, merely present the possibility of a nonstandard treatment without being sensitive to the subtle communications from the patient, or present information fairly superficially without going deeply into risks involved. Ethically trained and culturally sensitive clinicians working in tandem with others as events unfold—and not only afterward in a case consultation—provides an ethical scaffolding where we are more likely to be asked by others to face our own limitations, biases, and assumptions.

Values that shape and direct our consideration of what counts as 'better' might include consideration of harms, sustained trustworthiness, maintenance of integrity (self and others); or bridging epistemic and sociopolitical divides that entrench misunderstanding, anxiety, and distrust. We point out, though, that having more people involved in ethical decision making regarding patients does not guarantee a right answer, not only because the existence of 'the right action' is questionable but also because ethical norms are culturally grounded. Furthermore, people...