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The moral content of psychiatric treatment

  • Steve Pearce (a1) and Hanna Pickard (a2)
Summary

Psychiatric treatment can enhance human morality. It can promote the emergence of moral motives and intentions, aid in the acquisition of skills essential to moral action, and help to develop the ability to apply moral understanding and skills in particular circumstances. Good psychiatric practice demands an honest appraisal of its moral dimension.

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Copyright
Corresponding author
Steve Pearce, Complex Needs Service, Oxfordshire and Buckinghamshire Mental Health NHS Foundation Trust, Manzil Way, Oxford OX4 1XE, UK. Email: steve.pearce@obmh.nhs.uk
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Both authors contributed equally to the work.

Declaration of interest

None.

Footnotes
References
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2 Rollnick, S, Miller, WR. What is motivational interviewing? Behav Cogn Psychother 1995; 23: 325–34.
3 Treasure, JL, Schmidt, UH. A Clinician's Guide to Management of Bulimia Nervosa (Motivational Enhancement Therapy for Bulimia Nervosa). Psychology Press, 1997.
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5 Fonagy, P, Bateman, A. Progress in the treatment of borderline personality disorder. Br J Psychiatry 2006; 188: 13.
6 Charland, LC. Moral nature of the DSM-IV Cluster B personality disorders. J Pers Disord 2006; 20: 116–25.
7 Pickard, H. Mental illness is indeed a myth. In Psychiatry as Cognitive Neuroscience: Philosophical Perspectives (eds Bortolotti, L, Broome, MR): 83101. Oxford University Press, 2009.
8 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV). APA, 1994.
9 Szasz, T. The myth of mental illness. Am Psychol 1960; 15: 113–8.
10 Potter, N, Zachar, P. Vice, Mental disorder, and the role of underlying pathological processes. Philos Psychiatr Psychol 2009; 15: 27–9.
11 Fulford, B. Moral Theory and Medical Practice. Cambridge University Press, 1989.
12 Crisp, R. Virtue ethics. In Routledge Encyclopedia of Philosophy (ed Craig, E). Routlege, 1998, 2004 (http://www.rep.routledge.com/article/L111).
13 Aristotle. Nichomachean Ethics (trans. Thomson, JAK). Penguin, 1953.
14 McNaughton, D. Deontological ethics. In Routledge Encyclopedia of Philosophy (ed Craig, E). Routlege, 1998 (http://www.rep.routledge.com/article/L015).
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16 Tennant, R, Hiller, L, Fishwick, R, Platt, S, Joseph, S, Weich, S, et al. The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): development and UK validaton. Health Qual Life Outcomes 2007; 5: 63.
17 Keyes, CL. The mental health continuum: from languishing to flourishing in life. J Health Soc Beh 2002; 43: 207–22.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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The moral content of psychiatric treatment

  • Steve Pearce (a1) and Hanna Pickard (a2)
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eLetters

Re: Setting limits to moral content in psychiatry

Steve Pearce, Consultant Psychiatrist
10 November 2009

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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Conflict of interest: None Declared

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Psychiatry as a moral science.

Alison J Gray, Consultant Psychiatrist
28 October 2009

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 abad 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, whichwe all have to consider and form our own values. Being aware of our valueswill 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 professionalattribute (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 thereforefacilitate 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 theoryDuckworth 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 lastaccessed 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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Conflict of interest: None Declared

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Psychiatry, happiness and virtue

Liliya T. Bakiyeva, Psychiatric Core Trainee
28 October 2009

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. Ido 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 criteriafor 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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Conflict of interest: None Declared

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Setting limits to moral content in psychiatry

David M Foreman, Visiting Professor in Child and Adolescent Psychiatry
22 October 2009

While I agree with Pearce and Pickard (1) that psychiatric treatmentsof all kinds can enhance human morality, I think they are mistaken to assert that "helping patients to be more virtuous is a proper concern of psychiatry". I also believe that this assertion is potentially dangerous.

It is possible to reconstruct their vignettes so that the outcomes, while being equivalent in terms of our current understanding of mental health, are morally different. For example, the drunken criminal, taking advantage of his improved functioning through sobriety and improved self-confidence, rises to leadership of his gang and becomes a senior Mafia don. No credible psychiatrist would assert that being a Mafia don was symptomatic of mental ill-health, but Pearce and Picard's view would make this, through its association with an alcoholic diathesis, a possible object of psychiatric intervention. Several societal institutions (law, custom, religion, taboo) already work to maintain and improve human morality, to which psychiatrists may contribute their expertise as one class of "moral engineer". However, to claim that the discipline of psychiatry as a whole should move beyond health to delivering virtue breaches a key basic tenet of medicine, which goes back to Hippocrates (2)

"I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone."

The good that psychiatry, as a part of medicine, delivers, is specifically the individual good of the patient. Virtue, as Pearce and Pickard's vignettes show, goes beyond individual benefit, and may thus justify individual sacrifice or harm: Aristotle excluded neither in virtue's contribution to the "eudaemonia" Pearce and Pickard recommend as their new reference for psychiatric outcome. The importance of this restriction to good medical practice was illustrated in Pope and Guthell'srecent examination of the American Medical Association (AMA) and the American Psychological Association's (APA) ethical approaches to interrogation of detainees such as those at Guantanamo Bay (3). While theAMA takes the view that physicians may not take part in individual interrogations in any way, as it undermines their role as healer (though physicians may make general recommendations about humane techniques that respect individual rights) the APA mandates participation in interrogations, and does not place those detained for interrogation on itslist of those for whom standards are enforceable. This is justified on grounds of the undoubted good of national security. They also specificallymake clear that, in the event of a clash between professional ethics and "law, regulations or other governing body" the former must give way. Thus, without the restriction of providing good to the individual alone, there is the danger that psychiatry has less defence against those who would use it for maleficent ends.

1 Pearce S, Pickard H. The moral content of psychiatric treatment. Br.J.Psychiatry 2009; 195: 281-2.

2 Hippocrates. The Oath; 2009.

3 Pope KS, Gutheil TG. Contrasting ethical policies of physicians andpsychologists concerning interrogation of detainees. BMJ 2009; 338: b1653.
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