In this book, Guy Widdershoven and his three co-editors offer a collection of papers that tries to identify the procedures that are used in moral judgment and decision making in psychiatric health care settings and mental health practice. By developing evidentially informed hypotheses about the way in which psychiatrists, nurses, therapists, clients, patients, and other parties to psychiatric care think, reason, and interact on morally relevant and therapeutically germane matters, it is hoped that we will be in a better position to develop what the editors and contributors believe is an empirical ethics not just in psychiatry but for psychiatric care. The purpose of the book, they say, is to "demonstrate empirical psychiatric ethics through showcasing a number of specific examples" (p. 1).
If there is a Big Background Assumption about ethical theory in this book it is this: A reasonable care-giving psychiatric ethic can be made both wise and benevolent, when it develops out of the natural personal and social relations that care giving and therapeutic treatment may establish. At the ideal heart of such relations are forms of trust and commitment that develop when a client or patient is confident (as best they may be) that care-givers are concerned for their welfare and happiness and possess enough conscience to be sensitive to suitable moral requirements and prohibitions. Such an ethic would be 'empirical' in the best sense of that ambiguous term.
More than two dozen individuals author or help to author contributions in the collection, which consists of fifteen chapters. In number they represent mental health related professions, broadly understood, including clinicians and philosophers in medical ethics. Many of them are based in The Netherlands or United Kingdom. Among patient diagnoses that serve as the clinical backdrop are anorexia nervosa, dementia, and obesity (stemming from Prader-Willi syndrome). Moral concepts deployed range from autonomy and decisional competence to paternalism and responsibility.
The object of investigation or discussion in each chapter is to learn how psychiatric care-givers, clients, and concerned others (e.g. family members) recognize and think about the moral contours of psychiatric care, practice and treatment. In theory, at least four methods may be used to identify such modes of cognition. Three are structured interviews, participant (patients, etc.) verbal reports, and analyses of clinical records. Each of these methods provides interesting information, and can be conducted in different ways, though all are subject to well-known problems. Interviews are prone to response biases (e.g. patients may tell you what they feel you want to hear), verbal reports are difficult to edit, and access to files is subject to moral and legal constraint. More importantly, all three approaches may fail to identify the more textured and intimate elements of psychiatric moral judgment and decision making. For those finer and less transparent aspects of care, investigators should perhaps adopt a fourth method. This is to observe how health care professionals and care givers behave in day-to-day interactions with patients and clients and at staff meetings and discussions. Some of the contributors to the volume ought to be well positioned for such on-site or 'in Vivo' observations as part of their clinical or social scientific work, but the use of the technique in studies represented in the book is sparse and typically only indirect (in the form, for example, of reports of unstructured conversations). The most frequent technique deployed by the authors is structured interviews with patients, medical professionals, family members, and so on. While there is nothing inherently wrong with allowing one method to predominate, the results may be too method-centered to properly address the varieties of moral reasoning and cognition that actually are deployed.
Kevin Dunbar (2002), whose work on the role of cognitive strategies and judgmental procedures in scientific laboratories may offer useful suggestions for how to conduct on site observations in clinical settings, has pointed out that the ways in which people react to and spontaneously comment on unexpected events may be especially helpful in making evident the components underlying reasoning in a domain. Dunbar's claim applies to the work of the four editors and their book mates. To cite just one example: Ine Gremmen, one of the chapter authors in the collection, reports a case of a special kind of advance directive for patients who are subject to recurrent episodes of serious psychiatric symptoms and want others to interfere with their behavior when in the grip of harmful relapses. These directives are known as Ulysses arrangements in Dutch psychiatry and are modeled on the ancient Greek story of Ulysses and the Sirens.
Gremmen points out that a Ulysses arrangement may produce welcome but unpredicted consequences. A Ulysses arrangement is intended as a form of 'auto-paternalism' to avoid the charge that interference is involuntary or coercive. Unpredictably an arrangement may also help clients to feel that they are being taken seriously and are seen and heard rather than neglected or abandoned (p. 181). This result may help to build a relationship of trust and mutual respect between client or patient and care-giver.
What factors seem to drive moral reasoning in a psychiatric care setting? While many and diverse are the answers given to that question in this book, at the center of several of the chapters is the conviction that moral judgment and decision making is driven, often, by how the qualities of various personal relationships are perceived even in prosaic or non-therapeutic activities. In one reported case, patients refused to move from one hospital building to a more modern facility, not for fear of the unknown but of losing established contacts with each other and medical staff. Numerous vignettes like that dot the book.
Moral judgment hinges on experience, and this requires arriving at an appreciation of the powerfully context dependent moral attitudes of both care-givers and clients. Abstract moral rules are context invariant (at any rate, up to the point of permitting exceptions), and that is one of their liabilities, but moral judgment and decision making in psychiatric health care settings vary with context and circumstance. The authors and editors are to be commended for reinforcing that message and offering a book that should interest several types of readers, perhaps clinicians foremost.
Dunbar, K. (2002) 'Understanding the role of cognition in science: the Science as Category framework', in P. Carruthers, S. Stich, and M. Siegal, eds., Cambridge University Press, pp. 154-70.
© 2008 George Graham
George Graham, Ph.D. Graham is a frequent reviewer for Metapsychology and currently is writing a book on the philosophy of mind and mental illness. He will be taking up a position at Georgia State Department of Philosophy in Fall 2008.