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Philosophy, Ethics, and Humanities in Medicine

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Open AcceReviewEthical psychiatry in an uncertain world: conversations and parallel truthsAlexander M Carson1 and Peter Lepping*2

Address: 1School of Health, Social Care, Sport and Exercise Sciences, Glyndwr University, Plas Coch, Wrexham, UK and 2North Wales NHS Trust & Cardiff University, Wrexham Academic Unit, Technology Park, Croesnewydd Road, Wrexham LL13 7YP, UK

Email: Alexander M Carson - a.carson@glyndwr.ac.uk; Peter Lepping* - LeppingP@cardiff.ac.uk

* Corresponding author

AbstractPsychiatric practice is often faced with complex situations that seem to pose serious moraldilemmas for practitioners. Methods for solving these dilemmas have included the development ofmore objective rules to guide the practitioner such as utilitarianism and deontology. A moremodern variant on this objective model has been 'Principlism' where 4 mid level rules are used tohelp solve these complex problems. In opposition to this, there has recently been a focus on moresubjective criteria for resolving complex moral dilemmas. In particular, virtue ethics has beenposited as a more sensitive method for helping doctors to reason their way through difficult ethicalissues. Here the focus is on the character traits of the practitioner. Bloch and Green advocatedanother way whereby more objective methods such as Principlism and virtue ethics are combinedto produce what they considered sound moral reasoning in psychiatrists. This paper points outsome difficulties with this approach and instead suggests that a better model of ethical judgmentcould be developed through the use of narratives or stories. This idea puts equal prima facie valueon the patient's and the psychiatrist's version of the dilemma they are faced with. It has the potentialto lead to a more genuine empathy and reflective decision-making.

IntroductionIn professions that have direct contact with people, therole of humanities in professional education assumes aparticularly important value. Since the vast majority of thework of health care professionals is with colleagues andclients, it seems obvious that humanities in general andethics in particular should play a large part in both theireducation and their clinical practice. Doctors have tradi-tionally viewed the Hippocratic Oath as an ethical frame-work in which to practice medicine but as medicine hasbecome more complex, so has its ethical dilemmas. Therehas been a great deal of discussion about whether medi-cine in general and psychiatry in particular are faced withsuch unique circumstances in clinical practice that they

need a unique ethical framework [1]. In a recent, thought-ful article, Sidney Bloch and Stephen Green not only agreethat psychiatry needs an ethical framework that can cap-ture the complex moral dilemmas inherent in practice butthey also provide a framework that provides a comple-mentary model of ethical practice [2]. Their model isdesigned to link Principle based ethics with virtue ethics.This mix or complement of objective rules or Principlesand subjective character traits is, they contend, a methodof practitioners exercising what could be called, 'judgmentwithin limits'. Principles, according to Bloch and Green,provide the boundaries or limits in which practitionerscan exercise their judgments. To give justice to the actualsituation or relationship they advocate the use of charac-

Published: 25 June 2009

Philosophy, Ethics, and Humanities in Medicine 2009, 4:7 doi:10.1186/1747-5341-4-7

Received: 3 September 2008Accepted: 25 June 2009

This article is available from: http://www.peh-med.com/content/4/1/7

© 2009 Carson and Lepping; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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ter based ethics to provide the emotional core or 'heart' tothe ethical decision. Their model is a combination ofmind and heart that tries to complement each other inattempting to resolve difficult moral dilemmas. While rec-ognizing problems with both Principlism and virtue eth-ics per se, Bloch and Green assert that they can, incombination, provide a sound moral framework 'basedon conceptual compatibility and synergy'. In the next sec-tion of this paper, we point out some problems, bothmethodological and practical, with this position and sug-gest a way forward.

Ethics: The heart of the problemBloch and Green make an important point when they saythat we need to put 'heart' into ethical decision making.They think that a principle-based approach to ethical deci-sion making leaves out too much of the personal in deli-cate situations. They propose an additional or'complementary' framework which, they say, can make usmore sensitive to the real situation. To illustrate the com-plexity of clinical situations, they use a clinical scenariowhich they call 'Jill, Tim and the baby'. They then explorevarious possible ethical solutions to the scenario and findall the usual methods problematic. Deontologicalapproaches, they assert, cannot resolve moral conflictsand so the psychiatrist is 'denied an available remedy'.Utilitarianism is seen by the authors as too difficult to cal-culate benefits and risks and demands an impartiality thatclinicians would find difficult to achieve. Both deontol-ogy, a respect for patient autonomy, and utility, a meas-urement of consequences, are seen as theories that do nothelp clinicians in practice. This is particularly the case inconflict situations. For example, an older person maywant to stay in her home despite the risk she might poseto herself and others. Deontology would argue that weshould respect the patient's views while utilitarianismargues that we should decide the case, based on possibleconsequences [3]. Neither theory can resolve a complexclinical situation such as this as both are in conflict.

The authors then go on to examine the value of Principle-based ethics as a middle way approach to ethical dilem-mas. Their problem with this approach is that while itdoes provide ethical guidelines, the approach is 'far fromdefinitive'. Moral reasoning, they contend, based on aprincipled approach, 'falls between the poles of subjectiv-ity and objectivity'. They then turn to virtue ethics as apossible way of producing good ethical decisions in clini-cal practice. Virtue ethics, derived from Aristotle, links per-sons and actions in a virtuous circle. The idea is that acultivation of ethical qualities or character traits will leadclinicians to act ethically in clinical situations. One diffi-culty which they identify with this approach is that thereis no clear understanding of how these ethical or virtuouscharacteristics are developed in people, whether they are

genetically or socially derived. They conclude that virtueethics, by itself, 'cannot.....guide clinicians to deal with themoral complexity facing them'. In their search for a possi-ble way of resolving difficult ethical cases, they finally turnto a variation on virtue ethics, the ethics of care. Here, theyassert, emotions have a part to play in moral reasoning.However, they find that too much reliance on emotionswill just produce subjective judgments that undercut anyattempt to produce 'reasoned ethical debate' and willinstead produce a relativism, in which everyone is equallyright. In summary they find that all single approaches tothe development of sound ethical reasoning in complexclinical situations are problematic. They propose instead,a potential remedy to this problem.

They see the work of Annette Baier as part of a possibleway of developing sound moral reasoning in clinical situ-ations. Baier, they suggest, sees contributing to 'a climateof trust' as a primary responsibility for clinicians, particu-larly psychiatrists, in clinical situations. Promoting trustbetween clients and clinicians, they argue, is at the heartof all clinical situations. However, they also argue that thisshould be complemented by 'a more structured frame-work', namely, Principlism. This mix of guiding principlesand a context of trust, they argue, will provide clinicianswith the opportunity to examine 'the ethical nuts andbolts' of clinical situations through sound moral reason-ing. While this provides a more sensitive approach tocomplex clinical encounters, it has its own difficulties

The scenario and the narrativeIf we go back to Bloch and Green's scenario, we can per-haps see the problem. A consultant psychiatrist, Dr Jones,has to choose between enforced treatment for a womanwho does not see the need for her to have any medicalcare. The authors explore this scenario with their newcomplementary model. They show that a climate of trustmust first be built up, using a character-based approach,to extend care to the family. This can enhance Dr Jones'empathy and understanding of the family but it is notenough to approach the 'level of clarity required to reachreasoned moral judgments'. Here the four principles canbe used to structure the moral deliberations that Dr Joneswill make. Bloch and Green explore the scenario usingthese principles and conclude that Dr Jones may have toact paternalistically and treat the woman. Although, theyacknowledge that whatever intervention is finally decidedon by Dr Jones, there will be a degree of uncertainty inoutcome, they assert that they have provided a 'means toreflect iteratively on what constitutes the most apt ethicalaction'. We would agree, with Bloch and Green that out-comes are not necessarily everything, but we do haveproblems with their approach.

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The first difficulty is that while Bloch and Green criticizeothers for developing ethical methods rather than theories,they do the same thing. The paper is called 'An ethicalframework for psychiatry' but it is, in practice, a methodor procedure. It lays out a series of procedural steps forexploring ethical dilemmas but it does not ask itself aboutthe 'ethical dilemma' itself. This is because the iterativeprocess is carried out by the doctor without really hearingfrom the woman. Part of the reason for this is that the doc-tor implicitly relegates her views or story, as she is 'dis-turbed'. The scenario is already paternalistic before anyfurther exploration is carried out; this doctor already'understands'. The procedure he then adopts only con-firms him in his paternalism. If it was really a criticallyreflective process, the doctor could see that. Our problemwith Bloch and Green's framework is that it is not reflec-tive enough and could simply confirm a psychiatrist'soriginal impressions and outlook. We do not hear fromJill or Tim, only from the doctor.

Barons's work demonstrates that doctors may be dis-tracted from seriously listening to clients by their need tofollow the structured 'listening' inherent in the medicalmodel itself [4]. This kind of listening is a kind of detec-tive model in which client's narratives are re-structuredwithin assumptions and theories that professionals bringto the clinical encounter. As previously mentioned, arecent paper makes the point that psychiatric nurses fitwhat they hear from clients into their therapeutic contexts[5]. A family doctor, for example, may 'hear' a client'scomplaint about a headache as a 'neurological distur-bance'. Both participants in the conversation may, in prac-tice, be talking about different things. Clients' narrativesmight be automatically fitted into diagnostic criteria, asBloch and Green do in their example, where the client isalready 'delusional'. So although most doctors wouldclaim that they really do listen to their clients, we suspectthat this listening is already pre-judged, Bloch and Green'sethical framework could be seen as another professionalmodel of judgment that simply fits clients' points of viewinto something prepared earlier. Our version of active lis-tening is an appeal for more genuine openness and empa-thy from doctors.

While Bloch and Green do make a sincere attempt toempathize with Jill and Tim, it is a little difficult to vali-date this since we do not know what their empathy wouldlook like. It might be convincing the couple that the doc-tor really does have the couple's best interests at heart butJill and Tim cannot even say this. This is the heart of thematter. Bloch and Green want the patient or client to trustthem that they have their best interests at heart as theyhave a procedure for thinking about these complex ethicalsituations. What might help us to trust them is if the doc-tor allowed us to hear from Jill and Tim. They, perhaps,

would see things differently. Bloch and Green ask thesame of their readers as they do of their clients: trust me,I'm a doctor. However, they don't really give us or their cli-ents a reason for doing so. This is a problem with casestudies and clinical scenarios that has already been dis-cussed by the first author [6]. If we are going to explorecomplex ethical situations, we have to see the peopleinvolved and hear their story. The clinical scenario tells usabout the doctor and his story. It does not allow the doc-tor to reflect on his story and the other possible storiesthat Jill and Tim may have told. They may have contra-dicted or confirmed the story, but we shall never know; weare required to trust the doctor. While Bloch and Greenclaim that their model provides clinicians with a 'meansto reflect iteratively on what constitutes the most apt eth-ical action', there is no real iterative process, just the doc-tor talking to himself.

Other persons, other storiesWhat seems to be missing from Bloch and Green's modelis any real sense that there may be other stories to tell andother stories to hear. In their model, the doctor sees bothsides and makes ethical decisions weighing up 'bothsides'. As has already been pointed out, this is not anauthentic 'other' side, simply the doctor imagining it.However, in all professional/client encounters there arealways two sides to everything. Given this, we need tothink that a doctor could be wrong in a more fundamentalway than Bloch and Green imagine. It is not simply a mat-ter of doctors making the wrong ethical decision; this isalways a possibility. Bloch and Green try to provide a pro-cedure for minimizing these mistakes. But we are equallynot arguing merely for standardized best practice. Whilststandardized best practice is laudable in itself, our criti-cism is not a criticism of poor practice. It is a much morefundamental criticism of the way ethical decisions arebeing made in a prescribed process-driven manner.

The deeper problem for Bloch and Green's ethical modelis that the doctor could be seeing the situation wrongly. Intheir scenario, the doctor tests his view of the situationagainst his view of how the woman sees it. What seems toget in the way is the doctor's sense that his client(s) ismentally disturbed and this will, we believe, lead to an'instinct to mistrust' the client. Whilst skepticism in thevalidity of the patient's story may be justified in manycases, in will not be justified in some. However, it will notbe true in every case. In a recent book, one of the authorspointed out this problem for mental health nurses whobase their practices on the assumption that all their clientsneed therapy [5]. In this kind of 'procedural' practice, thefocus is on what kind of therapy rather than on the initialissue of whether clients need therapy in the first place.Bloch and Green are caught up in this procedural debateassuming that their view of the situation is the only way

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to see things. In this model there is no empathic relation-ship between doctor and client.

If psychiatrists are going to practice ethically, they have tobegin with the assumption that their clients have anequally valid point of view to the doctor's and have to beprepared to be wrong in their view of the situation. Thisgoes far beyond standardized current best practice. It isnot enough for the psychiatrist to have a set of Principlesand a virtuous character, though these are usefulattributes. Ethical psychiatry is more about initiallyaccording equal weight to the possibility that the clientmight have a story to tell. Here Ross's notion of paralleltruths can be helpful [7]. Ross wants to show that peopleoperate with different parallel truths, which they use tointerpret the world and situations they find themselves in.In practice, this means that psychiatrists and clients canpotentially operate within different moral universes and'forms of life' [8]. If we are going to develop a truly ethicalpsychiatry, it cannot be one where the psychiatrist does allthe imagining and evaluating, in other words: being judgeand jury in one person. Ross points us to the fact that peo-ple see things differently but from equally valid points ofview. If we are to take this seriously we need to develop aclinical method that values this notion of 'parallel truths'as a beginning for any clinical encounter.

What is needed is a way of engaging both psychiatrists andclients in conversations where there is an assumption thatboth have equally valid stories to tell. This is in keepingwith our assumption that there is no absolute truth andno absolutely right or wrong decision when it comes toethical dilemmas. This conversational model gives equalinitial weight to all narratives, both psychiatrist's and cli-ent's.

Ethical psychiatry and ethical conversationsWe have a problem with the notion of psychiatric ethics.Instead, we prefer the term 'ethical psychiatry'. Psychiatryis about helping people who suffer from mental illness.Here, the ethic of helping people comes first. This ethic isthe foundation of psychiatric practice. Although this is abanal truism, it is often overlooked in everyday practice.This is because practicing psychiatrists often see their eve-ryday practice as 'problem solving'. However, solvingproblems is not the same thing as helping people. Inmany ways, psychiatrists work much more closely withtheir clients than other clinicians. They are often facedwith a complex mix of technical, social and personalproblems. This is in contrast to more 'technical' clinicalpractices such as surgery and so on. After all, it is unlikelythat clients have strong views about particular surgicaltechniques. Given this, it is even more important that psy-chiatrists develop a genuinely iterative process in workingwith clients. We suggest a particular conversational frame-

work that might help psychiatry to practice in a more eth-ically reflective way.

Charles Taylor points out:

When we see something surprising, or something that dis-concerts us, or which we can't quite see, we normally reactby setting ourselves to look more closely: we alter ourstance, perhaps rub our eyes, concentrate, and the like [9].

This is something that we all do from time to time. Wesometimes see something that disrupts our normal per-ceptions. Here we question our first impressions. Theprocess involves us moving around, checking our equip-ment, getting more focused and so on. In a similar wayour conversational framework allows different percep-tions or views of the situation to question each other. Inclinical practice, the medical staff's view of the situation orproblem could be questioned by the client's alternativestory. Many doctors would want to argue that they doallow their clients' views to influence their clinical judg-ments. We would certainly agree with that. However, thepoint we are making is slightly different: The notion ofparallel truths provides firmer ground for conversationsbetween doctors and clients. It enables the doctors to takeseriously the client's story rather than automatically deval-uing it with their own story. We are not suggesting thatpsychiatrists and other doctors have not a good story totell; we are simply arguing that the client may have anequally good one. If we assume this, we need to developways of seriously engaging with this. In many situations,the doctor's view of the situation will prevail; but notalways. Our conversational model assumes an initialvalidity for each story. This allows the practitioner's viewof the situation to be explicitly challenged by the client's.By listening seriously to the client's story, it allows the cli-nician to get closer to the client as a person. It allows theclinician to engage in 'disciplined empathy' with the cli-ent. Disciplined empathy is about seriously and reflectivelylistening to the client's story.

The client's story provides an opportunity and a contextfor genuine empathy between professional and client.Empathy, on Bloch and Green's model is about the doctordoing all of the work by imagining things from the client'spoint of view. Seriously listening to the client's story givesthe doctor a real insight into the client's life context andthus frames and disciplines his or her response. It pro-vides a context for the doctor's deliberations and ongoingconversations with the client. It also provides an opportu-nity for clinicians to reflect on their own practice by seeingit from the client's point of view and could help in thedevelopment of clinical skills and ethical competence.Just knowing ethical theories will not necessarily make aclinician a good ethical practitioner. As well as developing

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ethical competence, treating patients' stories as of equalvalidity, will allow practitioners to gain a stronger degreeof empathy with their clients life and provide valuableinsights into their own practice.

ConclusionIn Bloch and Green's scenario, using narratives and paral-lel truths would have allowed Dr Jones to reflect on Jilland Tim's story. Valuing those stories as equal would havehelped to create empathy that allowed better reconcilia-tion between Jill's views and the available treatmentoptions. It would have avoided a cognitive frameworkwhich forced Dr Jones into looking at Jill's point of viewentirely through the eye of an illness model, as wellintended as this may have been.

In this paper, we have tried to suggest a more ethicallyaware framework for psychiatric practice in particular andmedicine in general. The framework is designed to be sen-sitive to each clinical encounter by enabling doctors toengage with their clients in serious conversations whereeach point of view or narrative is seen as equally valid.Underpinning this framework is the ethic of helping peo-ple. While not prescriptive, this ethic can help to evaluatethese narratives. The ethic becomes part of the conversa-tion as it provides a standard or measure in judging eachnarrative. Judgments in clinical practice are a matter ofreconciling available treatment options with individualclients. This narrative based conversation can help doctorsmake more ethically conscious judgments by getting themto see their initial impressions from a different perspec-tive. It provides a reflective opportunity for a clinician toexamine his or her own practice

We are not suggesting that ethical psychiatry or medicineis about clinicians giving up responsibility for their judg-ments in practice. We would imagine that in the majorityof cases, clinicians' experiences would be the deciding fac-tor. However, our framework for the practice of a genu-inely ethical psychiatry assumes that the clinician'sexperience may not always be the deciding factor. A clini-cian, using our framework, is open to this possibility. Wedo not provide any answers to particular situations but wesuggest that a genuinely ethical psychiatry and medicineshould begin with this assumption. By listening to a cli-ent's story, a clinician may gain some insight into the per-son behind the client role and that would really be abouthelping people. Narratives and story-telling are some-thing that we can all engage in. They emphasize the keyrole that the humanities in particular can play in the edu-cation of psychiatrists, doctors and health care profession-als.

Competing interestsThe authors declare that they have no competing interests.

Authors' contributionsBoth authors contributed equally to the text.

About the authorsAMC is a qualified psychiatric nurse. He changed clinicalpractice for an academic career and is now Head of Schoolat the School of Health, Social Care, Sport and ExerciseSciences at Glyndwr University in Wrexham, Wales,United Kingdom. He has a PhD in ethics and has widelypublished on narratives in ethical practice.

PL went to University in Münster, Germany. He has beenworking in the United Kingdom since 1995. He has a Mas-ters in medical ethics and won several research prizes. Hisresearch interests include violence and aggression, delu-sional infestation, ethics, risk mitigation and variousother projects. He has honorary academic appointmentswith the University of Wales, Bangor and Cardiff Univer-sity. He works as a consultant psychiatrist in Wrexham,North Wales. He runs a specialist clinic for adult ADHD.He is also the Associate Medical Director for ethics, capac-ity and consent for the North Wales NHS Trust.

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