Trends and clinical need of ethical principles

There exists in psychiatry an axiological pluralism. This means that there are, at least, two types of values involved in its exercise. Instrumental or technical values, on the one hand, related to the appropriate practice of the activity. On the other, hand, moral values, associated with the dignity of persons, the respect of their rights and the recognition of those duties inherent to every social interaction.

Values of the first type must be considered fundamental. No good psychiatry can exist without being a skilled one. The technical imperative, involving knowledge, skills, abilities and timely intervention, is the first obligation of a professional. On it is based an important part of the respect society accords a group of experts.

Without adequate understanding of moral values, however, any technical competence lacks human relevance. To respect persons, to act with beneficent intention, not doing harm and to consider justice and solidarity in actions are requisites of modern professions.¹

From the integration between moral and technical values emerge principles that guide daily practice. If values are universal that provide meaning to acts, principles are norms, sometimes not explicit, permitting the prudent and socially valid performance of professional activities.²

Ethics is a reflection and the analysis about what belief, custom or tradition consider good or just. It deals with discovering, founding, explicating and applying principles to concrete situations. It should consider what is rational and reasonable. Rational means supported by arguments. Reasonable implies real feasibility and permanence in social uses.³

Ethics in psychiatry should not be a critical imposition of philosophical thinking or norms emerging from abstract systems of thought. It should derive from the practice itself and be consistent with it. Nothing justifies delegating on “moral experts” decisions that only the practitioner can know and appreciate. In order to achieve this teaching courses or reading norms and codes do no suffice. The true ethical contexture is achieved in respecting tradition, in the example of the masters, in confronting beliefs, human diversity, traditions and the languages used by members of a given community. Ethical reflection is always local. It is rooted in the most immediate dimensions of the activity, support by reason and faith notwithstanding. Faith is understood here as any transcendent belief that illuminates acts and provides meaning.

Psychiatry is a heterogeneous activity. Historically, to help those who suffer, in consonance with the ethos of medicine, is one of its acknowledged goals. Is has also fulfilled roles controlling what is deviant, anomalous, and perverse. In one of its aspects it consists in acquiring valid and reliable knowledge. It includes accompanying and counselling those who suffer. Also, timely intervention in social affairs and support of decision makers. Adequate recover of persons’ capacities and their reinsertion into social networks, as well as the prevention of disorders and the promotion of welfare are essential to the activity of the professional group.

Research, clinical care and counselling, and social intervention, are dimensions demanding, each in a somewhat different form, ethical reflection. Social roles of investigator and clinician are different. Also their social prestige. The situation in which the therapist find himself is by definition diverse from that in which those seeking help are. The way of defining suffering must consider that it is not the same to have a disease, to feel ill or to be considered sick. The emancipatory task of modern psychiatry consists in providing universal help to people in need.⁴ This involves accurately diagnosing what demands intervention. Also in preventing ailments. In appropriate prognosis and, in an ever increasing importance, in correctly defining what constitutes a good therapeutic outcome. A good outcome is not only what the expert declares to be. It is what persons accept and recognize. “Cultural competence”, appropriate appraisal and respect of what is different, tolerance to diversity, are abilities demanded by our time.

In all these aspects, reflecting upon what is technically appropriate, good in the moral space and just in society is an inescapable task imposed by ethics.⁵ Nowadays, ethics is a community affair. It finds expression in the integration of perspectives and outlooks. The social institution of the committee–research, clinical, professional conduct–has become a must the world over. This does not exclude appropriate individual formation. It does not preclude personal conscience and beliefs. But is presupposes tolerance, critical spirit, appropriate integration of the moral and the technical in accordance with the axiological pluralism demanded by modern psychiatry.

Current trends in ethical contexture of psychiatry must be actively assumed by researchers, clinicians and industry and public administration advisors. It does not imply limitations but, on the contrary, new spaces of freedom and self-regulation permitting a better practice of the profession of psychiatry.