In an editorial on the teaching of psychiatric ethics in 1980, Bloch (1) expressed the hope that in light of a “dearth in systematic instruction,” “trainees [would] come to recognize the subject as an integral component of their professional education.” It seems timely to revisit this crucial dimension of psychiatric ethics over a quarter of a century later.
A review of the literature, coupled with our own inquiries in four English-speaking countries where psychiatric training is generally well advanced, yields an uneven picture (2). For instance, one survey of U.S. residency programs revealed that one-fifth contained no teaching at all (3). In another U.S.-based study of 10 training programs, almost half of the respondents had not received any instruction in ethics (4); the same team found that trainees’ expressed major criticism of their ethics education (5).
Systematic surveys of psychiatric ethics training have not been carried out in other countries such as the United Kingdom, Canada, or Australia, but our inquiries in the field over recent years lead us to conclude that the picture resembles that in the United States and that the position in the latter has not altered substantially since the above surveys were done. For example, an Australian academic program dedicates a mere 6 hours to the subject, although psychiatric ethics is also offered as an elective course, while another major Australian training center allocates 8 hours. The situation is haphazard in the United Kingdom, where trainees receive instruction only when people “interested enough to teach” are available. The picture in Canada appears to be somewhat more satisfactory, possibly in the wake of a sample curriculum in psychiatric ethics developed by the country’s Royal College of Physician and Surgeons. One program offers an introductory 1-day course at the commencement of the residency period and then quarterly seminars over the next 4 years. Another center provides 18 hours of tuition during the residency period, a third 14 hours, and a fourth 12 hours of “pure” ethics with mention of ethical aspects in other parts of the program on about six occasions each year.
Based on time allocated and the nature of the programs offered in the four countries cited above, we can summarize our own assessment of teaching developments in four main points:
1. Educational initiatives have been episodic, precluding sustained progress.
2. Only a small number of teaching programs stand out as potential models.
3. Psychiatric training bodies have generated only embryonic programs.
4. Reporting on specific teaching projects has been scanty and limited in its impact.
These findings do not match the strides made in the systematic study of psychiatric ethics (6–8) or the requirements of various training associations (e.g., the American Medical Association, the Royal College of Physicians and Surgeons of Canada, the Royal College of Psychiatrists, and the Royal Australian and New Zealand College of Psychiatrists) that ethics should be an integral part of the educational process.
After conferring with colleagues who participate actively in devising teaching programs, and examining the relevant literature, we suspect that a number of factors contribute to the current lack of progress, but we hypothesize that one factor emerges as pivotal—the vagueness and wide range of pedagogical objectives. These can be grouped as:
1. Promoting moral character.
2. Developing skills in moral reasoning.
3. Moral consciousness-raising.
4. Becoming familiar with what the psychiatric profession regards as desirable ethical norms.
More than one goal is obviously permissible in this complex field, but when educators offer such diversity, the outcome is bound to baffle the novice. Even more disconcertingly, such diversity might raise doubts about the coherence of the subject. Michels and Kelly (9, p. 504) have put it most cogently: “The failure to recognize, if not to resolve, the tension between [different objectives] can seriously undermine the effectiveness of a teaching program in ethics.” This risk has also been recognized in internal medicine and pediatric residency training in the United States, where “the commitment … to developing formal teaching of clinical ethics … [is] limited by the lack of clearly defined goals” (10, p. 94).
Let us elaborate on our contention that vague, diverse goal-setting in psychiatric ethics teaching is wholly undesirable. Consider the goal of molding moral character. Though laudable, the notion of changing trainees’ personal traits so that they become more considerate, compassionate, sensitive, selfless, humble, self-critical, and tolerant is overly ambitious and unrealistic. It requires a lifelong pursuit and is part of a professional’s gradual maturation into a person who has accumulated what Aristotle referred to as phronesis, or practical wisdom. Moreover, we face considerable hurdles in determining which virtues warrant attention in training, mapping out strategies to promote those arbitrarily selected, and devising methods to assess the effectiveness of any corresponding educational program.
At the other extreme, the goal of sensitizing the novice to the moral dimensions of clinical practice is, on the face of it, necessary but not sufficient. To distinguish between scientific and ethical aspects of such issues as involuntary treatment, suicide prevention, and therapist self-disclosure is certainly a prerequisite to sound ethical decisions, but in and of itself only constitutes a first step. In contrast with moral character development, the goal is modest and probably achievable during the residency years.
The other two goals cited lie between these poles in their level of complexity but are distinguishable from each other conceptually. Thus, developing skills in moral reasoning requires a familiarity with various moral theories and instruction on how to apply them. Becoming acquainted with the values and principles agreed upon by the professional group of which the trainee is a prospective member (usually a code of ethics or a series of ethical guidelines or both) calls for yet another form of education, in tandem with a collective commitment to respect the role of these principles in professional practice.
We contend that coherent and integrated goal-setting is the first priority in teaching psychiatric ethics. The related issues of curriculum—who should teach and the timing of instruction and assessment—are secondary considerations (9). We therefore proceed to offer some thoughts on the process necessary to formulate sound goals and what these should be.
Underlying the process is the notion that ethics is pivotal to “improving the quality of patient care” (11). Given the elusiveness of the nature of educational goals, we supplant them with “outcomes” or “competencies”—namely, what we want to see in the graduating trainee with respect to proficiency in ethics—a conceptual shift that has attained widespread support among educators in recent years. Given the complexity of ethical decision-making, we propose that more than one outcome is probably necessary; there are no logical grounds to place them hierarchically, as each has merit in its own right; any outcome warranting attention should be diligently examined and articulated so that its final form is clear and coherent; and outcomes should be formulated in a way that allows them to be systematically assessed.
To succeed in such appraisal we must establish that the trainee has acquired a relevant body of knowledge, can demonstrate a specific set of skills, and has cultivated certain attitudes. In the light of this process, we propose the following outcomes:
1. The trainee appreciates the relevance of ethical aspects of clinical practice and accords them the same importance as the scientific dimension.
2. The trainee identifies the particular ethical issues of a clinical situation (e.g., treating patients against their will, breaching confidentiality, proxy consent) that need to be dealt with.
3. The trainee acquires the skills required to handle these ethical issues (such as identifying the role of covert values influencing his or her decisions, realizing when principles clash, understanding the nature of dual agency, and recognizing the place of obligation, responsibility, and duty).
Since there is an abundance of theoretical approaches with varied rationales, trainees cannot possibly graduate as junior philosophers. On the other hand, if trainees are acquainted with the principal models, particularly their strengths and limitations, this can enable them to draw on pertinent moral concepts. These skills are complemented by the necessary empathy to facilitate the sensitive deployment of moral rules (12). Linked to the last outcome is an ability to appreciate the utility of collegially agreed-upon principles (usually in the form of codes of ethics or conduct) and instances when they collide with one another (e.g., telling the truth about a grim prognosis versus avoiding harm through demolishing hope). Using consensual guidelines in this way informs the trainee that he or she is not obliged to “reinvent the wheel” whenever encountering a moral quandary.
A Proposal to Promote the Teaching of Psychiatric Ethics
To allow another quarter of a century to pass before reappraising the state of psychiatric ethics teaching would be foolhardy. In an effort to avoid that circumstance we offer the following recommendations:
1. Weave an ethical dimension into routine clinical practice through positive modeling by senior clinicians, foster a norm of openly sharing moral dilemmas with peers, and convene “clinico-ethical rounds” as a regular feature of a department’s professional development program in which moral questions arising in clinical practice are discussed in the presence of an ethicist.
2. At the outset of training, distribute the code of ethics and related ethical guidelines and position statements of the national professional body (the code of the World Psychiatric Association in the absence of a national one) and encourage novices to consult it whenever they grapple with ethical questions.
3. Develop curricula that promote relevant knowledge and skills and foster desirable attitudes to the role of ethics in psychiatric practice (13, 14). Furthermore, national educational associations should collaborate in devising optimal training programs that could then be implemented universally, necessarily modified in the light of specific legal requirements and varying sociocultural norms and practices. As part of this endeavor, educational material should be published regularly, as has been done by such bodies as the U.S.-based Group for the Advancement of Psychiatry, APA, World Psychiatric Association, Royal College of Psychiatrists, and the Royal Australian and New Zealand College of Psychiatrists.
4. Develop academic opportunities allowing, for example, departments of psychiatry in conjunction with those of philosophy and law to offer courses in psychiatric ethics that culminate in formal qualifications for trainees with an interest in the subject. A research option as part of a Master’s or Doctoral program can also be made available to those with an academic inclination, as Warwick University in the United Kingdom has demonstrated.
5. Publish regularly in mainstream psychiatric journals, both general and subspecialist, articles on ethical topics that are seen by trainees to be an intrinsic part of psychiatric practice and research. Editors should also invite experts to coordinate symposia on the ethical dimensions of particular spheres as has been done to good effect in the American Journal of Psychotherapy, the Canadian Journal of Psychiatry, the Australian and New Zealand Journal of Psychiatry, and Psychiatric Clinics of North America. The newly established Journal of the Ethics of Mental Health is a free, online publication devoted exclusively to psychiatric ethics; it should be part of the staple diet of trainees. Articles dealing with clinical ethical topics and ethical aspects of research should feature regularly in journal clubs.
6. Organize conferences that incorporate sessions on ethics into the scientific program, including plenary addresses (15), symposia, workshops, and courses.
Finally, we reiterate the hope expressed in the 1980 editorial that trainees will see psychiatric ethics as a prominent part of their educational experience. We further wish that the psychiatric profession as a whole pursues an active role in ensuring that the ethics of clinical practice and research are as central to our enterprise as the science and the art.