Ethical framework in clinical psychiatry

Bloch & Green are to be congratulated for their lucid and helpful paper, which deserves to be read widely. The progression from Kant to the ‘ethics of care’ seems similar to that from the Old Testament rules/laws/commandments to the New Testament injunction of Christ that people love one another, consonant in turn with the recommendations of other faith traditions about developing wisdom and compassion together.

Bloch & Green's paper resonates with my sense that, as professional caregivers, we do well to acknowledge our own journeys towards personal, moral and spiritual maturity, as described by James Fowler (1981), who draws on both Erik Erikson and Lawrence Kohlberg. Dilemmas such as that described in the vignette offer people opportunities to grow wiser. Grieving losses occasioned by our limitations on the way, we may develop an incremental degree of emotional equanimity, enabling more detached observation and closer engagement.

By staying calm in difficult situations, we foster the trust of others, which is paramount in encouraging people at least to share - and sometimes with relief to relinquish - decision-making and control. Authority comes not only from a professional role and medico-legal powers, but crucially also through a competent, composed and thereby reassuring personal demeanour.

The subjectivity involved should not require an apology. On the contrary, it is essential in allowing us properly and privately to reflect later on our part in what has occurred. This aspect deserves greater emphasis in medical and psychiatric education; for is it not at the heart of why we choose our profession? We want to be good people as well as good doctors, and passing exams is only the half of it.

I disagree, therefore, with the authors' comment, ‘Nothing extraordinary is required of [the doctor]’. Consistently selfless devotion to the well-being of others is, sadly, well outside the ordinary these days; but it is exactly what we might choose to ask of ourselves if we are to get the fullest satisfaction from our professional lives. An ethical framework such as Bloch & Green have generously provided is welcome, but they are surely telling us that protocols alone will simply not be enough.