Amador

After 8 years of college, medical school, and internship, I began my residency in psychiatry in 1953 having never taken a single course in psychology! While that pedagogic travesty has been remedied, another of near-equal importance has not. Psychiatrists rarely study ethics; yet our clinical work is perfused with ethical concerns.

Psychopathology defines mental illness, but mental health is more than the absence of illness, and what makes for a good life and how to achieve it is the topic of ethics. It would also seem that ethics and certain psychopathologies bear an inverse relation to each other, better knowledge of which might throw light on both.

Fernando Savater is the Spanish academician who, in 1991, turned his effort to introduce his 15-year-old son to the subject of ethics into a book that sold 150,000 copies in Spain (the equivalent of a million copies in the United States) and remains in print around the world (although not in the United States). It is no small literary feat to present time-worn principles of decency and goodness that are systematically obscured by the exigencies of everyday life into a bestseller. The reader is welcomed into the world of ethics by an invitation to think (an activity that strongly favors ethical behavior) along some basic lines of inquiry: What is the importance of choice, and the relation between freedom of choice and responsibility? What is the difference between selfishness and taking proper care of oneself? What is the core of a moral compass and what guides us to it? And what are human beings for anyway? Each chapter addresses such a question and concludes with related quotations from philosophy, literature, or the movies.

Savater writes in the form of letters to his son; thus the book is a primer on ethics written in an engaging manner and format suitable for the serious beginner. He projects an intimacy with both his subject and his audience as he starts off with a deceptively simple assertion: The key to a good life is to know what suits you, and do it. “Do what pleases you” is a refrain that permeates the book, but Savater quickly thickens the soup by showing that what distinguishes humans from other creatures is our ability to think and to make choices. In fact, making choices is a necessity, for we cannot not choose, and in the harsh words of Sartre, “We are condemned to freedom.” Since we are inexorably responsible for the consequences we create, it serves us best to choose with deliberation and care, that is, thoughtfully. We must take our freedom seriously in order to use and preserve it, for it is the possession that distinguishes us from everything else in the universe.

How do we find what suits us? We must notice that some things make us feel good while others do not, and often there are legitimate and serious conflicts between our different needs and wants that we must think about in order to make good decisions. Then we must attend to consequences and remember them so that we can learn from our mistakes. The protagonist of Citizen Kane surrounded himself with material possessions, but in the end he longed for Rosebud and the sentiments that attended his childhood sled. Savater concludes that the most basic thing about humans is not the drive to accumulate material possessions but the need for human relationships. Value and interest in life derive ultimately from human interactions, and seeking material wealth in order to win love enslaves us and compromises our freedom.

In connection with doing what suits us, since conscience is part of our being, treating others poorly causes remorse. Conversely, nothing gives more pleasure than winning appreciation and love through actions taken with a good heart. If others take advantage of our goodwill we must protect ourselves, but if we react vindictively we recycle the damage. On the other hand, if we react to bad treatment with forgiveness and forbearance we have a shot at breaking the cycle of negativity—that is, doing good. Antagonism begets antagonism, mistrust begets mistrust, and it is easy to see the rewards of decency and a healthy respect for the dignity of each individual. We have more in common with the worst criminal—a common humanity—than with any nonhuman animal or material thing, and we share the potential to influence that person and to be influenced by him. Forgiveness and generosity move mountains.

To show how these ethical principles apply, Savater focuses on two of life’s major playing fields: sex and politics. He reserves his harshest criticism for Puritans who equate sexual pleasure with immorality, and he asks, “If we do not provide for the satisfaction of the needs of our bodies how can we possibly have any kind of good life, for we are our bodies.” The giving and taking of pleasure is essential to our well-being, and there is neither shame nor harm in taking pleasure that is at no one’s expense. But the Puritans seem able to take pleasure only in depriving others of theirs, and they hold that suffering is evidence of living rightly. Rubbish! says Savater. It is sometimes necessary to bear suffering, but it is never a virtue in and of itself. Virtue is doing good for others, and so Puritanism is about as opposite as can be from an ethical view of life.

Savater commends all pleasure but warns that excessive attention to one pleasure over all others can prove a distraction from the complexities of life. He calls for a balance in all things and temperance, which is an intelligent friendship with all forms of pleasure. Ethics is not about scrupulosity.

Regarding politics, it follows that the goal of all governing is to serve and preserve the dignity and freedom of each individual while safeguarding the common good. Individuals and groups who would undermine the common good must be opposed, but it is crucial in opposing them not to be corrupted by them. When we compromise our own ethics in dealing with criminals (or terrorists) we lose our battle against them, for we have then allowed them insidiously to invade us. It is one thing to protect ourselves from harm, but something quite else to deprive someone of his humanity and dignity in the service of protecting ourselves.

The ideal political system is one with minimal restraints on the freedom of individuals; one that treats all people with dignity, respect, and equality; one that provides help for those who need it, with equitable and intelligent distribution of resources (“war no more” is a given); and one with respect for the planet we inhabit.

Returning to the question of the relationship between ethics and psychiatry, in my own clinical work I have come to see that dishonesty, broken promises, and irresponsibility are always self-defeating, whatever the underlying psychopathology. Lies undermine the trust essential to any good relationship, and varieties of inconsideration are manifold. In treatment I can often make a tactful confrontation in a nonjudgmental clinical context that enables patients to see that they are unwittingly engaging in behavior which neither suits nor serves them, and seeing that leads to relational repair and clinical improvement. Contrition heals wounds.

Savater’s counsel to find what suits you and do it elaborates on the idea that there is a self to which one needs to be true—a True Self. Here, ethics and psychotherapy share common ground, for we always aim to improve patients’ ability to be honest and accepting of themselves and others. Familiarity with ethics enlightens that path. Should ethics ever become insinuated into psychiatry, then DSM-VI or DSM-IX might include “relational psychopathology,” which would address a whole range of interactional considerations like selfishness and abuses of power, to expand our nosology and techniques of treatment.

In his epilogue, Savater advises his son to take the words of this book seriously, but not too seriously:

Everyone could use a father, or psychiatrist, like Savater, who would express these thoughts:

Thanks, Fernando.