Moral Dilemmas Faced by Psychiatrists

To the Editor: The article by Stephen A. Green, M.D., M.A., and Sidney Bloch, M.D., Ph.D. (1), provides psychiatrists with a valuable review of the moral dilemmas faced by practitioners working in dysfunctional administrative environments. The article systematically highlighted utilitarian and existential aspects of these quandaries. However, an important third perspective, Kantian ethics, remains undeveloped.

As Drs. Green and Bloch explicitly pointed out, utilitarian ethics can be understood as a program of maximizing gratification for the greatest number of people. Hence, utilitarianism is most germane to the relationship between efficiency and equity in the delivery of mental health care. Existential ethics, on the other hand, may be seen as an elevation of an individual’s autonomous moral courage over the collective dictates of his or her social milieu. Thus, existentialism implicitly throws light on the struggle of the individual psychiatrist to maintain professional autonomy.

Kantian morality distinguishes itself from both utilitarianism and existentialism by assigning priority in ethical valuation to a peculiar combination of will and social logic. The first version of Kant’s categorical imperative erected the following standard: we should act only in a manner such that if all others acted similarly, then no self-contradiction would result. Hence, Kant’s ethical reasoning, like utilitarianism and unlike existentialism, drew on collective considerations. Kant added that moral value arises only from categorically mandated acts that require a denial of gratification. Hence, unlike utilitarians and like existentialists, Kant devalued gratification and instead opted for moral discipline. Elements of Kant’s categorical imperative, therefore, are both like and unlike other ethical frameworks, while Kantian ethics in totality is unique.

Kant’s standard provides a rigorous yardstick by which practitioners can gauge the merits of their own acts. Psychiatrists working in flawed systems might contemplate coping responses, such as adjusting diagnoses to obtain insurance coverage for endangered patients, openly challenging destructive administrative policies, and separating completely from pernicious systemic structures. Before acting, the Kantian clinician may first take the opportunity to imagine the potential consequences should the action be universalized. Predicted self-defeating contradictions can then serve as a moderating map of possible ethical outcomes.