This is not an easy book, but it is an exceptional volume that should have a place in the library of all reflective and morally serious mental health professionals. One of the book's many strengths is that it is a collaboration between a philosopher with broad expertise in the history and philosophy of psychiatric practice, ethics and policy, Jennifer Radden, and a philosophically oriented psychiatrist who has done extensive work at the intersection of values theory, psychiatric diagnostic classification and ethics, John Sadler. The product of their collaboration is a beautiful study of the place and power of virtue or character ethics, which emphasizes the virtues and ideals of moral excellence in psychiatric practice. Rooted in the Nicomachean ethics of Aristotle, (Aristotle, 1976) virtue ethics, has in the last several decades served as a salient alternative and counter-balancing force (Pellegrino & Thomasma, Reference Pellegrino and Thomasma1993) to the models based on core ethical principles that have dominated American bioethics (Beauchamp & Childress, Reference Beauchamp and Childress2009). However, character ethics has been virtually uncharted territory in the relatively unexplored domain of psychiatric ethics.
Whether and to what degree the ethical dilemmas and professional requirements of psychiatric practice are qualitatively different from other medical specialities and demand a higher standard of conduct and character has been a topic of debate. The academic Radden, and the clinician Sadler, construct a persuasive and powerful argument that psychiatry confronts unique ethical challenges necessitating exceptional professional qualities and distinctive personal habits. The argument is succinctly stated in the book's Introduction:
The foundations on which our work is developed are three: the conviction that ethics is important to any professional practice, including psychiatry; the notion that the settings within which psychiatry is practiced impose ethical demands on its practitioners that are distinctive enough to those settings to warrant a separate analysis, and the belief that the emphasis on character and moral psychology in virtue theory significantly augments our understanding of the ethical demands of psychiatric practice.
The foundation of the book is this contention that virtue ethics is particularly suited to function as the moral framework for mental health professionals. Only virtue ethics can appropriately respond to a practice setting characterized by highly vulnerable patients, codified boundaries, enormous power to deprive citizens of their liberty, diagnostic uncertainty, social responsibility, and an inherent tension between character ethics and role morality.
Two of the most impressive features of the work are its thought-provoking development of a gender-sensitive ethics for psychiatry and the use of ‘dramaturgical vignettes’ which are innovative forms of case studies integrating the traditional patient–physician dialogue with the monologue of the clinician.
The identification of patient autonomy, boundaries in the therapeutic relationship, and uncertainty regarding psychiatric diagnosis as critical areas of difference in psychiatric practice make the volume an ideal book for psychiatric training. The authors underscore the educational potential of their work as a means of cultivating the specific virtues that are as essential to psychiatric competence as clinical skills and scientific knowledge.
The detailed analysis of the virtues requisite for the psychiatric surround includes traditional traits such as trustworthiness and integrity common to all morality. Intellectual virtues such as propriety, realism and unselfing are formulated as role-constituted virtues integral to psychiatric practice. These virtues may not be as highly valued outside of the profession as more universal moral qualities. The authors present philosophically sophisticated, but clinically relevant descriptions of the key virtues of empathy, patience, fortitude, self-knowledge, self-unity, and respectfulness. The authors add to this mix of traditional and modern character traits, particular virtues required for ethical practice in the environment and era of managed care: moral leadership and integrity. The authors describe phronesis – the practical wisdom of discernment and prudence in decision-making, as a ‘metavirtue’ which directs the exercise of the various virtues in specific clinical circumstances. The text does assume a level of facility with philosophical works and terms that those without a liberal education may not possess, yet the clarity of the writing and coherence of the arguments enable both trainees and practising psychiatrists to grasp the book's salutary ideals. Those looking for a superficial review of psychiatric ethics or a professional cookbook will be disappointed, while those seeking to understand the distinctive ethical context of psychiatric practice and to aspire to a professional life of virtue will be richly rewarded.
