Behavioral science versus moral judgment

George S. Patton, Jr. commanded the Seventh United States Army, and later the Third Army, in the European Theater of World War II.  General Patton, a brilliant strategist as well as larger-than-life fount of harsh words and strong opinions, was also infamous for confronting two soldiers diagnosed with "combat fatigue" — now known as post-traumatic stress disorder, or PTSD — in Sicily in August of 1943.  (One such incident was depicted in the classic 1970 film "Patton" starring George C. Scott.)  Patton called the men cowards, slapped their faces, threatened to shoot one on the spot, and angrily ordered them back to the front lines.  He directed his officers to discipline any soldier making similar complaints.  Patton's commanding officer, General Eisenhower, firmly condemned the incidents and insisted that Patton apologize.  Patton did so reluctantly, always maintaining that combat fatigue was a pretext for "cowardice in the face of the enemy." Seventy years have passed, yet as a society we still feel the tension between moral approval or disapproval on the one hand, and value-neutral scientific or psychological description on the other.  Cowardice is a character flaw, a moral lapse, a weakness.  PTSD, in contrast, is a syndrome that afflicts the virtuous and the vile alike.  We similarly declare violent criminals evil — unless they are judged insane, in which case our moral condemnation suddenly feels misplaced.  Likewise, a student who is lazy or careless needs to shape up to avoid our scorn; a student with ADHD, in contrast, is a victim, not a bad person.

Personality descriptors — brave, cowardly, rebellious, compliant, curious, lazy, perceptive, criminal, and many more — feel incompatible with knowledge of our minds and brains.  It seems the more we explain the roots of human behavior, the less we can pass moral judgment on it.  It doesn't matter if the explanation is biological (e.g., brain tumor, febrile delirium, seizure) or psychological (e.g., PTSD, childhood abuse, "raised that way").  However, perhaps because we feel we know our own minds best, it does seem to matter if we are accounting for ourselves versus others.  We usually explain our own behavior in terms of value-neutral external contingencies — I'm late because I had a lot to do today, not because I'm unreliable — and more apt to tar others with a personality judgment such as "unreliable."  This finding, the Fundamental Attribution Error, has been a staple of social psychology research for decades.

Will we eventually replace moral judgments of others with medical or psychological explanations that lack a blaming or praising tone?  It appears our inclination to judge others will not pass quietly.  Much of the rancor between the political Left and Right concerns the applicability of moral language.  Are felons bad people, or merely raised the wrong way?  Are the poor lazy and entitled, or trapped in poverty by circumstance?  Was General Patton disciplining cowards who were shirking their duty, or was he verbally and physically abusing soldiers who had already been victimized?

The Left and Right disagree over where to draw the line.  But no matter how far we progress in our brain and behavioral sciences, we will still want to voice judgments of others — and negative judgments seem the more compelling.  Humans are notoriously inventive in the use of language to denigrate.  Originally neutral clinical terms like "idiot" and "moron" (and "retarded" and "deluded" and many more) eventually became terms of derision.  Euphemisms like "juvenile delinquent" didn't stay euphemistic for long.  While it may blunt the sharpness of our  scorn in the short term, "politically correct" language won't change this aspect of human nature in any lasting way.

Even logic doesn't stop us.  For example, terrorists are routinely called cowards in public discourse, although it isn't clear why.  Many terrorists voluntarily die in their efforts, an act considered heroic, or at least brave, in other contexts.  They often attack civilian rather than military targets.  But we did that in WWII, and we weren't cowards.  They use guile, sneak onto planes, employ distraction and misdirection — like our "cowardly" Special Forces do.  The point is, we find terrorists despicable, but that isn't a strong enough putdown.  If we didn't call them cowards, we'd have to call them something else to humiliate them.  Mama's boys?

Humans are a funny species.  Uniquely striving for intellectual understanding, yet not so far from the other beasts who purr or growl or screech their approval or protest.  Balancing the aims of morality and science is the stuff of constant, and perhaps endless, political debate.  Ultimately it's irresolvable, yet we do our best to pay homage both to our hearts and our heads.

Defining the competent psychiatrist

What defines a competent psychiatrist?  To staunch critics of the field, perhaps nothing.  Some believe psychiatry has done far more harm than good, or has never helped anyone, rendering moot the question of competency.  What defines a competent buffoon?  A skillful brute?  An adroit half-wit?  Having just finished Robert Whitaker's Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (Crown, 2010), a reader might easily conclude that psychiatric competency is a fool's errand.  From directing dank 19th Century asylums, to psychoanalyzing everyone for nearly anything during much of the 20th Century, to doling out truckloads of questionably effective, often hazardous drugs for the past 35 years, perhaps psychiatry is beyond redemption. Of course, I don't think so.  For one thing, critics often disagree about what is wrong with the field.  For every charge of over-diagnosis and overmedicating, another holds that debilitating disorders are under-recognized and under-treated.  A charge that psychiatry has become too "cookbook" and commodified is answered by the complaint that it is too anecdotal and not sufficiently "evidence-based."  Claims that the field stumbles because it is subtle, complex, and understaffed by well-compensated specialists, are met with counter-claims that checklists in primary care clinics can do most of the heavy lifting at less expense.  Contradictory criticisms offer no evidence that the field is faultless.  But the confusion does suggest that psychiatry's limitations reside at a different level of analysis than that engaged by its critics.

For another thing, the undeniable shortcomings of psychiatry don't make the patients disappear.  Whether the field teems with genius humanitarians or raving witchdoctors, there are still families watching their teenage daughters starving themselves to death; beloved aunts and uncles living unwashed and mumbling to themselves on the street; people ending their lives out of temporary tunnel-vision; tormented souls imprisoned in their homes by irrational fears.  And our society still harbors a nagging ethical sense that a crime is committed only when a person knows what he's doing — and that when he doesn't, he deserves help not punishment.

We can admit that psychiatrists are (at times meddlesome) do-gooders who take on misery and heartache and uncontrolled destructive behavior despite deep controversies over how best to help.  It's the same role filled, in different times and places, by clergy, by family, by shamans, by the village as a whole.  Every society fills it by someone.  This is the modest starting point that bootstraps a meaningful definition of psychiatric competency.

Lists of "core competencies" are issued by the Accreditation Council for Graduate Medical Education (ACGME) for psychiatry residents, and by the American Board of Psychiatry and Neurology (ABPN) for board-certified psychiatrists.  Both organizations categorize psychiatric competency under the six headings established by the ACGME for all medical specialties: Patient Care, Medical Knowledge, Interpersonal and Communications Skills, Practice-Based Learning and Improvement, Professionalism, and Systems Based Practice.  (These categories are also used by the Accreditation Council for Continuing Medical Education [ACCME], so that continuing education required to maintain one's medical license addresses one or more of these competency areas.)  A review of either of these detailed lists reveals two important truths.  First, a committee can make any aspirational standard byzantine and lifeless.  And second, in the eyes of  ACGME and ABPN at least, it's not so easy to be a competent psychiatrist.

However, these official competencies are unlikely to satisfy skeptics, nor do they get to the heart of the matter.  No such list can be exhaustive: the ABPN includes knowledge of transcranial magnetic stimulation, presumably a recent addition, but fails to require knowledge of specific pharmaceuticals.  Focus areas such as addiction, forensic, and geriatric psychiatry are mentioned, but not administrative or community psychiatry.  The linguistic philosopher Ludwig Wittgenstein argues that our inability to precisely define natural categories, even simple nouns like "chair," is a feature of language itself, not of psychiatric competence specifically.  Accordingly, any catalog of psychiatric competencies, whether intended to be comprehensive or a "top ten" list, captures some, but not all, of what constitutes a competent psychiatrist.

As implied above, the starting point, although not the end point, for defining the competent psychiatrist is intent.  A psychiatrist aims to relieve suffering in an uncertain human domain.  Brought to bear are skills, knowledge, and personality factors ("professionalism" etc) which bring this goal closer.  These cannot be listed exhaustively: virtually the whole of human knowledge and experience can inform one's understanding of a patient's emotional turmoil.  The best we can say, I believe, is that a competent psychiatrist is curious, has a wide fund of knowledge and life experience, and aims to keep an open mind.  Some of this knowledge certainly should be biomedical.  But knowing about the psychology of aging, common stressors such as job loss and divorce, gender differences, and many other areas are hardly less important. The practitioner's proclivity to observe the human condition both scientifically and humanistically is ultimately a better gauge of competence than whether a specific treatment modality such as TMS has been added to a long list, or whether the practitioner is able to cough up a specific fact.

Given the controversy and uncertainty in the field, another essential of competent practice is humility.  In most cases we don't know the etiology of what we're treating.  Any treatment we offer helps some patients but not others, and nearly always carries risk.  Whitaker makes many good points along these lines.  A competent psychiatrist tempers his or her urge to intervene with the realization that the road to hell is often paved with good intentions.  Psychiatrists virtually always mean well, and (contrary to some critics) help our patients far more often than not.  Nonetheless, a competent psychiatrist is always ready to admit misjudgment or miscalculation.  Self-correction is a feature of competence in psychiatry as well as in many, perhaps all, other domains of human expertise.

For another take on the competent psychiatrist, arriving at a similar endpoint using different reasoning, see this 2011 post by Dr. Raina.

I wrote above that psychiatry's limitations may reside at a different level of analysis than that engaged by its critics.  Psychiatry is a hard job because the brain is the most complex organ, because normality is so hard to define, because human development is a subtle interplay of nature and nurture, and because we don't understand the root causes of many forms of mental distress.  But even if we did know and understand these far better than we do now, the field would still be fraught with controversy and uncertainty.  Our attitudes regarding responsibility, free will, conformity versus deviance, and how we treat each other reflect our politics and deeply held values.  Psychiatry serves as a lightning rod for strong feelings around these matters.  By its very nature, it always will.  Psychiatrists must accept that many will view us skeptically, some with hatred — and others with undeserved adoration — and not let this dissuade us.  A competent psychiatrist hears criticism from individual patients and the public, neither dismissing it unthinkingly, nor allowing it to lead to demoralization and defeat.

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net.

Between medical paternalism and servility

Even today there are patients who leave diagnosis and treatment entirely to their doctors.  They make no effort to inform themselves about their illness or chart their own course; they do whatever their doctors advise.  Once the norm, this passive, willfully naive attitude has withered in the face of a multigenerational attitude shift, coupled with the wealth of medical information at hand today.  Direct-to-consumer drug ads on television, online peer support, medical websites and blogs of all stripes, "Dr. Google," PubMed — it almost takes dedicated effort to avoid learning about one's medical issue.   The complementary role of doctors as kindly but authoritarian caretakers feels outdated by decades, and to many nowadays, offensive.  "Paternalistic" has become the epithet of choice for doctors who fail to recognize, respect, and make room for patient autonomy and medical self-determination. Most doctors practicing today, even those of us decades into our careers, began medical training at a time when patient empowerment had already gained ground in the U.S.  Many of us supported it wholeheartedly.  In college I studied medical ethics and patient autonomy.  I volunteered at a community clinic called "Our Health Center" that aimed to empower patients.  My stated goal when applying to medical school was to help patients take responsibility for their own health.  Even today I tend to over-explain my reasoning to my patients, and to err — and sometimes it is an error — on the side of offering a smorgasbord of options along with their risks and benefits.

However, over the years the goalposts have moved.  For a growing subset of patients it is no longer enough that we doctors talk to them as fellow adults.  The one-time goal of shared decision-making has, in some circles, given way to a deep skepticism toward doctors and our expertise.  Some regard us as irksome gatekeepers who add little to medical decision making and serve mainly as roadblocks to obtaining the medical tests or treatments they already know they need.   In this jaundiced view, our role is reduced to rubber-stamping: ordering desired tests, signing requested prescriptions, drafting work excuses, and so forth.  For example, I've received many calls from would-be patients seeking a prescription stimulant for self-diagnosed "adult ADHD." The callers sound dismayed when I point out that my diagnosis may not agree with theirs.  Similarly, patients seek me out to provide documentation and advocacy on behalf of a psychiatric disability they swear they have, but I haven't yet evaluated.  I find myself wishing that such callers could face the consequences of their own decisions without involving the unwanted, apparently superfluous impediment of a doctor.

These examples from my practice could be dismissed as drug-seeking or "gaming the system."  But skepticism toward physicians and our expertise goes much further.  Patients insist on antibiotics for viral (or non-existent) infections.  Parents refuse to vaccinate their kids.  Online forums abound with horror stories of patients misdiagnosed and mistreated, who finally escape this nightmare only by taking matters into their own hands.  "Ask your doctor" drug ads imply that doctors will fail to consider the advertised treatment if not for patient self-advocacy (and the generous assistance of a multimillion dollar marketing campaign).  California has a voter initiative this fall that, among other provisions, would mandate random drug testing of physicians for the first time in the U.S.

There is a movement afoot to share medical records with primary-care patients, ostensibly for doctor-patient collaboration, but often justified on the basis of "transparency."  It is now deemed paternalistic for doctors to keep private notes of our own work, even though this is accepted in other professional and consultative fields.  Institutions no longer trust us to do high-quality work without oversight by non-physicians who track quality and patient satisfaction measures.  Some patients now balk when doctors ask personal questions, e.g., about religious practices or hobbies, that are not obviously related to a manifest disease process.  Learning about our patients as people, their strengths as well as weaknesses, is apparently also paternalistic.  Shouldn't the patient decide what areas of information to divulge?

Reducing doctors to servile technicians renders us safely powerless.  Never mind that we can no longer diagnose or treat illness as well, for example by drawing unanticipated connections between habits and disease.  For many patients, and apparently for society at large, it is more important not to feel a power differential.

This is an odd sentiment indeed.  Anyone offering a skilled service, professional or not, wields a degree of power — and at least a little paternalism — over clients or customers. The computer professionals and attorneys who come to my office expect their own clients to defer to their expertise.  My mechanic knows more about cars than I do, my barber about hair, my grocer about what produce is in season.  Somehow we don't find it threatening to put our faith in these authorities, especially when they welcome dialog and involve us in the decisions and recommendations that affect us personally.

People sometimes wonder when they may question a doctor's diagnosis or advice.  I say always.  I've spent a career encouraging patients to be curious, to ask questions, to understand their suffering and what may help.  This is the legacy of patient empowerment: all of us taking responsibility for our own well-being, and medical professionals respecting the right of patients to make their own well-informed health care decisions.

However — and it is a big however — this is not the same as physicians rubber-stamping everything patients believe or want.  Shared decision-making lies between "doctor's orders" and "patient's choice" and follows the ethical standard of acting in the patient's best interest (illustration courtesy of Practice Matters):

Nor should fear of sounding paternalistic silence us when detractors claim that everyone's opinion is equally valid.  It is falsely modest and politically naive to deny our own expertise.  When it comes to medical matters, we doctors, while admittedly fallible, are nonetheless right far more often than we are wrong, and far more often than even intelligent, well-read non-physicians are.  Like the attorney, computer professional, mechanic, barber, and grocer, we know things most other people do not.  There is no shame in that, nor is it a power trip to point it out.  A paternalism that demeans others is bad; a servility that demeans ourselves may be worse.

Top image courtesy of Ambro at FreeDigitalPhotos.net

On responsibility

I'll leave the "sloppy thinking" series for now, although I expect to return to it in the future.  In this post I'll share some thoughts about personal responsibility, especially as it pertains to the insanity defense.  It's a topic much in the news lately, due to tragic actions by now-household names such as James Eagan Holmes and Jared Loughner.  The matter goes much further though.  We normally assume that adults are responsible for their actions, and that these actions are freely chosen.  The extent to which we treat this as absolute versus a matter of degree determines our fundamental political views, and how we view our neighbors and ourselves. Many facets of everyday life are premised on personal responsibility.  The criminal justice system is the most obvious example.  In a wider sense our willingness to live in community with others depends on each person taking responsibility for his or her behavior.  Nonetheless, we've recognized exceptions to this default assumption for centuries.  Adults who are severely sick or injured may temporarily be unable to assume responsibility for themselves.  Likewise, infants and young children lack the ability to make informed choices and to exercise personal responsibility.  Non-human animals are exempt from personal responsibility and are never considered guilty of a crime — well, not anymore.

English common law recognized that the same lack of responsibility extended to insane adults:

By the 18th century, the British courts had ... developed what became known as the "wild beast" test: If a defendant was so bereft of sanity that he understood the ramifications of his behavior "no more than in an infant, a brute, or a wild beast," he would not be held responsible for his crimes.

The history of the insanity defense then records the trial of Daniel M'Naughten in 1843, where inability to distinguish right from wrong was established as the crucial legal test. This became the standard, both in Britain and the US, for more than 100 years; the "M'Naughten rule" is still the legal standard in many states.  Later modifications tended to liberalize its application, as with the "irresistible impulse" and "diminished capacity" doctrines, until the pendulum swung the other way in the wake of John Hinkley's attempted assassination of President Reagan in 1981.

As a society, we seem to be losing our inclination to forgive the mentally ill, and children, when they commit horrific acts of violence.  Even young teens are now tried as adults when an alleged crime is bad enough.  And although insanity defenses are rare in U.S. courts, and their successful use often results in involuntary hospitalization longer than the prison sentence would otherwise have been, there is nonetheless a popular view that the insane "get away with it."  Jared Loughner recently plea-bargained for life imprisonment despite clear evidence of mental illness and the possibility of an insanity defense.  The court will decide whether James Holmes has severe psychosis, an antisocial personality, or just a very bad attitude.  As in Loughner's case, this determination is unlikely to make a difference in terms of public safety — Holmes won't be freed for decades, if ever.  But the way we handle the question of legal insanity bears on how our society views itself.

Now that we are in a presidential campaign season, we hear rhetoric that cleaves the major parties around the question of personal responsibility.  "You didn't build that," a slightly misspoken point by President Obama about the government's role in promoting business, became a rallying cry for Republicans in defense of the entrepreneur.  Yet both sides have a point:  The government makes and maintains highways (and founded the internet); individuals create trucking companies (and online businesses).  It's really a matter of emphasis, and yet this emphasis is what most of the fighting is about.

Decades ago, social psychologists coined the term "fundamental attribution error" to highlight our tendency to over-apply dispositional or personality explanations to others, in the same circumstances we apply situational explanations to ourselves.  E.g., if others are unemployed we often imagine they are lazy or unqualified (personal factors), whereas if we are unemployed, we often blame a tough economy and a lack of jobs (situational factors).  Of course, some of the unemployed really are lazy or unqualified, just as some killers really have the criminal intent (mens rea) to be convicted of murder.  The question is whether and to what extent we allow for exceptions in cases other than our own.  Denying such exceptions flies in the face of our own legal tradition, our recognition of the fundamental attribution error, and our human kinship — the idea that we humans are more alike than we are different.  We are wise enough not to punish infants or "wild beasts" even if they hurt us; the severity of their behavior and its consequences has no bearing on whether they are personally responsible.  A person who cannot tell right from wrong due to severe psychosis is operating at the same level, and should be treated, not punished.  Personal responsibility is a strong enough concept that it can withstand some nuance and flexibility — especially when that happens to reflect reality.