Ethical Self-Evidence and the Principle of Proportionality: Two Fundamental Ethical Principles Applied to a Psychiatric Case Report

When confronting ethical problems, clinicians generally feel both unprepared as well as in need of orientation. Ethical norms issued by medical associations are necessary and helpful but insufficient: by definition, codes and norms are preethical; that is, they establish guidelines before the truly ethical question even arises. To arrive at a clear ethical formulation and to bridge the gap between a set of rules and their application in particular cases are essential. This article discusses some problems with ethical systems and then demonstrates that it is possible to formulate two fundamental ethical principles-ethical self-evidence and the principle of proportionality-applicable to treatment situations in a process of effective practical reasoning. Such a process forms an integral part of the doctor-patient relationship and can be practiced individually, and in staff and treatment sessions. The principles and the reasoning process are valid in all medical and mental health fields. The example shown here is their application in psychiatry, specifically, in a case of Huntington's disease. Keywords: ethical aspects; ethical issues; medical ethics; anthropology; psychiatry When an ethical question is raised, it is striking and often disconcerting to observe the hesitation, uncertainty, and (sometimes) dismay of psychologists, psychiatrists, and physicians in general. There seem to be two first reactions: (1) to fall back on professional ethical codes in an attitude of dutiful observance, and (2) to submit any decision to "ethical professionals," mostly members of an ethics committee. Neither reaction actually alleviates a professional's unease, because neither involves his or her own judgment and/or the complex superego structure we call conscience. All of us do make ethical judgments throughout our lives, even if we are not aware of doing so. Besides, we live in a multicultural society characterized by the often not-so-peaceful coexistence of widely divergent value systems that inform ethical decisions. In addition, there is constant reexamination of the doctor-patient relationship, within which ethical decisions are perceived as well as made. These factors together make ethical responses to new situations ever more difficult to identify. In this article, we discuss the characteristics of an ethical decision and describe how such decisions form part of human relationships, as well as how to practice making such decisions and to train ourselves in ethical reasoning. Toward this goal, first, we analyze ethical codes, principles, and value systems and their functions to determine the difference between these tools and ethical reasoning in its proper sense: an attitude we will call "effective practical reasoning." Next, we attempt to ground ethical reasoning in anthropology, for the simple reason that what we all have in common, despite our differences, is an existence as interrelated human beings. We show that anthropological reflection can yield two universal ethical principles-ethical self-evidence and the principle of proportionality-to guide any process of practical ethical reasoning. Third, we apply the two principles to a psychiatric case of Huntington's disease. Because we make a case for ongoing effective practical ethical reasoning, we close this article with a list of questions a clinician may ask himself or herself toward finding a solution to a presenting ethical problem. This does not mean clinicians should no longer consult with ethical specialists, but that effective ethical reasoning may go a long way toward integrating ethical reflection into mental health work and the doctor-patient relationship-and easing the nagging insecurity manifested by many professionals. In our following arguments, psychotherapists can be subsumed under the designations of psychiatrists or physicians, because in ethical terms, their quandaries are comparable or identical. ETHICAL CODES AND PRINCIPLES: MORE QUESTIONS THAN ANSWERS No shortage of ethics codes and declarations on ethical problems exists in medicine, neither on national nor international levels (Musto, 1981). …