By Nicholas Kontos

My biggest insecurity about being a psychiatrist with an interest in medical ethics is being a psychiatrist with an interest in medical ethics.  Either of those elements is fantastic on its own, and a handful of psychiatrists do advance the idea of our specialty having special ethical standing and knowledge.  Yet, having served on transplant listing committees and being consulted for medical decision-making capacity evaluations at an ever-rising frequency, my experience and opinion are that a psychiatrist assuming or assumed to possess the mantle of “ethicist” faces two risks.  He or she at best becomes a welcome repository for ethical concerns filed under the heading, “psychosocial,” and at worst may be regarded as a poseur or a pedlar of the esoteric.  It is an unfair but, in my opinion, very real state of affairs.

These anxieties lurked in the background of my thoughts as I researched and wrote my paper, “Ethics of Incongruity:  Moral Tension Generators in Clinical Medicine.”  On the one hand, the piece is an attempt to understand the intense and very human emotional discomfort we experience, seemingly paradoxically, in the face of dilemmas often framed dispassionately as intellectual abstractions.  What medical professional is better acquainted with uncomfortable feelings than a psychiatrist?  On the other hand, this moral tension, while emotional, is not pathological.  So, who am I to claim any special expertise in it, let alone in its ethical bases and implications?

As is often the case, the wisdom of mentors came to the rescue.  My late mentor, Dr. George Murray, emphasized to his fellows that professionally, “you are physicians first and psychiatrists second” (something he felt should go without saying in an ideal medical world).  With that maxim in mind, I set out to delineate and describe “incongruities” of values, agendas, actions, and regard as they occur between and within patients, clinicians, and society, using my observations as a hospital-based physician to guide my thinking and reading.

Make no mistake, though.  I am proud to be a psychiatrist and feel that my specialty has as much to contribute to ethical discussions as any clinical discipline.  My education and experience as a consultation psychiatrist foster ongoing consideration of what the word “medical” means when applied to terms such as “medical ethics” and “medical model.”  Minus those considerations, I doubt I would have written this paper at all, let alone in the way I chose to.

However, except when discussing specifically psychiatric ethical matters, I feel it is important to minimize psychiatric jargon and theoretical backing for one’s arguments.  In the case of “Ethics of Incongruity,” doing so shunted me toward new and useful ways to look at what riles people up ethically (e.g., akrasia and self-deception rather than intrapsychic “conflicts”).  Hopefully that process also yielded something useful for ethically engaged clinicians of all stripes.

Paper title: Ethics of Incongruity:  Moral Tension Generators in Clinical Medicine

Author:  Nicholas Kontos, MD

Affiliations:  Director of Fellowship in Consultation-Liaison Psychiatry – Massachusetts General Hospital; Assistant Professor of Psychiatry – Harvard Medical School

Competing interests: none

Email: nkontos@mgh.harvard.edu