2. Should there be a Chapter on Bioethics in a Book of Positive Psychiatry?

For that we have to first answer the fundamental question: what is the essential justification for the role of bioethics in psychiatry? It is that the problems facing psychiatry today are shaped by the emergence of dilemmas created by science and technology but not solvable by them (Lolas, 2002[50]). For example, issues like covert medication, involuntary hospitalization, informed consent, confidentiality in psychotherapy, electroconvulsive therapy, psychosurgery, and neuroethics. A lot of these dilemmas relate to health care values and preferences, where only the skill sets that bioethics provides can sort out issues.

This is as applicable to psychiatry as the whole of medicine. In medicine, take for example, an issue like stem cells or embryo research, which ‘has become a hot-button political issue involving scientists, policy makers, politicians and religious groups’ (Al-Rodhan, 2015[1]). Or, for that matter, cloning, brain like computer chips and smart pharmacology. Come to think of it, it is equally applicable to all science and technology. Take, for example, genetically modified organisms (GMOs), discussions on which ‘have mobilized civil society, scientists and policy makers in a wide debate on ethics and safety. The developments in genome-editing technologies are just one example that bioresearch and its impact on market goods are strongly dependent on social acceptance and cannot escape public debates of regulation and ethics’ (Al-Rodhan, 2015[1]). The John J. Reilly Center for Science, Technology, and Values at the University of Notre Dame has released an annual list of emerging ethical dilemmas for science and technology for 2015 which include issues like Brain-to-brain interfaces, Real-time satellite surveillance video, Resilient social-ecological systems, Artificial life forms, Robot swarms, Non-lethal weapons, Enhanced pathogens, State-sponsored hacktivism and ‘soft war’, Wearable technology and Astronaut bioethics (of colonizing Mars) (Baron, 2014[3]).

Indeed, bioethical implications are a concern in all endeavours that impact human life. The dilemmas related to such activities are created by them but not solvable by them. Here only the skill sets of bioethics can offer pointers.

The same cannot but be applicable to Positive Psychiatry.

It should now be easy to answer the question: why the bioethics of Positive Psychiatry. It is because the problems facing the nascent field today, and in the future, will be shaped by emergence of dilemmas created by related science and technology but not solvable by them. A lot of them will relate to health care issues and preferences, where the skill sets that bioethics can provide will help sort issues out.

Hence, a chapter on the Bioethics of Positive Psychiatry in a book on Positive Psychiatry is legitimate (see, for example, chapter by Singh, 2015[71]). In fact, a chapter on bioethics is legitimate in every textbook of every branch of medicine, including psychiatry. Come to think of it, a chapter on ethical implications is legitimate in every worthwhile textbook of every branch of science and technology. Sidestepping, or ignoring them, is mainly responsible for the hassles scientific branches develop when they come in conflict with social norms and values.

We will have occasion to look at some of these problems in relation to Positive Psychiatry in this paper, and apply the skill sets that bioethics provides to solve them. Future work should hopefully throw more light on further developments and related ethical health care dilemmas in the field.

3. How do we go about it in this paper?

We shall first lay the groundwork for further discussion by offering operational definitions of the concepts fundamental to the field – those of Bioethics, Positive Psychology, Positive Psychiatry and Positive Mental Health. We will carry out their conceptual analysis to show their areas of connect and disconnect. We will then study the implications of positive and negative findings in the field, and evaluate them on the basis of the 4-principled bioethical model of Beneficence, Non-malfeasance, Autonomy and Justice (Beauchamp and Childress, 2013[6]), first offering a brief clarification of these principles and then their bioethical analysis. The related concepts of ‘Common morality’, ‘Specific morality’, ‘Specification’, ‘Balancing’ and ‘Double effects’ and how they are connected to Positive Psychosocial Factors and Principlism will then be analysed. We will then look into the further development of the branch by studying the connectivity, synergy and possible antagonism of the various positive psychosocial factors, as well as enquire whether there is need for the use of technical terms with least baggage. We will also take note of the salient points of caution and alarm that many incisive analysts have presented about further development in the related field of Positive Mental Health. Finally, we will look at where, and how, the field is headed, and why, if at all, it is proper it is headed there, based on Aristotle’s well acclaimed concept of the 4 causes – Material, Efficient, Formal and Final.

Fundamental justification for Positive Psychiatry

The fundamental justifications for Positive Psychiatry are, therefore, basically three:

Principlism

Beauchamp and Childress’ (2009[5], 2013[6]) seminal work in biomedical ethics, Principles of Biomedical Ethics, details an approach, often simply called Principlism, which contains four biomedical ethical principles: (1) Beneficence, (2) Non-malfeasance, (3) Autonomy and (4) Justice.

• (1)
  Beneficence i.e. patient welfare, ‘Salus aegroti suprema lex’, means a medical practitioner should act in the best interest of the patient. In other words, patient welfare comes first, all else depends on it. For example, The Preamble to the Principles of Medical Ethics, American Medical Association, 2013[2], gives centrality to the benefit of the patient first, then of society, other health professionals, and of self, in that order: ‘The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self’ (American Psychiatric Association, 2013[2]).
• (2)
  Non-malfeasance i.e. no harm, ‘primum non nocere’, or ‘first, do no harm’, means even if a practitioner cannot do good, he should never do his patient harm. Some ‘hurt’ is understandable as part of a procedure, but ‘harm’ is never permissible (Singh and Singh, 2006[73]). For example, a surgeon’s incision ‘hurts’, but is sanctioned under the principle of beneficence since it is meant to carry out a much needed surgery. But the same incision ‘harms’ when it is meant to carry out an organ removal without the patient’s knowledge and consent and thus violates the principle of non-malfeasance.
• (3)
  Autonomy, i.e. consent, ‘Voluntas aegroti suprema lex’ means the patients have the right to refuse or choose their treatment. Coercion, forced or subtle, is out.
• (4)
  Justice, i.e. fair treatment to all, concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality). Also, every patient must get fair treatment irrespective of caste, creed, religion, nationality etc. Fair treatment is based of a code of professional ethics and relevant evidence based procedures and practice guidelines.

In other words, a medical practitioner works primarily for the welfare of his patient, should never cause harm, even if he cannot bring about care and comfort, should respect the patient’s right to chose/refuse treatment, and should give fair treatment irrespective of geographical/cultural/ideological/religious considerations (See Case Vignette 1).

Case Vignette 1: Following the 4-principles in medical practice

Dr. Z often prays, not that he should have more patients in his hospital, but that he should have the capability to do his best for whosoever comes to him. He never suggests surgery when conservative treatment can serve the purpose e.g. he always motivates his patients to consider normal childbirth rather than adopt the easier option of an elective caesarian section [Beneficence]. He never sends patients for unwanted procedures like costly investigations, or unduly alarms them into hospital stay, to inflate ancillary bills and make resultant profits [Non-malfeasance]. He insists of giving full relevant information before any procedure is carried out, and performs it only after obtaining an informed consent [Autonomy]. He treats patients of an inimical community with the same care as he does his own [Justice].

Dr. Z can be said to be following the 4-principles in his medical practice.

Specification

It is ethical principles in actual practice. It is a ‘…a methodological tool that adds content to abstract principles, ridding them of their indeterminateness and providing action-guiding content for the purpose of coping with complex cases. Many already specified norms will need further specification to handle new circumstances of indeterminateness and conflict’ (Beauchamp 2011, p 301[4]).

In other words, it gives the content relevant to a specific context. For example, which ethical code to adopt, which ethical/clinical practice guidelines to accept, which cultural norm to consider inviolate in treatment (See also Case Vignette 2).

Balancing

It is what to do and what avoid, as also balancing and adjudicating between two ‘goods’. To develop sound judgment and act according to justice. It is important for reaching sound judgments in individual cases and is ‘the process of finding reasons to support beliefs about which moral norms should prevail’ (Beauchamp and Childress 2009, p 20[5]). For example, what is better in a certain case – to reduce intolerable pain in terminal cancer by a procedure (Beneficence), which may increase morbidity and remotely even cause mortality (Non-malfeasance), or just allow the patient to suffer because of a justified concern it can cause mortality (Justice). Also worth noting is that since the particular ethicalities are different, people sometimes specify and balance the principles differently. Hence the principlists’ claim ‘that there can be different and equally good solutions to moral problems’ (Gordon, 2011, p 299[25]). For example, what do we do with life support systems in a patient with a permanent vegetative state? Both removing it, and continuing it, are justified from different standpoints, and so appear equally good. Balancing between primacy to life (absolutist stance) or giving a dignified exit to a life no longer worth living (utilitarian stance) will depend on the belief system of the patient/relatives/physician and law of the land (See also Case Vignette 2).

Case Vignette 3: Health risk factors offset by Positive Psychosocial Factors

Mr. X, is an obese 71 year old writer who hardly moves out of his house and exercises poorly, drinks 2 pegs of whisky every evening and smokes 5 cigarettes a day (Health risk factors). He has mild hypertension for which he takes a morning maintenance dose of Atenolol 50 mg.

Mr. X has never got admitted to hospital. He writes for 4-6 hours daily, waking up early morning to do so, and never misses writing deadlines. When a newspaper he edited and made immensely popular suddenly closed down, he just moved on and started writing syndicated columns (Resilience). He is known to always look at the bright side of things. He often jokes that if the newspaper had not booted him out, how would he have started his syndicated columns and made so much money (Optimism). He is not overly dependent on others for his needs. He makes his own breakfast and at times his own meal (Personal Mastery). He enjoys cracking jokes, and the company of pretty women (Engagement with pleasant events). He also enjoys meeting people from different strata of society at an ‘open house’ every evening at his home (Social connectivity). With appointment he is also known for giving sage advice (Wisdom). He takes care that doctors and a full time nurse tend to his wife, who is showing progressive signs of Alzheimer’s disease. He does not allow the inevitable deterioration in her condition to affect his work or leisure schedule (Resilience).

In spite of health risk factors like obesity, lack of exercise, smoking, alcohol, and the poor prognosis sickness of a loved one, positive psychosocial factors like optimism, resilience, self mastery, wisdom, engagement in pleasant events and social connectivity have helped offset negative health risk factors.

This of course does not mean that one voluntarily adopts health risk factors and then off sets them by positive psychosocial factors. It just means the latter have such powers.

Case Vignette 4: How Resilience and Optimism aid Recovery

Mr. X (67 years) and Mrs. X (66 years) both have type 2 diabetes and had their first myocardial infarction nearly 9 years back, within 6 months of each other (He first, and she later). Before their ailment, both were non-exercisers, had poor diet control, and had frequent late night parties.

Mr. X is the eternal optimist while Mrs. X is the perfect example of a pessimist. He adjusts to changed situations quickly, forgiving people and forgetting hurtful events (Resilience). Mrs. X finds it very difficult to adjust to changed situations, never forgives or forgets and keeps nursing past hurts and resentments (Non-resilience).

Following the ailment, Mr. X goes for a 30 min morning walk regularly as per the physician’s recommendation, never misses his scheduled check-ups, has given up smoking and regulates his diet as per the dietician. He also goes for an hour to the garden in the evening to spend some pleasant time with his friends, chatting in a relaxed manner over anything under the sun. He has an occasional late night party but doesn’t crave for it. Nor does he crib about losing out on all the fun.

Mrs. X, on the other hand, does not exercise, does not go for regular checkups in spite of her husband’s prodding, continues to default on her diet by gorging on sugar rich sweets and ice-creams. She avoids the late nights too but keeps cribbing about missing all the fun because of her ailment. She continues with her occasional kitty parties but keeps finding fault with others and returns home upset.

Mr. X has been an eternal optimist. He smiled in and out of the ICCU. He joked on entering there, ‘Ah, just proves I have a heart that can go wrong – like that of any teenager!’ He maintained his cool while emergency procedures were carried out there. He has since taken charge of his ailment and voluntarily follows whatever good advice his physician and dietician give.

Mrs. X was the exact opposite in the ICCU. She made her stay there a nightmare for the staff and her relatives by her constant cribbing. She continues to whine daily about the unkindness of her lot, keeps finding excuses for not doing exercise and following a diet, and blames the doctors and her husband for her plight.

Their doctor advised them to do yoga for control of diabetes and to improve their cardiovascular functioning. Both joined enthusiastically. While Mr. X completed the course and continues doing it regularly, Mrs. X gave up the course midway, saying it was too ‘boring’.

Mr. X’s diabetes is well under control, he is only minimally over weight, and has not suffered a CV episode again in the next 9 yrs. He was out of the ICCU in 3 days. Mrs X has uncontrolled diabetes, has become grossly overweight, and has suffered 2 more myocardial infarcts, for all three of which she had prolonged ICCU stays. She has since developed greatly compromised cardiac function.

Mr. X’s resilience on knowing his ailment (changing his lifestyle to suit recovery) and his optimism that recovery is possible help him sustain positive amends in lifestyle which aid his recovery and lead him to experience well-being in spite of his ailment.

Mrs. X’s non-resilience (sticking to old maladaptive patterns of behaviour) and her pessimism do not allow her to sustain amends in her lifestyle, obstruct her recovery and her well-being, and prevent her from reaching a state of well-being. In fact they contribute directly to her morbidity and her relapses.

Resilience and Optimism amongst the elder age group is found especially useful (see Case vignette 3 and 4 above). Numerous studies on Resilience and Optimism have been reported to be associated with a lower risk of all-cause mortality in longitudinal studies of older adults (Giltay et al., 2004[24]; Steptoe and Wardle, 2005[79]). People in their 90s who endorsed higher levels of Resilience had a 43% higher likelihood of living up to 100 years compared to their peers with lower Resilience (Shen and Zeng, 2010[76]). Resilience is associated with better emotional health and self-rated successful aging and with less pain and better health-related quality of life in older adults (Lamond et al., 2008[44]; Zeng and Shen 2010[95]; Tomas et al., 2012[84]). Optimistic older adults report higher levels of well-being and are more likely to engage in healthy behaviours than others (Giltay et al., 2007[23]). A meta-analysis of 83 studies of Optimism found a significant relationship between Optimism and physical health outcomes including cardiovascular outcomes, physiological markers (including immune function), cancer outcomes, outcomes related to pregnancy, physical symptoms, pain, and mortality (Rasmussen et al., 2009[63]). On the other hand, low Optimism has been associated with increased loneliness and increased inflammation markers among older men (Rius-Ottenheim et al., 2012[64]; Ikeda et al., 2011[33]).

Case Vignette 5: How social relationships and social support combine with resilience and engagement with pleasant events to keep her healthy

Ms. M, a 75 yr old widowed businesswoman, lives alone with servants who look after her household. Her husband expired 8 yrs ago due to heart failure. Her son and daughter live in different cities and have often invited her to shift residence with them, but she enjoys her autonomy and single living, and will not compromise her ‘pride’ by depending on others.

After her husband’s death, she took over the family owned business and joined a music group with strong interpersonal bondings (Resilience, Strong social relationships). The group meets at least twice a month formally, and 3-4 times informally at each others’ residence for evening long musical soirees. She takes active part in all these, and often invites the group over to her residence. Her mornings are full of music practice and preparation for the next programme, besides attending to her business. Her evenings are often with friends from the music group, or having friends and relatives over for dinner. Or watching a first day first show release of a movie, either alone or with a friend from the same group (Engagement with pleasant events).

When she had her knee replacement surgery, the members of this musical group took turns to look after her in hospital and later at home (Strong social support).

The strong social bonding of belonging to this group added meaning and purpose to an otherwise lonely life. She enjoys a morbidity free life, with just a statin to keep her cholesterol in check. The quality and quantity of her social relationship and social support, along with her optimistic outlook and resilience, have helped take care of her loneliness, kept her healthy and added to her feeling of wellbeing.

b. Social support

A number of studies have demonstrated a significant association between strong social support and reduced prevalence or severity of depression, anxiety, substance use disorders, hypertension, cardiovascular disease, and dementia, as well as longer survival (Uchino, 2006[85]). (See Case Vignette 5 above and 6 below).

Case Vignette 6: How a vibrant social circle, intimate connection with society’s welfare, self-transcendent attitude, sharing wisdom and having a deep spirituality aid longevity

Mr. X is celebrating his 90^th birthday with his wife Y aged 84. They still court each other, are the first to hit the dance floor, and enjoy socializing with friends and family. They take pride in helping friends in need, and are part of an activist group that helps destitute children and senior citizens find shelter (Self-transcendence). Every year they sponsor higher education for 2 students, one for post-graduation in the country, and one abroad. They have thus helped a large number of young aspirants for whom they are like foster parents. Their wise practical advice is available to them all through life (Wisdom).

They have a large number of friends and well-wishers who were there to help X and Y when he had a myocardial infarction at 66, and when Y had a hip fracture following a fall at 71 (Social support). Both the times, their children were abroad and only landed up after the critical phase was under control.

Mr. X and Ms. Y are also deeply religious and offer gratitude for their long and vibrant life to their parents and to God (Spirituality). During all their difficulties, they were confident that the Almighty would help them sail through.

Mr. X and Ms. Y have a vibrant social circle and are intimately connected with society, have a self-transcendent attitude in consistently helping others, share their wisdom and are deeply spiritual. All these positive factors aid their longevity.

Case Vignette 9: Controlled pessimism and Controlled optimism better than Pseudo-optimism or Pseudo-optimistic labelling

Mr. D was explained the warning signs of a heart attack after an earlier angina attack and angioplasty. He shrugged it off when he developed retrosternal pain a year later, saying it was just ‘gas’ and it often happened to him (’pseudo-optimism’). He held the opinion that doctors unduly alarmed patients so they could make more money (pseudo-optimistic labelling).

His wife was more realistic. However, she was often labelled by him as unduly alarmist because, according to him, ‘she takes medical advice rather too seriously, thinking of the worst case scenario immediately’ (pseudo-optimistic labelling).

Not trusting her husband’s bravado, she called her son. Fortunately, the son, a doctor, was around. He immediately rushed him to the ICCU, and Mr. D was found to have developed extensive myocardial infarcts. He was immediately put on emergency measures and survived.

His ‘pseudo-optimism’ would have cost him his life.

His wife’s ‘controlled pessimism’, which made her aware of a perilous situation, seemed better in this situation.

His son had ‘controlled optimism’, for he heeded the warning signs, but was optimistic prompt treatment would help his dad.

And so it happened.

Psychiatric counselling for depressive symptoms later could convince the patient to move from ‘pseudo’ to ‘controlled optimism’.

It is necessary to promote only ‘due’ optimism for the sick: an optimism which helps patients see the brighter side of things, believe in their recovery, help them face difficult situations with humour and courage; but prevents false bravado and treatment non-compliance by a ‘pseudo-optimism’ and ‘pseudo-optimistic labelling. Promoting blanket optimism without clarifying its nuances can amount to malfeasance (double effect).

Case Vignette 10: Pseudo-resilience born out of Pseudo-optimism which often masks Denial

Dr. G a physician was suffering extensive weight loss for 1 yr. Acquaintances who meet him infrequently were alarmed at his weight loss and his looks of premature aging. However his family members could not make out since they saw him day to day, though his wife did notice his weight loss and told him to meet a doctor. He brushed her aside, saying he himself was one (Pseudo-resilience born out of Pseudo-optimism).

He still managed to enjoy his work and workouts, saying good-humouredly he could now eat anything and not put on weight. He also felt excessive thirst and laughed it off, saying it was good he had to follow the advice he gave his patients – drink more water (Pseudo-optimism masking Denial). Later, he developed sleep difficulty, which he attributed to a defective mattress, and again laughed it away. Having always been resilient in life, he felt all would be well with a good exercise and diet schedule (Pseudo-resilience due to Pseudo-optimism. Denial seemed to be at the root – fearing the worst, malignancy or AIDS, and therefore adopting denial).

Till he developed sexual dysfunction. His wife insisted they both underwent a whole body checkup, at which he was found to have a blood sugar of 630 mg/L, with retinal damage having set in.

His physician counselled him the perils of such pseudo-resilience. Dr. G immediately took charge of the situation. One who never took medicines in his life, promptly handed himself over to efficient medication, diet control, exercise, and yoga (Proper Resilience).

His blood sugar was well in control in 3 months, and has so remained since for the last 2 yrs. His retinal damage has been arrested as found at 1 and 2 yr follow-ups.

It is necessary to tease out the ‘proper’ from ‘pseudo-resilience’. While the former is beneficent, the latter is not. Promoting blanket resilience without clarifying which one is proper can be a form of malfeasance.

It is also necessary to avoid ‘forced’ and ‘pseudo’ resilience. As also avoid promotion of resilience by pseudo means and the blame game it may give rise to. For example, the implication that resilience is associated with faster recovery from a disorder could result in blaming patients who don’t recover quickly for not trying to be more resilient(double effect). The physician must beware that, in his misplaced benevolent paternalism, he does not harm the patient’s self-esteem and damage the very cause he espouses (See Case Vignette 11).

Case Vignette 11: Benevolent Paternalism may amount to Promoting Resilience by Pseudo means

Dr. K is a cheerful gastroenterologist who enthusiastically greets his patients and is aware of the psychosomatics of GIT disorders. Lately he has read about the role of optimism and resilience in getting well. He enthusiastically advises his patients to change for the better, giving examples of how emotions control the GIT e.g. when anxious before an exam/test, some people experience intestinal hurry.

Patients who get well are great ego boosters for the good doctor. However those who do not, remain a challenge he finds difficult to explain. He offers a blanket judgment, blaming them for not being resilient and optimistic enough. He warns them to better change and become more optimistic and resilient in life if they wanted to get well, but does not offer ways to do so (Resilience promotion by pseudo means). He does not hand over his patient to a psychotherapist so that they became more resilient, claiming it was all waste of time, as he was a competent psychotherapist himself, since he kept abreast of psychosomatics.

Such benevolent paternalism may promote resilience by pseudo means.

Dr. K does not realize that having knowledge, and the expertise to implement it, are two different things. His tendency to blame those of his patients who do not recover as not being resilient or optimistic enough is one form of resilience promotion by pseudo means, and amounts to ‘harm’, albeit unintentionally caused.

While his espousal of resilience is well-intentioned, not implementing it correctly amounts to malfeasance and is an example of ‘double-effect’.

Case Vignette 12: The Perils of Excessive Social Connectivity in the Temperamentally Asocial

Mr. C, 56, is reserved by temperament and has enjoyed good health all through life. He has his small circle of friends with whom he is happy, and enjoys a quiet, contented life. Six months back, he got to hear of recent findings that greater social connectivity was a positive psychosocial factor and that brain plasticity meant newer neuronal connections could be established at any age. He started socializing with great vigour, stimulating his brain with strenuous cerebral activities like prolonged animated discussions, giving speeches at various functions, continuously interacting on emails in social groups, spending hours on Facebook and Twitter accounts. He started keeping his mobile phone on 24/7 so as not to miss any opportunity to be called over or to interact with new and old acquaintances.

In a few months the whole excitement got the better of him. He started losing sleep. He developed spells of severe headaches with giddiness. He started feeling exhausted most of the times with bouts of irritability over small matters, something that never happened with him before.

He was diagnosed with moderate hypertension.

A man who had lead an otherwise disease free life till a change he forced on himself, got afflicted with a chronic ailment.

His physician started him on anti-hypertensives with only mild improvement. Noting his irritability and lack of sleep, he felt there may be added depression and referred him to a psychiatrist. Here, the patient revealed his changed lifestyle and the reasons. Psychotherapy helped him realize he should lead a more relaxed lifestyle suited to his basic temperament.

Along with medication, he has since reduced his excessive social connectivity and got back to his earlier way of living. His symptoms are much under control.

Social stimulation has its positive effects. But excessive and unregulated social connectivity and stimulation unsuited to basic temperament can be malevolent and have its own negative consequences (double effect).

While suggesting the positive effects of these methods, the harm due to its excesses and sudden introduction should be equally emphasized by physicians, especially to those patients who may get carried away otherwise.

Further research into how much and what form of social connectivity and stimulation is useful in which type of person would help preempt chances of such ill-effects. And help reduce the malevolence that can otherwise result.

Case Vignette 13: Cross Cultural Differences in Coping Mechanisms

Mr. J, a Chinese immigrant to the US, is advised that along with medications for his irritable bowel syndrome, he should be more optimistic and cheerful to cope with his condition. Mr J says he would prefer to take the coping route he knows best as a Chinese – the spiritual route, along with medications.

The US physician should respect his cultural difference and not force humour on him, or deride his dependence on spirituality as a way to cope with his IBS.

There is a risk of creating a homogeneous society where everyone is apparently optimistic, social, etc, but suffering in trying to cope with the forced and sudden changes that over-enthusiastic physicians may force on patients, and often patients may force on themselves due to information bombardment from the internet and other such sources (double effect). This may be akin to the ill effects of eugenics.

The widely varying tapestry of human beings adds colour and variety to human living. We need optimistic, irreligious socializing people as much as we need religious, asocial, wise beings. Also, human beings have myriad means of coping, and there are different and apparently equally good psychosocial factors. There is no need to unduly promote one over the other till we have scientific evidence either way.

Case Vignette 14: How Autonomy works: the Example of two Physicians

Dr. A is a do-gooder who does not believe in presenting evidence before the patient and helping him make his choice. He decides what is best for the patient and will brook no discussion. He uses his physician’s position to force patients to select optimism and religiosity as the methods to cope with their disease.

Dr. B presents evidence for various positive psychosocial factors to his patients. He allows them to select what suits them best, discusses various alternatives and helps them arrive at the best methods that suit them, all the time patiently guiding them without allowing them to procrastinate, but also not forcing any methods.

Dr. A’s methods do not respect Autonomy. Dr B’s methods do. Both are guided by benevolence, but Dr B’s is coupled with Autonomy and is therefore more appropriate. Paternalism is no substitute for benevolence.

Moreover, the patient has the right to give or refuse consent to one or more of the procedures the physician/psychiatrist may consider better suited for the patient, except if the patient is legally incompetent. Even if the chances of a legally incompetent person adopting positive measures like optimism, resilience, wisdom are remote, this safeguard is necessary.

The safeguard is also necessary for special populations such as children, older people with mild or major cognitive impairment, people who are otherwise not fully competent to provide consent for treatment, etc. In such cases, legal guardians and health care proxies play a defining role.

Case Vignette 15: The Just Physician who respects all aspects of Principlism

Dr. X always keeps himself abreast with the latest developments in his branch and adopts only those evidence based procedures he knows will benefit his patient [Beneficence]. He will never carry out any procedure which he knows will harm him [Non-malfeasance]. He is careful to explain to his patients the procedure to be carried out without unduly alarming them, even as he informs them fully as to the benefits and risks involved, and carries out procedures only after obtaining a valid consent [Autonomy].

Dr. X offers all this to all his patients, irrespective of their sexual orientation/preference, colour, creed, nationality or religion [Justice].

Dr. X is not only a good physician but also follows the laws of justice. In fact he is a good doctor only because he carries out good procedures in a fair manner.

Justice has further nuances which need elaboration. It essentially means not crossing the border line from beneficence (desirable) to condescending paternalism (not desirable) e.g. doctor decides for patient, brushing aside his objections (see Dr. A in Case Vignette 12; Dr. W in Case Vignette 14(1) below). It also means not being so obsessed with non-malfeasance as to avoid due beneficence e.g. doctor so worried about lawsuits that he does not carry out legitimate treatment e.g. involuntary hospitalization in necessary cases (see Dr. P in Case Vignette 14(2) below). It also means not adopting malfeasance in the garb of beneficence e.g. adopting non-scientific or obsolete procedures in the name of treatment (see Dr. Y in Case Vignette 14(3) below). It also, further, means not giving absolute value to patient autonomy forgetting that such autonomy is relative e.g. not treating a patient incompetent to give consent (see Dr. P in Case Vignette 14(2) below). It also signifies not avoiding desirable beneficence in the name of patient autonomy e.g. covert treatment (see Dr P in Case Vignette 14(2) below).

Justice also means offering all these facilities equally to all patients, irrespective of which creed, culture, sexual orientation or religion/creed they belong to. Discrimination on any count amounts to malfeasance and non-beneficence (see Dr B in case Case Vignette 14(4) below).

Case Vignette 14 below will clarify all this.

Case Vignette 14: The Four Different Physician Errors of Justice

1. Dr. W is a busy knowledgeable cardiovascular surgeon who likes to take quick decisions for the welfare of the patient. In so doing, he often fails to explain what he intends to do, and also takes for granted that he knows best and patients better comply. He gets a blanket consent form signed by his patients without explaining the process involved. He just pronounces his decisions and his overbearing attitude brooks no refusal, or asking for explanation. If a patient asks for one, he is promptly told to go to another surgeon. Since he is known to be the best with his surgery, the patient meekly acquiesces, even when he is unconvinced about the procedure adopted
2. Dr. P is a well-known psychiatrist who refuses to treat involuntary patients because of potential legal hassles. He has heard of such cases happening with colleagues and therefore will just not handle any such patient, even by adopting due legal safeguards like getting consent from health care proxy, or after due certification by the court. He also firmly believes that involuntary treatment is unjust, because it is done against the patient’s consent, even if the patient were incompetent to give one. He will also not administer covert treatment, even when he knows the patient has an active psychosis, and is a threat to himself and family if left untreated, and cannot be subjected to involuntary hospitalization or certified by court
3. Psychiatrist Dr. Y continues to give insulin coma therapy for his schizophrenic patients and CO₂ narcosis for his neurotic patients as standard procedure, even when he knows these treatments are obsolete
4. Psychiatrist Dr. B refuses, or resists, treating transgenders and lesbians because he doesn’t like their sexual preferences. He is relieved if such cases do not come back for follow-up. He also has a dislike for those he calls ‘communists and atheists’. He enters into prolonged arguments with them in psychotherapy sessions over this almost unwittingly, then regrets it, but repeats it when the patient animatedly defends his position.

Case Vignette 15. The Methods of a Good and Just Positive Psychiatrist

Dr. D allows his patients to decide between the methods of positive psychiatry after offering them due information and counsel. He never presents his ‘hunches’ as scientifically proven, but does present them as ‘hunches’, for the patient to adopt or reject. He keeps abreast of developments in the field and offers the latest information on positive psychiatry to his patients, irrespective of their race, creed, religion, sexual orientation or socio-economic status. He never forces his personal preferences on his patients, helps them develop their own based on their basic strengths, preferences and shortcomings. He never hustles his patients into deciding this or that process, but does gently prod them forward to take purposive decision on which process to adopt.

Dr. D is not only a good positive psychiatrist, he is also a just one.

Justice demands that patients’ autonomy to decide which method to adopt be respected, only scientifically validated advice be given, due discretion be exercised in factors with scarce but emerging evidence, and ‘hustling’ patient into procedures be avoided. All this needs to be done in a non-discriminatory manner.

As a discerning reader would have realized, a just person is one who embodies a judicious mix of benevolence and non-malfeasance in his actions, with respect for the other’s autonomy. In other words, justice embodies the other three biomedical principles. A just person is also one distributes his expertise equally.

Case Vignette 16: The physician’s Evidence versus the Patient’s Belief system in Therapy: Beneficence and Non-malfeasance occasionally trump Autonomy and Justice

An Indian emigrant to the US, who teaches Indian Philosophy there, develops CVD with depressive symptoms and insists on maintaining a pessimistic outlook to life.

The positive psychiatrist advises that a change of attitude towards optimism would help. He presents data that optimism has been studied in the context of a number of serious medical conditions including cardiovascular disease and shown to be associated with less illness-related distress, higher quality of life and satisfaction, and lower incidence of depression [Carver et al., 2010[11]]. He also presents results from a meta-analysis of 83 studies of optimism which found a significant relationship between optimism and physical health outcomes including cardiovascular outcomes, physiological markers (including immune function), cancer outcomes, outcomes related to pregnancy, physical symptoms, pain, and mortality [Rasmussen et al., 2009[63]].

The patient still insists on continuing with his pessimistic outlook towards life, presenting metaphysical arguments that life is essentially full of suffering (the Buddhist position), and that the world is an illusion [the Advaita Vedanta position on ‘maya’].

The physician/psychiatrist had to decide between his duty of beneficence based on scientific findings and the patient’s autonomy to continue to hold on to cultural and religious beliefs which appear to hamper his recovery.

What does the physician do?

In ordinary circumstances, the physician should present the scientific findings, and allow the patient’s sense of autonomy to decide whether to accept it or not. He should wait for the patient to integrate it with his metaphysical beliefs.

But what if the patient resists this, and his pessimism, according to the physician/psychiatrist, is mainly responsible for the lack of recovery? Does he say so directly to the patient? For Beneficence prompts him to do so. Should he decline to continue to treat him, since by allowing the patient to stick to his beliefs, he is causing harm to the patient? (Non-malfeasance)

What about Justice? Being fair to the patient sanctions the patient the right to decide what advice to follow. And therefore to continue to stick to his pessimism. But being just to the patient’s interests enjoins upon the psychiatrist/physician to persevere to change the patient’s belief on the basis of scientific evidence, especially because it directly impacts the patient’s recovery and sense of well being.

Being just to the patient’s autonomy, or being just to the physician’s beneficence? How do we adjudicate?

Here, the psychiatrist seems well within his duties of Beneficence and Non-Malfeasance to discreetly and cautiously ‘override’ the patient’s autonomy and even the physician’s own sense of intuitive justice by ascending in his thinking to a critical ethical level wherein he adjudicates between two or more ‘goods’ and maximizes utility (Hare, 1984[29]). He would be right to persevere with helping the patient modify his pessimistic outlook to become more optimistic in his attitude towards his ailment, to life and living, so as to recover from his cardiovascular condition; even as he accepts that the patient has the right to hold on to his pessimism as a general metaphysical position and a general rule to make philosophical sense of life and living.

In other words, help the patient adopt optimistic means to aid his recovery, even if the patient continues to retain a generally pessimistic philosophy of life.

Both ‘Specification’ and ‘Balancing’ are involved here.

In psychiatric therapy, beneficence and non-malfeasance, therefore, are paramount, and may occasionally but most cautiously ‘override’ autonomy and justice in rare cases when they conflict.

What about the same case in a research setting? Here Autonomy and Justice always trump. See Case Vignette 16.

Case Vignette 16: The Physician’s Evidence versus the Patient’s Belief system in Research: Autonomy and Justice trump Beneficence and Non-malfeasance

Consider the other case of research. This same patient is a subject of research into the role of optimism in CV cases. The same arguments are presented on both sides. The patient decides to stick to his pessimism and demands that his autonomy be respected. The researcher will present data but stop short of trying to modify his attitude if the patient resists his attempts.

Here the patient’s autonomy and justice trump over the psychiatrist’s notions of beneficence/non-malfeasance, because as a research subject, the absolute right to accept or reject a certain therapy is with the patient and not with the psychiatrist. In therapy, the patient has the ultimate, but not the absolute, right. The difference between ultimate and absolute must be clarified. Absolute is ‘no questions asked’. Ultimate is after all questions are asked/clarified. And also when the person is ‘competent’ in legal/medical terms to understand what needs to be understood. This maybe especially applicable to small children, those in coma, those having cognitive decline, or those having loss of insight and judgment, say, in chronic schizophrenia.

Such bioethical ‘Balancing’ will give the much-needed ‘Specifications’ that correctly guide an ethically sound positive psychiatrist.

The authors wish to acknowledge the help of Dilip V. Jeste with the first draft and Barton Palmer with earlier drafts of this paper