Ethics and Boundaries
David Mays, MD, PhD
dvmays@wisc.edu
The Biological Basis of Ethical
Behavior
A Brief Review of Ethical
Decision Making
• Ethics is a branch of philosophy that involves the
analysis of the moral value of judgments and duties.
• Interest in ethics as a field of study has ebbed over the
centuries, but has been revived in no small part by the
growth of biomedicine in the second half of the 20th
century.
• Today most ethical discussion is framed as a contrast
between three ethical systems: deontology, utilitarianism,
principlism.
Deontology
• Deontology is an ethical system based on duties and moral
obligations. Religious laws generally impose a set of
obligatory behaviors that are right or wrong in and of
themselves, regardless of the consequences. Religious
“commandments,” Kant’s “categorical imperative” are
behaviors that are universally binding.
– Tell the truth
– Prohibitions against abortion, transfusions, divorce, murder, eating
certain foods, etc.
– Love your neighbor
– Etc
Utilitarianism
• Utilitarianism states an act is morally right if it imposes the
greatest benefit and imposes the least burden on those
involved. The end justifies the means. However, it is often
very difficult to calculate the consequences of particular
decisions.
– Lying is morally correct if it saves a life.
– Killing may be justified for a moral cause, like self-defense or in a
just war.
– Stealing to get food for your family is part of a higher duty.
Principle-Based Ethics
• Principlism is an attempt to reconcile the discrepancies
between utilitarianism deontology by tying moral decisionmaking to certain principles. This is what is usually taught
in ethics seminars. It is not strictly a theory and it is
intrinsically vague. It is also not hierarchical. It is an effort
to make ethics more practice friendly.
• Four principles often used in medical ethics:
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–
–
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Non-maleficence
Beneficence
Respect for autonomy
Justice
The Train Problem #1
• An out-of-control train is racing toward five hikers, who
are unaware that it is coming. Adam is standing by a
switch and can send the train down a side track, where one
hiker is hiking.
• Is it morally permissible for Adam to switch the train?
The Train Problem #2
• An out-of-control train is racing toward five hikers, who
are unaware that it is coming. Hitting a large object will
cause the train to stop automatically. Beth is standing on a
bridge over the track, beside a large man.
• Is it morally permissible to push the man onto the track,
stopping the train?
Moral Dilemmas: Other Examples
• You are a surgeon in an ER. Five people arrive in critical
condition, needing - 2 needing kidneys, one a heart, one a
liver, one a lung. A healthy young person is waiting to give
blood. Should you take the organs from him?
• You are driving a car in the fog. Suddenly there are 5
people standing in your lane. There is one person standing
in the other lane. Should you swerve and hit the one
person?
Moral Luck and Other Puzzles
• Different outcomes for the same behavior move us to
impose different consequences, even though the only
difference is bad luck.
• Drunk driving example
– How wrong was it to drive drunk? (both equally wrong)
– How bad is the character of each person? (both equally bad)
– How much punishment? (different)
Moral Luck and Other Puzzles
• Why should outcomes matter only for punishment?
– Humans learn better when they have consequences for their
behavior, even if it isn’t in their control.
• However, intent does matter for consequences, as well.
Beginning at 4 years old, intent gradually becomes very
important. In adults, it is the most important. Sort of.
Moral luck continues to operate around the edges of
morality.
• The ability to perceive intent is in the temporo-parietal
junction.
Right Tempero-Parietal Junction
• The temporoparietal junction (TPJ) is an area of the brain
where the temporal and parietal lobes meet, at the posterior
end of the Sylvan fissure. This area is known to play a
crucial role in self-other distinction (our body in space) and
theory of mind. Damage to this area has been implicated in
producing out of the body experiences. It is also the spatial
location of auditory hallucinations in schizophrenia.
• Electromagnetic disruption here has been shown to impair
individual’s abilities to make moral decisions!
Moral Dilemmas - Research
• There is no evidence that straightforward deontological,
utilitarian, or other rules account for the differences we
see in the train problems.
• People are confident in their judgments but are largely
clueless and incoherent in trying to explain why they
decide the way they do.
• There is strong emotional input accompanying the
decision. This emotional contribution is probably shaped
by an individual’s culture, and may serve to reinforce
action.
How Do People Make
Ethical Decisions?
• We know that ethical knowledge does not necessarily
result in ethical behavior, and that multiple personal and
interpersonal influences affect the decision-maker.
• We know that models of ethical decision-making all face
the problem of trying to explain something that is both
familiar and common, and whose mechanisms are
mysterious and complex.
Jonathan Haidt
• Haidt argues that rather than reaching moral judgments by
reasoning and reflection, people grasp moral truths
automatically through intrinsic moral intuitions. Moral
reasoning is used to justify the decision and influence other
people. When people “reason”, they take different
perspectives, activate new feelings, and weigh the feelings
against one another.
The Template for Morality
• Harm/Care
– empathy, concerns about violence, compassion
• Fairness/Reciprocity
– social contracts, equality, rights, justice
• Authority/Respect
– obedience, duty, respect for superiors
• In group/ out group
– loyalty, betrayal
• Purity
– Intuitions of divinity, mind and soul, moral disgust
Empathy
• A newborn baby, barely able to see, can imitate the facial
expressions of adults within 1 hour of birth.
• Empathy is a kind of contagious emotional expression. As
adults we speak and gesture in the same way as the person
speaking to us.
Monkeys and Raisins
• In 1997, four investigators from the University of Parma were
studying the electrical activity of small motor tasks in the brains
of macaques. One researcher walked into the room and picked
up a raisin and ate it. He happened to be looking at the monitor
and saw the electrodes firing indicating a motor activity.
Investigation showed the same pattern as the raisin picking
activity.
Mirror Neurons
• The firing neurons were called “mirror neurons.” The next
question was whether mirror neurons exist in humans.
• The answer is yes, but they are more widely distributed in our
brain, including some areas that have nothing to do with
movement.
• A region full of mirror neurons is Broca’s area.
Broca’s Area
• Mirror neurons in Broca’s area light up:
– When the subject performs an act
– When they see someone else perform the act
– When they hear a description of someone
performing the act
• Is this a key to how human language emerged?
Mirror Neurons
• Neurons in the pre-motor cortex show the same
level of activity when an individual reaches for an
object as when he watches someone else do the
same.
• This also occurs when subjects imagine an action.
• Recent research indicates that this system activates
when we see others experiencing a disgusting
event, or pain. It may underlie the experience of
empathy.
Mirror Neurons
• Mirror neurons fire involuntarily. Their firing patterns encode
not just movements, but the meanings behind the movements.
• They are identical to other neurons under a microscope, but
they have a enormous number of interconnections. They may
continue to expand these connections throughout life.
• And like other capacities, they differ among people.
Mirror Neurons and Empathy
• Subjects with higher empathy scores on psychological testing
exhibit stronger mirror neuronal reactions to facial expressions
of disgust and pleasure.
• Psychological tests of children indicate strong correlations of
mirror neuron activity with empathy scales, not with cognitive
scales.
The Challenge of Living
in Communities
• Functioning in a social context requires us to react to others,
understand the other’s emotional perspective, and separate
one’s own response from the other’s response.
• Mirror neurons fire automatically, allow us to infer intentions,
and fire more robustly when we perform the action ourselves
than when it is observed.
The Challenge of Living
in Communities
• Mirror neurons may represent an experience-based, nonreflective, automatic form of understanding another mind. We
can understand their intentions and predict their future
behavior. And at the same time, we can maintain a sense of
self-identity.
• Interdependence becomes possible.
Empathy Today
• Empathy is not only an innate capacity, but it is also
cultivated by experience. Empathy levels have been falling
among college students over the past 30 years. The last 10
years have seen an especially steep drop. (Not surprisingly,
self-reported narcissism in students has reached a new
high.)
• No one knows why this is happening, but it is
accompanied by a sharp decline in reading for pleasure
among this group. People are also more likely to live alone
and less likely to join groups.
The Dictator Game
• Player 1 is given $10.
• Player 1 offers some amount of money to Player 2.
The Dictator Game - Results
• Many players offer nothing, but some offer $5.
• People who play repeated games with identified people
develop a reputation and generally give around $5.
The Ultimatum Game
• Player 1 is given $10.
• Player 1 then offers some amount to Player 2.
• If Player 2 rejects the offer, nobody gets anything.
The Ultimatum Game - Results
• Players punish unfair offers even at personal cost.
• Responders universally reject offers at $2 or less.
Jonathan Haidt, PhD
• Communities that punish citizens for breaking the rules
have more cooperation among their members.
Brain Studies of Fairness
• When reciprocity fails, or the offer is unfair, imaging
studies reveal significant activation of the anterior insula,
which plays a role in negative emotions such as pain,
distress, anger, and disgust.
• When players engage in punishment, the caudate nucleus is
activated, a key center for pleasurable experiences.
Fairness
• Notions of fairness permeate almost all aspects of life. It is
universal among all cultures. Human beings have the innate
capacity to monitor fairness:
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–
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–
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Some ability to keep tabs
To place values on different things
To judge when an inequity has occurred
To distinguish accidental from intentional giving and reneging
To determine if an unfair act is worthy of retribution
How is the Notion of
Reciprocity Possible?
•
•
•
•
•
Innate sense of fairness
Strong sensitivity to and memory for “cheating”
Intuitions about trustworthy people
Commitment to revenge
Moral emotions:
– Warmth toward kindness, giving
– Guilt
Logic and Social Specialization
• Most people find the first problem is harder than the
second.
• Social contracts tap a specialization that is present in all
human beings. Our minds have evolved a unique
specialization to understand social contracts and to detect
violations.
• This kind of thought operates unconsciously and
automatically. The ability to detect cheaters is found even
in young children.
The Family
• Genetic relatives are more likely to:
•
•
•
•
Live together
Work in each other’s gardens
Protect each other
Adopt each other’s orphaned children
• Genetic relatives are less likely to:
• Attack and kill each other
• Those outside the “family circle” are less likely to be
incorporated in the culture’s “moral thinking” - i.e.
morality does not apply.
nation
community
extended family
family
self
Moral Disengagement:
Social Cognitive Theory
• When people act contrary to moral standards, they activate
disengagement mechanisms to avoid negative selfcondemnation. Moral disengagement is a cognitive process
by which a person justifies his harmful conduct by
loosening self-regulatory mechanisms. People rationalize
or justify harmful acts against others.
• Eight different mechanisms are typically used.
Mechanisms of Disengagement
• 1) Moral justification: the harmful behavior is transformed
into virtuous behavior (hiring young children for work
overseas is better than what might happen if they couldn’t
work)
• 2) Advantageous comparison: comparing the harmful
behavior to more inhumane or immoral behavior (I just
took a little money. Some people stole a lot. And it’s not
like I murdered somebody.)
Mechanisms of Disengagement
• 3) Euphemistic labeling: using sanitized language
(collateral damage, wasting (killing) the enemy)
• 4) Displacement of responsibility: actions are viewed as
the result of social or authority pressures (I had to steal
because I didn’t have a job. I was just following orders)
• 5) Diffusion of responsibility: acting collectively obscures
individual responsibility (Everybody does it)
Mechanisms of Disengagement
• 6) Disregarding or distorting consequences: reduces degree
of guilt or shame (the insurance company won’t miss the
money)
• 7) Blaming the victim: obscures personal responsibility (I
wouldn’t have taken the money if you hadn’t left it sitting
on the counter)
• 8) Dehumanization: victims are stripped of human qualities
and are viewed as objects (redskins, japs, kikes, chinks,
etc)
Moral Disengagement:
Cognitive Distortions Theory
• Three cognitive distortions are seen as leading to
antisocial behavior:
– 1) Causal attributions – blaming people and factors outside the
self
– 2) Minimizing/mislabeling – understating the consequences of
the behavior and/or using dehumanizing labels
– 3) Attributing hostile intentions to others, expecting the worstcase scenario for a social situation – (people are just waiting to
take advantage of me)
How Likely Are We
to Disengage?
• Empathy inhibits moral disengagement.
• Cynicism makes disengagement easier.
• Those who believe strongly in fate are more likely to
disengage.
• Those who think of themselves as moral people are less
likely to disengage.
Philip Zimbardo’s List:
The Lucifer Effect
•
•
•
•
•
•
•
Mindlessly taking the first small step
Dehumanizing others
Anonymity
Diffusion of personal responsibility
Blind obedience to authority
Uncritical conformity to group norms
Passive tolerance of evil through inaction or indifference
The Moral Emotions
• Pleasant emotions:
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•
•
•
•
Awe
Gratitude
Love
Compassion
Acceptance
• Uncomfortable emotions:
–
–
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Guilt
Shame
Regret
Remorse
Moral Emotions
• When emotions become involved in our beliefs, it may
involve us ascribing “sacred” status to what we think.
• A sacred value is more than just a strongly held belief; it is
a moral stance on which the believer will not budge, no
matter what the conditions. Examples may include “the
right to choose,” “the right to life,” the belief that sharia
(Islamic law) must be the law of the land, etc.
“Sacred Beliefs”
• Studies show that when people are offered money to
relinquish a sacred value, the respond with “moral
outrage,” even though the proposition is not objectively
immoral (offering compensation to remove Jewish settlers
from the disputed West Bank in Jerusalem, e.g.) Believers
usually become even more intransigent.
• When a value becomes “sacred”, the rules of negotiation
change. For instance, the stakes must be raised,
consequences of non-compromise must be dire, and both
sides must give up something they hold dear.
Problems With Intuition
• Intuition can be very accurate in many situations.
However, intuition also leads us astray in certain ways.
– We overvalue the possibility of regret. We feel losses more than
gains. We don’t act.
– The way choices are defined influences our emotions. (80% live vs
20% die)
– We think more memorable events are more frequent.
– Confirmation bias – we see evidence for what we believe to be
true.
– We find stories more compelling than data.
Gender
• Are there real differences in the way men and women think
about the world?
• Probably. It’s just that we don’t know what they are.
What About Gender?
• We all seem to believe there are fundamental differences
between men and women, but surprisingly, researchers
have found very few large-scale differences in brain
structure or function.
• Boys have larger brains (and heads) than girls from birth to
old age. Girls’ brains mature earlier, especially for impulse
control, language and fine motor skills. Brain scans show
some structural differences. But since experience itself
changes the brain, it is hard to determine what is inborn
and what is cultural.
Biology: Testosterone
• Sex hormone levels do not differ between boys and girls
from six months of age until puberty, so differences seen
in these years are due to either fetal testosterone exposure
or cultural differences.
• It seems that, on average, boys are more physically active
than girls (31% of girls are more active than boys!) This
is seen even in fetal movement.
• In infancy, both genders like dolls. By toddlerhood, boys
and girls who were exposed to high levels of testosterone
during pregnancy prefer trucks and cars. This is also true
with monkeys.
Biology: Visual / Spatial Skills
• Gender differences in spatial skills are among the largest of
the cognitive gaps. The average man can perform mental
rotation better than 80% of women. This difference is seen
in babies as young as 3 months and is probably due to fetal
testosterone.
• Some studies show that women use the prefrontal cortex
(landmarks and geometric cues) when solving a 3dimensional maze, whereas men use the left hippocampus
(memory and spatial mapping.) Women tend to be better at
remembering positions and landmarks. Men tend to
navigate by remembering directions.
Cultural Caveat
• Women do worse at math tests when they are required to
write their gender on their papers. Men do better.
• Women do 30% better on math tests when they are
reminded about what a good school they go to or how
much they have learned.
• Women, in general, perform better in college math classes
than their aptitude scores would predict, and men do
worse.
Culture: Activity
• Mothers discourage physical risk taking more in daughters
than sons. Fathers encourage more physical play and risk
taking in both genders. By eight weeks, babies picked up
by mothers will calm down, but when picked up by fathers,
will show an increase in respiration and heart rate.
• Peers strongly effect activity level: all-boy groups tend to
be more energetic, girl groups tend to settle down the more
active girls.
Culture: Play
• Peers reinforce gender norms even more than parents.
Girls tend to cross-over more than boys – they are
encouraged to play sports, wear pants, and play with Legos
more than boys to wear dresses and play house.
Biology: Aggression
• Boys are more physically aggressive than girls. This is due
to fetal testosterone, since aggression does not worsen at
puberty, when testosterone levels rise.
• Male bullies usually have few friends, act alone, are
socially inept, and don’t know the boy they bully.
• Under threat, men report a sharpening of senses and a
feeling of exhilaration (sympathetic nervous system
response)
• Men tend to be physically aggressive and then bond after
the fight.
Culture: Aggression
• Girls tend to be more indirectly aggressive than boys.
Gossip, ostracism, eye-rolling, and harassing text
messaging can do great damage to peers.
• Females tend to be aggressive by excluding and do not
make up and bond after the fight.
• Female bullies have many friends, are socially skilled, act
in groups to isolate a single girl, whom they know.
• Women report unpleasant feelings of dizziness and nausea
under threat (parasympathetic response.)
Biology: Empathy
• Girls and women score higher on most measures of
empathy, but this difference is fairly small. Women are
more likely to say they are good at knowing how others
feel, but men and women differ little in objectively being
able to read faces or voices – the average woman is better
than 66% of men.
Culture: Empathy
• Little girls start out a bit more sensitive than boys, but the
advantage grows over time due to stronger communication
skills, role playing with dolls, and having more intimate
friendships than boys.
Biology: Language
• Girls begin talking about one month earlier than boys and
are 12% ahead in reading by kindergarten. By the end of
12th grade, they are significantly better readers and writers.
This difference shrinks in adulthood.
• The superior temporal cortex (important language center)
is 29% larger in women than men, but this may reflect
environmental differences during development..
Culture: Language
• There is no neurologic evidence that girls process language
differently than boys. Differences are probably much more
due to environment and language exposure. Girls read
more than boys.
Biology?: Language
• Men’s talk tends to focus on hierarchy, women’s on
connection. Boys are very competitive, girls will even
imitate odd syntax when talking (“My babysitter has
already contacts.” “My mom has already contacts and my
dad does, too!”)
• Women may try to bond with a man by talking about
problems. Men may misinterpret that as a request for help.
He will then get blamed for failing to listen, whereas he
cannot fathom why she would keep talking about a
problem if she doesn’t want to do anything about it.
Culture: Visual / Spatial
Abilities
• The gap is smaller in children than adults. Exposure to
targeting, throwing, driving and shooting games widens
the difference. Girls improve if they are given these
experiences, just as boys become more empathic. Women
do better on 3-dimensional rotation tests when they are
told they are naturally good at it.
Culture: Humor
• Both men and women look for a sense of humor in a
potential partner. Humor is a good indicator of
intelligence. What women mean is: someone who makes
me laugh. Men mean: someone to laugh at my jokes.
• Both men and women laugh more at men than women.
• Men find women more attractive when they laugh.
Laughter seems to be a sign of enjoyment and an invitation
to continue. It is a powerful measure of the attraction
between two people.
Culture: Humor
• During courtship, men are usually the
producers of humor and women the
appreciators. However, in long-term
relationships, the woman’s sense of humor
predicts relationships that will survive. The
man’s humor may be more detrimental
(aggressive and disparaging.) Women’s
humor during tense discussions tends to
lower a man’s heart rate and relieve tension.
Biology + Culture
• Average IQ scores for men and women are
the same, but more males score at the very
top and the very bottom.
• Surveys show that at rest, men are more
attuned to the outside world, women to their
internal state.
Dads as Parents
• Dads are more stimulating to infants in part because they
tend to be more physical and unpredictable.
• Fathers are less verbal with their children, but fathers’
language use, not mothers’, independently predicts
language development at age 3. The size of the mothers’
vocabulary makes no difference. They use more unusual
words, talking about sports and cars, and fewer emotion
words.
• Kids who have stable and involved dads are better off on
nearly every cognitive, social, and emotional measure
that researchers can devise. The marriages are better and
they are happier.
Dads as Parents
• In many cases where dads are not functioning as active
parents, it is because moms use their power to block
fathers’ participation, acting as gatekeepers. This is
especially true of women with low self-esteem.
Culture: School
• In kindergarten, girls are more articulate, have better
handwriting, and answer questions faster.
• Girls outperform boys throughout the entire educational
process, including college.
• Men seem to be better at word problems, women at
calculation.
Culture: Math
• Boys younger than 13 scored 700 on the math part of the
SAT’s more often than girls at a ratio of 13:1 in 1983. In
2005, the ratio fell to 2.8:1. This is not “hard-wired.”
• At the International Mathematical Olympiad, top rated
teams from Bulgaria, Russia, and Germany have 15-20
girls. The US typically has ~3.
Biology + Culture
• Men are more likely to compete and show off, especially
violently, to attract a mate. This is true throughout the
animal kingdom.
• In terms of socialization, women have more intimate social
connections, are more concerned about them, and feel
more empathy toward friends. They smile and laugh more.
They are more attentive to infants’ everyday needs, but not
distress cries.
• Women tend to maintain friendships based on selfdisclosure. In men, self-disclosure arises out of shared
activities, often “rough-housing.”
Biology + Culture: Pathology
• Boys don’t see or hear as well as girls. Women are more
sensitive to sound and smell.
• In child mental health services, the patients are
predominantly boys, suffering from autism, hyperactivity,
learning disabilities, conduct disorders, and anxiety. Boys
have more stuttering, dyslexia, stress headaches, GI
problems, asthma and tics.
• Parents have more difficulties with their sons. Teachers
have more difficulties with boys.
Biology + Culture: Pathology
• This all changes at puberty when virtually all psychiatric
disorders (except substance abuse, schizophrenia, and
impulse disorders) become substantially more common in
women.
• Depression and anxiety disorders are twice as common in
adult women as men. Estrogen and testosterone have
effects on serotonin and GABA that contribute to this.
Substance Use
• The risk for substance use in adolescent girls is primarily
related to peer pressure, and participating in sports is
protective.
• In adolescent boys, playing sports is a risk factor for
substance abuse. Peer pressure is less important.
Biology + Culture: Pathology
• Friendship networks are larger in women, which tend to
buffer stress.
• Also, marriage is protective against mental illness in men,
but not women, who are more at risk after they are
married.
• Women, in general, act as caretakers of spouses, children,
and aging parents, and may “pay the price of caring.”
Biology + Culture: Stress
• When humans are stressed, oxytocin is released in the
brain causing increased bonding to others, nurturing of
children, and increased calming. Testosterone reduces this
effect, estrogen increases it.
• Men often withdraw to cope with stress – watch TV, work
on a project.
• Women often process stress by seeking out more
connections with people – talking about it.
Gender Differences
• Response to stress
– Men typically interrupt and give solutions when a woman is
talking about stress, and say “You shouldn’t be upset.” (This is a
mistake.)
– Women tend to offer advice to a man when he is not upset and
may be quite happy with what he is doing. This can cause a man to
“tune out.”
Gender Differences:
Cultural vs. Biological
• Men and women do not differ in moral reasoning, level of
intelligence, or basic emotional traits. They share virtually
all the same genes.
• Men are not from Mars and Women are not from Venus.
• Men and women are from Africa.
Summary: The Moral Faculty
• Human beings are born with the parts of a universal moral
“grammar” that constrains the range of possible moral
behavior.
• Human capacities that allow us to care about morality
include:
–
–
–
–
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Fairness
Reciprocity
Intuition about social contracts
Empathy
Moral emotions
Summary: The Moral Faculty
• Each principle generates an automatic and rapid opinion
about whether an act is morally permissible or forbidden.
• These principles are inaccessible to conscious awareness.
• Acquiring the moral system is fast and effortless,
requiring little or no instruction.
• Cultures “wire” these universal capacities in specific
ways, associating different behaviors with our moral
emotions. They become our cultural values: e.g.
autonomy, spiritual purity, etc.
Summary: The Moral Faculty
• It is the unconscious nature of the ethical decision making
process, combined with the power of the emotional
content, that makes moral conflicts so intractable.
“ PEOPLE WHO BELIEVE
THEY HAVE THE TRUTH
SHOULD KNOW THEY
BELIEVE IT, RATHER THAN
BELIEVE THEY KNOW IT.”
Jules Lequier
Research on Helping Others
Become More Ethical
• People who are emotionally secure show more empathy
to others. They are more likely to to offer to do an
unpleasant task for a stranger if they had been made to
feel more confident.
• Buddhist monks who practice compassion meditation
develop more compassion in day to day situations, as
measured by brain scans.
• One person who refused to shock the participant in the
classic experiment said he was raised in a home that
taught him to question authority and in the army he was
taught to refuse illegal orders.
Spirituality, Religion,
and Worldview in
Mental Health Care
Religion in America
• Religious membership in America is higher than in any
other industrialized country except Northern Ireland. There
are 300,000 religious congregations in the US – an
enormous variety compared to the rest of the world largely because there has never been an official “U.S.
Church.”
Christians in America
(Pew Forum on Religion and Public Life, Feb 2008)
America’s Four Gods
Froese, Bader 2010
The Four Gods
• This is for didactic purposes only. Most people have some
sort of mixture. This is a generalization.
America’s Four Gods
• Authoritative: We will lose God’s favor unless we do what
He demands. God is engaged in human history and
rewards countries that follow His will and gets angry,
punishing countries that disobey Him.
– Theme: the righteous vs. the heathen, obedience, duty, and the
loving embrace of God, the Father.
– Common beliefs: homosexuals choose to be homosexuals and are
sinners; abortion is murder; personal faith solves problems, not the
government; God causes or allows disasters as punishment, but
will reward you with love and happiness if you are faithful.
Case Example
• You are seeing an adolescent boy who is having
some school and mild behavior problems, possible
related to ADHD, as well as common adolescent
rebelliousness. You like this teen, but the parents,
especially the father, seem unreasonably harsh and
rigid. During the course of the therapy it comes out
that the family attends a church that teaches
unrelenting obedience to God and the tenets of the
Bible as the only path to happiness and salvation.
The parents believe if they let up on their son, they
are literally condemning him.
America’s Four Gods
• Distant: God is the cosmic force that set the laws of
nature in motion, but does not intervene. God is not
a person (God does not get “angry”, for instance.)
We see evidence of God in the beauty of the natural
world, which was created, but now runs according
to natural law.
– Theme: God is the master watchmaker. A storm is just
a storm.
– Common beliefs: God may be a force for good, but we
must take care of our own planet, our people, our
future.
Case Example
• Your client has come to see you for help regarding
ongoing grief after the death of his 8 year old son a year
ago. The issue is also proving to be a wedge between him
and his wife, who has found comfort in talking to their
minister. He has explained that life and death are all part of
a larger plan, and that we must surrender to “not knowing”
but also believe that God will take care of us. The husband,
you discover, does not believe that there is any meaning to
life or death; that the universe is vast and neutral, and that
we are alone in trying to manage our sorrows.
America’s Four Gods
• Benevolent: God is a force of good, and loves us, weeps
for us in our struggles, and will support us through
everything, even when we do bad things.
– Theme: God is love and will comfort the sinner and the saint, the
rich and the poor, the first and the last.
– Common beliefs: God often performs miracles outside the laws of
nature, but does not have a hand in disasters or tragedies, which are
the doing of either mankind or the natural world.
Case Example
• You are seeing a mother and daughter, referred by the oncology
service at University Hospital. The 14 year-old daughter has been
diagnosed with a life threatening leukemia and is undergoing
chemotherapy. The mother seems positive, almost cheerful, and the
daughter feels angry and dismissed. The mother keeps trying to explain
that God and his angels are watching over her, and will take care of
her, and that they just need to trust in His love.
America’s Four Gods
• Critical: God will sit in judgment on human beings in the
afterlife, but He is not involved in our day-to-day lives.
This view is held most often by the poor, ethnic minorities,
or exploited.
– Theme: this world is a vale of tears. Our rewards or punishments
will come in the afterlife.
– Common beliefs: God has no role in the rise or fall of
governments, natural disasters, etc. Don’t expect much in this life.
Case Example
• You are frustrated in your work as a case manager with a
large clientele of poor, unemployed clients. Many of them
refuse to vote in the upcoming elections because they say it
won’t make any difference, and anyway, their minister
says, “Don’t you worry about this life, you’re going to be
dancing on streets of gold for eternity if you just pray to
Jesus.”
Changes in the Last 15 Years
• There has been a move away from mainstream Protestant
churches to non-denominational “Mega-Churches.”
• Immigrants keep the percentage of Catholics in the US
around 32% despite losses in the established population.
• The greatest growth has been in the Evangelical Christian
group and in the Unaffiliated group.
• About 30% of Americans leave the religion they were
raised in. 50% of Americans who were not raised in a
church join one as an adult.
How Much Do We Know About the
Different Religions?
(Sample questions, all multiple choice, Pew Forum on Religion
and Public Life, 2010, n=3,400))
•
•
•
•
•
•
•
•
Who led the Exodus out of Egypt? (Moses)
What was Mother Teresa’s religion? (Catholic)
In what religion is Ramadan a holiday? (Islam
What religion did Joseph Smith found? (Mormon)
What is the primary religion of Pakistan? (Islam)
What religion is the Dalai Lama? (Buddhist)
Who was the important figure of the Reformation? (Martin Luther)
Which figure represents the tenet to obey God in spite of your
suffering? (Job)
• Nirvana represents freedom from suffering in what religion?
(Buddhism)
How Much Do We Know About
Different Religions?
(Pew Forum on Religion and Public Life, 2010, n=3,400)
A Few Findings From
the Survey...
• 64% believe that you cannot mention the Bible in a public
school, even as a topic of study.
• 53% of Protestants don’t know who Martin Luther was
• 47% of Americans don’t know who the Dalai Lama is
• Only 27% know that Indonesia is primarily Muslim
• 40% don’t know who the Vice President is, even on a
multiple choice.
Psychological Research
and Belief
• A person’s religious feelings includes a genetic
component. (It is known from twin and adoption studies
that early environment begins to become less influential
and genetic influences more important around the age of
18-25.) It is also fairly well established that the genetic
component of personality consists of 5 traits:
–
–
–
–
–
Extroversion
Neuroticism
Agreeableness
Conscientiousness
Openness
Beliefs and Personality Traits
Belief
Extroversi
on
Agreeablene Conscientio
ss
usness
Neuroticism
Openness
Religious
High
High
Fundamentali
sm
High
High
Low
High
High
High
Low
Low
High
High
Low
Spiritual
High
Creative
Authoritative
Paranormal
High
High
Beliefs and Personality Traits
• These effects are modest, but they have been found
consistently by many different studies (Saraglou, Sci Am
Mind May/June 2012). Specifically, the trait of openness
distinguished between people who were fundamentalist
and people who were more broadly spiritual.
• Research also suggests that people are more likely to be
religious if the community around them is religious (VT
vs. MS, Sweden vs. Egypt). It is a social rather than
individual force.
• Finally, religious people are happier than non-religious, but
only if the society to which they belong values religion
highly and they have friends in their congregation.
People in Need
• Americans are more likely to turn to religious institutions
when they have serious problems than to the government or
health and human services organizations.
• 77% of those who seek medical care feel that their religious
beliefs are directly related to their health concerns.
• Only 16% of health professionals ask about spiritual issues.
Spiritual Beliefs and Your Doctor
• 85% of patients trust their doctor more if the doctor
addresses their spiritual concerns.
• 95% want their family practice doctor to a consider their
spiritual beliefs in the case of serious illness, 86% when
they are admitted to a hospital.
Prayer and Health Beliefs
(CBS poll, 1999)
• 30% of Americans believe a moral life prevents illness
• 80% of Americans believe prayer can help people recover
from disease (2005 ABC and USA Today poll)
• 50% of patients would like their physicians to join them in
prayer. (Yankelovich 1996)
• 63% believe a doctor should join a patient in prayer if
requested
• 34% believe prayer should be a standard part of medicine
Belief in the Supernatural: Pew
Forum on Religion, 2009, n=4,000
Anomalous Experiences
• An experience that deviates from the usually accepted
explanations of reality
–
–
–
–
–
Mystical
Near-death
Telepathy
Clairvoyance
Precognition
Mystical Experiences
•
•
•
•
30-40%, increased during the last 30 years
Typically last 1-3 hours
Ineffable
Sense a unity of all things, timelessness, spacelessness,
loss of self
• Visions, voices, telepathy, contact with the dead, new
sense of purpose
• Often correlated with better psychological functioning,
promotes healing and change
Near-Death Experiences
• A clearly identifiable phenomenon that occurs in 5-30%
patients who are clinically dead and then resuscitated.
• Patients report a continuity of subjective experience,
including leaving the body, observing hospital events,
passing through a dark tunnel, experiencing a bright light,
meeting spiritual beings.
• Long-lasting effects include stronger empathy, more
involvement with family, greater sense of purpose, less
fear of death, more appreciation of life
Sacred Moments
• Many people perceive “sacred moments” in their lives –
moments of transcendence (apart from the ordinary),
boundlessness, and a feeling that a deep truth has been
revealed.
• Sometimes anomalous experiences become sacred
moments to individuals. Other times, a perfectly prosaic
moment may rise to sacred status.
• These are not unusual. (For example, the majority of
people who have lost a loved one report a continued
connection with them – a voice, feeling a touch, sensing a
presence, etc.)
Sacred Moments
• We do not need to get tangled up in trying to decide
whether these moments are factual, or to lose focus on the
client by getting wrapped up in our own beliefs or
unbeliefs.
• These moments have significant power for many people.
They offer the capacity to soothe, comfort, inspire and
empower. They can provide individuals with a way to find
meaning in life. They represent an important opportunity
for alliance and progress in therapy.
Definitions
• Worldview is an intellectual response to life’s most basic
questions. It is one’s philosophy of life.
• Religion is the form that spirituality takes within given
traditions and involves a belief in God.
• Spirituality is concerned with one’s connection to a larger
context of meaning - that there is more to life than the
material. In surveys, it has become hard to distinguish
purely humanistic beliefs from those involving a supreme
being or the sacred realm. There may be four different
focuses of spirituality (or a mix!)
Four Types of Spirituality
• Religious: sense of closeness and connection to the sacred
as described by a specific religion.
Four Types of Spirituality
• Humanistic: sense of closeness and connection to
humankind, often involving feelings of love, altruism
Four Types of Spirituality
• Nature: sense of closeness and connection
to the environment or to nature, often
involving feelings of wonder and awe.
Four Types of Spirituality
• Cosmos: sense of closeness and connection
with the whole of creation, often involving
reflecting on the vastness and magnificence
of the universe.
Philosophy of Life
• The worldview of the patient and clinician contribute to the
success or failure of the treatment.
– Understanding the patient requires the clinician to know the
patient’s worldview.
– The worldview of the clinician influences his or her clinical
impressions and judgment.
Research Problems of Religion
and Spirituality
• How do you measure religiosity and spirituality?
– Attendance at church? Attendance at other church events?
Frequency of prayer? Core beliefs and values?
• Almost all of the studies are done as cross-sections, not
longitudinally. How do these beliefs change in relation to
health? Sudden change may be unstable over time.
• We don’t know much about the mediators of R/S.
– Social support? Secular vs. religious coping? Optimism? Selfesteem? Confidence? Motivation?
The Research: Summary
• Most studies of religiosity and spirituality have been found
to be related to reduced morbidity and mortality, better
subjective health, and lower psychological distress. In
general, they are related to less substance abuse.
• Some studies have focused on religiosity and spirituality
linking to feelings of guilt, shame, passivity, and coping in
the form of prayer for vengeance and “righteous anger.”
The Research: Summary
• Studies comparing faith-based clinical care versus standard
care are mixed and inconclusive. 12-step programs work
better when the participants actively participate, rather than
merely attend, but we don’t know how important the
spiritual component of AA is. Increases in
religiousness/spirituality during participation do tend to
predict abstinence.
2011 Review of R/S in Therapy
(Worthington 2011)
• 51 studies, 3,290 subjects
• Results:
– Patients in R/S therapies do better than in “no treatment” control
groups
– Patients in R/S therapies have better spiritual outcomes than those
in other psychotherapies
– Psychological outcomes are the same for R/S therapies and
standard therapies
– Independent research indicates that accommodating patient
preferences modestly enhances treatment outcome.
Spirituality Effects Health –
Positive
• Church attendees with sickle cell disease had lower scores
on pain measures (J of Nerv Ment Dis, 2005)
• Personal devotion and conservative religious beliefs were
inversely related to substance abuse and dependence (J Am
Acad Child Adol Psych, 2000)
• Most associations of religious commitment and mental
health published in the professional literature are positive
(Am J Psych, 1992)
Spirituality Effects Health –
Positive
• Religiously involved youth are less likely to be antisocial
(J Soc Issues, 1995)
• Adolescents’ religious commitment delays the age of first
sexual intercourse, but also makes contraception less likely
(J Marr Fam 1987)
• Religiousness is inversely related to anxiety (Prof Psychol
Res Pract, 1983)
• Religious injunctions may encourage people to live a
physically healthy lifestyle.
Spirituality Effects Health –
Positive
• A 2011 study of alcoholism treatment found that in 364
people (mean age 44), changes in spirituality and
religiousness predicted decreased drinking and fewer
occurrences of heavy drinking when drinking did occur.
The effect was independent of AA participation. The
specific associations were with learning to forgive
yourself, praying, and stopping seeing oneself as punished
by God.
Spirituality Effects Health Negative
• Countless people have died because their religious beliefs
have led them to refuse medical care (Christ Sci, Jehovah’s
Wit)
Spirituality Effects Emotional
Resilience
• Elderly African Americans with religious involvement
show higher levels of personal growth, self-acceptance,
positive relations with others (J Couns Psych 2005).
• Religiosity predicts shorter time to remission of depression
(Handbook of Religion and Mental Health, 1998)
• Personal devotion buffers the effects of life events on
individuals prone to depression (Am J Psych, 1997)
Spirituality Effects Emotional
Resilience
• Being religious is associated with less depression, better
self-esteem and better self-care among family caregivers of
persons with serious mental illness (Psych Serv 2006).
• Religious coping in schizophrenia (Am J Psych 2006)
• R/S has a protective effect against the development of
depression (Am J Psych 2012).
Schizophrenia and Religion
• 100 clients
• 61% Christian, 9% other traditional religions, 12% from
minority religions (Christian Science, Scientology, etc),
18% no religion
• 56% did not practice with other people, 14% occasionally,
30% regularly
• Religion was important to 85%, 45% said it was the most
important thing in their lives. 78% said it was essential in
coping with day-to-day life.
Positive Coping - 71%
• “I always have the Bible with me. When I feel I am in
danger, I read it and I feel I am protected.”
• “For some time everyday, I feel other people can control
me from a distance. The Buddhist monk told me it was
only my imagination, and he teaches me how to meditate.
In this way, I distance myself from this idea of control. I
tell myself this is just a symptom of my illness.”
• “If you tell yourself that you have an eternal life ahead of
you, you know that the voices will end.”
Positive Coping - 71%
• “I am anxious about meeting people, so beforehand I pray
that everything will be OK. Then I am confident in the
situation.”
• “When I feel despair, prayer helps me find peace, strength,
and comfort.”
• “My life did not turn out like I wanted. I dreamed of being
a movie star. I do not have a wife. I am unable to work. I
have been hospitalized against my will. After all this, I
consider myself happy. God gives me all I need.”
Spirituality And Happiness
• Three character traits have been found to effect our overall
sense of well-being:
–
–
–
–
Self-directedness (responsible, purposeful, resourceful)
Cooperativeness (tolerant, helpful, compassionate)
Self-transcendence (intuitive, judicious, spiritual)
(Psych Annals 2006)
Schizophrenia and Religion
• 100 clients
• 61% Christian, 9% other traditional religions, 12% from
minority religions (Christian Science, Scientology, etc),
18% no religion
• 56% did not practice with other people, 14% occasionally,
30% regularly
• Religion was important to 85%, 45% said it was the most
important thing in their lives. 78% said it was essential in
coping with day-to-day life.
Positive Coping - 71%
• “I always have the Bible with me. When I feel I am in
danger, I read it and I feel I am protected.”
• “For some time everyday, I feel other people can control
me from a distance. The Buddhist monk told me it was
only my imagination, and he teaches me how to meditate.
In this way, I distance myself from this idea of control. I
tell myself this is just a symptom of my illness.”
• “If you tell yourself that you have an eternal life ahead of
you, you know that the voices will end.”
Positive Coping - 71%
• “I am anxious about meeting people, so beforehand I pray
that everything will be OK. Then I am confident in the
situation.”
• “When I feel despair, prayer helps me find peace, strength,
and comfort.”
• “My life did not turn out like I wanted. I dreamed of being
a movie star. I do not have a wife. I am unable to work. I
have been hospitalized against my will. After all this, I
consider myself happy. God gives me all I need.”
Negative Coping - 14%
• “I suffer from being so isolated. I went to church in order
to meet people. But when I read the Bible it disturbs me. I
begin to think I have behaved wickedly and then believe I
am the devil.”
• “I went to church to be healed. I believed Jesus would help
me, but this is a lie. More problems came, like a curse,
God is a cruel God. I want to die because I suffer too
much.”
Spirituality May Be the Focus of
Psychiatric Illness
• Clients with psychotic disorders frequently incorporate
religious delusions and themes.
Psychosis or Religion?
• Patients with religious delusions demonstrate intense belief
that occupies their entire thinking. They tend to endorse
details that exceed traditional expressions of this belief.
• Functioning and behavior typically deteriorate. Other
symptoms of psychiatric illness can be seen.
Psychosis or Religion?
• Religious delusions
– Persecutory: usually involving the devil
– Grandiosity: usually involving God
– Belittlement: usually involving unforgivable sins
• Many practitioners are concerned that addressing religion
may appear to support delusional thinking. (Spiritual
Competency Resource Center, www.internetguides.com)
When on unfamiliar ground, getting consultation with
appropriate religious authorities may help.
Spirituality is Fundamentally
Related to Suffering/Meaning
• The task of putting suffering into perspective requires that
the therapist and client grapple with larger questions, e.g. a
person who has always believed and trusted God to take
care of him/her may feel betrayed or even punished if
he/she experiences grave misfortune. (J Psychother Pract
Res, 2001)
Freud
• Freud’s worldview was strongly materialistic and
dogmatically atheistic, which fueled his intense lifelong
attack against spirituality. He believed religion was
childishness and hoped people would soon outgrow it.
(“God is nothing other than an exalted father.”)
• “Religious people lack qualities essential to mental
health.” (A. Ellis, 1983)
Spirituality and Psychiatry
• A recent survey shows that religious physicians may be
more prone to refer distressed patients to clergy or other
pastoral counselors rather than to psychiatrists.
Changing Times?
• A 2007 survey of 2,000 psychiatrists indicates that
psychiatrists are more likely than other physicians to
address religion/spirituality in the clinical setting and do so
comfortably.
• 75% of psychiatrists describe spiritual influences as
positive (slightly higher for other physicians.)
• Psychiatrists (82%) are more likely to say that religion can
also have a negative influence than other physicians (44%.)
The Clergy and Mental Illness
• The clergy serve ~40% of Americans with mental health
problems. In fact, some studies show that they are more
likely to be sought out for guidance on mental health
issues. Women, people who have been widowed, and the
elderly are more likely to seek out clergy.
• 50-80% of clergy report their counseling training in
seminary as inadequate, yet less than 10% referred those
counseled to a mental health professional. In a recent
study, almost half of 98 surveyed clergy members failed to
recognize serious mental illness in 2 vignettes, and said
they would not refer them to more professional help.
Doing the Assessment
•
•
•
•
Deal with personal discomfort
Listen (receive, appreciate, summarize, ask)
Be prepared to answer questions
Be aware of countertransference
Private Matters
• Spiritual beliefs and feelings are usually private and held to
be sacred. A trusting relationship and good treatment
alliance are crucial.
• Treaters need to be aware of their own beliefs and at the
same time increase their awareness and empathy for other
spiritual traditions. The clinician’s primary goal is to
promote the client’s self-determination and not be a
missionary for any particular value system.
Screening: FICA
•
•
•
•
F - Is religious faith important to you?
I - Has faith influenced your life?
C - Are you part of a religious community?
A - Are there spiritual needs that should be addressed?
Developmental History
•
•
•
•
•
•
First religious experience?
Religious training?
Similarity to parents’ beliefs?
Any traumatic religious beliefs?
Conversion experience?
Desires for spiritual development?
Community
• Participation in church, synagogue, etc?
• Have you changed churches and why?
• What support have you received?
God
•
•
•
•
Belief in the existence of God?
What is God like?
How has your belief influenced you?
How do you experience God?
Belief
•
•
•
•
•
Single most important religious belief?
Beliefs that you doubt the most?
Beliefs you doubt the least?
Your understanding of suffering in the world?
What is a life with purpose?
Rituals and Practice
• Prayer?
• Other private religious practices?
• Attendance of worship services?
Spiritual Experience
•
•
•
•
Any spiritual experiences?
Impact on direction of life?
Have you told others about these experiences?
Importance in daily life?
Fetzer Assessment Tools:
www.fetzer.org
•
•
•
•
•
•
•
•
•
Daily spiritual experiences
Meaning
Values
Beliefs
Forgiveness
Private religious practices
Religious/spiritual coping/history
Commitment
Organizational religiousness
Spirituality in the Clinical Setting
• The first step is communicating a genuine interest in and
compassion for the client.
• When clients talk about anomalous experiences
– Provide support without judgment
– Focus on how the client interprets the experience, not whether or
not it happened
– Normalize, if possible
Varieties of Therapy
• Some clients want religious/spiritual beliefs
accommodated in treatment. Some clients will accept
secular treatment. Still others who are willing to be in
secular treatment, might benefit from treatment in their R/S
framework.
• R/S psychotherapy will share the same goals as secular
therapy, but will also incorporate methods and goals that
are R/S in nature (prayer, religious imagery…) The therapy
may also include goals of a spiritual nature (being more
like Jesus, following the 8-Fold Path of Buddhism…)
Examples
• Christian–Accommodating Cognitive Therapy for
Depression
• Spiritual Self-Schema Therapy for Addiction
• Christian-Accommodating Forgiveness Therapy
• Muslim-Accommodating Cognitive Therapy for Anxiety
Potential Transference Problems
• Clients may respond to therapist like a religious figure in
their life
• Clients may be ashamed in the presence of a therapist of
their own faith
• Clients may be suspicious of therapists who do not share
their traditional values
• Practitioners need to remember they are moving into
emotionally volatile ground. Some clients have
experienced harsh or punitive forms of religion, or abuse at
the hands of authority figures.
Countertransference
• Some of us have a difficult time bringing up the issue at
all.
• Under the influence of religious countertransference, a
clinician can begin acting rigidly and thoughtlessly toward
a client, as if the client = religious beliefs. This obstructs
therapeutic relationships, obscures treatment options, and
demeans the humanity of the clinician.
Potential Countertransference
Problems
• A zealous therapist may feel compelled to convert the
client to his/her beliefs.
• A therapists from the same tradition as their client may be
tempted to act as a spiritual mentor.
• A therapist might recoil from a client with spiritual views
that the therapist finds repugnant.
Negative Countertransference
• Antidotes:
– Work toward experiencing the client as a complex human being
– Consciously utilize expressions of respect
– Show interest and listen attentively
• What life experiences made this an important belief?
• What was your life like at the time?
• With whom do you share this belief?
Potential Countertransference
Problems
• Therapists have been shown to pathologize beliefs that
they do not understand (karma, primary importance of the
soul, angels, what happens after death is more important
than what happens during life, etc.)
• Therapists may underestimate pathology in clients who do
share their beliefs.
Boundary Basics
• A boundary violation can occur when the therapist uses the
power of the therapist role to advocate for a specific
religious belief.
• Self-disclosures should be kept to a minimum because of
the power differential in the therapy relationship. Clients
may agree with the therapist’s personal spiritual approach
because they fear their care will be compromised if they
disagree.
Boundaries: A Conundrum
• Clients deserve to know how the therapist will respond
when he/she hears about the abortion, homosexuality,
religious beliefs, moral failures, etc. that are part of the
client’s history and possibly part of the chief complaint.
This is an issue of informed consent.
• However, many clients want to know more than the
therapist feels comfortable sharing, for personal and
therapeutic reasons.
No Clear Answers...
– There are no clear answers. The classic approach is the
safest: when a client desires more information about the
therapist, the follow-up should be an inquiry about the
significance of that information for the client and the
therapy. “How will this help you get better?”
The Request for Prayer
• You work at the Dean Clinic. A 45 year old man is seeing
you for an anxiety disorder and some career problems. He
is not psychotic and there is no evidence of personality
pathology.
• At the third session of therapy, he requests that you join
him in prayer. He explains that he is a Christian who tries
to incorporate his faith into all aspects of his life, and
wants to invite Christ to participate in his healing.
A Brief Review of
Ethical Decision Making
• Ethics is a branch of philosophy that involves the
analysis of the moral value of judgments and duties.
• Interest in ethics as a field of study has ebbed over the
centuries, but has been revived in no small part by the
growth of biomedicine in the second half of the 20th
century.
• Today most ethical discussion is framed as a contrast
between three ethical systems: deontology, utilitarianism,
principlism.
Deontology
• Deontology is an ethical system based on duties and moral
obligations. Religious laws generally impose a set of
obligatory behaviors that are right or wrong in and of
themselves, regardless of the consequences. Religious
“commandments,” Kant’s “categorical imperative” are
behaviors that are universally binding.
– Tell the truth
– Prohibitions against abortion, transfusions, divorce, murder, eating
certain foods, etc.
– Love your neighbor
– Etc
Utilitarianism
• Utilitarianism states an act is morally right if it imposes the
greatest benefit and imposes the least burden on those
involved. The end justifies the means. However, it is often
very difficult to calculate the consequences of particular
decisions.
– Lying is morally correct if it saves a life.
– Killing may be justified for a moral cause, like self-defense or in a
just war.
– Stealing to get food for your family is part of a higher duty.
Principle-Based Ethics
• Principlism is an attempt to reconcile the discrepancies
between utilitarianism and deontology by linking moral
decision-making to certain principles. This is what is
usually taught in ethics seminars. It is not strictly a theory
and it is intrinsically vague. It is also not hierarchical. It is
an effort to make ethics more practice friendly.
• Four principles often used in medical ethics:
–
–
–
–
Non-maleficence (no harm)
Beneficence
Respect for autonomy
Justice
The Request for Prayer
• Do no harm
– Transference
– Countertransference
– Boundaries (Is this what a therapist does?)
• Beneficence
• Respect for autonomy
• Justice
The Grieving Mother
• You are a therapist for Group Health. Your client is a 33
year old mother who is experiencing ongoing grief after
the loss of her 4 year old son in an accident 2 years ago.
After several sessions, it is clear that a big part of her
turmoil is her loss of faith that there is a God who watches
over us. She has talked to her minister, but remains at a
loss in how to understand what has happened to her, or if
she is being punished for her sins.
• She asks you, “Do you think this is this part of God’s plan?
Am I being punished for not believing?”
The Grieving Mother
• Do no harm
– Transference
– Countertransference
– Boundaries (Is this what a therapist does?)
• Beneficence
• Respect for autonomy
• Justice
The Angry Teen
• You are seeing a 16 year-old girl in family therapy at UW
for school and behavior problems that have worsened in
the last year – smoking, poor grades, defiance at school,
anger alternating with tearfulness, etc. You get the feeling
after spending time with her that she is yearning for some
support and affection from her mother and father, but they
are consistently harsh in their comments and discipline. In
your opinion, this is making the situation worse. Their
minister, however, clearly says, in a letter brought in by the
father, that the girl’s behavior is sinful and that she need to
renounce her behaviors and ask forgiveness.
The Angry Teen
• Do no harm
– Transference
– Countertransference
– Boundaries (Is this what a therapist does?)
• Beneficence
• Respect for autonomy
• Justice