O psiquiatra em conflito: fatos, valores e virtudes no dilema das internações involuntárias

Abstract

Castellana GB. The conflicted psychiatrist: facts, values and virtues in the dilemma of involuntary commitment [thesis]. Faculdade de Medicina, Universidade de São Paulo; 2019. INTRODUCTION: Some of the most complex situations faced by Psychiatry are clinical judgment and decision-making, constantly placing psychiatrists at odds about the best course of action. This is especially true in cases involving involuntary commitment, in which the patient's absence of consent with the treatment may constitute a moral dilemma for the physician. That is why these are considered "difficult cases", which must be weighed against the patient's autonomy and risk presented. The aim of this paper is to assess to what extent the psychiatrist's subjective dimension influences his/her decision-making in these cases, examining the relationship between facts, values and virtues in psychiatric clinic. METHODOLOGY: Grounded on qualitative methodology, based on content analysis, 17 third-year residents in Psychiatry of the same program were interviewed. These interviews had two parts: case studies and professional experience. For the first part, interviewees were presented with two hypothetical cases, both inspired by ordinary clinical practice, in which he/she was asked to either opt for involuntary commitment or discharge of patient, in each case with the relevant justifications. For the second part, the focus was on the interviewee's experience, going from Medical School to residency in Psychiatry. RESULTS: The interview results revealed that in both cases, clinical judgment and treatment proposed, each psychiatrist's subjective values influenced their assessment. These values were coupled with different epistemological perspectives of psychopathological knowledge adopted by the psychiatrists and revealed in their professional experience. Based on the use of such knowledge, it was possible to identify three types of psychiatric rationale: organicist, theoretically based on Neurosciences; psychodynamic, theoretically grounded on Psychoanalysis; and phenomenological, theoretically supported by Phenomenology. Analysis of the results also revealed that this judgment by psychiatrists requires some virtues, including empathy, self-knowledge, availability to interpersonal relationships and practical wisdom (phronesis). Accordingly, each final clinical decision revealed to depend on the psychiatrist's ethical and epistemological positions. CONCLUSIONS: clinical judgment and the corresponding decision-making are based not only on technical-scientific knowledge, but also on the psychiatrist's system of values and virtues. This whole, which combines scientific facts, values and virtues in psychiatric practice, places the habitus of psychiatrists at the border between natural and human sciences, which is responsible for the constant questioning of whether this speciality belongs to the hegemonic, organicist scientific realm of Medicine.