In recent years, there has been increasing interest in how medical professionals develop and articulate a moral foundation on which to base a way of leading their professional lives. In this essay, however, the author focuses more narrowly on how black physicians do it. The author explains that black physicians confront a unique set of circumstances and experiences that define reality for black doctors and other professionals from non-dominant groups in the United States. From this particular background, black physicians go on to develop a unique perspective on medical ethics. The author uses his own narrative to demonstrate his argument and to show its application to a current debate on the ethics of forensic psychiatry practice.
Biomedical ethics is a subject that these days is attracting much attention from both laypersons and health care professionals. Indeed, I believe that developments in other peripherally related areas are catalyzing this renewed general interest in ethics. The Abu Ghraib prison debacle in Iraq certainly has contributed to focusing light on the ethics of prosecuting war. But it is the possible direct or indirect involvement of physicians in the activity of torture that has furthered greater interest in the ethics of health care professionals.1,2 Other revelations have now suggested that the medical records of detainees at Guantanamo Bay, Cuba, have been made available to interrogators and those torturing the detainees.2,3 What medical professionals do, or don’t do, is of current interest to us all. Everybody wants to know how the medical professional develops and articulates a moral foundation on which to base a way of leading his or her professional life.
Of course, this curiosity and interest are not new. They have just been, once again, reawakened by the discovery of the conditions at Abu Ghraib and Guantanamo Bay. And while some would have us believe that those conditions reflect an unusual and aberrant context, commentators like Lifton4 remind us that any one of us, including physicians, can be caught in an “atrocity-producing situation” (Ref. 4, p 416). By that, Lifton meant that it was possible for doctors to be socialized to atrocity by being exposed to a context that was structured psychologically and administratively to facilitate commission of atrocities. While Lifton was preoccupied in his earlier work with doctors of the Nazi regime, he certainly noted that American physicians, like anybody else, could be exposed to institutional pressures that might lead them to violate their consciences. This leads inexorably back to the question of how medical professionals construct the moral foundations of their professional lives. It is an intriguing question, and I shall dwell on it in this essay, although with emphasis on how black physicians do it. However, given my intellectual interest in narrative and memoir, I have decided to concentrate first on a longitudinal exposition about the constructing of the moral foundation undergirding my professional life. For my narrative to make sense, I note that I am a member of the non-dominant black group in the United States; and my professional identity is that of a forensic psychiatrist.
I resort to telling a brief story about my life, not only because I am preparing a terrain of argument that will highlight a stark preference for narrative ethics. I also do not think it easy to articulate my own African-American perspective on biomedical ethics without outlining some personal experiences that have contributed to the shaping of my moral life. These experiences will be notably religious and cultural, which may immediately evoke sympathy from philosophers and scientists about the parochial nature of my background. Nevertheless, that is the way it is. I cannot invent another version of my longitudinal, psychosocial development. So, in sharpening my intent, I should say that I wish to focus on the pathways used by me, a black physician and forensic psychiatry specialist, to construct the moral foundation of my professional identity. I shall ultimately apply my argumentation to a current debate on the ethics of forensic psychiatry practice.
Early one morning in the 1940s, my father sent the usual message to the midwife who had served our family before. I understand she arrived and performed her duties effectively. As a consequence, I first saw the light of day in a small chattel house located in the Caribbean island of Barbados. In those days, that lovely piece of territory was a British possession, one of these outlying countries that the British Colonial Office followed attentively.
I was raised amid the multiple paradoxes that so traditionally characterized life in the British Empire. On the one hand, I received a solid education at the levels of primary and secondary school. I read widely and engaged in critical discourse with teachers and friends. Indeed, debate on all topics was a hallowed part of Barbadian culture. On the other hand, I came to understand that the British saw themselves differently from the way they viewed those they colonized. As a result, I internalized the metaphor of the club—in this case, the aquatic club and the yacht club. To their credit, the British did not put up signs saying that black Barbadians could not use the two clubs. As I have stated elsewhere,5 the British did not engage in such gauche behavior. Nevertheless, the unwritten rule that I was to stay away was as clear to me as any regulation could be to people with common sense. So I went to neither club. In subsequent years, I began to appreciate more acutely this idea that black people were accorded privileges that were different from ones enjoyed by whites. And it would unleash in me a preoccupation with this distinction between dominant and non-dominant groups.
The subtlety of the British is ineffaceable in my mind. I saw it at work even in the church context and I marveled at their technique. For several years I sang in the choir of the local Anglican cathedral; I was a part of the age-old British tradition of boy choristers. So I sang both at the Sunday morning matins service and at the seven o’clock evensong. I could never understand why the white Britishers had a preference for the morning service. Few were present at the evening service. This resulted in a peculiar separation of the black and white groups that helped me to formulate an understanding of difference in the British colonial context. It didn’t take me long to note that few bank tellers were black or that the head of this organization and the leader of that association were white.
When, in 1956, my family moved to the United States, another phase of my sociopolitical education began. It was around this time that I first read Richard Wright’s Native Son6 and confronted raw anger spilling from a writer’s pen. This was years before the formulation of African-American Studies, and I had to take responsibility for my own intellectual development. I cannot even remember what led me to read about the Harlem Renaissance, but I know it was not in formal courses anywhere that I encountered the term. It would be just after my graduation from college in 1963 that I heard Malcolm X give a lecture in Boston, saw him field questions expertly, spouting back rhetoric that frightened both blacks and whites. In those days, many of the people I knew wanted to find some ground for accommodation, for compromise. Only a few people in my circle wanted a revolution, a Baldwinian fire, or a Rap Brownian burning. But most of my friends did want change. After all, it was time for things to improve everywhere for blacks.
Without extending the story anymore, I realized that many of my social and intellectual experiences sensitized me to the peculiar context of the Anglo-American world. I learned that there was a dominant white group and a non-dominant black group, and the interactions between the two groups were complicated, often abrasive, and pervasively contentious. (This is not to suggest that there are not other non-dominant groups, or that the only way to think about dominant and non-dominant group interaction is on the basis of skin color. However, for purposes of simplicity, I will limit my attention here to the exchanges between whites and blacks.)
I turn now to the other important dimension of my early social experiences, both in Barbados and in the United States. These experiences took place in church. I use the term “church” in a broad Protestant sense and without reference either to the Catholic religion or Jewish dogma. I attended many different churches, as a result more of geographic convenience than any intended philosophical distinctiveness. But over time, I progressively came to see the church as a means of thinking about social justice, of reflecting on the plight of the poor, and as a mechanism for facilitating the interaction of dominant and non-dominant groups based on fairness and equity.
At this juncture, I am not insisting that any black individual growing up in the Anglo-American world would have or should have reached the same conclusions that I reached. We are all more sophisticated now than a decade ago, and we know that members of non-dominant groups are capable of formulating different approaches to their problems and to the articulating of solutions. But I decided that in the Anglo-American context, most of my acts are viewed as the movements of a black man and are weighed on scales ultimately controlled by non-blacks. It saddens me, too, that simply because of my membership in a non-dominant, non-white group, I spend considerable energy preoccupied with the task of living my life as a black individual. I reflect incessantly on the interaction of blacks and whites. Why? Simply because skin color matters, and racism, its derivative, is a pollutant that taints black-white interactions. Furthermore, black responses to the white dominant group are so complicated that the problem of responding strategically to whites is, in my view, a life-long task within the scheme of Levinson et al.7 When Levinson articulated his theory of life cycle stages, he assigned major tasks to each phase of life. For example, we understand now how a recent college graduate about 21 years old looks to the work of defining an early direction for his or her career and simultaneously struggles to establish a life that is set off from that of the parents. But Levinson never explicitly enunciated this task that I think is so important for blacks in this particular cultural setting of the United States. In all fairness, he understood it, something that was clear in many discussions that I had with him before his death. In addition, he was quite sensitive to the tasks of women, and he understood that the symbol of non-dominant/dominant group interactions had wider applicability than only to the dichotomous pair of black/white.
I wish to assert, and to do so more strenuously and energetically than Levinson, that black individuals do well to face the objective of measuring and even trying to control their interactions with whites. I make no bones about my special interest in how black professionals—in this case psychiatrists—prosecute the task. I intend to offer the outline of an approach to contending with this objective, which in my mind is almost synonymous with what I consider to be a duty of professionals from non-dominant groups. The approach requires that black professionals, for example, reflect earnestly on how they authentically represent their non-dominant group. They must also consider the phenomena of “belonging” and of “nigrescence building.” These three elements are powerful forces that impinge on the way black psychiatrists do their work and think about their lives. These forces also lead to a unique forging of an ethics-based platform on which to carry out one’s professional activity. I would like to render this process clearer and more palpable, thereby making it more readily understandable.
However, before moving on, I underline a point I made earlier. It is often expected that all those assigned to a particular non-dominant group have a common way of viewing the world, and that they accommodate to a clearly defined way of dealing with dominant group members. In a broad sense, that is why so many of us find it hard to understand that the black individual who defines himself as a conservative Republican is even conceptually possible as a definitional entity. But we certainly know now that black conservative Republicans exist. They are alive and functioning well and intent on growing in number. This means that the task of adapting to the dominant white group is open to interpretational adjustment, regardless of what our own personal preferences may be. This is why I prefer to emphasize comprehension of the problem and leave the question of stylized choice to each individual. This does not mean I have no preference. I just recognize that others may not like my preference. My point is, therefore, that I want us to agree with Gates’8 idea that the notion of a unitary black man is but an imaginary concept; hence the interest in my own narrative as a point of departure. There is some recognition then of the reality that every black man has his own gauntlet to run (Ref. 8, p XIV).
I turn now to the problem of authentic representation, which I point out is a special burden for black psychiatrists, although I have already conceded that, generally speaking, members of non-dominant groups must come to terms with the task of authentically representing their group. But clear understanding of the task requires its own deconstruction. So I shall deal first with representation.
The burden of representing one’s non-dominant black group has, for a long time, been a prominent theme in the cultural context of the United States. Race men like W. E. B. DuBois and Booker T. Washington understood it well. In Sister Souljah’s autobiography entitled No Disrespect,9 she noted that Harriet Tubman
…could have just chilled in the North, built a white house with a white picket fence, got a light-skinned husband and died with her fingertips in a jar of skin-lightening cream. But she didn’t. She marched her big black ass through the woods…and went back and got her African brothers and sisters (Ref. 9, p XIV).
Now this quotation is somewhat provocative, as Sister Souljah is wont to be. So for a bit, I suggest we look past the provocation of the comfortable white house, the light-skinned husband, and the skin-lightening cream. And no matter! We are still left with Sister Souljah’s insistence that we make a commitment to help save our brothers and sisters from the injustices and indignities meted out by members of the dominant white group. We must, therefore, represent them and not sit comfortably ensconced in whatever luxury our economic achievement will purchase for us. Others like Chester Pierce10 have raised the question in a more subdued but still penetrating tone: how will you serve the group, the non-dominant group that so lucidly contributes at least partly to the establishment of your identity in this country?
Now, when we return to the rest of Sister Souljah’s passage, we see that she articulates a polarized view of representation. After all, Harriet Tubman could have built herself a white house, found a light-skinned husband, dug deeply into the skin-lightening cream, and still marched back through the woods for her brothers and sisters. For the sake of argument, one could serve the group and still adhere to personalized concepts that may even seem to be at odds with one’s service to the group. So I place Sister Souljah, partly for pragmatic didactic purposes, at one polar end of a spectrum of possibilities.
At the other end comes what Gates calls soulless, colorless opportunism.8 That depiction speaks by and for itself. That end of the spectrum makes no pretenses about representing anybody. That is the plea for being just a human being and leaving the burden of representing to others. At this end of the spectrum, the salience of race or ethnicity is minimal, if not non-existent.
Between those two poles on the spectrum reside a host of stylized roads to representing the black non-dominant group. If I understand what Cross11 has to say about the complexity of developing both personal and group black identity, I expect that there is often ambivalence in us blacks about representing our constituency. So that while we are representing, we may also be rebelling against the very task. This explains Gates’ joke about blacks’ being embarrassed by another black who is too dark, too loud, and too wrong. “Nigger is loud and wrong,” Gates would say (Ref. 12, p XIII). And the unstated question is, who wants to represent someone like that?
Now Gates put his finger quite naturally on another special problem that educated, non-dominant group members like us must have. Our education, experience, and socialization as physicians and psychiatrists make it easy for us to engage in what Gates calls the constructing of “identities through elective affinity” (Ref. 12, p XV). So, for example, we play golf and hang around with golfers. As we participate in this endeavor, skin color is not an important characteristic. It allows us, in Gates’ terms, to “experience a humanity that is neither colorless nor reducible to color” (Ref. 12, p XV).
What I intended to show here is the marvelous array of options presented to the black psychiatrist who contemplates the task of representing his non-dominant group.
Obviously, the pervasive and extensive establishment of elective affinities can lead to one’s adopting the stance of colorless opportunism. I need not criticize that preference, to which some black professionals naturally gravitate. Suffice it to say that some blacks contemplate the burden of representation, define it as too heavy and costly a burden, and then move to activities where the salience of race matters is minimal. In my own case, I have adopted a clearly personal form of representation in my private and professional life. This I have done as a function of my background and narrative experience. But in addition, the salience of skin color is unambiguous in the areas of my professional interests: medicine and the law.13
I do wish to make explicit an idea that I assume others may have. I never intended to suggest that members of the dominant white group do not engage in the process of representation. Such a thought is to my mind preposterous. On the other hand, little effort is needed to point out that representing the dominant group must be a qualitatively different matter from representing a non-dominant group. That, after all, is at the heart of understanding what difference and hierarchical difference are all about when we talk of dominant and non-dominant groups.
First of all, except in the rare situation where dominant group membership is significantly smaller than non-dominant group membership or in the unusual context where non-dominant group members have become overtly rebellious and violent, dominant group members enjoy the luxury of avoiding reflection on the task of representing. Of course, they may enjoy engaging in representation of the values they hold dear. Some years ago when the Black Panthers attacked dominant group values with a certain vehemence and then went on to threaten violence, dominant group members became palpably terrified and even moved to the task of representing the dominant group with unaccustomed vigor.
However, for the most part, the members of dominant groups do not have to gear their style of representing to anticipated responses from the non-dominant group. The dominant group is taken with superiority and the image of spreading their ideas to others. In a few words, I dare say that the burden of representing a dominant group and doing it from what I shall call a “one-up position” must be qualitatively different from the task of representing a non-dominant group from a “one-down position.” This distinction is perhaps most movingly articulated in Linda Brent’s slave narrative, Incidents in the Life of a Slave Girl.14 There, Dr. Flint, the slave-master, certainly rises to the task of effectively representing the group of autocratic slave owners. And he demonstrated that the dominant group can also take on the burden of representation. Consequently, he takes a certain vindictive pleasure in asserting his role as slave-master and seeking to bend Linda Brent’s will to his as he tries, and I say it in modern-day parlance, to get into her pants. It was the good doctor’s view that both Linda and her pants belonged to him. With all of that said, I concede that dominant group representation may well be a function of how vigorously the opposing non-dominant group represents itself. So the luxury of dominant group representation may not always be as pronounced as non-dominant group members imagine.
I come now to the dimension of authenticity, which I argue adds more weight to the burden of representation. This notion of authenticity exerts a distinct pressure on the act of representing. It pulls the non-dominant group individual in a particular direction and adds a special patina to the process of representation. If we return to Sister Souljah’s characterization of Harriet Tubman, we must understand why Sister Souljah insisted that Harriet Tubman did not build a white house with a picket fence and that Ms. Tubman also gave up the light-skinned husband and the jar of skin-lightening cream. In other words, Ms. Tubman not only bore the burden of representing her non-dominant group brethren, she did so authentically. Sister Souljah had no hesitation in adding to the burden.
The insistence on the authentic prosecution of representation comes most forcefully at times from other members of our non-dominant group. That is why non-dominant group members enjoy the juxtaposing of our heroes: Jesse Jackson and Colin Powell; Martin Luther King and Malcom X; James Baldwin and Elridge Cleaver; Clarence Thomas and Leon Higginbotham. The juxtapositioning makes us confront our own fears. In each pair, we see stylized representing. Both individuals can be easily linked to the work of representing the non-dominant black group. But one of them is doing so more authentically than the other, although we may all differ on who is the authentic one. There is no empirical basis on which to make my claim, but my repeated conversations with psychiatrist colleagues and other black professionals have persuaded me that they are unduly preoccupied with carrying the burden of representation. They also dread the potential accusation that they are pursuing their representation inauthentically, which I see as proximate to a charge of treason, of betrayal. That is why I think it’s so important for minority professionals to settle in their minds what they conclusively feel is authentic representation.
Not surprisingly, of course, the situation is often rendered more complicated when members of the dominant group enter the fray and try to add their two bits to a discussion that non-dominant group members often see as no business at all of the dominant group. I have tried on numerous occasions to explain this to white colleagues, and they have always appeared nonplussed and confused at my explanation. I point out to them that in the trial of United States v. Marion Barry, many African-Americans were offended by the uniquely vicious way in which the authorities hounded Mayor Barry. African-Americans were offended too by the suggestion, which was implicit in the government’s charges, that the Mayor had represented his constituents inauthentically. In other words, the Mayor had not served his black brothers and sisters well. But many blacks thought that whites were intent on imposing their views on Barry’s black constituents.
This subject of authentic representation remains a topic of cardinal significance at least because it invokes the use of so much energy in its contemplation. But it is important also because it influences the way in which black professionals decide to live out their lives and to construct the moral base on which the professional orientation is founded. Lithwick’s critique of the recent biography of Clarence Thomas raises the fundamental question: how could a black man “who filters each and every public sling and arrow he’s suffered through the prism of his own victimization construct for himself a jurisprudence of disdain for victims?” (Ref. 15, p 10). It’s another way of asking how to move from Thomas’s personal narrative to his professional credo. What is clearly missing in Thomas’s story is the element articulated by Lawrence-Lightfoot in her portraiture of black men and women—that they are “courageous in pursuing their dreams and in reconciling with their roots” (Ref. 16, p 10). It is this reconciliation with Thomas’s roots that was of interest to Higginbotham, who phrased the question another way. Higginbotham wanted to know how, given Justice Thomas’s background, Thomas could formulate the moral basis to become hostile to affirmative action opportunities.17 Higginbotham therefore made the connection between personal narrative and the moral construction of one’s professional life, to which I shall subsequently return.
Belonging and Nigrescence Building
The metaphor of belonging refers to a developmental process that I shall describe shortly. Much like the burden of representation, working out the difficulties presented by the belonging process may take many years, and it extends across the life span. The process of belonging may be understood as a correlative activity to the constructing of one’s racial identity attitudes, what Thomas Parham18 and William Cross11 have labeled a process of psychological nigrescence.
What is meant by the phenomenon of belonging? Belonging has been described19 as a total and confident sense of being a member of an organization. It is markedly different from the feeling of being tolerated or, worse, the feeling that you are an uninvited guest, a party crasher, so to speak. It is even different from the feeling that you have worked hard to get there and deserve the opportunity to be there. This sense of belonging is also more than mere confidence. When you really have the feeling of belonging, you don’t waste time wondering what some white individual meant who only apparently slighted you; you don’t constantly look around trying to gauge your effect on the white people around you. You pursue your activities with efficient single-mindedness, mindful of the need to be gracious and respectful of others. When you belong, you move with grace and aplomb. You contribute to setting the tone of the interaction when dealing with your white peers, and you know the limits of what you will accept from your white superiors. To those less fortunate than you, you are always patient and helpful. This sense of belonging is definitely more than just confidence.
It is perhaps better explicated through the description of how a black belongs to a black institution. The black who “belongs” to his church is totally at ease with all the rituals. His knowledge of the rules constrains him only a little. And while parameters are set that influence thinking and behavior, his creativity is often enhanced. The black who “belongs” to his church will testify, pray out loud, fall in the Spirit. He has no hesitation in saying “Amen” out loud or in clapping and laughing when he wishes. He feels in control of his space and time and knows with absolute certainty that it is his church. In fact, he alters his behavior when he visits another church, even if he has good friends there, because that is not his home church. His belonging isn’t just psychological or social. It has physical and behavioral correlates that are reflected in his total deportment.
It should be emphasized that when an individual does not belong somewhere, he spends an inordinate amount of energy thinking about what the dominant group intends doing to him or about what the dominant group thinks of him. This is what Chester Pierce called “defensive, apologetic, and deferential” thinking,10 which leads to relative paralysis of his action and planning. In turn, this impacts on his self-esteem and effectiveness. Running away from the contentiousness of the dominant/non-dominant group interaction is not expected to be helpful in the long run. The important task is for members of the non-dominant group to learn how to negotiate the interactions with the dominant group and emerge with their self-esteem intact and elevated.
I come full circle now to Sara Lawrence-Lightfoot’s I’ve Known Rivers.16 In her analysis of six black lives, she drew attention to Harvard’s Professor Ogletree and his continuing question about whether he should be exercising his functions at a place like Harvard. Even those who apparently made it in the white-dominated marketplace seem unable to resolve effectively the complex struggle of being at peace with their membership in white-dominated organizations. Professor Ogletree, at least in the skilled portraiture hands of Lawrence-Lightfoot, comes across as a wonderful example of the problematic intermingling of the belonging process and the burden of representation. The professor is taken with the idea that his feeling comfortable and ultimately belonging at Harvard may dilute his capacity to represent his black brothers and sisters effectively.
Cross,11 in his early theorizing, suggested several phases of identity development, which Parham18 illustrated later with attention to the narratives of Malcolm X and W. E. B. DuBois. With reference to Malcolm X, for example, Parham explained how in the Pre-encounter stage, Malcolm was a high school adolescent who had little feeling about the business of being a black man. Then in the Encounter stage, Malcolm had his famous experience with the English teacher who tells Malcolm that being a lawyer is no realistic goal for a nigger. At that point, Malcolm begins to be more contemplative whenever he hears the word nigger. In his Immersion-Emersion stage, Malcolm begins to read voraciously whatever he can find in the prison library about black history. It is then that he is converted to the Muslim lifestyle. In his Internalization phase, Malcolm is on the pilgrimage to Mecca and encounters Muslims of different races. He begins then to reevaluate his perceptions about white men, and by extension, rethinks his views of the interactions between members of the non-dominant black group and members of the dominant white group in the United States.
Parham also made the point that a black individual’s movement from one state to the next, and often back again, is influenced by experiences with both whites and blacks. In addition, movement through the nigrescence process is a function too of the Levinsonian state at which nigrescence experiences occur. Parham further emphasized that any black individual may proceed through Cross’s nigrescence process in a stagewise linear fashion; one may also stagnate or recycle through the process. What is most crucial to understand, however, is that one’s style of adapting to the nigrescence or belonging process ultimately may shape one’s professional work.
Constructing a Moral Foundation
I have tried until now to expose the powerful forces that impinge repeatedly on black medical professionals in the course of their work. But I do not wish to be seen as encouraging disordered thinking and behavior among physicians who belong to the non-dominant groups of this country. In other words, I am not promoting chaos. However, I knew no other way to focus on the mission of creating an exposition of how I am struggling to do my professional work, without articulating a narrative of my experiences. Furthermore, it is my view that my personal story is starkly defined by my identity as a black professional. Gates (Ref. 8, p XVIII) has asserted that nobody happens to be black, and it is a definitional truth that flies in the face of the comforting old lie that I could be a professional who happens to be black. However, I reject the comfort and the untruth because they serve no purpose in my argumentation. I turn now to my reality, which is founded on the precept that in constructing a moral foundation for my work, I have had to take stock of the burden of authentic representation and of the phenomena of belonging and nigrescence.
I am aware, after having carefully reviewed recent work about African-American perspectives on biomedical ethics,20 that there is a difference of opinion as to whether one can claim a unique black approach to the constructing of a moral platform on which to found one’s medical work. Obviously, each professional must reach his own opinion. However, I am concerned that black professionals may indeed find it easier to voice opinions about the moral context of their work by expressing themselves in a way that may still strategically serve the interests of the dominant group, what Sampson21 calls an accommodative voice. It is a way of thinking about morality and ethics, but within the parameters of dominant-group discourse. In resorting to personal narrative, I seek to broker a position that I hope is transformative: I have tried to articulate my own constitutive reality, keeping it real as I feel it to be, and then, making it clear that the development and orientation of my own identity have influenced my effort to formulate self-determining self-representation.21 Consequently, my morality is harnessed to my narrative background.
Let us now examine a specific ethics dilemma I have encountered in my practice of forensic psychiatry, which is a unique specialty branch of clinical medicine. Since forensic psychiatric work takes place at the nexus of psychiatry and the law, the activities are often broader than those of traditional clinical psychiatry and therefore may create problematic situations that are somewhat unusual in clinical medicine.
Professor Alan Stone22 framed this particular dilemma some years ago, and he started by recounting an aged story, one that rightly deserves to be called a parable, because once he related the story, Stone went on to deduce from it a range of powerful arguments. Stone gave the account of a Jewish physician who went to a British court in 1801 to help with the defense of another Jew who had stolen some spoons. At cross-examination, the prosecutor asked Dr. Leo: “Have you not been here before as a witness and a Jew physician, to give an account of a prisoner as a madman, to get him off upon the ground of insanity?” (Ref. 22, p 65).
Given the relatively primitive knowledge of psychiatry at the time of Dr. Leo’s testimony, Stone felt justified in asking whether Dr. Leo could have been in court to do anything other than to help a fellow Jew escape just punishment. In other words, Dr. Leo was merely twisting justice and fairness to help his patient, the result of which was a desecration of his profession. Stone used the tale to examine the reference points or the ethics framework available to the good Dr. Leo. Stone pointed out that given the knowledge base of psychiatry at the time, neither a good clinical practice standard nor a scientific standard would have been of much use to Dr. Leo, who obviously knew little about his patient’s “mania” for stealing spoons. Stone implicitly suggested, therefore, that Dr. Leo was lured into the courtroom by his wish to save his patient, to help his patient, which is in the tradition of clinicians. However, it is this desire to help, the “ethical thesis of the practitioner” (Ref. 22, p 68) that became for Stone a fundamental problem in the legal context. Wishing to help leads the forensic psychiatrist into the temptation of going too far in his court testimony, of twisting things to help his patient. The result is ambiguity in the ethics boundaries of forensic psychiatry. The conclusion that flows from Stone’s argumentation is that psychiatrists should stay out of the courtroom.
Appelbaum23 took Stone’s criticism to heart and responded by delineating a theory of ethics for forensic psychiatry. Appelbaum was careful to define forensic psychiatry as the evaluation of subjects for the purpose of generating a report or testimony for an administrative or legal process (Ref. 23, p 238). In so doing, he sought to differentiate ethics principles as a function of the activities carried out by physicians. For Appelbaum, while beneficence toward his patient is a cardinal duty of a clinical doctor, a research physician may have an important commitment to the “production of valid, generalizable data” (Ref. 23, p 238). Similarly, he saw forensic psychiatrists as having a commitment to the value of advancing justice, not to promoting the health of a patient. In advancing justice, Appelbaum argued, the forensic psychiatrist should focus squarely on truth-telling and on maintaining respect for persons. Telling the truth requires saying what one believes to be true (a kind of honesty), as well as articulating the limitations on one’s testimony (such as acknowledging clearly what records one has not seen). Respect for persons involves making clear to evaluation subjects the role being played by the physician, obtaining informed consent, and respecting confidentiality. Appelbaum did not dispense with a physician’s duty to respect the traditional values of beneficence and non-maleficence. However, he emphasized that those traditional values were not primarily relevant to carrying out the functions of a forensic psychiatrist.
So far, I have tried to explicate a major debate that has erupted in forensic psychiatry ethics, fueled especially by the arguments presented by Professor Stone and the counter-arguments formulated by Professor Appelbaum. Elsewhere, I responded to both colleagues and tried to establish what I found so unsatisfying about their positions.24 First, I think it helpful and instructive to return briefly to Dr. Leo’s story, as I have concluded that this Jewish physician is an important symbol of the non-dominant group forensic psychiatrist. Dr. Leo had to confront his burden of representation. And given the anti-Semitic context at that time, he had to contemplate what commitment to his non-dominant group could mean, what would be his behavior as he sought to represent his group authentically. I also cannot say where he was in Cross’s framework of adult development and how his Jewish identity-building was linked to his decision.
Nevertheless, what has made me increasingly troubled with the considerations evinced by both Drs. Stone and Appelbaum is how unconcerned they seemed with the profound dilemma faced by Dr. Leo. Stone seemed almost joyful at the idea that modern-day psychiatrists should stay out of the courtroom, given the ethics-related confusion pervading the work of forensic specialists. Furthermore, Appelbaum seemed to decide that truth-telling and respect for persons would effectively serve all future Dr. Leos.
I can readily see that many colleagues will take up this last point and brandish it with fervor. In other words, Dr. Leo should forget his Jewishness and his struggles with dominant-group politics and simply tell the truth in the courtroom. This would solve a number of problems and should lead at least to striving for objectivity in his testimony. While I will ultimately dismiss this argument, I will not do so prematurely. Indeed, I pause here to amplify the point. In preparing this essay, I took the time to review it with several colleagues. One of them, a black pastor, suggested that Dr. Leo was wrong in approaching the dilemma the way he did. The pastor suggested that Dr. Leo should not have been swayed by ethnicity or socioeconomic status, and Dr. Leo should have been committed to the universal principles of justice and truth-telling. As a result, my pastor-colleague did not believe in leniency for minority groups and felt it unnecessary for them to be afforded a crutch or special helping hand. In his own language, he noted that he would recommend no breaching of the rules.
It surprised me how willing my colleague was to concede that blacks had had a terrible history in the Anglo-American context. Furthermore, he agreed that the current socioeconomic system was not fair to blacks. Neither were the legal and educational systems. He thought that Dr. Leo should have been constrained to tell the truth in court, while advocating outside the courtroom for equity and fairness for his non-dominant group peers. My colleague then resorted to his religion-based terrain. He recommended a stance of “patient enduring” and “perseverance and hard work” for blacks throughout the Diaspora, and he described his hopeful belief that eventually blacks will be victorious in seeking equality and justice.
I have just pointed out how one religious colleague prized the value of truth-telling and similar professional values. Even within a religious framework, this profound respect for such universal principles was desirable and important to maintain. On the other hand, another colleague (also a man of the cloth) pointed out that Dr. Leo deserved to be commended for the interest in his fellow man. Dr. Leo had an interest in the situation of his friends and neighbors, a sort of prophetic attachment to the orphan and the widow. Dr. Leo was responding to the injunction that we be concerned about feeding the hungry, about clothing the naked, giving drink to the thirsty, and visiting those who are sick and in prison. My colleague saw Dr. Leo’s behavior as, in a sense, imitative of Christ, calling to mind Christ’s notion (found in St. Matthew’s Gospel at Chapter 25:40) that “since as ye have done it unto one of the least of these my brethren, ye have done it unto me.” (While I have formulated this idea in Christian terms, I recognize that other religions also preach compassion for one’s neighbors.)
The juxtaposing of these religion-based views serves an important purpose. It highlights the crucial situational dilemma in which Dr. Leo found himself. And I am insisting that we must do right by Dr. Leo before blithely entertaining a solution. We must do better at understanding who Dr. Leo is. To dismiss the seriousness of his struggle is to undermine the personal narrative of non-dominant group professionals. By dint of my own story and experience, I am forced to keep an eye on the interests of my non-dominant group, even as I contemplate the values exhorted and underlined by my profession. Christ’s injunction in the Gospel makes Dr. Leo a more sympathetic figure to my Christian mind and amplifies Dr. Leo’s concern for his fellow Jew.
It worries me that one could observe Appelbaum’s rules of truth-telling and respect for persons without having any concern for the person who stole the spoons. At the same time, Dr. Leo could be concerned about his fellow Jew and go on to tell untruths and make false claims in court. The real task is to observe Appelbaum’s principles while appreciating Christ’s reminder about our interconnectedness. I am simply not satisfied by observing Appelbaum’s rules in court, while the judicial system continues to be viewed by many as an institution pervasively plagued by racism.25,26 Candilis and colleagues27 have also recognized that a tenacious respect for these ethics principles, with emphasis on objectivity, may lead to a less than humane consideration of our societal and professional obligations.
As a black forensic psychiatrist, proceeding from my background and experience, I am concerned both about the commitment to professional values and about my self-defined loyalty to my reference group and my responsibility to others in my community. As a result, I take a transformative stance, wishing to advocate for adherence to professional values in addition to arguing forcefully for considering why Leo’s group feels so disadvantaged and lacking empowerment. This approach also broadens and strengthens the business of respecting persons.
The position I am intent on formulating also has fundamental practical implications. Ignoring my personal narrative diminishes me in my own eyes. But it also leads to minimizing my group’s status in the context of professional-association politics. The result, as Cross11 understood so well, often leads to an obligatory refurbishing of the process of nigrescence building. Rendering invisible a personal narrative can be perceived as, in Cross’s terms, an unpleasant encounter experience, which in turn catalyzes a recycling through the nigrescence process. In other words, non-attention to Dr. Leo’s dilemma can dilute the confidence that links him to his reference group, while fragilizing his personal identity. I am also concerned that dominant group psychiatrists, some of whom spend little time reflecting on the situation of their non-dominant group colleagues, often pursue with enthusiastic single-mindedness the political interests of the dominant group in the context of our professional organizations.
Now I am not advocating commission of a wrong to correct an antecedent wrong. But I think it important and useful to advocate our participating differently in the work we do. First, we should approach the work while sensitively recognizing the pain and suffering of the defendants and others we are called to evaluate—recognizing them as one of us. In recognizing their status, we should work hard to make sure we do not exacerbate their suffering, although in some cases it may be unavoidable.
As we recognize the position of the disadvantaged in our midst and connect to them empathically, we must take on the responsibility to carry out our work as thoroughly as possible. It is in thinking more carefully about our evaluations—employing data from multiple sources when possible, emphasizing the need for completing the cultural formulation, checking and rechecking information—that we will do justice to the tasks we are hired to carry out. In other words, connecting to our subjects as human beings drives us to do our work professionally and humanely.
From time to time, those who represent the legal system will do their best to involve us in biased evaluations that harm or benefit the evaluee. It should be easy to resist the entreaties of those intent on harming. It is harder to reject the invitation to twist what we have to say so as to benefit our subjects. Resisting this latter temptation is feasible if the expert is able to say that he or she is really committed to participating in a judicial process that is founded on fairness and an effort to provide justice to those caught up in it. However, the emphasis here is not on a platitudinous commitment to theoretical principles of truth-telling and respect for persons. The emphasis is on a commitment to serving our neighbors fairly and respectfully—seeing them as members of our community and serving them as brothers and sisters.
Reflecting on the humanity in Dr. Leo’s deportment has persuaded me that it is important to ask about the intent of those who wish to hire us. For example, some years ago a prosecutor hired me in the case of an individual who had refused to pay income taxes owed the government. I found out by accident that the prosecutor intended to pursue the case regardless of what I found on examining the subject. In other words, the prosecutor stated boldly that he was not seeking justice. He simply intended to prosecute anyone who refused to pay taxes and he confirmed that his was a political agenda. This many years later, I regret having taken the case. I did strive for objectivity in the case and pursued truth-telling. I concluded that the subject suffered from a mental illness and that his thinking was delusional. But I did not think enough about the subject’s humanity.
One final point deserves consideration here. I am persuaded that our work takes on a different tone when truth-telling, respect for persons, and objectivity are leavened with humanity and generosity. The latter help us, after concluding for example that a criminal defendant’s state of mind has not reached the level of legal insanity, to ask whether the defendant suffered from extreme emotional disturbance at the time of the crime or was able to form the requisite intent necessary for prosecution of the crime.
This is not twisting facts to help the defendant. It is acknowledging that the defendant is a man like me, a recognition that induces me to redouble my efforts to make sure I have done my work thoroughly. Understanding that the defendant is among “the least of these my brethren” argues for greater sustained consideration of how I am going about the work.
I thank Michael Norko, MD, John Young, MD, and the Reverend Dr. Victor Rogers for their kind advice offered during their review and discussion of earlier versions of this article.
This essay is drawn from African-American Bioethics (edited by Lawrence Prograis and Edmund Pellegrino), forthcoming from Georgetown University Press.
- American Academy of Psychiatry and the Law