Abstract
Among the strengths of forensic psychiatry as a profession is its ability to support lively discussion of critical questions, such as how to characterize its own essence and whether it belongs to the practice of medicine. The American Academy of Psychiatry and the Law is fortunate that Michael Norko has taken the occasion of his presidential address to describe in depth the results of the advanced stage of his probing on a truly spiritual level the fundamental place of compassion in the practice of forensic psychiatry. In so doing, he casts inevitable light on the seamless connections binding forensic psychiatry and medicine, particularly the importance for both of practicing compassion in our search for truth.
Many are the intense changes that students experience during their first days of medical school. Among the strongest and most enduring of them for me and for most of my classmates was how open and disarming our first “patients” turned out to be. We were total strangers and much younger (generally); yet, even during these initial highly structured preclinical encounters, we regularly received self-disclosures that would be remarkably profound were they to be heard in the confessional, as I of course knew first-hand.
Reflecting now after 40-some years, it seems apparent that these proto-patients, along with most of their many full-fledged successors, were placing in us a trust. Its extent was highly variable, but often enough, it came close to being total. I now understand that they could see in each of us a commitment to learn the practice of medicine. We were on a mission, and each of them engaged to the extent they chose in making their contribution to our success. In the process, they doubtless hoped to be healed or at least helped significantly.
We cannot honestly be sure about how well we deserved the trust our earliest patients placed in us. Some of them were certainly able to parallel their anxiety with our insecurity and were thus in a position to collaborate deeply in the work at hand, fashioning an effective patient–doctor relationship. To the degree that this dyad continues to thrive, the better the outcome is likely to be. It is usually a delicate partnership, taxing the bio-psycho-social resources of both parties.
The doctor's contribution includes making great strides in acquiring knowledge without forgetting to strive for a comparable growth in wisdom.1 Such growth involves not only the ability to acknowledge one's own ignorance but also the insight that gaining knowledge means further appreciating how much there is yet to be learned. The wise physician can see that the role of paternalism ends where the patient's competent autonomy begins. The humble physician grasps the necessity of gaining as complete an appreciation of the patient as possible. Admittedly, this ideal is increasingly challenging for forensic inpatient units.2 It also challenges any forensic mental health professional who would embark on a full appreciation of the truth. Truth depends on a humility based on wisdom and directed toward the face of compassion.
Compassion's Gaze
True compassion is something visible, unmistakable in its power for good and thus highly desirable in the preparation and composition of forensic assessments and reports. The essential need for compassion is more regularly obvious in the other branches of professional medicine.3 Yet as these two vignettes illustrate, compassion is in fact more crucial in forensic settings.
The first quote is from Elder Zosima of Fyodor Dostoevsky's The Brothers Karamazov:
Keep company with yourself and look to yourself every day and hour, every minute, that your image be ever gracious. See, here you have passed by a small child, passed by in anger, and with a foul word, with a wrathful soul; you perhaps did not notice the child, but he saw you, and your unsightly and impious image has remained in his defenseless heart. You did not know it, but you may thereby have planted a bad seed in him, and it may grow, and all because you did not restrain yourself before the child, because you did not nurture in yourself a heedful active love [Ref. 4, p 319].
Fortunately, the reverse principle also applies; as evidenced from Be Free Where You Are, a small booklet by Thich Nhat Hanh,5 a moving account of a visit to a prison. Included is a conversation with an inmate who asked how he might bring joy and peace to the world. In part, the answer was:
Perhaps there is an inmate or a guard who acts aggressively toward you. If you can look with compassion at him—with kindness and love—and offer him a gentle smile, he will be receiving something very precious from you. When you understand the pain of those who cause you suffering and choose to let it go, forgiveness will come naturally because compassion will be present. When it is necessary, you can be firm and strong, but never lose your kindness or your beauty [Ref. 5, p ix].
As I see it, Michael Norko's account6 of the pausing step in forensic report writing is a further operational way of capturing the face or the nature of compassion as it works for him. It bears striking resemblances to professional descriptions of contemplative prayer. For example, I perceive a sense of mind and heart being raised, of their focused gazing outward beyond oneself and inward, reaching deeply for truth. It is more spiritual than it is religious. Above all, I tend to characterize it as compassion in search of truth.
In contrast, Pilate's quest for truth was hardly a true search in any sense, as Norko suggests twice. His position harmonizes with that of the respected scripture scholar, the late Raymond E. Brown. According to his commentary on the Gospel of St. John,7 Jesus was inviting Pilate to recognize, or belong to, the truth: “Everyone who belongs to the truth listens to my voice.” (18;37b) Despite his having experienced it at the closest possible range, Pilate turned away from the truth. The encyclical by Pope St. John Paul II, Veritatis Splendor (The Splendor of Truth),8 powerfully extended that same invitation to one and all. As for Pontius Pilate himself, his refusal ironically assured him the dubious but lasting distinction of being the only pagan individual mentioned by name in virtually every Christian creed ever since.
Some Applications
Several scholars have directed efforts to offer various formulations as candidate principles capturing the essence of forensic psychiatric ethics. Norko has summarized them well, and I would support the assignment of a central role for compassion in the pursuit of truth. Similarly, Norko's article simultaneously makes a strong case that we can count on humility as a basis for making ethically sound responses to the challenges that call upon us for the very best we can do.
At times, a well-developed virtue of compassion may serve to structure exactly what and how much we ought to disclose to victims and their caregivers in tragic situations. It will help us find and formulate what truth we ought to emphasize and what to suppress.9 This is especially the case when for some reason we have a share of the responsibility for the loss. Honestly admitting mistakes and sharing the disappointing outcome of an experimental protocol can present challenges to one's integrity.10 One might also find a related fundamental principle in the need to strive for social justice. This effort could at times call for investment in the distasteful arena of politics. Yet a failure to act can cost more at times than doing something, however lacking and imperfect it may be. In addition, some of the costs may be expected to come from unexpected sources. Often enough, a global dimension is involved.11 For example, efforts to assist developing countries can succeed only to the degree that they are designed to manifest an understanding respect for the receiving culture. The same has to be said of the United States. How many toddlers come home after costly procedures using high-end technology, only to have their feet gnawed upon by rats?
Finally, medical educators have found that exposure to the humanities fosters and nourishes compassion. Thus, a growing number of medical schools are taking a just pride in the exposure they require to the fine arts, especially painting and sculpture. The same is also true of literature, vast, readily available, and diverse as it is, including recently a biography of John Keats who trained as a physician.12 A more radical approach comes from the (posthumous) pen of Franz Ingelfinger:
One might suggest, of course, that only those who have been hospitalized during their adolescent or adult years be admitted to medical school. Such a practice would not only increase the number of empathic doctors; it would also permit the whole elaborate system of medical school admissions to be jettisoned [Ref. 13, p 1511].
Our approach has to be more vicarious, yet the goal is no less ambitious.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2018 American Academy of Psychiatry and the Law
