Everyday Morality in American Mental Health Care: A Comparative Ethnography

现代社会的许多职业都有正式的道德规范。但我们对专业人士如何在日常工作中解决道德困境知之甚少。抽象的道德规范是否显著影响专业人员理解和履行其道德义务的方式？还是当地实际的工作环境才是更重要的决定因素？这个为期两年的项目为现代职业生活中的“日常伦理”研究开发了新的实证方法，重点关注美国社区精神病学的案例。自从20世纪60年代去机构化以来，大多数严重的美国精神病患者都在社区环境中接受治疗。社区精神病学的一线临床医生面临着困难的道德困境：照顾不信任精神卫生系统的患者，说服或强迫患者接受治疗，以及充当稀缺医疗和财政资源的守门人。这个项目以深入的人种学为特色，并在威斯康星州密尔沃基的两种截然不同的环境中采访了心理健康临床医生：门诊诊所（类似于标准的办公室实践）和自信社区治疗的创新项目（在患者家中提供治疗，心理健康工作者参与患者生活的各个方面）。在这些环境中，在专业/病人关系、日常工作活动和工作场所任务方面，工作条件差异很大。该项目比较了不同环境下的临床医生如何谈论道德问题，如何与患者协商冲突，以及如何使正式的道德规范适应不断变化的日常现实。因此，它将决定工作场所条件如何影响临床医生的道德判断以及他们与患者面对面的互动。这一知识的更广泛影响是，它显示了职场的哪些方面促使专业人士放弃抽象的理想，并设计出新的、或更直观的道德解释。研究结果将广泛提交给社区精神卫生领域（社会工作、护理和精神病学）的教育工作者，以帮助他们认识到道德规范何时以及为何有用或无关紧要。这项研究还将通过展示对道德决策及其社会背景的实证、人种学研究的价值，推进生物伦理学——一个由神学和法律主导的领域。

Many professions in modern society have formal codes of ethics. But we know little about how professionals actually resolve ethical dilemmas in the midst of everyday work. Do abstract ethics codes significantly influence the ways professionals understand and act on their ethical obligations? Or are practical, local workplace conditions more important determinants? This two-year project develops new empirical methods for the study of "everyday ethics" in modern professional life, focusing on the case of American community psychiatry. Ever since deinstitutionalization in the 1960s, most severely mentally ill Americans receive treatment in community settings. Front-line clinicians in community psychiatry face difficult moral dilemmas: caring for patients who mistrust the mental health system, persuading or coercing patients to accept treatment, and acting as gatekeepers to scarce medical and financial resources. This project features in-depth ethnography and interviews with mental health clinicians in two contrasting settings in Milwaukee, WI: an outpatient clinic (resembling standard office practice) and an innovative program in Assertive Community Treatment (where treatment is delivered in patients' homes and mental health workers are involved in all aspects of patients' lives). The conditions of work differ dramatically across these settings, in terms of the professional/patient relations, everyday work activities, and the workplace mission. The project compares how clinicians in each setting talk about moral concerns, negotiate conflicts with patients, and adapt formal ethics codes to shifting everyday realities. It will thus determine how workplace conditions affect clinicians ' moral judgments and their face-to-face interactions with patients.The broader impact of this knowledge is to show which aspects of the workplace push professionals to abandon abstract ideals and devise new, or more intuitive, moral explanations. Results will be widely presented to educators in community mental health fields (social work, nursing and psychiatry) to help them recognize when and why ethics codes become useful or irrelevant. This research will also advance bioethics - a field dominated by theology and law - by demonstrating the value of empirical, ethnographic research into moral decision-making and its social context.