Everyday Morality in American Mental Health Care: A Comparative Ethnography

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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.