Abstract: This article explores the application of virtue ethics within psychiatric care, with a particular  focus on the four cardinal virtues: phronesis (practical wisdom), courage, temperance, and  justice. Building on classical philosophical sources (Aristotle) and contemporary psychiatric ethics (Radden, Brendel), the paper argues that technical competence must be complemented  by moral character in order to sustain high-quality care. Psychiatry, as a domain deeply  entwined with vulnerability, stigma, and existential suffering, requires not only procedural  knowledge but also the cultivation of professional virtues. Through clinical examples and  conceptual reflection, the article illustrates how virtue ethics can provide a robust normative  framework for ethically challenging decisions and interpersonal encounters in psychiatry.

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Introduction

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Psychiatry sits at a unique intersection of medicine, philosophy, and the human sciences.  More than other medical specialties, it requires the physician to engage with the patient  not just biologically (as a body), but existentially (as a person). Yet mainstream biomedical ethics, grounded in  principles such as autonomy and beneficence, often struggles to account for the moral  complexity of psychiatric practice, especially where patients' agency is impaired. 

     This article revisits the classical tradition of virtue ethics—with its emphasis on  moral character and practical wisdom—as a complementary and perhaps necessary  framework for psychiatric ethics. Drawing on Aristotle’s Nicomachean Ethics and recent  contributions by Radden, Brendel, and others, I argue that the cultivation of virtues such  as phronesis (practical wisdom), courage, temperance, and justice is essential for sustaining ethical integrity  in mental health care. These virtues do not replace professional standards; rather, they  embody the moral orientation required to apply those standards sensitively, humanely,  and with professional self-awareness. In the following sections I will examine each of the mentioned virtues.

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The Virtue of "Practical Wisdom" Among Physicians & Healthcare Professionals in Psychiatry

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     In his Nicomachean Ethics, Aristotle states that knowledge (epistēmē) is the most  complete form of wisdom. A wise person should not only understand the consequences  that stem from first principles, but also grasp the truth within those very principles themselves.[1] 

     In psychiatry, practical wisdom and self-reflection highlight  the physician’s ability to critically evaluate their decisions and act in the patient’s best interest. When assessing a patient's condition, the  psychiatrist must be aware of their own abilities and trust in their capacity to sensitively  select the most appropriate therapeutic approach. Jennifer Radden similarly  identifies phronesis as a necessary Aristotelian virtue for grasping and responding aptly  to practical situations—such as diagnosing mental illness, evaluating a patient’s current  psychological state, or determining a new medication plan.[2] Phronesis is central to  establishing coherence and integration among the other virtues. Psychiatry, in my view,  is marked by a high incidence of symptomatic manifestations across a broad spectrum of  disorders, each with a highly individual course. This reality demands a particularly refined communicative approach from the clinician, especially when working with  patients with intellectual disabilities. Here, the psychiatrist must apply both technical skill  and virtuous conduct, interconnected with other habits—such as temperance. Patients  should only receive information appropriate to their level of understanding and presented  in a plausible manner. It is not lege artis (i.e., not consistent with professional standards) to offer a patient a complex pathophysiological  explanation supported by biochemical data they are unable to interpret. On the other hand,  the physician must still provide sufficient information to ensure informed consent is genuinely obtained and a deficit of information does not occur. Psychiatrists—as well as psychiatric nurses and support staff—who are capable of integrating their personal  experiences and values with their professional roles are more likely to build deep,  trustworthy relationships with patients. According to David H. Brendel, one of the most  complex forms of friendship is that between psychiatrist and patient. He writes that this  relationship ranks among the most intricate interactions in modern society. Individuals  with diverse interpersonal challenges seek psychiatric help in the hope of receiving  precise diagnostic insight grounded in the latest medical knowledge, as well as emotional  support and sensitivity. Brendel views this relationship as one of maximal professional  integrity—characterized by discretion, respect, and confidentiality (the  duty to uphold medical secrecy). 

     In their professional work, psychiatrists integrate neuroscientific understanding of  brain function, holistic psychological phenomena, and social relationships—along with  clinical intuition—in order to ask the right questions, establish appropriate diagnoses, and  prescribe suitable psychopharmacological treatments. These may include psychotropic  medications, with or without combination with psychotherapy and other modalities (such  as neuroimaging techniques like CT, fMRI, or MRI).[3] The ultimate aim is to preserve and  promote the dignity of their patient—who, in the deepest ethical sense, may also be  regarded as a companion or fellow human being.[4] 

     Lee and Jeste have examined the relationship between aging and wisdom. The  benefits of wisdom extend beyond individual well-being and contribute to the flourishing  of society as a whole. As individuals grow older, the accumulation of life experience and  reflective insight enables them to thrive in later stages of life. Moreover, the so-called  “grandmother hypothesis” suggests that grandparents play a crucial role in enhancing the  survival of the species by transmitting their accumulated wisdom to younger generations.[5] 

     This, in essence, reinforces my conviction in the idea of a “senate of elders,” in which  senior members of society have traditionally passed on their accumulated wisdom to  successors in public service. A similar model, I believe, still holds today in medical  practice, where senior psychiatrists nearing retirement pass down their hard-earned,  experience-based knowledge to their junior colleagues and trainees. These younger  physicians—often preparing for board certification in psychiatry—then incorporate this  wisdom into their own understanding, further enriched by international perspectives and  the insights of respected authorities in the field.

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The Virtue of "Courage" Among Physicians & Healthcare Professionals in Psychiatry

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     The virtue of  courage - through the lens of Aristotle, particularly as presented in his Nicomachean  Ethics - provides us another cornerstone that can be discussed in psychiatry. Regarding fearfulness, he states that one ought to fear only certain things, and  only to a moderate extent; such fear is noble and fitting. A complete absence of fear, by  contrast, is seen as disgraceful—especially in relation to shame. According to Aristotle,  the person who fears shame is good and possesses a sense of modesty, whereas the one  who feels no shame has already lost that moral sensibility.[6] A courageous person, in the  truest sense, is someone who does not fear either a noble death or a life marked by illness.[7]

     So much for Aristotle. A courageous psychiatrist is undoubtedly exposed to intense levels of stress, which inevitably affect both their personal and professional life. Such a psychiatrist must remain resilient to external pressures and stressors, as  inconsistent or erratic behavior on the part of the physician can disrupt the patient’s  treatment process and potentially distort or undermine the uniqueness of the patient’s  condition. 

     Moreover, psychiatrists frequently face ethical dilemmas within their  environment—situations in which they must act bravely and often seek compromise, particularly in complex scenarios such as prolonged hospitalizations. To be courageous  means having the strength to confront danger or discomfort for the sake of another  person's well-being.[8] 

     The task of a courageous psychiatrist is, above all, to support and strengthen their  surrounding team—to inspire resolve where motivation may be fading. As a central figure  within the clinical team, the psychiatrist should provide steadfast support and reinforce  collective resilience with the aim of delivering the most effective care possible. 

     Their irreplaceable role lies particularly in managing team dynamics and  cultivating a positive working environment. It is essential that the physician—and  especially the broader multidisciplinary team—maintains professionalism and avoids any  expressions of personal frustration or retaliatory behavior toward a patient who, more  often than not, is not acting in a state of full mental competence. 

     The courageous psychiatrist must avoid, as previously mentioned, any inclination  toward retaliation or resentment. They must also be able to acknowledge their own  limitations, recognizing the boundaries of their competence and where their professional  capacity has been reached. At the same time, they should be aware of areas where growth  is possible—through additional training, participation in workshops, or further education. 

     Integrating newly acquired therapeutic skills can enhance teamwork, particularly  in challenging contexts such as working with uncooperative patients or with children. Radden once again offers her perspective on courage, while also highlighting the  importance of patience and perseverance. According to her, these are essential virtues for  psychiatrists, although she cautions against the assumption that they are uniquely relevant  to psychiatry alone. Nonetheless, psychiatry does possess certain distinctive features that  make these virtues particularly critical. 

     Severe psychiatric disorders often impact interpersonal dynamics, including one’s  attitudes, judgments, emotional stability, and communicative abilities. When these  aspects are disrupted, the result is often a breakdown in relational coherence—leading to  misunderstandings and a failure to properly recognize and validate emotional states.  Radden points out that while communication difficulties certainly arise in other medical  fields—for instance, in cases involving patients in a coma who cannot speak—psychiatry  is marked by a distinctive reliance on communication as a primary therapeutic tool. 

     There are numerous imaging techniques, particularly in emergency medicine, that  can help identify pathologies resulting from trauma. However, unlike physical injuries, it is impossible to directly and clearly visualize psychiatric disorders with imaging available in the field.  This uncertainty heightens communication challenges within  psychiatric care. With this comes an increased risk of diagnostic errors and  misunderstandings.

     For this reason, it is essential that professional psychiatrists demonstrate a high  degree of patience, courage, and perseverance in their efforts to understand and treat their  patients.[9] They must be able to accept patients as they are and recognize that conditions  such as schizophrenia—unlike, for example, transmural myocardial infarction—do not  enter remission within a matter of weeks. 

     McInerny also reflects on courage as the seemingly paradoxical reconciliation of  two opposing tendencies: fear and excessive boldness. Fear seeks to avoid a perceived  evil or threat, while excessive boldness attempts to confront and eliminate it head-on. The  act of bringing these two impulses into harmony constitutes true courage—an  achievement that requires regulation through the virtue of prudence.[10] 

     In practice, this means that individuals with psychiatric disorders—such as  depression—often face internal or external conflicts that can provoke either fear or,  conversely, excessive boldness. An appropriately structured therapeutic approach should  aim to balance these opposing tendencies. In such a framework, the psychiatrist helps the  patient better understand their fears, psychological complexes, and intrusive traumatic  impulses, while simultaneously offering support and identifying effective strategies to  quiet these distressing mental contents. This process enhances the patient’s resilience and,  consequently, contributes to a more favorable course of the illness. 

     Since the early days of medical training, death has been a constant companion in  the physician’s professional life. No matter how excellent the care provided, medicine  remains incapable of reversing the natural process of dying. At times, however, death  occurs outside of the typical trajectory of aging—arising instead from pathology, trauma,  or comorbidity. 

     One relatively common scenario involves the psychiatrist having to courageously  inform the family of a patient’s death, conduct the formal examination of the body, and fulfill all legal and procedural obligations related to exitus letalis. Perhaps most  challenging of all is facing the emotional aftermath: responding to a flood of questions,  offering comfort to the grieving family, and addressing the distress of fellow patients or  staff members from the psychiatric ward. 

A particularly demanding area of psychiatric practice involves the psychiatrist’s courageous conduct when working with deviant patients. I am referring  specifically to situations in which a patient has committed a criminal offense and has been  legally ordered to undergo protective detention pursuant to Section 100, paragraphs (1)– (7), and more precisely under paragraph (2)(a) of Act No. 40/2009 Coll., the Czech  

Criminal Code. This provision states:

 

"An offender who has committed a crime while in  a state induced by a mental disorder, whose release into society would be dangerous, and  for whom it cannot be expected that imposed protective treatment, considering the nature  of the mental disorder and the possibilities of therapeutic influence, would provide  sufficient protection to society, (…)".[11]

 

     In conclusion, it is worth noting that Robertson and Walter point out that various  groups of scholars and practitioners have compiled lists of desirable virtues for healthcare  professionals—lists that often build upon the four cardinal virtues discussed above.  Among these derived or context-specific virtues are soucit (compassion), pokora  (humility), věrnost (fidelity), důvěryhodnost (trustworthiness), respektování tajemství  (respect for confidentiality), pravdomluvnost (veracity), prozíravost (prudence),  vroucnost (warmth), citlivost (sensitivity) a vytrvalost (perseverance).[12]

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The Virtue of "Temperance" Among Physicans & Healthcare Professionals in Psychiatry

 

     Temperance, in Aristotle’s words, is a virtue opposed to intemperance—understood as its  extreme counterpart—and relates to pleasures that humans share with other animals.  These pleasures are considered slavish in nature and are primarily associated with the  senses of taste and touch.[13] 

     The virtue of temperance plays a key role in the field of psychiatry. Treatment grounded in temperance - “everything in moderation” - helps restore balance in both mind and brain through the  appropriate choice of psychopharmacological agents or psychotherapeutic approaches.  These centers are meant to operate in accordance with how evolution has shaped the brain,  yet for various reasons, may become dysregulated. 

     The influence of the pharmaceutical industry on some physicians’ prescribing  practices often deviates from the genuine therapeutic rationale. In my opinion, this  reflects a shift from the true aim of healing toward material exploitation—a pursuit of  financial gain at the expense of the patient’s well-being. 

     Temperance in behavior is equally crucial, as emphasized more recently by Cyril  Höschl. The positive extrapolation of learned behavioral patterns can help transform  a patient’s maladaptive cognitive style—such as the belief that “everyone is against  me”—and encourage introspection, leading to the realization that not all people on Earth are uniformly hostile, as the patient’s mental state might suggest. In such cases, it becomes necessary to erode faulty and distorted reasoning. 

     Höschl illustrates this with an example from Victor Hugo’s Les Misérables. The dignified Bishop Charles-François-Bienvenu Myriel, having been robbed of his  silverware, does not accuse Jean Valjean of theft. Instead, he mystifies the situation by  claiming he had given the silver as a gift. This unexpected act of mercy creates  a corrective experience for Valjean, a former convict, who is so profoundly affected that  he eventually reforms and becomes the mayor of Montreuil-sur-Mer.[14]

     This example illustrates not only the situational need for doing good but also the  virtue currently under discussion—temperance. I believe the attitude described by Höschl, which he employed in his earlier therapeutic practice, holds significant value. A physician, when under pressure, may intemperately resort to asserting rights afforded  to them by the legal framework, potentially engaging in retaliatory action.

However, one must ask whether anything meaningful is achieved through such  paternalism—particularly in cases involving patients with severe trauma. I would add an essential clarification to this point: for both psychiatrists and  psychiatric nurses, it is absolutely vital to maintain temperance in expressing  hypersensitive opinions or personal biases. They must carefully balance the boundaries  of empathy, pragmatism, and responsibility—avoiding both burnout on one end and an  overly detached attitude on the other. 

     Given the inherent complexity of psychiatric care, it is equally important to guard  against additional prejudices—especially the misguided notion that psychiatry is a kind  of “preventive spa treatment” for mental illness. When a patient finally finds the courage to face public stigma and humiliation and consents to psychiatric hospitalization in a state  of despair, helplessness, or emotional crisis, they do not seek further humiliation at the hands of the caregiving staff. In many cases, the medical team symbolically assumes the role of a surrogate family—one the patient may have suddenly lost. In such moments, a modest expression of empathy and commitment from the clinician may be a small act for the caregiver, but a potentially transformative step in the patient's journey toward healing. 

     When considering the field of addiction medicine, temperance remains equally  indispensable. In this context, the psychiatrist—specifically the addiction specialist— must exemplify temperance in managing therapeutic relationships, both with individual patients and among patients in group settings. The clinician must take into account each patient's unique experience and trajectory during the process of withdrawal and recovery. 

     In particularly severe cases, the physician must also be aware of their own clinical  limitations and be willing to take the collegial step of convening a consultation. For instance, according to the Professional Code of the Czech Medical Chamber (Directive  No. 10), a physician has the right to withdraw from treatment if the patient decides to  follow the recommendation of another consulting doctor [15]. 

     In addiction medicine, it is in the physician’s best interest to attempt to modify— but not impose—the patient’s patterns of thinking. The goal is to adapt to the patient's  mental framework while reflecting on the specific nature of their dependency. The  physician is expected to provide therapeutic feedback with temperance, without  forcefully imposing their own convictions regarding abstinence. Likewise, the  psychiatrist should exercise a tempered degree of patience when working with patients  who exhibit adequately paralogical forms of thinking—those who perceive reality in  significantly heterogeneous or distorted ways. 

     Temperate conduct is also essential for mental health professionals, particularly  when they are called upon—often by courts—to draft forensic psychiatric evaluations. In  composing such legal documents, the physician must carefully weigh not only legal but  also ethical consequences that their assessment may have on the individual being  evaluated. The court considers the expert opinion of the psychiatrist listed in the official registry of forensic experts maintained by the regional court. Ethically speaking, a lack  of relevant information in the report may be problematic—but so too is an excessive or  unbalanced assessment, which can result in disproportionate consequences such as  unduly harsh sentencing, exposure to trauma in prison, or social humiliation. 

     The psychiatrist must also act with temperance when reporting requested or proposed care to a patient’s health insurance provider. Only the services actually rendered should be reported. A temperate physician does not intentionally report unauthorized or non-existent care for the sake of financial reimbursement.

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The Virtue of "Justice" Among Physicians & Healthcare Professionals in Psychiatry

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     The final virtue to be discussed is justice. Aristotle wrote that a person who acts  illegally (contra legem) is unjust, whereas actions that are legal (secundum et intra legem)  are considered just, insofar as they align with the authority of the lawgiver.16 This virtue  appears to be perfect in its orientation toward others.[17]

Radden describes the character demands that must be met in order for a psychiatrist to be regarded as a true professional. Among these aspirational traits—such  as honesty, trustworthiness, fidelity, integrity, and respect for the fundamental contractual relationship between provider and recipient—is the ability to act in accordance with the  virtue of justice.[18] 

     With regard to justice, psychiatrists may encounter numerous situations in clinical  practice in which this particular virtue is put to the test. Turning briefly to Czech law,  bribery is defined in Section 331(1) of the Criminal Code as follows: "Whoever, directly  or through another, in connection with the management of matters of public interest,  accepts or agrees to accept a bribe for themselves or for another person, (…)".[19] 

     One of the ethical hazards a psychiatrist must face with justice is the issue of  corruption—specifically bribery—as defined in the aforementioned provision of the  Criminal Code. Like professionals in other fields, physicians may be exposed to the  temptation of accepting illicit incentives. Bribing a public official, police officer, or judge  is undoubtedly a contemptible act. However, while such offenses are serious, their direct  impact on human health may be limited.

     In contrast, a bribe offered to a physician—particularly a psychiatrist—can have  direct and profound consequences on a patient’s well-being. A psychiatrist may be  pressured to provide a more favorable forensic report, to shorten the duration of  institutional treatment, or to prescribe medications restricted to special prescriptions or  "blue stripe" authorizations. In such cases, the ethical breach is compounded by its  potential to compromise patient safety and public trust in the medical profession.[20] 

     A just psychiatrist may also encounter situations involving the phenomenon of  favoritism. The patient, their family, or a legal guardian may pressure the psychiatrist to  adopt a preferential or unequal approach to care. In practice, this means requesting  treatment that deviates from standard procedures and could be perceived as preferential  rather than equitable. Such exceptional treatment can disrupt the therapeutic plan for other patients. Fellow patients may become susceptible to feelings of envy or heightened anxiety — fearing that others are receiving better or different care. This perception can give rise to paranoid thoughts and foster a sense of inadequacy regarding their own, seemingly  inferior, treatment. 

     Aristotle’s ethical theory of well-being describes the path to  achieving eudaimonia [21] as one that proceeds through the cultivation of reason. Among  the beneficial qualities of character, he identifies are justice and truthfulness.[22] The virtue  of justice, therefore, is not confined solely to the realm of professional practice but is  integral to the whole of the good life itself—constituting one of its essential components.

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Conclusion

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      Virtue ethics offers psychiatry more than a historical curiosity or moral adornment—it  provides a compelling framework for restoring the human face of mental health care.  While principles and protocols remain indispensable, they are often insufficient for  guiding clinical action in ethically charged situations. The four cardinal virtues— phronesis, courage, temperance, and justice—shape not only the psychiatrist’s conduct,  but their moral being. 

      In a context where burnout, bureaucratization, and clinical nihilism are rising,  a return to the ethics of character may be one of the few viable ways to reclaim moral  clarity and professional integrity. Psychiatry, perhaps more than any other medical field,  demands not just competence, but virtue. It is important that psychiatry once again looks to character as the foundation of ethical practice.