Clinical decision making inevitably occurs not in discipline-specific isolation but in an ethical context. This chapter illustrates the ways in which the application of ethical principles, which represent the long-standing traditions of ethical decision making, may contribute to solving knotty problems in the clinical arena.

Although clinicians may not be aware of the specific philosophy they are espousing when they make a clinical decision, every clinical approach reflects some ethical position. That is, every treatment program embodies certain values, and each set of values is based on a model of what human beings are like and how, through their actions, they approach the dispensation of goodness. Each model uses a specific set of values and concepts in explaining how human choices have right-making and wrong-making consequences for their agents.

Conflict over which values should be promoted in treatment decisions is natural, as at times we all have conflicting internal values, and this conflict may be externalized into an interpersonal conflict between group members having otherwise common interests. But a conscious understanding of the ethical traditions that have influenced clinical decision making can help to enrich the clinical process and, in turn, its traditions can enrich and enlarge ethics. In mental health more than in any other area of medicine, as will be seen in our case example, the therapeutic alliance must avoid the Scylla of paternalism that can degenerate into coercion and the Charybdis of autonomy that can lead to abandonment.