Monday, August 17, 2009

The Ethics of Disclosure

For many years now I've chosen to be candid about having bipolar disorder, and I have a variety of reasons for doing so. Many are pragmatic. But one is not: "[Being up front about bipolar disorder] gives me a chance to combat, in a small way, the stigma that still attaches to mental illness. If a professor protected by tenure cannot summon the modest courage required for such an act, I do not know who can."

The quotation comes from a column I wrote three years ago. And although in it I used the phrase "modest courage," it would be more accurate to say "moral courage." That is to say, I would feel craven or gutless if I remained discreet about having bipolar disorder, even though the fact that I'm high-functioning means that people are oblivious to my having the disorder unless I tell them.

So if I kept this information to myself, would it be unethical? And if so, why?

Here at the Army War College we're midway through a ten-day course in "Strategic Thinking." I'm responsible for most of the remaining lessons -- the Uses of History and the capstone Gettysburg Staff Ride, for obvious reasons. And a bit less obviously: Ethical Reasoning, which comes up tomorrow. (I say "a bit" less obviously because anyone who knows my body of work is aware that much of it deals with the problem of moral judgment in war.)

At the AWC we faculty do not have carte blanche to prepare our own lessons. The readings, learning objectives, and the basic approach are designed by a lead instructor. The rest of us can adapt the lesson within certain limits, but we can't leave the reservation entirely. This sounds like a strait jacket, but it's really the only workable approach given the way that education is delivered here; i.e., within twenty tightly knit seminar groups with faculty members assigned to teach one particular group, and that group only, for most of the academic year.

This year the lead instructor has adopted what strikes me as a reasonable, easy-to-grasp approach. We're asked to discuss ethical reasoning through just two lenses: deontological, or principle-based reasoning; and teleological, or results-based reasoning (the latter primarily taking the form of utilitarianism).

What light do these forms of ethical reasoning shed on the ethics of disclosure? Indeed, are ethics even involved?

Certainly to me it feels unethical to keep silent about having bipolar disorder. From experience I know that my candor has been helpful to people who either have a mood disorder or know someone who does. So from a teleological perspective, I suppose a case could be made that if I remained silent I would deny those people whatever assistance or comfort I might otherwise provide. And one could add that my silence would do nothing to undermine the stigma associated with such disorders.

All the same, this strikes me as a pretty weak case. Equally weak would be to argue from a deontological perspective -- that I must be candid about the disorder as a matter of principle.

It therefore seems to me that only two conclusions are possible: either I'm mistaken to believe myself under a moral obligation to be open about having bipolar disorder; or else some other ethical framework must apply.

It seems to me that another ethical framework does apply: aretaic, or virtue-based reasoning. This basically flows from a moral imperative that is rooted in character, that comes from within. It differs from deontological and telelological ethics in that, unlike these two, it does not attempt to be universally prescriptive. Put simply, just because I perceive it as a moral imperative to publicly acknowledge having bipolar disorder, doesn't mean that everyone should. This was the basic problem with the tactic of "outing" gays. Yes, it would show that being gay was fairly common and would thereby reduce the stigma of being gay. It would also increase the political clout of the gay community. And one could certainly advocate in favor of having gays come out of the closet. But to strip from a person the option of privacy was wrong.

As I've pointed out in the past, my situation with bipolar disorder has certain analogs with battle stress injury, in particular the need to manage the two conditions and the stigma that clings to them. Military policy has become quite enlightened about encouraging service personnel to seek treatment for battle stress injury and, as much as possible, eliminating the adverse consequences of doing so. Here at the Army War College it's estimated that as many as a third of the incoming resident class have some symptoms of Post Traumatic Stress Disorder, and there are several ways by which officers can seek treatment confidentially. (The most obvious of these is to visit a chaplain, all of whom have both training and experience in counseling persons with PTSD.)

But policy will get you only so far. The culture remains one in which battle stress injury is still too often regarded as weakness. It may be okay for an enlisted man to receive treatment for PTSD. It may even be okay for an officer or senior NCO to receive treatment for PTSD. However, as I often heard officers maintain during my first year here at the Army War College, it is not okay for officers or senior NCO's to disclose publicly that they are being treated for PTSD. My comment in a post I wrote last year about the military use of antidepressants, etc., also applies here:

How does this relate to military personnel who take psychotropic meds? First, I wonder how many officers and NCOs self-disclose that they are taking the same meds. If they keep this info away from their soldiers, they send a double message: overtly it’s OK for you to take these meds, but tacitly it’s really not because I wouldn’t be caught dead letting you know that I take them myself. It would require real moral courage, but an officer willing to talk matter of factly about taking these meds, and at the same time functioning effectively as an officer, would serve as a powerful role model. (I find that’s the role I often play with my students.) Such an officer’s example could not only reassure the soldiers who take the meds, but would also help shift the military culture toward one in which other soldiers would find it easier to trust and support their comrades in arms.
I broached this subject to a number of officers and national security analysts and got the same response. Double messages, they acknowledged, do have adverse effects on organizations. But in this case it was just too bad. It would be fatal for officers who took medications for combat-related anxiety or depression to discuss it with their soldiers or, for that matter, anyone else. To command effectively an officer has to appear strong, and the stigma of weakness attached to battle stress injury was too potent to challenge.

In the months since, however, I've discovered that a few generals have done exactly as I proposed.

On November 8, 2008, USA Today reported that Maj Gen. David Blackledge had received "psychiatric counseling to deal with wartime trauma, and now he is defying the military's culture of silence on the subject of mental health problems and treatment." His decision to speak up apparently came from two sources: First, a statement from Admiral Mike Mullen, the Chairman of the Joint Chiefs of Staff, for leaders to set an example for all service personnel: "You can't expect a private or a specialist to be willing to seek counseling when his or her captain or colonel or general won't do it." And second, a campaign developed by Brig. Gen. Loree Sutton, an Army psychiatrist heading the defense center for psychological health and traumatic brain injury, to encourage service personnel (and their families) to share their stories. Blackledge volunteered to help.

On November 26, 2008, in an article picked up by Army Times, USA Today highlighted a four-star general, Carter Ham, who had also disclosed publicly that he was getting treatment for battle stress injury, partly to serve as an example to other service personnel -- "You need somebody to assure you that it's not abnormal. It's not abnormal to have difficulty sleeping. It's not abnormal to be jumpy at loud sounds. It's not abnormal to find yourself with mood swings at seemingly trivial matters" -- and partly to undercut the stigma surrounding battle stress injury. The article went on to discuss Brig. Gen. Gary Patton, who had also chosen to talk publicly about having battle stress injury.

A March 2009 CNN article further explored the cases of Generals Ham and Patton, and offered clues about their reasons for coming forward:

"If you go ask for help somehow you believe it or you might believe others think it of you, that you're somehow weak. That's wrong and intellectually we all know it's wrong, but it's still there. It's still palpable in some communities," Ham said.

Patton wants to see a change in the way post-traumatic stress disorder is viewed by the military.

"We need all our soldiers and leaders to approach mental health like we do physical health. No one would ever question or ever even hesitate in seeking a physician to take care of their broken limb or gunshot wound, or shrapnel or something of that order. You know, we need to take the same approach towards mental health," Patton said.

Having two generals talk publicly about their own battles with stress and how counseling helped should help remove some of that. Patton said he wants servicemen and women to know that they can come forward.

"Know absolutely that your chain of command and your leadership in the military at our highest levels recognize this issue and want to encourage our soldiers to seek out that mental health assistance," Patton said.

Again, neither deontological nor teleological ethical reasoning seems to apply here. Generals Blackledge, Ham, and Patton (and for that matter Admiral Mullen and Brig. Gen. Sutton) do not come close to arguing that it is a moral imperative for all officers to publicly battle the stigma associated with battle stress injury. But plainly, it seems to have been a moral imperative for them -- a case of aretaic reasoning in action.


J. L. Bell said...

How has knowledge of your condition (your own knowledge and other people's knowledge) affected your discussion of Gen. William T. Sherman's strategic thinking? Here's a case when what some historians view as bipolar disorder intersects with your research field.

Mark Grimsley said...

It really hasn't affected my view of Sherman's strategic thought, though I agree with those who think Sherman had bipolar disorder. See especially Janann Sherman, “The Jesuit and the General: Sherman’s Private War,” Psychohistory Review 21:3 (Spring 1993):255-294. Michael Fellman has told me that his view of his subject in Citizen Sherman (1995) was informed by the possibility that Sherman had bipolar disorder. Personally, I am convinced that he did -- most likely Bipolar II, which is characterized by occasional hypomania and depressions but not by full-blown manic episodes.

Lee Kennett, in his biography of Sherman, postulates that Sherman had narcissistic personality disorder. I don’t think so, though I believe that, thanks to his father’s early death and his mother’s giving him over to the Ewings, he surely had a deep “narcissistic wound,” which though similar sounding, is not the same thing. John Marszalek’s biography rejects speculation as to any disorder, and judging by a conversation I once had with him, he seems to believe that a high-functioning person cannot, by definition, have a serious mental illness. Obviously, I reject that proposition.

At this point I think that the theory that Sherman had bipolar disorder is useful for understanding the man, but not necessarily the soldier. For that matter, I don't think knowing that I have bipolar disorder is useful for evaluating my teaching or scholarship, either.

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