We're just waiting for Dr. Levin to join us, but I'm gonna go ahead and get started. My name is Rebecca Brendel. I have the honor of being your APA president, and I have an even bigger honor of calling Ezra Griffith my dear teacher, mentor, colleague, and above all, friend. So I'm so honored to be here today to welcome all of you to this lecture of the Chester M. Pierce Human Rights Award. Originally established in 1990 to raise awareness of human rights abuses, this award was renamed in 2017 to honor the late psychiatrist, Dr. Chester Middlebrook Pierce. Dr. Pierce was the founding president of the Black Psychiatrists of America, speaking on racism in America, and first proposing the term microaggressions. He was a dedicated leader who served our profession with distinction through the American Board of Psychiatry and Neurology, the American Orthopsychiatric Association, the World's Association of Social Psychiatry, and the Carter Center Mental Health Task Force. He was also active in numerous organizations, including the National Institute of Mental Health, the National Research Council, the National Science Foundation, and the National Aeronautics and Space Administration. Dr. Pierce spent the majority of his career at the Massachusetts Institute of Technology, Harvard University and Medical School, and Massachusetts General Hospital, where the Global Psychiatry Program is named after him. His legacy and influence lives on and continues to inspire researchers and physicians today. In 2021, this award was endowed by the APA Foundation through the successful efforts of the Chester and Pierce Human Rights Endowment Campaign Workshop. I'd like to take a moment to thank the generosity of all the award donors who helped make this award and lecture possible. And now I'd like to pass it to Dr. Levin to continue with the introductory remarks. Sorry for being a little late. I was at the other side of the convention theater. So how is it you can't have the rooms closer to where we are? It gives me no pleasure, more pleasure, than to invite Ezra Griffiths to be with us here now to honor him with the Chester Pierce Human Rights Award that recognizes an individual for the efforts of all individuals focusing on promoting and supporting the human rights of populations with mental health needs. It honors the legacy of Dr. Pierce, including his dedication as an innovative researcher on humans in extreme environments, as an advocate against disparities and discrimination, and as a pioneer and a visionary in global mental health. He truly understood that we are one world and that we all need to come together with equality and equalness, particularly in the mental health world. Ezra has an immeasurable influence on medicine and psychiatry as a whole. He's a forensic psychiatrist, an academician, an ethics pioneer, and a clinician. And above all, he is one of the best mentors anyone could ever have. His humaneness, he's always willing to take your calls, give advice, whether it's advice that he knows you're not gonna wanna hear, but he will give it to you, and in some ways, ultimately you'll realize this is why you need to do exactly what he says you should do. But, his decades-long participation in leadership in the APA only strengthens the foundation of APA. With all APA's history of discrimination, he has stood up to say he will always be at the table, he will always argue for human rights of everyone and equality, and it's the one thing that I've greatly admired for him. His decades-long participation and leadership in the APA have strengthened these foundations of our profession. He has served as the President of the American Academy of Psychiatry and the Law, APAL, the American Orthopsychiatric Association, the American Board of Forensic Psychiatry, Connecticut Psychiatric Society, and the Black Psychiatrist of America. As my mother would say, he's a great achiever. He is the past recipient of the APA Isaac Ray Award and the Golden Apple Award, which recognizes significant contributions in the field of forensic psychiatry. As the author of a book, Race and Excellence, My Dialogue with Chester Pierce, Ezra provided a personal account of his time with Chet Pierce, as well as engaged in a dialogue of race relations in America and the impact of racism on mental health. Along with the influence of Chester Pierce, Ezra Griffith's voice will continue to lead us into the future, in which race and racism is no longer negatively affect our patients, our practices, our professions, and every individual. I'm honored to recognize my teacher, mentor, colleague, and friend, Dr. Ezra Griffiths, for this year's Chester Pierce MD Human Rights Award. I'm going to very quickly say one other thing. I know that at times I can be a very divisive leader. I'm very opinionated, I know that. Chester Pierce was always the one, when I began to sort of speak or take the organization a little out of sync to where everyone was. It was Ezra, who would come to me and say, Saul, let's have a chat. And the moment he said, let's have a chat, I knew, okay, Saul, you know you've done something that you shouldn't have done or doing. And Ezra, every day of my life, when I'm now at the APA, it's been 10 years now, and I start thinking, oh God, do we do this, don't we do this? Yes, it's pushing the envelope, and is the membership ready? I think of you and think, what would Ezra say for me to do? And invariably, that warning bell at the top of my head would go off to say, if you worried about that, then you know only do one thing. You pick up the phone and you call Ezra. It's not call Saul, it's call Ezra, right? And with that, we'd now like to present to you as truly a true inspiration to all of us, and we can't thank you enough for the dedication your life to those of mental health needs. Please accept this award in recognition of your extraordinary efforts and our immense gratitude. I just want everybody to know that I'm not a total fool. I got a look lanced at me from somebody in the audience who said, none of that stuff is happening at home. I've been asked to declare that I have no conflicts of interest to disclose. Madam President of the American Psychiatric Association, my dear friend, and Madam President of the Black Psychiatrists of America, my dear friend, the presence of these two associations being together here today marks an incredible moment in the history of American psychiatry. And I hope everyone understands that. It didn't come about because of me. It came about because of serious contributions from Chester Middlebrook Pierce. It's interesting that the two presidents are here and the people who know me in the audience know that that's what I've been striving for for a long time. Thank you both for leading the organizations in these directions. Now, if Chester Pierce were still alive, he would telephone me. In that hoarse voice he had, he would remind me that Ezra, age brings honors. He enjoyed pulling my coattail quietly. He agreed that rewards are a bomb for the soul. Taking them too seriously could lead to unbounded pride. And he especially would urge me to avoid using attributed honors to claim superiority over others. That was a fundamental point of Chester Pierce's philosophy. However, the opportunity to deliver this lecture would be another matter. He thought it reasonable to put forward ideas that promote discussion and debate, especially in an effort to improve community life. It is in that spirit I approach the discussion today of Chester Pierce and the concept of human dignity. I am sure that Chester Pierce would have noticed in the New York Times of October 13, 2022, the report by Glenn Thrush. It concerned a federal judge in Florida who had severely criticized prison officials and prosecutors for their professional conduct toward a prisoner named Frederick Bardell. Mr. Bardell was sentenced in June 2012 to a prison term of about 12 and a half years for distributing pornography of adolescents. Sometime after, doctors determined that Mr. Bardell had colon cancer. Can you put up the first slide for me? His first application for compassionate release in November 2020 was rejected because of the claim by prosecutors that his condition was not terminal. The following February 2021, Mr. Bardell submitted a second petition, this time supported by an oncologist. The prosecutor claimed to have a report stating that there was no malignancy. On this occasion, the judge ordered that the Bureau of Prisons prepare a court-approved plan for Mr. Bardell's release. The Bureau discharged Mr. Bardell, but without a plan. And he died nine days later at a relative's home. The judge chastised the Federal Bureau of Prisons and a prison warden for the inhumane treatment of Mr. Bardell. The judge stated that Mr. Bardell was a convicted child pornographer, but still a human being. He also stressed that the Bureau of Prisons had been indifferent to the human dignity of an inmate in its care. Chester Pierce would have found this treatment of Mr. Bardell to be offensive and unnecessary. Chester Pierce would have agreed with Pless and colleagues, for example, that, quote, it is the irony of dignity that its relevance becomes most obvious once it is violated and undermined in the most extreme ways. In the vignette, the judge seemed to understand that dignity came into play through the glaring visibility of the indignity. The judge also obliquely illustrated how labeling the inmate as a convicted child pornographer may have contributed to his inhumane treatment. From the news account, the prison personnel and government lawyers likely helped undermine Mr. Bardell's self-esteem and identity. Pierce would not have been surprised by any of this, as prisons served as exemplars in his conceptual schemes of an extreme environment. That is to say, places where one's space, time, and energy are controlled and exploited by others. Added to this are the unpredictability of mundane events, the unstructured reoccurrence of traumatic happenings, and the lack of fidelity in social relationships. Mr. Pierce fought against the processes of such systematic dehumanizing in broad swathes of social structures. He felt that the systematic deprivation of luring of one's human dignity could lead to degradation of the human spirit. He disliked the inclination of those sitting high on the so-called caste ladder to treat individuals on lower rungs with scant respect. He was also concerned about the tendency of minoritized persons to devalue their own worth, or as he stated in sharper language, to appear to verify their inferiority through their behavior. For those reasons, I will argue that if we maintain a focus on human dignity in much of what we do, we may improve our interactions with each other, clarify our self-definitions, and reaffirm our moral commitment to patients and our communities. The ethics scholar Edmund Pellegrino has referred to human dignity as estimations of our personal worth and worthiness. Examining literature about the origins of the concept of human dignity often reveals controversies and debates about what Pellegrino described as, quote, humanity's claims to a unique dignity and to the moral entitlements such a status entails. Now Pellegrino was concerned about the encroachment of biotechnology's influence on reshaping what it is to be human and what human being is. It seems that it is within these debates that consideration is given to what constitutes humanity. Adam Shulman suggested that there are at least four sources of human dignity that deserve mention. Historical discussion of the sources of human dignity generally starts with classical antiquity, which produced the Latin dignitas that is the basis of the English word dignity, meaning worth and implying excellence and distinction. This is readily associated with rank and social status. While the Stoics in classical antiquity are mentioned as part of this first source, they emphasized possession of reason as part of this form of dignity. Shulman described a second important source of dignity found in biblical religion. This form conceives of humans as having a type of dignity that is sacred, inherent, and inalienable, linked to the notion that we are made in God's image. David Gelernter teased his readers by noting that modern academics rely on a definition of human dignity that is irreducibly religious while still trying to avoid talking about religion. He emphasized within the religion source our duty to care for others. The third source of human dignity was attributed by Shulman to 18th century Kantian philosophy. It was Immanuel Kant who argued that all persons possess human dignity because of their rational autonomy. That is to say, their capacity for free obedience to the moral law of which they themselves are the authors. The fourth source highlighted by Shulman is the common use of human dignity that you see in 20th century constitutions and international declarations. And this refers to a class of human dignity that is inviolable and entitles us to basic human rights and freedoms. Shulman stated that the forms of dignity derived from these different sources all have weaknesses. So the point is not to read into this that this is perfection that I'm talking about. It isn't. The classical source, for example, is problematic because of its, quote, ambiguous relationship to technological progress, and in part because of its aristocratic and inegalitarian tendencies. The biblical source of dignity evokes opposition quite simply because a lot of people don't want to be talking about religion. It is also not clear, for example, how it should be applied to the problem of destroying human embryos and to other technological innovations. The Kantian idea of human dignity also has its problems in bioethics because its emphasis on rational autonomy gives little guidance on what we would do with infants, for example, who obviously aren't all that smart when they're young, and how to treat persons born with other cognitive and physical disabilities, and how to confront individual suffering from things like dementia and lacking rational autonomy. Twentieth-century constitutions and international declarations, the fourth source, while often relying on the concept of human dignity, rarely define its meaning. Shulman articulated these criticisms but concluded, nevertheless, that human dignity still has been reasonably functional and, quote, served liberal democracy well, fostering tolerance, freedom, equality, and peace, close quotes. Next slide. Daniel Davis considered a different approach to the evolution of human dignity in bioethics. He emphasized the impact of public discussion and events on the advancement of human dignity in bioethics. He started with President Richard Nixon's signing of the National Research Act into law in July 1974, and that act created the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. A central task of the National Commission was to identify the ethical principles that should govern the conduct of biomedical and behavioral research with human subjects. Davis pointed out that a major catalyst for creation of the Research Act and the National Commission was the public discovery in 1972 of the notorious Tuskegee syphilis study. This abuse of the Tuskegee research subjects along with other bad treatments led to congressional hearings in 1973 with eventual formation of the National Commission and termination of the Tuskegee project. Davis stated that the commission issued seven reports between 1975 and 79 as required by its legislative mandate. The seventh and the last report, popularly known as the Belmont Report, was published in the Federal Register in April of 1979. The commission identified three principles as among those generally accepted in our cultural tradition and especially relevant to the ethics of research involving human subjects. One was respect for persons, two, beneficence, which is the obligation to secure another's well-being and to do no harm, and justice, which refers to fairness and distribution of burdens and benefits. Davis emphasized that the commission derived these principles from cultural tradition, from what some theorists refer to as a common morality. Davis maintained that the Belmont Report ultimately became an authoritative statement not only for research ethics, but for our interests, guidance in the arena of clinical practice where interactions between physicians and patients are central. He concluded that the concept of a person has become universalized to include every human being regardless of a person's level of autonomy. By including public bioethics in his historical review, Davis started with the National Commission for the Protection of Human Subjects, which I talked about first, and then he linked it to the decision in 2001 of President George Bush to establish, by executive order, the President's Council on Bioethics. And I mention that point because the President's Council on Bioethics has served many, many scholars because of that publication that they produced in 2008, which was a publication on human dignity and bioethics. That publication has subsequently influenced considerable scholarship related to human dignity in biomedicine. Next slide. Now let's go to the classification of human dignity, which I will try to go as simply as possible so that we can have fun with this. It's at the heart of the talk, and I think tremendously useful in the thinking about human dignity and how we apply it, not only in research, but particularly in clinical work, and also the way it applies in the running of institutions, such as the APA. That was meant to be funny, Saul. No. Daniel Somassi recommended three broad categories of usage for the term that would simplify its use, this term of human dignity. I'm going to mention, I'm going to spend much time on two of them, little time on a third, because it's really not as practically useful to us. But the two, I'm going to try and explain it so that we can get something out of this. The three broad categories were intrinsic dignity, attributed dignity, and the inflorescent dignity. The inflorescent dignity, I'll say quickly, is the one that refers to process. And so people talk about, for example, dying with dignity, and I'll repeat that at the end, dying with dignity. So that is talking about a process in which you're going through, and you're doing this with dignity. That's inflorescent dignity. We aren't going to come much back to that. The first two, the ones I'm going to spend time on. So Somassi starts with the idea, when we speak of human dignity then, it is to say something about the worth, stature, or value of a human being. That's the general definition that we're using. Intrinsic dignity is the value that human beings have simply by virtue of the fact that they are human. So the fact that you are born gives you the right to claim this intrinsic dignity. This is not, I emphasize, this intrinsic dignity is not related to any biopsychosocial, economic, or political conditions. Neither is it connected to any talents, skills, or power of the individuals. So if you're walking around and you're cool, and you're this, and you're that, that has nothing to do with intrinsic dignity. Attributed dignity, on the other hand, refers to worth, stature, or value that human beings confer upon others by acts of attribution. Somassi explained that attributed dignity is a created value. We attribute worth or value to dignitaries, those we admire, those who carry themselves in a particular way, hence the reference to being cool, or those who have certain talents, skills, or powers. However, in fluorescent dignity refers to this process that I've talked about, and I won't go back on that. In the discussion of his classification scheme, Somassi demonstrated how his definition should be employed. He explained how in discussing patients, one might say that all the patients in a hospital ward should be treated equally because of their, which, what word comes next? Intrinsic dignity. Excellent. Which cannot be, which cannot be, and I'm emphasizing these characteristics, which cannot be lost or diminished. One may say, too, that some patients, by virtue of disfigurement by their illnesses, for example, have lost their attributed dignity. Or one could also draw attention to how some patients have coped well with the intense suffering caused by their illnesses and demonstrated influorescent dignity. Pellegrino accepted Somassi classification structure and emphasized the differences between intrinsic and attributed dignity. And of course, he was less interested in the character of influorescent dignity. I return to other dimensions of his work later on with Somassi in another section. Now I turn to contemplate how Jeanette Pools, a medical anthropologist, has contributed to explicating dignity through her scholarship and clinical work. Stay with me, please. She viewed dignity as related to ideas about what it means to be human and how to treat people humanely. She noted that there are generally two types of dignity. And don't get bothered by the names, just listen to the characteristics. She uses the titles humanitas and dignitas. She defined humanitas as what I have referred to as intrinsic dignity, or the dignity of being human. She pointed out that humanitas should be considered a founding category for the universal rights of people. It refers to ethical and juridical principles such as freedom, equality, autonomy, and independence. What she also calls citizen values. For Pools, humanitas as a universal normative claim that reposes on the principle of equality, that is the cornerstone of a just society. Pools seems to conflate here, say it slowly, she seems to conflate the biblical source, right, this whole business that you're born in the image of God, and the 20th century declaration source that Suman mentioned. You remember that the 20th century declarations, those refer to the human rights, the citizen values that Pools is talking about. So there's no distinction then between Sumasi and Pools on the business of intrinsic dignity. We are all in agreement on that. So this term, the intrinsic dignity, we should be fluent with that now. That's intrinsic dignity. You can't mess with it, you can't increase it, you can't pay for it, you can't buy it, that's intrinsic dignity. Now she further refined her definition of dignitas. This is the social dignity or the dignity of merit. That's the classical source in human system that I talked about earlier. She understood Sumasi's view of it as attributed dignity. Now one of the reasons that Pools doesn't like the expression of attributed dignity is that she worries about its being used to diminish the equality among individuals. Because a lot of us like to say when we attribute dignity to something or someone, that that means that this group of people, this group of people is inherently superior to another group of people. I mean, we're all specialists at that. There's nothing you can see better than to see how universities, churches, everybody uses attributed dignity in a way that creates inequities and misunderstandings. And Pools wants you to understand that. That's why she worries about the attributed dignity of people when they're saying it's dignity of merit. So Pools doesn't like the expression dignity of merit much. She prefers to see attributed dignity as referring to this classification of aesthetic values or values that you prefer. So I think I've said enough of that and then I can just summarize it so that you get accustomed to this. Pools applied dignitas then to the examination of medical care. She noted parenthetically that in the 18th century, good manners and looks were characteristics of a good doctor. Her focus though was patient care and she presented abrasive examples for consideration to help us think more about the distinction between the two forms of dignity. She observed, for example, that nurses respecting patients' privacy to make their own decisions relied on the value of humanitas. This is referring to inherent dignity, right? Other nurses defended the value of cleanliness for patients' bodies and external appearances based on dignitas, which is attributed dignity. In considering the examples, I think it useful to reiterate that Pools' view of humanitas emphasized it as a fundamental value for thinking about the value of being human and about protecting humans. In contrast, her dignitas or her attributed dignity referred to aesthetic values as values that organize differently the genre of aesthetic practices. So while you talk about the normativity in inherent dignity as sort of declarative and mandatory, the attributed dignity has characteristics that are different. It's based on citizen values. And she's talking about the contrast between the permissive of attributed dignity and the prescriptive of fundamentally inherent dignity. So aesthetic values are permissive and motivating and they create, I like that last word that she puts in the literature, they create socialities. In other words, we all tend to cohere in a social sense based on the notion of attributed dignity. Having helped us appreciate this differentiation then, Pools used her observations of nursing care on psychiatric units to caution us about sticking rigidly. She was against this rigid use of the characteristics of human dignity to apply to clinical care. The next slide. So here I am coming back to Pellegrino. Pellegrino formulated the notion of lived experience of human dignity and defined it as the way that human dignity is perceived by human beings as they respond to the valuations of their worth and worthiness by others or by themselves. He asserted that it was difficult to appreciate fully the concept of human dignity unless it was grounded in our lived experiences on a personal or collective basis. He was especially interested in dignity concerns arising in the context of medical care and between physician and patient. He appreciated that medical patients under stress often lose confidence related to their own worth or inherent dignity. In that situation, now follow this, in that situation when the patient worries about losing aspects of their inherent dignity, he says it should be an important therapeutic objective to reassure patients that intrinsic dignity is enduring and inviolable. He conceded readily that in the context of illness, there are common challenges that provoke feelings of self-deprecation and unworthiness which may run deep enough to induce ideas that one has lost inherent dignity. But experiencing a loss of autonomy is to experience a loss of only or imputed dignity or attributed dignity. Pellegrino explained that indignities may produce feelings of guilt, shame, being inferior to the physician or sadness at having exposed one's body and having revealed personal life stories. Similar sensations come from exposure to hospital procedures like mandatory questioning and feelings of humiliation may be evoked by a variety of other factors. Pellegrino concluded that caregivers have an obligation to use the information about human dignity to preserve individual self-worth and to prevent indignity. The 2008 contributions of Pellegrino and others were published close to the 2007 appearance of Harvey Chochinoff's principal article. And Chochinoff noted the connection between patienthood and dignity, relying on research findings showing in cancer patients an association between dignity and feeling a burden to others in the sense of being treated respectfully. Thus, Chochinoff advanced four elements in the basis of what he called dignity-conserving care. They are attitude, behavior, compassion, and dialogue. The attitude had to do with clinicians' attitudes that enable them to establish open and empathic relationships with patients. Behavior has to do with clinicians' behavior towards patients that should be based on kindness and respect. Compassion suggests a deep awareness of the patient's suffering linked to the desire to relieve it. And dialogue, which refers to the interpersonal exchange of information and conversation between clinician and patient, that should verify the patient's personhood beyond the illness. That summarizes the classic notion of ABCD, ABCD of basic clinical care. He also contributed to the notion of development, developing dignity therapy, and developed a patient dignity inventory, which some of you I know would be familiar with. Now, Gustafson and colleagues did their work looking at forensic psychiatry patients. And those authors stated that the nursing care of forensic psychiatric patients offers a complex challenge, especially when the patients may have committed violent crimes. These authors noted that forensic patients may be lost in their existence and in their relationship to other human beings. It is common that these patients have an insecure and problematic image of their own dignity as well as that of others. We may then worry that their dignity is diminished in the eyes of caregivers who may knowingly or unknowingly be displaying horror or anger in front of the patients. The clinicians may be outraged by the gravity of the crimes their charges have committed using aesthetic values to reach their conclusions. So that's a good example of how the attributed dignity operates on the ward because it's the nurses themselves who are making the classifications. And if you come in having committed a certain crime, in their eyes, you get classified as a certain type of person. And that alters the relationship between the nurses and the patients. Gustafson and his colleagues have found similar findings. They had three main elements related to maintenance of patient dignity in the forensic setting. The first was through nurses confirming to patients that patients had the right to things that others in the society enjoyed. And the second element was nurses' respect for patients. This required teaching patients about creating respect without having to get violent, for example, or scream on the ward. The third theme was linked to nurses displaying care for the patients as human beings through behaviors that increased patients' sense of worth. And it's fascinating how they found the elements that contributed to that. You execute that through nurses taking additional time with patients and giving them extra space. It's quite mindful of Chester Pierce's notion that when people control your time, your space, and your energy, that it feels like an invasion of your dignity. The name that these researchers came up with for this attitude then towards the patients was to meet the patients with dignity. And I wonder how many of us actually execute this theme on wards with forensic patients. Ascola and colleagues, they did some similar observations and they talked about things such as the effects of coercive acts like the use of restraints and forced medication and seclusion, which all of us are familiar with, and the events of humiliation experienced by fellow patients. They talked about staff actually laughing at patients as an event of humiliation in the interaction with patients. Next slide. Now this renewed focus on human dignity in psychiatry, for me, deserves serious consideration. In this section, I consider a progressive and renewed focus on human dignity in psychiatry, as well as in the broader biomedical sphere. I'm not claiming that this movement has suddenly appeared out of the blue. I'm aware, for example, that in 1897, Walter Channing described how psychiatrists were guided in the performance of forensic evaluations by a commitment to thoroughness and respect for the evaluee. In exploring the literature on dignity, I've also come across early 20th century concerns expressed by psychiatrists about the problems caused by European expansion and colonial domination. And many of us are familiar with Chester Pierce's agitations on behalf of black psychiatrists in 1969, over 50 years ago. Paul Applebaum published his work on the new ethics for forensic psychiatrists in 1997, which eventually led to a sharpened focus on human dignity in psychiatry. And this was followed by substantive scholarship, to which many of us in the mental health disciplines have contributed. Michael Norco published a paper that I considered, that considered the importance of forensic work as a vocation, serving others and seeking the common good. It included the idea that we need one another and have a shared responsibility for others. It also suggested the significance of rediscovering the meaning and richness of forensic work. Norco enunciated several elements that characterize forensic work. Presence, critical curiosity, humility, compassion, empathy, centering, and respect for human beings. Brevity obviously prevents further explication of these factors. However, I contend that Norco's work ultimately deepened and extended to the forensic sector what Chochinov considered dignity-enhancing care. Other scholars have participated recently in this extension of elements that are connected to the close relationship between evaluation and evaluees. For example, Candeliz and Martinez, reviewing the evolution of forensic ethics, noted the role of robust professionalism in ensuring the dignity of forensic evaluees. Now I come to a section of the literature which I find absolutely fascinating. It's been a novel experience to me and I just chose a couple of authors to mention. In a remarkably complementary fashion, the psychoanalyst Anton Hart has recommended that clinicians increase their empathic availability to patients across terrains of difference. Hart described his dislike of the current wave of training focused on multicultural competence. Those efforts, he argued, offer a set approach to difference and othering that ignores the chance for reflection and deep engagement. He advocated that clinicians learn how to become undefended when interacting with patients who are different from them along racial, ethnic and cultural axes. His proposal concerned radical openness, which he described as a stance of noticing, questioning and relinquishing presumptions about oneself and the other. I suggest that this openness should be linked to a curiosity about the evaluee that enhances respect for the individual's dignity. Thus, considerations of dignity are fundamental for striving for objectivity in clinical work. And I hope the forensic psychiatrists in the group hear this point that I'm trying to make. Furthermore, Hart recommended that we aspire to being... Let me start that sentence again because it's a cautious sentence. Hart recommended that we aspire to being open rather than to being neutral. And I find this notion really arresting. And that argument, I am not deeply into psychoanalysis and the philosophy of it, but I am fascinated how they're making now, they're trying to make this distinction between open as opposed to being neutral. He emphasized that openness means interacting with the evaluee. He underlined what he called receptivity or taking the other into account, which is akin to the notion of recognizing the other. And this is where I'm going in my current thinking because this mutual recognition is showing up in other literature. And I am worried that the forensic psychiatrists are being left behind and not following the importance of this. So that you have to be, in a sense, while being objective and looking for objectivity, nevertheless struggle to find a way that connects you to the evaluee in front of you so that you can do the work and transmit the sense of respect to the evaluee. Withdrawing and being neutral. I won't argue with the psychoanalyst because I don't have the experience, but I can argue for the forensic psychiatrists. It is a fundamental mistake in forensic psychiatry to stay neutral and withdrawn from the evaluee. The whole point is to be respectful and striving for objectivity but using it through this sense of connecting and exuding a recognition of the other and the other's place in which the other finds him or herself. Edmund Pellegrino has emphasized that this intersubjective recognition and mutuality are at the heart of dignity attribution, which is the point that I want to make to the forensic psychiatrists, that the minute you walk through the door to do the evaluation, you're already psychologically into the exercise of attributing dignity or non-dignity to the person in front of you. And that's the trick in handling the evaluation. Incidentally, I pause here to remind you that Larry Davidson and Michael Rowe, colleagues at Yale, have stressed that intersubjective recognition is a necessity in thoughtful community psychiatry. So I'm not being all that revolutionary and novel when I when I'm arguing for the forensic psychiatrists. I've been intrigued by further thinking about and the observations of the relationship between clinician and patient in this new era. For example, Veronique Griffith, a University of Manchester medical anthropologist physician, has examined the doctor-patient relationship in the context of chronic illness. She illustrated examples of indignity that occurred both inside and outside the medical clinic. Clinic staffs collectively agreeing, for example, quietly to label an individual as a difficult patient resulted ultimately in the patient's extrusion from the clinic and referral back to the primary care physician. Griffith also described how patients feeling ignored and not listened to within the clinic sometimes resorted to developing a symptom diary that they could use to defend themselves against the opposition of the caregivers. Noteworthy is that this often resulted in souring the doctor-patient relationship and turning it into a bilateral power contest. And we haven't begun to talk about this in forensic psychiatry, but actually in the exchange of the interviews often a bilateral power contest goes on where the evaluee wants to stay quiet to defend himself and his interests because his lawyer has told him, don't talk to those guys. And the evaluator, of course, loses neutrality and so on because the evaluator is now upset by the ability of the evaluee to speak up as opposed to staying quiet and agreeing with everything. The psychologist Lauren Levine talks about this historic moral injury related especially to race and gender in our society. It requires our participation in its dismantling. We do so by opening the possibility for honest open dialogue with our patients and evaluees. However, we must be willing to be, quote, present and affectively engaged, close quotes, with those we serve. That's the point I just finished making. This language is likely to be more readily understood in the context of mundane clinical psychiatry. However, I am expressly pointing out the applicability of these new developments to forensic psychiatry as well. Following Levine's thinking, I argue in concert with a host of forensic colleagues that we should, within the context of the forensic evaluation, get, quote, proximate to suffering, unquote, reflect on how discrimination and privilege affect us and then we can appreciate better Richard Dudley's notion of the evaluee's life story. We will more effectively bear witness to the evaluee's life trauma and ferret out its relation to the legal conundrum in which the evaluee or patient is unmatched. I am now on the conclusion. The next slide. So far, I have pointed out how aspirations related to human dignity in our work may provide a panoply of wonderful results for our patients. Some of you may well imagine, with some consternation, that I've been drinking in the elixir offered by sophisticated organizations like those led by my friend Saul at the APA. Nobody laughed at that, Saul. You did, you did cackle. You may have concluded that I am enamored of my theorizing and believe that it will magically be implemented because of my new status as a Chester Pierce awardee. In other words, I'm putting some bets here on the fact that being an awardee has now given me special attributed dignity. It has? But what I've written here, Saul, my next sentence is, believe me, I know better than that. In illustration, come with me on a side trip. In 2002, a black psychoanalyst named Hugh Butts wrote a stunning paper on ethnic discrimination and post-traumatic stress disorder. Butts pointed out that many psychiatrists had difficulty accepting that African-American victims of discrimination might show symptoms consistent with the diagnosis of PTSD. I hope that situation has now changed. I believe it has. It is due partly, I think, to the current plethora of scholarship urging us to confront injustice and unfairness that we encounter. It is also partly because scholars and advocates within organized psychiatry have highlighted the persistent and the powerful influence of obstructionist biopower, and that comes from the anthropologists, that you see in organized medicine. Oh, are we wonderful at obstructing. So the thinking about PTSD has changed, comma, I hope, as has the thinking about the time to diagnosis of endometriosis, which is something the anthropologists have been working on. So I understand that change takes time in organizations and in the broader community. That is reality. But I've concentrated in this communication on the concept of human dignity and its relevance to the daily work of psychiatrists. Recent events have brought focus and increasing clarity to the concept, and these have been, you know, Chochinov's theorizing, the 79th publication of the Belmont Report, the President's Council on Bioethics, Somassi's work on the variety of human dignity, and subsequent research on the application of human dignity in medicine and psychiatry. I have reconsidered the doctor-patient relationship and the factors that influence the relationship. Kless and colleagues, they have said something special. They have discussed dignity as a factor in the humanization of organizational cultures, such as places like the APA, workplaces, relationships, in addition to its powerful influence in the socio-political arena. This discussion draws attention to the task of rendering equitable our interactions with each other, especially within our organizations, defining who we are and reaffirming our moral commitment to the others we serve. I return to the initial vignette about prisoners and the need for dignity of their conserving care. Reginald Betts, now a poet-lawyer and creator of this group called Freedom Reads, which is apparently a project for installing curated libraries in prisons, he stated that, quote, people don't understand how many of us sought to become more than our crimes, or how many of us starved for lack of a conduit to the dignity that we sought. Betts sees the delivery of a book, I repeat, he sees the delivery of a book to these individuals as an act of enhancing dignity. In your private thoughts, you must decide where you are. Leaning on Chester Middlebrook prayers, I hope you agree that, I hope you agree that today I have extended his contribution to the history of American psychiatry. He asked me years ago to place a brick in the wall. You know what that means. I know what he meant. And in doing so, I state that we have a responsibility to commit to serious reflection on the place of dignity in our work and lives. Only you can decide, only you can decide whether you accept it as an obligation. I thank you most humbly for attending my presentation. I'm trying to think how do you follow Ezra Griffiths, and one thing that did jump to my mind is there are times sometimes you walk amongst the giants. Ezra Griffiths is one of our giants, and I think that's who we honor today. Ezra may you continue to be part of APA, always keeping us on the right road, reminding us when we begin to veer to the wrong way, and Ezra thank you for all you do for APA, for psychiatry, and I think for the country. They see you as our leader in terms of ethics. Thank you. I think we have a little time. Would you would like to take some questions? Okay. Questions, thoughts? Yeah, James Griffiths, thank you again. You came and gave grand rounds at George Washington, and I heard you there. I would make a little quick comment, and then the question I have is going to be about educating psychiatry residents. The comment is that Howard Thurman said many times the great truths of religion aren't true because they're in religion. They're in religion because they're true. I'm responding to the group that objected to the religious sources, okay, but my question is different. There's been a lot of discussion yesterday and today about how to educate residents in global mental health, thinking about global in a very broad way, not simply go into another country but across town, and from your lecture we should not be telling residents that they should be giving dignity. They should not be attributing that intrinsically as a devaluing message. They should assume intrinsic dignity of the populations they're working with, and my question is any thoughts about how you do that teaching? I mean to give maybe a specific context, we do have international missions. We also have a project in Appalachia that there are many different places where we go to try to respond to people that have mental health problems and their gaps in culture and language and socioeconomic and power. Well, I'll tell you one thing I've figured out and I think I've learned it after pursuing this project now for several years because you know I've been trying to present this lecture and improving the lecture every time I think about it because it's complicated. One of them is thinking about what dignity is. I've given you a number of definitions. The second thing is the tendency to conflate or preferably to confuse inherent dignity and attributed dignity. Once you straighten those two things out, I say with a certain degree of humility because now I've looked at its application to the institutions we occupy and in fact every institution I've looked at is taken with the notion of inherent dignity. See I go mixing them up again. With the notion of attributed dignity. I've looked at the church. I'm not going to accuse anybody else's church. I'm going to talk of my church. My church is a specialty. They are experts on using attributed dignity within the rituals of the service. The choirs wear the fancy robes on Easter. They invite guests and they all put on fancy robes. People know the distinctions between the robes and so on so forth. And I learned that very clearly in my research in the Caribbean on a new religious movement that in fact everybody's taken with attributed dignity. So you can't walk around saying people can't do X or Y or Z with attributed dignity because that simply isn't going to work. The academic communities, they're experts at it. You have assistant professors, associate professors, full professors and that now changed. Now you have professors with endowed chairs. That changed. That's not enough. We want more attributed dignity. So places like Harvard has a style of the university professor which is a full professor with an endowed chair and still he's above that. We all do it. So everybody loves this attribute to dignity thing. I think, I think Mose taught me best how to try and avoid it because the way we use attribute to dignity, often we try to help ourselves and our institutions differentiate groups. And that's one of the things that Poe's talks most clearly about. That we use fashion, we use our preferences in the institutionalizing of attribute to dignity. Now I never thought about it like that. But she uses, in terms of fashions, she uses a fashion term. You know, I'm talking about female fashions and male fashions. To see how we think about this and how we apply it. And so, first of all, the institutional leaders have got to understand what they do. And I've learned this from the anthropologists. Physicians don't think much of what they do. We do think of our enactments. What we guide them to is trying to deal better with the patients. We don't say, well, what is bad about what we do that applies, for example, to our colleagues? I don't know how many departments of psychiatry run like that. I haven't heard about them. We do things. We don't think seriously about its impact on other people. And this impact has a tendency to differentiate. And I don't know, once I've learned all that, how long it's going to take us to teach it. Would you favor not teaching about dignity, but how to show it? In fact, the way I think about that is having meals together, you get to know each other's children. So you can invent all kinds of things. And I think this is something that not only the physician can think about, but other people in other parts of the university or parts of the hospital ought to come together to try and think about what we do with our classification systems. This is a classification system that is operative. We like to, forensic people, I can tell you, we love to walk into prisons and observe how guards make this attributed dignity sections. They section it out, you know. They section it out. They reward certain prisoners for doing X. They move prisoners to another section for doing Y. They understand how they use attributed dignity. But we as physicians don't like to think about how we do it in our groupings. So it isn't as easy as talking about it theoretically. And that's why I found it so valuable to keep repeating my discussion groups, so that eventually, I'm doing two things. One, I'm getting more fluent about the distinctions in the groupings, you know, the attributed versus. And the second thing, I'm able to teach it better and talk about it better. And I'm trying to encourage people to think about it in terms of their institutions. But let me tell you, as you go back home, your chair of the department, the dean of your medical school, the president of the university, all are engaged fundamentally in setting up attributed dignity relationships and so on. And they are into it. It's a way of rewarding people for what they do within the structure. So I can't give you something that's prescriptive, because I think it's more complicated than that. But the first conversation is necessary. We talk to each other about what it all means. And that's what I'm trying to do. Thank you. Sandy Walker from Seattle. I'm probably going to say some things that irritate people, or maybe say more than that, get them a little bit bothered. I'm sorry. You stay away from the microphone. Okay, can you hear me now? Yeah, that's better. I'm probably going to say some things that people might consider inflammatory. So don't forgive me if you don't want to. I've had a lot of experience in the APA now, going back for a few decades. And I think that I've had an opportunity to observe both the way organizations function and the way in which different clinical settings function. And I think we've all maybe seen that over my lifetime, from the point at which I became kind of cognizant of what was going on in health care in the 70s, there's been a shift to a model of systemization of care delivery that dehumanizes people. And you see it in psychiatry. I do work in private practice setting. I do analytical work where the individual patient is highly valued. I work in public psychiatry where clinicians value the patient, but the system values the diagnosis, the prescription, and the reimbursement. And the travesties that happen in terms of dehumanizing the whole experience, I think, are leading to some crises in medical education. Just a couple of weeks ago, the event that the University of Washington held for the volunteer clinical faculty offered CME, and the CME was on moral injury to residents and trainees based on the fact that what they're learning about delivering excellent care is not something that they can deliver to people in the systems of care that we allow to persist. So how do we conceptualize as an organization our whole way of looking at our profession? I, as a guest of the board, because I chaired the Council on Minority Mental Health and Health Disparities, and previously that committee of black psychiatrists, sat through a lot of the DSM process. And it seems to me that for all of the benefits that that process entails, it also had to do a lot with career building and money, and it gets used often for purposes of reimbursement or not reimbursing. So these are things that concern me from the perspective of humanity. Of? Humanity. Of humanity. I find a lot of it's dehumanizing, and I think it's really hurting a lot of trainees and people who practice, and a lot of people in medicine in general, not just in psychiatry. I've seen somewhere that 57% of doctors today wish they hadn't gone into medicine. But did somebody tell you that I would disagree with any of what you just said? No, I wasn't speaking to you. Oh, no. I was speaking to the room. Thank you. Let me just say one thing in response. What you're saying is so important, and I agree with you so much. I can tell you that no one wants to invite me to dinner, for example. And the reason they don't want to invite me to dinner, that I want this kick related to dignity, and it has to do with my concerns as now an older citizen. I'm older than Saul. How would they implement the rules of whether you can bring someone for a medical appointment or not? I am just shocked by how our systems in New Haven change the rules from one day to the next without explanation. Were you reading my speech, looking at the research from Ascola and Gustafson and so on? I sort of laughed to myself. Because you can't implement what they're talking about, creating a dignity-caring situation in a forensic hospital, unless you have the staff. Charles Dike knows better than I do because he runs a whole system statewide. You've got to have the staff in order to do what I'm talking about. You heard some of the prescriptive things? Give them time. Teach them. Give them time. Let them know that they have the right to demand the things that people on the outside have. That's fantastic. But you've got to have staff to be able to implement that in any forensic system. We don't have any in Connecticut, easily. More power to you. I react extremely positively. I let you know that my heart goes out to everything you've said. One of the previous questioners highlights the complexity in really getting this implemented. Because my health system, for example, and all outpatient care, the biggest you can have, if it's repeated, is 20 minutes. That's all you can get. We have time for two more questions. Again, Ezra, I congratulate you on your award and also on your delivery of this extremely difficult area. I think there are two words in English that are very helpful, to be kind and to be nice. What was the second one? Niceness and kindness. Right. My question to you would be, what is the role of language and culture in affirming dignity? Many years ago, when I was at the University of Pennsylvania, I had a chat with the chairman of the department. He opened the door for me to go ahead, and then we talked about that. He said that in America, if you open the door for somebody, there's some reciprocity. The next time, you do the same for him. I disagreed, because I'm an African, I'm a Nigerian. We are trained to do things not for any reciprocal benefit, if you see what I mean. Also, if you go to Auschwitz and you see what happened there, it's very quiet. What we communicate, our understanding of the situation, our misunderstanding of the situation, our understanding, by the quietness. I think there was a woman working in the University of Pennsylvania, too, who talked about language and suffering. If you give somebody an injection, that is invasive. I think we all have to learn to be kind, to be nice, and to be open, and to respect all cultures. I'd like to see what you say about this. Sam, I would say to anyone, language and behavior are fundamental to the implementation of dignity. Absolutely fundamental. It starts early. I can give you examples, because those things are fluent in the culture of Barbados. I'm sure I have Barbadians here sitting in the audience, and they would agree with this. In my house, for example, it was just not permissive for me to come out of bed and sit at the dining room table without saying good morning to my father and mother. That's just ridiculous. The things I hear about in some of the other cultures I visit, they say, you can't get them to do it. You wouldn't eat in my house. You just wouldn't eat. I can tell you, and I'm proud to say it, we squelched that very, very early when I had children. I don't care if it's 6 o'clock, 9 o'clock, or 10. You come to the table, you've got to say good morning. It doesn't matter who's sitting there. That's an inviolable rule. Those things are important. The same thing, you can't come to the table screaming. I don't care if you're 5 months or 5 years old. You've got to start with them early. You don't scream at the table. That's a place that becomes sanctified. Those are the kinds of things that for me go on at work. I'd walk up and down. We're getting off. I don't want to tell you things that are personal, because I may have to apologize back home. Ezra, I just want to thank you for your work in this space. To really highlight what you're telling us, I think, which is that if we can attribute dignity, then we can unattribute dignity, which means that we have the power to dehumanize, which is the very first step in othering on the way to atrocity, misunderstanding, cruelty, and evil. I thought you were going to go a different place, because I always confuse this when we're having conversations. I'm happy to know that I'm still invited to dinner, because nobody else wants to talk to you about this. I thought I had something to contribute to the conversation. It might just be any willing listener. Rhyming with Poles is Anne-Marie Moles, who we spent some good time reading together, probably close to a decade now, about the ways in which we bring ourselves into a care of logic rather than a logic of care. If we really began by thinking, what would it mean for the person before us to feel our care, we might be able to recapture the humanity and the dignity in our very practice, whether it be in a clinical setting or a forensic setting, or in a collegial setting as an institution and an organization. I just want to thank you for your incredibly erudite treatment of the topic in a way that touched all of our hearts, which is exactly where we need to be and we need to stay. Thank you so much. Thank you. Hey, Dr. Griffith. My name is Tai Wu. I'm a psychiatrist and at Yale, actually. At Yale? Yeah. I'm sorry we haven't met in New Haven. Are they treating you all right? It's okay. My question is, I don't know if there's any other trainees in the room, but just thinking about, and I'm thinking a lot about what you were asking about, kind of the, to me, what sometimes feels like the over-medicalization of the human experience as it relates to dignity, and thinking about what maybe psychiatry was, and not saying that it was always this beacon of goodness, but how it feels like it's kind of moved away from that in some ways, with really focusing so much on diagnosis, not really thinking about the person that we're taking care of. I wonder what kind of things you might hope that trainees keep with them as they go through the experience of training and becoming the future of this field in mental health. Well, listen, the first thing, we don't have the time to talk it out today, and you can give me a call. Despite what they say about me at Yale, I'm happy to talk to you personally. But the reward systems in these institutions are extremely problematic, and everybody hides behind them, and then, you know, the dean and the president get together, and they give the rewards out again next year for the same thing. But this is foolishness. It's not all that complicated, not all of it. Some of it is complicated. Some of it is complicated, because they're competing issues, right? I mean, everybody wants to make a lot of money, because this is America. So they're not going to give you the chance to see a patient for 45 minutes, and say you can see everybody for 45 minutes. You can't see everybody for 45 minutes, because you can't make money doing that. That's simple. That's complicated. But there are other things. Like, for example, I'm a leading award, and I have to make an important decision. You know, it takes an extra few minutes to talk to the head nurse about the implications of it. You think of that. It's not all that complicated. The chairman has the same difficulties. Chairs walk around making decisions and implementing them, and not talking to the right people, not saying, how does it affect your work? You know, I mean, some of these things can be done. Some of these things can be done. And things like the boss. When I ran a mental health center, I got somebody to organize for me that I would have lunch. They'd just pick somebody from the staff. I'm talking about the whole staff. Whatever they do, sweep the floor, whatever. Choose somebody for me to have lunch with. And force me to sit down and have lunch with. Because, you know, five people are going to call me the day for that lunch. But it has to be a sacred task. And that's what you do when you try to get your groups together to help you out with it. Last example, because I know Saul is watching me. But it's an example that I keep running in my head when I run the mental health center. I came in, and at Christmas time, I wanted to do a celebration for everybody. They gave me the model. They said, well, this is what we've been doing for the last 20 years. What have they been doing the last 20 years? They set up a thing on one of the days between 2 and 4. Nobody can come to it. It's very, very busy. They serve stale cheese. And they're not serving anything that anybody wants to drink at 2 o'clock in the afternoon. It's ridiculous. I sat down with a number of people. This is not brilliance, you know. This is common sense. I sat down with people, and they said, what would you like? Let's have a fest. Friday night after work. And it starts at 9 o'clock. You should see what people taught me about cultural psychiatry. The women took it over. They came dressed, let me tell you. And our people, am I right? Our people dress now. You should see the people showing up for this Christmas thing. Dressed. One woman started a fashion. She came in a formal outfit. Tuxedo. I wear a tuxedo. People started competing. As soon as I left, it's done. You know that expression? Have you ever read an expression? It's done. Does that make sense? And it had nothing to do with me. It had to do with just sparking it. Just taking the time to talk to people about it. And everybody said, what they've been serving as a Christmas party for the last 20 years is nonsense. It's undignified. It's disgusting. It's insulting. The blacks came, and the blacks sat in a corner. And I don't mind talking about this publicly, because this is public business. You shouldn't put on a Christmas party where people aren't going to come. You shouldn't put on a Christmas party where the boss decides what is the Christmas party. That's ridiculous. That boss needs to be taken to the woodshed. You don't put on a Christmas party like that. You put on a Christmas party with people participating. And people say, let's tell you what the Christmas party is about. Man, I came out, I was the sweetest smelling CEO they ever had. And none of it came from any brilliance. Being trained as an MD or administrative experience. All I had to do was thinking about the thing as a product of decency. Because the person who swept the basement wanted to come to the party. And I said, the invitations have to be handed and hand carried to the people in the basement. They clean the basement. They should know that we want them to come to our party. Because I thought it insulting to not do it that way. That's humanizing the environment. I've talked too much. I've said too much. Do not go back to Yale. I'm giving a psychiatric lecture. So let us all acknowledge our wonderful Chester Pierce awardee, Ezra Griffiths. Thank you all. Thank you all very much.

human dignity

psychiatry

medical ethics

Chester M. Pierce

microaggressions

human rights

mental health

healthcare systems

dehumanization

empathy

forensic psychiatry

patient care