Moral Claudication
Nonjudgment and Flight from Truth
The longer I practice medicine, the more I recognize a peculiar weakness in modern clinical care, not of knowledge but of nerve. Physicians are trained relentlessly to be nonjudgmental. We are warned that judgment poisons the doctor-patient relationship, that moral language alienates, and that neutrality is the highest form of professionalism. Yet when confronted with patients whose primary problem is not disease but behavior, this training produces a kind of moral claudication. We walk the terrain of care, but we stop short. The moral muscle aches, and instead of pressing forward, we reach for a diagnosis.
This is not because physicians are cruel or indifferent. It is because we are uncomfortable naming agency when agency implies blame. Faced with misbehavior, we are taught to soften rather than confront, to translate conduct into category, to convert choice into symptom. The diagnosis becomes a way to continue walking without having to say what we know. The patient behaves badly, therefore the patient must have a disorder. The behavior is reframed as a symptom of a disease, thereby excusing it and removing the sense of agency that might otherwise inspire a patient to change it.
This is not compassion. It is avoidance.
Medicine once distinguished between misfortune and misconduct. Today it equivocates, collapsing them into a single clinical category. In doing so it has confused kindness with indulgence and healing with affirmation. Patients arrive not seeking restoration but seeking recognition of a diagnosis, as though the proper label could absolve them of responsibility for their lives. Illness is no longer something one has. It becomes something one is.
Illness has become identity. The transformation is subtle but unmistakable. A diagnosis becomes a badge. A prescription becomes a proof. The disorder becomes the total explanation for everything troubling in a patient’s life, and therefore the patient is exempt from any expectation to change. What once required courage is reframed as what requires treatment. What once called for discipline now calls for documentation. The vocabulary that once described character has been quietly replaced by the vocabulary of disease.
Sloth becomes fatigue.
Pride becomes narcissism.
Wrath becomes conduct disorder.
Gluttony becomes an eating disorder.
Immaturity becomes a neurodevelopmental disorder.
These substitutions do not explain behavior. They merely rename it. Unlike diabetes, which names the pathophysiology that explains hyperglycemia, most psychiatric labels describe patterns of conduct without explaining their origin. “Oppositional defiant disorder” does not identify a disease state that inexorably causes aggression or antisocial behavior. It simply describes a person who behaves in those ways. The behavior comes first. The label follows. Physicians understand this tacitly, yet we hesitate to say it aloud.
That hesitation is moral claudication. We know that diagnosis, in these cases, is functioning as a substitute for judgment, but we proceed anyway. We tell ourselves that nonjudgment preserves the therapeutic alliance. We fear that speaking plainly will poison the relationship. It is true that calling a patient a bad person is neither therapeutic nor appropriate. It is also true that refusing to tell a patient that their choices are destructive is not kindness. It is abdication.
We do not hesitate to speak plainly about smoking. We do not shrink from telling patients that obesity worsens disease. We do not avoid discussing alcohol use when livers fail. Yet when confronted with violence, theft, abuse, or chronic antisocial behavior, we retreat into diagnostic language. We medicalize what we would otherwise condemn. The label softens the interaction, but it also freezes the trajectory. Diagnosis excuses the behavior and, paradoxically, ensures its continuation. We tolerate a certain amount of judgment when it concerns habits, but we flee it when it concerns character.
These new identities make the physician’s task nearly impossible. For patients who have fused diagnosis with selfhood, questioning the diagnosis is experienced as a personal attack. To suggest agency is to commit a kind of heresy. Compassion, as currently practiced, requires unconditional acceptance of the patient’s self-narrative. This is not care but capitulation.
The tragedy is that the system rewards this capitulation at every level. Bureaucracies demand codes, not character. Insurers demand pathology, not virtue. Schools demand accommodations, not expectations. Patients learn that helplessness is a resource. Clinicians learn that challenging helplessness is dangerous. It is far safer to label a behavior than to ask a person to rise above it. Diagnosis becomes permission, and permission becomes destiny.
The ER reveals this dynamic in its starkest form. It sits at the intersection of medical and moral failure. I meet patients whose actions are plainly chosen yet must be treated as involuntary because the system cannot tolerate the idea of willful harm. I meet patients who weaponize fragility because fragility has been taught as power. Families arrive believing that a diagnosis will resolve a moral or spiritual crisis that no medication can touch.
The ER becomes the staging ground for these contradictions. I am asked to intervene in crises that are described as medical but are unmistakably moral. I am asked to manage despair that grows out of meaninglessness, relationships that collapsed under resentment and avoidance, and patterns of behavior that were decades in the making. I am asked to heal what is not medical.
Psychiatry cannot define the full range of human suffering, nor can it account for every form of dysfunctional behavior. There are limits to what medicine can meaningfully address. Medicine can sedate, but it cannot cultivate strength. It can stabilize, but it cannot provide purpose. It can quiet a mind, but it cannot shape a character. These tasks belong to families, communities, churches, mentors, and the moral world that once gave structure to human life. Those institutions have eroded, and medicine has been conscripted to replace them. It is a poor substitute.
We have created a culture in which people cannot be asked to change because change implies judgment, and judgment has been declared the unforgivable sin. Yet healing requires responsibility. It requires the belief that one can choose differently tomorrow than one chooses today. Without this belief, diagnosis becomes fate and care becomes containment.
Compassion is indispensable, but it is not synonymous with nonjudgment. True compassion does not excuse destructive choices. It insists that human beings are capable of better ones. The task of medicine is not to shield patients from this reality but to help them meet it. When diagnosis is used to avoid moral truth, it does not heal. It merely spares discomfort while ensuring decline, allowing the physician to keep walking while the patient remains stuck.