Running head: APPLIED ETHICS IN CUBA

Applied Ethics in Mental Health in Cuba:

Part I - Guiding Concepts and Values

Laura Sánchez Valdés,

Iteso, Mexico

Isaac Prilleltensky

Victoria University, Australia

Richard Walsh-Bowers

Wilfrid Laurier University, Canada

Amy Rossiter

York University, Canada

Authors Note

Laura Sánchez Valdés, Department of Psychology; Isaac Prilleltensky, Department of Psychology; Richard Walsh-Bowers, Department of Psychology; Amy Rossiter, Department of Social Work. The research is based on the first author's M.A. thesis while she was at Wilfrid Laurier University in Canada.

This research was supported by the Social Sciences and Humanities Research Council of Canada. We wish to thank the participants for their hospitality, collaboration, time and effort.

Correspondence concerning this article should be sent to Isaac Prilleltensky, Department of Psychology, Victoria University, POBox 14428, Melbourne MC 8001, Australia.

C:My documents\CUBA\cuba1.e&b.july 2001

Abstract

As part of a project on professionals' lived experience of ethics, the article explores the guiding concepts and values concerning ethics of mental health professionals in Cuba. The data, obtained through individual interviews and focus groups with 28 professionals, indicate that Cubans conceptualize applied ethics in terms of its central role in professional practice and its connection to the social context and subjective processes. Findings also show that Cuban professionals are guided not only by a set of professional values, but by a specific set of civic values as well. The former are subdivided into other-oriented values and self-oriented values. The study of ethics in another culture such as Cuba offers a unique point of view from which to critique the social construction of our own conceptions of applied ethics in North America.

Applied Ethics in Mental Health in Cuba: Part I -- Guiding Concepts and Values

The purpose of this article is to report on a qualitative study of professional ethics in Cuba. The research, conducted with mental health clinicians in Cuba, offers a unique perspective on applied ethics that can serve to critique our own constructions of the topic in North America. The objective of the study was to investigate the ethical values and dilemmas experienced by Cuban clinicians and the resources they use in dealing with them. We concentrate here on guiding concepts and values. In a separate article in this issue of Ethics and Behavior we report on dilemmas, resources and limitations.

The investigation was guided by two primary aims. First, the need to create frameworks of applied ethics that are constructed on the lived experience of workers; and second, the need to understand how conceptions of ethics are related to culture and society. Current models of applied ethics tend to define the subject in narrow terms and do not take sufficiently into account the contexts in which ethical dilemmas occur (Attig, 1995; Bowden, 1997; Brown, 1997; Bursztajn, Gutheil, & Cummins, 1987; Chambliss, 1996; Dokecki, 1996; Kitchener, 1996; Prilleltensky, Rossiter, & Walsh-Bowers, 1996; Rossiter, Prilleltensky, & Walsh-Bowers, 2000; Trevino, 1987; Wegener, 1996). In order to develop more useful models of applied ethics, we are investigating the lived experience of ethics with several groups of service providers in the human service and mental health fields in North America and Cuba (Prilleltensky, Walsh-Bowers, & Rossiter, 1999; Rossiter, 1998; Rossiter, Walsh-Bowers, & Prilleltensky, 1996; Walsh-Bowers, Rossiter, & Prilleltensky, 1996). We use the data from Cuba to understand ethics in a vastly different culture and to re-evaluate our own models of ethics in light of cross-cultural perspectives.

Conceptual Orientation

Our conceptual orientation is informed by grounded, contextual, critical, and feminist approaches. A grounded theory methodology suggests that theory building requires the input of lived experiences. Otherwise, theoretical postulates remain disconnected from the phenomenology of the object of study. In our view, much of the literature on professional ethics remains less than useful because it lacks the lived experience component. Professionals do not see themselves readily reflected in the literature because it is based either on aspirational statements (e.g., Clark & Abeles, 1994; Garfat & Ricks, 1995; Walker, 1994) or simplified research vignettes (e.g., Chevalier & Lyon, 1993; Seitz & O'Neill, 1996). In either case, accounts documenting the daily ethical struggles of professionals are missing.

While statements of values and principles abound, descriptions of lived experiences of ethics are scarce. Some exceptions include research by Chambliss (1996), Holland and Kilpatrick (1991) and by Reiser, Bursztajn, Appelbaum, and Gutheil (1987). Research identifying ethical concerns faced by psychologists comes closer to our goal of obtaining grounded input (Pope, Tabachnick, & Keith-Spiegel, 1987; Pope & Vetter, 1992), but that line of research does not delve into the subjective experience of the clinicians or into the organizational contexts of the dilemmas. Thus, we lack an understanding of the social processes implicated in professionals' conceptions of ethics. This study shows one of our ongoing efforts at theory building through the collection of grounded input.

The second source of our thinking is contextual theory, according to which ethics are constructed by culture and social location. While the search for moral answers may cross boundaries of nations and cultures, the specific norms to be followed in each society and subculture are uniquely shaped by diverse historical circumstances. We could not automatically transfer principles from North America to Cuba or vice versa; we seek knowledge that is culturally specific. We try to answer Toulmin's call for an approach to applied ethics that is "particular not universal, local not general, timely not eternal, and -- above all -- concrete not abstract" (1996a, p. 7). This is why we attempted to examine Cuban ethics from Cubans' perspectives.

The third influence that shapes our thinking is critical theory. Critical theory advances a concrete epistemology as well as a moral philosophy. From an explanatory point of view, it postulates that human interaction can be rendered intelligible only when power differentials are taken into account. From a moral point of view, it claims that the Good Life and the Good Society are predicated on equality, fairness, and justice (Geuss, 1981; Gustavsen, 1996; Habermas, 1990; Richardson & Fowers, 1997).

Feminists (e.g., Hare-Mustin & Marecek, 1997; Wilkinson, 1997) and gay and lesbian psychologists (e.g., Kitzinger, 1997) have documented the abuse sustained by women and gays and lesbians in the hands of "caring" professionals. The history of the helping professions is replete with examples of abuses of power. These abuses provide ample argumentation against the romantic notion that professionals can overcome personal interests for the public's sake. In a culture that glorifies individual success and personal gratification above all else, professionals are at definite risk for engaging in abusive behavior (DeVaris, 1994; Dineen, 1996; Dokecki, 1996; Mack, 1994; Pilgrim, 1992; Spinelli, 1994). Critical of institutional arrangements that perpetuate patriarchy and inequality, feminists strive to deconstruct the machinery of oppression and turn it into a tool for mutual respect and dignity (Bowden, 1997; Haraway, 1988; Lather, 1991; Maynard & Purvis, 1994). Thus, like critical theory, the project of feminism also has dual objectives of explanation and transformation. In our research, we use feminist resources to sensitize us to potential gender and racial discrimination inherent in professional helping relationships.

To summarize, we are involved in the process of formulating a framework of applied ethics that is informed by grounded, critical, and feminist theory, and that emphasizes the need for context-sensitive knowledge (Bowden, 1997; Chambliss, 1996; Fox & Prilleltensky, 1997; Gustavsen, 1996; Kincheloe & McLaren, 1994; Morrow, 1994; Toulmin, 1996a; 1996b). In order to enliven and refine our emerging conceptualizations, we need grounded input from people involved in the helping encounter. This research constitutes another step in our efforts to build applied ethics theory and translate it into useful aids for professionals.

Research Objectives

The research had a theoretical as well as an applied objective. As part of a larger study on applied ethics, the research in Cuba was intended to contribute to the development of theory and to the creation of relevant and useful ethical frameworks. As an applied research project, the research inquired about clinicians' (a) general concepts of applied ethics, (b) values, (c) ethical challenges, (d) ethical resources and impediments, and (e) recommendations for maintaining or improving ethical decision-making processes. This article reports on the concepts of applied ethics and the values that guide professional work. Challenges, resources, limitations, and recommendations are reported separately in the second article of this series.

Social, Historical, and Professional Context of Research

The 1980's represented the "golden decade" for Cuba. During those years a great deal of social progress was achieved: free health care, guaranteed education, reduction in infant mortality, declining fertility rate, provision of day care, housing, increments in social security, increase in employment opportunities for women, and provision of social welfare (Eckstein, 1994; Ellwood, 1998; Torre & Calviño, 1996). In addition, funds were allocated for research and professional development (Torre & Calviño, 1996). However, all of the advances achieved during the eighties turned to extreme difficulties in the nineties. With the collapse of the Soviet Bloc, which had accounted for some 85% of Cuba's foreign trade, the country's economy plummeted. Compounding these difficulties was the economic embargo which had been imposed by the United States, threatening to cut subsidies of Third World countries that traded with Cuba (Centeno & Font, 1997; Eckstein, 1994; Ellwood, 1998; Meeks, 1993; Torre & Calviño, 1996). The country suffered an economic collapse (Eckstein, 1994; Torre & Calviño, 1996). Today, Cuba continues to experience "a war type economy in times of peace" which requires great sacrifices from the population (Eckstein, 1994).

The revolution's biggest challenge is "to create a pluralistic, participatory democracy based on social justice while finding an independent place in the emerging global economy" (Ellwood, 1998, p. 19). The term used by Cubans to describe the current historical juncture is "special period." This term explains the hardships and justifies initiatives offered to address the crisis (Centeno & Font, 1997; Ellwood, 1998). The "special period" has disrupted the socio-cultural and scientific life of the country (Centeno & Font, 1997; Torre & Calviño, 1996). Before the revolution in 1959 the majority of psychologists in Cuba had been trained in the United States and espoused a therapeutic orientation (Ardila, 1986). The social project of the revolution demanded that psychologists engage in more community work (Ardila, 1986; Tovar Pineda, 1993). Subsequently, psychology evolved in Cuba in the materialist-dialectic tradition of the socialist countries, and was enriched by the ideas of José Martí and the evolution of indigenous Cuban psychology itself (González Serra, 1997; Torre & Calviño, 1996).

Some of the interviewees commented that psychologists in Cuba are professionals with a high sense of community service, personal integrity, and professional ethics. Psychologists work hard to update their knowledge. However, this is only possible with great difficulty due to lack of resources such as printing facilities and transportation to conferences and libraries. When psychologists graduate they find work immediately and are incorporated in practically all sectors of society: industry, education, health, human services, and corrections among others (Ardila, 1986).

Presently the work of psychologists is focused on helping citizens face the difficult economic situation. Research is directed at the effects of the "special period" on the Cuban family, formation and strengthening of values, and the impact of tourism on society (Torre & Calviño, 1996). Psychologists are aware of the impact of the "special period" on their own subjectivity and professional behaviour, as they are not immune to the adverse effects of the social and economic crisis (Torre & Calviño, 1996).

Ethics in Cuba is seen as central to the practice of psychology. Psychology, in turn, is seen as central in ethics, education, art, and politics (González Serra, 1997). One of the main scholars of ethics in Cuba discusses the relevance of incorporating moral goals in psychology:

We consider that the psychological sciences cannot be reduced to simple knowledge or a technique, rather it has to have moral goals and make efforts to form people and a society that is spiritually superior in creativity, independence, humanism, compassion with the humble, and patriotism, at the same time promoting national and regional identity. (González Serra, 1997, p. 168)

Many Cuban psychologists regard the promotion of sound moral values as fundamental to their civic and professional duties (Zaldívar Pérez, 1997). Fostering values in politics and education is part and parcel of a psychologist's job (González Serra, 1997).

There are two formal associations of psychologists in Cuba, the Society of Health Psychologists and the Society of Psychologists of Cuba (Torre & Calviño, 1996). The latter has developed a professional code of ethics in 1986, which consists of six sections: (1) general principles and functions of the psychologist in different service areas; (2) research; (3) teaching; (4) evaluation tests and instruments; (5) relations between colleagues and other specialists; and (6) violations of the code and sanctions. The code states that one of the main ethical tasks of the psychologist is to advance the cause of the revolution. Through the use of Marxist-Leninist theory, there needs to be a contribution to the solution of the economic and social problems of the country. Similarly, education needs to contribute to the political-ideological formation of the students, developing in them qualities that are in accord with the country's socialist ideals. The code emphasizes that the interaction among colleagues and other professionals should be centred on collaboration, respect, critique, self-critique, honesty and collectivism (Sociedad de Psicólogos de Cuba, 1986).

Research Process

This study consisted of six main phases: (1) two researchers (a male professor and a female student) travelled from Canada to Cuba to carry out interviews and focus groups in two cities; (2) the interviews were transcribed and a summary of the results was prepared; (3) results were discussed among research team members, which included one female academic, two male academics and a female graduate student; (4) two key informants from Cuba came to Canada to discuss the findings of the study; (5) the key informants who visited Canada discussed the findings with their colleagues back in Cuba and provided further feedback to the research team; and (6) one of the researchers went back to Cuba to present the final research report.

Research Relationship

Although the researchers were themselves from Latin America (the professor was originally from Argentina and the student from Mexico), there were vast cultural differences that needed to be negotiated with Cuban participants. The research required a fair degree of trust in the researchers, as the subject matter of the investigation was rather sensitive. Because of previous negative experiences, Cubans are justifiably concerned with the potential distortion of their reality by foreigners. Understandably, some of our colleagues in Cuba were cautious in relating to us, least we engage in the type of bad publicity for Cuba that other foreigners have engaged in before. However, for the most part, we think that we established trustworthy relationships with our participants. During our stay in Cuba we developed genuine friendships with some of our hosts, and were able to discuss openly their ethical dilemmas. They were not shy about advancing ideas for the improvement of their own organizations. The validity of our findings were discussed with two Cuban colleagues who joined our research team in Canada for further deliberations.

Methodology and Analysis

Individual Interviews and Focus Groups

We used qualitative methodology to elicit participants' perspectives on applied ethics. We organized semi-structured interviews and focus groups parallel to the research objectives. We asked questions about concepts of ethics, values, dilemmas, resources, barriers, and recommendations. The main questions were: what does ethics mean to you in your work? what values guide your practice? what type of ethical dilemmas do you encounter in your job? what barriers do you encounter in attempts to resolve ethical dilemmas? what resources help you resolve ethical dilemmas? and what recommendations can you make at the personal, professional, and organizational levels for improving ethical thinking and action? Workers were encouraged to provide concrete examples of their struggles and not to remain at a conceptual level. This was meant to facilitate a phenomenological understanding of their dilemmas. With participants' permission, each interview was tape-recorded and later transcribed. All interviews and focus groups were conducted in Spanish.

Participants

A total of 28 people were interviewed in two cities: Santiago de Cuba and Havana. Fifteen participants were interviewed on an individual basis, and 13 in four different focus groups. Most interviews took place during a conference in Santiago de Cuba. Announcements were made during the conference about the research and some participants volunteered to be interviewed. The conference was a propitious venue for the research because it attracted psychologists from different parts of the country. With the help of a conference participants, a focus group was also held in Havana. The individual interviews had a duration of 40 to 60 minutes and the focus groups met for an average of one and a half hours. Out of the 28 professionals there were 23 psychologists, three pedagogues, one psychiatrist and one philosopher with interests in mental health. Twenty-two of the interviewees were females and six were males. Although we cannot claim to have had a representative sample of the Cuban population of psychologists, we had a fair degree of diversity. Twenty interviewees resided in Santiago de Cuba, four in Havana, two in the Province of Camagüey and another two in Cienfuegos. About half of the participants had less than ten years of work experience. Roughly one quarter had between 10 and 20 years of experience and the remaining quarter had been in the work force between 20 and 30 years. Most participants worked in clinical and educational settings, with a few working in industrial or community settings. Half of the sample were university professors. The rest of the participants were practitioners. It should be noted though that most psychology professors in Cuba also have an active practice in a clinical, educational, community, or industrial setting.

Data Analysis

Transcripts of the interviews and focus groups were read line by line and themes related to the six research questions (concepts, values, dilemmas, resources, limitations, recommendations) were identified. Potential illustrative quotes were selected during the third reading of the transcribed interviews. A second level of categorization included grouping the themes under a particular category. This was a consensual process whereby team members agreed on the best conceptualization of the data. The emerging categorization was later shared with two Cuban key informants, who made recommendations for contextualizing the data in contemporary Cuban reality. The meaning of the data was discussed during intensive and extensive consultations between the authors and the two Cuban key informants. The Cuban key informants, one male and one female, were selected on the basis of their seniority and experience.

Findings

This section is divided into two main parts: concepts of professional ethics and values. In each part we present main themes emerging from the data and selected quotes to illustrate the main issues. An overview of the findings is presented in Table 1.

Concepts of Professional Ethics

The interviewees were asked to express in their own words their understanding of professional ethics, beginning with the definition of what applied ethics meant for them. The answers were grouped in the following themes:

• Centrality of ethics

• Ethics in social context

• Ethics and subjective processes

  Centrality of ethics. For this group of participants, ethics is seen as the pillar of professional practice. There is a synergy between the professional ideals of service to the community and the revolutionary goals of prosperity for all. In the following sentence the relevance of ethics in professional practice is emphasized: "In our profession ethics play a fundamental role; it promotes efficiency and good outcomes." The following statement highlights the close relation of ethics to human agency: "Human beings are defined by ethics, there is no behaviour, there is nothing in our thinking where morals are not involved."

  Ethics was defined as the principles and values guiding thinking and action. The following statement expresses the moral character of professional actions:

  I see ethical issues in all decisions I have to make as a professional. When I, as a professional, have a decision to make with respect to my patient or my work, or with respect to a community, or anything else where my actions could be right or wrong, just or unjust, moral or immoral, I'm involved in ethical decision-making. The dilemma is choosing the right action from the possible array of options available to me.

  
  
  

  Participants claimed that ethics goes hand in hand with scientific and critical thinking. By scientific rigour participants meant a practice that is based on evidence and knowledge. They used this terminology to contrast it with a practice that lacks systematic knowledge.

  Ethics doesn't just happen, it's a process that accompanies another process. Principally, that of becoming a scientist. This implies that you have to be an excellent scientist. Conceivably, you could be very ethical but not rigorous enough in your scientific practice, in which case you would be undermining ethics altogether. Psychologists need to be good scientists and highly sensitive people to perform their work ethically.

  
  
  

  Ethics in social context. Participants believed it is necessary to understand professional ethics as part of the larger social context in which he or she is immersed. In addition, it is important that the preferred conception of ethics respond to the problems and needs of the community. This position requires that the psychologist be knowledgeable not only about professional issues, but also about cultural, social, and political issues. This broad reading of the social, cultural and political context should help psychologists reflect on their role in society. This view was expressed by a psychologist, stating that

  Professional ethics is typically restricted to secrecy and confidentiality. Professional ethics should go much further than that. The psychologist needs to have a comprehensive understanding of social phenomena, has to be a person with general knowledge and political sophistication. Psychologists need to realize not only the problems of the people they want to help; they also need to know for whom they work and whose interests they represent. They need to know what is their social role and what interests they are responding to.

  
  
  

  Ethics and subjective processes. Ethical decisions are connected to psychological processes and personal dynamics. The main processes considered by our participants were:

• Emotional responses

• Lifestyle and personal choices

• Professional growth

  Emotional responses. Some of the participants said that ethical dilemmas produce diverse emotional reactions, ranging from frustration, distress, and discomfort with themselves or others, to satisfaction when resolving conflicts productively. Ethics, we were told, cannot be just a cognitive enterprise.

  I don't like to think of ethics just as a cognitive exercise; in reality it needs to transfer to the affective level, and it needs to be incorporated, it needs to be internalized. It is not enough to know ethics, it has to be felt.

  Lifestyle and personal choices. The interviewees pointed out that ethics extend beyond the realm of work; they constitute a value system applied to all areas of their professional and personal lives. For them, personal ethics are intertwined with professional ethics; one does not exist without the other. One psychologist commented:

  The profession is a system of knowledge, it's also a method, and a way of life as well. I don't stop being a psychologist when I leave my office or leave the hospital, rather I am actually a psychologist in life.

  
  
  

  Another psychologist noted the following:

  It is difficult to separate professional ethics from personal ethics, because personal qualities facilitate the advancement of professional ethics.

  
  
  

  Professional growth. Participants referred to the "dialectic of ethics" as the different instances of confrontation and reflection around ethical dilemmas. An ethical dilemma leads to confrontation with an issue or a person. The subsequent reflection places the practitioners in a new ethical plane. One psychologist remarked:

  One has, as a professional, different stages in one's development. In each of these stages one is ethical in a certain way. Later one can be ethical in a different way, that is, it's not something that one achieves, rather it is something that we are always striving to achieve... I think it is necessary to have a certain ability to reflect on one's practice dispassionately. What am I? what do I need to do? But this dispassionate reading is only achieved when we have control over what we do. Ethical errors will occur until this control is achieved.

  
  
  

  Values that Guide the Work of Mental Health Professionals in Cuba

  For this second section the participants were asked what are the ethical values that support their professional work. The values they mentioned were grouped in two main categories: (a) civic values, which refer to the values professed by citizens in society, and (b) professional values, which refer to the values that are characteristic of Cuban professionals in their workplace.

  Civic values. Civic values refer to the principles and ideals which characterize the Cuban people and which were forged through the struggles which gave origin to the Cuban Revolution. Participants credited national poet José Martí with many national ideals, such as liberation from external oppression, and the development of personal and collective welfare. According to our participants, the moral foundation of their professional work is rooted in historical values transmitted through generations.

  The putative intention of the revolution is to unify Cubans and to work together for the development of socialism. The values promoted by the revolution, and expressed by our informants, were solidarity, collectivism, equality, justice, dignity, freedom and independence.

  Promotion of socialism. One participants mentions the socialist political ideology guiding Cuban society:

  We are a society that is rooted in a Marxist-Leninist ideology. So, the concepts of democracy and equality help us shape our thinking, our point of view on any subject. Also, the political conviction of our people, the political/ideological preparation given to us from birth, I think this also helps us to promote these values.

  Another participant commented that this social project is an utopia that has been only partly realized and that requires the continuous effort of the whole population:

  It is the dream of reaching a better society, it's not having the doors closed and to think that we are finished and that there is no way out of here....we have to prepare the population for this better moment. This dream has to be based fundamentally on economic transformations in the country. Imperialism tries to avoid utopia, it says that 'man' does not live from utopias. For this country it was impossible to think that every child would have schooling, that there would be no barefoot children, that there would be no children dying without medical attention, and that every child would be able to go to school. It was utopia at some time, utopia which we converted to reality.

  
  
  

  The participants mentioned that the utopia of building a humanitarian society is being threatened by ideological movements in capitalist societies. These ideologies disengage people from their values and uproot them from their history. The following statement expresses this viewpoint:

  I think that Cuba is an example for the world, and we work also for our brothers and sisters of Latin-America, we want a better life for our brothers and sisters, not just a better material life, a richer spiritual life. So, what is happening now? People are robbed of their past and don't let them see the future. In so doing, they exclude the dialectic of the past and of the future, and let them live just in the present. The person who lives in the present alone is a person totally demoralized, because he has no roots, nothing to grab on. What are the values for this man? Consequently, taking away the past and taking away the future is leaving him completely unarmed.

  
  
  

  Solidarity and Humanism. A value that was frequently expressed by all participants was solidarity. This value was understood as the altruistic help given by psychologists to the community. A participant said:

  We are very solidarious, perhaps due to the influence of the politics, we have been educated in equality, which also shows at the level of practice. We see everybody as equal....there is a relationship of camaraderie.

  
  
  

  Most values described by participants were of a humanitarian nature, marked by affection and care for others. These humanitarian values are symbolized through the figure of Ernesto "Che" Guevara, major hero of the Cuban Revolution. One of the participants commented:

  If I were asked what should a young Cuban be like, I would reply that he/she should be like The Che, who is an example of all those values, solidarity, honesty, authenticity, and all the other things that makes his personality unique. This is ethics for me.

  
  
  

  Dignity and Independence. Dignity is another value that characterizes the Cuban identity and its high degree of patriotism. Participants referred repeatedly to the pride they felt knowing that they are agents of their history. Cubans feel proud and united in their struggle against foreign domination. Various participants referred to dignity as follows:

  The dignity of the Cuban people is very closely tied to national pride, the pride to know their history, it is very much embedded in the thought of Jose Martí....Every Cuban feels very much wedded to his/her social project, and this gives their lives meaning, it gives them dignity, and it gives them pride.

  
  
  

  The first article in our constitution refers to the dignity of man (sic). Cubans have always had this idea of not letting themselves being dominated by others.

  
  
  

  Love of independence and national identity, these are values that are firmly embedded and characterize us as a society...We have imposed the psychology of resistance, not to give up, under no circumstance, under no condition, what is ours, what belongs to us, and, this is not just now, it has many precedents.

  
  
  

  Cuban national values, such as the search for freedom and independence, are seen as values of moral character. "Our first thinkers have always associated ethical and moral values with the independence of their country. Independence as political and moral value." That is why psychologists and other professionals in Cuba are trying to adapt socialist ideals into the work setting.

  Professional values. Professional values refer to ethical principles that guide the professional practice of psychologists in Cuba. The interviewees mentioned values directed towards others (any person they come into contact with during their professional practice --patients [their word to describe clients], patients' families, members of the community, colleagues, other professionals) and towards themselves. We call the former other-oriented and the latter self-oriented.

  Other-oriented values:

  Respect. Participants mentioned the value of respect throughout the interviews. This is an attitude projected towards patients, colleagues, other professionals, and members of the community. The attitude of respect is understood as the acceptance of service recipients without judging them. Participants emphasized that respect also has to do with confidentiality and with the fact that patients should not be rushed in their process of reflecting about their problems. Clinicians emphasized "not to hurt the patient at any time."

  Empathy and commitment. Empathy helps clinicians to establish an adequate relationship with the patient or with the person requesting help. This value was expressed by one psychologist saying:

  When we put ourselves in the position of the other (person) and we respect the position of the other person, and, when we treat them with warmth, with love, trying not to hurt them, being sensitive, it is very difficult not to be just.

  
  
  

  Participants also mentioned the value of commitment and sensibility. In their view, for the Cuban psychologist it is gratifying and essential to know that he/she is very involved with the person whom he/she is helping. This involvement implies extending oneself to the patient's community and family members in search of solutions to the individual's problems. This value was expressed by one psychologist as follows:

  Another value is the high emotional identification with the problem brought to us. Maybe the fact that our services are free contribute to our work being inspired in itself, we feel that we are committed to the patient.

  
  
  

  Collectivism. Some psychologists and pedagogues working in schools promoted the value of collectivism, defined as the principle of sharing essential resources with community members for the promotion of collective well-being. The advancement of collectivism was their main occupational task. Their job was to encourage students, teachers and families to cooperate and promote the values of collectivism and solidarity. This mandate was provided by the educational authorities in order to preserve and promote moral values.

  Community participation. The value of community participation was exemplified in a number of community interventions headed by psychologists and other social scientists. One participant provided an example concerning the quality of life of a rural community in which very basic needs had not been secured. The government intervened to provide basic necessities such as food, housing, and clothing. Following a period of time in which the community had enjoyed these services, a needs and resources evaluation was conducted to assess the quality of life of the residents. The needs and resources assessment revealed that community members had their basic necessities fulfilled but were unhappy with their lives. An investigation took place to involve the community as a whole in determining their priorities and the type of activities they would like to see in the community. This study shows how professionals were sensitive to community members determining their own preferences and social priorities.

  Self-oriented values:

  Authenticity. This value represents honesty towards oneself, others, and towards one's background and culture. This value rejects prefabricated notions of how one should behave. Instead, it calls for the creative evolution of one's unique outlook on life. Authenticity is viewed as a basic feature of healthy psychological development.

  Self-respect. Psychologists emphasized that one fundamental value in professional practice is respect for the work they do. This appreciation for their work is expressed in the following paragraph:

  To respect is to have an attitude through which one projects a certain value, a sense, and a meaning to oneself as a professional. I value being a psychologist, I am proud to be a psychologist, I chose this profession and have to exercise it fully and with clear goals in mind.

  
  
  

  Scientific rigour. Another relevant value for the interviewees is scientific rigour, which consists in "being consequent with a theoretic and methodological position." This scientific rigour is seen by the interviewees as a self-critical attitude of constant evaluation of one's work, which is different from the positivistic rigour of proving hypothesis by quantitative methodological procedures. For this value to take hold, a flexible mentality is needed which allows for the acquisition of new theoretical and methodological positions. Discussion Research in another culture enhances not only our understanding of other people's conceptions of ethics, but also of our own. By comparing and contrasting our conceptions of ethics with that of another culture we have the opportunity to reflect on the strengths and weaknesses of our own approaches. For self-reflective purposes, it is particularly useful to contrast our North American ideas and practices with that of a vastly different culture, like Cuba.

  The findings resonate with our conceptual framework. According to our participants in Cuba, ethics have to be grounded in culture, history, and politics. This is congruent with our grounded, feminist and critical approach that seeks to complement abstract and cognitive conceptions of ethics with real life events and subjectivity. In other words, our participants concur that we cannot decontextualize ethics. In their view, and in ours, subjectivity suffuses ethical decision making. Based on this insight, Cubans promote rigorous thinking, according to which subjectivity is to be scrutinized in light of theory and moral philosophy. This is their way of ensuring that subjectivity, while acknowledged, does not lead to relativism. The constant struggle to apply a set of principles to a specific context, without personal subjectivity undermining the principles, or vice versa, is a recurring theme in feminist thought and in critical psychology (Hollway, 2001; Jaggar, 1994; Prilleltensky & Nelson, in press). In the next article we present the dilemmas that psychologists face in reconciling moral postulates with personal and vested interests.

  Reflective of the cultural context of the study, participants talked at length about the importance of civic values. They talked about solidarity but also about personal dignity, they value empathy, but also self-respect. Their values attended to both personal and collective wellness. Feminist thought and critical theory claim that personal emancipation is tied to the emancipation of the many. Subordination of the one or the many devalue the moral stature of the entire society. Standing up for private rights but engaging in actions of solidarity at the same time is an important legacy of feminism and other social movements invested in the eradication of oppression. Under external political pressure and economic strangulation, Cubans are reminded of the importance of solidarity but also of reduced resources for the individual.

  We note certain similarities between Cuban and North American conceptions of ethics, primarily with regards to values in the therapeutic encounter. The importance of empathy and sensitivity was repeatedly mentioned in the interviews. This is a definite commonality between the two cultures. Professionals in both places hold interpersonal values of respect for the dignity of clients, empathy for their concerns, and commitment to doing what is best for them in high regard. These similarities at the micro-level of the helping encounter notwithstanding, there are noteworthy distinctions at the macro-level related to the social role of the professional and the influence of culture in applied ethics.

  Cubans' conceptions of applied ethics and values can be interpreted as representing a social and humanist orientation. In addition, Cubans seem to favor the permeability and integration of personal, professional, cultural and political values; a stance that is reminiscent of the feminist precept that the personal is political. In contrast, North American approaches focus more on the individual, legal, and objective aspects of ethics (Prilleltensky, Rossiter, & Walsh-Bowers, 1996). Moreover, North Americans seem to espouse the compartmentalization of personal, professional, cultural, and political values.

  Cubans espouse a social orientation to applied ethics. They are socialized to believe in the socialist ideal, in the importance of collectivism, and in the primacy of the community and the nation over the individual. Unlike North Americans who focus on the needs and resources of the individual client, Cubans interpret personal difficulties in light of social problems. Consequently, they think of solutions not only in terms of micro-level but also of meso- and macro-level interventions. A clear benefit of this orientation is the promotion of solidarity and sense of community. A potential risk our participants talked about is the promotion of conformity and the suppression of individuality and uniqueness. The power of the group can diminish expressions of diversity and deviations from the norm. This is the other coin of strong communal ties. Whereas strong ties help in times of need and offer ongoing support, rigid norms discourage alternative pathways and lifestyles.

  The individual focus of the North American approach has the advantage of promoting personal emancipation, albeit in a limited fashion. Attention is paid to internal sources of oppression and suffering, such as fears, anxieties, and repressions. The client is helped to liberate him or herself from psychological chains, but little attention is paid to the social dynamics of oppression and domination, hence its risk of individualizing and personalizing problems (Pilgrim, 1992).

  The second dimension concerns the interplay between objective and subjective approaches. Cubans seem more attentive to the role of subjective processes such as personal background, vested interests, and affective responses; whereas North Americans attend more to norms and minimize the role of subjectivity in ethical decision-making (Prilleltensky, Walsh-Bowers & Rossiter, 1999). Cubans seem more attuned to the psychology of the psychologists, whereas North Americans are more in tune with the need for rules and normative expectations. We believe there are risks and benefits associated with each position. The subjective position has the advantage of realizing that the mental health worker is not a "cognitive-problem-solving-machine" devoid of personal feelings and investments in the outcomes of ethical conflicts. This leads to a serious consideration of the role of subjective processes in deciding what is the most ethical course of action in any given situation. Once subjectivity is acknowledged, it is easier to deal with it. There is, however, a possible risk in the subjectivist position. If so much attention is given to subjective processes and what the helper considers best for the client, emphasis may be diverted from the need to follow certain rules and principles in decision-making processes. A self-aware clinician with the best intentions still needs to attend to moral principles.

  We believe that the merit of having clear norms and regulations may overshadow subjectivity. An implicit assumption may be that if we have sound codes of ethics their guidelines will lead to ethical outcomes. But guidelines and codes, however meritorious, need to be implemented by human actors with personal and professional investments. We believe that much effort has been placed on constructing cogent documents and not enough on their applications to real life by human actors (Bowden, 1997; Chambliss, 1996; Rossiter et al., in press).

  The final comparison relates to the permeability of personal, professional, cultural and professional values. Cubans seem to hold a more integrative view of applied ethics whereby personal values are not segregated from professional ethics. This approach seems to promote a more holistic attitude than the one espoused by North Americans whereby a somewhat rigid separation is maintained between personal, professional, and political beliefs. The latter position may promote a fragmented view of the self and others. For a long time, Western notions of applied ethics have encouraged a separation between our beliefs as citizens and our obligations as professionals (Brown, 1997). In contrast, we think the Cuban stance fosters a holistic and more integrative approach toward oneself and others. The merit of this position notwithstanding, it risks biasing what is deemed good for the client on the basis of personal and political convictions of the helper.

  Conclusion

  The purpose of this article was to report the values and concepts of applied ethics of 28 Cuban mental health professionals. We have documented their views with regards to the centrality of ethics in their practice and with regards to the role of subjective processes and social context in ethics. We have seen that their collectivist orientation contrasts with the North American individualistic orientation to values. By comparing their views with the predominant culture of applied ethics in North America we have discussed the risks and benefits of each approach. We have tried to learn about Cubans' perspectives from their own point of view, thus fulfilling our commitment to a contextual orientation. But our understanding of applied ethics in Cuba would not be complete without a discussion of conflicts and dilemmas encountered by professionals in Cuba. This article dealt with conceptions of ethics. To obtain a more complete picture we need to know people's attempts to apply these notions on a daily basis. This is the object of the next article.

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  Table 1

  Overview of Findings

  Main Categories	Themes
  Concepts of Professional Ethics	Centrality of ethics Ethics permeates all aspects of work Ethics in social context Ethics has to be grounded in culture, history, and politics Ethics and subjective processes Emotional responses, lifestyle and personal choices, professional growth
  Values	Civic values Promotion of socialism, solidarity, dignity, independence and freedom, humanism Professional values Other-oriented Respect, empathy, commitment and sensibility, collectivism, community participation Self-oriented values Authenticity, self-respect, scientific rigour