Colleagues sometimes ask why the American needs its own code of ethics when other organizations, in particular the American Psychiatric Association, have similar codes. Does this mean that our members should ignore any code but ours? Of course not. We expect our members to adhere to other ethical codes which appropriately relate to them. Further, we fully recognize that the most important factor governing the ethical behavior of an individual is his own internalized code of ethics, the ethical values promoted by his superego.
However, it is still advisable that the American, as a public professional organization, have its own code of ethics for psychoanalysts, to parallel those of similar public organizations as a statement to the public and to the profession. Further, we need procedures for dealing with the unfortunate and infrequent occasions when one of our members does engage in some unethical conduct. Taken together, the Principles of Ethics and the Provisions for Implementation represent an expression of one of our most important organizational functions, the safeguarding of the public and the related function of maintaining the standards of our profession. These are the foundation upon which our regulatory and certifying capacities are based; these are important parts of our professional raison d'etre.
In reviewing the “old” Principles of Ethics, we discovered that the process for dealing with breaches called for full hearings, with witnesses and lawyers, before the Executive Council and even, possibly, before a full meeting of Members. While this may have been appropriate in more leisurely days, we realized that now the relatively large Executive Council, and the even larger meeting of Members, were poorly suited to deal with such matters; all business of the Association could have become paralyzed.
Here is a review of the new Principles of Ethics. The section numbers are the same as they have been in the past. I will point out the important changes, and offer comments on some of the related issues. Readers will find it useful to have available a copy of the revised Principles of Ethics. It can be obtained from the Central Office.
The Preamble and Sections 1, 2 and 3 are essentially unchanged. These are general statements; their content is reflected by their titles:
Section 1. “Objectives of the profession and the individual psychoanalyst.”
Section 2. “Responsibilities to the individual and to society.”
Section 3. “Treatment to have a scientific basis.”
Section 4. “General conduct of the psychoanalyst.” This section called upon the analyst to “…observe all laws…” It was felt that entirely ethical motives could lead one to engage in actions of social protest that could involve disobeying some laws. Actions of civil disobedience would be an example. Accordingly, we changed the phrase “obey all laws” to “respect” all laws.
Section 5. “Relationships with patients and colleagues.” Section 5 dealt with obligations to patients and other professionals. It called upon the analyst who has a patient who was recently in treatment with another therapist to ascertain if the patient had informed the other therapist of the subsequent consultation. If not, the analyst was advised to “…obtain consent, if possible, to inform the other therapist himself as soon as may be practicable.”
There was concern that this could burden the patient's right to consult with another analyst and could hurt the treatment. As a result, we added a qualifying phrase which suggested that the analyst take steps to inform the other therapist, “… provided this will not interfere with the treatment …” More reliance was placed upon the reasonable judgment and good faith of the analyst to protect the welfare of his patient while upholding the dignity of the profession.
Section 6. “Protection of confidentiality.” Confidentiality is such a complex issue that a full discussion is not possible here. We worked closely with the Committee on Confidentiality on this issue.
The concern for confidentiality is shared with all of the treating professions. We had to consider such issues as the supervision of psychoanalytic cases, clinical case discussions, consultations (Section 9), publications, and even issues like training analyst reports. None of these is a simple matter; all involve technical issues in the management of treatment in addition to the legal and ethical perspectives. In many instances, the psychoanalyst, in the face of conflicting demands from these different points of view, may have to rely upon his own best judgement to reach what may be a difficult decision.
Our basic position is quite clear; patients have the right to confidentiality unless they waive it with informed consent. We view this right with such seriousness, that we expect our members to take all reasonable legal steps to preserve the patient's right to confidentiality even when called upon by a court to provide information about a patient. Some members felt that analysts should even be required to risk contempt of court rather than give information. While we believe that such a course of action is always open as a matter of individual conscience and decision, we did not feel that it was appropriate for our Association to advise this.
Accepted usage generally considers the right to confidentiality to pertain to the patient's identity as a person. If the patient cannot be identified, and no embarrassment or harm is caused to him, it may then be possible to use case material for scientific purposes. The right to confidentiality is protected further by attention to the channel through which information is provided. For example, while it might be appropriate to discuss a case with colleagues, the same discussion may be (usually is) entirely inappropriate in a social setting, or in a newspaper.
When editing case material to avoid revealing the patient's identity, the analyst must decide what can be eliminated or changed without altering the scientific value and reliability of the data. This may involve difficult choices, but the patient must be protected. If information must be included which threatens to be revealing of the patient's identity, the analyst should not proceed without obtaining the patient's consent. However, he must consider the advisability of introducing such an issue into treatment, and must deal with the technical issues which arise. At times, the
Accepted usage generally considers the right to confidentiality to pertain to the patient's identity as a person. If the patient cannot be identified, and no embarrassment or harm is caused to him, it may then be possible to use case material for scientific purposes.
need to preserve confidentiality, or the treatment problems connected with it, preclude publication of the case material. The patient's right to confidentiality and the welfare of the treatment and of the patient are primary goals.
We added what has been called an “anti-gossip” admonition, which obligates the analyst who learns confidential information from a source other than the patient to “fully and appropriately respect” the confidentiality of that information. As a result, an analyst who has appropriately protected the identity of his patient can reasonably rely on the knowledge that his colleagues who might hear a discussion about the case material will also respect the need to protect its confidentiality.
Section 7. “Emoluments for services.” This section deals with fees, and is quite straightforward. It also prohibits the analyst from any exploitation of treatment for his own gain, financial or otherwise. Obviously, this does not deprive the analyst of reasonable gratification from doing his work well, but it clearly rules out exploitation of the patient.
Section 8. “Dispensing of drugs.” This was changed slightly to allow the prescribing of drugs by any psychoanalyst legally licensed to do so. The old version limited this right to physicians.
Section 9. “Consultation.” This section also touches upon issues of confidentiality. It was changed slightly to make the seeking of consultation less of a mandatory obligation. However, it clearly indicates consultation is a desirable course to consider if it may be beneficial to the treatment. When he believes that it will be beneficial, an analyst may consult with a colleague providing he fully protects the patient's rights of confidentiality by not revealing his identity. It is not the intent of the Principles of Ethics to interfere with traditional and useful methods of individual case-consultation or of discussion with a group of one's peers provided that protection to the patient described in the section on confidentiality is observed.
Section 10. “Sexual misconduct in relation to patients.” This section was changed so that its wording more directly, clearly, and simply states its view, i.e., “…any sexual activity with a patient constitutes a violation of this principle of ethics.”
Section 11. “Remedial measures for the psychoanalyst.” This calls upon the analyst to seek help for personal disorders which threaten the quality of his work. This section was unchanged.
Section 12. “Safeguarding the public and the profession.” This section was expanded. As stated previously, the aims with which this section deals are basic to all activities of the Association. The establishment of standards of training, of certification, and of membership are ail derived from this.
The section distinguishes between training for the clinical practice of psychoanalysts, per se, and training in the applications of psychoanalysis to other fields, such as psychotherapy. It recognizes the importance of the role of the psychoanalyst as a teacher while highlighting the special responsibilities involved in psychoanalytic training. It states that the analyst offering training in the practice of psychoanalysis has a serious moral, and possibly legal, responsibility to be sure that the necessary ethical and educational standards are maintained. The welfare of present and future patients must be protected in this way.
In what our attorneys call a “safe harbor” concept, the training standards of the Board on Professional Standards and its approved training programs can be considered to fulfill these obligations. The psychoanalyst can participate in these programs with confidence that the ethical and educational issues have been adequately considered. Training in the practice of analysis should be offered only when there is careful selection of participants and thorough evaluation of the training and the progress of those enrolled in it; one should not attempt “solo” training. Finally, no psychoanalyst may claim that training is in any way connected with the American unless
that training is authorized by the Board on Professional Standards.
There was concern expressed that the requirement (Section 12A) to notify the appropriate ethical body on learning of unethical behavior by a colleague might interfere with the patient's rights to confidentiality. The wording was changed to respond to this concern.
A final change involved the deletion of the word “illegal” as a designation of activities which should be reported to ethical bodies. Reflecting the concerns voiced about a similar problem in Section 4, Section 12A now requests simply that “unethical” behavior be reported.
The procedures for implementing the Principles of Ethics were changed considerably. Space does not permit details, but what is taken up largely spells out the respective roles of the local society and the Association in dealing with possible breaches of ethics by members—steps in the process, ambiguities and conflicts which might arise, and safeguards and rights of appeal which assure a complete hearing of the charge and opportunity for rebuttal. Within the Association itself, the Committee on Ethics now does the reviewing and, if indicated, conducts a hearing, where before the Executive Council had been required to do so. The Council's action, in closed session, is still required before any decision becomes final.
Details of the procedures and of the Principles of Ethics themselves are available to all. The Committee on Ethics urges all members to acquaint themselves with the work of our committee and with the new edition of the Principles of Ethics. We are always available or consultation. We welcome any suggestions concerning ethical issues that members with to send us.