Ethics is a branch of philosphy that deals with the question of which actions should be taken and which avoided. The word comes to us almost unchanged from the Greek ethikos, meaning moral art. The Greek philosophers understood ethics as the study of what is good or bad in that part of human conduct for which human beings bear personal responsibility. Since the Renaissance the focus has been on practical judgments— how one can determine and justify the standards to be met in human behavior.
When a choice is made concerning an action, it may be made in deference to an ethical principle. The person taking the action is presumed to know the relevant principle and to have applied it to the action contemplated.
Whether there is a need for psychoanalysts to have a code of ethics applying especially to them is a question to be considered. Although almost everyone expects professionals to adhere to ethical principles—the lawyer in dealing with clients, the physician with patients, the teacher with students—the need for special principles for subspecialties within these professions is often ignored.
The work of psychoanalysts is set apart from that of other health professionals by a modus operandi that not only evokes but depends on regression and transference. (Anyone conducting a psychotherapy, however defined, encounters these processes and should accede to the principles under discussion.) Analysts knowingly allow and observe manifestations of regression in order that infantile conflicts may be exposed and interpreted within the transference relationship. Because of the authority thus invested in the analyst, certain values must predominate if analysts are to meet their obligations to the patient. These values come to constitute a code of ethics guiding their work.
Implicit in the very idea of a code of ethics for psychoanalysis is the premise that something of its essence (or that of any dynamic psychotherapy) will not be provided if certain principles are violated. For example, a sexual relationship between two people precludes the possibility of an analytic relationship.
Motives other than ethical ones may determine the choice of an action. These include convenience, profit, and, always, the superego of the person performing (or not performing) the act. The motives of the individual performing an action do not enter into consideration of the justification for that act. Nor do the beliefs or ideals of that person affect the ethical nature of that act, although accountability may be attenuated by cultural practices, strongly held beliefs, etc. (It may be difficult for psychoanalysts to withhold from the patient their beliefs, long-held prejudices, or unconscious influences. Nonetheless, the standards under discussion relate to the action taken, not to the person taking that action.
Confidentiality is one of the ethical cornerstones of pychoanalysis. The psychoanalyst holds in confidence everything learned about the patient, for the reason that the information belongs to the patient and has been entrusted to the analyst solely for the purpose of understanding its meaning and communicating it back to the patient for therapeutic reasons. The patient's right to autonomy over personal information is acknowledged and this autonomy is respected even when the information has been imparted to the analyst. The expectation of confidentiality allows the individual to seek professional help that otherwise might not be sought. This bond of secrecy has reverberations beyond any particular therapeutic relationship; when maintained, it reassures individuals who may in future need to consider such a relationship. Known violations of this bond lend realistic support to what otherwise might be considered a neurotic resistance to treatment.
“Confidentiality is one of the ethical cornerstones of psychoanalysis.”
In the world in which we live and work there are numerous demands that information be revealed, even when it has been received under the bond of confidentiality. Insurance companies, law enforcement agencies, school officials, relatives, employers, credit unions, journalists, colleagues, and numerous others insist that we reveal information that is not ours to reveal. At times revelation is dictated by legislation (when another's life is in danger) and at other times by rationalization (the patient wouldn't mind, or the public would like to know). It is an unfortunate fact that legality and morality do not always coincide, and the guardian of information is often faced with a dilemma.
Probably the most frequent breaches, of confidentiality are casual and unintended. Such inadvertant lapses occur in elevators, at the lunch table, and in other social situations. Less innocent are the self-serving lapses of the therapist who has treated someone famous. In seminars and scientific papers confidentiality is also breached. When there is adequate protection of the patient's identity, however, such breaches are permissible.
The psychoanalyst knows better than anyone that what is revealed and what is concealed has a meaning for the patient more profound than what its manifest content might suggest. We have all helped patients deal with painful and powerful resistances, later to find that when uncovered the material seems not to merit the effort its concealment has required. Apparently innocuous or meaningless material may seem to the therapist hardly worth cloaking in the mantle of secrecy. What is most relevant, however, is the meaning of the material for the patient. Whether the therapist considers the material so neutral that its revelation would be inconsequential, or so positive that its exposure would help the patient, there is no justification for violating the pledge of confidentiality.
It must be kept in mind that this discussion concerns actions rather than persons. The motivations, beliefs, aims, or ideals of the therapist do not affect the ethics of an act. Although it may be difficult for psychoanalysts to abstract from considerations of individual subjectivity, it is precisely because we live with inconsistency, conflict, and ambivalence that it is incumbent on us to develop and live by defined principles and to have a degree of certainty that colleagues do the same.
A course of action is acceptable or not in the light of three considerations:
The nature of the action. The imparting of information to another, considered in isolation, is always acceptable.
The circumstances in which the act is performed. When information has been obtained within the bond of secrecy, to transmit that information to a third party is not permitted. If, however, the patient is placing the life of another at risk, the bond of secrecy is not binding.
The purpose of the therapist. If the goal of the therapist is in itself bad, this is reason enough for the act to be interdicted. However, there are numerous
instances where the goal of the therapist is acceptable if not laudatory. A frustrating and possibly painful example comes to mind. An analyst, upon learning that an analysand has come into a large sum of money, may wish to alert his Institute regarding the possibility of much-needed donation. Even a laudable reason of this sort would not neutralize the limitations imposed by (2), as the circumstances that placed the therapist in possession of the information preclude any action's being taken.
The process of rationalization can make it deceptively easy to justify a violation of confidence—“the patient's interests will be served better”, “it is in good cause”; “the patient wouldn't mind.” In every case, however, the information belongs to the patient even when—it has been entrusted to the therapist. Only the patient has the freedom to reveal it.
Can the patient authorize the release of information by the therapist? If so, what circumstances are determining? This is a difficult and at times thorny question. Insurance companies frequently request a complete record including not only the patient's communications but the analyst's understanding of what is communicated as well as its transference implications.
Here we encounter an impenetrable barrier to revelation: unless it can be assumed that the transference has been completely analyzed, the patient gives permission to reveal data not knowing that it may expose more than is intended.
Ethical principles, founded on reason, require consistency in their application. As emotions are always involved in ethical decisions, how their consistent application is quite difficult. The path to any decision to act or not to act is determined by the state of the ego at the moment of decision. For this reason it is valuable to have reliable principles to aid difficult decisions.
William R. O'Brien, M.D. is the chairman of the Joint Committee on Ethics.