Recent approval of the new Principles and Standards of Ethics for Psychoanalysts and last spring's publication of the Ethics Case Book of the American Psychoanalytic Association raise anew the question, “How should psychoanalysts think about ethical issues?” The Ethics Revision Subcommittee of the joint Ethics Committee that drafted the new Principles and Standards and supplemented it with the casebook struggled with this question. It sought a workable consensus regarding the moral acceptability of such behaviors as setting the fee, reporting abuse, handling impaired colleagues, and using confidential information. My aim here is to characterize briefly the kind of ethical reflection the Revision Subcommittee came to regard as uniquely compatible with psychoanalysis.
At first glance, the Principles and Standards appear to adopt a duty-oriented approach that particularly focuses on boundary violations. The code is set out in two sections:
A short list of ten highly general moral principles, like “truthfulness” and “respect for persons,” that provide justifying reasons for …
A longer list of more specific rules (the standards), intended to guide conduct more precisely than the principles.
For example, the principle of truthfulness, which requires the analyst to deal “honestly and forth-rightly with patients, patients' families … and colleagues,” is further specified in the standards section as requiring the analyst to speak candidly with the prospective patient about “the benefits and burdens of psychoanalytic treatment” before beginning analysis.
The reasons for each standard, like the prohibition on “any kind of sexual activity between the psychoanalyst and a current or former patient,” are contained in its justifying principle. In the case of sexual relations, the principle “Avoiding Exploitation” instructs that the ordinary duty to avoid harming others becomes especially strong in the asymmetrical transference relationship in which the patient is particularly vulnerable to manipulation and harm.
Despite its duty-oriented or deontological structure (deon in Greek means “duty”), the new code is not meant to encourage analysts to think primarily in terms of moral rules in deciding moral dilemmas. Explicit rules are necessary but of limited usefulness. They serve mainly to provide an explicit framework within which the free play of analysis can occur and to provide clear grounds for ethics committees to adjudicate complaints for egregious misconduct.
Rules alone, no matter how well formulated, fail to provide sufficient moral guidance. Explicit rules not only construct moral issues too narrowly to do justice to the multiple meanings—conscious and unconscious—ordinarily involved in moral behavior; they also routinely conflict with one another. Good moral decisionmaking is rarely about following an applicable rule. This is why there are so few precise guidelines in the new standards section. Good decisionmaking is about balancing conflicting values and responsibilities in relationship to the particular facts and dynamics of specific situations.
One function of the guidelines is to identify many of the main principles and rules that are found to conflict in clinical practice and to suggest a framework for thinking about these. The widespread impression among analysts that the new guidelines set forth a form of boundary ethics misses much of what the guidelines are about. The boundary metaphor fails to do justice to the ethical thinking encouraged by the new guidelines, which is more aptly captured by “playing the game well within the court.”
Consider the new confidentiality guidelines. The Principles and Standards specify that the patient's privacy must be protected in presentations by disguising the information and/or obtaining the patient's informed consent. But there are many variables to consider: the potential harmfulness to treatment of the analyst's request for consent the likelihood of identification despite the disguise; the unintended consequences of misleading colleagues with the chosen disguise; the likely effects on the transference/countertransference of different strategies; the risk of patient harm from the type of communication (small group discussion, lecture, publication); the audience (whether clinicians governed by confidentiality or the public); and so on. The introduction to the Principles and Standards expressly acknowledges that “no code of ethics can be encyclopedic in providing answers to all ethical questions that may arise in the practice of … psychoanalysis,” precisely because most moral decisions concern dilemmas that typically outstrip the explicit standards that govern them.
Instead of relying on rules, the new Principles and Standards follow Aristotle in relying on “wise judgment” (phronesis). “Sound judgment and integrity of character are indispensable in applying ethical principles to particular situations and individuals.”
The casebook was prepared to supplement the Principles and Standards to help analysts become familiar with the complexities of moral decisionmaking before they arise in the context of treatment. The outstanding virtue of the case method is that it engages the reader in actively thinking, under realistic conditions, about typical situations, as contrasted with complying passively with rules. Cases have no “solutions.” Their value lies in encouraging an examination of feelings, biases, selections, and preferences before making decisions appropriate to unique circumstances. For psychoanalysts, this kind of preparation is especially relevant, because ethical problems for us are intertwined with technical considerations that also involve moral issues, insofar as the point of technique is optimum benefit for the patient.
An important thread running through the new guidelines, casebook, and ethics policies is that ethical reflection is often best when done collaboratively. The morally perplexed analyst is repeatedly encouraged to consult colleagues about the issues at stake and how to handle them.
Ernest Wallwork, Ph.D., is a member of the Ethics Revision Subcommittee of the joint Ethics Committee, a professor of ethics at Syracuse University, and a practicing psychoanalyst in Washington, D.C., and Syracuse, N.Y.