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How Much?Why Some Things Should Not Be for SaleWisdom, Intuition and EthicsWithout ConscienceWomen and Borderline Personality DisorderWomen and MadnessWondergenesWould You Kill the Fat Man?Wrestling with Behavioral GeneticsWriting About PatientsYou Must Be DreamingYour Genetic DestinyYour Inner FishYouth Offending and Youth Justice Yuck!
Perhaps in essence, as Kevin Walsh indicated, there
is no such thing, strictly speaking, as a neuropsychological test: there are
just psychological tests, the inferences one draws from the results are of
course informed by a clinical neuropsychological training and approach. Testing is of course not assessment either
as Joseph D Matarazzo pointed out in his capacity of President of the APA, just
a part of it.
Inference becomes opinion
when a report is written, and the environment in which it is written, and the
purpose for which it is written lead the words and the circumstances in the
provision of quandary for the writer.
Such quandaries are the
substance of this book. Each invited
author puts forward a seemingly part factual part fictitious scenario for
discussion. In each, a neuropsychologist
or like professional is asked to carry out an assessment on some person under
some circumstances. The resultant mayhem can emerge from just about any
situation, but of course the medicolegal arena is the most likely to present
challenges, as are issues of informed consent, as well as privacy,
confidentiality and so on. Each scenario includes some narrative around
resolution of the case or issues, as a guideline.
Most, if not all, ethical
codes common to all professional organisations that act as either guilds or
gatekeepers or protectors of the public (it varies) have similar terms in
common, such as non-malfeasance, confidentiality, dual relationships and roles,
and other related terms and concepts.
Acting within the boundaries of one's profession, one's training and
experience, above all else doing no harm and staying within the boundaries of
consent, all should be easily recognized and observed. 'Should be', but life is complex and so it
is not that simple. Vexing scenarios
can easily be imagined especially when culture intervenes as a complicating
factor or conflicting interests especially when third party referrers are
Issues of construct validity
and what like professionals would consider valid or proper are more easily
complex and vexing.
And so Bush puts together a
volume composed of what others have experience in these and other regards.
For instance, an assessment
of competency is done faultlessly, but later on, after conviction, the expert
returns to discuss punishment, out of the range of the original informed
consent or body of data. Experts are
used to deny entitlements, swimming unwittingly or wittingly in the wrong end
of the pool of bias versus advocated opinion.
Experts leave the test room, and come back to find the test anonymity
violated by theft and unauthorized approval. A client gives his consent for
assessment under duress.
These are everyday events
for most of us, trying to do what is correct and proper. So many times, assessment is not within the
culture of the doctor-patient relationship, but complex and with conflicting
interests and roles being major pitfalls.
Can a patient give consent, and then when the testing is over, withdraw
consent? If the report is written? If the report is not yet written or
served? Or written but not served? Like rape, you can say no before, no during,
but not say no afterward? Or can you?
What then of normal clinical
practice, let's say in medical settings?
One scenario is of the patient about to undergo surgery, taped to all
kinds of machines, with all kinds of metabolic activity taking place. Another is of colleagues who want to use the
tests themselves to make inferences about cognitive functioning, who want to be
taught to screen without the necessary knowledge of how inference is made. Conflicts of interest may frequently arise
when multiple roles are inhabited, or in arenas where there are multiple
interests and groups represented.
Nonmaleficence is hard for anyone to action as a philosophy, and my
spell checker finds it as hard and unusual a concept as any layperson. The line between right and wrong is always
grey at the edges.
In an assessment, when a
client demands the neuropsychologist hear most troubling facts related to her
future health, and at the same time demands confidentiality, what does the
Psychiatric settings within
medicine come with their own risks and the book reserves special space for
this. A patient is interviewed for her
competency to make a decision about refusing medical treatment. There is no neuropsychological deficit, and
she can choose to die, can't she? A second
assessment by another expert agrees she is competent from that point of view,
but finds her in the grip of a depression.
This depression makes her unfit to be taken at her word, so her choice
to die is coloured and amiss, and the inference that she is
neuropsychologically intact is right, but the inference that she is competent
is thus wrong.
One essential point that
emerges at this stage is the desirable faculty of training neuropsychologists
initially as clinical psychologists
before their speciality in the neural domain.
This is shown to be the common opinion among at least American
neuropsychologists even though several western countries train their
neuropsychologists with little such input or above average expertise in the
issues germane to clinical psychology vs. clinical neuropsychology.
Psychiatric settings are one
thing, rehabilitation settings (such as mine) also provide fertile ground for
examining principles such as fidelity, confidentiality, beneficence (which my
spell checker recognizes, as does the general public). Another strong issue is the need to perhaps
modify, and thus depart from, strict administration rules during the
administration of commonly used tools, perhaps invalidating the norms while
still providing what one author here refers to as meaningful clinical
information (page 98). Here, the
mirroring is of the abovementioned Matarazzo exhortation to yield
diagnostically meaningful and thus useful information, when inference becomes opinion. The interested reader will find the
arguments made here revealing, for as Victor Nell has noted elsewhere, norms
without constructs are just numbers, and that is precisely the dilemma
here. How does one make meaningful and
informed observations when the norms have been rendered meaningless by a
transgression of the rules that created the norm table that has reference? Then again, norm tables were created on
specifically defined populations, and drawing on a client from a different
population makes the norms similarly into meaningless numbers. Linking this
particular chapter by John DeLuca with those by authors such as Joseph D
Matarazzo and Victor Nell would make compelling teaching material for
interns. A minor irritation in this
chapter was the miss-citation of Cushman and Scherer's book, being the
Psychological Assessment in Medical Rehabilitation, not Medical Practice.
rehabilitation setting focus, it does not shift from informed consent needing
to adequately reflect the referral questions, or an anticipation of what might
emerge, such as removal of a privilege such as a driving license. This would be especially true if another
agency used the report for a purpose not outlined, or predicted, or if the
tests lacked real application in the assessment of the real-life capacity. Confidentiality in a team is difficult, as
there may be members of that team whose use of the information, let alone
access to that information, may exceed the original envisaged scenario when
consent was obtained.
The neuropsychology of pain
is oddly enough also entertained as a source of ethical quagmires. Again, the special responses of persons
afflicted with pain need to be known at an expert level, and knowledge of all
and everything associated with a case is strengthened. This would include the literature on pain
affecting or at least having an impact on the functioning of widespread
cortical and subcortical areas, as well as the results of clinical assessment.
If clinical neuropsychology
is a rocky road strewn with minefields, then pediatric neuropsychology is
strewn with disembowelled practitioners who wished they were dead: literature
and testing in children, given developmental variance, is difficult. Issues of
informed consent are also liable to cloud the water, as is parental involvement
and issues of confidentiality, and statutory reporting of abuse and so on. The presence of others in the room, either
family, or court observers, is also an issue.
Geriatric patients are likewise in a vulnerable position requiring some
expertise, as are geriatric patients from other cultures different to the
origin of the examining neuropsychologist. Both geriatric and cultural concerns
are dealt with here, including in the former a thorough review of the impact of
illness and age overall, and the limitations of testing.
Ethical challenges move with the times, and the book
now introduces the theme of information technology. No fewer than 13 standards within ethics are challenged
immediately in the scenario where an Internet based assessment using a remote
company is contemplated, with few guidelines yet published. Another issue is
that of providing details on websites, and imitations of confidentiality when
prospective clients, where no contract exists, make contact.
Research design has always attracted a risk of ethical
violation, and the book notes concerns such as the use of tests being trialed,
the interests of others, ideas that the research tools or protocols constitute
a thorough and valid workup, or test results or test protocols are not protected,
or the rules are fudged with regard to how the results of a particular
assessment are used, when other clinicians are involved.
Research into new instruments also presents hazards
for the participants. The determination
of response validity is another, well recognized challenge. It does of course happen that insurers
request the use of certain tests, even if they can be deemed inappropriate, or
sometimes even out of date. Some responses may look suspicious, but there may
be other reasons for this.
The book finishes with an appendix containing the
APA's Ethical Code for Psychologists as a reference.
The book overall seldom provides a scenario that is
beyond the average neuropsychologist's experience, or at least that resonates.
Perhaps one from my own stable. A Supreme Court Judge is hearing a
matter. He finds it hard to accept the
plaintiff's contention that she has a brain injury following an accident where
she did not lose consciousness, but an experienced clinical neuropsychologist
has found her to be so damaged. The
judge interrupts the trial and demands that a second neuropsychologist see
her. Reviewing the results, the second
neuropsychologist would tend to agree that the test results showed something
was really wrong. However, on applying
his own tests, the neuropsychologist finds no indications, and she performs
well. On perusing her list of
complaints given to the first neuropsychologist, he notes she suffers from
migraine. She admits that on the day of
the first evaluation she had a bad migraine, but in her culture, one doesn't
complain too much, and so she didn't tell the neuropsychologist, who didn't ask
if she felt fine on the day.
I wonder if any of us simply ask the question: Are you
feeling fit today? Are you at your best? Are you particularly tired today? Can
you do your best today? Are you on any
medication that might affect these results?
Did you have three espressos this morning?
Clinical neuropsychology is after all designed to pick
up subtle deficits. Kevin Walsh, the
doyen of the Australian community used to note that if the deficits were so
gross that the next door neighbor could elaborate on them, then one would not
need a neuropsychologist. The problem
is that when sensitivity is high, then specificity is not, with regard to test
profiles, and also, vice versa.
One must therefore always come back to the work of
Joseph Matarazzo, and accept that variance on tests is a function of the
diversity of human capacity, of the presentation of the average human, not
necessarily of the presence of pathology. This is what happens when inference
becomes opinion, devoid of context.
It is the context that is explored in this volume,
with the resultant impact on professional practice and opinion explored in
differing scenarios depending on whom is referring, who they are referring, for
what ultimate purpose, and most importantly for whose gain? Above all else, we have to do no harm, but
that is not easy in practice, as harm waits to pounce whenever one human
delivers comment on another.
© 2006 Roy Sugarman
PhD, Acting Director of Psychology, Royal Rehabilitation Centre, Sydney