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Writing about Patients is an exploration of the practices and views of psychoanalysts on the issue of publishing clinical reports and papers containing information about patients. The book is the result of author and analyst Judy Kantrowitz's years of investigation and publication on this topic. In an advance review, Lewis Aron, Director of the New York University postdoctoral program in psychoanalysis, commented that Kantrowitz's book marked a turning point in the clinical and ethical culture of psychoanalysis, as more analyst authors now believe it necessary to seek consent from patients before including patients' clinical material in publications. According to Aron, this is a result of a "dramatic change in how psychoanalysts understand the nature of the therapeutic process." I found the truth of the book a little more prosaic. Kantrowitz does indeed document a trend towards seeking consent. This trend is most marked among those holding to the emerging "relational school" of psychoanalysis, whose theoretical orientation sees the analyst as an active player in the analytic process, rather than the more traditional and impersonal "blank screen" analyst for whom any mention of a personal life (including a professional life as an author of academic literature) is anathema. But my sense was that this emergent trend is confined to a group within the psychoanalytic community, and that the more traditional analysts are trenchantly committed to the view that seeking consent is an unnecessary and unhelpful intrusion into the clinical encounter.
Writing about Patients is in part a compilation of previously published reports of analysists' publishing practices, and in part a synthesis of a long period of research in this area. Judy Kantrowitz is a psychoanalyst committed to promoting publication, but also to protecting patients from its possible harms. The tension between these two imperatives is palpable, and by the end of the book it remains unresolved. Such is the nature of ethical dilemmas. In the course of preparing this book Kantrowitz interviewed 141 analysts either by phone or email or both, studied the publication records of various specialist journals, as well as the latter's policies on consent. She has amassed an impressive array of information on views about publication and about the possible harms intrinsic to the publication process and arising as a result of unforeseen loss of privacy. Readers of this book will come away better informed about how practicing analysts actually make decisions, and better informed about the issues involved in publishing clinical material.
Views of analysts varied along a continuum from those who disguise clinical material but who are opposed to the idea of seeking consent, to those who regard seeking consent as an ethical imperative. In between there is a range of practices, with varying degrees of disguise, different interpretations of what it means to seek consent, and a discernible shift in the balance of opinion since the 1970s. But the chances of consensus seem remote, and at the end of the book Kantrowitz is forced to conclude that "All analysts can do is try to be sensitive in their requests and in their writings, and alert to the ramifications of their decisions." (p. 309). The weakness of this conclusion, which is an accurate reflection of the state of the discipline, seems to be a result of the primacy accorded by psychoanalysts to the therapeutic relationship. The discipline appears reluctant to yield to wider social forces that have seen something close to a revolution in medical and health care ethics in the past thirty years. Psychoanalysis appears to occupy a position formerly held by medicine: understandable only by its practitioners, and answerable only to its own standards. As medicine found, this is not only an ethically questionable position, it exposes patients, practitioners, and the profession itself to severe risks. At the moment psychoanalysis seems aloof to these dangers, even if many of its individual practitioners such as Kantrowitz are not.
Kantrowitz doesn't specifically identify herself as a researcher, and it seems that her primary role in conducting interviews and analyzing the content of those interviews is as an investigative psychoanalyst, rather than a researcher. Although she describes development of a systematic method of selecting participants to approach for her study, range of factors mitigate against any claim for representativeness. Kantrowitz is well aware of this limitation, and in itself it does not detract from the credibility of her work. But the lack of an explicit methodology for the work is a more serious limitation. This is especially true in light of Kantrowitz's dual role as investigator and analyst. Her discussion of the content of interviews is in part analytic interpretation, in part data analysis, although without a specific method. While a dual role is common to practitioner-researchers, most such researchers are more explicit about this, and describe methods of managing the potential conflicts. My sense in Writing about Patients is that the balance tipped towards the psychoanalytic interpretation, something which seems from this book to be a problem for the discipline, that it is somewhat insulated from the wider world of research and theory.
There are real dilemmas for analysts wishing to publish, and these are well exemplified by the many excerpts included in this book. Apart from the internal struggle with questions of motivation (narcissism, revenge etc), the preservation of confidentiality poses particular issues, especially when the clinical material is highly explicit and therefore recognizable. Kantrowitz discusses approaches to these concerns, but they are difficult to resolve. One result is that the literature is likely skewed in terms of what it is considered acceptable to publish. Again, there is no simple solution to this problem. However it is not confined to psychoanalysis. Many cases in clinical psychiatry have been subject to media coverage; still others involve events that it would be hard to disguise, especially from the main protagonists. For this reason, some things just don't get published. Clinicians are left with the responsibility of using multiple sources of information, including case conferences and supervision where cases can be discussed in privacy.
Something I found striking in this book is the degree of freedom psychoanalysts have in deciding what they will do with patient information. All options seem to be possible, from publication without consent or disguise to negotiated consent on commencement of analysis. Kantrowitz provides extensive discussion about the issues raised, but these are always considered from the perspective of the discipline of psychoanalysis. Patient rights seem to be one more matter for analysts to consider, but not something that creates binding obligations. In my experience this degree of autonomy is rare in the health professions, and poses considerable risks, such as the potential for self interested or paternalistic decision making.
I expected that the chapter on ethics would step back to take a broader view of the issues identified in the first 13 chapters. However I found this was not the case: discussion in ethical terms is subsumed by the clinical concerns of psychoanalysis. Kantrowitz cites the 18th century ethical theorist Clifford's ethics of belief to provide a model of ethical decision making, but provides no general review of ethical theory as it relates to health care. Much of the discussion in this chapter reiterates issues of transference and motivations to publish or resist publication. There are some helpful sections on manner of writing and other matters, but these are not really matters of ethics so much as of style.
Kantrowitz identifies a primary responsibility of psychoanalysis to "do no harm" (p. 265). Such a stance initially places the discipline on the same ethical footing as medicine and the other health professions. But where medicine has conceded that, aside from cases where competence is lacking, the medical determination of "best interest" should not trump the patient's view, this appears to be contested ground within psychoanalysis. The more traditionally trained analysts apparently believe that decisions on consent "should relate only to the ramifications of the psychoanalytic situation." (p. 266). Medicine would not get away with that, and neither would psychology, social work, nursing or other health professions, so how is psychoanalysis different? It is evident that for many psychoanalysts, common standards of ethics are simply not good enough. Kantrowitz notes that this position is at odds with the stance of the International Committee of Medical Journal Editors, who require consent for any use of patient information in a clinical report. On page 265 Kantrowitz states: "Ethicists' views…may not take into account the complexities of clinical situations, as well as and unconscious as well as conscious, factors influencing patient-therapist relationships and their interactions." The section on ethical principles is notable for its lack of attention to commonly accepted principles of health care ethics, such as those outlined by Beauchamp and Childress (2005) and referenced in almost every basic text on health ethics. Kantrowitz constantly raises the specter of transference as a limitation on individual autonomy. Transference makes a "truly informed decision impossible" (p. 282). This is tantamount to saying that patients in analysis lack capacity until (in their analyst's view) they have worked through their transference.
There is a disquieting sense that psychoanalysis is simply too much above the everyday world to be burdened with a common ethical framework. On page 273, Kantrowitz betrays a serious misunderstanding of the purpose of ethical principles, when she states that "ethical principles are based on assumptions that there is a "right" and a "wrong" way that apply to all situations." This is precisely what ethical principles do not do. A principle such as beneficence requires interpretation in specific situations, not slavish rule-following. Kantrowitz reiterates this view of ethics in the conclusion to the book, when she states that "Ethicists would like to find a standard that can be applied invariably" (p. 296). Once again this betrays a limited understanding of the clinical ethics literature, which in general is supportive of Kantrowitz's argument that "there can be no substitute for the judgment of the individual clinician" (p. 296).
One solution to the issue of consent would be for the professional body of psychoanalysts to require that all analysts inform patients at the outset of treatment of the possibility of a request for consent to publish. This would have the advantage that the "rule" was a given; not something to be bargained away by either party. Is this so different to other rules, for example about sexual contact? While this is a position consistent with the stance of some of the relational analysts interviewed by Kantrowitz, I cannot see it being adopted. It seems that many psychoanalysts value their own autonomy over that of their patients, and would not accept such an intrusion into their practice.
My sense of reading this book is that analysts will continue to do what they already do. Those who place the tenets of psychoanalysis above widely accepted ethical frameworks will publish without consent, using their own judgement about the nature and extent of disguise. Those who routinely seek consent are not likely to be persuaded to the more traditional analyst-cantered worldview. Perhaps the group in the middle will continue the trend towards consent.
One gets the sense from this book of a rather inward psychoanalytic community in which today's analyst is tomorrow's patient, in which conference attendees are a mix of current and former patients, analysts and supervisors, in which it is not uncommon for an initial period of analysis to lead to a career as an analyst. The complications of working in such an insular context are such that one would think it wise to strengthen theoretical links to other health professions, rather than find more reasons why psychoanalysis should resist such pluralism. Sadly, in the area of publishing ethics, this does not seem to be the case. Kantrowitz's contribution is to document the current range of views and practices within the profession. She is at pains to show respect for the varying views of her colleagues, while also pointing out where patients' interests are at risk from these views. Her work should challenge the profession, not just its individual members, to take seriously the issue of consent to publish, and to question the limits of professional autonomy.
© 2007 Tony O'Brien
Tony O'Brien, RN, MPhil, Senior Lecturer, Mental Health Nursing,University of Auckland, [email protected]
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