The Ethical Issues of Psychotherapy
心理治療的倫理議題
張宏俊
Hung-Jung Chang, MD, MA
101-03-24
大綱
Outline
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Introduction
The Beneficence Issues in Psychotherapy
The Autonomy Issues in Psychotherapy
The Non-maleficence Issues in Psychotherapy
The Justice Issues in Psychotherapy
Conclusion- How ethics affect psychotherapy?
倫理的理論與運用
The Theory and Practice of Ethics
Theory:
The illustration of “ought and should” in
interpersonal relationship
 Practice:
Working with dilemmas in human
relationship/making space for and reflecting on
different values between people
 In health care:
Ethical problems are commonly viewed as the
tension between two or more morally defensible
alternative actions, including inaction.
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The Affinity between Ethics and Psychotherapy
Ethics
Psychotherapy
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Theory:
the illustration of “ought
and should” in
interpersonal relationship
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Practice:
Working with dilemmas in
human
relationship/making space
for and reflecting on
different values between
people
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Theory:
relating to what happens between
people within the interpersonal
space, both conscious and
unconscious
Practice:
people thinking together about
human dilemmas, within a
boundaried space
Adopted from: Michael S. Gazzaniga, Richhard B. Ivry, George R. Mangun: Cognitive Neuroscience-The
Biology of The Mind, 2009,W.W. Norton, New York:631
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如何處理倫理困境?(1)
How should we make difficult ethical decision?(1)
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We need to find some mechanism for resolving ethical
dilemmas that goes beyond an appeal to our ‘gut
instincts’.
In order to convince others, it is necessary to point to
some coherent reasoning process, or moral principle,
which explains or justifies one’s position.
It is usually not possible for bioethics to look for an
right answer. One possibility might be that reasoned
argument and deliberation is simply the most rational
way to resolve difficult or controversial questions.
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如何處理倫理困境?(2)
How should we make difficult ethical decision?(2)
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基本倫理理論 Basic Moral Theories:
效益論/結果論 Utilitariansim /Consequalialism
judges an action/inaction by its consequences or outcomes.
道義論 Deontology (Duty)
based on the argument that moral duties or obligations determine
whether an action/inaction is moral or immoral. Deontologists
concern the rightness of an action itself and the respect for a
person’s rights.
德行論 Virtue ethics
is concerned with working out what a “virtuous” person would do
in a particular situation. Virtue ethics values intention.
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如何處理倫理困境?(3)
How should we make difficult ethical decision?(3)
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當代的生命倫理學 Contemporary bioethics
原則論 Principlism
The ‘principlist’ approach lay out for key principles:
autonomy, beneficence, non-maleficence, and justice.
決疑論 Casuistry (Case)
In casuistry, in stead of starting with broad, abstract theories and
principles (a top-down approach), we instead begin with our
response to concrete cases and reason by analogy (a bottom-up
approach).
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「我是師姊…」-精神科居家治療個案-1
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A君，男性，26歲，未婚，國立大學會計系畢業
畢業退伍後，民國99年底進入某會計事務所任職，不久後
被派至大陸深圳，A表示他在大陸工作壓力很大(被迫作假
帳、曾被公司其他幹部持槍威脅…) ， 100年初君即因失眠、
情緒不穩、自殺意念等問題被遣送回台並且離職。
回台後，家人即發現A會自言自語、比手劃脚，並出現半夜
跑去墳場的怪異行為。家人幾次帶至精神科門診治療，但A
自認沒病，拒絕服藥。雖家人會將藥物加入食物騙他服用，
終究A的病情日益嚴重…
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「我是師姊…」-精神科居家治療個案-2
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100年7月，A終於在一次與家人衝突時，以穢語辱駡家人
並在4樓陽台聲稱要跳樓自殺， 被送至某精神科專科醫院
急診後住院治療。
住院3週後，症狀有明顯改善，在A要求下，醫師同意其出
院轉門診治療。
門診追踪期間，A沒有明顯的症狀， 在家準備會計師執照
考試。然而A始終不認為自己生病，他表示在考前會配合
吃藥，但考後即決定不再返診並拒絕吃藥。在家人與醫師
討論後決定轉介居家治療。
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「我是師姊…」-精神科居家治療個案-3
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居家治療護理師在收到轉介單後，開始評估並以電話聯
繫安排家訪…
「林護理師….你來家裡的時候…可不可以說你是慈濟
的師姊…不然，A一定會不高興…大概…你也會見不到
他….. 」電話的那頭是A的媽媽不安的聲音，娓娓說出
她的懇求…
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Financial Incentives for Medication Adherence
in Psychiatric Practice (Claassen 2007)
First applied to his patients in England
 10 GBP for 1 depo injection
 Significant effects3/4 patients never readmitted to hospital in 2 years
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Claassen, D. (2007). Financial incentives for antipsychotic depo medication: ethical
issues. Journal of Medical Ethics. 33:189-193.
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Financial Incentives for Medication Adherence
in Psychiatric Practice (Claassen 2007)
NO!
YES!
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High effects and low cost
Less coercive
Rewards already exit
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Incommensurable Value
Exploitation
Fairness
Financial incentives, like instant foods, may be easy,
quick, and efficient, however, it is not good for longterm benefits.
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Let’s begin with a case: “Jury finds
psychiatrist was negligent in pedophile case”
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Dr. Douglas H. Ingram: a prominent Manhattan psychoanalyst,
from the faculty of New York Medical College
Dr. Joseph Demasi: the third year resident, to be trained for child
psychiatrist, and to be trained in the psychiatric subspecialty of
psychoanalysis
In 1987, 4 months after he confessed to being a pedophile in
psychoanalysis with Dr. Ingram, Dr. Demasi molested Denny
Almonte , a-10-year-old boy, in Danbury Hospital.
The victim 10 years later filed a lawsuit against the psychiatrist, Dr.
Ingram, charging that he could and should have taken steps to
insure that the pedophile, Dr. Demasi, was not allowed to interact
with children in a professional setting.
Out-of-court agreement
(www.nytimes.com/1998/10/09/nyregion/jury-finds-psychiatrist-was-negligent-in-pedophil-case)
The Beneficence Issues in Psychotherapy(1)
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The scope of beneficence issues: It does not
benefit patients./Any benefit would have
happened anyway./It is not a medical
benefit./It is harmful to patients./ It does
benefit patients, but it is not cost effective.
Some argue that only cost-effective therapies
should be provided./ How patient’s
preference should be respected.
The Beneficence Issues in Psychotherapy(2)
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Resources allocation/ Justice issue
Endless therapy may contravene the principle
of justice, but it is equally ‘unfair’ to offer
chronically ill patients brief ‘package’ when
evidence suggests that only long-term therapy
is likely to help.
The Autonomy Issues in Psychotherapy(1)
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Informed consent
Information should include: the therapist’s
qualifications/ what is involved in
treatment/ how long it is likely to take/
what alternative treatments might be
considered/ what adverse effect might arise
The Autonomy Issues in Psychotherapy(2)
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Most treatments in medicine aim to relieve pain or
discomfort. However, psychotherapy works
differently. In psychotherapy it is often considered
that the patients’ difficulties arise precisely because
he has adopted strategies not to feel pain and the
aim is to encourage to experience rather than avoid,
deny, split off, project or press unpleasant
emotions.
The complexity of autonomy in mental health/
What ‘autonomous’ choice means?
Psychotherapy may linked to an orthopedic
intervention.
The Non-maleficence Issues in Psychotherapy (1)
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Exploitation/ Infringement of professional
boundaries (Boundary violation)
Significant aspect of psychotherapeutic
exploitation: patient’s vulnerability/ the
inherent intimacy and dependency of
therapeutic relationship/ unconscious wish in
the patient (to be used) and the therapist (to
exploit patients in the guise of ‘helping’ them)
The Non-maleficence Issues in Psychotherapy (2)
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Common types of boundary violation :
Sexual boundary violation
Self-disclosure
Financial exploitation (brief treatments might be
a false economy/raising fees/ Robin Hood
arrangement)
Political exploitation arises when therapist put
their own political agendas (values) before the
patient’s needs. -false memory, homosexual issue
The Justice Issues in Psychotherapy
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Resource allocation
Exploitation
Therapeutic neutrality
Limit of confidentiality/ Duty to protect
Confidentiality (1)
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Whatever I shall see or hear in the course of my
profession…if it be what should not be published
abroad, I will never divulge, holding such things to
be holy secrets. (Hippocratic Oath)
Three people can keep a secret if two of them are
dead. (Benjamin Franklin)
Reciprocity is the usual safeguard against
exploitation for breaching confidentiality, however,
the patient-therapist relationship is asymmetrical.
Confidentiality (2)
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The limit of confidentiality continue to be
debated.-absolute or relative
Interpersonal communications strategy that cease
to function unless strictly adhere to absolute
confidentiality. (Kottow, 1986)
Some even argued that mental heath professionals
have a role in controlling deviant behavior.
( Lindenthal and Thomas, 1992)
Confidentiality (3)
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Privilege (private+law) is a legal concept that
refers to the right of a person to control which
information, communicated in confidence, can
be revealed in judicial or administrative
proceeding.
Privileged communication: attorney-client,
spouse, priest-penitent, psychotherapistpatient…..(Federal Rules of Evidence, 1975)
Confidentiality (4)
Some circumstances are not unethical to
breach confidentiality:
 Scientific need
 Public interest (Previous therapist had sexual
relationship with your client)
 Tarasoff case
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Tarasoff v. Regent of the University of California(1)
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Prosenjit Poddar, from India, came to UC Berkeley as a
graduate student in 1967. He met Tatiana Tarasoff at folk
dancing classes……
On Oct. 27, 1969, Podder carried out the plan he had
confided to his psychotherapist, Dr. Lawrence Moore,
stabbing and killing Tarasoff.
“The public policy favoring protection of the confidential
character of patient-psychotherapist communication must
yield to the extent to which disclosure is essential to avert
danger to others. The protective privilege ends where the
public peril begins.” (Justice Mathew O. Tobriner)
(Tarasoff v. Regent of the University of California (1976) 17 Cal. 3d 425,442)
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Tarasoff v. Regent of the University of California(2)
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Dissents:
Prediction of violence is inherently unreliable. (Justice
Mosk)
 Notifying police is in a better position… (Justice Mosk)
 “The very practice of psychiatry depends upon the
reputation in the community that the psychiatrist will not
tell.” (Justice Clark)
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(Tarasoff v. Regent of the University of California (1976) 17 Cal. 3d 425,442)
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Tarasoff v. Regent of the University of California(3)
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Duty to warm(1974) >Duty to protect(1976)
The professional may discharge the duty in several ways,
including notifying police, warning the intended victim,
and/or taking other reasonable steps to protect the
threatened individual, such as committing the patient to
hospital.
(Tarasoff v. Regent of(the University of California (1976) 17 Cal. 3d 425,442)
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Tarasoff case的解讀(1)
(The Interpretation of Tarasoff Case)
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溝通特權止於公共危害之起
“Protective privilege ends where public peril
begins.”
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Confidentiality is a privilege, not a (absolute)
right and when in doubt should be overridden
by considerations of safety.
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Tarasoff case的解讀(2)
(The Interpretation of Tarasoff Case)
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Only imminent risk(即將發生)of serious
harm(嚴重傷害) would justify disclosure.
Only if the treat is serious
Ｉ and disclosure the
only means of averting harm(揭露是防止傷害
發生的唯一徒徑).
“Disclosure can therefore only be justified where
an identifiable person(可指認的他人) is at
serious risk.” (The General Medical
Council,GMC, UK)
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Tarasoff case的解讀(3)
(The Interpretation of Tarasoff Case)
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The key issue here is transparency and being
honest with the patient about plans to
disclosure, why and to whom.
Against: Is there anyＩ“friend’s duty”?
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Consequent development after Tarasoff Case:
Jaffee v. Redmond, 1996 (1)
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Mary Lu Redmond was a police officer. On June 27,
1991, she received a fight-in-progress call.
At the point in the chase, it appeared to Redmond that
Ricky Allen was about to stab the man he was chasing,
and so she shot Allen. Allen died at the scene.
Allen’s estate, Jaffee, filed suit, claiming that Redmond
had used excessive force during the altercation.
Redmond had sought counseling from licensed social
worker.
Consequent development after Tarasoff Case:
Jaffee v. Redmond, 1996 (2)
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For:
“Effective psychotherapy…depends upon an
atmosphere of confidence and trust…..”
If there exited no privilege for communications
between psychotherapists and their patients, people
would decide not to seek treatment for mental illness,
Fair treatment to all 9 specific privileges in the Federal
Rules of Evidence in 1975
Consequent development after Tarasoff Case:
Jaffee v. Redmond, 1996 (3)
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Against:
The relative social importance of psychotherapy was
not established.
How to distinguish psychotherapists from others in
society in whom people place valuable confidences,
such as mother-child, friends, bartender..
The professionalism of the therapist
Consequent development after Tarasoff Case:
Jaffee v. Redmond, 1996 (4)
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In 1996, psychotherapeutic privilege was reviewed by the
US Supreme Court which ruled that such
communications need not be disclosed in Federal trial.
March examined the role of psychotherapist-patient
privilege after this case, and found that the existence of
privilege was associated with greater willingness to
disclose information.
Is confidentiality a ‘decrepit concept’?
March JE. Empirical support for the United States Supreme Court’s protection of the psychotherapistpatient privilege. Ethics and Behavior 2003;13:385-400.
Consequent development after Tarasoff Case:
People of the State of New York v. Robert Bierenbaum(1)
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Dr. Robert Bierenbaum, a plastic surgeon, was charged to
murder his wife, Gail.
The confidentiality privilege involved 3 psychiatrists, Dr.
Michael Stone, Dr. Stanley Bone, and Dr. Carl Kleban.
During his session with the 3 therapists, Dr. Bierenbaum
discussed his serious marital problems in 1983.
Dr. Stone exercised his ”Tarasoff duty”, an action which
Bierenbaum assented.
Two year later, in 1985, Bierenbaum’s wife disappeared,
and her body never been found.
Consequent development after Tarasoff Case:
People of the State of New York v. Robert Bierenbaum(2)
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Two arguments of the prosecutors:
The prosecutor claimed that the issuance of the warning to
Bierenbaum’s wife with the patient’s consent abrogated the
protection afforded to all communications with the 3 psychiatrists.
The prosecutors also claimed that Bierenbaum had told third
parties that he was in the therapy because of marital troubles.
Neither a psychiatrist issuing a Tarasoff warning nor a
patient telling his friends he’s in treatment constitutes a
waiver of a patient’s psychiatrist-patient privilege, Judge
Snyder ruled.
She likened the strength of this privilege to the
sacrosanct one between a lawyer and client.
保密的判斷處境/預警與舉發(通報)
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妨害秘密罪:
刑法第二十八章第316條妨害祕密罪，載明專業人員須保守業務機密 ：
「醫師、藥師、藥商、助產士、心理師、宗教師、律師、辯護人、公
證人、會計師或其業務上佐理人，或曾任此等職務之人，無故洩漏因
業務知悉或持有之他人秘密者，處一年以下有期徒刑、拘役或五萬元
以下罰金。」
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溝通特權:
刑事訴訟法第182條，載明專業人員出庭時非當事人允許得拒絕證言：
「證人為醫師、藥師、助產士、宗教師、律師、辯護人、公證人、會
計師或其業務上佐理人或曾任此等職務之人，就其因業務所知悉有關
他人秘密之事項受訊問者，除經本人允許者外，得拒絕證言。」
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The Other Dangerous Circumstances
May Break Confidentiality
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Suicide
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Child abuse
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Not currently (still a child)
A adult patient was abused as a child
The patient abused a child who now is not a minor
The pedophile…
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HIV and AIDS
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Others: no identifiable victims (the alcoholic bus driver?)
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How ethics affect psychotherapy?
-tripartite model
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Ego: (negotiating the conscious interface between therapy and the
real world)
Informed consent/therapeutic contract
Understanding the nature of and need for boundaries (exploitation
avoiding)- confidentiality, sexual transgression
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Id: The ethically responsible practitioner should be aware how
values underpin therapy, operate as unexamined basic
assumptions, and unconsciously influence practice.
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Superego: Psychotherapy organizations have been compelled to
draw up ‘superego-type guidelines and to consider how ethical
practice may be encouraged and transgressions punished.
謝謝聆聽!! 問題與指教?!
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