The Ethical issue of Competence in Working With the Suicidal Patient

In this article, I discuss the ethical need for competence in the assessment and management of the suicidal patient, and further suggest that this specific competence be considered a routine element in professional psychological practice. I also argue that this particular competence necessitates adequate training in working with this high-risk population, as well as the need for every clinician to personally evaluate her or his own technical and personal competencies to work with suicidal patients before beginning independent practice activities in clinical situations wherein he or she may be called on to evaluate or treat a suicidal patient. This article concludes with a discussion of specific ethical dilemmas (e.g., the issue of confidentiality), and a list of suggestions for specific competencies in working with the suicidal patient is provided.     

The ethical issue of competence in working with the suicidal patient

In this article, I discuss the ethical need for competence in the assessment and management of the suicidal patient, and further suggest that this specific competence be considered a routine element in professional psychological practice. I also argue that this particular competence necessitates adequate training in working with this high-risk population, as well as the need for every clinician to personally evaluate her or his own technical and personal competencies to work with suicidal patients before beginning independent practice activities in clinical situations wherein he or she may be called on to evaluate or treat a suicidal patient. This article concludes with a discussion of specific ethical dilemmas (e.g., the issue of confidentiality), and a list of suggestions for specific competencies in working with the suicidal patient is provided.     

Confidentiality: a survey in a research hospital

Despite the many justifications for protecting patient confidentiality, we recognize that confidentiality cannot be absolute. Our world of automated information and easy access and storage poses many threats to confidentiality. This paper has described a survey conducted at the NIH Clinical Center to assess the knowledge, attitudes, and behaviors of clinical physicians and nurses about confidentiality of patient information. The survey findings demonstrate the need for reminders and increased awareness about confidentiality in our setting. Most of the survey respondents had a good knowledge of what was expected of them, and they believed that confidentiality was important and maintaining it was their responsibility. Of interest was that in several simulated clinical situations, there was a discrepancy between what respondents indicated they should do and what they thought they would do. The biggest discrepancies appeared in situations that involved overhearing a patient conversation on the elevator, approaching an unfamiliar person who is reading a medical record in the nurses' station, and answering a patient's inquiry about the status of another patient. The findings support the speculation that this difference may be attributed to discomfort or decreased awareness, and not necessarily to lack of knowledge. Results indicate that policies and administrative expectations should be frequently communicated and enforced, and that educational programs that address issues of confidentiality should be provided. The results of this survey have been influential in guiding educational strategies and administrative activities at the clinical center. The clinical center initiated a confidentiality awareness campaign, displaying a new poster every three months in strategic locations and distributing other tangible reminders (such as pens, magnets, and buttons) containing the same confidentiality message.(ABSTRACT TRUNCATED AT 250 WORDS)     

The Romantic Absolute

In this article I argue that the Early German Romantics understand the absolute, or being, to be an infinite whole encompassing all the things of the world and all their causal relations. The Romantics argue that we strive endlessly to know this whole but only acquire an expanding, increasingly systematic body of knowledge about finite things, a system of knowledge which can never be completed. We strive to know the whole, the Romantics claim, because we have an original feeling of it that motivates our striving. I then examine two different Romantic accounts of this feeling. The first, given by Novalis, is that feeling gives us a kind of access to the absolute which logically precedes any conceptualisation. I argue that this account is problematic and that a second account, offered by Friedrich Schlegel, is preferable. On this account, we feel the absolute in that we intuit it aesthetically in certain natural phenomena. This form of intuition is partly cognitive and partly non-cognitive, and therefore it motivates us to strive to convert our intuition into full knowledge.     

The travails of Martin Orne: On privacy,public disclosure,and confidentiality in psychotherapy

The experiences of one psychotherapist have brought to the fore the entire issue of privacy and confidentiality and the responsibilities of mental health professionals. In a computer driven culture, where data about patients become subject to public scrutiny, how does the mental health professional practice, guided by the concept of confidentiality? Where does confidentiality begin and end? What about the patient's right to self-disclose? What about patient autonomy? In this paper, illustrated by one particular case where the rule of absolute confidentiality, an intrinsic part of the practice of psychotherapy, was questioned, our current confusion comes to the surface. The reader is urged to re-think the concept of confidentiality and patient self-disclosure.     

Ross and the particularism/generalism divide

W. D. Ross is commonly considered to be a generalist about prima facie duty but a particularist about absolute duty. That is, many philosophers hold that Ross accepts that there are true moral principles involving prima facie duty but denies that there are any true moral principles involving absolute duty. I agree with the former claim: Ross surely accepts prima facie moral principles. However, in this paper, I challenge the latter claim. Ross, I argue, is no more a particularist about absolute duty than a utilitarian or a Kantian is. While this conclusion is interesting in its own right, it is also important, I argue, because it prevents us from overlooking Ross's criterion of moral obligation and because it may have implications on the broader debate between particularists and generalists.     

‘QUIS CUSTODIET?’: WHO HAS ULTIMATE RESPONSIBILITY FOR CONFIDENTIALITY IN MENTAL HEALTH SERVICES?

Confidentiality is a complex and engaging subject. One of the questions I would ask the reader to consider is whether ‘absolute’ confidentiality can truly exist within the analytic relationship and whether it is worth asking the same question in relation to psychotherapy as it is practised within the NHS. Is the position of absolute confidence a noble aspiration or could it be regarded as a rather inflexible stance whose advocates occupy an arrogant and even omnipotent position? This last question deliberately invokes a false dichotomy and I would argue that the clinical reality of working with patients continually dispels the myth that ‘absolute’ confidentiality can exist within the analytic relationship. If we can accept this position, then the stage is set for a potentially more fruitful, if complex, debate about where the line of disclosure lies for individual cases. It would seem timely, in view of the recent publication of the Royal College of Psychiatrists' report Good Psychiatric Practice: Confidentiality & Information Sharing (2006 Royal College of Psychiatrists. 2006. Good Psychiatric Practice: Confidentiality & Information Sharing, London: Royal College of Psychiatrists. Council Report CR133 [Google Scholar]), to reflect upon how the ‘contract’ of confidentiality is drawn up in the apparently dyadic relationship of analytic therapy as practised in the private sector and to consider the particular conflicts and threats to patient confidence posed by the multidisciplinary and highly transparent ways of working that have evolved within modern NHS mental health services.     

Psychologists' perceptions of legal and ethical requirements for breaching confidentiality

This paper outlines the legal and ethical duties of psychologists in relation to preserving as well as breaching confidentiality in therapeutic relationships. It analyses the results of a questionnaire examining psychologists’ perceptions of the legal and ethical constraints on confidentiality and their likelihood of breaching confidentiality in different situations. The vast majority of participants indicated that the law permits them to disclose confidential information and that there is an ethical duty to disclose information to a third party when the patient is perceived to be dangerous. The results suggest that there is some uncertainty as to when confidentiality should be breached in practice and it is argued that the law is overly complex in this area and that guidelines are needed to assist psychologists in their clinical practice.     

The Argument from Underconsideration as Grounds for Anti‐realism: A Defence

The anti‐realist argument from underconsideration focuses on the fact that, when scientists evaluate theories, they only ever consider a subset of the theories that can account for the available data. As a result, when scientists judge one theory to be superior to competitor theories, they are not warranted in drawing the conclusion that the superior theory is likely true with respect to what it says about unobservable entities and processes. I defend the argument from underconsideration from the objections of Peter Lipton. I argue that the inconsistency that Lipton claims to find in the argument vanishes once we understand what the anti‐realist means when she claims that scientists are reliable. I also argue that collapsing the distinction between relative and absolute evaluations, as Lipton recommends, has its costs. Finally, I briefly examine Richard Boyd’s influential defence of realism.     

Hegel on Kant's Analytic–Synthetic Distinction

In this paper, I argue, first, that Hegel defended a version of the analytic/synthetic distinction—that, indeed, his version of the distinction deserves to be called Kantian. For both Kant and Hegel, the analytic/synthetic distinction can be explained in terms of the discursive character of cognition: insofar as our cognition is discursive, its most basic form can be articulated in terms of a genus/species tree. The structure of that tree elucidates the distinction between analytic and synthetic judgments. Second, I argue that Hegel has an interesting and so far unexplored argument for the analytic/synthetic distinction: Hegel argues that the systematic relationship between concepts expressed in a genus/species tree can only be expressed through synthetic judgments. Third and finally, I explore some of the implications that the arguments in the first two parts of the essay have for understanding the way in which Hegel differs from Kant. I argue that Hegel accepts Kant's point that discursive cognition cannot be used to cognize the absolute. However, Hegel thinks that we can, nevertheless, cognize the absolute. I explore the character of this non‐discursive cognition and argue that we can understand Hegel's glosses on this form of cognition—as simultaneously analytic and synthetic and as having a circular structure—through contrasting it with his account of discursive cognition. As a consequence, I argue that we must give up on attempts to understand ‘the dialectical method’ and ‘speculative cognition’ on the model of discursive cognition.     

A risk of confidentiality

The concept of confidentiality is examined from its absolute position espoused by some psychoanalysts to the many exceptions to this position allowed by others. The suggestion made in this paper is offered as a psychoanalytic one which urges us to see confidentiality as posing risks in both positions, that is, the absolute and the necessary exceptions. Confidentiality is representative of many, if not all, of the rules and methods that are implicit in the conduct of an analysis and thus may well be taken for granted. The suggestion offered is for a periodic re-examination of the implicit background of psychoanalysis.     

“The Most Difficult of all Phenomenological Problems”

I argue in this essay that Edmund Husserl distinguishes three levels within time-consciousness: an absolute time-constituting flow of consciousness, the immanent acts of consciousness the flow constitutes, and the transcendent objects the acts intend. The immediate occasion for this claim is Neal DeRoo’s discussion of Dan Zahavi’s reservations about the notion of an absolute flow and DeRoo’s own efforts to mediate between Zahavi’s view and the position Robert Sokolowski and I have advanced. I argue that the flow and the tripartite distinction it introduces into consciousness is firmly grounded in Husserl’s texts and is philosophically defensible. The absolute flow is distinct but inseparable from what it constitutes. It is intentional in a nonobjectivating way, and accounts for the awareness I have of my individual acts of consciousness and of the unity and continuity of my conscious life. In its absence, consciousness would become an incoherent stream of episodic acts. There is nothing mysterious about the flow. What would be mysterious is consciousness without the flow.     

A Puzzle about Consent in Research and in Practice

In this paper, I will examine a puzzling discrepancy between the way clinicians are allowed to treat their patients and the way researchers are allowed to treat their subjects: in certain cases, researchers are legally required to disclose quite a bit more information when obtaining consent from prospective subjects than clinicians are when obtaining consent from prospective patients. I will argue that the proper resolution of this puzzling discrepancy must appeal to a pragmatic criterion of disclosure for informed consent: that what needs to be disclosed in order for consent to be valid depends on what the patient/subject needs to know in order to make a decision. I will then use this pragmatic criterion of disclosure to argue that when obtaining consent researchers should be permitted to omit the same information clinicians are, given certain qualifications. I will also examine how this puzzle forces us to confront some perhaps surprising truths about valid consent. My broader aim in this paper is to examine, not so much the puzzle itself, but rather what this particular puzzle can teach us about more theoretical issues surrounding informed consent.     

Reconsidering Absolute Omnipotence

Philosophical debate about the problem of evil derives, in part, from differing definitions of almighty power or omnipotence. Modern atheists such as John McTaggart, J. L. Mackie, Earl Condee, and Danny Goldstick maintain that an omnipotent God must be able to accomplish anything, even if it entails a contradiction. On this account, the Christian God cannot be omnipotent and benevolent, for a benevolent, omnipotent God would have forced free agents to desist from evil and this prevented the introduction of suffering into the world. It does not matter if the idea of creating free agents that were forced to be good entails a contradiction. On this account, a God who is truly omnipotent can perform contradictory feats.
In this paper, I argue that the atheistic tradition is mistaken. In the first place, even an absolutely omnipotent God could, as an act of benevolence, create a world in which there is suffering. In the second place, I argue that the concept of absolute omnipotence is fatally flawed. An absolutely omnipotent God would lack, in a decisive sense, power. He would be weak rather than strong. So the atheist's argument fails when it is evaluated in light of a more rational account of omnipotence and when it is carefully considered on its own terms.     

Projectibility and Explainability or How to Draw a New Picture of Inductive Practices

Summary  Goodman published his “riddle” in the middle of the 20th century and many philosophers have attempted to solve it. These attempts almost all shared an assumption that, I shall argue, might be wrong, namely, the assumption that when we project from cases we have examined to cases we have not, what we project are predicates (and that this projectibility is an absolute property of some predicates). I shall argue that this assumption, shared by almost all attempts at a solution, looks wrong, because, in the first place, what we project are generalizations and not predicates, and a generalization is projectible (or unprojectible) relative to a given context. In this paper I develop the idea of explainable–projectible generalizations versus unexplainable–unprojectible generalizations, relative to a specific context. My main claim is that we rationally project a generalization if and only if we rationally believe that there is something that explains the general phenomenon that the generalized statement in question asserts to obtain, and that a generalization is projectible, if and only if its putative truth can be explained, whether we know that it can be or not.     

Child Abuse: parental rights and the interests of the child

ABSTRACT I criticise the 'liberal'view of the proper relationship between the family and State, namely that, although the interests of the child should be paramount, parents are entitled to rights of both privacy and autonomy which should be abrogated only when the child suffers a specifiable harm. I argue that the right to bear children is not absolute, and that it only grounds a right to rear upon an objectionable proprietarian picture of the child as owned by its producer. If natural parents have any rights to rear they derive from duties to bring their children into rational maturity where they can exercise rights for themselves. The presumption that natural parents are best suited to rear their own children should be discounted, as should the assumption that alternatives to natural parenting are unacceptably bad. I reject the suggestion that parents should be 'licensed'but argue for a much closer monitoring of the family. Familial privacy, which such monitoring breaches, is shown to have a culturally specific and, given the facts of abuse, dubious value. In conclusion, I briefly specify the forms of monitoring I approve.     

Neonatal Euthanasia Is Unsupportable: The Groningen Protocol Should Be Abandoned

The growing support for voluntary active euthanasia (VAE) is evident in the recently approved Dutch Law on Termination of Life on Request. Indeed, the debate over legalized VAE has increased in European countries, the United States, and many other nations over the last several years. The proponents of VAE argue that when a patient judges that the burdens of living outweigh the benefits, euthanasia can be justified. If some adults suffer to such an extent that VAE is justified, then one may conclude that some children suffer to this extent as well. In an attempt to alleviate the suffering of extremely ill neonates, the University Medical Center Groningen developed a protocol for neonatal euthanasia. In this article, I first present the ethical justifications for VAE and discuss how these arguments relate to euthanizing ill neonates. I then argue that, even if one accepts the justification for VAE in adults, neonatal euthanasia cannot be supported, primarily because physicians and parents can never accurately assess the suffering of children. I argue that without the testament of the patient herself as to the nature and magnitude of her suffering, physicians can never accurately weigh the benefits and burdens of a child’s life, and therefore any such system would condemn to death some children whose suffering is not unbearable. I conclude that because the primary duty of physicians is to never harm their patients, neonatal euthanasia cannot be supported.     

The Role of Regret in Medical Decision-making

In this paper, I explore the role that regret does and should play in medical decision-making. Specifically, I consider whether the possibility of a patient experiencing post-treatment regret is a good reason for a clinician to counsel against that treatment or to withhold it. Currently, the belief that a patient may experience post-treatment regret is sometimes taken as a sufficiently strong reason to withhold it, even when the patient makes an explicit, informed request. Relatedly, medical researchers and practitioners often understand a patient’s post-treatment regret to be a significant problem, one that reveals a mistake or flaw in the decision-making process. Contrary to these views, I argue that the possibility of post-treatment regret is not necessarily a good reason for withholding the treatment. This claim is justified by appealing to respect for patient autonomy. Furthermore, there are occasions when the very reference to post-treatment regret during medical decision-making is inappropriate. This, I suggest, is the case when the decision concerns a “personally transformative treatment”. This is a treatment that alters a person’s identity. Because the treatment is transformative, neither clinicians nor the patient him/herself can ascertain whether post-treatment regret will occur. Consequently, I suggest, what matters in determining whether to offer a personally transformative treatment is whether the patient has sufficiently good reasons for wanting the treatment at the time the decision is made. What does not matter is how the patient may subsequently be changed by undergoing the treatment.     

The commitment in feeling absolutely safe

The experience of feeling safe even in the midst of trials and temptations seems to be a central feature of the Christian faith. In this article I will try to solve some possible difficulties in understanding this kind of absolute safety by discussing some problems noted by philosophers in connection with the related statements by Socrates that a good man cannot be harmed, and by Wittgenstein that he sometimes feels absolutely safe, that nothing can injure him whatever happens. First, I will investigate whether there is an invalid prediction implied in this feeling of absolute safety: how can someone know that nothing will hurt him or her? Second, I will examine whether this experience of complete safety is dependent upon impossible requirements, such as to be a good man or an impeccable Christian. Third, I will consider the character of the people who claim absolute safety as portrayed by different philosophers: do these people really need to be so cold and inhumanly detached from the world for them to be able to say that nothing can hurt them? I will argue that if, instead of asking how someone can claim absolute safety, we ask to what someone commits him- or her-self in making this claim, these difficulties disappear.