Potential roles of the medical ethicist in the clinical setting

The medical ethicist is a fairly recent addition to the clinical setting. The following four potential roles of the clinical ethicist are identified and discussed: consultant in difficult cases, educator of health care providers, counselor for health care providers and finally patient advocate to protect the interests of patients. While the various roles may sometimes overlap, the roles of educator and counselor are viewed as being more congruent with the education and training of medical ethicists than are the roles of consultant and patient advocate.     

Teaching ethics on rounds: The ethicist as teacher,consultant, and decision-maker

This paper explores the relationship between teaching and consulting in clinical ethics teaching and the role of the ethics teacher in clinical decision-making. Three roles of the clinical ethics teacher are discussed and illustrated with examples from the authors' experience. Two models of the ethics consultant are contrasted, with an argument presented for the ethics consultant as decision facilitator. A concluding section points to some of the challenges of clinical ethics teaching.     

Reflections of a reluctant clinical ethicist: Ethics consultation and the collapse of critical distance

The obvious appeal and growing momentum of clinical ethics in academic medical centers should not blind us to a potential danger: the collapse of critical distance. The very integration into the clinical milieu and the processes of clinical decision making, that clinical ethics claims as its greatest success, carries the seeds of a dilution of ethics' critical stance toward medicine and medical education. The purpose of this paper is to suggest how this might occur, and what potential contributions of ethics to medicine might be sacrificed as a result. Medical sociology will be used for comparison. Sociologists have found that they may function either as students and critics of established medical practices and educational philosophies, or as collaborative participants in them — but rarely both. It may be that professional ethics is most effective when it plays the role of stranger rather than insider, and is continually able to question the most basic assumptions and values of the enterprise with which it is associated. As with medical sociology, ethics and humanities must ask to what extent their desire for acceptance in the clinic requires their acceptance of the clinic: specifically, acceptance of basic assumptions about optimal ways of organizing medical education, socializing physicians-in-training, providing care, and even of defining medical ethics itself. The paper concludes by recommending that ethics reassert its strangeness in the medical milieu even as it assumes a more prominent role within the medical center.     

Psychoanalysis,class & politics: Encounters in the clinical setting

Abstract

There is little research and literature available in the United Kingdom which addresses the issues for black and ethnic minority families who have dealings with the family court system. Therefore, this article is based largely on the personal views and experiences of the author. In it I shall be commenting on the functioning of the court in terms of private law concerning children.     

Discussion: Reflections from the clinical trenches

This paper involves a series of personal reflections on the deleterious impact of excessive bureaucracy and other institutional forces on the psychosocial treatment of the chronically mentally ill. The writer appeals to three groups of mental-health practitioners—behavior analysts, practicing clinicians, and academic clinicians—to promote cultural change by advocating a restructuring of large-scale bureaucracies with the concurrent establishment of multiple community-based associations.     

Anti-Semitism in the clinical setting: transference and countertransference dimensions.

Despite the salient presence of Jews in the history of psychoanalysis, literature on the subject of anti-Semitism in the clinical setting is surprisingly sparse. This paper attempts to comprehend the reasons for the dearth of literature on this important topic. A clinical section then breaks the silence surrounding expressions of anti-Semitism in the consulting room. The major focus is on transference and countertransference reactions that arise with regard to anti-Semitism in the clinical setting. Since the first section is concerned with silence in the psychoanalytic community, its focus is primarily on countertransference issues that may hinder the analyst's understanding and use of anti-Semitic material. The second, clinical section focuses on the ways both transference and countertransference reactions combine and influence one another and how they may, when properly attended to, serve as catalytic tools for advancing therapeutic goals.     

A methodology for teaching ethics in the clinical setting: A clinical handbook for medical ethics

The pluralism of methodologies and severe time constraints pose important challenges to pedagogy in clinical ethics. We designed a step-by-step student handbook to operate within such constraints and to respect the methodological pluralism of bioethics and clinical ethics. The handbook comprises six steps: Step 1: What are the facts of the case?; Step 2: What are your obligations to your patient?; Step 3: What are your obligations to third parties to your relationship with the patient?; Step 4: Do your obligations converge or conflict?; Step 5: What is the strongest objection that could be made to the identification of convergence in step 4 or the arguments in step 4? How can this objection be effectively countered?; and Step 6: How could the ethical conflict, or perceived ethical conflict, have been prevented?     

An analysis of ethics consultation in the clinical setting

Only recently have ethicists been invited into the clinical setting to offer recommendations about patient care decisions. This paper discusses this new role for ethicists from the perspective of content and process issues. Among content issues are the usual ethical dilemmas such as the aggressiveness of treatment, questions about consent, and alternative treatment options. Among process issues are those that relate to communication with the patient. The formal ethics consult is discussed, the steps taken in such a consult, and whether there should be a fee charged. We conclude with an examination of the risks and benefits of formal ethics consults.     

Reflections on a do-it-yourself training program in clinical psychology

This paper is a somewhat modified version of the inaugural Rapaport—Klein Memorial Lecture at Austen Riggs Center presented June 21, 1974. The author describes the experiences, the series of “apprenticeships” and clinical exposures, which coalesced into his education, from teenage days in the New York Madison House settlement, through Harvard undergraduate and graduate work, to Worcester State Hospital as head of psychological services and research. In conclusion, the author discusses the effects of the kinds of training experiences he has described on the issues that arose in the formulation of formal standards of training in clinical psychology.     

Searching for the facts in the clinical setting with couples

This paper describes a research proposal to examine whether or not the underlying analytic concepts behind the couple psychoanalytic psychotherapy model used at the Tavistock Marital Studies Institute in London are sufficiently coherent, both conceptually and clinically, to be used as the basis for a system of audit which respects the unique data produced in analytic psychotherapy. This 'psychoanalytic' system of audit is one which is characterized particularly by the use of the therapists' subjectivity, rather than attempts to be objective and gather data through such things as random controlled trials or generic outcome questionnaires. The paper describes the approach to the subject and the mix of qualitative and quantitative methods used. As the Tavistock Marital Studies Institute has a history of contact with Jungian analysts from the Society of Analytical Psychology, Jungian concepts are included in the model. The research is part of a professional doctorate in couple psychoanalytic psychotherapy at the Tavistock Marital Studies Institute in conjunction with the University of East London, entitled 'Conceptualizing audit in Couple Psychoanalytic Psychotherapy'.     

Depression in children: Parent,teacher, and child perspectives

Depressed and nondepressed children were found to differ in the types of behavior problems manifested at home and at school. Children rated as depressed by their parents on the Personality Inventory for Children evidenced significantly more conduct problems, anxiety, impulsive hyperactivity, learning problems, psychosomatic problems, perfectionism, and muscular tension at home than children rated as nondepressed. Depressed children were rated by their teachers as displaying more inattentionpassivity than nondepressed children. A significant but modest relationship was found between parent report and child selfreport of the child's depression. Depressed children attributed positive events to external causes and negative events to internal causes significantly more than did nondepressed children. The specificity of these results to depression was also examined;the particular features of childhood depression are compared to the features of adult depression. The investigators would like to thank Jim McFerren and Ralph Zalazar for their work as research assistants and David Watson for his help with the statistical analyses. The helpful comments of Eric Klinger and Auke Tellegen are gratefully acknowledged. The cooperation of Dr. Loren Benson, director of personnel services of the Hopkins School District #274; Mr. Edward Ryshavy, principal of Glen Lake Elementary School; and the teachers of that school is greatly appreciated.     

The social concomitants of competitive and impatient/aggressive components of the Type A behavior pattern in preschool children: peer responses and teacher utterances in a naturalistic setting

The Matthews Youth Test for Health (MYTH) was used to classify 120 children from 9 preschool classrooms as high or low on behaviors associated with the Type A pattern. Peer responses to the children were gathered sociometrically and utterances of classroom teachers were tape recorded in a naturalistic setting. Boys gave higher sociometric ratings to high competitive girls and girls gave higher ratings to low-competitive boys. Teacher verbal utterances addressed to high-competitive children were characterized by less challenging cognitive processes and lower affective quality. Teacher verbal utterances addressed to children high on impatience/aggression were characterized by lower affective quality, fewer opportunities for child autonomy, more social/behavioral instructions, and more physical expressions of affection.     

Priority setting in family change and clinical practice: the Family FIRO Model.

We update a theoretical framework for understanding priority setting for the management of family change, with special emphasis on developmental change. We propose that three core dimensions of family interaction--inclusion, control, and intimacy--constitute an optimal priority sequence for managing major family change stemming from life-cycle transitions and other stressful experiences. In the next section of the article, we compare the Family FIRO Model and other models of family change. Finally, we suggest that therapists can benefit from an explicit, clinical decision-making model for setting priorities in treatment: issues of inclusion take precedence over issues of control, which in turn take precedence over issues of intimacy.