When careproviders should give advice, disclose personal information, and reveal their feelings

Journal of Clinical Ethics

Volumn 14, Issue 1-2, 2003, Pages 3-17

  Howe, Edmund G ^a  

^a UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CLINICAL PRACTICE; EDITORIAL; EMPATHY; EMPIRICISM; HUMAN; INTERPERSONAL COMMUNICATION; MEDICAL DECISION MAKING; MEDICAL ETHICS; PARENT; PATIENT CARE; PATIENT INFORMATION; SEXUALITY; SHAME; ARTICLE; COUNSELING; ETHICS; HEALTH CARE PERSONNEL; HUMAN RELATION; PROFESSIONAL PATIENT RELATIONSHIP; PSYCHOLOGICAL ASPECT; SELF DISCLOSURE; TRUST; UNITED STATES;

PROFESSIONAL PATIENT RELATIONSHIP;

COUNSELING; ETHICS, CLINICAL; HEALTH PERSONNEL; HUMANS; PROFESSIONAL-PATIENT RELATIONS; SELF DISCLOSURE; TRUST; TRUTH DISCLOSURE; UNITED STATES;

EID: 0642342960     PISSN: 10467890     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Editorial

References (57)

1. "To genuinely support autonomy in medicine requires a paradigm shift because patients, as sufferers, need assistance in regenerating the capacity to set future goals." J. Halpern, From Detached Concern to Empathy (New York: Oxford University Press, 2001), 106.
2. See, also, J. Halpern, "Reluctant Patients: Autonomy and Delegating Medical Decisions," JCE 13, no. 1 (Spring 2002): 78-84.
3. See, especially note 1 above, p. 93.
4. Ibid., 6 and 7.
5. A.N. Sabo, "Working with the Borderline Patient," in The Real World Guide to Psychotherapy Practice, ed. A.N. Sabo and L. Havens (Cambridge, Mass.: Harvard University Press, 2000), 171.
6. H. Kawasaki et al., "Single-neuron Responses to Emotional Visual Stimuli Recorded in Human Ventral Prefrontal Cortex, Nature Neuroscience 4, no. 1 (January 2001): 15-16.
7. J.S. Morris, A. Ohman, and R.J. Dolan, "A Subcortical Pathway to the Right Amygdala Mediating 'Unseen' Fear," Proceedings of the National Academy of Sciences, USA 96 (February 1999): 1680-5.
8. S.W. Porges, "The Polyvagal Theory: Phylogenetic Substrates of a Social Nervous System," International Journal of Psychophysiology 42, no. 2 (Oct 2001): 123-46.
9. J.D. Greene et al., "An fMRI Investigation of Emotional Engagement in Moral Judgment," Science 293 (September 14 2001): 2105-8.
10. R.D. Truog states of JCE in this issue that "'non-directiveness' has been championed as the ethically correct approach to counseling individuals" [emphasis added].
11. R.D. Truog states, "... I have often seen pediatricians ... inappropriately influence decisions about patients under their care." Ibid. In regard to "manipulation," see M.T. White, "Making Responsible Decisions: An Interpretive Ethic for Genetic Decisionmaking," Hastings Center Report 29, no. 1 (1999): 14-21, 21.
12. White, ibid., 15. See also R.M. Veatch, "Abandoning Informed Consent," Hastings Center Report 25, no. 2 (March-April 1995): 5-12.
13. White, ibid., 15. See also R.M. Veatch, "Abandoning Informed Consent," Hastings Center Report 25, no. 2 (March-April 1995): 5-12.
14. "A nondirective approach denies clients the full benefit of counselors' knowledge and expertise." M.T. White, see note 12 above, p. 17.
15. See, for example, D. Londino, L. Wiggins, and P. Buckley, "Part 2: For Nonpsychotic Uses, Evidence Varies with the Diagnosis," Current Psychiatry 1, no. 10 (October 2002): 5454-64.
16. Halpern states, for example, that such patients can feel emotionally abandoned. Speaking of one, she states, "Her physicians failed to recognize ... [that] ... by their detachment, [they] exposed her to ongoing shame, a most intolerable emotion." J. Halpern, see note 1 above, p. 117.
17. L.F. Ross notes in her piece in this issue, however, that she offers "loopholes" to reduce any hesitation patients have about contradicting her recommendations.
18. F. Broucek and W. Ricci, "Self-Disclosure or Self-Presence?" Bulletin of the Menninger Clinic 62, no. 4 (Fall 1998): 427-38, 433.
19. See, for example, W.R. Miller and J. C'de Baca, Quantum Change (New York: Guilford Press, 2001).
20. Havens states, speaking of psychotic patients, for instance, that for these patients, personal instructions are "a form of domination and intrusion." L. Havens, "Treating Psychoses," in The Real World Guide to Psychotherapy Practice, ed. A.N. Sabo and L. Havens (Cambridge, Mass.:, Harvard University Press, 2000), 159. Others less severely impaired may, also respond in this way.
21. Careproviders may believe that they can tell those who patients really want advice from those who don't. This is, however, untrue. Patients who are upset by what careproviders tell them may show no evidence that this has occurred. L. Wheeler, Interpersonal Influence (Boston: Allyn and Bacon, 1970), 52.
22. am indebted to Marsha Linehan, MD, for this approach. She developed Dialectic Behavior Therapy. A.N. Sabo, see note 6.
23. "Hope comes into being when one discovers that... feelings of despair can be shared with a fellow human being ... rather than stigmatizing one as something less than human." H.F. Searles, Countertransference and Related Subjects (New York: International Universities Press, 1979), 484.
24. Careproviders might be concerned with this not being wholly honest. Jordan states, "Most people think of authenticity as being about total honesty, [but this] does not take into account the possible impact on others." J.V. Jordan, "A Relational-Cultural Model: Healing Through Mutual Empathy," Bulletin of the Menninger Clinic 65, no. 1 (Winter 2001): 92-103, 98.
25. The careprovider then must responds in a way that maximizes the patient's capacity to use the advice. To do this, the careprovider should not too readily accept a patient's view that a decision must be only one option or the other. The careprovider should attempt to find an overarching concern that can reconcile these conflicting values if this is possible. Mutually exclusive solutions are often not as exclusive as they seem. M.M. Linehan, Cognitive-Behavioral Treatment of Borderline Personality (New York: Guilford Press, 1993), 34. See, generally, 31-5 and note 23.
26. T.G. Guthiel and G.O. Gabbard, "Misuses and Misunderstanding of Boundary Theory in Clinical and Regulatory Settings," American Journal of Psychiatry 155, no. 3 (March 1998): 409-14.
27. What information careproviders should disclose, for legal reasons, is a largely unanswered question. One attorney asks, "What of a dentist who has had a recent argument with this wife. Should he have a duty to disclose this prior to doing an endodontic procedure?" P.M. Sfikas, "The Private Lives of Professionals," Journal of the American Dental Association 130 (November 1999): 1649-51, 1651.
28. G.O. Gabbard "Gibraltar Shattered," American Journal of Psychiatry 159, no. 9 (September 2002): 1480-1, 1480 and 1481.
29. O. Renik, "The Ideal of the Anonymous Analyst and the Problem of Self-Disclosure," Psychoanalytic Quarterly 65 (1995): 466-95, 493.
30. Jordan, see note 25 above, p. 96, citing Chin et al., Diversity in Psychotherapy: The Politics of Race, Ethnicity and Gender (Westport, Conn.: Praeger, 1993).
31. Ibid., 100-1.
32. F. Broucek and W. Ricci, see note 17 above, p. 436.
33. Ibid., 435.
34. Gabbard gives as a possible example a patient's blushing. G.O. Gabbard, Psychodynamic Psychiatry in Clinical Practice, 3rd ed. (Washington, D.C.: American Psychiatric Press, Inc., 2000), 564. Outside the therapeutic relationship, however, calling this to patients' attention could cause them shame.
35. Ibid. See, also, S.L. Dilts, C.A. Clark, and R.J. Harmon, "Self-disclosure and the Treatment of Substance Abuse," Journal of Substance Abuse Treatment 14, no. 1 (1997): 67-70, and A.J. Mallow, "Self-disclosure/Reconciling Psychoanalytic Psychotherapy and Alcoholics Anonymous Philosophy," Journal of Substance Abuse Treatment 15, no. 6 (1998): 493-8.
36. Ibid. See, also, S.L. Dilts, C.A. Clark, and R.J. Harmon, "Self-disclosure and the Treatment of Substance Abuse," Journal of Substance Abuse Treatment 14, no. 1 (1997): 67-70, and A.J. Mallow, "Self-disclosure/Reconciling Psychoanalytic Psychotherapy and Alcoholics Anonymous Philosophy," Journal of Substance Abuse Treatment 15, no. 6 (1998): 493-8.
37. Ibid. See, also, S.L. Dilts, C.A. Clark, and R.J. Harmon, "Self-disclosure and the Treatment of Substance Abuse," Journal of Substance Abuse Treatment 14, no. 1 (1997): 67-70, and A.J. Mallow, "Self-disclosure/Reconciling Psychoanalytic Psychotherapy and Alcoholics Anonymous Philosophy," Journal of Substance Abuse Treatment 15, no. 6 (1998): 493-8.
38. J.A. Flaherty, "Disclosure in Therapy: Marriage of the Therapist," American Journal of Psychotherapy 33, no. 3 (July 1979): 442-520.
39. See for an example, A. Ellis, "Rational and Irrational Aspects of Countertransference," Journal of Clinical Psychology 57, no. 8 (August 2001): 999-1004.
40. See Halpern's discussion of this and particularly Sir William Osier's views. Halpern, see note 1 above, pp. 22-25. Osler influenced the future practice of medicine profoundly and thought "detachment served rationality." Halpern indicates that despite this view, he responded to patients' emotional needs in his practice.
41. This is illustrated by a careprovider who cried when a three-year-old boy was dying. When reprimanded, she felt like "ripping out her lacrimal glands [tear ducts]." She later learned after years of practice that when her patients saw her tears they knew that "they were not alone in theirs." P.S. Krauser, "Tears," Journal of the Medical Association 261, no. 24 (June 23/30, 1989): 3612.
42. "Grief," Lambe states, may involve "a torrent of tears and screams." Patients may feel more supported, then, if they see careproviders express grief, as it is. M. Lambe, "Now I Understand Grief," Medical Economics (May 2001): 76,78.
43. Jordan, see note 23 above, p. 99.
44. The staff might, here, have first, gone together with the family to the state district attorney to get a preliminary opinion as to whether, if the patient had tracheotomy and then declined, the family's understanding of her wishes would be enough to then allow her to die.
45. S. Sarangi and A. Clarke, "Constructing an Account by Contrast in Counseling for Childhood Genetic Testing," Social Science and Medicine 54 (2002): 295-308.
46. For an unusual approach regarding what careproviders should do when they serve more than one party and must give advice, see G.A. Diamond, A. Rozanski, and M. Steuer, "Playing Doctor: Application of Game Theory to Medical Decision-Making," Journal of Chronic Diseases 39, no. 9 (1986): 669-77.
47. A possible example is the following: J.H. Cocerdale et al., argue that when a pregnant woman is severely depressed, since this depression can physiologically harm her fetus, directive counseling (to get treatment) is justified. This is because, in addition to benefiting the fetus, it "builds on the patient's actual or implicit values." J.H. Cocerdale et al., "Ethically Justified Clinically Comprehensive Guidelines for the Management of the Depressed Pregnant Patient," American Journal of Obstetrics and Gynecology 174 (1996): 169-73, 172.
48. T.S. Dharmarajan, D. Unnikrishnan, and C.S. Pitchumoni, "Percutaneous Endoscopic Gastrostomy and Outcome in Dementia," American Journal of Gastroenterology 96, no. 9 (September 2001): 2556-63.
49. I am indebted to Daniel Sulmasy for this most insightful and sensitive wording.
50. McGowan, see note 13 above, p. 198.
51. Halpern, see note 1 above, p. xii.
52. Havens states, "I can recall many ... mistakes ... and how slowly I learned, if I did at all." Havens, see note 2 above, p. 19, p. 157.
53. T.E. Quill, R.M. Arnold, and F. Platt, " 'I Wish Things were Different': Expressing Wishes in Response to Loss, Futility, and Unrealistic Hopes," Annals of Internal Medicine 135 (2001): 551-5, 551.
54. The authors in the preceding note conclude that even when careproviders express caring wishes, they can "elicit deeper feelings of anger, hopelessness, or blame." Ibid., 554.
55. Healing from trauma, at least, may require the assistance of others. J. Halpern, "Comment," in Seeing the Difference, ed. C.M. Gillis (Berkeley, Calif.: Doreen B. Townsend Center for the Humanities, 2001).
56. Ethics consultants and careproviders in analogous roles who are exceptionally subject to patients' "ambiguous perceptions" should limit information about themselves or their feelings, because these disclosures are more likely to be negatively misconstrued. If, for example, they share personal examples, they should limit these to those that are supportive, such as when they felt what seems like similar pain: "I had to face a decision like this once. It was horrible for me too to decide." If the patient then asks for more information, the consultant then can respond more fully, for example: "My mother lost her mind from a massive stroke, and it was clear she would never recover. I, too, felt terrible, thinking that if she didn't die, she would exhaust her life savings."
57. Linehan, see note 24 above, p. 176.