Switzerland: Assisted Suicide Remains Legal

Story from the BBC



The Suicide
Madalina Iordache-Levay



Voters in Zurich, Switzerland, have rejected proposed bans on assisted suicide and "suicide tourism".

Some 85% of the 278,000 votes cast opposed the ban on assisted suicide and 78% opposed outlawing it for foreigners, Zurich authorities said.

About 200 people commit assisted suicide each year in Zurich, including many foreign visitors.

It has been legal in Switzerland since 1941 if performed by a non-physician with no vested interest in the death.

Assistance can be provided only in a passive way, such as by providing drugs. Active assistance - helping a person to take or administer a product - is prohibited.

'Last resort'

While opinion polls indicated that most Swiss were in favour of assisted suicide, they had also suggested that many were against what has become known as suicide tourism.

Many citizens from Germany, France and other nations come to die in Switzerland because the practice remains illegal abroad.

One local organisation, Dignitas, says it has helped more than 1,000 foreigners to take their own lives.
Another group, Exit, will only help those who are permanently resident in the country - saying the process takes time, and much counselling for both patients and relatives.
 
Its vice-president, Bernhard Sutter, said the result showed Swiss voters believed in "self-determination at the end of life".

The referendum had offered a proposal to limit suicide tourism, by imposing a residency requirement of at least one year in the Zurich area in order to qualify for the service.

It was backed by two conservative political parties, the Evangelical People's Party and the Federal Democratic Union.

But the major parties of the left and right, including the Swiss People's Party and the Social Democratic Party, had called on their supporters to vote against both motions.

The BBC's Imogen Foulkes, in Geneva, says the size of the vote against a ban on assisted suicide reflects the widely held belief among the Swiss that is their individual right to decide when and how to die.
Their rejection of the proposal to limit assisted suicide to those living in Zurich shows that concerns about suicide tourism carry less weight with voters than their conviction that the right to die is universal, our correspondent says.

But the debate in Switzerland will continue, she adds. Polls show voters do want clearer national legislation setting out conditions under which assisted suicide is permitted.

The Swiss government is planning to revise the country's federal laws on assisted suicide.

It has said it is looking to make sure it was used only as a last resort by the terminally ill, and to limit suicide tourism.

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Blogger Note: Many ethical issues are found in this story.

To Friend or Not to Friend: That is the Question

Anthony S. Ragusea, Psy.D.

Florida Psychological Association

Guest Blog 


Recently on the Florida Psychological Association (FPA) listserv there was a spirited debate about whether or not it is professionally appropriate to accept a “Friend” request on Facebook by a client.  The fact that the debate was happening at all speaks to the enormous change that the Internet and a private social media company, Facebook, is having on the practice of psychology.  For the uninitiated, Facebook provides a space, much like any personal web page, where one can post pictures, text, links to other sites, and share all that personal information with a select group of “Friends.” Friends are other users of Facebook who are invited by you to see everything you’ve posted on your page, engage in conversations with you, and otherwise interact with you.  One can also create professional pages, but most users prefer personal profiles.

Facebook has over 500 million users worldwide, so the chances are good that some of your clients have Facebook pages.  In fact, as the debate on the FPA listserv suggests, many psychologists who use Facebook have encountered situations where clients have asked to become Friends of their psychologist.  Whether or not to accept such a request is a complicated decision, depending on one’s level of comfort with dual relationships, whether the dual relationship is unethical, the theoretical orientation of the psychologist, the risk management practices of the psychologist, the unique circumstances of the request, and perhaps other factors as well. 

In other words, there are legal, ethical, professional, and personal factors to consider.  Each of these general factors is separate from the others.  For example, a psychologist may be personally comfortable with having a client as a Friend, but from a psychoanalytic orientation may have concerns about what that relationship may have on the development of transference in therapy.  Or, a humanistic psychologist may feel that to draw a relationship boundary with a client over Facebook would be a sign of disrespect, a way of creating a hierarchical relationship with the client that suggests “you must be self-disclosing with me, but I will not disclose myself with you,” yet may still choose not to accept a client as a Friend because of concerns that the relationship may increase the chances of the client filing a complaint against the psychologist or terminating therapy.  Several articles have been written recently about managing such concerns on Facebook, Google, and the Internet in general.  A very good one about Facebook was written by psychologist Ofer Zur (2011), and the full text is available on his website.  I will briefly address the ethical dilemma with current clients here. 

As always, when deciding whether a professional behavior is ethical or not, we look first to the APA’s Ethical Principles of Psychologists and Code of Conduct.  The most relevant standard relates to Multiple Relationships (3.05).  This standard reads in part:

“A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

 Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.

(b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code.”

This standard informs us that to “friend” a client is not inherently unethical, because a Facebook relationship is not intrinsically harmful and may not impair the psychologist’s effectiveness in the professional relationship.  It is up to the psychologist to predict whether harm may come to the client or to the professional relationship.  Some conceivable harms could include: the client learns personal information about the psychologist which causes the client to dislike the psychologist; the client develops an unhealthy fantasy about the psychologist as a result of this window into the psychologist’s life; the psychologist comes to view the relationship as more casual than professional, resulting in impaired objectivity or failure to maintain professional standards of behavior; or, finally, the online relationship results in an accidental breach of confidentiality that offends or harms the client in some way. 

The risk of harm by “friending” must also be weighed against the harm, albeit unlikely, that could come to the client by not accepting the request.  For example, the client may be inappropriately offended by the refusal, resulting in damage to the professional relationship.  This harm could likely be avoided through a frank discussion with the client about why the client wants to be Friends, and why the psychologist does or does not wish to accept.  If the psychologist does accept the request, there is still an obligation to be vigilant so that if harm occurs it can be minimized as quickly as possible.
 

If the FPA listserv may be considered a crude survey of the prevailing attitudes of psychologists, most maintain a policy to not accept Friend requests, and maintain strict controls over privacy on Facebook to prevent possible clients from viewing their personal profiles.  To “friend” a client is not automatically unethical, but clearly there are many risks with few apparent benefits, so the answer to the question posed in the title according to emerging consensus appears to be, “Not.”

Reference

Zur, O. & Zur, A. (2011). The Facebook Dilemma: To Accept or Not to Accept? Responding to Clients' "Friend Requests" on Psychotherapists' Social Networking Sites. Independent Practitioner, 31(1), pp. 12-17.

What should I call myself?

Samuel Knapp, EdD, ABPP

Director of Professional Affairs

The names and titles that psychologists use, the clothes that they wear, and the decor in their offices are part of the “public self-disclosure” of the psychologist. That is, psychologists convey something about themselves and their relationships with their patients by the names and titles they use, the way they dress, and the way their offices are decorated.

How should psychologists refer to themselves in professional settings? Should psychologists who have doctorates always refer to themselves as “doctor;” should they refer to themselves by their first name; or should they use some other mode of address? Do psychologists who fail to insist on using the title “doctor” diminish the profession or fail to recognize the substantial academic and personal accomplishment involved in becoming a psychologist? After all, physicians refer to themselves as “doctor.” Or, does insisting on the title “doctor” reflect elitism, classism, or an assertion of power or privilege over another person?

Dr. Richard Small usually introduces himself as Dr. Small. When asked what he prefers to be called, he responds “either Rick or Dr. Small.” When she meets with adults for the first time, another psychologist introduces herself with her full name, but does not use her title (which is on her business card and on her office door). She asks patients what they would like to be called and follows a pattern of mutuality in titles. She says “If you would prefer to be called by your first name, you may call me by mine. If you would prefer that I use a courtesy title to address you, you may use mine.” Both of these approaches allow adult patients to use (and to be called by) whichever name or title appears comfortable for them, and recognizes that individuals vary in their comfort with titles, which often differ according to age, social background, or perceptions of courtesy. Sometimes when given an option, patients will adopt a middle ground and refer to the psychologist as “Dr. Sam,” “Dr. K.,” or some other polite variation. Giving adult patients options of what name to use also avoids the appearance of trying to establish a hierarchy of power or distance between individuals. The assumption is that the effectiveness of therapy will occur because of the quality of the relationship and the effectiveness of the therapeutic intervention.     

The use of titles and names depends a lot on context, and it is impossible to establish one rule for all situations. Although insisting that patients use the title “doctor,” in and of itself, is unlikely to cure many patients, at times it may be clinically indicated to do so. One attractive woman psychologist initially refers to herself as “doctor” when working with men to ensure that they do not misconstrue the use of her first name as an invitation to enter into inappropriate boundary crossings. However, she allows women or men she knows well who do not appear to have boundary issues to call her by her first name. Also, it is generally considered bad manners for children to refer to adults by their first name (other than relatives, such as “Aunt Sally,” or “Uncle John”), although this standard has become weakened in recent years. Some psychologists will allow children to call them “Dr. First Name,” which balances familiarity with respect for the adult.

Of course, patients who usurp the right to use first names may be showing clinical features of relevance. For example, a psychologist who conducts child custody evaluations notes that some fathers will use his first name at their first meeting or even the first phone call, which he interprets as an effort to create a male-to-male bond or alliance in the relationship. Rebellious adolescents may also use first names as a way to assert power or defiance of authority. The appropriate response may vary according to the situation and patient dynamics, but the overriding goal should be to respond in a manner consistent with overarching ethical values that promote professional goals in the context of a supportive but structured relationship.

Vignette 2: A Suffering Caregiver

A colleague of yours, Dr. Solomon, contacts you for advice regarding a new client she has just seen. The client, Mr. Don Tellanyone, is a 47-year-old man who is seeking services for depression. During the initial phone contact, he asked repeatedly about privacy and wanted assurances that information discussed in session was confidential. The patient repeated this line of questioning during the first face-to-face session.

As the session progressed, he revealed that the source of his depression was the death of his mother one year ago. His mother had suffered from a combination of severe respiratory problems and Alzheimer’s. Mr. Tellanyone had been caring for her and his father in his home for 6 years prior to her death.  During the last two years, she required total care. He revealed that she had been suffering greatly and, out of compassion for her, he gave her an excess dose of her sleeping and pain pills. Medical personnel never questioned the death as the woman had been quite sick and “It was only a matter of time.”

Mr. Tellanyone goes on to explain that he is now caring for his father in similar circumstances, although there is no dementia. His father has declined rapidly since the death of his wife and now requires total care. Mr. Tellanyone reveals that recently he had a conversation with his father in which the father commented how peaceful his wife’s death was and how he hoped for a similar passing.

Mr. Tellanyone is feeling quite guilty about his mother.  Simultaneously, he strongly believes he made the right decision. He would like help to work through the issues. He is also very concerned about confidentiality and wants assurances from Dr. Solomon.

Dr. Solomon, feeling uncomfortable with the situation, contacts you for a consultation about the potential ethical issues for this case.

What are the potential ethical issues in this case?

What would you advise?

Amending the Ethics Code

APA’s Council of Representatives voted to amend the association’s Code of Ethics to make clear that its standards can never be interpreted to justify or defend violating human rights.

The action, which came during the winter meeting of APA’s governing Council of Representatives, amended the code’s Introduction and Applicability section, as well as Ethical Standards 1.02 and 1.03, to resolve any potential ambiguity in the original language. These changes become effective June 1, 2010.

“APA’s longstanding policy is that psychologists may never violate human rights,” said APA President Carol D. Goodheart, EdD, announcing the changes. “These standards now unquestionably conform to that policy.”

The standards, from APA’s “Ethical Principles of Psychologists and Code of Conduct” (2002), address situations where psychologists’ ethical responsibilities conflict with law, regulations, other governing legal authority or organizational demands. Previously, it appeared that if psychologists could not resolve such conflicts, they could adhere to the law or demands of an organization without further consideration. That language has been deleted and this new sentence added: “Under no circumstances may this standard be used to justify or defend violating human rights.”

These amendments to the Ethics Code provide clear guidance to psychologists regarding their ethical obligations when conflicts arise between psychology ethics and the law or ethics and organizational demands.

An APA Ethics Committee task force last revised Ethical Standard 1.02 on conflicts between ethics and law in September 2001. The standard, which had been previously revised in 1992, had been criticized by psychology practitioners, particularly those in the forensics community. The 1992 standard said that when ethics and law conflict, psychologists should “make known their commitment to the Ethics Code and take steps to resolve the conflict in responsible manner.” Practitioners were concerned because at times judges, who were unfamiliar with psychology ethics, would order that clients’ raw test data and psychotherapy notes be submitted into legal proceedings. Judges had also made custody, visitation or supervision recommendations without first seeking appropriate evaluations. Psychologists said they were being placed in a conflict between ethics and law.

The task force had responded to such concerns by revising Standard 1.02’s language to say that if a conflict arises between ethics and law, psychologists should make known their commitment to the Ethics Code and seek to resolve the conflict. If that process was not successful, a psychologist had the option of following the “law, regulations or other governing legal authority.”

The language created a process for resolving a conflict between ethics and law but did not require a psychologist to violate a court order and thus risk being jailed or fined. The psychologist could, however, engage in civil disobedience, if he or she chose. The ethics task force approved the revision with minor edits and APA’s Council of Representatives adopted it in 2002.

That solution was called into question after Sept. 11, 2001, when the Bush administration used abusive interrogation techniques that it defended under the law. The question arose as to what a psychologist’s ethical obligations would be if they were ordered to engage in torture or cruel, inhuman or degrading treatment or punishment and whether Ethical Standard 1.02 could be used as a defense.

The full story can be read here.

Book Review: The Singularity is Near

by John Gavazzi, PsyD, ABPP

Disclaimer: The Singularity is Near by Ray Kurzweil is dense with facts, ideas, and future projections. However, space limitations of this blog post prevent me from a much more detailed review.

If you are interested in the interface of technology and human existence, then this book is a meaningful read. While the text is dated (published in 2004), I never imagined that this book would try to deal with consciousness and “self” within the context of non-biological intelligence.

Consciousness is the most complex outcome of evolution, so far. However, The Singularity focuses on possible paths in which the human brain will be enhanced through nanotechnology and other engineering developments. Kurzweil also makes the claim that non-biological entities will achieve consciousness, most likely near 2045!!

Sound farfetched? Too Star Trek for you?

Kurzweil covers a wide range of topics including brain science, technological advances, nanotechnology, reverse engineering the brain, the importance of chaos theory and algorithms, and some advances in medical research. The brain science portions of the book explore the human brain from intracellular processes of the neurons, to neurotransmitters and synapses, to localized brain functioning, to overall brain functioning, to mind as an emergent function of a chaotic, complex system.

Kurzweil’s engineering perspective and sharp insights are effective throughout the text. While Kurzweil writes in a friendly, easy manner, make sure that you have a working knowledge of complexity theory (chaos theory), quantum physics, and biological conceptualizations (DNA, RNA, epigenetics) to appreciate fully the depth and breadth of his points.

There are some minor weaknesses. First, Kurzweil gives short shrift to the general idea of consciousness. Because consciousness is not well defined or well measured, the author does not spend much time on consciousness. However, he addresses that non-biological entities will achieve consciousness, but, other than passing the Turing test, he does not elaborate in a meaningful way. Furthermore, consciousness is tied up with sensation, perception, acculturation, expectations, etc. that are not addressed within the context of non-biological enhancements.

Second, the concept of “self” is sketchy at best for Kurzweil. He does not connect how a "centered self" applies to non-biological intelligence or enhanced intelligence. Kurzweil seems to argue for a de-centered “self” or a distributed model of consciousness. While I agree with this premise (that many portions of consciousness are distributed), Kurweil only implies this possibility, without spelling out all of the ramifications of a de-centered self.

Overall, the book is a fascinating foray into the melding of human intelligence and non-biological enhancements to human existence. The book raises the issue of what makes us human, and, how far can we create hybrid life forms that are still considered human?  So, the ethical issue stems from the degree to which human beings are willing to use cognitive and physiological enhancements and still consider us to be human.  Medical devices have already been implanted into the human body to repair damaged or unhealthy organs (implantable cardioverter-defibrillator).  The future challenge is: how far will individuals go with cognitive, emotional and physiological enhancements and society still considers that hybrid entity to be “human”? 

  

Kurzweil makes some interesting projections as to how possible inventions will change the human race in 20, 30, or 40 years.  This brief video highlights some of the main points in this book.

If you choose to read this book, hopefully you will enjoy it as much as I have.  The Transcendent Man is a related movie that I have yet to see.

Professional Connectedness and the Quality of Professional Services

by Sam Knapp, EdD, ABPP
Director of Professional Affairs

Self-reported happiness is correlated with being a member of a valued social group, whether it is family, a circle of friends, a faith community (church, synagogue, or mosque), or another social environment. Social support is also related to better health, longevity, and more productivity and effectiveness at work. 

Also, evidence suggests that socially connected health care practitioners tend to do better than “outliers.” For example, Knapp and VandeCreek (2009) found that psychologists who belonged to their state psychological association had significantly fewer disciplinary actions than non-members. Similarly, Kilmo, Daum, Brinker, McGruire, and Elliot (2000) found that orthopedic surgeons who belonged to their professional association had lower rates of malpractice complaints than non-members. Of course, self-selection may account for some of this finding in that the more conscientious health care professionals may select themselves into the professional association. Nonetheless, membership itself may have some benefits in terms of providing resources. 

Perhaps the membership or the continued social contact that comes from membership helps health care professionals learn new information and compare their knowledge base with others. For example, Knapp and Keller (2004) found that psychologists rated contacts with their colleagues as their most important source of learning new information related to the profession. Also, Pope, Tabachnick, and Keith-Spiegel (1987) found that discussions with colleagues were the most important source of knowledge about the profession that psychologists had.

In addition to the information benefits, social support helps moderate the emotional stressors caused by work, and institutions that value employees and solicit their active involvement tend to give better service to their patients. So it would seem that psychologists who strive toward excellence in their work will structure their lives to ensure continued contact with other psychologists.

In addition to whatever personal benefits they derive from social contacts, connected  psychologists also contribute to the advancement of the profession and public welfare to the extent that their interactions help upgrade the knowledge base or otherwise help support the activities of other psychologists.  When asked about how they maintain their social connectedness and sense of community, several psychologists noted that they

• participated on a professional listserv;

• as supervisors ensured that there was sufficient time for supervisees to meet and learn from each other;

• attended continuing education programs;

• maintained memberships in professional associations (and attended meetings);

• formed a journal club; and

• established and maintained professional contacts through electronic media, such as Facebook, Plaxo, or LinkedIn.

However, creating a supportive environment cannot be reduced to a list of several options alone. Instead, it requires openness to meet and discuss with others. It is possible to be physically present at a continuing education workshop, but to be so involved in texting or responding to phone calls during breaks that the event involves little more contact than doing a home study.

What do you do to maintain your professional extroversion?

Feel free to contact Dr. Eric Affsprung, chair of PPA’s Colleague Assistance Committee (Eaffspru@bloomu.edu) with your ideas.

Feel free to post your ideas here.

References

Kilmo, G., Daum, W., Brinker, M., McGruire, E., & Elliott, M. (2000). Orthopaedic medical malpractice: An attorney’s perspective. American Journal of Orthopaedics, 29, 93-97.

Knapp, S., & VandeCreek, L. (2009, fall). Disciplinary actions by a state board of psychology: Does gender and association membership matter? Focus on 31: Division 31 Newsletter, p. 7.

Knapp, S., & Keller, P. (2004, March). What enhances the professional skills of psychologists? Pennsylvania Psychologist, 64(3), 11.

Pope, K., Tabachnick, B., & Keith-Spiegel, P. (1987). Ethics of practice: The beliefs of psychologists as therapists. American Psychologist, 42, 993-1006.

Lifelong Learning: An Ethical Responsibility

by Melba J.T. Vasquez, PhD

How long does it take before half the psychological knowledge you hold in your area of specialization becomes obsolete? Estimates range from five to six years, according to participants at APA’s 2010 Education Leadership Conference. What’s more, scientific knowledge about best care takes an average of 17 years to be applied broadly and systematically in actual clinical practice, according to the Institute of Medicine. I wish all of you could have been at the conference to be infused with motivation and insight about the importance of lifelong learning, but for those of you who couldn’t, here are some highlights.

Presenters emphasized that it is our ethical responsibility to maintain competence in all our work as researchers, educators and/or practitioners through lifelong learning. To that end, the conference featured science that showcased the best ways to learn, detailed better continuing-education (CE) options and underscored the reality that we spend more time in lifelong learning than in preparation for our careers.

The particular activities that comprise lifelong learning range widely, partly based on specialization. Researchers who need to stay abreast of new methodologies as well as findings may do so by reviewing journal manuscripts, attending APA’s Advanced Training Institutes and going to various conferences. Educators may benefit from those activities and also from tapping centers for teaching and learning available on campuses. Practitioners can also review the literature, as well as attend CE programs and workshops.

Read the rest of Dr. Vasquez's article here.

Vignette 1: Psychologist in the Middle



A psychologist works in an outpatient substance abuse treatment facility.  His patient reveals, during the course of therapy, that a staff person paid to have sex with another patient, who is a prostitute.  The staff member works in another department in the agency.  And, according to the psychologist’s patient, the patient is not aware that one of her customers works in another part of that facility.  

The psychologist does not know the therapist well, but has provided some consultation for the therapist in the past.

The psychologist does not dwell on the situation with the patient.  However, after the session, the psychologist feels uneasy about what his patient revealed.

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Are there any ethical obligations of the psychologist who hears this information?

What are potential ethical pitfalls in this scenario?

What, if anything, should the psychologist do?