Legal, Ethical, and Professional Issues in Psychoanalysis and Psychotherapy
An Ethic of Free Association:
Questioning a Uniform and Coercive Code of Ethics
Patrick B. Kavanaugh, Ph.D.
A culture's world view, dominant rationality, and core ideology provide the defining context that speaks to how a culture understands and interprets itself. A culture's ethical doctrine provides the text that speaks to the body of values by which a culture understands and interprets itself with regard to what is good and bad and right and wrong (Scott, 1990). A culture's ethical doctrine is inextricably linked to its view of people and theory of life. It defines, reflects, and perpetuates that which is held out to be the dignity, the values, and the ideals of human life. Finally, the ethical doctrine reflects the ethos, the underlying system of values, which permeates and colorizes the ideological strands in the culture's fabric. This broad-based understanding of ethics speaks to the inseparable interweave of the culture's world view and ideology with its core beliefs and values. As a doctrine, ethics refers to a grouping of principles that provide the moral foundations underlying legitimate knowledge, sound value judgments, and good conduct in the discourse of everyday life. Ethics, it has been said, is the point at which philosophers come closest to practical issues in morals and politics (Hare, 1997). Ethics, it might also be said, speaks to the practical relevance of moral philosophy in the lived experiences of everyday life as both citizens and professionals.
In the psychoanalytic culture, the legacy of Freud has been described as a dialectic in which every psychoanalytic proposition blends science with humanism (Bornstein, 1985). Historically, this legacy has guided the development of psychoanalysis from the paradigm of biology, medicine, and the natural sciences - a way of thinking that continues to dominate in the analytic culture to this day. In this modernistic mythology, a natural science of the mind is unprejudiced and unmediated by theories, assumptions, or values, and humanism provides the values that humanize the harshness of the science and its objectively discovered knowledges. In this medicalized version of psychoanalysis, the largely unquestioned biomedical objectives of curing and healing various psychic structures are contextualized by the humanistic values of caring and helping to alleviate pain and suffering. Historically, psychoanalytic organizations have actively advanced psychoanalysis as a health care profession, or a specialty thereof. Each of the major psychologies of drive, ego, object, and self have understood people from the organizing conceptual framework of symptomatology, etiology, and pathology, and psychoanalysis has been considered to be a medical technique concerned with the diagnosis and treatment of various mental disorders, diseases, and illnesses. Not surprisingly, the moral foundations for ethical directions, decisions, and conduct for the psychologist-psychoanalyst are to be found in a medical code of ethics such as the American Psychological Association's (APA; 1992) The Ethical Principles of Psychologists and Code of Conduct. Succinctly stated, the psychoanalytic culture subscribes to a medical code of ethics and its medicalized ethic of caring. Such medical codes of ethics make certain assumptions as to the basic nature of people, assume a particular theory of life and moral philosophy, and adopt a specific ethical doctrine and theory of moral obligation for the analyst. They provide the body of values by which the analytic culture currently understands and interprets itself with regard to what is good and bad and right and wrong.
In this paper I examine certain ethical concerns regarding the largely unquestioned medicalized assumptions underlying ethics codes that govern the thought, judgments, and conduct of the analyst, using three conceptually distinct but interrelated perspectives, as suggested by Callahan (1988): the metaethics, the theoretical normative ethics, and the role of applied ethics in psychoanalysis. This questioning places particular focus on the moral philosophers of the modern era as exemplified by the philosophy and ethical doctrine of John Stuart Mill's utilitarianism, and particular emphasis is on the ethical implications and imperatives that derive for the analyst from medical codes of ethics and its ethic of caring. Second, I reconsider the question of ethics from the perspective of an ethic of free association, which proceeds from a different set of core values and ethical principles, lays claim to a different ethical standard, and defines a different context for the concept of an ethic of caring. This consideration is from the perspective of a skeptical phenomenalist and is intended as a contribution to the study of ethics in the psychoanalytic arts.
THE NATURAL SCIENCES, THE SOCIAL SCIENCES, AND THE METAETHICS OF UTILITARIANISM
The ethical doctrine to which the psychoanalytic culture subscribes has been an integral part of the Westernized intellectual traditions tradition which is, perhaps, best understood as an argument extending through time in which certain fundamental agreements are continuously defined and redefined through conflict with critics external to the tradition and through internal interpretive debates (Maclntyre, 1988). For example, the tradition of thinking and arguing about ethics and morality in the Westernized cultures finds its foundational framework in Plato's The Republic and Aristotle's Ethics, extends through time to Aristotle's Christian disciple St. Thomas Aquinas' Summa Theologiae and De Regno, and moves to the great liberal thinker of the nineteenth century, John Stuart Mill. In the Ethics, Aristotle understood human action in terms of ends and means and claimed that the ultimate end of human action was happiness. Happiness was understood as acting in accordance with reason and logic (Norman, 1983). St. Thomas Aquinas was to give a Christian rationale for the legal enforcement of ethics and morality. His thinking went something like this: What is good for everybody in the end is getting to heaven. The attainment of heavenly beatitude is the central common good and concern of the people, of Christianity, and of government (George, 1993). This Christian contextualization of Aristotelean thinking provided a religious justification for the legal enforcement of ethics and morality, and speaks to the long and sacred tradition of organized religion joining with government in defining and enforcing the ethical standards of the community, in the best interests of saving the eternal soul of the other. John Stuart Mill was to extract this Christian spirit and tradition for his ethical doctrine of utilitarianism, which resembles the structure of a scientific theory and formulary derived from a nineteenth-century world view and set of values (Mill, 1974). Of the modern theories of moral philosophy, perhaps none has been more influential in shaping the ethical doctrine and directions of the helping professions than that of John Stuart Mill, the leading British philosopher of the nineteenth century and one of the founders of the modern social sciences.
First published in 1872, Mill's (1990) Logic of the Moral Sciences has been acknowledged as one of the founding documents of the social sciences. This document speaks to the belief that all natural phenomena are governed by predictive and natural laws that could be objectively discovered through the application of the scientific method. People are subject to the same natural laws as are physical events. Consistent with a nineteenth-century world view, the objective of this science of human nature was the discovery and application of natural social laws that govern the acts of people. If we know a person thoroughly and know all the factors impacting upon that person, the social sciences should be able to discern empirical regularities, establish normative standards, and predict behavior and conduct with as much certainty as the natural sciences could predict the ebb and flow of the tides. The contexualizing metaethic for the helping professions is to be found in Mill's classical utilitarian theory. First published in 1863, Mill's (1962) philosophy of utilitarianism has provided the fundamental underlying principles of morality, the primary source of moral obligation, and the theoretical justification for the largely unquestioned ethic of caring in the helping professions. As an ethical doctrine, utilitarianism rests on the metaphysical assumptions of the mathematical sciences of the modern era, including the assumption that the laws of nature, people, and society are mind independent and value neutral. As a moral philosophy, utilitarianism contains the quantitative and qualitative principles underlying the ethical doctrines, standards, and formulae embodied in current codes of ethical conduct for helping professions, namely, that we should always choose that which will tend to produce the greatest good for the person or for the greatest number of people. Mill's theory of life as expressed in the "Greatest Happiness Principle" states that "pleasure and freedom from pain are the only things desirable as ends" (Cahn & Markie, 1998, p. 347). This theory of life has provided the framework for his theory of morality in which actions are right and good in proportion to the amount or degree of happiness promoted for the greatest numbers of people. Actions are wrong and bad insofar as they produce the reverse of happiness.
As a philosophy, utilitarianism has been one of the major and defining influences in the development of an ethical code and its ethic of caring in the psychoanalytic culture. Utilitarianism provides the standards and the formulary by which actions of the analyst are assessed in terms of their ends and consequences, their contribution to human happiness, and the prevention of human suffering. As such, it has provided the precedent, the justification, and the formula for ethical directions, decisions, and actions in which the moral value of an action becomes a function of the consequences of that action. The primary concern of ethics and morality for the analyst follow in the tradition of natural science blended with humanism: a right moral action becomes that which enhances the well-being of others (Prilleltensky, 1997). Utilitarianism has provided the metaethics that contextualize and define the meaning of such moral terms as good and bad and right and wrong.
A THEORETICAL NORMATIVE ETHIC: PSYCHOANALYTIC THEORIES AND GOOD MENTAL HEALTH
As the natural sciences were paradigmatic for the social sciences, the natural sciences were to provide a model for discovering normative ethical propositions and developing a theoretical normative ethic. The establishment of normative principles central to theories of behavior and ethics proceeds from the basic assumption of self-evident axioms similar to those of mathematical theories from which their theorems arc derived (Clarke, 1997). Normative ethical principles are conceived on the model of such mathematical axioms and are thought to be as self-evident to the rational mind. The empirically constructed normative provides a standard for people to which their thoughts, feelings, and actions can be evaluatively compared and to which they either conform or fail to conform (Copp, 1995). Deviations from this normative Ought-to-Be" have been understood in modernistic psychoanalytic theories as symptomatic of deeper underlying pathology, the cause of which has been attributed to the lack of development of specific psychic structures and functions. Psychopathology has been conceptualized in binary opposition to the normative. Specifically, the psychologies of drive, ego, object, and self - developed in a health care context - have conceptualized differences amongst people as evidences of pathology. Each of these respective psychologies has assumed that people are lacking something quite basic in their psychic structure(s) necessary for their adaptation and survival in everyday life. That which is lacking has been understood as development deficits which cause the symptomatology, explain the etiology, and constitute the psychopathology - and at the same time. These theories provide bodies of knowledge about people, structure certain kinds of conceptions of self-as-analyst and other-as-analysand, and are largely accepted as natural and self-evident in the psychoanalytic culture. Indeed, there has been a disturbing lack of skepticism about the underlying assumptions and implications of such theories resting on this organizing conceptual framework of symptomatology, etiology, and pathology.
In this ethos of healing, the psychologies of psychoanalysis have provided rational justification for a theoretical normative ethic in which psychoanalysis is intrinsically good by encouraging, if not enabling, positive mental health in people who otherwise would continue to lack that which is necessary for their adaptation, survival, or quality of everyday life. Significant underlying ethical and normative dimensions upon which such psychologies are based structure the analytic discourse and experiences. Normative propositions inform, if not direct, the analyst as to how a person ought to develop, how he or she ought to feel and think, and what he or she ought to do in certain situations. All too often these normatively based views of the Other guide the analytic discourse to a theoretically anticipated outcome reflecting how the analysand Ought to be. In a health care context, getting better in psychoanalysis has come to be understood as making progress toward the idealized normative standards of how the person ought to be as a rational, reasonable, and responsible adult, and good mental health is assumed to conform to these normative standards. A psychoanalysis of conformity has evolved in which the normative principles central to both theories of behavior and ethics assume the empirically established Oughts to be natural, universal, and objective standards.
APPLIED ETHICS: KNOWING WHAT IS BEST FOR THE OTHER AND A THEORY OF MORAL OBLIGATION
Modernistic psychologies of psychoanalysis such as drive, ego, object, and self construct a particular view of people based on these standards of an idealized normative Ought, a view that contains core ethical issues in its very assumptions and conceptions of self and Other. Such deficit theories of people are inseparable from the prevailing theory of moral life and ethical obligations of the analyst. The implications for applied ethics are quite far-reaching. More specifically, the kinds of actions and practices morally permissible by the analyst to resolve specific problematic issues in everyday professional life rest on combining insights from the metaethics of utilitarianism and the principles of its theoretical normative ethic, an ethic that assumes that people who consult with a health care professional are, by definition, not fully capable of managing, choosing, or otherwise functioning in an autonomous manner. It is probably in this space of applied ethics where the underlying principles of a theoretical normative ethic most often collide with the professional ethics of many analysts.
Situated in a health care context, these psychologies of psychoanalysis speak from a particular philosophical, ideological, and political position in the culture at large. As such, they are inextricably linked to the discourse and relations of ethics and power, such as, for example, the power to evaluate the Other; the power to signify meaning, purpose, motive, and intent; and directly or indirectly, the power to influence, if not abridge, an individual's political, social, and personal freedoms and responsibilities. In such a health care context, the analyst has the ethical obligation to be a social and moral agent who acts on behalf of the analysand, who is signified as a helpless, powerless, and passive victim by virtue of consulting with a health care professional - assuming, of course, that it is a virtue. For the mental health professional, the moral logic, the goals of moral conduct, and a theory of moral obligation are organized around the self-evident assumptions of easing another's emotional as well as physical pain (Dougherty, 1996). To the question "Who decides what is best for the other in easing this emotional pain?" comes the reply, those who are competent to judge such matters, are willing to serve as repository figures representing the conscience of the collective, and are willing to serve the best interests of the individual. The mythology of blending amoral scientific proposition with core humanistic values provides the largely unquestioned justification for the moral piety of knowing what is best for the Other. In effect, the psychological Haves decide what is best for the Have Nots.
As considered and discussed by Norman (1983), Mill's ethical doctrine emphasizes a distinction between the higher and lower pleasures. Those activities associated with reason and the higher pleasures of the mind such as intellection and mastery of core bodies of knowledge are superior to the lower pleasures. According to Mill's doctrine, that which constitutes the higher pleasures is decided by individuals competent to judge for those not competent to judge. Those not competent to judge are individuals who indulge in that considered to be the lower pleasures. The right to judge is grounded on the presumption of what a person's own judgment would be if that person could really experience the alternatives to the lower pleasures. As an ethical doctrine, utilitarianism advocates and institutionalizes a hierarchical dichotomy of psychological Haves and Have Nots. The Haves are assumed to have achieved a higher state of being and a more superior position than the Have Nots. In a health care context, the psychological Haves are hierarchically positioned to evaluate the psychological Have Nots. And the Haves are expected to provide for the pathologized Have Nots via an ethic of caring in which doing what is best for the other is assumed, if not required, by ethic and law. Endowed through higher education and training, the analyst as a health care professional has achieved this more superior position, thereby justifying the paternalistic use of power and influence to benevolently guide and persuade, if not direct, the thinking and behaviors of fellow citizens. Such an ethic of caring claims its moral justification and the piety of compassionately knowing what is best for the other from normative theories of behavior and ethics. These normative theories have conceptually contributed to a culture of compassionate altruism and psychological victimization in which the Haves benevolently minister to the Have Nots. This medicalized ethic of caring derives from the Golden Rule of Jesus of Nazareth, instructing people to do unto others as you would have them do unto you. According to Norman (1983), utilitarianism extracts from Christianity the essential spirit of its ethics and attempts to inspire people as an exalted ethical religion, detached from its Christian context. A medicalized version of an ethic of caring walks hand in hand with such deficit conceptions of people and assumes foundational moral values for the mental health professional such as compassion, helping, and altruism. And also, such an ethic of caring justifies and requires the moral obligation of looking out for the best interests of the other.
In the role of applied ethics, enhancement of the well-being of the other translates into a moral theory and set of ethical obligations in which mental health professionals are expected and required to function in loco parentis for the individuals with whom they meet. As mediated through a medical ideology, the analyst's ethical obligation to the patient and society is to assume responsibility for the Other, and in so doing, to protect patients from themselves, protect society from patients, and protect patients from society. Such is the nature and role of applied ethics as reflected in the various duties to report, to warn, and to protect. Of course, it is to be recognized that the patients are to be protected from the analyst. Ethical codes are devised to control the potentiality to do harm based on the assumed universal nature of people as inherently evil. The liberal tradition assumes that, if left to the wants, desires, and interests of the individual, there would be a generalized collapse of society into amoral chaos with individuals feeling little, if any, sense of responsibility to the Other. If the social contract breaks down, the obligation to the public good evaporates and only self-interests would remain (Neville, 1989). Thus, the liberal doctrine defines individual freedom and responsibility exclusively within the social contract. In the liberal tradition, individual rights are ultimately derived from a consideration of the collective interests, and individual freedoms and responsibilities are defined by the group. Thus, the ethical responsibilities of the analyst are defined by the interests of the collective, authorized by the social contract, and embodied in the codifications of ethics and law.
The ethical doctrine underlying current codes of ethics is constituted by authoritative, systematic, and instructive ways of thinking by which analysts are to judge social thought and behaviors and upon which they are to base their ethical decisions and conduct in the applied ethics of everyday professional life. Ethics codes for heath care professionals assume a common ethical standard and set of common values for the psychoanalytic community in (1) establishing shared moral judgements in the analytic culture, (2) defining the ethical obligations to share that information with other health care professionals, and (3) sharing that information with representatives and agencies of the culture at large when the occasion warrants, such as peer reviews, accreditation audits, quality assurance evaluations, assurances of appropriate treatment plans for diagnostic conditions, judicial proceedings, and the various duties to report, warn, and protect. In utilitarianism the interests of the collective take precedence over the individual. Individual freedom, rights, and responsibilities are defined and privileged by those who know what is best for the Other. Ever wonder what happened to privileged communication? It should come as no surprise in these historical and political times that the personal ethic and lived experiences of the analyst matter only to the degree that he or she conforms or fails to conform to the prevailing ethical theory and obligations as prescribed in the applied ethics for health care professionals. The authoritative authorities have become morally responsible not only for the social good but for the moral character of the analyst.
The role of applied ethics collides with psychoanalysis if one's version of psychoanalysis does not assume that individual freedoms, rights, and responsibilities derive from the interests of the collective; does not assume psychological structural defects in the person and, thus, does not assume the moral responsibility and obligation of functioning in loco parentis for a person presumed to be neither competent nor responsible for himself or herself; and, last, does not assume the responsibility to coerce another to conform to the normative expectations of the collective. Such a medicalized ethic of caring is, by definition, coercive and immoral for those analysts and analysands whose principled systems of thinking, beliefs, core values, and personal ethic are otherwise. For them, such codes of ethics and psychoanalysis collide. For these analysts and analysands, ethics collide with psychoanalysis when an institutional(ized) ethical system presumes, perpetuates, and sanctifies the moral piety of knowing the Truth, the Right, and the Good for the Other. Indeed, for many of these analysts, fundamental civil liberties are violated when they are required to report fellow citizens to the proper authorities when certain behaviors unacceptable to the collective are suspected. For them, the ends do not justify the means, no matter how virtuous and noble the ends might appear to be when wrapped in the cloak of a compassionate ethic of caring. Are we moving closer to Fascism? Or are we already there and just beginning to catch glimpses of it?
The study of ethics and moral philosophy has been often undertaken as if the underlying principles of ethics and morality were timeless, natural, universal, and unchanging, as if these underlying ethical principles exist independently of the historical and political context in which they first make their appearance (Maclntyre, 1988). Ethical codes, however, are the creation of a particular historical-political community; its doctrine, tradition, and theory of life must be understood in that context. This historical-political context includes the lived antagonistic relations mediated by power and struggle rooted in structural and ideological oppositions. For example, the industrialization and commercialization of the health care professions of our own historical moment provide the unique opportunity to see, first hand, how economic and political forces combine to redefine the very concept of ethical and the meaning of that which constitutes integrity, quality, and caring for the health care professions. The so-called managed care threat with its emphasis on a business ethic and profit motive has been redefining the standards of ethics, of practice, of care, and of education. As Farber (1993) has rather succinctly stated: "The two medical models which dominate in the field today are the psychoanalytic model and the biochemical imbalance model; the former is rapidly losing ground to the latter" (p, 117). It is of more than just passing interest to note that utilitarianism, as a social philosophy, provides the basic assumptions for cost-benefit analysis and other formal methods of assessment for technological decisions to be made in our health care delivery systems (Barbour, 1993). Those rules and practices that will tend to produce the greatest good for the greatest number are to be chosen. According to a rules utilitarianism (Callahan, 1988), the most ethical decision to be made is that which produces the greatest net balance of social good. The well-being of the larger community takes precedence over the individual.
The professional community of psychoanalysis as a whole is affected by the complex processes, the changing social structures, and the redefinitions of core values by the health care industry. Changing professional standards are being incorporated into an increasingly uniform, coercive, and instructive medical code of ethics. The issue confronting the psychoanalyst, however, is neither the managed care threat nor the business profit motive. The defining issue is a medicalized psychoanalysis and a theory of moral obligation embodied in a metaethics, a theoretical normative ethics, and an applied ethics premised on outmoded nineteenth-century ways of thinking about people, the world, and life. Ethics in psychoanalysis has become subordinated to the political ideologies and power alliances of our historical and political moment. Any consideration of the question of ethics of psychoanalysis moves far beyond an interesting academic debate as these Ethical Principles (American Psychological Association, 1992) by which we are to abide rest on a supposedly "common set of values upon which psychologists build their professional and scientific work" (p. 86) and constitute "enforceable rules for professional conduct and decision making; and, may be applied by state psychology boards, courts, and other public bodies" (p. 2). A theory of moral obligation resting on these gratuitous assumptions and this authoritative rationality has evolved in which the questions of legal exposure for the analyst are decided by the degree and severity of violations of assigned duties, questions of legal responsibility are defined by the standards of a medical ideology, and questions of legal liability are determined by those with the "deepest pockets."
In many respects, ethics has become a remote, specialized, and marginalized body of knowledge separated and far-removed from the lived experience of the analyst's everyday professional life. In its very codification, ethics has been distanced from the realm of individual ethical systems and personal moral issues and has transformed ethics, itself, into a set of instructive, technological rules to be implemented for the presumed good of the Other. The analyst has been transformed into a repository figure of moral conscience, an advocate of the prevailing political ideology, and an agent of social control.
A uniform code of medical ethics, in and of itself, raises certain ethical and political questions about our freedom to question, to conceptualize, and to practice outside of a prohibitive health care context. It is this very capacity to question certain practices that constitutes our freedom as citizens and professionals (Rajchman, 1985).
Like other professionals, analysts have the ethical obligation to question the received wisdom, values, and pieties of conventional morality established by tradition and directed by customary rule (Callahan, 1988). In such a reflective morality, we are obligated, individually and collectively, to continuously reflect on what principles will govern our actions. This reflective morality speaks to the analyst as an autonomous moral agent who questions the received wisdom and knowledges and acts on the basis of their principled convictions. "The way it has always been" serves as little, if any ,justification for unreflectively continuing an ethical tradition, perpetuating a theory of moral obligation, or forming a new committee to revise, update, and otherwise fine-tune an ethical code based on the model of a mathematical science and the humanistic values of an exalted ethical religion from the nineteenth-century. If we do question received wisdoms and moral pieties based on a set of principled beliefs, values, and convictions, is there a moral justification, if not a moral requirement, to transgress current law or the current code of ethics?
The industrialization and commercialization of the health care professions has generated a maze of oftentimes contradictory ethical rules, regulations, and instructions to be followed by the health care professional. In these political and historical times, it has become increasingly prohibitive and difficult for one to speak easy and to listen easy in the analytic discourse. During the 1930s, an earlier time of Prohibition in the social order, underground speakeasys were developed for those who might choose to frequent such places. In many respects, it seems to me, analysts of the 1990s operate a similar kind of establishment when they provide a space and place to which a person might come to speakeasy in the analytic discourse. They do so, however, at risk of breaking the law and violating the code of ethics by which they have been subsumed as health care professionals.
SOME THOUGHTS ON AN ETHIC OF FREE ASSOCIATION
An ethic of free association speaks to the question of freedom and moves far beyond the narrowed definitional concept and meaning of the fundamental rule in psychoanalysis of free association. This ethic of free association speaks to foundational and implicit meanings of an individual's political, social, and personal freedoms. This view of freedom is premised on the recognition that the authority for a person's thoughts and actions is inalienably his or her own (Neville, 1989). Each person is the responsible author for himself or herself, for his or her own actions, and for the public good. The seat of responsibility is to be found in the speaking subject.
This ethic of free association recognizes, acknowledges, and appreciates that we are born into preexisting systems of meaning and signification. However, this understanding does not in any way abrogate nor remove notions of individual self-reliance, self directedness, self-determination, individual choice, or personal responsibility. An ethic of free association values this fundamental principle of freedom and its core values in the individual's political, social, and personal spheres. The fundamental nature of freedom to which I speak is the freedom that flows from the constituted experiences of self (Bergmann, 1991). The abridgement of this freedom and responsibility constitutes a deep and profound evil and does violence against the person.
An ethic of free association speaks to this question of freedom and, above all else, the freedom to question. This freedom includes the freedom to question the structures of our traditional social institutions, the assumptions of our received knowledges, and self evident truths in the forms of our experiences. This freedom includes the freedom to question the received wisdoms, values, and pieties of the institutional(ized) truth and ethic of psychoanalysis; the constituted experience of the culture, of the individual; and, in the analytic discourse, ourselves as analysts and analysands. This freedom to question is central and basic to a psychoanalysis situated in philosophy, the arts, and the cultural sciences. From this perspective, psychoanalysis derives from philosophy, is contextualized by philosophy, and is fundamentally concerned with philosophical issues, and its discourse is a discourse of moral philosophy. Essentially, psychoanalysis is considered to be an intellectual discipline for understanding the interplay of human values (Bowman, 1996), wherein reality, good, and truth ultimately reduce to the values of the subject (Vattimo, 1988), and each image of self and Other is a moral construct expressing what has been forbidden, allowed, and expected in the individual's experience and construction of a social context (Margolis, 1998). As such, psychoanalysis is fundamentally concerned with the moral issues and matters of the enunciating subject and the moral issues and integrity of the analyst. Situated in philosophy, psychoanalysis is concerned with the soul and the mind in contrast to biochemical imbalances and the brain.
In the philia, or friendship, of the philosophers of ancient times, there was to be found a way of life dedicated to pursuing the sophia, or freedom in Knowing and Being through their questions and games of language (Rajchman, 1991). It is this philia, or friendship, and this sophia, or questioning, which speaks to the philosophical friendship to be found in the analytic discourse. It is this philosophy that contextualizes the discourse of psychoanalysis. As a discourse of moral philosophy premised on a radical subjectivism, psychoanalysis speaks to a way of thinking by which and in which an individual might question the fundamental "What is" of his or her world and life and the "Why" of that "What is," and in such questioning attempt to make that world more comprehensible, coherent, and meaningful. As a moral philosophy, the focus and purpose of analysis is to be found in listening, understanding, and responding in the interpretive moment to the quest(ion) of the speaking subject. The analyst attempts to understand the nature of the Truth, Goodness, and Beauty according to the person; psychoanalysis speaks to the "something more" of spirituality and the unknowable mystery, magic, and muscle of people as both the analyst and analysand mutually search for identity in each and every discourse of analysis. This unique psychological discourse is understood to be a friendship in difficulty, which contextualizes the struggle and difficulty of questioning the natural order of things in one's world and life; the difficulty of questioning one's personal ethic in the lived experience of everyday life and the analytic moment; and the difficulty of the quest(ioning) in seeking an identity. This passionately held freedom to question derives from and leads to a different understanding of the dignity, the values, and the ideals of human life. It reflects a much different understanding of the analytic discourse and its ethic of caring. This friendship in difficulty in this most intimate and difficult of struggles speaks to an ethic of caring in which one cares enough to attempt to understand the enunciating subject's construction of reality, the interpretive design of his or her world, and the interpretive theories as to the nature of that world and the laws by which it operates. Further, this ethic of caring extends to caring enough to attempt to symbolize in words in the interpretive moment the as of yet unsymbolized; to elaborate further in words concealed dimensions of experiences not yet known, revealed, or recognized; and, to explain certain discontinuities in the person's experiences from their world of significance, meaning, purpose, and internal adaptation. This ethic of caring rests on a different view as to the basic nature of people and a different theory of life and moral philosophy, and has a different theory of moral obligation for the analyst. It is certainly recognized that this ethic of caring runs the risk of violating many of the traditional health care values, objectives, and standards of the helping professions such as helping the less fortunate, healing the pathogenic, caring about the alleviation of pain, and curing that which causes the suffering. Such medicalized assumptions, values, objectives, hierarchical orderings, and normative standards of the Ought, however, are repudiated by the very conceptual framework and discourse of analysis as a moral and ethical philosophy. Indeed, this ethic of free association is inherently incompatible with such health care and accreditation standards and ways of thinking. Human suffering and pain are understood, appreciated, and accepted as an integral aspect of the human condition and life, the experiences of which are to be understood in the analytic discourse - if one so chooses.
An individual's decision to participate in such a discourse serves as its own justification and rests on a fundamental social freedom in which the opportunity to freely associate in the social order is a constitutional right in a democratic society. Authority for one's own actions and decisions to participate in such a discourse is inalienably one's own and reflects the individual's claim on authorship and responsibility. Political, social, and personal freedom entails this responsibility for one's decisions and actions. Furthermore, and most importantly, this ethic of free association recognized that the analytic discourse is of a much different epistemological order than is the social discourse of everyday life: one speaks easy and listens easy in a much different way in the analytic discourse about whatever comes to mind as reflected in the fundamental principle of free association. An ethic of free association involves the freedom to think, the freedom to speak easy, and the freedom to live in a permanent state of questioning the "What is" and the "Why" of that "What is," if one so chooses. In such a discourse, one may speak easy, as the principles of strict confidentiality extend to the very existence of the analytic relationship itself.
It is in the very freedom to think, to speak, and to question in such a discourse that a different relationship to self is possible, one in which there might be new possibilities for thought or action (Rajchman, 1985). Therein is to be found one's personal freedom in the capacity to choose among these possibilities. Freedom, power, and possibilities intersect in this most personal of freedom: The freedom to choose from various possibilities is power, and the power to choose among these possibilities is personal freedom. This personal freedom includes making those political, social, and personal decisions with which society, family, or analyst might individually or collectively disagree. Differences amongst people in the decisions they might make, however, are considered to be the stuff of life in contrast to evidences of psychopathology. The tolerance for such differences among people is respectful of a fundamental political freedom arising from the nature of responsibility as subjectively located in the individual. Authority and responsibility for one's own decisions and actions are inalienably one's own. Personal responsibility walks hand in hand with such personal freedom.
The question of ethics in psychoanalysis, from this perspective, has a plurality of complex principles and is not reduceable to a set of uniform rules, universal laws, or abstract master principles modeled after a nineteenth-century view of science. Psychoanalysis is understood as art rather than science and is conceptualized as an ideographic enterprise without nomothetic laws. As a unique psychological discourse, the analytic discourse is constituted by ethical principles internal to it, the principles of which derive from the context that structures the specific meanings of the discourse. In such a discourse, the character and the moral integrity of the analyst is central and fundamental. In such a discourse, the analyst's personal ethic is his or her professional ethic. Such a discourse is regulated only through the ethical integrity and mutual agreements of the analyst and the analysand, both of whom are assumed to be capable of deciding, determining, and managing the best and most appropriate parameters of the discourse.
In the United States, the identity of an analyst has been inextricably linked by history and politics with the ethical duties and responsibilities of a health care professional. This identity has shaped a medical code of ethics with its largely unquestioned ethic of caring. Such a code of ethics, with its implicit and explicit theory of moral obligation to the collective, coercively erodes individual responsibilities and freedoms in the analytic discourse. Furthermore, attempts to bring the unique discourse of psychoanalysis in line with other forms of rationality, normative principles, and scientific propositions may be at the cost of divesting psychoanalysis of its essence. Ethics in psychoanalysis has become inseparable from a medicalized system of logic, beliefs, and values. Questions not consistent with this core ideology have been discouraged and suppressed. Questions consistent with and perpetuating the dominating rationality of symptomatology, etiology, and pathology have been encouraged. From this perspective, a uniform code of medical ethics is, by definition, inherently antithetical to those versions of psychoanalysis situated in philosophy, the humanities, and the arts. There is an absolute incompatibility of such versions of analysis with health care and accreditation standards. This is not to suggest, however, an abandonment of ethics. To the contrary, ethics as values and judgments returns again and again in the very question of ethics in the lived experiences of the analytic discourse.
The practice of psychoanalysis is the practice of morality and ethics. Psychoanalysis involves the freedom to continuously place into question the morality and ideology of the culture and the very personal identity and ethic of the analysand, and of the analyst. Rajchman (1991) encourages making the question of ethics an unavoidable part of ethics and, in so doing, no longer separating who we think we are as analysts from what we think is proper in analysis, or what the good is assumed or prescribed to be in its discourse. If the question of ethics is to be an integral aspect of ethics, then the analyst, it seems, must resituate herself or himself in a place in which identity as an analyst as a health care professional is neither assumed, nor sought, nor received. In this place, identity as an analyst, itself, must be continuously questioned. Such questioning reintroduces the question of our bonds with one another and our communal understanding as to the question of ethics; disrupts and disturbs the complacency encouraged by medicalized traditions, assumptions, and ways of thinking; and, serves as the impetus to reconsider, reexamine, and rethink our received ethical doctrine and its values. There is a pressing urgency to do so. In so doing, we speak to the as of yet unspoken ethical questions in psychoanalytic theory, practice, and education.
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This paper was originally published in The Psychoanalytic Review Vol. 86, No. 4, August 1999. It is reprinted here with permission. Copyright 1999, Patrick B. Kavanaugh.
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