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fully predict or control this impact, or even know what aspects of it may have eluded our perception. Our ethical commitments are divided between acknowledging that we need to share clinical material as part of training and advancement in our work, but that this very sharing is a threat to the sacred commitment to our patients’ confidentiality.
The Issue of Digital Capture
The complexity of publishing clinical accounts is magnified by the ubiquity of digital capture of much that is written. Patients can find our articles, even when they are written for obscure journals. Any writer publishing clinical material in the present day should assume that their patients will read their words, given that any patient could indeed do this. The presence of clinical material on psychoanalytic e-journal sites is a particular cause for concern. Increasingly, e-versions of articles become available at the same time as the print edition or may be republished electronically at a later date. Protection and control of this material is often seriously inadequate, while its readership is global and unlimited. Additionally, some journals post submitted articles online, before there is any opportunity to secure the protection of patient confidentiality. This is again concerning in that readership of these articles is global and unlimited.
Conferences frequently advertise online, increasing the risk of patients identifying themselves in the case description.
E-journal and website administrators need to be vigilant to their ethical commitment to protect patients’ confidentiality.
Problems with Disguise; Problems with Informed Consent
In a survey of journal editors, respondents were divided on how to handle publication of clinical material. Some respondents saw consent as a thorny issue with irresolvable and unknown consequences for the patient that should be avoided. They viewed informed consent as unethical due to our inability to fully detect or correctly predict a patient’s reactions when information is shared, along with the risk of après- coup understandings that were unanticipated at the time when consent was requested. They questioned whether informed consent is truly possible, taking account of the unknown influences of transference dynamics. Can a patient truly feel free to say “no” to her analyst? Whereas in most other professions the ethical requirement of informed consent is relatively straightforward, in psychoanalysis it is anything but. The object of analytic inquiry, the unconscious, complicates any notion of informed consent within the transferential field. Neither the analysand nor the analyst can be immediately aware of all the unconscious motives that impel permission for the sharing of clinical material and neither of them can predict the future après-coup impacts of such a decision. There are documented cases in which a patient has given consent to share clinical material and still felt that the analyst breached their trust. These analysts concluded that there is an inherent ethical uncertainty about informed consent in psychoanalysis, given the always-only-partial knowability of transference and countertransference.
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