Legalism, Countertransference, and Clinical Moral Perception

Abstract

This target article focuses on dynamics that arise in three typical ethically complex cases in which psychiatric consultations are requested by physicians: a dying patient refuses life-prolonging treatment, an uncooperative patient demands to be allowed to go outside and smoke, and an angry patient demands to be admitted to the hospital. The discussion canvasses what is at stake morally and clinically in each of these cases and explores clinician-patient interactions, dynamics in relationships between consulting physicians and consultant psychiatrists, patient transference, and physician countertransference. The article defines legalism and countertransference and argues that an ethically and clinically important consequence of these phenomena for patients is distortion of clinicians' perceptions of patients' decisions and vulnerabilities. The discussion also describes how legalism and countertransference adversely affect how clinicians treat their psychiatrist colleagues. Finally, the article suggests how the effects of legalism and countertransference can be mitigated.

How Should Clinicians Respond to Transference Reactions with Cancer Patients?

“…More specifically, transference can be understood as repetition of feelings, attitudes, and behaviors attached to early formative relationships in the context of a therapy relationship [6]. The clinician's unconsciously motivated response to a patient is known as countertransference [7]. Utilizing transference (and countertransference) in understanding patients, the ethical complexities of interacting with seriously ill patients [6], and promoting healing is at the heart of the psychotherapeutic process.…”

“…In the same way that patients develop a variety of emotions toward the physician based on their past experiences, physicians bring their past to the room as well, and these memories-along with the patient's transference-may unconsciously influence their reactions to a patient [7]. While it is normal to have all kinds of feelings towards the patient, it is important to recognize and manage these emotional responses.…”

Do All Physicians Need to Recognize Countertransference?

“…Multiple authors have suggested how patient and physician satisfaction can improve and physicians can practice medicine more effectively and empathically if they pay attention to their own feelings in complicated patient care encounters (Halpern 2007;Novack et al 1997). Rentmeester and George (2009) have provided important insights by elaborating on countertransference's influence on the genesis of ethical dilemmas. While their work is an important addition to the literature, their conclusion that physicians must learn to recognize countertransference to prevent ethical dilemmas fails to consider the complexity in integrating its teaching into current medical curricula and the insufficient evidence base demonstrating its effectiveness.…”

What Reason Can Do for Clinical Moral Perception

“…

The need for expansive, generous clinical moral perception and for mutual regard and respect in physician-patient and physician-physician relationships is the central lesson of the valuable target article by Rentmeester and George (2009). But their approach-how they discern and frame problems, how they analyse and argue about problems, and how they develop recommendations for handling problems and for institutional responses to prevent problems-evinces an equally important lesson about the nature of method and reason in bioethics in particular and medicine and morality in general (and, indeed, elsewhere).

…”

“…The approach of Rentmeester and George (2009) emphasizes that physicians as well as patients are vulnerable human beings who experience emotions that can either support or hinder doctor-patient relationships. In particular, emotional distress can distort judgement and corrode, if not block, relationships.…”