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Monday, 26 March 2012

Patient Autonomy after Death - the Case of Anne Sexton

I hadn't thought about the controversy surrounding Diane Middlebrook's biography of Anne Sexton since its publication in 1991 until I saw a recent Boston Globe article about Dawn Skorczewski's new book about Sexton.

Sexton's first psychiatrist, Dr. Martin Orne, had made tapes of psychotherapy sessions available to Middlebrook, for which he was roundly condemned, as in a New York Times editorial titled "Betrayed: The Poet and the Public":
Anne Sexton likely assumed that the relationship between psychiatrist and patient was as confidential as that between priest and penitent. Anyone who enters therapy does so with that assumption. Confidentiality is at the heart of the process. Betrayal is, or should be, unthinkable.

By taking the tapes, Ms.Middlebrook followed her profession. But by offering them, Dr. Orne dishonored his.
Sexton became Orne's patient in 1956 when she was hospitalized after a suicide attempt. At the time she was a depressed and lost housewife with a high school education. Orne encouraged her to respect her latent strengths and find ways to make her life feel more meaningful. Sexton began to write poetry. Her first book - To Bedlam and Part Way Back was published in 1960. In 1967 she won the Pulitzer Prize for Live or Die.

Sexton's symptoms interfered with remembering what happened in therapy, so in 1960 Orne began to record sessions. Sexton would then listen to the tapes and make notes. This unconventional technique was very useful to her. She continued in treatment with Orne until Orne moved from Boston to Philadelphia in 1964.

But Sexton was never free from the impact of mental illness. On October 4, 1974, a year after separating from her husband of 25 years and being dropped by her third psychiatrist, she committed suicide.

In my review of contemporary comments on Orne's allowing Middlebrook to listen to the tapes, I was impressed with how scathing the criticism was. Dr. Willard Gaylin, Professor of Psychiatry at Columbia and co-founder of The Hastings Center, who I admire but do not know, said:
Doctors have no obligation to history and certainly should not act as a research assistant to a biographer...[Dr. Orne's actions were] a betrayal of his patient and his profession.
And my good friend Dr. Jeremy Lazarus, who in 1991 was chair of the American Psychiatric Association Ethics Committee and is now President-elect of the American Medical Association, commented:
A patient's right to confidentiality survives death. Our view is that only the patient can give that release. What the family wants does not matter a whit.
The position Drs. Gaylin and Lazarus took about Orne's release of the tapes followed from an opinion rendered by the American Psychiatric Association Ethics Committee in 1983:
Question: Can I give confidential information about a recently deceased mother to her grieving daughter?

Answer: No. Ethically, her confidences survive her death. Legally this is an unclear issue varying from one jurisdiction to another. Further, there is a risk of the information being used to seek an advantage in the contesting of a will or in competition with other surviving family members.
 Three years later the Ethics Committee was questioned as to whether this opinion was too rigid:
Question: It seems to me your earlier opinion about revealing confidential information after the death of a patient is too restrictive. Can there be exceptions?

Answer: Theoretically, yes, although such a circumstance has not yet been brought to our attention. As with maintaining the confidences of a living patient, exceptions can be made to protect others from imminent harm or under proper legal compulsion. However, weakening this view reduces our responsibility to living patients who trust us to protect their confidences even after their death.
I agree with the questioner - the 1983 opinion is at best a half truth, and potentially a source of dubious ethical advice.

If the information at question had clearly been regarded as confidential by the deceased person - as by saying "this is for your ears only" - of course the confidence should apply in death as it did in life. But suppose the deceased patient had given no explicit guidance, but had loved and trusted her daughter? If the daughter had asked for information or to talk with the psychiatrist when her mother was living, the psychiatrist would have asked his patient/her mother for guidance. In that spirit, after the patient's death I believe the right thing for the psychiatrist to do is to make the best judgment he can about what his patient would have wanted him to do. Simply treating anything for which explicit anticipatory guidance wasn't given as confidential can result in harms to the living the deceased patient would have wanted to avoid.

That's the thought process Dr. Orne followed with regard to the psychotherapy tapes. In an op ed in the New York Times he wrote:
In 1964, when I left Massachusetts, I offered to return all of the therapy tapes to Anne. She asked that I keep them to use as I saw fit to help others, though she retained a few for herself...In the judgment of all who knew her well, Anne definitely would have wanted the tapes released exactly as was done. What others would see as exposure, she saw as honesty. Sharing her most intimate thoughts and feelings for the benefit of others was not only her expressed and enacted desire, but the purpose for which she lived.
Posthumous judgments aren't infallible. If there's life after death, Anne Sexton's spirit might say - "Doc, you got it all wrong about the tapes!" But Orne made a responsible determination, based on his own direct experience with Sexton, the view of her daughter (the executor), and the views of people like poet Maxine Kumin, Sexton's best friend. That kind of judgment is the best we can do.

What survives a patient's death is our commitment to conducting the relationship in accord with the patient's wishes within the parameters of professional responsibility. If a patient wanted revenge against a family member we wouldn't carry it out. But on the basis of a thoughtful conclusion that Anne Sexton would have wanted Diane Middleton to be able to listen to the tapes, Orne was continuing to relate to his patient in a respectful, caring manner!


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