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Promise not to tell a soul

You Have to Promise Not to Tell a Soul, by Rick Brenner

You’re at lunch with one of your buddies, who’s obviously upset. You ask why. “You have to promise not to tell a soul,” is the response. You promise. And there the trouble begins.
Someone, sometime in the past month, has probably asked you, “If I tell you this, do you promise not to tell a soul?” If this has happened to you, you probably agreed. And it’s reasonably likely that you later heard the same story in a slightly different form from somebody else, which meant that someone other than you was spreading the word. You were respecting a confidence, while others were out there blabbing. CLICK on title to read the rest of this article.

Harvard Medical School in Ethics Quandary

March 3, 2009

Harvard Medical School in Ethics Quandary

BOSTON — In a first-year pharmacology class at Harvard Medical School, Matt Zerden grew wary as the professor promoted the benefits of cholesterol drugs and seemed to belittle a student who asked about side effects.

Mr. Zerden later discovered something by searching online that he began sharing with his classmates. The professor was not only a full-time member of the Harvard Medical faculty, but a paid consultant to 10 drug companies, including five makers of cholesterol treatments.

“I felt really violated,” Mr. Zerden, now a fourth-year student, recently recalled. “Here we have 160 open minds trying to learn the basics in a protected space, and the information he was giving wasn’t as pure as I think it should be.”

Mr. Zerden’s minor stir four years ago has lately grown into a full-blown movement by more than 200 Harvard Medical School students and sympathetic faculty, intent on exposing and curtailing the industry influence in their classrooms and laboratories, as well as in Harvard’s 17 affiliated teaching hospitals and institutes.

They say they are concerned that the same money that helped build the school’s world-class status may in fact be hurting its reputation and affecting its teaching.

The students argue, for example, that Harvard should be embarrassed by the F grade it recently received from the American Medical Student Association, a national group that rates how well medical schools monitor and control drug industry money.

Harvard Medical School’s peers received much higher grades, ranging from the A for the University of Pennsylvania, to B’s received by Stanford, Columbia and New York University, to the C for Yale.

Harvard has fallen behind, some faculty and administrators say, because its teaching hospitals are not owned by the university, complicating reform; because the dean is fairly new and his predecessor was such an industry booster that he served on a pharmaceutical company board; and because a crackdown, simply put, could cost it money or faculty.

Further, the potential embarrassments — a Senate investigation of several medical professors, the F grade, a new state law effective July 1 requiring Massachusetts doctors to disclose corporate gifts over $50 — are only now adding to pressure for change.

The dean, Dr. Jeffrey S. Flier, who says he wants Harvard to catch up with the best practices at other leading medical schools, recently announced a 19-member committee to re-examine his school’s conflict-of-interest policies. The group, which includes three students, is to meet in private on Thursday.

Advising the group will be Dr. David Korn, a former dean of the Stanford Medical School who started work at Harvard about four months ago as vice provost for research. Last year he helped the Association of American Medical Colleges draft a model conflict-of-interest policy for medical schools.

The Harvard students have already secured a requirement that all professors and lecturers disclose their industry ties in class — a blanket policy that has been adopted by no other leading medical school. (One Harvard professor’s disclosure in class listed 47 company affiliations.)

“Harvard needs to live up to its name,” said Kirsten Austad, 24, a first-year Harvard Medical student who is one of the movement’s leaders. “We are really being indoctrinated into a field of medicine that is becoming more and more commercialized.”

David Tian, 24, a first-year Harvard Medical student, said: “Before coming here, I had no idea how much influence companies had on medical education. And it’s something that’s purposely meant to be under the table, providing information under the guise of education when that information is also presented for marketing purposes.”

The students say they worry that pharmaceutical industry scandals in recent years — including some criminal convictions, billions of dollars in fines, proof of bias in research and publishing and false marketing claims — have cast a bad light on the medical profession. And they criticize Harvard as being less vigilant than other leading medical schools in monitoring potential financial conflicts by faculty members.

Dr. Flier says that the Harvard Medical faculty may lead the nation in receiving money from industry, as well as government and charities, and he does not want to tighten the spigot. “One entirely appropriate source, if done properly, is industrial funds,” Dr. Flier said in an interview.

And school officials see corporate support for their faculty as all the more crucial, as the university endowment has lost 22 percent of its value since last July and the recession has caused philanthropic contributors to retrench. The school said it was unable to provide annual measures of the money flow to its faculty, beyond the $8.6 million that pharmaceutical companies contributed last year for basic science research and the $3 million for continuing education classes on campus. Most of the money goes to professors at the Harvard-affiliated teaching hospitals, and the dean’s office does not keep track of the total.

But no one disputes that many individual Harvard Medical faculty members receive tens or even hundreds of thousands of dollars a year through industry consulting and speaking fees. Under the school’s disclosure rules, about 1,600 of 8,900 professors and lecturers have reported to the dean that they or a family member had a financial interest in a business related to their teaching, research or clinical care. The reports show 149 with financial ties to Pfizer and 130 with Merck.

The rules, though, do not require them to report specific amounts received for speaking or consulting, other than broad indications like “more than $30,000.” Some faculty who conduct research have limits of $30,000 in stock and $20,000 a year in fees. But there are no limits on companies’ making outright gifts to faculty — free meals, tickets, trips or the like.

Other blandishments include industry-endowed chairs like the three Harvard created with $8 million from sleep research companies; faculty prizes like the $50,000 award named after Bristol-Myers Squibb, and sponsorships like Pfizer’s $1 million annual subsidy for 20 new M.D.’s in a two-year program to learn clinical investigation and pursue Harvard Master of Medical Science degrees, including classes taught by Pfizer scientists.

Dr. Flier, who became dean 17 months ago, previously received a $500,000 research grant from Bristol-Myers Squibb. He also consulted for three Cambridge biotechnology companies, but says that those relationships have ended and that he has accepted no new industry affiliations.

That is in contrast to his predecessor as dean, Dr. Joseph B. Martin. Harvard’s rules allowed Dr. Martin to sit on the board of the medical products company Baxter International for 5 of the 10 years he led the medical school, supplementing his university salary with up to $197,000 a year from Baxter, according to company filings.

Dr. Martin is still on the medical faculty and is founder and co-chairman of the Harvard NeuroDiscovery Center, which researches degenerative diseases, and actively solicits industry money to do so. Dr. Martin declined any comment.

A smaller rival faction among Harvard’s 750 medical students has circulated a petition signed by about 100 people that calls for “continued interaction between medicine and industry at Harvard Medical School.”

A leader of the group, Vijay Yanamadala, 22, said, “To say that because these industry sources are inherently biased, physicians should never listen to them, is wrong.”

Encouraging them is Dr. Thomas P. Stossel, a Harvard Medical professor who has served on advisory boards for Merck, Biogen Idec and Dyax, and has written widely on academic-industry ties. “I think if you look at it with intellectual honesty, you see industry interaction has produced far more good than harm,” Dr. Stossel said. “Harvard absolutely could get more from industry but I think they’re very skittish. There’s a huge opportunity we ought to mine.”

Brian Fuchs, 26, a second-year student from Queens, credited drug companies with great medical discoveries. “It’s not a problem,” he said, pointing out a classroom window to a 12-story building nearby. “In fact, Merck is right there.”

Merck built a corporate research center in 2004 across the street from Harvard’s own big new medical research and class building. And Merck underwrites plenty of work on the Harvard campus, including the immunology lab run by Dr. Laurie H. Glimcher — a professor who also sits on the board of the drug maker Bristol-Myers Squibb, which paid her nearly $270,000 in 2007.

Dr. Glimcher says industry money is not only appropriate but necessary. “Without the support of the private sector, we would not have been able to develop what I call our ‘bone team’ in our lab,” she said at a recent student and faculty forum to discuss industry relationships. Merck is counting on her team to help come up with a successor to Fosamax, the formerly $3 billion-a-year bone drug that went generic last year. But Dr. Marcia Angell, a faculty member and former editor in chief of The New England Journal of Medicine, is among the professors who argue that industry profit motives do not correspond to the scientific aims of academic medicine and that much of the financing needs to be not only disclosed, but banned. Too many medical schools, she says, have struck a “Faustian bargain” with pharmaceutical companies.

“If a school like Harvard can’t behave itself,” Dr. Angell said, “who can?”

Copyright 2009 The New York Times Company

Things We are not Suppose to Admit

Janet Atwell asked:

My children are grown. My daughter will soon be 31, she has two daughters that are 9 and 10, and my son just turned 25 a couple of months ago, he has a 2-year-old son. I have been watching them with their children and I see many of the parental characteristics in them that I saw in myself and their father. Some of which were wrong!

We all make mistakes of course but to see them repeated by our children is the ultimate slap in the face. We hope that we have taught them better. We had hoped that we were honest enough to tell our kids, “Hey, I was wrong when I did such and such, don’t repeat that mistake.” In many respects, I have done just that. I try to keep my mouth shut as the kids are dealing with their own children and talk to them when the grandkids are not around. It is hard; but, (for the most part), I have been able to do just that.

On occasion, I find myself compelled to contradict my children in front of my grandchildren. They resent it of course but how can you sit by and see those little faces in such emotional stress when Daddy or Mommy is harping about something that we ourselves harped over, knowing that we, and in their turn, our children are also wrong. Especially if a spanking or sitting in a corner is involved.

My daughter does not spank. My son does. My daughter admits that there were times when the spankings she got were the only thing that prevented her from doing other things later on. My son remembers, and resents, every spanking he ever got. (In his memory, there were more than he actually got and they were each more severe than in reality.) He swears that they never helped him or hindered him in any way.

As I watch my children, especially my daughter, with their own kids I find myself wondering about the values they are teaching them. For example I do not at any time remember telling my kids, “You are (or, I am) no better than anyone else.” I never said to them, “I don’t care what others think of me.” Although I did say, “Don’t be concerned about what people call you; be concerned about what names you answer to.”

Recently I found myself asking my daughter about this ‘You aren’t any better than anyone else’ thing. Her response was, “Well they aren’t Mom and neither are any of the rest of us.”

I realize, of course, that the context of my daughter’s statement has a lot to do with what she is trying to teach my grandchildren but in this case, it was not to reprimand a prejudice against a person that was poorer than my granddaughter or another color or not quite as smart as she is. (This particular granddaughter is a genius.) It was in reference to a bully of sorts that my granddaughter had denied the permission to come to a sleepover party. This bully happens to be the daughter of one of, my very much younger, first cousins.

“I have to argue with that ‘You are no better’ comment. I am better than a lot of people and not quite as good as others.” I told my eldest child. She appeared somewhat shocked by this statement.

“Mom! How can you stand here with your certificate of ordination hanging above your head and say such a thing?” she wailed.

“How can you sit there and put yourself, or more to the point, my granddaughter in the same class with a bully?” was my response.

That is the key to my argument with statements such as these. I am better than say the rapist, the murderer, the liar. I do not rape, murder, molest children, (or adults for that matter) or lie just to hear my own voice the way some do. I would never rape, molest or lie just to hear my own voice under any circumstances. In fact, my children used to warn all their friends and their friends parents that before asking me a question, on any subject at all, they should first ask themselves if they really wanted the answer, because I would give it to them even if it hurt one of us. It was a point of pride for both me and my children.

Of the four things mentioned in the paragraph above, (as you may have noticed) there is only one of which I feel that I might be induced into committing. That one is murder. Yes, murder is something that I am quite capable of committing. If my life or the life and or safety of my loved ones were threatened, I could and would kill. In my mind, I would justify it as self-defense or defense of that loved one but it would still in effect be murder. “Thou shall not kill.” says the Bible. The Bible never makes any reference to self-defense, it does not say, “Thou shall not kill unless thou art threatened.” Therefore, no matter how I lived with the act on a personal level, it would still in effect be murder. That is beside the point.

The point is that I am better than some people. I am not as good as others. I know a couple of people that would give their lives for others. We have several of our young people doing just that every day. More now, with the war in the Middle East. I would not. I do not agree with this war. I did not agree with it from the start. I do not know how I would feel or how I would react to a war that I felt justified. I am not young enough to be involved and have never faced such a situation in my youth.

I know people that will give the last morsel of food that they have to a person in need, even when they themselves are hungry. I am not one of those people.

That is not to say that I have not given to the needy, I have. I have even given most of what I have to someone in need before. I was not hungry at the time and I did retain enough food to sustain myself, in comfort, until I could get more. So yes, I think that those people that would have given all that they had in the same situation are better than me. I am glad that they exist because they give us all hope. I wish I was one of them but the fact that I am not is something that I have to live with and accept.

As for the, “I don’t care what others think of me” statement, who do we think we are kidding when we say that? I care what others think of me. I care that just before this paragraph I admitted to something I consider a character flaw in myself and that you are reading it and could have thought better of me had I not admitted it.

I remember a time when my daughter came home each day from school crying. I discovered, after a lot of cajoling and digging, that she was being teased by a group of what was then called, ‘the preps’. Apparently they had discovered that my daughter was not in fact one of them even though they had accepted her during the previous two years of school. You see I was a truck driver. It would have been different if I had worked in an office and my husband had driven a truck but the facts were that my husband had no interest in working at all and that I was the breadwinner of the family.

I had worked in an office for several years. One of the biggest law firms in Chicago in fact. I had been a litigation expert. However, it did not pay well enough. I had another full time job at the same time, working nights in a 24-hour veterinary clinic and kennel. I also waited tables on the weekends and still, when it came time to send my daughter to junior high, I was unwilling to send her to the local public school and could not afford private schooling. I had to do something and there was no time left in my weeks for yet a fourth job. I studied chemistry and got a job cleaning up and hauling hazardous waste, the highest paying position I could find.

Being self educated and terrible at math, the chemistry did not come easy to me. The driving was something that I was not exactly a natural at. Nevertheless, I found it was necessary and we do what we must when it is for our children. I was proud of my accomplishment. My daughter was harassed because of it.

I won’t tell you what the general opinion of a woman driving a truck alone was; it was nasty and not relevant to this writing. The fact is that while my daughter now tells her children that she doesn’t care what others think about her and they shouldn’t care what they are called either, she did care about what I was called when she was even older than they are now.

In my work on a community newspaper recently, I found myself in a position where I was able to interview several of the more prominent members of the community, members of the community that seemed to be involved with every volunteer project that came along. (I was involved in quite a few myself.) Those that allowed themselves the luxury of being honest, (after I promised not to reveal any names) admitted that they had not actually considered it consciously but that yes, they started getting involved in community affairs to be thought of as ‘better people’ by the ‘regular’ members of the community.

One person, whom shall remain nameless, admitted that he became involved in community volunteer work because he intended to be the mayor of a certain community when he retired. He is the mayor of that community.

One exceptionally honest member of a volunteer committee even admitted that she joined a local church and appeared devout specifically to be thought better of by others.

The bottom line is that most of us do care what others think of us. Some of us do nothing to raise the opinion of others about ourselves and some of us do. Some of us will hear a nasty name called and wonder if it is directed at us and be bothered about it. Some of us will hear a nasty name and be bothered knowing it is directed at us and others will hear a nasty name, know it is for them and not care at all.

I am glad to be among one of those that care, it makes me a better person.

Ethical Situations in Counselling

Pedro Gondim asked:

A prominent aspect of counsellor training involves the analysis of ethical situations. Counsellors need to be malleable to the variety of situations in which the client’s personality traits and environmental circumstances are prominent barriers to the relationship’s progress.

Codes of practice, ethical guidelines and counselling micro-skills play a role in supporting the counsellor’s decision-making process towards the relationship; however, client and situation uniqueness are not the exception in the therapeutic process – they reign supreme. Effective counselling invokes the ongoing need for adaptability and critical analysis.

In this context, three situations which frequently give rise to ethical dilemmas are dual relationships, mandatory reporting and informed consent. Are you aware of the particular conditions which delineate each of these situations, and how to act upon them? This article provides a snapshot of the topic, along with some strategies for practising and student counsellors who are likely to face similar situations throughout their careers.

Dual Relationships

Dual relationships can be defined as social interactions between counsellor and client, in addition to their professional (or therapeutic) relationship. Because the relationship was initiated in a therapeutic environment – which invokes behavioural restrictions and requires particular decorum from both entities – clients and counsellors are likely to face natural obstacles when developing relationships outside of the counselling room.

As Corsini (2000, p. 447) states: “It is often awkward for both the therapist and the client when interactions occur outside the psychotherapeutic relationship. Some relationships, such as those that include sexual or financial involvement, clearly violate the ethical codes of almost all professional organizations. Others, such as allowing a client to buy the therapist a cup of coffee after a chance meeting in a restaurant, appear to be quite harmless. Most decisions are not this straightforward, however, and deciding whether to accept a Christmas gift or flowers for the waiting room can become a vexing dilemma”.

The main question to be asked is how much influence particular social interactions can wield in the professional relationship – that is, the counsellor’s perspective towards the client, and vice-versa. Simple interactions, such as a chat on the street or even the cup of coffee cited by Corsini are likely to have little influence over both entities’ mindsets, thus it is generally not perceived as a challenging situation. But certain situations which induce emotional attachment can be damaging to counselling goals and/or outcomes.

Mental health professionals diverge in opinions when it comes to dual relationships. However, the vast majority of therapists agree that dual relationships should be avoided, arguing that transference and counter transference are powerful responses that will inevitably influence the therapeutic relationship. Along with most ethical dilemmas, it is largely a matter of each case: context, individual personality traits and nature of the counselling relationship.

According to Karen Kitchener (1988), the types of dual relationships which were most likely to be detrimental to a therapeutic relationship included the following aspects: “incompatibility of expectations between roles; diverging obligations associated with different roles, which increases potential for loss of objectivity and; increased power and prestige between professionals and consumers, which increases the potential for exploitation”.

To surpass difficulties with dual relationships, counsellors ought to ascertain clear and realistic boundaries around the professional relationship with their clients. Such boundaries need to consider the needs and characteristics of each client, and how that will reflect in the overall relationship. Codes of practice and guidelines are important to set these boundaries; however, professionals must be sensitive to particular needs in each relationship and apply such knowledge to improve decision-making in the counselling process.

Mandatory Reporting

Mandatory reporting, or duty to warn, is one of the most sensitive topics in therapy and mental health. The bare existence of this concept already conflicts with ethical principles of confidentiality, thus deciding to report a client is a paradoxical pattern of thinking for any such professional. Nevertheless, it is an extremely important issue.

It can be defined as the necessity to break client confidentiality in order to protect the client or the community as a whole, when the client imposes a threat to his/her own safety, the community’s safety or the framework of law to which the community abides by. When laws and values conflict, which side should you take? Most cases of information disclosure in therapy are for the benefit of the client, such as sharing information with colleagues or supervisors in order to obtain an alternative opinion or perspective. However, when it comes to mandatory reporting, best interest of the community or society are preceded over the client’s interests. Thus, the default answer to the previous question is in fact, the law.

Needless to say, counsellors should be flexible when making decisions regarding mandatory reporting. There are several law frameworks which govern countries, states and regions, and each of them has its own agenda in respect to mandatory reporting requirements. Additionally, a wide variety of codes of conduct are also likely to influence the decision-making process for therapists and mental health professionals.

A common basis for reporting a client is the imminence of danger for the individual (self harm) or others (e.g. an ex-partner). “Exceptional circumstances may arise which give the counsellor good grounds for believing that serious harm may occur to the client or to other people. In such circumstances the client’s consent to change in the agreement about confidentiality should be sought whenever possible unless there are also good grounds for believing the client is no longer willing or able to take responsibility for his/her actions. Normally, the decision to break confidentiality should be discussed with the client and should be made only after consultation with the counselling supervisor or if he/she is not available, an experienced counsellor.” (Australian Counselling Association – Code of Conduct)

Informed Consent

Informed consent involves the communication of any information which matters to the client and which is pertinent to the therapeutic relationship. A building aspect of the client-counsellor relationships is the development of trust and rapport. A premise for creating trust and rapport is good communication. Good communication, conversely, is based on honesty. Thus, informed consent is not only an ethical requirement for the counsellor, but also a condition to achieve the collective goals of the relationship.

“Clients are entitled to know about all matters that affect them. They deserve to know the likelihood of harm (physical or mental) that could result from treatment, the possibility of side effects, the probability of success for treatment, the limits of confidentiality, whether student counselors will be involved, and the likely duration and cost of treatment.” (Corsini, 2000)

An effective way to ensure clients are adequately informed is to produce a standard information disclosure statement: a contract which comprises the counsellor’s and clients’ responsibilities and rights. A well-defined statement will provide the client with valuable information about areas such as: confidentiality, record-keeping, counselling management, relationship boundaries, and more. It is also a measurement which improves the quality of the service provided as it creates a clear framework of conduct for clients which are not acquainted with the process of therapy.

“Counsellors are responsible for reaching agreement with their clients about the terms on which counselling is being offered, including availability, the degree of confidentiality offered, arrangements for the payment of any fees, cancelled appointments and other significant matters. The communication of essential terms and any negotiations should be concluded by having reached a clear agreement before the client incurs any commitment or liability of any kind.” (Australian Counselling Association – Code of Conduct)

Reference List:

Australian Counselling Association (2002). ACA Code of Conduct. (4th version). Brisbane: Author. Corsini, R., & Wedding, D. (2000). Current Psychotherapies. (6th Edition). Belmont: Brooks/Cole. pp. 445-453. Kitchener, K. S. (1988). Dual role relationships: What makes them so problematic? Journal of Counseling & Development, 67(4), pp. 217–221.

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