Sexton's last tapes

...So it is that the courts, as in the Tarasoffcase, must adjudicate the fine line between an obligation to a patient and an obligation to society, in that case the endangered girlfriend...

...God was the omniscient author, but he died," Ronald Sukenick famously claimed in his story "The Death of the Novel": Authors can no longer manipulate their characters in imitation of a divine will, since divine will has absconded, leaving the earthlings grappling with metaphysical and textual confusion...

...The controversy has swirled around the release of her complete psychotherapy record including more than 300 audiotapes by Martin Ome, one of Sexton's psychiatrists...

...i DEAD, BUT STILL WITH US BARTHELME'S FADING CATHOLIC INTUITIONS PAUL GILES " ' ~ espite being brought up Roman Catholic and attending parochial schools, Donald Barthelme clearly cannot be thought of as a religious writer in any orthodox sense...

...He seems to have concluded that she would have agreed to the tapes' release, particularly because of the possible benefits to others...

...The majority opinion in that case, though recognizing the importance of the patient's privacy and the confidential nature of psychotherapeutic treatment, argued in favor of the "public interest in safety from violent assault...

...These are familiar arguments, and in their own way they are true enough...

...9 efore answering this question, there are two funD damental moral considerations...

...indeed, many patients have...

...Although release of the tapes violated Sexton's privacy and breached doctor-patient confidentiality, Orne says that Sexton "would have jumped at the opportunity to share what we did...

...SEXTON'S LAST TAPES BREAKING THE SEAL OF THE THERAPIST'S CODE JAMES E KEENAN biography of the poet Anne Sexton has been published with all of the notoriety and penchant for self-exposure that seems to have characterized much of her life, which she ended, a suicide, in 1974 (Anne Sexton: A Biography, by Diane Wood Middlebrook, Houghton Mifflin, 488 pp., $24.95...

...Orne gave the record to the biographer with the agreement of Sexton's daughter who is also her literary executor...

...Sexton's daughter and friends raised no objection to Orne's release of the tapes to Middlebrook...

...But is this supposition correct...

...His suspension of the rule would be valid if his obligation rests only on her individual right to confidentiality...

...Nevertheless, the philosophical and theological paradoxes in Barthelme's works demonstrate a fascinating example of the Catholic literary sensibility at work...

...Orne's release of Anne Sexton's records to her biographer is a dramatic departure from ethical norms and the exceptions permitted by the law and professional practice...

...Other instances where a psychiatrist would be asked by the patient to breach confidentiality might include civil procedures, such as divorce or child custody, or criminal cases where the defendant petitions the psychiatrist to testify on the defendant's own behalf...

...Certainly others may be harmed...

...Here the psychiatrist's judgment must be finely balanced, taking into consideration the dangers of violating confidentiality and the impact of treating a patient in a paternalistic fashion over against the urgency that someone's life is endangered...

...The dissenting opinion highlighted the singular importance of confidentiality: "First, without substantial assurance of confidentiality, those requiring treatment will be deterred from seeking assistance...

...Orne maintains confidentiality not because he is Sexton's psychiatrist, but because he is a registered psychiatrist...

...In the case of Orne and Sexton, there would be no need for a more urgent rule if Orne's obligation of confidentiality could be suspended by Sexton's consent, or, as he seemed to argue, her implicit consent...

...If he is obliged because she made confidentiality a condition of her therapy, then he is free of that obligation if she changes that condition...

...In releasing her record, Ome is reported in the Times story to have been motivated by a desire to show that troubled people, like Sexton, could be helped by therapy to overcome their mental and emotional conditions, and even become productive and successful people...

...It is possible that by releasing the records, Orne may JAMES E KEENAN, S.J...

...Unlike writers such as Flannery O'Connor or his friend Walker Percy, Barthelme, who died in 1989, had almost nothing to say about his childhood religion or its influence upon his subsequent work...

...Of course there is some truth in the fact that the confidentiality of their sessions rested with Sexton, because she was always free to discuss her therapy with anyone...

...The late Paul Ramsey in a widely cited article, "The Case of the Curious Exception," showed that an exception to any general role requires that the exception itself be justified by and be subject to another rule...

...Only more urgent rules, related to a psychiatrist's other responsibilities, could override the responsibility to maintain a confidence...

...But is it simply Sexton's right to confidentiality that binds Orne to his obligation...

...Most readers will probably share the supposition that Orne's actions are fight or wrong according to whether they think Sexton would have granted the release...

...Independently these three common points are not sufficient grounds for breaking confidentialy...

...It was during Sexton's eight-year therapy with Orne that she first began writing poetry...

...So, for example, a psychiatrist might break a confidence when a patient wants to get a job and asks the therapist to certify that he or she is capable of assuming, or reassuming, a position...

...But apart from her views on the matter, the central issue remains: Every breach of patient confidences affects the profession of psychiatry and the entire community...

...The exception being made in the Tarasoffcase, where the patient actually carried out his threat and killed his girlfriend, is that a psychiatrist must take steps to protect an endangered life even at the cost of breaching patient confidentiality...

...By accepting these recognitions of his training and skills, he also accepts responsibilities, obligations, and duties, which are not private, but public...

...Despite his avowed agnosticism, Barthelme in fact shares at least as many conceptual characteristics with the avowed believer Walker Percy as he does with his more obvious generic companions, PAUL GILES teaches English at Portland State University in Portland, Oregon...

...But while Barthelme can be interpreted synchronically, in terms of the postmoderuist culture of his time, he can also be interpreted historically through the perspective of a Catholic cultural tradition of radical antihu8 November 1991:637...

...Quite clearly, Dr...

...only that, generally speaking, while the patient's authorization is necessary, it alone is not sufficient justification for releasing a 636: Commonweal therapist from confidentiality...

...Under such circumstances, the therapist could conclude that patients' fears of betrayal would be significantly diminished...

...That Sexton's daughter found much of the material (some of which concerns herself) "extremely painful," as one supposes others may as well, makes clear how little benefit there is likely to be in this transaction...

...This does not mean that the decision to follow a more urgent rule should normally be made without the patient's consent (obviously in a case like Tarasoff, the court's ruling would require the psychiatrist to act whether he had the patient's consent or not...

...Orne could, of course, press his case further: Since he believes Sexton would have concurred in the release, he could say that he did not breach confidentiality so much as presume that she implicitly suspended him from that obligation...

...Orne's obligation, I believe, precedes Sexton's right: the obligation existed before she---or any patient---ever entered his office...

...Should he have done it...

...For much the same reasons, the psychiatrist's breach of confidence is qualitatively different from a friend's breach...

...Second, the guarantee of confidentiality is essential in eliciting the full disclosure necessary for effective treatment...

...While the court's decisive exception to the general rule shows that the rule does not hold absolutely, more to the point of this essay, it shows that the rule almost always does hold...

...Considering the degree of difficulty many patients have in confiding their deepest fears and expectations to a therapist or even in beginning treatment because of an inability to trust others, this counterargument seems all the weightier...

...have made the prospect of troubled people seeking therapy less, rather than more, likely...

...some even said the poet would have approved...

...and so it is, that medical societies require their members to maintain the confidentiality of every patient's record, "even after the patient has died," as the World Medical Association did in 1968...

...Thus the question is whether Sexton could give her psychiatrist the right to release the account of her therapy for the sake of a biography...

...Regents of the University of California...

...because his profession is thoroughly institutional, the rightness or wrongness of his actions should be judged under public, institutional norms...

...Orne's own consequentialist rationale--that the record of Sexton's therapy might encourage others to seek psychiatric help---can easily be argued the other way...

...only together do they serve as the conditions where an emerging rule could override the general obligation to maintain confidentiality...

...What is new in this case is the transaction from Orne to Middlebrook...

...A patient--Anne Sexton among them--does not, therefore, possess the authority to free the therapist from confidentiality as a simple matter of course (nor does her daughter, or any other relative or friend...

...On the other hand, the psychiatrist's action is public...

...It is hard to avoid the conclusion that Orne's unilateral decision has caused unnecessary and unjustifiable harm...

...for example, when a patient is a clear and present danger to him- or herself or to another person...

...But his fellow psychiatrists strongly objected...

...Reviewing the biography in the New York Times (August 13), Michiko Kakutani offers substantial evidence from the biography itself that Anne Sexton may have cared far more for her privacy than her daughter, friends, and colleagues think...

...Thus, the law recognizes that a psychiatrist, like a priest, but unlike a friend, enjoys "privileged communication...

...She could...

...And though Sexton is dead and cannot be harmed from the breach of confidentiality, her name and reputation may be...

...His is a world of"epistemological skepticism," as the critic Larry McCaffrey put it, where authority in all its forms--fathers, priests, psychoanalysts--has been overturned, with the result that the authority of the text itself is also necessarily thrown into disarray...

...Third, even if the patient fully discloses his thought, assurance that the confidential relationship will not be breached is necessary to maintain his trust in the psychiatrist--the very means by which treatment is effected" (Tarasoffv...

...it was the psychiatrist, not the patient, who released the records...

...In fact, a patient's authorization is required not because an individual patient claims it, but because the community, through the institution of psychiatry, has established that authorization as ethically mandatory...

...Though we might accept Orne's reasoning, we must still ask whether his whole argument is correct...

...His role in the community as a psychiatrist is recognized by a degree from an academic institution, induction into a society of peers, and a license granted by the state where he practices...

...Certainly his decision to release virtually the entire history of Sexton's eight-year treatment, in order to demonstrate the effectiveness of his clinical methods, does not constitute a serious or urgent reason...

...is assistant professor of moral theology at Weston School of Theology, Cambridge, Massachusetts...

...In his fiction Barthelme prefers fragments rather than linear narratives, collage rather than thematic sequence, irony rather than direct statement...

...All of these exceptions to the general rule of confidentiality have certain common points: the patient's initiative, a matter of urgency, and testimony or judgments that have a direct bearing on the patient's own interests...

...His obligation is not based on the decision of any patient, but rather on the social nature of his profession...

...Orne's action victimizes not only Sexton, but the practice of psychiatry as well as current and future psychiatric patients who rightly expect that theirs is a privileged communication, breached only under certain specific conditions over which they largely have control...

...Sexton seems never to have left instructions about the tapes (New York Times, July 15, 1991...

...Does Sexton have the right to release her psychiatrist from his obligation to maintain 8 November 1991: 63~ confidentiality, which she--and all patients have as alegitimate expectation...

...He could go on to argue that no psychiatrist should ever release any records unless he or she had a reasonable expectation that unavailable former patients would grant the release...

...His release of the tapes may put in jeopardy the confidentiality that patients expect from their psychiatrists...

...The first is that 'i general rules apply generally, and the second, D related one, is what counts as a legitimate excep-,~ tion to general rules...

...postmodernist fabulators such as John Barth or Robert Coover or Thomas Pynchon...

...In the Tarasoff case, the psychiatrist is not so much exempted from the rule of confidentiality as he is obliged to follow the still more important rule that requires he protect an endangered life...

...Such a scenario received considerable attention in a case where the California Supreme Court ruled that a psychiatrist whose patient confided his intention to kill his girlfriend had an obligation to inform the potential victim...

...But even here it is the psychiatrist's judgment about the patient's condition and not a record of the therapy that is being requested...

...Thus an exception to a rule is really the case of another more urgent rule taking precedence...

...That there was debate over the issue even in such an extreme case only underscores the great reluctance we have as a society in releasing a psychiatrist from this critical obligation to maintain confidentiality...

...It is evident enough as well that Barthelme's texts do not subscribe, either explicitly or implicitly, to Catholicism as an accredited system of belief...

...In fact, Orne's obligation to preserve confidentiality exists not because Sexton or any individual has a right to it...

...This brings us to the second moral consideration...

...In the case at hand, the general rule that a psychiatrist not breach patient confidences is strong, but not absolute...

...Please note that the question is not whether Sexton could release her own account of the therapy sessions...

...The friend's betrayal of a secret or a confidence is a private matter and reflects on the individual, not on his or her profession...