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1 This article was downloaded by: [Shapiro, Sanford] On: 28 March 2011 Access details: Access Details: [subscription number ] Publisher Routledge Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK International Journal of Psychoanalytic Self Psychology Publication details, including instructions for authors and subscription information: Philosophy and Psychotherapy Part 2: Ethics The Question of the Good George E. Atwood ab a Department of Psychology, Rutgers University, New Brunswick, New Jersey, USA b Institute for the Psychoanalytic Study of Subjectivity, New York, New York, USA Online publication date: 18 March 2011 To cite this Article Atwood, George E.(2011) 'Philosophy and Psychotherapy Part 2: Ethics The Question of the Good', International Journal of Psychoanalytic Self Psychology, 6: 2, To link to this Article: DOI: / URL: PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: This article may be used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

2 International Journal of Psychoanalytic Self Psychology, 6: , 2011 Copyright The International Association for Psychoanalytic Self Psychology ISSN: print / online DOI: / Philosophy and Psychotherapy Part 2: Ethics The Question of the Good George E. Atwood, Ph.D. A dialogue with the anonymous psychiatrist, Dr. E., is presented, dealing with the nature of the ethical values underlying psychoanalytic psychotherapy. A difficult clinical case is the focus of the discussion that of a woman who was not to be deterred from committing suicide and whose deadly plans appeared to raise serious ethical questions for the clinician. Keywords: authenticity; ethical values; suicide; will to live T he following interview is the second in a series exploring the philosophical foundations of psychotherapy. Its subject is ethics: the question of the good. Dr. E., the aging psychiatrist who offers his thoughts, is a gentleman who resists becoming lost in abstractions and who insists on relating all his discussions to a specific clinical case. Our conversation focused on the ethical issues raised by the treatment of a woman who had decided to commit suicide (G.A. = George Atwood): G.A.: Dr. E., good morning! Today I want to continue on philosophical themes, even if the discussion remains entirely in the clinical realm. So, what about ethics? You said in our last discussion about the question George E. Atwood, Ph.D., is a Professor of Psychology at Rutgers University, New Brunswick, NJ; and a Founding Faculty Member of the Institute for the Psychoanalytic Study of Subjectivity, New York. 269

3 270 George E. Atwood of the real that we ended in a nowhere place. Perhaps we could get somewhere by turning to the area of the ethical. Tell me, what is your philosophy in this regard, and how does it become manifest in your career as a psychotherapist? Dr. E.: Here we go again, with cosmically abstract questions, G.A. I suppose I can take a deep breath and force myself to answer you. Here are a few thoughts that appear. We are our brothers and sisters keepers. We are all siblings in the same darkness, as my friend Robert Stolorow likes to say. We are the guardians of the earth and all its living creatures. That is my ethical philosophy, and in my professional work I have always tried to give it expression. I don t want to talk any more about ideas that are posed in this way. Bring the discussion down to a clinical situation, G.A., or I will ask you to pick up your belongings and go away. G.A.: Maybe I can describe a case that raises ethical issues and questions, and we can think about how your philosophical attitude plays out in a specific human context. Then we can discuss further whether you are a philosopher. Although you resolutely deny it, I find much of your discussion has a noteworthy philosophical content. This story involves a tragedy. This is the case of a suicidal patient, a woman of 49, who announced in a tone of certainty that she planned to end her life. It was only a question of when, not if. She showed an interest in the possibility of psychotherapy during the short period she would be remaining alive. She was without question going to kill herself, but considered it potentially beneficial to speak to someone nevertheless about her situation. No one was available to her, however, because all the clinicians she contacted said that they would work to avert her death. She had no interest in speaking to such a person. Dr. E.: And what does this have to do with ethics? G.A.: I ask you what you would do if called upon by this woman? She insisted she was going to end her life, but asked for an opportunity for some counseling over the short period remaining to her. You say we are our brothers and sisters keepers how does this principle apply to someone who has elected to die? Another feature of the situation was that she refused to speak to anyone who would form any sort of attachment to her above all it was required that her therapist, if she could find one, be someone who would not be hurt by her suicide. The freedom to die without having to worry

4 Philosophy and Psychotherapy Part about her therapist s feelings was an absolute condition of her agreeing to undertake the counseling. Dr. E.: So she was looking for someone to talk to who would neither interfere with her planned death nor be negatively affected by it when it occurred. G.A.: Exactly. Dr. E.: This is about something, G.A. May I ask what this could have been? What I would do with her would depend on my understanding of the meaning of her situation. G.A.: Two factors seem to have been involved in her decision: first, that she was the child of Holocaust survivors, and had in her childhood been made to feel the purpose of her existence was to honor the dead rather than live a life of her own; and second, that she had become massively addicted to a variety of drugs and alcohol, and saw no possibility of recovering from this. She said her life had zero meaning for her, was filled with suffering, and needed to end. Dr. E.: I wonder why it was though that she was interested in some form of counseling before her death do you have an answer to this question? G.A.: No, just that she seemed to want to wrap things up in a conversation with someone, if she could find a person who would not obstruct her in carrying out her decision. She said only that she thought it might be useful. Dr. E.: I think I see that this woman s life depended on the locating of that person. All that remained here of the will to live was her interest in a short period of so-called counseling. She wanted to talk about the meaning of her situation, and the life force resides inside such a desire. I would assume that if she could not locate anyone to provide this, she would carry out her suicide. G.A.: That is exactly what occurred: all the clinicians she contacted made it clear they wanted to help her recover a wish to live. They also responded in a way indicating to her that they would be very upset if she committed suicide and would regard their work with her to have been a failure. This was intolerable to her, so she skipped the counseling and killed herself. The method she chose showed her absolute determination: she overdosed on a lethal amount of sleeping medications, drank a whole fifth of vodka on top of that, and put a plastic bag over her head so that she would suffocate. She really meant business.

5 272 George E. Atwood Dr. E.: A very sad story, G.A.: they did not understand her and they killed her with their concern. I don t particularly see what this has to do with ethics. A person falls into despair, the world destroys her last particle of hope, and she kills herself. This woman turned to the professionals in our field for help, and they turned away from her. Suicides occur when hope is destroyed, and my philosophy includes the idea we should support hope rather than extinguish it. I would not however regard this as involving any ethical failure on anyone s part; the problem was their human failure, due to emotional stupidity. They knew not what they were doing. G.A.: I am asking you what you would have done with this woman. You say you try to live by the principle that we are our brothers and sisters keepers, and yet this woman wanted a carte blanche on ending her life as a condition for even entering psychotherapy. How could one have reconciled the one aspect of this and the other? Dr. E.: Why do you think it was that she needed her therapist, if she could have found one, to be someone who would not oppose her suicide and not be negatively affected by it, G.A.? It is obvious from the brief story, as I think about it. There was no basis for continuing to struggle and suffer, since she had been slated for a life of honoring the already dead. Her parents harnessed her very being into their everlasting trauma and grief, and within this project there was no room for her existence as a person in her own right. She was one of those whose life was never her own. Such people often kill themselves. G.A.: Dr. E., if she had come to you, you would have told her, directly or indirectly, that you try to be your sister s keeper. Wouldn t this mean you would want her to stay alive? And wouldn t you then have become one of those clinicians who killed her with their concern? Dr. E.: Perhaps not, my dear Atwood. I would have seen her life, what little there was of it, inhabiting her will to die and her wish to find someone who would not be hurt by her suicide. This is, evidently, all that was left of this woman, and I would have wanted to communicate that I understood what she was doing and she was not to concern herself with protecting my feelings. In the meantime, perhaps we could have had some good conversations. If she felt free in my presence not to take care of me, and at liberty as well to end her life at any moment of her choosing, it is possible that a space would have opened up she had never known before, a space that belonged entirely to her. Who knows what could have happened then? A miracle might have occurred.

6 Philosophy and Psychotherapy Part G.A.: But you would be offering your support for her suicide! Is this not a violation of your own ethical code? Dr. E.: You are once again falling into the concrete and the literal, G.A., and it is making you say stupid things. I would be supporting the single manifestation in this woman of a life that was hers! It was her last remaining hope, and I would do my utmost not to destroy it. This would require, as I was saying, that I approach her in a way that involved no opposition to her deadly plans. G.A.: I hear the voices of our profession shouting at you, Dr. E.: This is tantamount to encouraging your patient s suicide! It would subject you to censure by your colleagues, possibly to charges of unethical conduct in facilitating the act of self-destruction, and her relatives could even have sued you for damages, old man! What would you do with that? Dr. E.: You are still being concrete, G.A. Can you not see that in approaching the case in the way I am suggesting, this woman s life would have been supported in the only way that was possible? The ostensible care and concern of the clinicians she sought out precipitated her suicide, and what I have proposed would have been a chance for her survival. If we open our hearts and minds, a pathway might then be found to our brothers and sisters that otherwise would be lost to us. If the patient finally carried through with her intention to kill herself, and if I was then sued because someone thought, wrongly, that I had encouraged her, I would defend myself by arguing that I had given her every possible response that could support her life. This death might well have been inevitable, but at least she would have had the opportunity to talk her story over with someone before signing off. Even then I would have known I had been my sister s keeper, or done everything I could based on my understanding of her, and I could have lived with her death. I wonder how the clinicians who told her they wanted to preserve her life feel about it now. If I were one of them, I would be suffering very significantly. G.A.: I actually understand what you are saying Dr. E., but I don t know that our shared field would be able to do so. As I have tried to explain to you a number of times, I often am voicing the questions and reservations that are out there, and I think it is a worthwhile enterprise to elicit your thinking in response. You generally get frustrated and angry with me at such times, but I want you to remember I am trying to make your ideas accessible to people. If it were not for me, after all, you would just be sitting in your little trailer, walking your dogs, and communicating otherwise with no one.

7 274 George E. Atwood Dr. E.: I know you mean well, Atwood, but the jury is still out, to say the least, on whether your questions and our resulting conversations communicate anything. I am skeptical, but play along with you in the hope that I turn out to be wrong. Come back later, my friend. G.A.: Okay. Let s talk later about epistemology the question of knowing. George E. Atwood, Ph.D. 20 Harver Farm Rd. Clinton, NJ ufoatw01@earthlink.net Translations of Abstract In questo lavoro è presentato un dialogo con l anonimo psichiatra, Dr. E., un dialogo attraverso cui si affronta la natura dei valori etici impliciti alla psicoterapia psicoanalitica. Il focus della discussione è costituito da un caso clinico alquanto difficile, cioè quello di una donna che non si riuscì a dissuadere dal suicidarsi e i cui letali piani sollevarono importanti questioni etiche in ambito clinico. Le dialogue présenté avec le psychiatre anonyme, Dr E., confronte la nature des valeurs éthiques qui sous-tendent la psychothérapie psychanalytique. Un cas clinique difficile y est discuté présentant une femme qui ne pouvait pas être détournée de son projet de suicide et dont les plans mortels semblaient soulever des questions éthiques sérieuses pour le clinicien. Hier wird ein Dialog mit einem Psychiater, Dr. E. angeboten, in dem es um das Wesen der ethischen Werte geht, die der psychoanalytischen Psychotherapie zugrunde liegen. Im Fokus der Diskussion steht der schwierige klinische Fall einer Frau, die nicht davon abgehalten werden konnte, Selbstmord zu begehen und deren todbringende Absichten schwerwiegende ethische Fragen aufzuwerfen scheinen. Se presenta el diálogo con el psiquiatra anónimo Dr. E., diálogo que versa sobre la naturaleza de los valores éticos que subyacen la psicoterapia psicoanalítica. El foco de la discusión es un caso clínico difícil: una mujer que no iba a ser disuadida de cometer suicidio y cuyos planes mortíferos generaban graves cuestiones éticas en el clínico.