November 20, 1998

Your reporter Lynda McCullough covered a lot of legal and ethical ground in her interesting story about the dilemmas of a training analyst with an analysand who went on to commit sexual abuse of children (Psychiatric News, September 4). However there are parts of the big legal picture in such cases that I believe need more emphasis.

Most of our basic ethical principles, like the duty of confidentiality, grow out of and apply to the doctor-patient relationship. Our principles were formulated during the era when psychiatrists functioned as independent practitioners within the psychoanalytic paradigm. Legal and organizational changes over the past 25 years have shifted the locus of professional power away from us and to the corporate entities with which we are affiliated.

This has meant that most of us have lost some professional independence and are now part of larger corporate entities and therefore are subject to new forms of regulation and legal entanglements. Although our ethical principles are not adapted to this new organizational terrain, the law keeps forging ahead. The law in many states may hold the corporate entity vicariously liable for the misdeeds, including sexual abuse, of its member professionals and directly liable for its failure to screen, monitor, supervise, and discipline these professionals to protect patients.

Along with this increased legal responsibility has come centralization of authority and increased scrutiny of professionals by their institutions, by licensing boards, and by federal agencies. The growth of this legal-medical bureaucracy and the centralization of power is well known to most psychiatrists. One direct result of the loss of our autonomy is the constraint on the individual professional's ability to maintain confidentiality as we could in the past.

In the lawsuit discussed in Psychiatric News, the plaintiffs sued the New York College of Medicine as well as the training analyst. This reflects the legal development I am describing in which the corporate entity may be liable directly or vicariously for the alleged negligence of the training analyst. Corporate entities, for example, medical schools, psychoanalytic institutes, hospitals, and health plans, have a legal and financial interest in what goes on in our therapeutic and supervisory sessions-an interest that simply did not exist 25 years ago. Cases like the one reported by Lynda McCullough may seem unique and extreme, but seen in context, they demonstrate the erosion of our professional autonomy as therapists and supervisors.

lan A. Stone, M.D.
Cambridge, Mass.

Dr. Stone is a former APA president and a professor of law and psychiatry at Harvard Law School.