Ethics Rounds

The National Gallery of Art is a short distance from the APA building in Washington, D.C.-close enough for an afternoon walk through one of our nation's most treasured art collections. A favorite painting for visitors is Orazio Gentileschi's "The Lute Player." The subject of "The Lute Player," which Gentileschi painted in the early 17th century, is a young girl sitting at a table, concentrating intently on finding a chord as she strums her lute. The girl, her hair in braids and her face turned toward the viewer, wears a white blouse and a flowing canary-yellow dress, while on her table rest her music scores and other musical instruments, including a violin. A rich, velvety cloth covers the table and the stool on which she sits.

Light in the painting falls on the girl's upper body and so emphasizes her complete focus on the music and her lute. The light also partially illuminates the violin resting on the table, whose stem-or "neck," as it is properly called-is pointed outward. A reason why "The Lute Player" is so popular-aside from its beauty-is that the violin's neck points at the viewer regardless of where the viewer stands in relation to the painting. Stand to the painting's left or right, or at its center, and the neck of the violin points toward you. What makes visiting "The Lute Player" especially fun is that the violin's neck will actually follow you as you walk across its horizon. Delight inevitably accompanies a visitor's discovery of what Gentileschi has done.

Gentileschi's painting and our ethics

"The Lute Player" can be interpreted in a manner that resonates deeply with practicing ethically as a clinical psychologist. The setting suggests that the young girl spends many hours in practice, expending enormous effort to perfect her technique and enhance her skills as a musician. Competence has been called the cornerstone of ethics, for good reason. Competence is the foundation for Principle A in the Ethics Code, Beneficence and Nonmaleficence, which begins, "Psychologists strive to benefit those with whom they work and take care to do no harm." Psychologists can neither benefit patients nor avoid harm if they are not practicing in a competent fashion, which takes our continuing effort and attention to maintain a high standard of clinical work.

As she hones her skills, the girl is fully immersed in her endeavor. The movement of the violin's neck conveys her focus on the viewer, wherever the viewer may be or move. The ethical starting point for our clinical work is recognizing where a client stands in relation to what we offer and following the client's movement as we maintain the relationship. The girl is firmly settled in her seat, balanced and secure in her setting, surrounded by the accoutrements of her profession. Firmly secure in our professional identity and in the ethical parameters of our work, we can more freely allow our patients to move, to explore different positions in relation to us, and so to discover and examine aspects of themselves that internal obstacles have constrained them from experiencing. The girl's posture, head turned with her ear almost touching the lute, conveys that her primary tool is her ear-listening. Good ethics and good clinical care come together when we most skillfully and attentively do what we are trained to do, central to which is listening to our patients in an open and receptive manner.

Competing needs

In discussions about ethical aspects of clinical work it is sometimes said that in order to be ethical, psychologists should avoid meeting their own needs and desires or should always put the needs of their patients first, before their own. Both ways of thinking about ethics strike me as missing the mark, in ways that "The Lute Player" eloquently addresses. The girl in the "The Lute Player" is fully present in her work. Her hair, her dress and her posture are all unmistakably hers. She is not one to hide or apologize for who she is or what she does. Her interest in and enjoyment of her music seem much more to enhance-rather than detract from-her artistry. Gentileschi leaves no doubt that for this girl making music is deeply meaningful and richly rewarding.

As clinical psychologists, we meet many of our own needs and desires through working with our clients. These include engaging in creative and interesting professional endeavors, enhancing the well-being of others and perhaps contributing to the profession through scholarly publications. Meeting such wants and needs is highly appropriate and can make us better clinical psychologists.

We meet other needs as well, sometimes in ways that conflict with the needs of our clients. We charge fees, offer appointments at times that fit our schedules, take vacations in light of non-work-related commitments and obligations, and sometimes cancel appointments when the unforeseen necessity of doing so arises. Meeting such needs, even when they conflict with those of our clients, may be perfectly appropriate. The most ethical posture is not that we deny our desires and needs, or that we always put those of our patients' first. Both of these positions are complex, even problematic, from an ethical perspective.

Differentiate and assess

A more helpful way of thinking about ethics legitimizes meeting our own desires and needs and embraces what we derive from our clinical work. The challenge from this perspective on ethics is not to deny our own needs or always to place our patients' needs first. The challenge is rather to differentiate our desires and needs from those of our patients and to determine which of our interests are legitimate to meet through our clinical work and which are not. Each of these tasks-differentiating and assessing the legitimacy of a want or need being met-is central to benefiting our patients and avoiding harm.

Differentiating our desires and needs from those of our patients entails a measure of insight into our inner life. Until we know ourselves in this way, it will be difficult if not impossible to separate what we want and need from what our patients want and need. Because a lack of differentiation leads inevitably to confusion about where our needs and desires end and those of our patients begin, clinical work has strong ethical underpinnings in self-other differentiation.

Determining which of our desires and needs we may legitimately meet through our clinical work is a more overt exercise in ethics. The APA Ethics Code provides significant guidance about specific behaviors. As valuable as the code is for maintaining an ethical practice, however, no code of conduct can adequately capture the many ways in which patients can be used inappropriately. A code must always be supplemented by an ethical orientation that views patients primarily as ends, rather than as a means to satisfy ourselves. This way of thinking about our ethics will lead us, I believe, to where we find Gentileschi's lute player: fully present and engaged in the work by which we earn a living, enjoying and enlivened by a creative professional life, and using our talents and skills in a manner that benefits our patients and does them no harm.

Further Reading

Send questions, comments or suggestions regarding "Ethics Rounds"—or submit vignettes (without identifying information) for column discussion—via e-mail. "Ethics Rounds" welcomes your involvement and will confer with authors before publishing letters to discuss any confidentiality concerns.

Previous "Ethics Rounds" columns can be found at the APA Ethics page, in the "From the Director" section.