Ethics Rounds

A request to sing at a patient's funeral raises challenging clinical and ethical questions. Engaging in a thoughtful process to explore the implications of various possible responses best fulfills the psychologist's professional responsibilities.

The following is based upon a vignette submitted by an "Ethics Rounds" reader:

Dr. Tatia is a psychologist working in small community. She has a busy private practice where she treats adolescents and adults. Three of her elderly clients live in a nursing home, where one day every other week Dr. Tatia goes to see them. In Dr. Tatia's free time she is a singer in a local band that plays mostly blues, along with some contemporary "soft" music. Given the size of the community, many of Dr. Tatia's clients know about her singing. For the past three years Dr. Tatia has been treating Ms. Green, who is in her mid-80s and appears to be at the beginning stages of a dementia. Ms. Green has recently been diagnosed with a terminal cancer and has been given six to eight months to live. She is able to comprehend her situation. One morning, at the beginning of her session, Ms. Green leans over, places her hand on Dr. Tatia's and says, "It would mean so much to me if you sang at my funeral. Would you do that for me?"

This brief yet rich vignette raises a number of clinical and ethical considerations. Some psychologists in Dr. Tatia's position might feel an impulse to say "yes" without further reflection and characterize this response as the "human" thing to do. One could hardly fault Dr. Tatia for granting Ms. Green's wish. An immediate and unreflective "yes" may nonetheless not be the response most respectful of Ms. Green, their professional relationship, or Dr. Tatia's other clients.

Being the professional in a professional relationship entails having obligations that do not apply in a purely personal relationship. Dr. Tatia will want reflect on what her professional obligations entail at this particular time with Ms. Green. That Ms. Green appears to be at the beginning of a dementing process and likely has six to eight months to live are features central to the clinical context in which Dr. Tatia is working with Ms. Green. These clinical features, poignant as they may be, do not remove Dr. Tatia from a professional relationship. Rather, they inform how Dr. Tatia will respond to her client. For Dr. Tatia to respond to Ms. Green's request as if they had a personal but not a professional relationship risks losing sight of what Dr. Tatia may be able to offer as a psychologist, and thus may fall short of what Ms. Green is entitled to expect as a client.

In reflecting on her response, Dr. Tatia may begin by her own reaction, what some psychoanalysts refer to as the "countertransference." A variety of reactions are imaginable. Although Dr. Tatia may have an immediate impulse to say "yes," she may also be ambivalent or not want to attend the funeral at all, much less to sing. Her feelings could range from sadness over an impending loss to a feeling of being trapped, that she cannot say no. Dr. Tatia's reaction to this moment between her and Ms. Green may shed light on a part of Ms. Green's psychology or her life experience that would represent a piece of unfinished work in the psychotherapy. An immediate and unreflective response could therefore deprive Ms. Green of an opportunity that the psychotherapeutic work still offers. On the other hand, a simple yet indirect response to Ms. Green such as, "Tell me how you would like your funeral to be," might provide an opening for Ms. Green to express more clearly how she imagines the end of her life will unfold and whether there is unfinished life business she would like to address in her final months.

As Dr. Tatia reflects on what clinical opportunities the moment might offer, the question of whether she will sing at the funeral may fall into the background. If Ms. Green returns to the question, Dr. Tatia may decide that it is clinically beneficial to address the question directly. A variety of considerations, including but not necessarily limited to the four below, will inform whether Dr. Tatia decides to sing at the funeral.

What Dr. Tatia wants to do. Singing at a funeral is a different role for Dr. Tatia in relation to Ms. Green that blends the personal and the professional. For her own reasons, Dr. Tatia may either want to sing, or wish to avoid mixing the two roles in this way. It will be valuable for Dr. Tatia to explore her own desires about the request and to give herself permission to acknowledge that singing at Ms. Green's funeral is something she may not want to do, if in fact she does not. This consideration, which can be especially relevant in rural and small communities, involves self-care by virtue of acknowledging our own needs, desires and limits in our ability to be present for our clients in the way they sometimes want us to be.

Confidentiality. Dr. Tatia's role in the funeral may raise questions about her relationship with Ms. Green, especially in the small community where Dr. Tatia's profession is widely known. Dr. Tatia can address her concerns about confidentiality by discussing them with Ms. Green, who may be perfectly happy to for Dr. Tatia to disclose their relationship in the context of her involvement with Ms. Green's funeral. If Ms. Green consents to this disclosure, it may be helpful if the family were informed of the arrangement.

The effect on other clients. Should Dr. Tatia sing at the funeral, other clients may request that Dr. Tatia sing at their important events, such as weddings and bar or bat mitzvahs. This consideration need not be the determining factor for Dr. Tatia, but she should be aware that saying no to other clients will take on a new complexity should she choose to sing at Ms. Green's funeral.

Dr. Tatia's own grieving process. This consideration may be the most challenging, insofar as there are few socially sanctioned ways for psychologists to grieve a patient's death. Music at a funeral or memorial service is a way to comfort those who are grieving. Because Dr. Tatia will likely be in the midst of her own grieving process, participating in the funeral service may present a complex mixing of roles for her. Self-care may again become an important theme as Dr. Tatia sorts out her need to grieve the loss of her patient at the same time as she is being asked to help others mourn the loss of Ms. Green. A consultation could be helpful to Dr. Tatia in exploring whether the memorial service is an appropriate venue to engage in her own grieving process, and how else Dr. Tatia may meet her own need to mourn the loss of patient for whom she may have felt a close attachment.

No decision we make in relation to a client is without consequences for ourselves, the client and our other clients. Our professional obligation is to consider these consequences in the context of our background, training and experience as psychologists. We fulfill our clinical and ethical responsibilities best when we engage in a thoughtful process of exploring what our actions mean in light of our clients' psychologies, treatments and goals, and when we take the time to explore fully the impact of our work on ourselves.

Stephen Behnke, PhD, JD, directs APA's Ethics Office.

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