Tag: consultation

Blog Posts (10)

October 12, 2016

Clinical Ethics Consultation Services and Expectations: Is It That Much Different From Other Clinical Services?

Two recent presentations at the 2016 Annual Meeting of the American Society for Bioethics and Humanities in Washington, DC – offered within just a couple of hours of each other – had a similar theme but approached the issue from different angles. The first presentation was a case review by David Kappel, MD, a surgeon at the University of West Virginia, and Valerie Satkoske, MSW, PhD, a bioethics professor at the University of West Virginia Center for Bioethics and Health Law. The case involved a 75-year-old-man admitted for surgery. Unfortunately, following the surgery, he was delirious. The delirium continued for several days. He had to be restrained and fed with a nasogastric tube. The situation was very upsetting to his family; they were completely taken aback by this complication. The delirium was so unexpected and surprising that the family wondered whether or not the patient would have agreed to the surgery if he had fully understood that the extended delirium might result. The title of this presentation was: “You Should Have Told Me! Struggling to Meet the Spirit of Informed Consent.” As one can imagine, the presenters asked if information about the possibility of an extended delirium should have be included as a part of the informed consent process. The delirium was not part of the patient’s and family’s expectations. Of course, even with a more extensive, informed consent process, the family still may have not been fully prepared to deal with the complication anyway. Perhaps the answer turns more on the likelihood of the complication arising in this patient’s case given the particulars and context? Some complications are more probable than others given the circumstances?

The second presentation, titled “I Never Promised You a Rose Garden: On the Necessity of Not Meeting Expectations Regarding Clinical Ethics Consultation,” was given by Virginia L. Bartlett, PhD, and Stuart G. Finder, PhD, of Cedars-Sinai Medical Center. This presentation too dealt with expectations: the expectations those who ask for a clinical ethics consultation might have of clinical ethics consultants. The presenters suggested that the expectations might range from “ethics policeman” to “ethics superhero.” The presentation ended with the relatively unsatisfactory mechanisms available to evaluate the effectiveness or helpfulness of clinical ethics consultation services interventions. From the presentation, it was clear that clinical ethics consultants should be prepared for not meeting expectations of those who request assistance.

Regardless, both presentations highlight how important it is for clinicians – whether physicians or surgeons directly caring for patients or clinical ethics consultants offering advice or recommendations to colleagues or patients or families – to understand stakeholder expectations as well as they can. With doctors and nurses it may be a bit easier: mostly likely the patient wants to be restored to health or a baseline with the least discomfort and minimal aggravation. With clinical ethics consultation services, the expectations are often not this clear. Moreover, with both clinical medicine and clinical ethics consultation service interventions, there are complications and unintended consequences. One cannot always fully anticipate which way a case may turn, or which word or phrase at a particular moment may result in a worse situation rather than a better situation.

For good or ill, there is no informed consent equivalent for clinical ethics consultation services when stakeholders ask for a consultation. The various stakeholders – when they request a clinical ethics consultation – may or may not know exactly what they are asking for anyway. But, most likely, what they are asking for is help with a very troublesome or thorny issue that has ethical implications or dimensions. In this respect, clinical ethics consultants perhaps should worry less about meeting expectations than other clinicians, since the goals of clinical ethics consultation services often times are much less clear – at least when the consultation is requested – than restoring the patient’s health or previous baseline with the least discomfort and minimal aggravation. However, may always be better for the clinical ethics consultant to ask, “How do you think we can help?” and try to set or reset expectations as well as one can at the beginning of the process.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

September 12, 2016

“Humanists,” Academic Philosophers, Critical Distance, and Clinical Ethicists

The October 2016 Annual Meeting of the American Society for Bioethics and Humanities (ASBH) announced its theme for the Washington, D.C., convocation several months ago: “After over half a century of work, and as ASBH celebrates its coming-of-age, we have chosen to focus on ‘critical distance’ and our ‘insider-outsider’ status at our 18th annual meeting.” Some may be relatively unfamiliar with these notions of “critical distance” and “insider-outsider” status.

            In the early 1970s, when medical center and medical school thought leaders began hiring “humanists” to teach, round with teams, and attend morning reports and noon conferences, it was unclear what – if any - specific outcomes might result. However, the center executives and deans wanted to try something to help inject human values and humanistic thought into the educational process to offset the very strong influences of advancing technologies, specialization, and materialism, and to assure the outraged public in the face of recently revealed research scandals.

            These pioneer “humanists” were theologians, religious studies scholars, and philosophers. In just a few years, the philosophers were predominating in this growing field of applied ethics educators and scholars. In explaining this transition, Art Caplan wrote: “It proved very difficult to do bioethics in public in anything approximating a religious voice. ... [I]t quickly became clear that to command the attention of scientists and physicians, as well as policy-makers, a more secular voice was required. Philosophy, emerging out of decades of mainly futile wrangling about meta-ethical issues, was more than happy to oblige ... .” Caplan AL. The birth and evolution of bioethics. In Ravitsky V, Fiester A, Caplan AL. The Penn Center Guide to Bioethics. New York: Springer Publishing Co., 2009, p. 5.

            But, the philosophers who taught applied ethics or their philosophy colleagues in the academy challenged medical ethics in the classroom and at the bedside. The academic philosophers were concerned that the medical school philosophers might be losing their bearings. This difference of opinion was stated by Harvard philosophy professor F.M. Kamm in 1988: “[P]hilosophers should try to bring ‘real-life’ problems (and those that have them) up to the abstractions of philosophy, rather than just bring philosophy down to the level of the problems. [Emphasis in original.]” Kamm FM. Ethics, applied ethics, and applying applied ethics. In Rosenthal DM, Shehadi F, eds. Applied Ethics and Ethical Theory. Salt Lake City: University of Utah Press, 1988, p. 170.  To be even clearer, she continued: “[C]reative solutions to practical problems come only after a period of detaching ourselves from them to consider more fundamental concepts. ... [E]mphasizing the discovery of solutions to problems conflicts with a detached interest that goes wherever an illuminating, but not obviously or immediately useful, aspect of a questions leads one.” Ibid, p. 170-171. “If philosophers who do applied ethics do not maintain such attitudes, in common with academic philosophers, they run the risk of being bad philosophers and becoming merely the bearers of simplified, falsely reassuring news from the theorists.” Ibid, p. 171.

            In thinking back, it must have been a phenomenal trial for several medical school philosophers to attempt to satisfy the academic philosophers while taking a new path. For the academics the question must have been how does one comment upon the matters at hand without learning so much about related topics and processes or becoming deeply enmeshed in the milieu that one is no longer an “outsider” but an “ insider” without critical distance? This turf battle must have been particularly worrisome for some distinguished philosophers who gained national and international reputations as academic philosophers and who then moved to medical school and clinical settings. Of course, a good many philosophers and theologians thought doctors were too close to the problem  (that is, lacked critical distance) to be part of any solution. (And quite naturally, some of the doctors thought the theologians and philosophers lacked a sufficient clinical knowledge base to fully understand the contexts in which they were involved.) History has shown that many of the medical school philosophers transitioned and cared little about what the academic philosophers said anyway.

            By the early and middle 1980s, other professionals joined the philosophers and theologians in broadening the bioethics or clinical ethics base and voice: physicians, nurses, social workers, chaplains and pastoral care workers, and lawyers, just to name a few. For health care professionals, chaplains, and lawyers, this notion of “critical distance” as not an overriding factor. If these bioethicists gave any thought to “detachment,” they probably interpreted it as “objectivity.” Objectivity calls to mind: “impartiality,” “lack of bias,” “fairmindedness,” “neutrality,” “open-mindedness,” “fairness,” and “justice.”

            Today, as clinical ethics consultants move toward professionalization, the outsider-insider issue has lost its relevance. Few may even understand the context of the initial problem now. Clinical ethics consultants exist in great part to improve patient care and the patient care experience; they are undoubtedly insiders. And, whether one thinks in terms of critical distance or not, objectivity in providing service to others remains critically important.

March 18, 2016

Meditations on the Flood

When I first moved to Albany several months ago in pursuit of the exciting and glamorous life of a clinical ethics fellow, I brought with me only a handful of my earthly possessions; if the Fates have their way with me, I will likely leave with even less.

During this past month, in the late-night hours one night I awoke from my slumber to discover that while I had slept the majority of my basement apartment had been transformed into a bog. Yes, I was experiencing wintery real-life application of the law of thermal expansion as it applies to dihydrogen monoxide (i.e., a water pipe burst). After an emergency call to my landlord, I proceeded with my own separation of sheep from goats: what could be saved and salvaged was transported to the little dry land remaining in my now water-logged kingdom, while those items clearly destined to doom and decay were left languishing amidst the advancing liquid army. Few of my books survived, but among them was one I thought quite fitting to the circumstances: Marcus Aurelius’ Meditations.

Essential reading for any good Stoic (and, to my mind, useful if not essential reading for all human beings), Meditations, and the ancient words of wisdom it contains, helped me to navigate through and reflect upon my experience of the flood and its corresponding aftermath. Some choice morsels include:

Casting aside other things, hold to the precious few; and besides bear in mind that every man lives only the present, which is an indivisible point, and that all the rest of his life is either past or is uncertain. Brief is man’s life and small the nook of earth where he lives… (Book III, Number 10)

But among the things readiest to hand to which you should turn, let there be these two: One is that things do not touch the soul, for they are external and remain immovable; so our perturbations come only from our inner opinions. The other is that all the things you see around you change immediately and will no longer be; and constantly bear in mind how many of these changes you have already witnessed. The universe is transformation: life is opinion. (Book IV, Number 3)

Everything is only for a day, both that which remembers and that which is remembered. (Book IV, Number 35)

“I am unhappy, because this has happened to me.” Not so: say, “I am happy, though this has happened to me, because I continue free from pain, neither crushed by the present nor fearing the future.” For such a thing as this might have happened to every man; but every man would not have continued free from pain on such an occasion. Why then is that rather a misfortune than this a good fortune? (Book IV, Number 49)

One of the main life lessons Marcus Aurelius (and indeed all stoics) reiterates time and again is that the essential nature of our human existence is flux and fleetingness. Another is that our ability to respond to this flux and fleetingness, and how we choose to respond, constitute a great human power and our capacity for nobility. Our ability to bear the small things – minor losses of time, possessions, or our sense of control – help to prepare us for the inevitable big things with which we will one day be faced. The major losses.

I sometimes think that one of the most valuable things we can do as clinical ethicists is to help people – patients, families, physicians, etc. – with these particular life lessons. For many, the hospital experience is the epitome of flux, the reason for hospitalization a reminder of life’s fleetingness. Whatever the official reason for requesting an ethics consultation, minor and major losses are always there, whether in the present situation or looming on the horizon. We are consulted, I believe, in large part to help people bear these losses. 

And this becomes another part of my meditation: that this experience, and indeed each of my experiences, has the potential to become a tool for me to help others. The patient’s flood or the family’s flood may not be the same as my own flood, but in reflecting on how I could bear my flood, hopefully I can help guide or companion others as they bear theirs.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.
September 8, 2015

Thoughts on Flexner and Professionalism, 1915 and 2015

<p style="font-size: 11.2px; line-height: 19.04px;"><span style="font-size: 11.2px; line-height: 19.04px;">Education reformer <a href="/BioethicsBlog/">Abraham Flexner</a> (1866-1959) is regarded by many as the father of Modern America’s medical education curriculum. He authored the Flexner Report for the Carnegie Foundation after making site visits to all the country’s medical and osteopathic medical schools of the day. He harshly criticized the vast majority of the schools he visited. His insightful recommendations were adopted for the most part within just a few years and his Report continues to influence medical education today.</span></p> <p style="font-size: 11.2px; line-height: 19.04px;">In 1915, Flexner addressed the National Conference of Charities and Corrections. The title of his speech was “<a href="http://scholar.google.com/scholar_url?url=http://thorn.pe.kr/attachment/cfile10.uf%4018606E444E7FBD4D025599.pdf&amp;hl=en&amp;sa=X&amp;scisig=AAGBfm2BgvQhpf9d1DrnsPpZz_hCI3a1-g&amp;nossl=1&amp;oi=scholarr">Is Social Work a Profession?</a>” He answered that <a href="https://www.ssa.uchicago.edu/reassessing-social-works-first-critic">it was not</a>. Flexner compared social workers of the day against the “benchmark” professionals of medicine, law, and preaching, and found that those who provided social work services had not yet achieved true professional status. He saw the social worker of the day as a “narrow minded technician.” In deference to social workers, Flexner also viewed nurses and pharmacists the same way.</p> <p><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;"><strong>The Alden March Bioethics Institute offers a Master of Science in Bioethics, a</strong> </span><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;">Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong></p>
July 7, 2015

Clinical Ethics Consultant Professionalization: A Response to Dr. Shelton

<p><span style="font-size: 11.1999998092651px; line-height: 22.3999996185303px;">In his <a href="/BioethicsBlog/post.cfm/does-the-work-clinical-ethics-consultation-lend-itself-to-professionalization">last AMBI blog</a> </span><span style="font-size: 11.1999998092651px; line-height: 22.3999996185303px;">posted on June 18, 2015, Wayne N. Shelton, PhD, MSW, discussed recent movement toward the professionalization of clinical ethics consultants. He noted the adoption of a Code of Ethics for Health Care Ethics Consultants by the American Society for Bioethics and Humanities (ASBH), which has been praised as important milestone toward the professionalization of clinical ethics consultants. Moreover, Dr. Shelton listed several challenges that “professionals” who call themselves “clinical ethics consultants” currently face, including: “[1] </span><span style="font-size: 11.1999998092651px; line-height: 22.3999996185303px; color: #273049;">how to make sense of the diverse educational backgrounds and training of those who perform clinical ethics consultations and how far to push such requirements; [2] the lack of a national body to set requirements that leaves local hospital leaders with little incentive to pay for highly qualified CECs and view this as a sound investment; and finally [3], most seriously, the way in which many problems in patient care are misidentified as clinical ethical problems while other serious clinical ethical problems may be entirely overlooked or if recognized, not viewed as requiring the expertise of a CEC.” He concluded his post with: “These challenges are indications that clinical ethics consultation will not likely achieve professional status in the healthcare system in the near future.” Of course, Dr. Shelton is correct in his analysis, but some might see the challenges he listed as surmountable if those who practiced clinical ethics consultation were to: (1) establish minimum uniform educational standards for new clinical ethics consultants; (2) create national certification and accreditation standards so employers would more fully understand the nature and value of their work; and (3) provide consultants themselves and other stakeholders unmistakable guidance on what clearly constitutes the work of clinical ethics consultants. (This third point sounds very much like a “scope of practice” definition found in state professional licensing statutes.) However, it may take something much more for clinical ethics consultants to be a separate professional category.</span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong></p>
June 17, 2015

Does Clinical Ethics Consultation Lend Itself to Professionalization?

<p style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Let me say emphatically at the outset of this blog, as someone who has been a clinical ethics consultant for over 20 years, I am quite sure that clinical ethics consultations overall improve the quality of patient care and currently are an important, even essential, part of the providing excellent patient care in hospitals. Contemporary medicine is filled with value laden questions and issues that often can be effectively addressed by someone with expertise and training in clinical ethics. Having said this, I am still somewhat skeptical about clinical ethics consultation becoming a professional area of healthcare that parallels other professional areas like medicine, nursing, and social work. I think there are some special considerations about the field of clinical ethics consultation that makes its future status as a professional activity uncertain.</span></p> <p style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">First of all it is well-known that CEC’s come from a variety of backgrounds and training—from philosophers to physicians to social workers to nurses and lawyers and on and on. People enter the field of clinical ethics consultations from very different disciplinary backgrounds and seemingly learn a common vocabulary and methodology of clinical ethics and a basic familiarity with and ability to function in the clinical setting. They learn this vocabulary in very different ways—some informally, some through short 1-2 week long intensives, some with certificate programs, some with master’s degrees, and some with 1-2 year long fellowships. No other area of healthcare work admits of such diversity. Though this is a positive feature in some ways by providing diverse perspectives in understanding value dilemmas, it creates a challenge of considerable controversy when we try to define the kind of educational training a future CEC should have. At the moment there seem to be many pathways into the field and no clear answer has emerged.</p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; line-height: 19.0400009155273px; font-size: 12px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong></p>
December 21, 2014

A Role for Clinical Ethics Consultants in Stem Cell Tourism

<p class="MsoNoSpacing" style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">Recently Dr. Christopher Thomas Scott of Stanford University wrote a great paper titled “The Case of Stem Cell Counselors” in </span><em style="line-height: 19.0400009155273px;">Stem Cell Reports</em><span style="line-height: 19.0400009155273px;"> which draws parallels from the field of genetic counseling arguing for the need for stem cell counsellors (1). Scott outlines that due to increases in the number of stem cell trials combined with fraudulent therapies being offered around the world, the time is ripe for having counsellors help patients navigate the clinical stem cell research/therapy landscape. These experts can help patients identify and distinguish legitimate trials from unproven interventions, explain the risks, benefits and therapeutic options, and serve as a resource to provide them with educational information.</span></p> <p class="MsoNoSpacing" style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">On a related topic, my colleagues and I at AMBI were going to write a paper arguing that clinical ethics consultants should be involved in countering the impact of stem cell tourism and serve as a resource for patients who are contemplating undertaking an unproven stem cell based intervention (SCBI). We thought that clinical ethics consultants are in a unique position to offer advice and counselling to patients seeking unproven SCBIs for a few reasons.</span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;"> </span></p>
August 11, 2014

What Is Philosophical Ethics Doing?

<p>In my last blog I asked the question, “What is ethics doing?” where I contrasted the armchair, academic ethics that I knew as a graduate student with the clinical ethics cases in which I am now involved in clinical ethics consultations. I alluded to the famous paper by Stephen Toulmin (1922-2009), “How medicine saved the life of ethics” by providing ethics with many practical value laden problems to address. The very process of becoming involved with applied ethics and ethical problems of practicing physicians in the healthcare system was itself as, or perhaps more, transformational for ethics than it was for medicine. Even though medicine needed a serious study of its value-laden issues, which has evolved into bioethics and clinical ethics, the very activity of doing applied ethics has evolved into a better defined field of inquiry with a clearer purpose. But what about the armchair, academic pursuits of philosophical ethics of old? Is there anything left for it to do? This is the question I will attempt to answer in this blog.</p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 20px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="text-decoration: underline; color: #000099;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 20.399999618530273px;"> </span></p>
July 22, 2014

What Is Ethics Doing?

<p class="MsoNormal" style="text-align: left;">I recall being a PhD candidate in philosophy in the 1970’s, I often pondered the subject matter of my graduate courses in ethics. I would ask myself, what does any of this have to do with ethics? What are we doing?</p> <p class="MsoNormal" style="text-align: left;">As our courses went from Kant to Mill to G.E. Moore to the Emotivists and others, I couldn’t help but have a sense of unreality about the content of what I was learning.</p> <p class="MsoNormal" style="text-align: left;">How can we use reason to find a basis for knowing right action? What are the ways we can define right action based on a normative moral theory?</p> <p class="MsoNormal" style="text-align: left;">What is the meaning of good? Right? And obligation? Can these terms be defined within a theoretical, substantive moral framework or are they just expressions of feelings and emotions without any cognitive content? If they are more than the latter, what do they mean?</p> <p class="MsoNormal" style="text-align: left;"><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 20px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="text-decoration: underline; color: #000099;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong></p>
June 11, 2014

Teaching Graduate Students the ASBH Core Skills of Communication and Interpersonal Skills Through Mock Consultations

<p>For over a decade the faculty of the Alden March Bioethics Institute has been designing and developing simulated cases for our graduate students who wish to learn the core skills of clinical ethics consultation. The model that we use is called “mock consultations”, which provides students the opportunity to perform an ethics consultation on a simulated case from the beginning when the request is made, to data collection, interviewing key players in the case, and on to case analysis the final recommendation.</p> <p class="MsoNormal">In the process of developing simulated cases we have made every effort to make them as real to life as possible. All of the cases we use are from ethics consultation cases that have been deidentified and made into anonymous teaching cases. We have benefitted immensely from working closely with Albany Medical College’s (AMC) Patient Safety Clinical Competence Center (PSCCC). Those involved in medical education will recognize the importance of simulated cases using standardized patients (SP) and the role they play in training new doctors to communicate effectively with patients and families.</p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 20px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 20.399999618530273px;"> </span></p>

Published Articles (1)

American Journal of Bioethics: Volume 9 Issue 10 - Oct 2009

Legalism, Countertransference, and Clinical Moral Perception