code itself. Lack of privilege in judicial proceedings, and statutory obligations to report certain types of behaviour, mandate breaches of confidentiality in some ...
Confidentiality in Psychological Practice: A Decrepit Concept? MARILYN McMAHON La Trobe University
ANN D. KNOWLES Swinbume Universityof Technology
lthough the principle of confidentiality in the relationship between psychologistand client has been vaunted, and is emphasised in the Australian PsychologicalSociety‘s Code of Professional Conduct (the APS code; 1994), the confidentiality of this relationship is circumscribed by the absence of legal protections, the ethical beliefs of psychologists, institutional practices, and the provisions of the APS code itself. Lack of privilege in judicial proceedings, and statutory obligations to report certain types of behaviour, mandate breaches of confidentiality in some circumstances. Ethical beliefs of psychologists may support disclosure, especially where it is believed that there is danger of serious physical harm to the client or others. Multidisciplinaryteams and institutional settings require the exchange of information for optimal delivery of services. Recent amendments to the APS code may require disclosure without the client’s consent when a client is believed to be suicidal. Such developments, when considered at all, are typically regarded as exceptions to a general obligation of confidentiality. However, discussion of exceptions presupposes agreement on fundamental principle: the significance of, and rationale for, confidentiality in the psychologist-client relationship. It is argued in this paper that the obligation of confidentiality has been assumed rather than vigorously analysed and empirically explored. A critical examination of this obligation is the most appropriate starting point for the rehabilitationof contemporary principles of confidentiality in the psychologist-client relationship.
A
Posing the question of whether confidentiality in the psychologist-client relationship is a decrepit concept requires some explanation. The question being considered here is whether our notions of confidentiality are “weakened or worn out by age and infirmity” (Australian Concise Oxford Dictionary, 1992). that is, decrepit. In seeking to answer this question, we shall consider: the principles outlined in the Australian Psychological Society’s Code of Professional Conduct (the A P S code; 1994), with particular reference to recent amendments; salient aspects of the legal framework governing psychological practice; and empirical information concerning the attitudes and practices of psychologists. To anticipate the conclusion, it will be argued that confidentiality is a decrepit concept in contemporary psychological practice, and the rehabilitation of this concept ~~
requires a fundamental examination of its significance and rationale.
The APS code Examination of the APS Code of Professional Conduct (1994; incorporating the 1991 amendments) reveals a strong, but not absolute, endorsement of the principle of confidentiality in the psychologist-client relationship. Specific provisions exist which restrict the disclosure of information obtained through consulting relationships (Section B:1)and assessment procedures (Section A:7), or from other professionals (Section B: 18, 1991 amendment). Restrictions are placed on the disclosure of information to other professionals (Section B:l ) , and protections are required for the storage and disposal of records (Section B:3, 1991 amendment). Psychologists are prohibited from disclosing the criminal acts of clients “unless there is an overriding legal or social obligation to do so” (APS,1994, p. 5). General principle IIIa is the clearest statement of principle: it requires that psychologists respect the confidentiality of information obtained from persons in the course of their work as psychologists, and states that disclosure may only occur with the client’s consent, “except in those unusual circumstances in which not to do so [that is, not to disclose the confidential information] would result in clear danger to the person or to others” (APS,1994, p. 4). Thus the endorsed position is that of limited, discretionary confidentiality, where a psychologist may exercise hisher discretion to breach a client’s confidence in limited circumstances, such as where the client is suicidal (see A P S , 1994: “Guidelines relating to suicidal clients”, incorporated as Appendix G). Such a position is consistent with the ethical codes of other professions involved in the provision of mental health services. For example, the Code of Ethics of the Australian Association of Social Workers (AASW) permits a breach of confidentiality where the law demands or where “ethical or moral” reasons exist which justify disclosure (AASW, 1986). Similarly, the Australian Medical Association’s (AMA) Code of Ethics advises medical practitioners: “In general, keep in confidence information derived from your patient, and divulge it only with the patient’s permission, except when a court demands” (AMA, 1992, p. 2). A consensus exists that confidentiality is important but may legitimately be breached, a viewpoint which is also
~
Address tor conespondence: Marllyn McMahon, School of Law and Legal Studies, La Trobe Unlversity,Bundoora VIC 3083, Australia. ~~
NOVEMBER 1995 Y AUSTRALIAN PSYCHOLOGIST VOLUME 30 NUMBER 3 pp. 164-168
164
CONFIDENTIALITYIN PSYCHOLOGICAL PRACTICE: A DECREPIT CONCEPT?
dominant in the literature on this subject (Appelbaum, Kapen, Walters, Lidz, & Roth, 1984). Given that this is the dominant position in the professional literature, and the position endorsed in the APS code, investigation of the compatibility of the attitudes and practices of Australian psychologists, as well as members of the public, is relevant. Generally, this research suggests that the attitudes of both practitioners and the adult public are congruent with the position endorsed in the APS code, as are attitudes of adolescents (Collins & Knowles, 1995).
Empirical Research on Attitudes to Confidentiality Surveys of psychotherapists in the United States have shown considerable variation in attitudes and practices pertaining to confidentiality (Baird & Rupert, 1987; Jagim, Wittmann, & Noll, 1978; Lindenthal & Thomas, 1982; Little & Strecker, 1956; Szasz & Nemiroff, 1963; Wise, 1987; Wiskoff, 1960). A study of 220 Victorian psychologists engaged in counselling andor clinical work found that most believed that confidentiality in the relationship with clients was important, but could be breached in some circumstances (83%). Only a small minority (15%) thought it was essential and could never be breached, and even fewer (2%) thought confidentiality was of marginal importance. Most of the psychologists surveyed indicated that they routinely discussed the possibility of having to disclose confidential information to other persons (McMahon & Knowles, 1993). A survey of 181 members of the public in Melbourne regarding their expectations of confidentiality in the relationship with a psychologist revealed that respondents expected that a psychologist would breach a client’s confidence where the information concerned a murder (planned or confessed), client suicide, discussion with a colleague, child abuse, or treason, or where a parent was seeking information about a child 1 2 years of age or younger. Conversely, respondents did not approve of a psychologist disclosing confidential information divulged by a client during counselling to an insurance company, spouse of the client, family doctor, court, or parent (where the client was a teenager), and did not approve of disclosure concerning a client’s admission of illegal drug usage or having committed a major theft (Knowles & McMahon, 1995). Thus, members of the public endorsed the importance of confidentiality in the psychologist-client relationship but identified circumstances when, and parties to whom, confidential information could legitimately be disclosed. In Australia there are several mechanisms available to clients for the protection of confidentiality in professional relationships with psychologists, including complaints to registration boards, health complaints offices, and a professional body such as the A P S (for a general discussion of these issues in relation to health care providers, see Department of Health, Housing and Community Services, 1992). Little empirical research is available on consumer satisfaction with these bodies. However, exploratory research conducted with persons who had complaints against medical practitioners suggests that many aggrieved clients are dissatisfied with these processes (Coventry et al., 1993).
The Legal Framework Generally, the legal framework in which psychologists operate does not afford any particular protections to them as a professional group, or to their clients, regarding the confidentiality of information disclosed by clients during a
professional relationship. In relation to the criminal law, some European countries, for example, make it a criminal offence for a psychologist to divulge confidential information disclosed by a client; no such specific statutory penalties exist in Australia (Fox, 1984). In the civil law (covering matters such as breach of contract, negligence, and defamation) legal remedies exist, but are fraught with technical difficulties and financial cost for an aggrieved client. Nevertheless, inappropriate violations of confidentiality have been used as the basis of negligence actions against other professionals (e.g., Furniss v. Fircherr, 1958). To our knowledge, no client in Australia or England has ever won a legal action against a psychologist for breaching hisher confidence, although we know such an action was recently settled out-of-cow in NSW without the psychologist admitting liability.’ Also, as will be discussed later, actions have been brought against psychiatrists for analogous acts. The issue of privilege (i.e., the right of a client to have information withheld from disclosure in evidence in court) is sometimes raised in relation to psychologists and their relations with clients. Confidentiality is different from, but related to, the concept of privileged communication. Psychologists (or, more correctly, their clients) generally do nor have privilege in relation to proceedings in court.2 A psychologist requested to disclose in court confidential information concerning a client usually cannot, therefore, rely on claims of privilege if reluctant to provide such information, but could cite ethicdprofessional reasons justifying nondisclosure and request a judge to exercise hidher discretion and permit the nondisclosure. If a judge declined this request, a psychologist still refusing to disclose information may be held in contempt of court. Thus, psychologists cannor claim a general legal right to refuse to disclose information in court simply on the ground that it was disclosed to them in confidence. When considering the legal framework, it should also be noted that disclosure of confidential information is sometimes required by law. For example, most Australian States now have legislation which makes it mandatory to report cases of suspected child abuse or maltreatment. Several States impose this obligation upon psychologists. For example, in South Australia the legislation imposes the obligation to report on, inter alia, any employee of an agency established to promote child or community welfare (s.82D, Community Welfare Act, 1972-1976). Other examples of disclosure compelled by law include public servants following official directions, requests in response to search warrants (even if this involves client records), subpoenas or summons to testify or produce documents, and requirements of individual psychologist’s terms of employment (Fox, 1984). Recent case law has also tended to support disclosure of confidential information in some circumstances. A patient who was being investigated by the police in New South Wales in relation to child abuse charges made disclosures to a psychiatric nurse who was caring for him. Subsequently, the patient sought to have the nurse’s notes withheld from the police. The Supreme Court of New South Wales refused to support the patient’s claim that the information was confidential, and held that the necessity of investigating child abuse overrode any obligation of confidentiality (Brown v. Brookes, 1988). Similarly, in W v. Edge11 (1990) a psychiatrist assessed a patient who some years previously had killed five people and who was currently being detained in a secure hospital in Britain. The evaluation was sought as the patient was requesting a transfer to a less secure facility. When the psychiatrist tendered a negative report (he regarded the client as still dangerous), the solicitor acting NOVEMBER 1995 Iy AUSTRALIAN PSYCHOLOGIST
165
MARILYN MCMAHON AND ANN D. KNOWLES
for the client chose not to use the report. The psychiatrist, learning of this decision, then forwarded a copy of his report to the board which was to decide whether the patient should be relocated. Upon learning of this, the patient sued the psychiatrist for breach of confidence. The court held that the psychiatrist had e n justified in voluntarily disclosing the information because the public interest in protecting the community from danger overrode the client’s interest in confidentiality (Wv. Edgell, 1990). The thrust of this brief analysis has been to suggest that the legal framework in which Australian psychologists practice does not make it easy for clients to enforce confidentiality, and that increasingly the law has been willing to acknowledge circumstancesin which confidentialitymay be breached (see Pizer, 1994). The significance of this may well be that the protection of confidentiality becomes the province of professional organisations (such as the APS) and a focus of ethical, rather than legal, concern. Given this discussion, one may well ask “Where i s the problem?’. If it is being argued that the protection of confidentiality falls as a responsibility to the A P S through its ethical guidelines, and if there is congruency between ethical guidelines, professional practices, and attitudes and public expectations, why is it being argued that confidentiality is a decrepit concept? The following discussion considers some of the problematic aspects of psychological practice in relation to confidentiality.
The Diversity of Practices by Psychologists Reference has been made previously to the results of a survey of Victorian psychologists regarding attitudes to confidentiality (McMahon & Knowles, 1993). An interesting feature of the results was that the clinical orientation of psychologists significantly affected their attitudes towards confidentiality. Psychodynamically oriented psychologists were significantly more likely to believe that absolute confidentiality was essential to counselling / clinical work than were cognitive-behavioural, eclectic, or experientially oriented psychologists. Notably, psychodynamically oriented psychologists tended to discuss limits to confidentiality with clients only when necessary, whereas family, cognitive-behavioural, and eclectically oriented therapists and counsellors were significantly more likely to routinely discuss possible limits with clients. Thus, the psychologists who valued confidentiality most were the least likely to discuss it with their clients (McMahon & Knowles, 1993). Given the range of views expressed in relation to confidentiality, it is important to note that a client attending a given psychologist may be unaware of hidher attitude to confidentiality, and thus there is the possibility of a mismatch between practitioner behaviour and client expectations. Note that General Principle IIIa of the APS code requires that: “Where appropriate, psychologists must inform their clients of the legal or other contractual limits to confidentiality” ( A P S , 1994, p. 3). To give effect to this principle. it is suggested that psychologists should routinely provide information to clients and potential clients regarding their attitudes and practices pertaining to confidentiality, and that it would only be-in unusual circumstances that psychologists would not discuss these policies. A further, disquieting consideration concerns how psychologists exercise their discretion in relation to breaching client confidentiality. It is possible that breaches may occur in relation to idiosyncratic biases andlor prejudices or other irrelevant considerations. For example, research by Jensen and Nicholas (1984) in the United States established NOVEMBER 1995 Q AUSTRALIAN PSYCHOLOGIST
166
that the social characteristics of both a suspected “abuser” and possibly “abused” child influenced respondents’ tendencies to report child abuse. The case most likely to be reported was that of a “socially unattractive” father (unemployed, limited education, low status) with a “socially unattractive” child (difficult, disturbed behaviour, irritable) (Jensen & Nicholas, 1984). Also, consider the following dilemma: A psychologist is treating an HN+ client who refuses to discuss his HIV status with his wife. Afer questioning by the psychologist as to whether he is still having sexual relations with his wife, the client answers ambiguously. The client cancels his subsequent appointment and refuses to speak with the psychologist on the telephone. Should the psychologist breach the client’s confidence and inform the client’s wife? No matter what the answer to this dilemma, it should be conceded that the manner in which the client became HIV+ (e.g., sexual activity, intravenous drug use) should be irrelevant in determining how the psychologist should act. However, prior research has indicated that mode of transmission of HIV infection appears to play a major role in determining the degree of sympathy and comfort counsellors feel toward HIV+ individuals (Morgan & Moore, 1991). In relation to the vignette, research with postgraduate students in psychology revealed that attitudes to breaching confidentiality were related to mode of infection. Respondents were significantly more likely to believe that the psychologist had a legal duty to inform the client’s wife where the client became HIV+ through homosexual activity or sex with a prostitute, as compared with the client who was infected through a blood transfusion or heterosexual sex. The influence of the irrelevant factor - mode of infection - raises the possibility that these respondents were influenced by notions of “innocent” and “guilty” victims of HIV infection, and would have exercised a discretion to breach the confidence of a client in a discriminatory manner (McMahon, 1993). The conclusion from this is that where disclosure of confidential information is discretionary, caution must be exercised so that psychologists are not influenced by irrelevant factors when deciding whether to breach or maintain confidentiality. Perhaps consideration could be given to including in the APS code a provision similar to Principle D in the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (1992); this principle requires that psychologists be aware of their own biases and respect differences in their clients. Principle D states that “psychologists [should] try to eliminate the effect on their work of biases ... and ... not knowingly participate in or condone unfair discriminatory practices” (American Psychological Association, 1992, p. 1599). Obviously, such a provision would not eliminate psychologists’ biases and prejudices, but it could-provide a starting point for discussion and clarification of values in relation to professional practice and confidentiality.
Defensive Psychology Most people are aware of the issue of defensive medicine (medical practices and procedures adopted through fear of litigation rather than for good clinical reasons). Something similar may be happening in psychology in the formulation of principles relating to confidentiality. That is, recent principles seem to have been formulated with potential legal liabilities as primary considerations. Consider two recent amendments to the A P S code, in relation to the potentially suicidal client and the rights of employers.
CONFIDENTIALITY IN PSYCHOLOGICAL PRACTICE: A DECREPIT CONCEPT?
The Guidelines Relating to Suicidal Clients, constituting Appendix G of the A P S code, include in the first section the statement that “Psychologists should always be aware of the need to make appropriate assessment of the presence of suicidal tendencies. Avoidance of this is likely to amount to professional negligence [italics added].” The guidelines then move through a series of stages, and ultimately, in selected circumstances where the risk is deemed to be imminent and the client refuses to disclose intent to another person, they mandate a breach of confidentiality. The guidelines do not mention client autonomy, self-determination, incompetence, or soundness of mind; they state that psychologists undertake a responsibility for their clients’ welfare where suicide is a risk, and, at least implicitly, embody the view that all client suicides must be prevented, no matter what the mental state of the client. The psychologist who is aware of a client’s suicidal intent and does nothing to stop the client is, under these guidelines, unethical. But, arguably, mandatory disclosure here is just as unreasonable as absolute confidentiality. Respect for the autonomy of the person could conceivably, in some circumstances, override the psychologist’s interest in preserving the client’s life. For example, some commentators have argued that “seriously medically ill” persons who refuse treatment and/or request assistance in dying present different ethical considerations when compared to depressed, otherwise medically well persons who wish to die. Cogent arguments have been advanced that would justify, after optimising medical and psychiatric treatment and determining that the patient was competent to make decisions, respecting a seriously ill patient’s desire to die (Sullivan & Yonygner, 1994). The problem is not addressed by making simple distinctions between refusal of treatment and suicide (Kuhse, 1986). The continuing “dying with dignity’’ debate in the medico-legal arena highlights these issues (see Social Development Committee, 1986; Social Development Committee, 1987; Sullivan & Yonygner, 1994) and it is perhaps premature, simplistic, and “defensive psychology” for ethical guidelines to mandate that a psychologist must always disclose a client’s suicidal state. Another possible example of defensive psychology is the 1991 amendment to the APS code which states that psychologists must not refuse any reasonable requests from clients for the release of data, and that such data may be released only to appropriately qualified persons with a legitimate interest in the data subject to the lawful requirements of their employment conditions (Section B A. emphasis added). Disclosure of confidential information compelled by the terms of a psychologist’s employment is not new; a decade ago Fox (1984) noted that: Whenever psychologists ... are employed in an institutional setting, whether in government service or private employment, they are liable to be directed by their superiors in the hierarchy to write repoh, hand over files or supply information regarding services provided to others in the course of employment (p. 177).
However, what is new is that this legal requirement has been transmuted into an ethical obligation by appearing in the APS code. Such a development simultaneously decreases an employee psychologist’s capacity to determine appropriate policy regarding confidentiality with clients, and increases the employer’s (who may not be a psychologist) power to establish such policies. Although it has been argued that psychologists concerned with confidentiality should reach an explicit understanding with their employers and have this incorporated into a contract of employment, the position of the individual psychologist negotiating this matter is weakened when the APS code itself acknowledges
the primacy of the employer’s claim. Again, the incorporation of this requirement into the APS code suggests defensive psychology, where the motivating factor has been concern with legal liabilities and responsibilities rather than with appropriate clinical and professional practice. Other strategies that could be adopted by the APS that might be helpful in exploring these .issues include organising forums in which to discuss these matters and preparing model clauses regarding confidentiality that psychologists could seek to have incorporated in their contracts of employment. For these reasons - the diversity of attitudes and practices of psychologists, the possibility that improper matters are taken into account when discretion is exercised, and defensive psychology - it is argued that the concept of confidentiality in contemporary psychological practice is decrepit. Bearing in mind that it has previously been argued that the protection of confidentiality may now primarily be an ethical task for organised psychology, the rehabilitation of this obligation requires concerted professional activity.
Why Confidentiality? How do we revive the concept or evaluate its worth? A great deal of the debate on issues relating to confidentiality is obscured by failure to address the basic issue: Why do we advocate confidentialiry in the relationship with clients? Instead, attention is directed to particular cases where maintaining or breaching confidentiality is controversial, for example, mandatory reporting of child abuse, suicidal clients, and “dangerous” clients. Establishing the value to be attached to confidentiality in contemporary psychological practice requires an examination of why, and to what degree, it is significant. The potential rationales for confidentiality are manifold and include respect for the client’s autonomy, respect for the relationship between psychologist and client, and utilitarian justifications. Bok (1989). in her general discussion of secrecy in diverse social settings and circumstances, provides a fruitful starting point for the reevaluation of the principle of confidentiality. Bok identifies four principles to be considered when determining whether client confidentiality should be maintained or breached: respect for the person (client autonomy), respect for the relationship between professional and client, respect for the information disclosed, and utilitarian justifications. Examination of the relevance of each of these principles for psychological practice, and the possible conflict between different principles, provides a fruitful starting point for contemporary discussion.
Summary The APS code places the onus on the psychologist to explain the limits of confidentiality to a client (General Principle ma). Perhaps a more basic task is for organised psychology to examine reasons for endorsing the principle of confidentiality, thereby permitting a rational development of both the significance and limits of confidentiality for the profession and clients. Such fundamental re-examination constitutes a necessary prelude to the rehabilitation of the now decrepit concept of confidentiality in contemporary psychological practice.
Footnotes It is acknowledged that examination of reported cases does not necessarily reflect whether this issue is litigated. It is possible that this type of case is either settled out of court or not reported in the law reports. 2. Note that this is the general legal position of psychologists. However, psychologists working within pdcular statutory frame-
1.
NOVEMBER 1995 Y AUSTRALIAN PSYCHOLOGIST
167
MARILYN MCMAHON AND ANN D. KNOWLES
works may have privilege in relation to information obtained while working within that framework. For example, psychologists (and others) working as court counsellors within the Family Court of Australia are prohibited from disclosing in any other legal proceedings information obtained during reconciliation, pre-filing. conciliation counselling, or a conciliation counselling conference. This is in direct contrast to reportable counselling. where the COWmay order the court counsellor to prepare a report to be received in evidence (s.62A. Family Law Act 1975 Cth).
References American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1597-1628. Appelbaum, P., Kapen, G., Walters, B., Lidz, L, & Roth, L. (1984). Confidentiality: An empirical test of the utilitarian perspective. Bulletin of the American Academy of Psychiatry and Law, 12, 109-1 16. Australian Association of Social Workers. (1986). Code of ethics. Melbourne: Author. Australian Concise Oxford Dictionary. (1992). Melbourne: Oxford University Press. Australian Medical Association. (1992). Code of ethics. Melbourne: Author. Australian Psychological Society. (1994). Code of professional conduct. Melbourne: Author. Baird, K., & Rupert, P. (1987). Clinical management of confidentiality: A survey of psychologists in seven states. Professional Psychology: Research and Practice, 18,347-352. Bok, S . (1989). Secrets: On the ethics of concealment and revelation. New Y o k Vintage. Brown v. Brookes unreported, Supreme Court of NSW, 1988. Collins. N., & Knowles, A. (1995). Adolescents’ attitudes towards confidentiality between the school counsellor and the adolescent client. Australian Psychologist,30, 179-182. Community Welfare Act 1972-1976 (SA). Coventry, G.,Daly, J., Evans, M., Lowy, C.. McMahon, M., & Roberts, G. (1993). The healthhedical care injury case sfudy. Canberra: AGPS. Department of Health, Housing and Community Services (1992). Compensation and professional indemnify in health care: A discussion paper. Canberra: AGPS. Family Law Act 1975 (Cwlth). Fox, R. (1984). Ethical and legal principles of confidentiality for psychologists and social workers. In Nixon, M. (Ed.), Issues in psychological practice. Melbourne: Longman-Cheshire. Furniss v. Fitchett (1958) NZLR 3%. Jagim, R., Wittmann, W., & Noll, J. (1978). Mental health professionals’ attitudes towards confidentiality, privilege and third
NOVEMBER 1995 Q AUSTRALIAN PSYCHOLOGIST
168
party disclosures. Professional Psychology: Research and Practice, 9 , 4 5 W . Jensen, R.,& Nicholas, K. (1984). Influence of the social characteristics of both fatha and child on the tendency to report child abuse. Professional Psychology: Research and Practice. 15,121-128. Knowles, A., & McMahon, M. (1995). Expectations and preferences regarding confidentiality in the psychologist-client relationship. Australian Psychologist, 30, 175-178. Kuhse, H. (1986). Active and passive euthanasia. In Social Development Committee, Victoria First repon on inquiry inro options for dying with dignity. Melbourne: Parliament of Victoria Lindenthal, J., & Thomas, C. (1982). Psychiatrists, the public and confidentiality. Journal of Nervous and Mental Disease, 170, 319-323. Little, R., & Stnckcr, E. (1956). Moot questions in psychiatric ethics American Journal of Psychiatry, 113,455460. McMahon, M. (1993). The efect of knowledge of mode of client infection with H N on attitudes to disclosure of confidential information disclosed during counselling. Paper presented at the 28th Annual Conference of the Australian Psychological Society. McMahon, M., & Knowles, A. (1993). Psychologists’ views on confidentiality in counselling/clinical practice. Unpublished manuscript. Morgan, C., & Moore, S . (1991). Can counsellors cope with clients who are HIV positive? Paper presented at the 26th Annual Conference of the Australian Psychological Society. Pizer, J. (1994). The public interest exception to the Breach of Confidence action: Are the lights about to change? Monash UniversityLaw Review, 20,67-109. Social Development Committee, Victoria. (1986). First repon on inquiry into options f o r dying with dignity. Melbourne: Parliament of Victoria. Social Development Committee, Victoria. (1987). Inquiry inro options for dying with dignity. Melbourne: Parliament of Victoria. Sullivan, M., & Yonygner, S. (1994). Depression, competence and the right to refuse life-saving medical treatment. American J O U Of~Psychiao. 151,971-978. Szasz, T., & Nemiroff, R. (1%3). A questionnaire study of psychoanalytic practices and opinions. The Journal of Nervous and Mental Disease, 137,209-221. W v. Edge11 (1990) Ch 359. Wise, T. (1987). Where the public peril begins: A survey of psychotherapists to determine the effects of Tarasoff.Stanford Law Review, 31 (Pan l), 169-190. Wiskoff. M. (1960). Ethical standards and divided loyalties. American Psychologist, 15,656460.
