Legalism, Countertransference, and Clinical Moral Perception

Abstract

This target article focuses on dynamics that arise in three typical ethically complex cases in which psychiatric consultations are requested by physicians: a dying patient refuses life-prolonging treatment, an uncooperative patient demands to be allowed to go outside and smoke, and an angry patient demands to be admitted to the hospital. The discussion canvasses what is at stake morally and clinically in each of these cases and explores clinician–patient interactions, dynamics in relationships between consulting physicians and consultant psychiatrists, patient transference, and physician countertransference. The article defines legalism and countertransference and argues that an ethically and clinically important consequence of these phenomena for patients is distortion of clinicians' perceptions of patients' decisions and vulnerabilities. The discussion also describes how legalism and countertransference adversely affect how clinicians treat their psychiatrist colleagues. Finally, the article suggests how the effects of legalism and countertransference can be mitigated.

Keywords:

• clinical reasoning
• countertransference
• consultation
• decision-making capacity
• “difficult” patients
• legalism
• moral perception
• psychiatry
• psychodynamics
• reflection
• transference

Acknowledgment

We are grateful to Sandy Eaton for her generous hospitality, to Kate Tworek, Chris Jorgensen, and Alex George for their assistance and support, and to several anonymous reviewers of the Journal for their insightful, helpful comments.