Ethical Issues in Clinical Neuropsychology. Shane S. Bush and Michael Drexler, eds. Lisse, The Netherlands: Swets & Zeitlinger Publishers, 2002. 347 pages, hardcover, $79.00.

This book is a compilation of 13 chapters dealing with a variety of ethical issues in clinical neuropsychology. It is divided into two major sections-the first on evaluation, assessment, and intervention, and the second on ethical issues encountered with special populations. In their forward, the editors state that the book seeks to increase sensitivity to ethical issues in clinical neuropsychology, provide guidance for negotiating difficult ethical situations, and facilitate the process of evaluating the applicability of the American Psychological Association (APA) Code of Professional Ethics to neuropsychology. Although I believe the chapters succeed more in meeting the first two objectives than the last, in no way does that detract from my very positive reaction to this text. The chapter authors consistently provide insightful observations about the ethical subtleties (and minefields) of neuropsychological practice, provide and discuss numerous and often very provocative vignettes illustrating ethical dilemmas, and make frequent attempts to show how various standards of the 1992 APA Ethics Code might be applied in problematic situations.

As many readers of this review will know, however, the 1992 Ethics Code has been superseded by the 2002 version, constituting an unfortunate instance of timing that might incline potential readers to dismiss this text as outdated. Indeed, Abigail Sivan wrote an afterward, doubtless at the behest of the publisher's marketing department, to downplay the book's reliance on the 1992 Code. In any event, it would be a great misfortune for readers and potential purchasers to summarily dismiss this text because of its utilization of the 1992 Code because the value of so many of its insights and analyses are anchored in thoughtful ethical reflection that more illuminate the ethical compass of neuropsychology than depend upon whatever formulation of the APA Ethics Code is currently in use.

Prominent concerns among the first four chapters include ethical problems over the release of raw data, assessing patients who are culturally different, professional role confusion and the possibility of bias (e.g., doing a neuropsychological evaluation per a physician's request and paid for by the patient's health insurer but knowing that it will most likely be used for forensic purposes), maintaining test security, the presence of third parties at testing sessions, and, most of all, ethical issues over the validity and reliability of the tests themselves. The authors examine paradoxes inherent in clinical assessment practice, such as the problem of a patient's informed consent to testing when his or her decisional capacity is precisely at issue. Or, the problem of coerced or involuntary consent to testing when testing is ordered by the court but the client resists. Although advice and recommendations are sometimes pedestrian (e.g., "Clinicians should know for what purposes the instruments can be validly used and what the limitations of the test might be"), the vignettes of this section-especially those in chapters 3 and 4-are often quite provocative (e.g., incorporating new norms into test instruments, interpretations of problematic testing, effort and motivation as patient characteristics, limits of certainty in interpreting test results).

I found the chapter by Anderson and Palozzi the most interesting of this group because it was the only chapter that took a "meta-ethical" perspective in asking certain questions about ethical limitations of the APA Code itself. There is a considerable amount of literature opining that codes of ethics are generally motivated more by a political than an ethical sensibility as (1) their appearance heralds a new profession that has come of age (because now it has an ethical code), (2) the code serves to protect its members from interlopers, whose functioning as a member would be "unethical," and (3) that codes of ethics are not terribly useful when they are used to resolve specific, contextually rich cases. Anderson and Palozzi hint at some of these issues, especially with regard to how strictly one ought to interpret the 1992 ethical standard 2.02(b), which, in part, requires neuropsychologists to refrain "from releasing raw test results or raw data to persons [horizontal ellipsis] who are not qualified to use such information." Although they note good reasons for that standard, they also note that "an extremely rigid policy on test security could be harmful to some patients" who might, for example, simply want to know more about their performance than they've been told. Moreover, "[i]t would seem that we, as a profession, are lacking in respect for the autonomy and self-determination of our clients when we deny them knowledge of procedures and instruments by which they are assessed." Also, Anderson and Palozzi point out that certain raw data such as grip strength scores are hardly beyond the comprehension of nonpsychological professionals such as physiatrists and physical and occupational therapists.

At the risk of angering the (neuro)psychological community, I could go considerably farther than Anderson and Palozzi and allude to the commonly accepted postmodern axiom that no single group or profession holds the interpretational mortgage on any X-whether that X be a novel, a conversation, or raw test results. Any interpretation invariably proceeds from a particular ideological lens and no one lens, postmodernists hold, can claim to be the supremely right one for determining what X "really" means. Doing so only exhibits the group's political insistence and insecurity that no one else be allowed to interpret X. And I would hazard a guess that any psychologist who has been raked over the coals by a skillful attorney on what a particular set of data "really mean" might have some (perhaps grudging) appreciation of the postmodern position.

The second part of the book deals with a potpourri of topics relating to particular patient populations (pediatrics, geriatrics, forensics, rehabilitation, psychiatric, medical, and culturally diverse). Another chapter deals with managing ethical violations of the Code and another extremely interesting one is on the use of virtual reality as an assessment or treatment tool. This chapter on virtual reality offers a strikingly honest account of the promises and caveats of this intervention. The authors describe the extraordinary "stimulus delivery power" of virtual reality but also caution about the need for clinicians to be exquisitely trained, the risks that virtual reality presents to patients (e.g., cybersickness, addiction to the modality) and the risks to clinicians, such as allowing the technology to dominate the session or letting it substitute for clinical competence.

I was most taken, and perhaps readers of this journal would be most taken as well, by Swiercinsky's remarkable chapter on neuropsychology in the rehabilitation setting. His is not only a thoughtful articulation of the central ethical role of the neuropsychologist in rehabilitation, but it also is an angry chapter that ventilates the frustration of a profession increasingly straining at the seams. Swiercinsky rails against "shortsighted economics" and "ruthless case managers." He rightly notes that "[i]ssues of 'medical necessity' and lack of empirical outcome studies (i.e., issues of treatment justification) lie at the heart of ethical conflicts in advocating for the patient versus restraining intervention based on scientific merit." And he is precisely on point, I think, in arguing the ethical centrality of the neuropsychologist, who "must maintain and constantly renegotiate the 'big picture.' Such an integrative viewpoint for the neuropsychologist is necessary to catch ethical and moral snags at any point in the process." I would heartily recommend the synthetic power and observations of this chapter to anyone seeking a deeper understanding of the ethical ethos as well as the dilemmas confronting today's rehabilitationists.

No text is perfect. There are inevitable repetitions of material (e.g., informed consent issues); there are numerous throw-away observations; and there are not enough, I think, critical reflections on the difficulty of applying certain of the standards to practical cases. But these reservations are modest in comparison to my enthusiasm for the text as a whole. Any number of its chapters should be required reading for graduate or postdoctoral students in neuropsychology, and the professional in the field who is struggling with role conflict or patient care issues might find this text rich with moral insight and analyses. I very much commend the authors and editors for bringing it out and sincerely hope that its popularity is not dimmed-as it shouldn't be-by the appearance of the most recent version of the APA Code of Ethics.