case study
Codes of Ethics: Guides Not Prescriptions A set of rules and directives that would result in efficient and ethical professional practice would be something clearly welcomed by student and professional alike. However, as should be clear by now, such prescriptions or recipes for professional practice do not exist, nor does every client and every professional condition provide clear-cut avenues for progress. Professional practice is both complex and complicated. The issues presented are often confounded and conflicting. The process of making sense of the options available and engaging in the path that leads to effective, ethical practice cannot be preprogrammed but rather needs to be fluid, flexible, and responsive to the uniqueness of the client and the context of helping. The very dynamic and fluid nature of our work with clients prohibits the use of rigid, formulaic prescriptions or directions. Never is this so obvious as when first confronted with an ethical dilemma. Consider the subtle challenges to practice decisions presented in Case Illustration 7.1. The case reflects a decision regarding the release of information and the potential breach of confidentiality. The element confounding the decision, as you will see, is that the client was deceased and it was the executrix of the estate providing permission to release the information to a third party.
Case Illustration 7.1 Conditions for Maintaining Confidentiality While all clinicians have been schooled in the issue of confidentiality and the various conditions under which confidentiality must be breached (e.g., prevention of harm to self or another), the conditions of maintenance of confidentiality can be somewhat blurred when the material under consideration is that of a client who is now deceased. Consider the case of Dr. Martin Orne, MD, PhD. Dr. Orne was a psychotherapist who worked with Anne Sexton, a Pulitzer Prize winner. Following the death of Ms. Sexton, an author, Ms. Middlebrook, set out to write her biography. In doing her research, Ms. Middlebrook discovered that Dr. Orne had tape-recorded a number of sessions with Ms. Sexton in order to allow her to review the sessions, and he had not destroyed the tapes following her death. Ms. Middlebrook approached Linda Gray Sexton, the daughter of the client and the executrix of the estate, seeking permission to access these tapes of the confidential therapy sessions as an aid to her writing. The daughter granted permission for release of the therapeutic tapes. A number of questions could be raised around this case, including the ethics of tape-recording or the ethics of maintenance of the tapes following the death of the client. However, the most pressing issue involves the conditions under which confidentiality should be maintained. The challenge here is, should Dr. Orne release the tapes in response to the daughter’s granting of permission, or does his client have the right to confidentiality even beyond the grave? As noted, the main question to be considered in this case is, does confidentiality extend into the grave and if not, under what conditions can (should) it be violated? You may find it informative to discuss that question with your classmates or colleagues, and to aid in that discussion, you may want to consult the following website for additional information on the case While our standards and professional codes of practice can help us in resolving questions, such as that found in Case Illustration 7.1, they do not (nor do they purport to) provide clear direction and solution in any and all situations. Even principles such as informed consent , confidentiality , and boundaries , while appearing clear and easily applied, can be challenging to enact in professional practice. Consider these principles in light of some challenging practice conditions
Clearly, as a human service provider, you will encounter situations in which you are confronted by an ethical dilemma. The situation may include if and when to disclose confidential information without a client’s consent (e.g., a suicidal client) or the ethics of limiting a client’s right to self-determination (e.g., when involuntary hospitalization is required) or even the appropriateness of engaging in nonprofessional relationships with a former client. These ethical dilemmas are difficult to resolve, because by one definition, that of Kitchener as cited in Shiles (2009), an ethical dilemma occurs when “there are good but contradictory ethical reasons to take conflicting and incompatible courses of action” (p. 43). As such, the ethical dilemmas we encounter are by definition often subtle and always, by definition, without a singular clear path to resolution. Consider the findings of one study assessing 450 members of the American Psychological Association’s Division 29 (Psychotherapy) by Pope, Tabachnick, & Keith-Spiegel (1987). Of the 83 separate behaviors the members were asked to rate according to ethicality, very few—for example, having sex with a client or breaking confidentiality if clients are suicidal or homicidal—were clear-cut. Most of the 83 fell in what the authors termed “gray areas” between being ethical and unethical. Such data highlights the difficulty one experiences when faced with an ethical dilemma and the need for a sound model of ethical decision-making. Ethical Decision-Making: A Range of Models Life—at least our professional lives—would be easier if all practice decisions and ethical dilemmas were black or white. As should now be evident, the ethical nature of our practice decisions are most often colored in many shades of gray, and thus the path to follow is not always clear. For some, the goal is to follow the ethical codes from a mandatory perspective and thus be true to the letter of the law. While this is a basic level of ethical functioning and may serve to protect the human service provider to avoid legal trouble, this should not be the main focus of our ethical choices. We are called to embrace our ethics on an aspirational level. For one embracing aspirational ethics, the goal is not self-protection but rather client welfare. While it is our duty, our responsibility, to understand and embrace our codes of ethics (i.e., mandatory ethics ), the execution of these codes in practice demands that we engage in self-reflection and the employment of a decision-making process that results in what is best for each of our clients (i.e., aspirational ethics ). Reliance on one’s “gut-feelings” or intuition, in the absence of reflection on that which is both mandatory and aspirational, presents an ethical problem in itself, given the greater risk to the public (Welfel, 2010). In complex situations, the American Counseling Association’s (ACA) Ethics Committee, for example, recommends that counselors explore professionally accepted decision-making models and choose the model most applicable to their situation (Kocet, 2006). This position has even been codified in the ACA Code of Ethics where it is noted: “When counselors are faced with an ethical dilemma, they use and document, as appropriate, an ethical decision making model … ” (ACA, 2014, Code I.1.b). While there is no one specific ethical decision-making model that has been identified as most effective and globally embraced, it is important, as noted by the ACA (2014, p. 3), for practitioners to be familiar with a credible model of decision-making. To this end, numerous authors have offered models for ethical decision-making, a sampling of which is offered in the next section. Each model offers a unique perspective or lens through which to view practice decisions and ethical dilemmas and as such are worthwhile, considering as each may reflect your style of practice and/or the context in which you work. Ethical Justification Model Kitchener (1984) has provided what some feel is the foundation for ethical decision-making (see Sheperis, Henning, & Kocet, [2016]). In fact, many of the ethical decision models use Kitchener’s virtues as a springboard for their development (Urofsky, Engels, & Engerbretson, 2008). Kitchener (1984) was aware of the then existing limitations to ethical codes and thus directed psychologists to consider the fundamental ethical principles that not only serve as the foundation for professional codes but provide a conceptual vocabulary for analyzing ethical issues when direction is less than clear. Kitchener invited practitioners to employ the values of autonomy, nonmaleficence, beneficence, fidelity, and justice (see Chapter 3 ) as reference points when making ethical decisions. From this perspective, clinicians would ensure that their decisions not only treated each client equally given equal circumstances (justice) but also supported client freedom to choose (autonomy). Further, based on these principles, a practitioner’s ethical decisions would be made in a way that not only avoided harming the client (nonmaleficence) but promoted help and health (beneficence). For example, while having a sexual relationship with a client is clearly unethical, the question of ethics when applied to other nonsexual, multiple-role relationships with former clients may be less obvious (Anderson & Kitchener, 1998). In these situations, the codes may not be clear and directive. Kitchener (1984) would suggest that clinicians allow their concern about not undoing therapeutic gains (i.e., nonmaleficence) along with their desire to refrain from affecting client self-determination (i.e., autonomy) to guide their decision to engage or not to engage in these nonsexual, multirole relationships. To further clarify this perspective, we invite you to engage in Exercise 7.1, applying foundational values. When exploring an ethical dilemma, reflection on these moral values or principles may offer insight into the path best chosen. However, it has been suggested (e.g., Forester-Miller and Davis, 1996) that in complicated cases the employment of a step-wise decision-making model may be useful. Step 1: Identify the problem articulating the ethical concern. During this step, the practitioner needs to gather information that sheds light on the depth and breadth of the situation. The authors suggest that the practitioner consider questions such as, is this an ethical, legal, professional, or clinical problem or perhaps some combination? Is the issue a reflection of me, the client, others in the client’s life, and/or the system in which I work? Answering these questions helps focus the targets for resolution. Step 2: Apply the ACA Code of Ethics. While developed for use by counselors and thus the reference to ACA Code of Ethics , this decision-making process could be employed by all mental health professionals by making reference to the appropriate professional standard and code at this step in the process. It is important to review the codes in order to identify all standards that may apply to the situation. If the codes do not provide clear and direct insight into the path of resolution, additional steps of the decision-making process will be necessary. Step 3: Determine the nature and dimensions of the dilemma , noting the scope of the issue engaging the current professional literature, colleagues, and even professional associations to ensure the most current perspective on this type of problem is incorporated. Step 4 : Generate a possible course of action that could result in resolution. During this step, be creative; brainstorm in order to develop the widest possible selection of options. Step 5: Consider the potential consequences of all options. It is important to identify all possible implications of each course of actions as it may impact the client, others, and even yourself. Identify the option or combination of options that best serve the situation. Step 6: Evaluate the selected course of action. At this step, it is especially important to be sure that the path selected will not create additional ethical concerns. Step 7: Implement the course of action . Once the pathway has
been selected and implemented, it is important to assess to ensure that the desired impact or outcomes were achieved. The employment of such a step-wise approach DOES NOT ensure that each practitioner, in similar situations, would arrive at the same path or outcome. However, the use of this or similar systematic models allows each clinician to not only give evidence of their valuing of ethics and ethical decision-making but to be able to articulate and explain their deliberations and reflections in the selection of a course of action.
Jordan and Meara (1990, 1995) introduced a rather unique perspective on the issue of ethical decision-making. Their virtue ethics model focuses not on what the counselor should DO but rather on HOW as well as on WHO the counselor should be. Advocates of virtue ethics argue that practitioners should not merely seek to conform to codes but should aspire to an ethical ideal. For example, consider the situation in which a therapist approaches a termination session with a Chinese American couple. They have worked together for over a year, and the therapy has helped the couple achieve their goals. At the end of this last session, the couple presented the therapist with an original pen-and-ink drawing of their parents’ village back in Mainland China. The questions that flooded the therapist included, is it appropriate to take the gift? Is something in reciprocation required? Are boundaries being threatened? Would it be disrespectful not to take the gift? Turning to his code of ethics, the therapist can clearly see that taking a gift as a form of bartering (AAMFT, 2015, Principle 8.5) is something that a therapist should ordinarily avoid. However, when it comes to simple reception of gifts from clients, there is not clear directive as to its appropriateness, and there even seems to be a general reluctance to discuss the issue (Zur, 2007). While turning to one’s code of ethics may help direct the clinician’s response, it is, according to this model, important for the therapist to reflect upon his own personal values as they reflect his desire to both respect the persons of the clients and their culture. From this perspective and understanding that the gifts came from a desire to celebrate their success and give thanks for the professional assistance, the therapist decided to gracefully and gratefully accept this gift. Jordan and Meara’s emphasis on the values, the virtues, and the person of the therapist certainly fits with the primary theme of this text, a theme that encourages BEING ethical rather than simply knowing ethics. Jordan and Meara’s approach appears to these authors as a valuable addition to any step-wise model of ethical decision-making. Further, with its emphasis on ever-increasing self-awareness and ongoing reflection and development, their model offers valuable direction for each of us as we continue to grow and evolve both personally and professionally. Integrating Codes, Laws, and Personal-Cultural Values Tarvydas (2012) offers an integrative approach to decision-making that highlights the need for the practitioner to view all decision-making in light of not just ethical codes and laws but cultural and social values and context. The Tarvydas Integrative Decision-Making Model of Ethical Behavior comprises four stages: (a) interpreting the situation through awareness and fact finding; (b) formulating an ethical decision; (c) weighing competing non-moral values and affirming course of action; and (d) planning and executing the selected course of action. Each of these stages is described below as applied to the following brief scenario (Case Illustration 7.3). Stage I. Interpreting the Situation Through Awareness and Fact Finding During this stage, the counselor will reflect upon the client’s unique circumstances and characteristics as well as the nature of the specific concerns and claims of all stakeholders. In addition, the clinician will engage in a fact-finding process that unearths all the facts reflecting the situation and the dimensions of ethical concern. For example, in reviewing the case of Dr. Thwarp (Case Illustration 7.3), she would want to process the event through her knowledge of the content and dynamic of the session; her reflections on her own responses prior to, during, and after the event; as well as the client’s unique familial, cultural, and perhaps Stage II. Formulating an Ethical Decision An initial step in the formulation process is to review and clearly identify the various levels or elements of potential ethical concern. Continuing our brief illustration of the unexpected hug, the therapist in this situation may identify potential concerns around issues of power, transference and countertransference, and most clearly boundary violations. Clearly, the theme of abuse and its implication of power and trust needs to be considered. Each of these concerns would then be viewed through relevant ethical codes, laws, and principles as well as institutional policies and procedures that apply to the situation. With this clarity of situation, as contrasted to the standards and codes, the therapist would next consider both the positive and negative impacts of various potential courses of action. Perhaps in our scenario, the therapist is considering the following potential courses of action: (a) to immediately contact the client to define boundaries of their relationship; (b) to engage in a dialogue around boundaries at the beginning of the next session; (c) to invite the client to reflect upon her actions and the meaning they may have; (d) to increase her own sensitivity to the potential for such action and to be sure to preempt it in the future with this or any client; or (d) to simply accept the hug as a reflection of a deep sense of appreciation. As directed by the model, she would then consider the positive and negative impacts of each. During this process, it is recommended that a clinician confer with a colleague or supervisor before selecting a course of action. Stage III. Selecting an Action by Weighing Competing, Non-Moral Values, Personal Blind Spots, or Prejudices The model reminds us that we all have blind spots and personal prejudices that can impact our decisions, and as such, it is important to engage in reflective recognition and analysis of personal, competing non-moral values and personal biases. Our illustrative therapist would need to be open to the possibility of her own seductive behavior or countertransference. She would want to consider what, if any, impact the lack of an intimate relationship in her own life may have on her feelings and her behaviors around this client and this experience. In addition, she may want to reflect on own personal experience with hugging: Was it always and only in a sexual context or was hugging a common form of social greeting? In addition to reflecting on personal values and biases, it is important to filter the experience through an awareness of contextual influences, including institutional, cultural, and societal, before determining the best course of action. Stage IV. Planning and Executing the Selected Course of Action In the final stage, the clinician identifies a sequence of specific actions to be taken, with awareness of the potential personal and contextual barriers to effective implementation. For example, Dr. Thwarp recognizes that her schedule and the fact that she has a client waiting prevents an immediate reaction or follow-up response to the client. Further, as she reflected on the session in light of the client’s history, she believes that any quick, impersonal response to her, like a phone call, may be received as evidence of her rejection and may result in the client’s developing feelings of shame. As such, she decided to assess the nature and strength of their relationship at the time of her next session, and if it appeared to be of therapeutic value, she would invite the client to review the hug in light of the previous session and her needs and feelings at that time. Should the nature of the next session be such that review of this incident did not seem productive, Dr. Thwarp would be aware of future attempts of physical contact, at which time she would invite the reflection while establishing a boundary.
Parsons, Richard D.,Dickinson, Karen L.. Ethical Practice in the Human Services (p. 359). SAGE Publications. Kindle Edition.
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Parsons, Richard D.,Dickinson, Karen L.. Ethical Practice in the Human Services (p. 333). SAGE Publications. Kindle Edition.
Parsons, Richard D.,Dickinson, Karen L.. Ethical Practice in the Human Services (p. 333). SAGE Publications. Kindle Edition.