Disorders of Development and Aging [WLOs: 1, 2] [CLOs: 1, 2, 3, 4, 5]
NeuroRehabilitation 23 (2008) 447–454 447 IOS Press
Ethical considerations in geriatric neuropsychology
Thomas A. Martina,∗ and Shane S. Bushb aMissouri Rehabilitation Center, University of Missouri-Columbia, USA bLong Island Neuropsychology, P.C., Lake Ronkonkoma, NY, USA
Abstract. The practice of geriatric neuropsychology demands specialized training and experience that enables the practitioner to appreciate the unique challenges and opportunities that are encountered when working with older adults. In addition to maintaining advanced knowledge regarding medical and psychological conditions, assessment issues, and treatment needs specific to older persons, clinicians working with older adults must be prepared to recognize and confront ethical dilemmas that arise. For example, ethical challenges related to professional competence, informed consent, assessment, and privacy and confidentiality may be prominent when working with older persons. Maintaining an emphasis on “positive ethics” and utilizing an ethical decision-making model will promote the practitioner’s ability to avoid, identify, and resolve ethical challenges. The present article reviews (1) the concept of positive ethics, (2) a comprehensive ethical decision-making model, and (3) ethical issues that are commonly encountered by geriatric neuropsychologists. A case vignette is presented to illustrate the application of the aforementioned tools to promote ethical practice.
Keywords: Ethics, geriatric neuropsychology, positive ethics, ethical decision-making model
1. Introduction
In 2007, it was estimated that persons age 60 or old- er comprised 11% of the worldwide population. That percentage is up from 8% in 1950, with this age group projected to account for 22% of the worldwide popula- tion in 2050 [21]. The United States (US) is also expe- riencing an aging population, with 2000 census figures estimating that 35 million people living in the US were aged 65 or older [22]. This segment of the population is projected to total 47 million people in 2016 and 62 million persons in the year 2025 [23]. Because near- ly all of the countries in the world are experiencing a growing proportion of older adults [21], it is reasonable to expect that an increased demand for specially trained health care professionals who can provide needed ser-
∗Address for correspondence: Thomas A. Martin, Psy.D., ABPP, Missouri Rehabilitation Center, 600 North Main Street, Mt. Vernon, MO 65712, USA. Tel.: +1 417 461 5238; Fax: +1 417 461 5735; E-mail: martinta@health.missouri.edu.
vices to older persons will be realized throughout much of the world during the coming years [16].
The practice of geriatric neuropsychology demands specialized training and experience that enables the practitioner to appreciate the unique challenges and opportunities that are encountered when working with older adults [18]. In addition to maintaining advanced knowledge regarding medical and psychological condi- tions, assessment issues, and treatment needs specific to older persons, clinicians working with older adults must be prepared to recognize and confront ethical dilemmas that arise [9]. For example, ethical challenges related to professional competence, informed consent, assess- ment, and privacy and confidentiality may be promi- nent when working with older persons [10]. Maintain- ing an emphasis on “positive ethics,” which includes assuming a proactive approach to ethics can promote ethical competency [7,12]. When ethical dilemmas are encountered, use of an ethical decision-making model provides a structured method of information collection and analysis that can assist with the identification of a preferred course of action [7].
ISSN 1053-8135/08/$17.00 2008 – IOS Press and the authors. All rights reserved
448 T.A. Martin and S.S. Bush / Ethical considerations
In keeping with the goal of promoting ethical prac- tice in the field of geriatric neuropsychology, this pa- per presents a number of specific ethical challenges that are commonly encountered in clinical practice. A review of “positive ethics” is then provided, followed by the presentation of a previously developed ethical decision-making model that has been recommended for use by neuropsychologists [6,8,10,11]. Lastly, a case vignette is presented to illustrate the utilization of the aforementioned ethical decision-making model to ad- dress ethical challenges related to confidentiality that are often encountered when working with older adults.
2. Ethical competence and ethical and legal resources
While the focus of this article is to present ethi- cal challenges often encountered by geriatric neuropsy- chologists and identify ways to promote ethical prac- tice, a brief review of the concept “ethical competence” and the primary resources that are available to guide ethical conduct is warranted. Geriatric neuropsycholo- gy requires specialized knowledge that includes an ap- preciation of the ethical responsibilities expected of its practitioners [18]. Competent ethical practice does not happen by accident; it requires an intimate familiarity with pertinent ethical standards and governing laws as well as relevant professional literature. Professional experience, formal coursework and continuing educa- tion in professional ethics, and the routine exchange of ideas and experiences among colleagues also promotes ethical competence [9]. Maintaining ethical compe- tence is a dynamic process that includes the incorpora- tion of new ethical and legal requirements and guide- lines and an evolving appreciation of the unique aspects of one’s professional activities (e.g., providing services to special populations) [9].
Clinicians who examine and treat older adults have numerous sources of moral, professional, ethical, and legal authority available to them to promote their aware- ness of ethical issues and guide professional con- duct [10]. For example, Beauchamp and Childress [4] proposed four core biomedical ethical principles – re- spect for autonomy, nonmaleficence, beneficence, and justice – that have since become widely referenced and utilized as anchoring points to guide ethical decision- making in a variety of healthcare settings [10]. Briefly, respect for autonomy refers to valuing a person’s capac- ity for self-determination, including the right to make choices in accordance with one’s own value and belief
system. Nonmaleficence refers to causing no harm to the patient, while beneficence is the promotion of the welfare of patients. Lastly, justice speaks to fairness and, in medical contexts, an equal opportunity to obtain appropriate health care services [10].
The spirit of these four principals is represented in the five General Principals that are offered to inspire psychologists towards the highest ethical ideals out- lined in the most recent version of the American Psy- chological Association (APA) Ethics Code [2]. The APA Ethics Code is a comprehensive guide designed to promote ethical conduct among psychologists, and it is the primary ethical reference for neuropsycholo- gists practicing in the United States [7]. In keeping with its goal of maintaining the welfare and protection of persons served by psychologists, the APA Ethics Code presents Ethical Standards that are requirements for appropriate professional behavior. The Standards are enforceable for members of the APA and for psy- chologists who practice in a US state whose psychol- ogy board has adopted the APA Ethics Code for its professional requirements [10]. Because of the varied professional activities of psychologists, the APA Ethics Code was not designed, nor is it able, to address every ethical concern that could arise in professional prac- tice. Accordingly, supplementary materials, including guidelines of other relevant professional organizations and institutions, published articles and position papers, pertinent scholarly works, local psychology board reg- ulations, and applicable laws are invaluable resources that contribute to understanding and promoting ethical conduct [7,10].
3. Ethical challenges commonly encountered in geriatric neuropsychology
The transition into late adulthood is often associated with a myriad of physical, psychological, and social changes [10]. Evaluating and treating individuals dur- ing this dynamic period can pose unique profession- al and ethical challenges for health care providers, in- cluding neuropsychologists [13]. Being mindful of the ethical issues that may develop during the practice of geriatric neuropsychology and considering avenues to address these challenges before they develop, can pre- pare the neuropsychologist, and promote the likelihood of a favorable resolution that is consistent with the best interests of the patient.
Morgan [18,19] and McSweeny [17] commented on ethical considerations in geriatric neuropsychology,
T.A. Martin and S.S. Bush / Ethical considerations 449
identifying areas related to professional competence, unique assessment considerations, and respect of the rights and dignity of the patient as specific concerns. Bush and Martin [10] also identified common ethical challenges specific to geriatric neuropsychology, in- cluding professional competence, human relations, in- formed consent, cooperation with other professionals, institutional practice, privacy and confidentiality, as- sessment, and treatment and health promotion. Be- cause of the propensity of 4 of these areas (professional competence, informed consent, assessment, and priva- cy and confidentiality) to contribute to ethical dilem- mas in clinical practice, they will be reviewed in greater detail. However, it is noted that the ensuing discussion of these four areas provides an overview only that is by no means inclusive of all relevant considerations.
3.1. Professional competence
Professional competence is based on the general bioethical principle of nonmaleficence (do no harm) and APA Ethical Standard 3.04, Avoiding Harm [10]. To minimize the potential of harming a patient, clini- cians must possess the requisite specialized knowledge and skill set needed to perform the requested services. Given the increasing demand for providers to meet the health care needs of older adults, neuropsychologists may find themselves asked, and tempted, to conduct geriatric evaluations despite having limited expertise in this area. As with any other subspecialty of neuropsy- chology (e.g., pediatric or forensic neuropsychology), the competent practice of geriatric neuropsychology is based on education and training that prepares the prac- titioner to meet the unique needs of the population they are serving [19].
At a minimum, neuropsychologists working with older adults should possess a working knowledge of gerontology that includes an in-depth understanding of the neuropathology and psychopathology of the elder- ly, as well as the impact of normal aging upon neu- ropsychological functioning. Neuropsychologists who evaluate and treat older adults should have a reason- able understanding of the following: (1) how the neu- ropathology and psychopathology evidenced by the el- derly translate into performance on measures of cog- nitive and psychological functioning; (2) the potential side effects of commonly used medications, as well as other treatment and rehabilitation options; (3) local and national resources, (4) the needs of families and/or caregivers who are involved in the lives of the patient; and (5) the integration of neuropsychology, gerontol-
ogy, and the neuropathology and psychopathology of the elderly [10,20]. As discussed previously, compe- tence is not a static trait. The rapid advances being realized in the field of geriatric health care demand that the practitioner maintain an evolving knowledge base that is consistent with current scientific literature.
3.2. Informed consent
The bioethical principle of respect for autonomy ad- dresses the right of persons receiving neuropsycholog- ical services to be fully informed about the nature and purpose of the proposed services as well as the possi- ble impact it may have upon their lives. Respect for patient autonomy also requires that practitioners value a competent patient’s capacity for self-determination, including their right to refuse services. The APA Ethics Code also dictates that neuropsychologists inform pa- tients of the nature and purpose of the services they are going to provide and discuss issues related to fees, involvement of third parties, potential risks, and limits of confidentiality (APA Ethics Code; Standards 3.10, Informed Consent; 9.03, Informed Consent in Assess- ments; and 10.01, Informed Consent to Therapy). The patient should also be provided an opportunity to ask questions and express any concerns. It is noted that the informed consent process should be tailored to the meet the unique needs of the patient as well as the setting in which the services are performed (e.g., inpatient vs. outpatient services).
The APA Ethics Code recognizes that informed con- sent is not always possible because of a patient’s com- promised neuropsychological status and/or the situa- tion of the evaluation. For example, individuals with impaired cognitive functioning may not be able to ful- ly comprehend the purpose of the examination or the possible ramifications of their participation. Similarly, patients mandated for services (e.g., forensic evalua- tion) may not provide their consent for an evaluation. Nonetheless, the practitioner maintains a responsibility to inform these patients, to the extent possible, about the nature and purpose of the proposed services, iden- tify any questions and concerns they may have, and seek their assent. For patients who have been deemed incompetent to make healthcare related decisions, in- cluding consenting to neuropsychological services, and for those whom a surrogate decision-maker has been appointed, the surrogate decision-maker should be ful- ly informed of the issues noted above and offered the same opportunity to have any questions or concerns they may have addressed [10].
450 T.A. Martin and S.S. Bush / Ethical considerations
As necessary, neuropsychologists who serve older adults should also clarify for family members or other involved parties (1) the role of the neuropsychologist, (2) who the patient is (e.g., the older adult or the family member who initiated and paid for the services), (3) the probable uses of information obtained, and (4) the bounds of confidentiality including who will be privy to evaluation findings [10]. Establishing the parame- ters of the evaluation with all involved parties prior to initiating service may significantly minimize the risk of a subsequent ethical dilemma [10]. Additionally, the clinician should document the assent/consent process, whether oral or written.1
3.3. Assessment
The comprehensive assessment of an older adult’s cognitive, psychiatric, or behavioral symptoms is of- ten best addressed through an interdisciplinary pro- cess that includes a variety of specialized health care providers [3]. Neuropsychological assessment offers an important and unique contribution to this process as evaluation findings are often helpful in clarifying diagnostic considerations and in developing personal- ized treatment interventions. However, a number of factors, including diminished sensory functioning and endurance, the presence of chronic medical conditions, routine use of multiple medications, and limitations of many psychometric measures (e.g., normative data) complicate the assessment of older persons. The APA Ethics Code (e.g., Standard 9.02, Use of Assessments) and other resources such as the Standards for Educa- tional and Psychological Testing (SEPT) [1] highlight the need for psychologists to be familiar with the the- ory, research, and practice of the assessment methods they employ, and to select instruments that are psy- chometrically appropriate for the population they are evaluating.
In recent years, an enhanced appreciation of the growing elderly population has contributed to the devel- opment of specific neuropsychological measures, and the accumulation of expanded normative data for ex- isting measures, to aid in the assessment of older per- sons. However, much more can be done in this regard. Additionally, confounding variables (e.g., diminished sensory functioning) may compromise the assessment
1A sample consent form can be downloaded from the Nation- al Academy of Neuropsychology website at www.nanonline.org/ NAN/PAIC/PositionPapers/InformedConsentInClinicalNeuropsy- chologyPractice.aspx.
of older persons and necessitate the nonstandardized administration of tests (e.g., enlarged print size, repeat instructions) for which representative normative data is unavailable. Although geriatric neuropsychologists work to tailor evaluations to accommodate both the spe- cific characteristics of the patient they are seeing and the context in which the evaluation is performed [3], the practitioner is obligated to indicate any significant limitations of the evaluation that may have impacted their findings and conclusions (APA Ethical Standard 9.06, Interpreting Assessment Results; SEPT, Standard 12.19). The interested reader is referred to the article by Weyer Jamora, Ruff, and Connor and the article by Caplan and Shechter that are also included in this special issue ofNeuroRehabilitation for an expanded discussion on these particular assessment issues.
3.4. Privacy and confidentiality
Supported by the bioethical principle of respect for autonomy,privacy is a fundamental human right that contributes to one’s dignity and freedom of self- determination [15]. In a healthcare setting, privacy underlies the right of patients to choose how much of their personal information may be communicated to others.Confidentiality is based on the right to privacy and sets limits on the patient information that health care providers can share with others [10]. Neuropsy- chologists have a primary ethical obligation, with some exceptions, to protect information that is related to their patients (APA Ethics Code, Standard 4.01, Maintaining Confidentiality). Moreover, consumers of neuropsy- chological services must be informed of the nature and limits of confidentiality related to the professional rela- tionship (APA Ethics Code, Standards 4.02, Discussing the Limits of Confidentiality, and 4.05, Disclosures). In addition to being an ethical obligation, confidentiality is typically a legal requirement for health care providers, with legal ramifications for practitioners if confiden- tiality is inappropriately violated.Privilege is a related legal concept that allows certain professional relation- ships protection from disclosure in legal proceedings. Privilege belongs to competent patients, and in some ju- risdictions privilege applies to the psychologist-patient relationship [5].
While performing their professional duties, clini- cians working with older adults often come into con- tact with family members, caregivers, and other people who are directly involved in the lives of their patients. Additionally, evaluation and treatment services provid- ed to older adults are often interdisciplinary in nature,
T.A. Martin and S.S. Bush / Ethical considerations 451
involving a number of health care professionals. While the involvement of these various persons may foster the gathering and exchange of important information that can promote the care and treatment of patients, such involvement also increases the potential for violations of patient privacy [10]. For example, family members or other health care providers may ask the neuropsy- chologist to share information about the patient that the practitioner is not authorized to disclose. Such requests may put unprepared clinicians in an awkward bind or result in the inappropriate release of confidential infor- mation. As noted previously, identification of those family members and/or treating professionals who will be privy to confidential patient information should be clarified as early as possible, and as often as needed. Although clinicians often consult collateral sources of information regarding patient history and current lev- el of functioning, practitioners and patients are often well served by discussing confidentiality issues in pri- vate to discern patients’ wishes which may otherwise be unduly influenced by family members or others.
4. Positive ethics
Positive ethics challenges a practitioner to assume a proactive approach to ethical practice that includes the pursuit of their highest ethical potential and the pro- motion of exemplary behavior throughout all aspects of their professional endeavors [7,12]. This approach represents a shift away from remedial ethics in which practitioners strive to meet the minimum requirements of their ethics code or assume solely a “risk manage- ment” stance to ethics where the primary goal is sim- ply to avoid ethical misconduct or causing harm to a patient [7,12]. Positive ethics also encourages prac- titioners to integrate their personal ideals with their professional lives because identifying a connection be- tween personal values and the values underlying pro- fessional behavior may promote ethical awareness and conduct [7,12]. Maintaining an intimate familiarity with pertinent ethical and legal requirements, as well as one’s personal values and beliefs, while pursuing avenues to enhance the welfare of patients, can be chal- lenging. Indeed, the time and expense required to prac- tice positive ethics has been identified as a barrier to adopting such an approach. However, these excuses have been deemed inadequate justification for failing to pursue high standards of ethical practice [7].
5. Ethical decision-making model
Ethical issues may become an ethical dilemma when ethical, legal, or organizational requirements are at odds with one another, when the ethics code or laws do not address a particular issue, and/or when practitioners are required to rely solely upon judgment to render a solu- tion [7]. Ethical dilemmas are often complex and may be difficult to sort through and resolve. A structured method of information collection and analysis can aid in clarifying the relevant issues and identification of a preferred course of action. Additionally, utilization of a decision-making model can assist practitioners with documenting pertinent information that demonstrates their appreciation of the problem(s) and efforts to iden- tify an appropriate course of action. A variety of ethical decision-making models have been proposed over the years, with some models developed for use in specific settings (e.g., health care) [7,10].
Knapp and VandeCreek [14] reviewed a number of ethical decision-making models and identified five common steps: (a) identification of the problem, (b) development of alternatives, (c) evaluation of alterna- tives, (d) implementation of the best option, and (e) evaluation of the results. In a summary of their find- ings, Knapp and VandeCreek commented that despite their utility, those models did not adequately consider emotional or situational factors or the possible need for an immediate response. Bush expanded upon previous- ly developed models and created a 10 stage model that was designed to offer a more comprehensive approach to ethical decision-making with older adults [8]. The 10 stages of this new model include: (a) Identify the problem, (b) Consider the significance of the context and setting, (c) Determine patient and family/caregiver assets and limitations, (d) Consider obligations owed, (e) Identify and utilize ethical and legal resources, (f) Consider personal beliefs and values, (g) Develop pos- sible solutions to the problem, (h) Consider the po- tential consequences of various solutions, (i) Choose and implement a course of action, and (j) Assess the outcome and implement changes as needed.
6. Case vignette
The following case vignette illustrates the applica- tion of the aforementioned decision-making model to address ethical challenges related to confidentiality that are encountered by a geriatric neuropsychologist who is practicing in an outpatient setting.
452 T.A. Martin and S.S. Bush / Ethical considerations
Mr. Smith is an 80 year-old man who has been living alone since his wife passed away 13 months ago. His daughter, who resides out of state, called to schedule a neuropsychological evaluation because she has noted, via telephone conversations, her fa- ther to be increasingly confused and forgetful. She also stated that she would pay for the evaluation. Mr. Smith’s daughter informed the neuropsychol- ogist that Mr. Smith’s primary care physician was performing laboratory tests and he had written an order for neuropsychological testing.
On the day of the evaluation, Mr. Smith drove to the appointment accompanied by a long-time fami- ly friend who had been in contact with Mr. Smith’s daughter. The neuropsychologist had Mr. Smith sign a release allowing the neuropsychologist to ex- change information and test results with the primary care physician. The subsequent evaluation revealed significant cognitive deficits in multiple cognitive domains. Immediately after completion of the test- ing, the neuropsychologist informed Mr. Smith of the results, as well as the recommendation that Mr. Smith have supervision to ensure his safety.
Mr. Smith subsequently became very angry and before storming out of the office, he instructed the neuropsychologist not to mention the results to any- one. Seeing Mr. Smith so upset, the family friend approached the neuropsychologist to find out what had happened. Feeling somewhat overwhelmed and unsure of how to proceed, the neuropsycholo- gist asked the friend to remain in the waiting room for a few minutes.
This case vignette identifies a number of potential threats to Mr. Smith’s privacy and confidentiality. This case also highlights the importance of anticipating the specific ethical issues that may arise in clinical practice as early as possible, when the neuropsychologist may be in a position to take steps that eliminate or minimize the potential risk for subsequent ethical dilemma(s) to develop. Utilization of the previously identified ethical decision-making model will aid in clarifying the ethical issue(s) and preferred course(s) of action:
6.1. Identify the problem
Mr. Smith’s long-time friend, daughter, and prima- ry care physician all want the neuropsychologist to re- lease or discuss confidential patient information that the neuropsychologist has not been authorized to disclose. Although the patient initially authorized the neuropsy- chologist to exchange information with the referring
physician, he rescinded that consent when he realized that the test results may lead to a diminished level of independence and personal freedom.
6.2. Consider the significance of the context and setting
With Mr. Smith currently living independently and still driving, the neuropsychologist would likely pro- mote Mr. Smith’s safety and welfare, and very likely the welfare of others, by discussing the evaluation re- sults with the physician, family friend, and/or daugh- ter. However, the neuropsychologist failed to anticipate problems with the communication of the results and, unlike inpatient or residential settings where the patient is typically available, the neuropsychologist may nev- er again have access to the patient in order to try to remedy the situation. Had the neuropsychologist an- ticipated that problem, he may have chosen to provide feedback to Mr. Smith and the friend and/or daughter at the same time or provide feedback to the patient after communicating the results to the referring physician.
6.3. Determine patient and family/caregiver assets and limitations
Mr. Smith is experiencing significant cognitive im- pairments that place him, and possibly others, at in- creased risk of being harmed. Although Mr. Smith has reportedly been able to live independently without being hurt or taken advantage of, his cognitive deficits suggest he would benefit from increased supervision. While Mr. Smith has a supportive and caring friend and daughter he has instructed the neuropsychologist not to speak to them.
6.4. Consider obligations owed
The neuropsychologist’s primary obligation is to Mr. Smith. However, he has conflicting ethical obli- gations involving maintaining confidentiality and pro- tecting Mr. Smith from probable future harm. The neu- ropsychologist does not believe that Mr. Smith has the cognitive capacity to make a variety of decisions for himself, but at this point he has not been deemed in- competent by a court. The neuropsychologist also has obligations to the referring physician and Mr. Smith’s daughter because both of them need the results of the evaluation to make important decisions. Also, the neu- ropsychologist is concerned that if he does not inform Mr. Smith’s daughter of the evaluation results, she will not pay for the evaluation.
T.A. Martin and S.S. Bush / Ethical considerations 453
6.5. Identify and utilize resources
The neuropsychologist knows that he can and should consult ethical and legal sources of authority to help clarify what he should do. Such resources include the APA Ethics Code, relevant state laws, and a trust- ed colleague who practices geriatric neuropsychology. The neuropsychologist determines that sharing infor- mation to promote Mr. Smith’s welfare is consistent with the principle of beneficence. However, disclosing this information without considering Mr. Smith’s wish- es would constitute a failure to respect his autonomy. Also, APA Ethics Code Standards 4.01 (Maintaining Confidentiality) and 4.05 (Disclosures) and state law require the neuropsychologist to obtain Mr. Smith’s consent before disclosing his confidential information to the parties in question.
6.6. Consider personal beliefs and values
Examination of his own personal beliefs reveals that the neuropsychologist values open communication among parties who have a vested interest in Mr. Smith’s welfare. He also holds patient safety above all other professional matters. While the neuropsychologist re- spects his patients’ right to autonomy, including their decisions regarding who to release their confidential information to, the neuropsychologist believes that in this case the confidentiality requirements will not serve the purposes for which they were developed (i.e., pro- tecting the patient’s interests).
6.7. Develop possible solutions to the problem
The neuropsychologist considers the following so- lutions: (1) informing the family friend of the evalu- ation results, mindful of the probability the Mr. Smith will forget their neuropsychological feedback and his subsequent outburst entirely; (2) calling the patient’s daughter and physician and sharing the requested infor- mation; (3) calling the daughter and physician but stat- ing that he was not permitted to discuss the results of the evaluation because of confidentiality requirements, letting them “read between the lines”; (4) calling only the primary care physician because he has a signed re- lease to do so (Mr. Smith did not rescind his consent in writing); and (5) calling Mr. Smith when he has had a chance to calm down and ask for his permission to discuss the results with the others.
6.8. Consider the potential consequences of various solutions
The neuropsychologist determines that he can on- ly discuss the results of the evaluation with those for whom he received written permission from Mr. Smith. He also believes that he must do something quickly to help Mr. Smith and to minimize the possibility of Mr. Smith and/or others being injured. Thus, options 1, 2, and 5 are discarded.
6.9. Choose and implement a course of action
The neuropsychologist informs the family friend that after learning the results of the evaluation, Mr. Smith instructed the neuropsychologist to not discuss the re- sults with anyone else. The friend does not seem to un- derstand and is perplexed as he leaves the office. Con- sistent with option 3, the neuropsychologist next calls the patient’s daughter and physician. He explains his dilemma, which they seem to understand, and answers their questions in indirect but suggestive ways, hoping to convey his concerns without violating confidentiali- ty.
6.10. Assess the outcome and implement changes as needed
The neuropsychologist believes that his responses to the patient’s daughter and physician conveyed his concerns about Mr. Smith’s welfare without revealing the specific evaluation results. While a difficult situa- tion, the neuropsychologist believes that he took steps to promote Mr. Smith’s well-being without violat- ing the letter of confidentiality requirements. He un- derstands that he was fortunate that the physician and Mr. Smith’s daughter were understanding of the prob- lem and seemed to grasp his subtle cues. He renews his commitment to ethical preparedness and examining his practice procedures for ways to avoid such ethical challenges in the future.
7. Conclusion
A growing demand for health care professionals who can serve older adults is anticipated in the coming years as persons over the age of 60 become an increasing proportion of the worldwide population. Geriatric neu- ropsychologists are trained to provide a number of im- portant services to older persons, including assessment
454 T.A. Martin and S.S. Bush / Ethical considerations
of cognitive and psychological status and the provision of treatment interventions to promote overall function- ing and quality of life. Although the competent practice of geriatric neuropsychology is based on specialized training and knowledge regarding medical and psycho- logical conditions, assessment issues, and treatment needs specific to older persons, clinicians must also be prepared to recognize and confront ethical dilemmas that arise. Maintaining a proactive approach to ethics that includes harboring an appropriate familiarity with pertinent ethical standards and governing laws can pro- mote the clinicians appreciation of ethical dilemmas. Utilization of an ethical decision-making model can provide a structured method of information collection and analysis and assist the practitioner in determining a preferred course of action. Ethical competence is an essential component of professional preparedness that can promote piece of mind and allow the clinician to fo- cus on the personal and professional rewards that often accompany the provision of services to older persons.
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