Clinical/Ethical Decision

DISCUSSION AND REVIEW PAPER

When Rules Are Not Enough: Developing Principles to Guide Ethical Conduct

Elizabeth M. Kelly1 & Kaitlin Greeny1 & Nancy Rosenberg1 & Ilene Schwartz1

Accepted: 11 September 2020 # Association for Behavior Analysis International 2020

Abstract Currently, certified behavior analysts are required to adhere to the ethical rules established by the Behavior Analyst Certification Board® (BACB®) known as the Professional and Ethical Compliance Code for Behavior Analysts (BACB, 2014; hereafter referred to as the BACBCode). Applying these rules without context, however, can result in an overly simplified andmechanistic approach to ethical problem solving. Ethical rules that lack guiding principles may also pose dissemination challenges for behavior analysts tasked with communicating the field’s ethical ideals to nonbehavioral colleagues and stakeholders. This article describes the process that our applied behavior analysis organization used to develop a set of guiding ethical principles to supplement the BACB Code. These principles guide our members’ ethical decision making and assist them in disseminating our organization’s ideals. Following a description of the principle development process, we present our organization’s ethical principles and discuss how behavior analysts can use them to make clinical and ethical decisions, and address dissemination challenges.

Keywords Applied behavior analysis . Behavior analysis . Dissemination . Ethical decisionmaking . Ethics . Principles

Applied behavior analysis (ABA) is a natural science ap- proach to studying behavior in context. One of the most im- portant defining characteristics of ABA is its attention to the relationship between the behavior of interest and the context in which the behavior occurs. Baer, Wolf, and Risley (1968) initially addressed this idea when they proposed that behavior analysts study behaviors that are important to individuals in the environments in which they naturally occur, rather than those that may be more convenient for the researcher or the therapist. Since Baer et al. (1968), many other behavioral re- searchers have proposed a contextual approach to the analysis of behavior (e.g., Biglan & Hayes, 1996; Morris, 1988). This approach supposes that context contributes to a behavior’s relevance, and it therefore encourages ABA researchers and practitioners to consider context, as well as behavioral func- tion, when developing intervention strategies for the individ- uals they serve. Knowledge of both function and context is critical for effectively and meaningfully improving the quality

of life for individuals receiving ABA services (Carr et al., 2002; Moes & Frea, 2000; Verdugo, Schalock, Keith, & Stancliffe, 2005).

Ethical behavior warrants the same contextual consider- ation as all other behavior. Currently, certified behavior analysts are required to adhere to the ethical rules established by the BACB®, known as the Professional and Ethical Compliance Code for Behavior Analysts (BACB, 2014; hereafter referred to as the BACB Code). Applying a set of rules without context, however, can re- sult in an overly simplified and mechanistic approach to ethical problem solving. Ethical rules alone do not provide sufficient guidance to address the multiple contexts and complex challenges faced by professionals (Brodhead, Cox, & Quigley, 2018; Noddings, 2015). Many profes- sional organizations, such as the American Psychological Association (APA), American Medical Association (AMA), and American Speech-Language-Hearing Association (ASHA), have addressed this by developing overarching principles (e.g., beneficence, nonmaleficence, integrity) that help contextualize their ethical rules (AMA, 2016; APA, 2017; ASHA, 2016). Many revisions to the BACB Code have been made since the BACB first established rules to guide behavior analysts’ ethical

* Elizabeth M. Kelly [email protected]

1 College of Education, University of Washington, Box 357925, Haring Center, 1981 NE Columbia Rd., Seattle, WA 98195, USA

https://doi.org/10.1007/s40617-020-00515-x

/ Published online: 23 October 2020

Behavior Analysis in Practice (2021) 14:491–498

behavior (BACB, 2001); however, none of the revisions have included a set of guiding principles.

The Use of Principles to Contextualize Ethical Rules

Ethical principles are broad statements that help individuals transform conceptual and philosophical beliefs into ethical behavior (Allan & Love, 2010; Gauthier, Pettifor, & Ferrero, 2010). Principles provide overarching information and guid- ance that can be used to interpret, prioritize, and contextualize ethical rules (Kidder, 2005). Thus, principles are mechanisms that can encourage behavior analysts to consider both function and context during the ethical decision-making process. They are translational; they remind members of a profession about the core values that guide their work and the ideals that mem- bers of their professions use to make decisions about ethical dilemmas (Allan & Love, 2010; Seitz & O’Neill, 1996).

One of the most challenging activities that certified behavior analysts experience throughout their careers is addressing ethical dilemmas. These are, by definition, difficult situations that pres- ent competing value propositions—not simple situations where there is a clear right or wrong answer (Kidder, 2009). Behavior analysts routinely encounter ethical dilemmas and must decide how to interpret and solve them. They are also required to comply with the BACB Code, but this list of ethical rules is likely inadequate to provide the guidance that behavior analysts need to address all ethical situations. It is impossible to create a code of ethical conduct that provides a rule for every ethical dilemma that behavior analysts will encounter given the breadth of clients, contexts, and cultures1 that they work with. Principles provide an overarching framework to guide ethical decision making when contextual or cultural variables suggest actions that are in conflict with the BACB Code or when two or more ethical rules are incompatible (Allan and Love, 2010; Rosenberg & Schwartz, 2019; Sinclair, Poizner, Gilmour- Barrett, & Randall, 1987).

Another challenge commonly faced by behavior analysts is describing their work in a manner that is both technically accurate and understandable to nonbehavioral colleagues and stakeholders (Critchfield, 2014). This dissemination challenge is present in ethical work and exacerbated when behavior analysts attempt to explain to non-behavior analysts all of the discrete rules that gov- ern their ethical behavior.Many behavior analysts do not have the discrimination and fluency necessary to describe the 71 separate ethical codes in the BACB Code. Having an understanding of specific, relevant ethical principles may improve behavior ana- lysts’ ability to communicate the ideals that frame their work to other nonbehavioral colleagues and stakeholders. Behavior

analysts who communicate ideals, rather than codified rules, can likely better contribute to the dissemination of ethics in ways that are understandable and meaningful to others (Limentani, 1999).

Thus, ethical principles can contribute to improved ethical decision making and dissemination for behavior analysts in critical and meaningful ways. The purpose of this article is to describe our organization’s process of principle development and the resulting outcome. We are a university-based ABA program responsible for teaching and supervising future be- havior analysts, providing ABA services, and conducting ap- plied behavioral research. Although we believe that the field of ABA would benefit from guiding principles to contextual- ize current ethical rules, we are not positioned to engage in the work at that level. Therefore, we developed guiding principles for our own organization. In developing principles to supple- ment the BACB Code, behavior analysts within our organiza- tion are provided a critical tool to guide ethical decision mak- ing in line with our organization’s ideals. Guiding principles assist our behavior analysts in making ethical decisions that are compliant with the BACB Code and aligned with our organization’s professional and ethical ideals.

Ethical principles have been noted in some behavior- analytic literature. Bailey and Burch (2016) described princi- ples in their ethical text for behavior analysts; however, these principles are absent in the BACB Code (BACB, 2014). Furthermore, these principles were not informed and devel- oped by behavior analysts; they were borrowed from the broader field of psychology and other allied professions (Koocher & Keith-Spiegel, 1998). Additionally, Brodhead et al. (2018) mention principles from the field of bioethics in their text addressing practical ethics. Our work was not fueled by disagreement with the principles stated by previous au- thors. Rather, our work was guided by what we see as the critical importance of developing a shared set of values that includes the voices of our organization’s members to better guide the ethical decisions theymake daily in their profession- al practice and to disseminate our organization’s values. As we began our process of principle development, we were reminded of Sidman’s call for behavior analysts to have their feet firmly planted in their convictions while being open to other points of view (cf. Sidman, 1960, p. 41). We met this call by developing ethical principles for our organization root- ed in the implicit values of the BACB Code and our field’s ethical literature (e.g., Brodhead, 2015; Witts, Brodhead, Adlington, & Barron, 2018) and guided by the work that other disciplines have already done to develop ethical principles to contextualize their ethical rules (e.g., Allan & Love, 2010).

The Process for Developing Ethical Principles

The process of developing ethical principles for our organiza- tion was informed conceptually by a long history of work in

1 For a more comprehensive discussion of ethics and culture, see Conners and Capell (2020) and Fong and Tanaka (2013).

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professional ethics. First, we drew upon the work of ethicist Rushworth Kidder as a process model for establishing shared ethical principles across our organization’s members. We agreed with an important premise proposed by Kidder (2005) that some universal ethical values remain constant across contexts and cultures. This premise is consistent with the work of bioethicist Beaucamp, who proposed that a com- mon value system exists “as a set of norms shared by all persons committed to the objectives of morality” (Beauchamp, 2003, p. 260). Both theories suggest that univer- sal ethical values exist across groups and environments to improve the quality of life for all individuals. Though partic- ular behavioral rules or standards may change over time and across environments, universal ethical values are more likely to remain permanent (Beauchamp & Childress, 1994). This ethical framework, along with two different models of princi- ple development, informed our process.

The Process of Principle Development for Our ABA Organization

We began our process by forming an ethics workgroup consisting of two ABA faculty members (doctoral-level Board Certified Behavior Analysts) and two ABA doctoral candidates (Board Certified Behavior Analysts). All four members of the ethics workgroup identify as White women. All members have extensive knowledge of the BACB Code and experience teaching the BACBCode to graduate students. We teach ethics using multiple perspectives, resources, and decision-making tools. The context of the ABA program in which we work and our own backgrounds and experiences influenced the conversations that we had regarding ethical principles and, ultimately, the principles that we developed for our organization.

Our workgroup initially followed a process similar to that of Allan and Love (2010), who guided the development of ethical principles for the Australian Psychological Association. All four members of our ethics workgroup first conducted an extensive literature review of ethical principle development. We reviewed articles and texts describing the process of principle development frommultiple fields, includ- ing psychology (Allan, 2011; Allan & Love, 2010; Seitz & O’Neill, 1996), bioethics (Baker, 2005), and education (Campbell, 2000), as well as literature related to universal ethical values (Gauthier et al., 2010; Kidder, 2005; Schwartz, 1994). Next, our workgroup members analyzed ethics codes from allied professional organizations (see Table 1), comparing each profession’s ethical values and principles.

After reviewing the literature and analyzing other professional ethics codes, our workgroup moved to a process used by Kidder (2005) to develop a shared set

of ethical principles. First, workgroup members defined the word principle to achieve a shared understanding of the term and limit confusion. We defined principle as “a broad statement that helps individuals transform concep- tual and philosophical beliefs into behavior.” Next, we generated a list of 11 relevant principles informed by our ethical literature review, allied professional organiza- tions’ principles and values, and our own professional experiences as ABA practitione rs, educators, and re- searchers. These initial principles were nonmaleficence, beneficence, respect for people’s rights and dignity, social justice, fairness, inclusion, professional excellence, re- sponsibility, autonomy, self-determination, and integrity.

Over the course of several meetings, we discussed each principle, its importance to our organization, and its relevance to the broader field of ABA. We then separately identified three principles that we felt best represented our program. We compared our individual lists, noting that at least two principles overlapped for each workgroup member. We fur- ther discussed each overlapping principle, its definition, and its relevance to our organization until we came to a consensus on five guiding principles for our program.

Following the initial development of these five prin- ciples, we engaged in an iterative process of feedback, validation, and revision with non-workgroup members of our ABA organization. Non-workgroup members were faculty who had taught or supervised students in our university-based ABA program within the past 12 months. Soliciting contributions from organization or professional membership is widely accepted as an im- portant procedural step in the development of ethical principles and standards, and we did not want to adopt a set of principles without input from our membership, as a lack of input leads to a lack of buy-in, belief, and belonging (Gauthier et al., 2010; Hobbs, 1948).

We distributed multiple web-based surveys to all nonworkgroup colleagues (n = 16) to solicit anonymous feedback on our proposed principles. All surveys were de- signed and distributed using Qualtrics, an online survey platform for designing, distributing, collecting, and analyz- ing survey data. Survey questions asked participants to rate their agreement with each proposed ethical principle and its definition using a 5-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree). We also included write-in options for respondents to provide more detailed feedback. Demographic information was not collected. In the final survey, members were given the option to forego anonym- ity to allow workgroup members to follow up on individual respondent results. Ten non-workgroup members responded. Of the 10 respondents, 8 agreed or strongly agreed with all five principles and their definitions. Two respondents agreed or strongly agreed with four principles;

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they neither agreed nor disagreed with one principle. One respondent provided further feedback. Following the in- corporation of the feedback, we finalized our principles.

Our Organization’s Guiding Principles

The principles that guide the mission of our ABA organization are as follows:

& Beneficence. Behavior analysts have a responsibility to engage in practices that maximize their clients’2

well-being and avoid those that cause harm. We un- derstand that behavior-analytic services are most likely to benefit our clients when they are provided in the context of a trusting and compassionate rela- tionship. Where conflicts of interest arise between consumers of behavior analysis, we prioritize out- comes for the most vulnerable clients.

& Inclusion. Behavior analysts have a responsibility to pro- vide clients of all backgrounds and abilities access to and authentic participation in meaningful activities that pro- mote relationships, a sense of community, and an im- proved quality of life.

& Professional excellence. Behavior analysts have a respon- sibility to be honest and transparent. We engage in ongo- ing professional development and analyze our own prac- tices. Professional excellence requires respectful and ef- fective collaboration with individuals from other disci- plines, while maintaining a commitment to data-based de- cision making. Analyzing evidence from different meth- odologies is encouraged as a way of collaborating with others and improving practice.

& Self-determination. Behavior analysts respect clients’ rights and promote client dignity, privacy, and autonomy. We assist clients in setting and achieving their own goals, developing their own agency, and making decisions about their own lives.

& Social justice. Behavior analysts have a responsibil- ity to attend to injustice where they see it, avoid perpetuating inequitable systems, and advocate for change to produce equitable systems. We are uniquely qualified to identify controlling and contex- tual variables that contribute to inequitable

2 Client is broadly defined as an individual, group of individuals, organization, or community receiving ABA services by a Board Certified Behavior Analyst. These services may include the instruction, supervision, research, or profes- sional practice of ABA.

Table 1. Common Ethical Principles/Values Across Six Allied Professional Organizations

Principle AOTA APA ASHA CEC NASW AMA

Respect for people’s rights and dignity X X X X X X

Integrity X X X X X X

Autonomy/self-determination X X X X X

Safeguarding the welfare of persons served X X X X X

Responsibility X X X X

Professional competence or excellence X X X X

Maintaining collaborative professional relationships X X X

Beneficence X X X

Nonmaleficence X X X

Altruism or service to others X X X

Justice/equality/fairness X X X

Social justice X X X

Nondiscrimination X X

Privacy/confidentiality X X

Fidelity/loyalty X

Inclusion X

Maintain challenging expectations for persons served

X

Promoting diversity X

Human relationships as central tenant X

Note. AOTA = American Occupational Therapy Association; APA = American Psychological Association; ASHA= American Speech-Language-Hearing Association; CEC = Council for Exceptional Children; NASW = National Association of Social Workers; AMA = American Medical Association

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educational and service-delivery systems and devel- op solutions to supplant them.

We are focused on ABA education and intervention for community members, education of future behavior analysts, and applied research. Four of our principles (beneficence, inclusion, self-determination, and social justice) are client cen- tered. Our professional excellence principle specifically speaks to our responsibility to the broader ABA profession and to interdisciplinary collaboration. Our principles are situ- ated in culturally responsive contexts, recognizing that all cli- ents and ABA practitioners have experiences, beliefs, and cultural practices that influence the way they apply these prin- ciples to guide their ethical decision making. These principles assist our organization’s behavior analysts to better collabo- rate with all individuals within their unique communities.

To disseminate our principles, we created a document3

containing a preamble, important definitions, and descriptions of each principle. The preamble provides an explanation of how these principles are situated within context and culture and describes how we hope that they evolve over time. It serves as a guide for interpreting and applying the principles. The values of our ABA organization are reflected in this doc- ument and embedded in themission statement of our program. This document provides a strong framework for our graduate coursework, where students are encouraged to consider how their own cultures, values, and beliefs influence their ethical decision making.

Discussion

The purpose of this article was to describe the process that our ABA organization used to develop principles to guide our work in training, research, and practice. Our guiding princi- ples do not replace the ethical codes that all certified behavior analysts are obligated to follow. Rather, they provide a useful context for applying the rules of the BACB Code, especially when ethical dilemmas arise for which there is no simple solution. Guiding principles and the BACB Code are both necessary to help us engage in complex ethical decision mak- ing as behavior analysts. These principles also improve our ability to describe our ethical ideals and practices more effec- tively to nonbehavioral colleagues and stakeholders. Finally, we have found that our organization’s principles provide our behavior analysts and ABA students with guidance about how to answer the why questions often posed in ABA practice. Why choose one intervention over another?Why target behav- ior X before behavior Y? These principles help the behavior

analysts in our organization make ethical decisions in service of our shared values. In lay terms, you could say that they serve as our North Star.

Using Principles to Guide Practice Decisions

Principles can help behavior analysts select intervention tar- gets and strategies. Behavior analysts have the luxury of accessing multiple lists of evidence-based practices for indi- viduals with autism spectrum disorder (ASD; e.g., Steinbrenner et al., 2020; Wong et al., 2015). Not all evidence-based practices, however, are culturally or contextu- ally appropriate in all environments. For an intervention to be successful, strategies must be selected that consider clients’ needs and preferences, the professionals’ or caregivers’ abili- ties and willingness to implement the strategies, issues sur- rounding intervention fidelity, the skill(s) being taught, and so on. Principles can help practitioners more successfully match evidence-based practices to specific teaching opportu- nities. They help practitioners remember to consider why they are seeking specific outcomes, rather thanwhat they are teach- ing. For example, there are multiple function-based interven- tions effective for preventing escape-maintained challenging behaviors (Geiger et al., 2010). However, some may be more likely to cause a sudden increase in harm and lack consider- ation of client autonomy (e.g., extinction), whereas others honor client autonomy and minimize harmful side effects (e.g., choice). Behavior analysts who consider principles such as beneficence and self-determination when recommending function-based interventions for their clients may be more likely to recommend interventions that maximize their clients’ well-being while maintaining their dignity and autonomy.

Using Principles to Guide Ethical Decision Making

Principles can guide behavior analysts to make ethical deci- sions when faced with dilemmas in which two or more ethical rules seem to conflict with each other. Consider this example: A behavior analyst in a rural community is working in the home with a family that has two children with ASD. The parents report feeling overwhelmed and stressed most of the time. The behavior analyst has provided many suggestions and strategies for reducing the children’s challenging behavior and increasing their daily living and leisure skills. Despite ongoing training, both parents generally implement fewer than 25% of the behavior analyst’s suggestions. The behavior analyst is empathetic but also sees that the children are not mastering functional skills and their challenging behaviors are not improving. In consulting the BACB Code, she feels that she is being confronted by conflicting codes. After consider- ing Code 2.09(a), which states that “clients have the right to effective treatment,” and Code 4.07(a), which states that “if environmental conditions prevent implementation of a

3 The document containing the preamble and ethical principles can be found on our ABA program website at https://education.uw.edu/programs/graduate/ special-education/aba

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behavior-change program, behavior analysts recommend that other professional assistance . . . be sought,” the behavior analyst concludes that she should consider transferring care, as she is not being effective (BACB, 2014, pp. 8–12). However, she knows in her rural community there is no alter- native professional assistance available. Code 2.15(e) tells her that “behavior analysts do not abandon clients” (BACB, 2014, p. 10). Principles might provide this behavior analyst with an additional tool for consideration in this scenario. Suppose that she first considers the principle of professional excellence be- fore making a decision. She analyzes her own professional practice and recognizes that this is not the first time she has struggled with parent-implementation challenges. Though she is providing instructions and modeling evidence-based behav- ioral strategies for reducing challenging behavior, she may not be using other critical evidence-based training methods, thus directly contributing to a lack of implementation fidelity. She also realizes that she has not been empathetic to the parents’ stressful situation, thus inadvertently ignoring their needs. As a result of analyzing her own professional behavior, she de- cides to improve both her technical and interpersonal skills before considering the option of transferring services to an- other provider.

Using Principles to Communicate Ideals

Principles can help behavior analysts communicate ethical and professional ideals to nonbehavioral colleagues and stakeholders. The use of technical behavior-analytic termi- nology has been recognized as a barrier to effective com- munication with nonbehavioral colleagues and stake- holders (e.g., Kelly, Martin, Dillenburger, Kelly, & Miller, 2019). Behavior analysts who use broad principles to describe their ethical ideals may be less likely to miscommunicate these ideals to non-behavior analysts. Take the example of the term punishment. In conversations with laypeople about punishment, behavior analysts can often get bogged down in making distinctions between their technical use of the term punishment and the collo- quial use of the term. The precise, technical language of the BACB Code, although helpful to behavior analysts in guiding their use of punishment, can further confuse and even alienate consumers. Principles might help behavior analysts communicate their ethical position on punish- ment. Consider the common scenario in which an educator requests that her colleague, a school-based behavior ana- lyst, help her to design a classroom-wide behavior chart that uses response cost to decrease students’ out-of-seat behavior. Behavior analysts are aware that even minimally invasive punishment-based strategies such as response cost can induce harmful side effects such as anger, aggression, and avoidance (Balsam & Bondy, 1983). Rather than recit- ing Codes 4.08a–d governing the use of punishment

procedures, behavior analysts might communicate their commitment to the principle of beneficence: maximizing student benefit and doing no harm. Ethical principles like beneficence are embedded in both the ethical codes of oth- er professions and in common consumer understandings of ethical behavior, thus constituting a shared, nontechnical language between behavior analysts and nonbehavioral colleagues.

Conclusion

There has been a shift in the field of ABA toward adopting and integrating cultural humility, responsivity, and compassion into clinical practice (e.g., Brodhead, 2019; Taylor et al., 2018; Wright, 2019). These considerations are equally rele- vant to ethical practice. This shift creates many challenges for behavior-analytic professionals, but it is critical for the surviv- al of our field. This journey toward compassion may be the 2020 version of ABA’s search for its heart (Wolf, 1978). It is an exciting time to be a behavior analyst. The number of training programs in our field has increased dramatically, as have the number of newly certified professionals (BACB, n.d.; Carr & Nosik, 2016). Behavior-analytic services are now covered by medical insurance in all 50 states (Autism Speaks, 2020). Although these are positive changes, they may also make it difficult for our profession to identify and follow its North Star. At this time when there are so many opportunities to commercialize work in behavior analysis, it may be relatively easy to lose sight of the values that drew us to this field in the first place.

In this article we described the process we used to establish the ethical principles for our ABA organization. These princi- ples do not supplant the BACB’s set of ethical codes—they enhance them. They provide our organization’s members with additional guidance for making ethical decisions, particularly when faced with difficult situations, all while balancing the science of behavior and the sought-after outcomes for clients. These principles also help us describe our values to consumers and address criticisms about our practice. Most importantly, they provide an important ethical foundation to help guide our graduate students’ and new colleagues’ ethical decision mak- ing, and share with them the values inherent in our work. Our process of developing these principles may serve as a model for other ABA organizations, university programs, and indi- vidual practitioners eager to develop guiding ethical princi- ples. Our hope, though, is that ethical leaders within the pro- fession of behavior analysis use a similar process to arrive at a set of principles that can guide our profession as a whole. Just as behavior analysts who are currently practicing would not consider addressing ethical dilemmas without the assistance of the BACB Code, we hope that in the near future all behav- ior analysts will use guiding principles to help them translate those rules into effective and sustainable ethical practices.

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Funding The authors did not receive funding for this manuscript.

Compliance with Ethical Standards

Conflict of Interest The authors declare that they have no conflict of interest.

Informed Consent This manuscript did not involve human or animal participants; therefore informed consent was not collected.

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