Integrating principle ethics, transcultural considerations, and action-oriented models for ethical decision-making in therapy
Portions of this post were previously submitted as a preclinical paper entitled Trends in Ethical Decision Making.
We frequently encounter moral ambiguities, value conflicts, and ethical dilemmas in clinical practice. Although some of these challenges – such as sexual intimacy with clients and mandated reporting of abuse or neglect – are addressed by legal mandates or clearly-defined directives in professional codes of ethics (i.e., mandatory actions and prohibitions), other situations demand critical thinking and discretionary decision-making by the therapist (Corey et al., 2014; Wilcoxon et al., 2013). Ethical codes are often aspirational: they may offer principles to guide our decisions, but they don't necessarily delineate our professional responsibilities or dictate how to carry them out in the context of moral and ethical “grey areas” (Corey et al., 2014). Many ethical decision-making models have been proposed (Annas, 2006; Freeman & Francis, 2006; Metz & Miller, 2016; Slote, 2010; Urofsky et al., 2009) and may be generally divided into:
Models based on expected consequences (consequentialism)
Models based on maximization of potential benefit to the client (utilitarianism)
An appeal to “highest ideals” to determine the “best” action (principle ethics)
Reasoning action from intention (virtue ethics)
Recognition of the “duty of care” and the consequent considerations of equity, compassion and communalism (relational/care ethics), or
Extrapolation from previous cases (casuistry).
Although these decision-making models can provide clearer reasoning and deeper guidance than professional codes of ethics, they may also be limited in their applicability to specific cases. The seminal Kitchener principle-ethics model, for example, emphasizes respect for client autonomy, the necessity to ensure that treatment benefits (beneficence) and does not harm the client (nonmaleficence), and mandates equitable treatment (justice) and honesty (fidelity). Prima facie, Kitchener's model offers a solid, quasi-objective, structured foundation for ethical decision-making. The devil, as they say, is in the details (Freeman & Francis, 2006; Hill, 2004; Sherbersky, 2016).
Those principles may conflict with clients’ personal or socioculturally-defined values. For example, interventions may be irrelevant or damaging to clients or their relationships due to cultural factors.
Our principles and interventions may even conflict with other foundational principles. Most of us would agree, for instance, that there's a clear need for involuntary hospitalization when a client has a well-defined plan for SI, the means to carry out that plan, and an intent to follow through with it. And yet involuntary hospitalization, by definition, short-circuits autonomy, even though our intent is based in beneficence.
So ethical codes, law, and decision-making models must be seen as merely contributory factors in the decisional process: ultimately, courses of action require our personal judgement and careful deliberation (Wilcoxon et al., 2013). These are, of course, going to differ from therapist to therapist, but the point of this post was to share a framework I developed throughout my preclinical training for my own use. I wanted to incorporate the aspirational, practical, and diversity aspects of the Kitchener principle-ethics, Corey, and Transcultural Integrative models, respectively (Corey et al., 2014; Garcia et al., 2003; Urofsky et al., 2009). My personal framework consists of three steps.
Formulation — Determining whether a dilemma really exists, and how my own biases and attitudes might contribute to the issue.
Information Collection — Identifying "stakeholders," missing information, and issues of power, privilege, client welfare, and culture relevant to the issue. This step might include consultation for legal clarification, or consultation with colleagues, mentors, and my organization to get a different perspective and clarify my organization's expectations and operating guidance.
Action — Collaborating with my client to consider all possible courses of action, evaluate potential positive and negative outcomes and responses, determine the best course, and document and evaluate its implementation.
You can click the image below to zoom in.
Case application
Let's take a look at how we'd apply this framework to an example case.
Vignette: Your client is a 10-year-old adoptee who identifies as Chinese and male. His American mother referred the client following his disruptive behavior at school and at home. The father also supports the mother's decision to initiate therapy. You are able to establish a good rapport with the boy and work through some of his issues. In session with the parents, the mother reveals that she does not allow her son to speak his native language at home and that she is uncomfortable with him identifying with his culture because she feels it disconnects her from him. She begins to talk about racially biased behaviors from herself and her family with whom the son is in contact regularly.
Setting aside the details of this vignette, we'd like to address the biases of the client's nuclear and extended family. Again, you can click on the image below to zoom in.
Again, as with any model, my framework can only serve as guidance: ultimately, a therapist's course of action is at their discretion and their client's, and in any case, any rationale and selected actions should be carefully documented and evaluated. But I'm offering it here in case others find it useful.
References and Further Reading
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Annas, J. (2006). Virtue ethics. The Oxford handbook of ethical theory, 515-536.
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Centers for Disease Control and Prevention. (2022). Health Insurance Portability and Accountability Act of 1996 (HIPAA). Retrieved Jun 29 from https://www.cdc.gov/phlp/publications/topic/hipaa.html
Corey, G., Corey, M. S., Corey, C., & Callanan, P. (2014). Issues and ethics in the helping professions. Cengage Learning.
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Freeman, S. J., & Francis, P. C. (2006). Casuistry: A complement to principle ethics and a foundation for ethical decisions. Counseling and Values, 50(2), 142-153.
Garcia, J. G., Cartwright, B., Winston, S. M., & Borzuchowska, B. (2003). A transcultural integrative model for ethical decision making in counseling. Journal of Counseling & Development, 81(3), 268-277.
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