Episode 4: Ethical Decision-making (Part 1)

John Gavazzi, Psy.D. ABPP

Describe the difference among ethical and clinical decision-making

Outline the Acculturation Model

List the five foundational principles for ethical decision-making

The process is often ambiguous

1. Move away from the “ethical” versus “unethical” decision.

2. In some ethical decisions, there is not “right” or “correct” answer for everyone.

3. Most clinicians make ethical decisions on a daily basis

Rational Psychologist: Know the Code!!

Learn the rulesApply the rulesOutcomes will follow

Learn the rulesApply the rulesOutcomes will follow

Understand patient dynamicsUnderstand the relationship

Know the Code + Know your patient

Clinical Decision-making

Risk management

Legal Decision-making

Ethical Decision-making◦ Professional Ethics◦ Personal Ethics, Values, or Morality

What is the best clinical intervention for this patient in this situation?

What are the best psychological instruments to answer the referral question?

Am I conceptualizing this patient correctly?

My patient continues to struggle after eight sessions. What should I do?

How do I work with a patient to minimize risk or liability?

Avoid types of work that have high liability risks, such as custody evaluations or clinical complex patients.

Do I have essential paperwork signed? Informed Consent or practice policies current

Always have a suicidal patient sign a “no suicide” contract

Never touch a patient

Always remain at a professional distance emotionally and socially

Boundary crossings vs. boundary violations

Am I compliant with state laws and regulations?

Is my practice HIPAA compliant?

Am I aware of relevant case law in my state?

Questions are usually asked of an attorney

Professional Ethics

Do I follow the American Psychological Association’s Code of Conduct?

Am I aware of and do I comply with the APA’s Guidelines for treatment?

Am I performing at the minimum or reaching for the aspirational ceiling?

Personal values, ethics, and morality

Is what I am doing consistent with my values?

What is my emotional response to the patient, lifestyle, or behavioral issue?

Looking at how well a psychologist integrates his/her values and behaviors into the ethical culture of psychology

Psychology has a set of normative principles and behaviors related to ethical behavior and appropriate conduct

One way of remaining a life-long learner

Provides another way to discuss ethical behaviors and decisions

A process to change the cultural behavior of an individual through contact with another culture.

The process of acculturation occurs when there is an adaptation into an organization or society.

An outgrowth of positive ethics that integrates personal ethics and professional obligations.

Psychology has a system of shared and distinctive norms, beliefs, and traditions.

This set of beliefs is reflected in our ethics code.

Can be a complex process

Some parts of a psychologist’s practice and lifestyle may be easily acculturated while others not

Process that will likely continue throughout the education or career as a psychologist

Identification with personal value system(higher vs. lower)

Identification with value system of psychology

(higher vs. lower)

Acculturation Model of ethical development

IntegrationIntegration SeparationSeparation

AssimilationAssimilation MarginalizationMarginalization

Higher on Professional Ethics

Higher on Personal Ethics

Lower on Personal Ethics

Lower on Professional Ethics

Matrix: Lower on professional ethicsLower on personal ethics

Risks: *Greatest risk of harm*Lack appreciation for ethics*Motivated by self-interest*Less concern for patients

Matrix: Higher on professional ethicsLower on personal ethics

Risks: Developing an overly legalistic stance

Rigidly conforming to certain rules while missing broader issues

Matrix: Lower on professional ethicsHigher on personal ethics

Risks: Compassion overrides goodprofessional judgment

Fail to recognize the unique role of psychologists

Matrix: Higher on professional ethicsHigher on personal ethics

Reward: Implement values in context of professional roles

Reaching for the ethical ceiling

Aspirational ethics

AutonomyBeneficence

NonmaleficenceFidelityJustice

Does not mean promoting autonomy (individuation or separation)

Means respecting the autonomous decision making ability of the patient

It encompasses freedom of thought and action.

Individuals are at liberty to behave as they chose.

- Determining goals in therapy- Making life decisions (e.g., marriage, divorce)- Scheduling appointments and terminating treatment

Foundational Standard 3.10

“When psychologists conduct research or provide assessment, therapy, counseling or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person ……”

The principle of benefiting others and accepting the responsibility to do good underlies the profession.

- Providing the best treatment possible

- Competency

- Referring when needed

Basis of foundational standard 2.01

“Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence.”

The principle is doing no harm.

- Demonstrating competence

- Maintaining appropriate boundaries

- Not using an experimental technique as the first line of treatment

- Providing benefits, risks, and costs

Foundational Standard 3.04

“Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm when it is foreseeable and unavoidable.”

This principle refers to being faithful to commitments. Fidelity includes promise keeping, trustworthiness, and loyalty.

- Avoiding conflicts of interests that could compromise therapy

- Keeping information confidential

- Adhering to therapeutic contract (e.g., session length, time, phone contacts, etc.)

Foundational Standard 4.01

“Psychologists have a primary obligation and take reasonable precautions to protect confidential information.”

Justice primarily refers to treating people fairly and equally.

In their work-related activities, psychologists do not engage in unfair discrimination based on age, gender, gender identity, race, ethnicity, culture,

national origin, religion, sexual orientation, disability, socioeconomic status, or any basis

proscribed by law. (3.01)

The means to comply with a standard may not always be readily apparent

Two seemingly competing standards may appear equally appropriate

Application with of a single standard or set of standards appear consistent with one or more aspirational principle, but not another

We reviewed that ethical decision-making can be complex

Distinguish ethical decision-making from clinical decisions, risk management, and legal questions, while there is likely overlap

We reviewed the Acculturation Model both as ways to acculturate to psychology as well as how ethical decisions are made

We reviewed the five foundational principles on which the APA ethics code is founded

We touched on the idea the idea that the APA ethics code does not have an ethical decision-making strategy

Ethical dilemmas are usually a function of two competing foundational principles