Interactive Ethics:Principles, Acculturation, and Vignettes

John Gavazzi, PsyD ABPPJanuary 13, 2012

Learning Objectives

Online Information: Ethics blog and other sites

Structured information sharing

Vignette analysis and case discussions

Overview

1. List at least three ethical principles related to APA’s code

2. Compare and contrast positive ethics and risk management

3. Describe the Acculturation Model

4. Explain one ethical decision-making model

5. Analyze one ethical vignette by identifying conflicting principles

Learning Objectives

Ethics Education and Psychology

www.papsyblog.orgWhere Ethics is More Than a Code

Ethics Blog

Self-education

Connecting with others: Blogs & other sites

Becoming politically active

Using the Internet

Introduction and Applicability

Preamble and General Principles(Aspirational and based on principle-based ethics)

Ethical Standards (Enforceable and represent minimum standards)

APA Ethics Code

The ethics code does not include federal laws, such as HIPAA

The ethics code does not include case law, though influence is noted

The ethics code is distinct and separate from guidelines approved by the APA Council of Representatives

Quiz Question: How many are there?

APA Ethics Code

AutonomyBeneficence

NonmaleficenceFidelityJustice

Principle-Based Ethics

Respect for Autonomy

Does not mean promoting autonomy (individuation or separation)

Means respecting the autonomous decision making ability of the patient

Autonomy

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

Beneficence The principle of benefiting others and

accepting the responsibility to do good underlies the profession.

- Providing the best treatment possible

- Competency

- Referring when needed

Beneficence

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. . . “

Nonmaleficence

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

Nonmaleficence

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.”

Fidelity

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.)

Fidelity

Foundational Standard 4.01

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

Justice

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)

Acculturation Model

Acculturation

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.

The process involves developing relationships with those within the culture to learn the traditions, rules, roles, and behaviors to

become part of that group or community.

Ethical Culture of Psychology

Our system of common beliefs, shared meanings, norms and traditions that distinguish psychologists as professionals.

It is a learned set of skills, bases of knowledge and ethical beliefs, as described in our ethics code.

Our culture of ethics moves beyond ourselves as individual psychologists.

Expands into our ability to become connected with the profession of psychology as well as other professionals.

Our ethical culture “happens” everyday when we relate to our patients, peers, or general population.

Ethical Culture of Psychology

Acculturation as a Process

Can be a complex process

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

Process that may continue throughout the education or career as a psychologist

Ethics Autobiography

Exploring religious upbringing

Exploring interpersonal relationships

Understanding your cultural Self

Memes

Meme: a cultural unit (an idea or value or pattern of behavior) that is passed from one person to another by non-genetic means (as by imitation);

"memes are the cultural counterpart of genes"

Ethical Acculturation

Identification with personal value system(high vs. low)

Identification with value system of psychology

(high vs. low)

These are on a continuum more so than boxes.

Acculturation Model of Ethical Decision-making

Integration Separation

Assimilation Marginalization

Higher on Professional Ethics Lower on Professional Ethics

Higher on Personal Ethics

Lower on Personal Ethics

Marginalization

Style: Lower focus on professional ethics Lower focus on personal ethics

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

Separation

Style: Lower focus on professional ethics Higher focus on personal ethics

Risks: Compassion overrides good professional judgment Fail to recognize the unique role of psychologists

Assimilation

Style: Higher focus on professional ethics Lower focus on personal ethics

Risks: Developing overly legalistic stance Rigidly conforming to individual

rules while missing broader issues

Integration

Style: High focus on professional ethics High focus on personal ethics

Reward: Implement values in context of professional roles Reaching for the ethical ceiling Aspirational ethics

Risk Management, Remedial Ethics, and

Positive Ethics

Our level of acculturation and our style of ethical decision-making

Remedial Ethics

Mandatory “floor”

Minimum standards adopted by the profession

Focus on the law or standards to protect the public

A means to reduce risk in an uncertain situation

Decision-making strategies to avert problems or liability of the psychologist

False risk management strategies (memes, such as the No Suicide Contract)

Risk Management

No evidence to indicate that it helps reduce suicidal behavior

Cannot be used an part of an assessment

Contract implies a legal tool to reduce risk

May actually harm the therapeutic alliance, not promote it

No Suicide Contract

Remedial Ethics

Overemphasis on regulations and enforceable standards

Incomplete view of ethics

Ethics is more than just a code

Positive Ethics

Ethics as a movement away from the punishment and anxiety-producing components of ethics

Fulfill their highest ideals

A means to help interpret and apply ethics standards

Positive Ethics is NOT

An avoidance of ethical codes, case law, regulations, and statutes

A rationalization to explain inappropriate behaviors or decisions

Benefits of Positive Ethics

Broadens a psychologist’s understanding of ethics in a larger context

Sensitize psychologists to ethical implications of decisions on a daily basis

Benefits of Positive Ethics

Heighten awareness related to ethics beyond our offices

Assist psychologists in balancing competing ethical demands

Remedial: Acquiring and maintaining minimal formal

qualifications

Positive: Striving for highest standardsIncludes self-awareness and self-

careEmotional competence

Competence

Relationships

Remedial: Avoiding boundary violations Focus on sexual

boundariesAdhere to strict interpretation

Positive: Striving to enhance quality of all professional

relationships

Understand issues related to multiple relationships

Patient Empowerment

Remedial: Fulfilling legal responsibilitiesto get consent forms or

Privacy Notices signed

Positive: Working to maximize client participation with goals

and treatment processes

Trust

Remedial: Avoiding prohibited disclosure

Emphasis legal requirements

Positive: Striving to enhance trust Understanding nuances

when working with families

What are some resources related to

ethical decision-making?What are some options?

The APA Ethical Principles and Code of Conduct do not include a model of

ethical decision-making

In certain situations, we need to construct or create a

solution instead of looking up the enforceable standards in

the APA Ethics Code.

Code Has No EDM Strategy 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

Common Dilemmas

Often ethical dilemmas involve apparent conflicts between respect for patient

autonomy versus beneficence

or

Respect for autonomy versus general or public beneficence

5 Step Decision Making Model

SScrutinize

H Hypothesize

A Analyze

PProceed

EEvaluate

Five Step Method1. Goal is to define the problem

2. Generate a wide range of possible solutions and identify pros and cons

3. Merge or knit the possible solutions together in a way that maximizes the benefits and limits the disadvantages

4. Implement

5. Look back or evaluate

Five Step Method

“integrative framework”

steps two and three generate solutions that maximize your personal values within the

context of your professional role

Five Step Model- 4

Avoid dichotomous thinking– either I have to do x or y.

For example, either I have to warn the potential victim of a threat or I have to protect confidentiality.

Overemphasis on regulations and enforceable standards

“Thou shall not” oriented

Minimum standards or the “ethical floor”

Incomplete view of ethics

Remedial Ethics

Ethics as a movement away from the punishment and anxiety-producing components of ethics

Fulfill their highest ideals

A means to help interpret and apply ethics standards

Positive Ethics

Knowledge base: APA code, Pennsylvania law, regulations

Emotional factors

Cognitive biases/situational factors

Outcomes are uncertain

Ethical decision-making is a complex process

Ethics occurs within the therapeutic relationship

Commitment to the relationship and high quality of care

Pulling together the code, your training, and current professional role within the context of the relationship with patient

Ethics in the Relationship

Ethics happens within the relationship

Active approach to ethics, the relationship, and decision-making

Combines psychologist factors (which includes emotions and biases) with clinical features and the patient

Ethics in the Relationship

Questions, Vignettes, and Feedback