Ethical decision making among family therapists and individual therapists

In this study, we investigated the ethical decision making of 30 individual and 30 family therapists in order to detect the types of decision making used by practicing therapists. Informants responded to three ethical dilemmas. Two of the situations were hypothetical. The third dilemma was a situation the informant had experienced in practice. Each interview was assessed for decision-making style, using content analysis. Kohlberg's justice reasoning and Gilligan's care reasoning provided the conceptual foundations for this analysis. The results suggest that both family and individual therapists prefer care reasoning on all dilemma types. There was significantly more care reasoning demonstrated on the personal dilemma than on the hypothetical dilemmas. Characteristics of informants did not provide clear explanations for the differences found in reasoning.     

Being ethical: more than obeying the law and avoiding harm.

In this article, I provide the reader with a model for considering ethical dilemmas that arise in the settings in which assessors practice. The overarching set of principles necessary to consider to make an effective ethical decision are presented as well as a series of steps through which the assessor should proceed in considering a situation. The role of ethics codes in decision making is also described.     

The futures of physicians: Agency and autonomy reconsidered

The corporatization of U.S. health care has directed cost containment efforts toward scrutinizing the clinical decisions of physicians. This stimulated a variety of new utilization management interventions, particularly in hospital and managed care settings. Recent changes in fee-for-service medicine and physicians' traditional agency relationships with patients, purchasers, and insurers are examined here. New information systems monitoring of physician ordering behavior has already begun to impact on physician autonomy and the relationship of physicians to provider organizations in both for-profit and ‘not-for-profit’ sectors. As managed care practice settings proliferate, serious ethical questions will be raised about agency relationships with patients. This article examines health system dynamics altering the historical agency relationship between the physician and patient and eroding the traditional autonomy of the medical profession in the United States. The corporatization of medicine and the accompanying information systems monitoring of physician productivity is seen to account of such change, now posing serious ethical dilemmas.     

Ethics and Changing Mental Health Care: Concerns and Recommendations for Practice

Recent developments in health care delivery in the United States have left many professionals baffled by the continuing changes in practice sparked by the relatively new managed care environment. Psychologists who practice in medical settings are struggling to balance the seemingly competing needs to deliver quality care to clients and patients, while meeting the demands of third-party payers and trying to remain true to their ethical responsibilities. Critical elements of managed care, which many suggest compromise the ethical provision of quality care, include utilization review, financial incentives, and threats to confidentiality. Recommendations are proposed so that mental health professionals may be proactive in protecting their ethical responsibilities in this changing environment.     

Complexity of ethical decision making in psychiatry

Psychiatric residents and psychiatrists have little difficulty in making judgments about a clinical course of action to take with patients. However, making ethical clinical decisions is more challenging, because psychiatric residents are usually provided little formal training in ethics. Further, many ethical dilemmas are complex, requiring knowledge of the psychiatric profession's ethics code, moral principles, law, and practice standards and of how they should be weighed in the decision-making process. The purpose of this article is to demonstrate this complexity in regard to the identification of potential ethical dilemmas, understanding the issues that these dilemmas raise, and formulating potential solutions to them. Two common but important areas of treatment in which ethical dilemmas arise (informed consent and competence of care) are used as examples for our presentation. The article demonstrates that to successfully engage in ethical analysis in psychiatry is impossible without substantial formal training in the process.     

Moral Orientation as a Component of Ethical Decision Making

Morals are foundational to professional and ethical counseling practice. Moral orientation may play an integral role in ethical decision making. The authors review the literature regarding moral orientation and discuss the connection to ethical decision making. Implications for counselor preparation and practice are addressed.     

An A-B-C-D-E Worksheet for Promoting Beneficence When Considering Ethical Issues

An A-B-C-D-E worksheet has been prepared to promote beneficence when considering ethical issues. The components of the worksheet are derived from ethical principles and ethical decision-making models. The worksheet makes abstract concepts of decision-making models concrete and practical. In addition, it provides a shorthand for remembering key elements necessary to good ethical decision making. It is systematic and useful and can aid students of ethics and mental health professionals to think more critically about ethical dilemmas.     

Surrogate medical decision making on behalf of a never-competent, profoundly intellectually disabled patient who is acutely ill

With the improvements in medical care and resultant increase in life expectancy of the intellectually disabled, it will become more common for healthcare providers to be confronted by ethical dilemmas in the care of this patient population. Many of the dilemmas will focus on what is in the best interest of patients who have never been able to express their wishes with regard to medical and end-of-life care and who should be empowered to exercise surrogate medical decision-making authority on their behalf. A case is presented that exemplifies the ethical and legal tensions surrounding surrogate medical decision making for acutely ill, never-competent, profoundly intellectually disabled patients.     

At the crossroads: managed mental health care,the ethics code,and ethnic minorities

Mental health clinicians are facing an increasing number of ethical problems related to the delivery of managed mental health care services to ethnic minorities. The authors argue that (a) economic pressures have led to the development of the managed health care movement; (b) the combination of such economic pressures and the development of that managed care movement have influenced the promulgated ethical standards of the American Psychological Association; and (c) those influences may have a negative impact on the mental health services available to ethnic minority individuals and communities. The authors review some of the specific potential threats to mental health services for minorities in the face of such health management policy and psychologists' professional standards.     

Trauma Recovery in Interprofessional Cross-Cultural Contexts: Application of an Ethical Framework

Research into the complex interactions of personal, professional, and interprofessional ethics is in its infancy. Where interprofessional decision making is made in cross-cultural contexts, ethical dilemmas multiply; inversely, research to guide judgments is sparse. This study sought to explore interprofessional ethical decision making within a project, which delivered Western trauma-recovery training to counselors in Palestine. A cross-cultural interprofessional ethical framework was adapted and later applied to project decision making. A case study is presented based on field note reflections. Researchers perceived the following to be important in addressing ethical decision-making dilemmas: defining interprofessional and cross-cultural language; long-standing relationships of trust; workers liberated from organizational agendas; democratized processes; and flexible structures. Recommendations are provided to help plan and evaluate interprofessional cross-cultural initiatives.     

The personal is the organizational in the ethics of hospital social workers

Understanding the social context of clinical ethics is vital for making ethical discourse central in professional practice and for preventing harm. In this paper, we present findings about clinical ethics from in-depth interviews and consultation with 7 members of a hospital social work department. Workers gave different accounts of ethical dilemmas and resources for ethical decision making than did their managers, whereas workers and managers agreed on core-guiding ethical principles and on ideal situations for ethical discourse. We discuss the research team's initial interpretations, the relevance of the extant ethics literature to organizational structures and dynamics, and alternative perspectives on clinical ethics.     

Counsellor conflict in managing the frame: Dilemmas and decisions

An essential feature of psychodynamic counselling is a secure frame for the work that holds boundaries as sacrosanct, both to ensure ethical practice and to provide a vehicle through which unconscious processes can be recognized and understood. Conscious or unconscious attacks on the frame are inevitable in any therapeutic relationship, and provide an opportunity for exploration and insight. However such incidents also have an impact on the therapist who must decide how to respond. In order to understand more about the therapist process when there is an attack on the frame, an investigation was carried out into ways in which psychodynamic counsellors manage the difficulties and dilemmas that arise as they try to hold a secure therapeutic frame. Ten counsellors were interviewed using a semi‐ structured interview format during which they were asked about an instance when the frame was challenged and the process by which it was resolved. The resulting dilemmas were categorized using grounded theory. Three categories of dilemmas emerged a) prior to making a decision about how to deal with it, b) after making a decision, and c), as a result of the outcome of the action taken. The nature of the dilemmas and the process of resolving them are reported and discussed.     

Cognitive functioning as a contraindication to organ transplant surgery: Dilemmas encountered in medical decision making

A case is presented to illustrate some of the difficulties encountered when providing psychological consultation to evaluate the readiness of patients for pediatric heart-lung transplantation. The outcome of complex medical decision making can often hinge on information provided by the psychological consultant who is attempting to simultaneously serve the needs of the patient as well as the transplant team. Ethical dilemmas frequently arise when medical decision making is driven by limited health care resources and cost constraints. The utility of cognitive functioning as a variable in pediatric transplant decision making is discussed. Recommendations are made for further work in this area on both conceptual and empirical grounds to guide the integration of psychological information into transplant decision making as health care delivery continues to evolve in the future.     

The Ethics of Smart Pills and Self-Acting Devices: Autonomy,Truth-Telling,and Trust at the Dawn of Digital Medicine

Digital medicine is a medical treatment that combines technology with drug delivery. The promises of this combination are continuous and remote monitoring, better disease management, self-tracking, self-management of diseases, and improved treatment adherence. These devices pose ethical challenges for patients, providers, and the social practice of medicine. For patients, having both informed consent and a user agreement raises questions of understanding for autonomy and informed consent, therapeutic misconception, external influences on decision making, confidentiality and privacy, and device dependability. For providers, digital medicine changes the relationship where trust can be verified, clinicians can be monitored, expectations must be managed, and new liability risks may be assumed. Other ethical questions include direct third-party monitoring of health treatment, affordability, and planning for adverse events in the case of device malfunction. This article seeks to lay out the ethical landscape for the implementation of such devices in patient care.     

The Personal Is the Organizational in the Ethics of Hospital Social Workers

Understanding the social context of clinical ethics is vital for making ethical discourse central in professional practice and for preventing harm. In this paper we present findings about clinical ethics from in depth interviews and consultation with 7 members of a hospital social work department. Workers gave different accounts of ethical dilemmas and resources for ethical decision making than did their managers, whereas workers and managers agreed on core-guiding ethical principles and on ideal situations for ethical discourse. We discuss the research team's initial interpretations, the relevance of the extant ethics literature to organizational structures and dynamics, and alternative perspectives on clinical ethics.     

The Stories We Tell: Introduction to the Special Issue on Ethical Challenges in Community Psychology Research and Practice

This Special Issue examines ethical challenges in community psychology research and practice. The literature on ethics in community psychology has remained largely abstract and aspirational, with few concrete examples and case studies, so the goal of this Special Issue was to expand our written discourse about ethical dilemmas in our field. In these articles, researchers and practitioners share stories of specific ethical challenges they faced and how they sought to resolve them. These first‐person narratives examine how ethical challenges come about, how community psychology values inform ethical decision making, and how lessons learned from these experiences can inform an ethical framework for community psychology.     

Relationships between personal values and reported behavior on ethical scenarios for law students

Lawyers' values might be considered to play some role in the decisions that are made in everyday legal practice. This study aimed to explore the effects of personal value hierarchies on ethical decision making within the context of several ethical dilemmas. A questionnaire was administered utilizing hypothetical situations presented in 11 ethical scenarios and including the Rokeach Value Survey. Logistic regression results suggested that different personal values were significant predictors of reported behavioral choices on respective ethical scenarios. However, the most important values associated with behavior consistent with ethical conduct in scenarios were 'honesty' and 'equality'. The implications of results are discussed in the contexts of ethics education in a tertiary educational environment and in relation to regulation for the professions.     

Aboriginal Health Care and Bioethics: A Reflection on the Teaching of the Seven Grandfathers

Contemporary bioethics recognizes the importance of the culture in shaping ethical issues, yet in practice, a process for ethical analysis and decision making is rarely adjusted to the culture and ethnicity of involved parties. This is of a particular concern in a health care system that is caring for a growing Aboriginal population. We raise the possibility of constructing a bioethics grounded in traditional Aboriginal knowledge. As an example of an element of traditional knowledge that contains strong ethical guidance, we present the story of the Gifts of the Seven Grandfathers. We note a resemblance of this Ojibway teaching to virtue ethics in European traditions, but we suggest that there are also important differences in how these two traditions are currently presented. We hope that further engagement with a variety of indigenous moral teachings and traditions could improve health care involving Aboriginal patients and communities, and enrich the discipline of bioethics.     

The Tat Newsletter

In this article, we argue that the student's first lessons in ethical decision making in personality assessment are in those assessment courses that have a practice component. In these courses, the student has an opportunity to experience in vivo how ethical problems are identified, addressed, and resolved. The faculty member's demonstration of a process wherein the ethical principles activated are highlighted and explored, will enable students to internalize a model for addressing future dilemmas. Four particular ethical situations are considered: (a) the students' procurement of personal experience with personality testing, (b) the identification of assessment participants, (c) the development of informed consent procedures for assessment participants, and (d) classroom presentations. This discussion does not provide concrete solutions to ethical problems but offers a consideration of the relevant ethical principles that any adequate solution must encompass.     

Ethical dilemmas in personality assessment courses: using the classroom for in vivo training.

In this article, we argue that the student's first lessons in ethical decision making in personality assessment are in those assessment courses that have a practice component. In these courses, the student has an opportunity to experience in vivo how ethical problems are identified, addressed, and resolved. The faculty member's demonstration of a process wherein the ethical principles activated are highlighted and explored, will enable students to internalize a model for addressing future dilemmas. Four particular ethical situations are considered: (a) the students' procurement of personal experience with personality testing, (b) the identification of assessment participants, (c) the development of informed consent procedures for assessment participants, and (d) classroom presentations. This discussion does not provide concrete solutions to ethical problems but offers a consideration of the relevant ethical principles that any adequate solution must encompass.