Toward a Hermeneutic Model of Ethical Decision Making in Clinical Practice

Documented ethical violations and empirical research have demonstrated that, despite professional standards and formal training in ethical principles, some psychotherapists engage in unethical behaviors that compromise the welfare of clients. It appears that competing values and interests that emerge in the therapeutic endeavor can interfere with therapists' considerations of ethical standards and their willingness to act ethically. Expanding current models of ethical decision making, this article offers a hermeneutic model that recognizes that in addition to moral reasoning, the context of the therapeutic relationship and the therapist's subjective responses are fundamental considerations in the interpretation and application of ethical interventions. Implications for understanding and training of ethics in psychotherapy in this broader context are explored.     

The Calling of the Whole People of God into Ministry: The Spirit,Church and Laity

This article discusses implications of Bonhoeffer's notion of maturity (being of age), particularly for the notion of redemption and the ethical self. This is done through a reading of the relation between maturity and redemption in Kant, Nietzsche, and Levinas, which again is compared with Bonhoeffer's late thought as we find it in his Prison letters and his Ethics. All three philosophers share with Bonhoeffer the important premise that otherworldly redemption is downplayed to the benefit of a strong demand put on the self. At the same time, their notions of maturity show important differences, with subsequent consequences for their notions of redemption; Kant's notion is based on ethical autonomy, Nietzsche's on aesthetical autonomy, whereas Levinas presupposes ethical heteronomy. The reading of Bonhoeffer shows that he shares premises with all three thinkers, but particularly with Levinas. This is shown in the analyses of religionless Christianity as a turn to the practical dimension of faith, in the messianic structure of the ethical self, and in the turn to the Old-Testamently and the arcane discipline. Bonhoeffer's high estimation of the worldly and the aesthetic, however, also illustrates his affinities to Nietzsche.     

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.     

Including a Spiritual Dimension in Family Therapy: Ethical Considerations

The inclusion of a spiritual dimension in family therapy theory and clinical practice may well be viewed as an important professional challenge of the nineties. Following a working definition of terms, this paper explores the ethical complexities inherent in operationalizing a spiritual orientation in therapy in light of the following principles adopted from medical ethics: Respect for clients' autonomy, safeguarding clients' welfare, protecting them from harm, and treating them justly and honestly.     

Psychotherapy through the Group Process by Dorothy Stock Whitaker and Morton A. Lieberman

Ethics deals with right and wrong behavior. It can be used to check whether group therapists with their patients “abstain(s) from whatever is deleterious and mischievous,” an Hippocratic concern, and whether they safeguard their personhood, a Kantian requirement. Therapists' paternalism weakens the patients' moral agency and challenges their autonomy. Personal therapy lessens this tendency.

The group models Plato's and Socrates' ancient dialectic. Both see the end point, self-knowledge, as a virtue and seek it. Increased care of group members for each other is the modus operandi of treatment. This, with the therapist's clinical input, brings about patient wholeness. Reduction in the distorted treatment relationship returns autonomy to the patient. Group therapy is an ethical way to change patients psychologically. Gratuitously, they become more virtuous.     

Ethical and Professional Issues for Psychologists and Counselors Employing Biofeedback in Counseling Settings

Biofeedback training is a relatively new procedure that is being incorporated into the counseling services of psychologists and counselors. If the highest professional standards and the appropriate safeguards for clients' welfare are to be maintained, careful attention should be given to the ethical and professional issues involved. The American Psychological Association's (1977) ethical standards for psychologists are the basis of the discussion. It is hoped that the discussion will stimulate further consideration of ethical and professional issues of the clinical application of biofeedback among practitioners.     

Assessing and restoring competency to be executed: Should psychiatrists participate?

Ford v. Wainwright (1986) is one among several recent U. S. Supreme Court decisions granting psychiatrists a distinct but awkward role in the capital punishment process. Ford affirms the right of the condemned to be spared execution while mentally incompetent, and validates state laws requiring psychiatric evaluation and treatment of capital inmates who plead that they have become insane while awaiting execution. The ruling raises troublesome questions for psychiatry, including whether it is ethical for psychiatrists to assess or treat prisoners, thereby enabling their execution. This article argues that evaluation and treatment of capital inmates is in accordance with medical practice standards that emphasize respect for patients' autonomy and rationality.     

The effect of evolving resource synergy beliefs on the intentions–behavior discrepancy in ethical consumption

Consumers are less likely to buy ethical products than their stated intentions in marketplace polls, due at least in part to the distinct temporal frames guiding their poll responses versus actual purchase decisions. We propose that as consumers' beliefs about the synergy between the resources a firm devotes to their ethical and functional attributes evolve, as part of the broader ethical marketing/corporate social responsibility movement, from negative to positive, this discrepancy between intentions and behavior is likely to disappear. Two studies provide support for this basic contention, implicating the importance consumers ascribe to a brand's ethical attribute as the driver of the temporal frame- and resource synergy beliefs-based differences in their preference for that brand.     

Kant,Oppression, and the Possibility of Nonculpable Failures to Respect Oneself

I argue that Kant's ethical framework cannot countenance a certain kind of failure to respect oneself that can occur within oppressive social contexts. Kant's assumption that any person, qua rational being, has guaranteed epistemic access to the moral law as the standard of good action and the capacity to act upon this standard makes autonomy an achievement within the individual agent's power, but this is contrary to a feminist understanding of autonomy as a relational achievement that can be thwarted by the systematic attack on autonomy that occurs within oppressive social conditions. Insofar as Kant's negative duty of self‐respect is unable to accommodate the ways immersion in oppressive social environments can warp an individual's understanding of what she is owed and capable of as a moral agent, it perpetuates the cruelty of unjust social systems in the guise of respecting individual autonomy. I conclude by considering Carol Hay's argument that those who are oppressed have an obligation to themselves to resist their own oppression, in order to explore how this limitation in how Kant conceives of the duty to respect the self may reach expression in contemporary ethical theory inspired by Kant.     

Genetics and the Interpersonal Elaboration of Ethics

Confidentiality in genetic testing posesimportant ethical challenges to the currentprimacy of respect for autonomy and patientchoice in health care. It also presents achallenge to approaches to decision-makingemphasising the ethical importance of theconsequences of health care decisions. In thispaper a case is described in which respect forconfidentiality calls both for disclosure andnon-disclosure, and in which respect forpatient autonomy and the demand to avoidcausing harm each appear to call both fortesting without consent, and testing only withconsent. This creates problems not only forclinicians, families and patients, but also forthose who propose clinical bioethics as a toolfor the resolution of such dilemmas.In this paper I propose some practical waysin which ethical issues in clinical geneticsand elsewhere, might be addressed. Inparticular I call for a closer relationshipbetween ethics and communication in health caredecision-making and describe an approach to theethics consultation that places particularemphasis on the value of interpersonaldeliberation in the search for moralunderstanding. I reach these conclusionsthrough an analysis of the concept of `moraldevelopment' in which I argue that theachievement of moral understanding is anecessarily intersubjective project elaboratedby moral persons.     

Responses of School Psychologists and Special Education Teachers to Administrative Pressures to Practice Unethically

Abstract

Responses of school psychologists (N = 141) and special educators (N = 130) to ethical dilemmas involving conflicts between administrative directives and ethical obligations were examined. Respondents completed a survey asking them to predict their own and others' responses to four ethical dilemmas. The majority of respondents predicted that they, immediate colleagues, and professional peers would make the choices judged as ethical in all situations. Predictions of ethical response were highest for self prediction and varied across the four dilemmas. Respondents who viewed their immediate colleagues as supportive of autonomous decision making were more likely to predict ethical choices than those who viewed their colleagues as supporting deference to administrative authority. No differences in predictions related to gender, degree level, job security, preservice training in or knowledge of professional ethics or special education law were found.     

Ethical dilemmas in pharmacy practice

The purpose of this study was to document the responses of pharmacy students and pharmacists to various ethical dilemmas. The responses of the first professional year students, third professional year students and pharmacists were evaluated and compared. In most instances, responses indicated a high priority for patient/client welfare. Pharmacists and students reportedly act with regard to the dignity of life, individual freedom, and an inner sense of right.     

Addressing the dual relationship problem in forensic and correctional practice

The dual relationship problem in forensic and correctional practice emerges from conflict between two sets of ethical norms: those associated with community protection and justice versus norms related to offender/defendant well-being and autonomy. The problem occurs because forensic practitioners typically have their professional roots in mental health or allied disciplines such as psychiatry, clinical psychology, social work, or law, and as such, often struggle to ethically justify aspects of forensic and/or correctional work. First, the problem of dual relationships will be described and its nuances explored. As will become apparent, the problem extends beyond the straightforward conflict of roles and resides at the very heart of professional practice. It is a core normative conflict created by practitioners varying ethical allegiances. Second, contemporary ways of resolving the dual relationship problem will be briefly outlined, that is, approaches that assert the primary of one set of codes over the other or involve the construction of hybrid ethical codes. Third, after briefly reviewing the shortcomings of these approaches I present a possible way forward drawing from relational ethics and the concept of moral acquaintances.     

Shaping Medical Students' Attitudes Toward Ethically Important Aspects of Clinical Research: Results of a Randomized,Controlled Educational Intervention

The effects of research ethics training on medical students' attitudes about clinical research are examined. A preliminary randomized controlled trial evaluated 2 didactic approaches to ethics training compared to a no-intervention control. The participant-oriented intervention emphasized subjective experiences of research participants (empathy focused). The criteria-oriented intervention emphasized specific ethical criteria for analyzing protocols (analytic focused). Compared to controls, those in the participant-oriented intervention group exhibited greater attunement to research participants' attitudes related to altruism, trust, quality of relationships with researchers, desire for information, hopes about participation and possible therapeutic misconception, importance of consent forms, and deciding quickly about participation. The participant-oriented group also agreed more strongly that seriously ill people are capable of making their own research participation decisions. The criteria-oriented intervention did not affect learners' attitudes about clinical research, ethical duties of investigators, or research participants' decision making. An empathy-focused approach affected medical students' attunement to research volunteer perspectives, preferences, and attributes, but an analytically oriented approach had no influence. These findings underscore the need to further examine the differential effects of empathy-versus analytic-focused approaches to the teaching of ethics.     

The Well- and Unwell-Being of a Child

The concept of the ‘well-being of the child’ (like the ‘child’s welfare’ and ‘best interests of the child’) has remained underdetermined in legal and ethical texts on the needs and rights of children. As a hypothetical construct that draws attention to the child’s long-term welfare, the well-being of the child is a broader concept than autonomy and happiness. This paper clarifies some conceptual issues of the well-being of the child from a philosophical point of view. The main question is how well-being could in practice acquire a concrete meaning and content for a particular issue or situation. A phenomenological-hermeneutic research perspective will be outlined that allows the child’s well-being to be elucidated and specified as an anthropological and ethical idea. It is based on a contextual understanding of generative relationships, a combination of the theory and practice of making sense, here described as ‘generative insight’, which could provide ethical guidance for decision making in families, legal practice, medicine or biomedical research.     

The Concerned Mental Health Practitioner

Summary

A discussion is provided regarding a fundamental principle of psychology, a concern for other's welfare, as set out in the American Psychological Association's (2002) Ethical Principles of Psychologists and Code of Conduct. Although the principle concern for others' welfare is essentially aspirational in nature, this is an ethical principle that is at the core of the mental health professions' stated values, and that must be positively put into operation in a variety of professional contexts. Unlike so much else in professional ethics codes that involves injunctions of what not to do, or which attempts to limit the self-serving tendencies of professionals, this general principle is essentially positive, pointing to the need to approach others and to consider their welfare first.     

Militarism,Human Welfare,and the APA Ethical Principles of Psychologists

A case study is presented of the American Psychological Association (APA), as a health care organization that promotes human welfare. APA includes policies on human welfare in its Ethical Principles of Psychologists and even lists the advancement of psychology "as a means of promoting human welfare" on its letterhead. Nevertheless, APA has other policies and activities based on military and weapons work that appear to conflict with its promotion of human welfare. Although military work in and of itself may not necessarily be problematic, work that contributes to people purposely being harmed or killed should be squared with the association's ethical guidelines. The results presented here show that this may not be the case: There currently appears to be little justification in the Ethical Principles for work intended to harm people. APA's active lobbying, research, and development for the military are documented here, in relation to an analysis of the Ethical Principles. APA's uncritical support for Operation Desert Storm is examined specifically, with regard to weapons technology and therapeutic treatment of U.S. soldiers on the battlefield. This one-sided support for victims of the war is not in keeping with a Hippocratic health care ethic to treat patients needing care, and to do so with neutrality and impartiality. Similarities to a historical example of nationalistic mental health ethics are discussed, with a review of the development of the German Institute for Psychological Research and Psychotherapy and of the German Society for Psychology in the Nazi wartime effort and the Holocaust. The results here show similar deficiencies in APA's ethical standards, not the least of which is that the code applies to individual members but not to APA policies, committees, or activities. This article concludes with suggested criteria for the Ethical Principles that would at least (a) recognize the ambiguities in systematically developing and using weapons to hurt people and (b) provide an initial rationale of potential justifications.     

Toward a hermeneutic model of ethical decision making in clinical practice

Documented ethical violations and empirical research have demonstrated that, despite professional standards and formal training in ethical principles, some psychotherapists engage in unethical behaviors that compromise the welfare of clients. It appears that competing values and interests that emerge in the therapeutic endeavor can interfere with therapists' considerations of ethical standards and their willingness to act ethically. Expanding current models of ethical decision making, this article offers a hermeneutic model that recognizes that in addition to moral reasoning, the context of the therapeutic relationship and the therapist's subjective responses are fundamental considerations in the interpretation and application of ethical interventions. Implications for understanding and training of ethics in psychotherapy in this broader context are explored.     

A Goodness-of-Fit Approach to Informed Consent for Pediatric Intervention Research

As children and adolescents receive increased research attention, ethical issues related to obtaining informed consent for pediatric intervention research have come into greater focus. In this article, we conceptualize parent permission and child assent within a goodness-of-fit framework that encourages investigators to create consent procedures “fitted” to the research context, the child's cognitive and emotional maturity, and the family system. Drawing on relevant literature and a hypothetical case example, we highlight four factors investigators may consider when constructing consent procedures that best reflect participants' rights, concerns, and well-being: (a) the child's current assent capacity and the likely impact of study information on the child's mental and physical development, (b) parents' understanding of their child's treatment needs and distinctions between treatment and clinical trials research, (c) the family's history of shared decision making, and (d) the child's strivings for autonomy within the context of their parents' duty to make decisions in the child's best interest.     

SOME GOOD AND BAD NEWS FOR ETHICAL INTUITIONISM

The core doctrine of ethical intuitionism is that some of our ethical knowledge is non-inferential. Against this, Sturgeon has recently objected that if ethical intuitionists accept a certain plausible rationale for the autonomy of ethics, then their foundationalism commits them to an implausible epistemology outside ethics. I show that irrespective of whether ethical intuitionists take non-inferential ethical knowledge to be a priori or a posteriori , their commitment to the autonomy of ethics and foundationalism does not entail any implausible non-inferential knowledge in areas outside ethics (such as the past, the future, or the unobservable). However, each form of intuitionism does require a controversial stand on certain unresolved issues outside ethics.