Ethical dilemas for nurses and their emotional implications

Some of the ethical and emotional problems that are presented to nurses are described. Nurses dealing with them are often the same age as medical students who are just starting their training and on qualifying as doctors will be less experienced in dealing with various life-and-death dilemmas than the nurses looking after their patients. It is contended that despite the fact that almost everyone at some time in their lives is going to depend upon a nurse, the subject of nursing and its dilemmas has been largely neglected, particularly by psychoanalytic/psychotherapy training organisations. Training is described which it is hoped would remedy some of the deficiencies of current nurse-training and encourage personal development and growth. It is also suggested that the training of medical students should include a period of nurse experience and training. The power which can be invested in the nurse is also described, along with the corrupting effect this can have on the nurse/patient relationship.     

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.     

Applied ethics in mental health in Cuba: part II--power differentials,dilemmas, resources,and limitations

This article is the second one in a series dealing with mental health ethics in Cuba. It reports on ethical dilemmas, resources and limitations to their resolution, and recommendations for action. The data, obtained through individual interviews and focus groups with 28 professionals, indicate that Cubans experience dilemmas related to (a) the interests of clients, (b) their personal interests, and (c) the interests of the state. These conflicts are related to power differentials among (a) clients and professionals, (b) professionals from different disciplines, and (c) professionals and organizational authorities. Resources to solve ethical dilemmas include government support, ethics committees, and collegial dialogue. Limitations include minimal training in ethics, lack of safe space to discuss professional disagreements, and little tolerance for criticism. Recommendations to address ethical dilemmas include better training, implementation of a code of ethics, and provision of safe space to discuss ethical dilemmas. The findings are discussed in light of the role of power in applied ethics.     

Black and White and Shades of Gray: A Portrait of the Ethical Professor

This article is the second one in a series dealing with mental health ethics in Cuba. It reports on ethical dilemmas, resources and limitations to their resolution, and recommendations for action. The data, obtained through individual interviews and focus groups with 28 professionals, indicate that Cubans experience dilemmas related to (a) the interests of clients, (b) their personal interests, and (c) the interest of the state. These conflicts are related to power differentials among (a) clients and professionals, (b) professionals from various disciplines, and (c) professionals and organizational authorities. Resources to solve ethical dilemmas include government support, ethics committees, and collegial dialogue. Limitations include minimal training in ethics, lack of safe space to discuss professional disagreements, and little tolerance for criticism. Recommendations to address ethical dilemmas include better training, implementation of a code of ethics, and provision of safe space to discuss ethical dilemmas. The findings are discussed in light of the role of power in applied ethics.     

Some ethical dilemmas in sensitivity training, encounter groups and related activities

Some ethical dilemmas in connection with sensitivity training, encounter groups and related activities are discussed. We distinguished between pre-group, in-group and post-group dilemmas. Pre-group dilemmas consisted of competence of leader, screening of participants, contract, voluntary participation, conflicting roles, organization of group work and conducting of research. In-group dilemmas were optimum level of awareness, leadership style and personality, image of man, issue of "casualties", confidentiality and freedom to make errors. Post-group dilemmas included "re-entry" difficulties, repression of changing individuals and follow-up procedures. Conclusions were as follows: ( a ) There exist indeed a series of ethical dilemmas in conducting growth groups. ( b ) The good group leader must learn to live with this seemingly chronic ethical dissonance. ( c ) The one most significant ethical guideline is to establish the optimum level of awareness in the group. ( d ) There is a pressing need for more adequate research on such ethical dilemmas.     

Psychodynamic therapists' dilemmas in providing personal therapy to therapists in training: An exploratory study

Aim: This study explores dilemmas facing psychodynamic therapists who provide personal therapy to therapists in training. Method: Eight experienced psychodynamic psychotherapists were interviewed using a semi‐structured interview format during which they were asked about the importance of personal therapy, if they encountered any dilemmas and, if so, how they resolved those dilemmas. Their responses were analysed using a qualitative form of content analysis. Findings: Two categories of dilemma emerged: clinical and personal. Clinical dilemmas arose out of the mandatory requirement for therapy, boundaries, fitness to practice and the suitability of trainees. Personal dilemmas included pressure to model, sense of responsibility, therapeutic narcissism, countertransference reactions, over‐use of self and stressful involvement. The therapists' strategies for resolving the dilemmas are described. Conclusion: The results show participants considered personal therapy to be essential for trainees and thought it should be mandatory even though it led to difficulties in the therapy. Questions arose about the suitability of some trainees, the person of the therapist and stressful involvement. Further research into these important areas is recommended.     

From Theory to Practice: Facing Ethical Challenges as a Clinical Intern

Although formal ethics classes provide a basic foundation in managing ethical dilemmas, professionals often point to their experiences on internship as an important training ground for consolidation of their ethical development. Clinical interns face many personal and professional transitions that can lead to a number of ethical dilemmas. Effective collaboration between administrative staff, supervisors, and interns can create a pragmatic model for negotiating these dilemmas. In this paper, issues related to balancing intern competency with training and patient/client needs, managing dual relationships with supervisory staff, and dealing with differences in orientation are addressed from the perspective of both the site and the intern. We also discuss ways in which problems can arise and how both sides can work together systematically to negotiate those problems. To illustrate this process, we discuss cases involving effective collaboration between interns and sites. Finally, the authors assert the need for formal, empirically supported training in classic ethical issues, but also in contemporary ethical issues arising from the ever-evolving field of mental health service delivery and unique challenges accompanying these advances.     

The Role of Decision-Making Models and Reflection in Navigating Ethical Dilemmas

The ACA Code of Ethics (American Counseling Association [ACA], 2014) mandates counselor competency in using ethical decision-making models (EDMs) and mandates that counselors use an EDM when confronted with making ethical decisions. Additionally, researchers have highlighted the importance of counselors continually evaluating and reflecting when faced with ethical dilemmas and working through a decision-making model. Using a phenomenological research design, the authors examined how counselors address ethical dilemmas, including how reflection and EDMs are incorporated into the decision-making process. Emergent themes from data analysis include (a) incomplete following of EDMs, (b) varied dilemmas, (c) power, and (d) ethics training.     

Substance Abuse Counselors and Ethical Dilemmas: The Influence of Recovery and Education Level

The authors examined the impact of substance abuse counselor (SAC) recovery status and education level on (a) SACS' sensitivity to ethical dilemmas and (b) extent to which training might help resolve dilemmas. Results revealed a significant difference between SACS with a graduate degree and SACS with an associate's degree/high school diploma regarding sensitivity to ethical dilemmas, with the latter being more sensitive. This study could be used to develop educational materials to improve SAC competency in resolving ethical dilemmas.     

Stimulating ethical awareness during training

This paper argues for a preventative approach to ethical violations through developing and maintaining ethical awareness in training and in the group life of each society. Rather than teaching ethics as a theoretical subject, a method is proposed that encourages direct personal confrontation with ethical dilemmas through the consideration of key examples, in the Talmudic manner. This develops ethical 'muscles' and allows candidates to explore the dilemmas of what Primo Levi called the 'grey zone' where the boundaries between good and bad are unclear. Several illustrations of such ethical dilemmas are described, as used in workshops that the author has run in several societies and developing groups. In this way, ethical awareness becomes part of the group life of the society so that analysts become an ethical resource for each other.     

Emotions associated with counterfactual comparisons drive decision-making in Footbridge-type moral dilemmas

Based on the dual-process theory of moral judgment, it has been suggested that in Footbridge-type dilemmas the anticipation of the emotional consequences of causing intentional harm might contribute to the decision of rejecting utilitarian resolutions. However, no empirical data have been reported on the emotions felt by participants after their decisions, and the role played by emotions in Trolley-type dilemmas remains to be determined. The present study investigated the specific emotions engaged both after decision choices and after the generation of the counterfactual scenario in Trolley- and Footbridge-type dilemmas. The results support the idea that in Footbridge-type dilemmas decision-making is driven by the attempt to minimize the aversive emotional state evoked by the decision outcome. A greater increase in emotional intensity was found overall for Footbridge-type than Trolley-type dilemmas after the counterfactual generation following typical (non-utilitarian) choices, with guilt, regret, and shame being the emotions that increased most. Critically, in Footbridge-type dilemmas only, typical choices were predicted by the increase in regret intensity experienced after counterfactual generation.     

The Genetic Counselor’s Role in Managing Ethical Dilemmas Arising in the Laboratory Setting

Ethical dilemmas are encountered commonly in the setting of the clinical genetic testing laboratory due to the complexity of genetic testing and the number of relevant stakeholders involved in the genetic testing process. Based on their clinical training and role within the laboratory, genetic counselors are uniquely equipped to identify and facilitate management of ethical dilemmas. This paper reviews the historical context of ethical theory and its application to the field of genetic counseling. Theoretical and applied ethics are explored in the context of dilemmas arising in the laboratory setting, with a focus on the role of the laboratory genetic counselor in managing ethical dilemmas. Two illustrative case examples are provided.     

Supervising the person of the therapist: Issues,challenges and dilemmas

A major critical issue in marriage and family therapy today is the professionalization of the discipline. Thus the focus on training individuals for a career in marriage and family therapy necessitates the revisitation of the debate over personal growth versus skill development. The trend toward training the person of the therapist, however, would suggest that the field is moving toward the integration of self awareness and skill in the therapeutic system. With the popularization of training the person of the therapist comes other issues, challenges, and dilemmas for the field, including the crucial issue of training gender and culturally sensitive therapists. The potential for creating dual relationships when training the person of the therapist is both a dilemma and a challenge.     

A Survey of Ethical and Professional Challenges Experienced by Spanish Health-Care Professionals that Provide Genetic Counseling Services

Genetic testing is increasingly applied for diagnosis and clinical treatment. In some countries, genetic counseling services are provided by professionals with specific training in this discipline, whereas other countries have no teaching programs and counseling is offered by physicians, nurses, pharmacists or biochemists. This counseling raises more and more ethical dilemmas for health professionals at their clinics. The purpose of this study was to analyze the characteristics of Spanish professionals devoted to providing genetic counseling services and to investigate the frequency of the ethical dilemmas they face. Results from 72 survey respondents revealed this counseling is provided by an almost even number of male and female professionals, mostly physicians with many years of professional experience. The overall frequency of the ethical dilemmas encountered was not high. The most frequent dilemmas corresponded to emotional responses by patients, informed consent, uncertainty about test results, and limitations on health-care resources. The frequency of dilemmas involving discrimination and provider directiveness was very low. Additional findings, practice implications, and research recommendations are presented.     

Egocentric Interpretations of Fairness in Asymmetric,Environmental Social Dilemmas: Explaining Harvesting Behavior and the Role of Communication

This research explores the effects of egocentric interpretations of fairness, expectations about other actors’ harvesting decisions, and communication on the focal actor's harvesting decisions in asymmetric social dilemmas. We found support for the predictions that egocentrism exists in perceptions of fairness in asymmetric dilemmas, overharvesting is positively related to the amount of egocentrism, and egocentrism is stronger before discussion than after discussion. Furthermore, in a comparison between asymmetric and symmetric dilemmas, we found that egocentrism and overharvesting were greater in asymmetric dilemmas than in symmetric dilemmas. Finally, the results indicate that among certain actors, overharvesting in asymmetric dilemmas is positively related to the amount of harvesting expected from the other parties. This study contributes to the social dilemma literature by (1) introducing the idea of egocentric interpretations of fairness as an explanation for overharvesting behavior, (2) demonstrating that egocentrism is more pronounced in asymmetric versus symmetric dilemmas, (3) suggesting that the reduction of egocentric interpretations of fairness is another reason why communication enhances cooperative behavior, and (4) demonstrating that beliefs about what others will do is related to harvesting decisions in asymmetric as well as symmetric dilemmas.     

The Balancing Act—Ethical Issues in Parent Training Research: Confidentiality,Harm Reduction,and Methodology

Attention and disruptive behavior disorders present considerable challenges for children and their parents. These challenges have led to the development of parenting programs; however, there is a paucity of literature that discusses the ethical dilemmas parent training researchers face. This article reviews ethical principles and professional standards relevant to parent training research and provides case material to illustrate the challenge of balancing ethical adherence and empirical rigor using three ethical issues that commonly arise in parent training research. In particular, this article focuses on ethical issues surrounding confidentiality in a group setting, use of control groups, and limiting changes in medication/treatment status outside of the treatment protocol.     

The practice of psychology in rural communities: potential ethical dilemmas

The practice of psychology in rural areas offers unique challenges for psychologists as they try to provide optimal care, often with a minimum of resources. Psychologists are frequently required to be creative and flexible in order to provide effective services to a wide range of clients. However, these unique challenges often confront psychologists with ethical dilemmas and problems for which their urban-based training has not prepared them. The author examines how certain characteristics of rural communities may lead to specific ethical dilemmas. By being a part of a small community, psychologists will inevitably face multiple relationship dilemmas. Confidentiality is harder to maintain in a small town, particularly with its informal information-sharing network. To provide services to meet community needs, with a limited number of referral options, psychologists typically need to be generalists. This may lead to concerns about scope of practice, training, and experience with diverse populations. Psychologists also face other competency issues, such as a lack of supervision and consultation resources. Other concerns addressed include the psychologist's personal life, and the blurring of professional and personal roles. Suggestions are made for coping with each of these ethical issues, although more quantitative research and discussion are needed on the practice of psychology in rural areas.     

The Effect of an Ethical Decision-Making Training on Young Athletes’ Attitudes Toward Doping

This article examines whether a training program in ethical decision making can change young athletes’ doping attitudes. Fifty-two young elite athletes were randomly assigned to either an ethical decision-making training group or a standard-knowledge-based educational program group. Another 17 young elite athletes were recruited for no-treatment control purposes. The ethical decision-making training comprised six 30-min online sessions in which the participants had to work through 18 ethical dilemmas related to doping. The standard-knowledge-based educational program was also conducted in six online sessions of comparable length to that of the ethical training. A short version of the Performance Enhancement Attitude Scale was administered to measure the effects of the trainings on doping attitude. Prior to as well as after the intervention, the mean doping attitude scores of the young athletes were low to very low, indicating vehement rejections of doping. The results of our experiment showed that the ethical training led to an attenuation of these rejections. No intervention effect was found in the standard education group. The observed slight increase in the doping attitude score could be an indication that the ethical decision-making training was successful in breaking up the athletes’ stereotypical style of reasoning about doping.     

Formal training is antithetical to the spirit of psychotherapy: A review and commentary

To suggest that formal training is antithetical to the spirit of psychotherapy appears inherently contradictory. This paper is, however, an invitation to a critical examination of the dilemmas and paradoxes sourrounding formal training courses and the practice of psychotherapy. More specifically, the paper examines the ethical and institutional arguments which surround formal training courses and the practice of psycho-analytical therapies. A review of the opinions of several leading psychotherapists and a selective review of the research literature is used to reconcile the tensions between formal training and the process of psychotherapy. It is concluded that, with appropriate safeguards and flexibility, formal training need not be antithetical to the spirit of psychotherapy.     

Strategies School Practitioners Report They Would Use to Resist Pressures to Practice Unethically

Abstract

This study focused on strategies school psychologists and special education teachers report they would use to resist administrative pressures to practice unethically. Data came from a national sample of 141 school psychologists and 130 special education teachers who responded to a survey by predicting how they and others would respond to four ethical dilemmas. Qualitative analysis of data revealed four strategies that were generalized across all dilemmas. These general strategies were: preventing dilemmas from occurring; educating and/or threatening others; involving others in solutions; and combining strategies into more comprehensive responses. Qualitative analysis also revealed three strategies that were suggested for only some of the dilemmas (dilemma-specific strategies). Both the general and dilemma-specific strategies appear potentially useful to practitioners seeking ways of resisting pressures to practice unethically.