Making Ethical Decisions

A Step-by-Step Model for Making Ethical Decisions

All programs should have a consistent process for dealing with ethical concerns. Although ethical issues are usually complex enough to require a case-by-case evaluation, agency practices should provide for a routine process for approaching an ethical issue. For example, an agency might have, as a policy and procedure, a practice where the employee consults with a supervisor or an ethics consultation team within the agency, within a specified timeframe, and guidelines are provided for how to document such discussions.

There could also be agency protocols for situations that have arisen in the past, such as a client’s admission that she is suicidal or homicidal, clients who come to the facility intoxicated and insist on driving home or clients who admit to illegal activity. Given the ambiguous nature of ethical dilemmas, it is helpful to clarify the process for resolving dilemmas, even if the resolution may differ from case to case.

Identify the clinical issues. When an ethical issue arises, the counselor should review the larger picture in her work with the client or system. Identifying the clinical issues is the first step. What are the clinical needs of the client? How does the ethical dilemma relate to what the client presented with initially? It is important to assess the clinical issues so that pertinent information is not missed. For example, if a client with advanced AIDS is asking for help in ending his life, the counselor would review the client’s previous mental health history and current emotional issues, look for any significant changes in the client’s support system, and determine if the client is experiencing social or psychological issues that might influence his decision. Until this is done, it is impossible for the counselor to address the ethical issue regarding the end of life.

 Identify the legal issues. There can be significant legal issues to consider. Has the counselor reviewed the State and local laws regarding the issue? If necessary, has the counselor checked with an attorney for consultation or informed his supervisor of possible liability questions?

 Identify the system issues. What are the policies and procedures of the counselor’s agency regarding the ethical question? In some agencies, the answers may be hard to find, but they can shed light on any restrictions the counselor may face or make the choices clear. For example, if it is against policy to accept a gift from a client, the counselor can avoid a personal rejection by referring to the policy. Agency policy also can help a counselor in a legal challenge. For example, if the counselor followed agency policy, it is less likely that the counselor can be challenged legally for actions pertaining to that policy (although the agency can still be challenged).

 Identify the cultural issues. Cultural issues often are glossed over in the midst of a dilemma or crisis. Yet cultural issues are significant for understanding the client’s motivation and whether or not the client will act according to the proposed treatment plan. For example, a gay, African American client may have difficulty dealing with his homosexuality and as a result, may be having anonymous unprotected sex impulsively. In the African American culture, it can be especially difficult for men to acknowledge their homosexuality. If the client is HIV positive, there is an ethical need to educate him about protecting others. If the counselor does not acknowledge the client’s discomfort on a cultural level, the education process will be limited and the counselor will miss the “larger picture.”

 Identify the ethical issues. What is the counselor’s reaction to the situation? Ethical issues often are revealed when there is a “gut instinct” that something is not right. Confusion, anxiety, or uncertainty about what to do next with the client, are indicators that an ethical issue is at stake. If basic principles seem to be compromised, the counselor should stop and evaluate further. A significant step is for the counselor to examine her own feelings about the situation. The counselor needs to identify any countertransference issues regarding the situation to ensure that the issue can be viewed objectively.

 Review what principles are at stake. What is the true dilemma? Is there a dilemma at all? So much can be occurring with a client that it is difficult to see the real issue, or whether the issue is significant. Is harm being done either by the client or to the client? Can the client make her own decisions, and is she not being allowed to do so? Is the client being treated fairly regardless of race, culture, or lifestyle? Is there a threat to the client’s confidentiality? These are the questions relating to basic ethical principles.

 What are the possible options? By this point, the counselor’s next step may be clear already. Or, there may be choices of possible options. It is useful to simply list all of the possible options and then examine them.

 Review the pros and cons of each option. List the pros and cons of each possible option, noting the impact of the options on the welfare of the client, the counselor, the agency, and others involved in the situation, such as the client’s support system.

 Act. At this point, the counselor should be ready to make a decision. Sometimes the decision may not be one that everyone is comfortable with, but it may be the least objectionable plan. The client should understand the rationale for the counselor’s decision, and there should be evidence of the counselor’s thought process in the documentation of consultations, discussions with the client, and supervisory meetings.

 Follow up and evaluate. An ethical decision should be evaluated and the impact to the client monitored. For example, if the counselor decided to breach confidentiality for the protection of the client, how has this affected the clinical work with the client? These issues should be considered once an initial crisis has passed.

The Keys to Ethical Decisions

The key to ethical client relationships is to inform the prospective client, meaning before they officially become your client, of the rules and boundaries that you intend to firmly maintain. This confession protects you and the client. You, the counselor need to be self-aware and mindful of your role in the client's successful outcomes.

Cases Examples:

Your agency policy reads, “No hugging or client contact other than a handshake.” A client is walking out of your office after a counseling session and trips. She’s falling to the floor. Do you reach out to grab the person from hurting themselves, despite company policy? Your reactions may even be instinctive, reaching out automatically.

It’s a cold, snowy afternoon. You are on your way home, driving your car in a blinding snowstorm. No other cars are on the road, no taxis, no buses. You come to a street corner and observe a client of yours whom you’d seen today, walking home. He lives three miles from there. He has no way to get home other than walking. Do you pick him up and drive him to a safe place? What if your agency policy is to not ever transport clients? What risks are you incurring by driving the client?On the other hand, how would you feel if tomorrow morning you read in your local newspaper that the client froze to death while trying to walk home? How would you deal with this situation?

Boundary issues are arguably the most common concerns in counseling. There is a distinction between a boundary crossing and a boundary violation. The two above examples may illustrate a boundary crossing: a benign action that may benefit the client’s well-being. A boundary violation is one in which harm is done to the client, to a professional’s credibility and standing, or to an agency’s reputation. A boundary violation is coercive or exploitive. Factors that affect a boundary violation are when the action occurs (after hours, between sessions), place (culture, out of the office) and purpose. The key question to ask oneself when faced with boundary issues is intent. Why am I doing this? Giving my Turkish clients a peck on the cheek is a proper form of greeting in Turkey but not in Texas.

A few fundamentals apply to boundary issues: Good intentions are not enough justification. The impact on the client is essential. Never do anything inside your office you wouldn’t feel comfortable doing in the hallway.

Dual relationships are also a common complaint against counselors. A dual relationship is an abusive use of a counselor’s power, one that takes away the client’s autonomy and freedom of choice. It may involve intentional personal gain for the counselor, and harm is always done to the client and the therapeutic relationship. However, we need to make a distinction between a dual relationship and a dual quality. I live in a small town of 3,000 people. It is not uncommon for me to run into a client in the local supermarket. That’s a dual quality. You may see clients in a faith community, a civic activity, a 12-Step meeting. The key is how you prepared the client (and your partner) for the possibility that such chance meetings may happen, and how you dealt with them then and afterward.

These are questions a counselor should ask themselves about dual relationships:

Is this relationship necessary?
Who benefits from it?
Will it hurt the client or affect the therapeutic alliance?
Is the decision-making process documented? Have I told my supervisor about it?
Have I discussed the risks and issues with the client?

The ethical agony that comes with attempting to put the client's needs first and protecting them to the best of our ability can often be found in specific areas where client welfare must be held paramount.

Other Considerations When Making Ethical Decisions

In addition to identifying specific ethical standards, White (1993) suggested consideration of the following when making ethical decisions:

1) Autonomy: To allow others the freedom to choose their own destiny. The client's ability to make informed decisions about their own care.

2) Obedience: The responsibility to observe and obey legal and ethical directives

3) Conscientious Refusal: The responsibility to refuse to carry out directives that are illegal and/or unethical

4) Beneficence: The client's right to healthy, beneficial care.

5) Gratitude: To pass along the good that we receive to others

6) Competence: To possess the necessary skills and knowledge to treat the clientele in a chosen discipline and to remain current with treatment modalities, theories, and techniques

7) Justice: Fair and equal treatment, to treat others in a just manner

8) Stewardship: To use available resources in a judicious and conscientious manner, to give back

9) Honesty and Candor: Tell the truth in all dealings with your clients, colleagues, business associates, and the community.

10) Fidelity: To be true to your word, keeping promises and follow through on commitments.

11) Loyalty: The responsibility to not abandon those with whom you work.

12) Diligence: To work hard in the chosen profession, to be mindful, careful and thorough in the services delivered.

13) Discretion: Use of good judgment, honoring confidentiality and the privacy of others.

14) Self-improvement: To work on professional and personal growth to be the best you can be.

15) Non-malfeasance: Do no harm to the interests of the client.

16) Restitution: When necessary, make amends to those who have been harmed or injured.

10 Ethical Principles

Principle 1: Client Welfare-Protecting the client.

Principle 2: Cultural Diversity-Respecting and understanding the client's cultural background.

Principle 3: The Counseling Relationship-Understanding the three relational components of therapy: tasks, goals, and the therapeutic bond between the client and the clinician.

Principle 4: Proper Use of Written Clinical Material-Included the safe storage of client information.

Principle 5: Proper Use of Spoken Clinical Material

Principle 6: Responsibility

Principle 7: Competency

Principle 8: Workplace Standards

Principle 9: Professional Rapport

Principle 10: Societal Obligations