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Steps in Ethical Decision-Making

Kenneth S. Pope, Ph.D., ABPP

Melba J. T. Vasquez, Ph.D., ABPP

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The following excerpt is from chapter 17 in Ethics in Psychotherapy and Counseling: A Practical Guide (5th edition) by Ken Pope & Melba Vasquez (John Wiley, 2016). John Wiley, the book's publisher, holds the copyright to this material and questions about reprinting it or other uses involving copyright should be addressed to the publisher. © 2016 John Wiley & Sons.

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It's easy to miss an ethical dilemma's vital details or possible solutions. Competing values, conflicting regulations, scarce resources, misinformation, deadlines, fear of making a catastrophic mistake, and a stampede of other pressures and complications can make it hard to think clearly, carefully, and creatively.

This chapter provides useful steps for understanding, thinking through, and responding effectively to ethical dilemmas, especially when faced with complex ethical gray zones. The steps help identify key aspects of a situation, consider benefits and drawbacks of our options, and discover better approaches.

The Canadian Psychological Association (CPA) emphasized the importance of such steps by including seven in its original ethics code (1986) and increasing the number in subsequent editions. The asterisks in the following list mark steps that are versions of those that appear in the CPA code.

Seventeen steps appear here, but not every step fits every situation, and some steps may need to be adapted.


1 State the question, dilemma, or concern as clearly as possible

Does the statement do the situation justice? Does it make clear what the problem is and why it is a problem? Does it miss anything important to thinking through possible courses of action? Does any part of it get lost in the mists of vagueness, ambiguity, or professional jargon? Are some of the words misleading or not quite right? Is there anything questionable about the statement's scope, perspective, or assumptions? Are there other valid ways to define the problem?

Tight schedules, urgent situations, and an eagerness to solve the problem can rush us past this step, but coming up with the best approach depends on clearly understanding the ethical challenge.

2 *Anticipate who will be affected by the decision

No one lives in a vacuum. How often do our ethical decisions affect only a single person and no one else? A client shows up for a session drunk. Whether the client drives home drunk and kills a pedestrian can depend on how we define our responsibility. A colleague begins to show signs of Alzheimer's. Our choices can affect the safety and well-being of the colleague and his or her patients. A therapy client tells us about embezzling pension funds. Confidentiality laws may direct us to tell no one else, and the client may refuse to discuss the issue. How we respond can determine whether hundreds of families retain the pensions they earned or are thrown into poverty. An insurance claims manager refuses to authorize additional sessions for a client we believe is at risk for killing his wife and children and then committing suicide. Our supervisor may agree with the manager that no more sessions are needed. Whether the family lives or dies may depend on what we do.

3 Figure out who, if anyone, is the client

Is there any ambiguity, confusion, or conflict about who the client is (if it is a situation that involves a psychotherapist– client relationship)? If one person is the client and someone else pays our fee, do we feel any divided loyalty, any conflict that might shade our judgment?

4 Assess whether our areas of competence—and of missing knowledge, skills, experience, or expertise—are a good fit for this situation

Are we well prepared to handle this situation? What steps, if any, could we take to make ourselves more effective? In the light of all relevant factors, is there anyone available to step in and do a better job? If so, what reasons weigh against referring the client?

5 Review relevant formal ethical standards

Do the ethical standards speak directly or indirectly to this situation? Does this situation involve conflicts within the ethical standards or between the ethical standards and other (e.g., legal) requirements or values? In what ways, if any, do the ethical standards seem helpful, irrelevant, confusing, outdated, or misdirected when applied to this situation? Would it be helpful to talk with an ethicist, a member of a national, state, or provincial ethics committee? 

6 Review relevant legal standards 

What legislation and case law speak to this situation? Does a legal standard conflict with other standards, requirements, or values? Do the relevant laws support— or at least allow— the most ethical response to the situation, or do they seem to work against or even block the most ethical response? Would it be helpful to consult an attorney who has experience and expertise in these issues? 

7 Review the relevant research and theory

Have we kept up with the emerging theory, research, and practice that might help us think through this situation? An occupational hazard of a field with such diverse approaches— cognitive, psychodynamic, pharmacological, behavioral, feminist, psychobiosocial, family, multicultural, and existential, to name but a few— is that we often lose touch with new ideas, findings, and approaches arising outside the walls of our own theoretical orientation.

8 *Consider whether personal feelings, biases, or self-interest might affect our ethical judgment

Does the dilemma make us angry, sad, or afraid? Do we want to please someone? Do we desperately need to avoid conflict? Do we fear that choosing the most ethical path will get us into trouble, make someone mad at us, be second-guessed by colleagues, or be hard to square with the law or the ethics code? Will doing the right thing cost us time, money, friends, referrals, prestige, a promotion, our job, or our license? Being relentlessly honest with ourselves as we feel our way through as well as think our way through ethical challenges can help us avoid rationalizing our way off the path toward the most ethical response for this specific situation.

9 Consider whether social, cultural, religious, or similar factors affect the situation and the search for the best response

An act can take on sharply different meanings in different societies, cultures, or religions. The most ethical response in one context may violate sacred values in another society, culture, or spiritual tradition. What contexts— or conflicts between contexts— may have escaped our notice? Does our own social identity in relation to the client's social identity enter into the process? Could our own limited or biased view of other cultures, religions, and so on, throw off how we think through this ethical dilemma?

10 Consider consultation

Is there anyone who could help us think through the issues and possible responses? Who has expertise in the relevant areas? Is there someone who has faced a similar situation and handled it well— or who might tell us what does not work and what pitfalls to avoid? Is there a colleague whose perspective might be helpful? Is there someone whose judgment we trust? When drawing a blank in the face of these questions, sometimes it is useful when a question takes this form: If what we decide to do were to end in disaster, is there some particular person we wish we had consulted?

As noted in earlier chapters, consultation— unlike communications protected by therapist– patient or attorney– client privilege— is usually discoverable in legal proceedings. This may be an important consideration in some situations.

11 *Develop alternative courses of action

What possible ways of responding to this situation can you imagine? What alternative approaches can you create? At first we may come up with possibilities that seem not bad or good enough. The challenge is not to quit too soon but to keep searching for our best possible response.

12 *Think through the alternative courses of action

What impact is each action likely to have— and what impact could each have under the best possible and worst possible outcome that you possible outcome that you can imagine— for each person who will be affected by your decision?

What are the immediate and longer-term consequences and implications for each individual, including yourself, and for any relevant organization, discipline, or society? What are the risks and benefits?

Almost any significant action has unintended consequences— what could they be for each possible course of action?

As with so many aspects of thinking through ethical dilemmas, one of the best strategies is to imagine that you decided upon the option, tried it out, and it ended in disaster— What flaws do you spot? What do you wish you would've considered before you acted on it? How could that option have been strengthened? Or should it have been discarded in favor of a better option?

13 Try to adopt the perspective of each person who will be affected

Putting ourselves in the shoes of those affected by our decisions can change our understanding. What would each person consider the most ethical response? This approach can compensate for the distortion that often comes from seeing things only from our own perspective. One example is correspondence bias (Bauman & Skitka, 2010; Blanchard-Fields et al., 2007; Ross, 1977; Ross & Nisbett, 2011; Stockus & Walter, 2015; see Chapter 5, "Ethical Judgment Under Uncertainty and Pressure: Critical Thinking About Heuristics, Authorities, and Groups"). Although we often explain our own behavior in specific situations as due to external factors, we tend to attribute the behavior of others to their dispositions.

Another example is what Meehl (1977) called a "double-standard of morals" (p. 232): We hold other people's explanations to much higher scientific standards of logic, plausibility, persuasiveness, and proof than we use for our own explanations. 

14 *Decide what to do, review or reconsider it, and take action

Once we decide on a course of action, we can— if time permits— rethink it. Sometimes simply making a decision to choose one option and exclude all others makes us suddenly aware of flaws in that option that had gone unnoticed up to that point. Rethinking gives us one last chance to make sure we have come up with the best possible response to a challenging situation.

15 *Document the process and assess the results

Keeping track of the process through documentation helps us remain clear about what went into our decision: the elements of the problem; the options and potential consequences; the guidance provided by others; the perspective of the client, including the relevant rights, responsibilities, risks, and possible unintended consequences. Careful record keeping involves tracking not only what led up to our decision but also what happened afterward. What happened when we acted? Did we accomplish what we'd hoped and intended? Did unseen factors and unforeseen consequences spring up? Knowing what we know now, would we have taken the same path or tried a different response?

16 *Assume personal responsibility for the consequences

If what we did seems clumsy, misguided, or downright wrong in hindsight, if it brought about needless trouble, pain, loss, or problems, how do we respond to the fallout of what we did or failed to do? Can we openly and honestly admit and own our mistakes and shortcomings and take clear steps both to set things right, if possible, and to avoid these missteps in the future?

17 *Consider implications for preparation, planning, and prevention

*Consider Implications for Preparation, Planning, and Prevention Does this situation, how we responded to it, and the effects of our response suggest useful possibilities in the areas of preparation, planning, and prevention? What could we do to head off future problems or strengthen our responses? Would making changes in our policies, procedures, or practice help?

 

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