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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 11 in Ethics in Psychotherapy and Counseling: A Practical Guide (4th edition) by Ken Pope & Melba Vasquez (John Wiley). 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.

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This chapter provides steps helpful in thinking through how to respond to ethical dilemmas.

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 to ten in subsequent editions (1991, 2000). 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's 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 the colleague’s 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 affect 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 can 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/patient is (if it is a situation that involves a psychotherapist-client/patient relationship)? If one person is the client and someone else is paying our fee, is there any divided loyalty, any conflict that would influence 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 else who is available that we believe could step in and do a better job? 

5 Review relevant formal ethical standards

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

6 Review relevant legal standards 

Do legislation and case law speak to this situation? Are the legal standards clear? Does a legal standard conflict with other standards, requirements, or values? Do the relevant laws seem to 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 and obtain legal guidance? 

7 Review the relevant research and theory

Is there new research or theory that helps us think through the 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 the research and theory emerging outside our own theoretical orientation.

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

Does the situation make us angry, sad, or afraid? Do we want to please someone? Do we desperately want to avoid conflict? Do we fear that doing what seems most ethical 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 what seems right cost us time, money, friends, referrals, prestige, a promotion, our job, or our license?

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

The same act can take on sharply different meanings in different societies, cultures, or religions. What seems ethical in one context can violate fundamental 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 any potential issues of stereotyping or bias be relevant?

10 Consider consultation

Is there anyone who could provide useful consultation for this specific situation? Is there an acknowledged expert 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's 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'd consulted?

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 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?

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

Putting ourself in the shoes of those who will be 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 what Jones (1979; see also Blanchard-Fields, Chen, Horhota, & Wang, 2007; Gawronski, 2003; Gilbert & Malone, 1995; Weary, Vaughn, Stewart, & Edwards, 2006) called “correspondence bias.” 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 tend to hold explanations provided by other people to much more scientifically and logically rigorous standards than we use for our own explanations. 

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

Once we have decided 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've 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 can help 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 not only tracking 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? Were their unforeseen consequences? 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 our response to the situation now seems in hindsight to have been wrong or has caused unnecessary trouble, pain, loss, or problems, do we need to address the consequences of what we've done or failed to do? 

17 *Consider implications for preparation, planning, and prevention

Did this situation and the effects of our response to it suggest any useful possibilities in the areas of preparation, planning, and prevention? Are there practical steps that would head off future problems or enable us to address them more effectively? Would changes in policies, procedures, or practices help?

 

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