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Identifying and Implementing Ethical Standards for Primary Prevention

Kenneth S. Pope

Abstract: As yet, there is no formal, comprehensive system of ethics for those involved in primary prevention in human services, no explicit ethical code, and no mechanism for enforcement. This article presents a set of conceptual and procedural issues for establishing formal ethical accountability in the area of primary prevention. Three prerequisites are identified: group identity, recognition of need, and active participation. Areas of ethical concern are categorized and examined in terms of five ancient principles (avoiding harm, competence, avoiding exploitation, respect, and confidentiality) as well as two more historically recent principles (informed consent; social equity and justice). Finally, three processes necessary to the creation of a useful and effective system of ethical accountability are discussed: the creation and revision of standards, the implementation of standards, and program evaluation.

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A formal system of ethics is the means by which professionals establish explicit standards of behavior and hold themselves accountable to those standards. An ethical code helps both professionals and those affected by the professionals' actions (e.g., clients and consumers) identify and understand the principles which must guide the professionals' work. Less altruistically but more practically, professionals' systems of ethics can also represent or be motivated by the profession's desire to minimize regulation by external organizations and systems (e.g., state licensing boards, the civil and criminal courts). The origin or elaboration of formal ethical systems can also be a response to pressure from consumers, clients, and the public who seek a change from laissez faire and caveat-emptor approaches to professional responsibilities. The paternalism inherent in the attitude that professionals "know best" and are beyond accountability is not tolerated among the public as it once was.

As yet, there is no formal, comprehensive system of ethics for those involved in primary prevention in human services, no explicit ethical code, and no mechanism for enforcement. Primary preventionists may belong to professional associations which do articulate ethical standards, but such codes tend to address issues of primary prevention tangentially if at all. This article is an attempt to organize a set of conceptual and procedural issues which may be useful to those thinking through the possibilities of establishing a formal ethical code for primary preventionists.


Group Identity

Perhaps the first condition which must be met for the development of a formal system of ethical accountability within a given area of endeavor is that those engaged in the endeavor view themselves as members of a group, that they identify with that group and share a sense of identity and community as part of it. Many of us may belong to various associations, receive journals and other benefits of membership, and yet have little sense of identity or community in terms of the group.

The diversity of backgrounds (including training), values, goals, and activities of those who fall within the broad category of primary preventionists may make such identification and shared sense of community difficult. Furthermore, the cohesiveness necessary to create and sustain a system of genuine accountability may take a substantial amount of time to develop. For example, the American Psychological Association held its first meeting in 1892, ratified its constitution in 1894, and became incorporated in 1925.

Yet it was not until the late 1930s that APA was able to create an ethics committee in an attempt to ensure high standards among its membership. Prior attempts included three separate efforts in the 1920s to establish a system of certifying psychologists performing clinical services (Fernberger, 1932). The third attempt ended when less than thirty psychologists could be persuaded to apply for certification -- even when the application fee was drastically reduced from $35 to $5. While these proposed models of certification did not involve creation of explicit ethical codes, nevertheless they were the initial at tempts of the profession to ensure certain explicit standards or pre requisites for practice.

Fernberger (1932) quotes the Committee on Certifications report on this failed attempt:
" Circumstances suggest that the Association should either (1) make it plain that it disclaims responsibility for the conduct of its members or (2) provide means by which charges may be brought and appropriate action taken if they are sustained."

Elsewhere in the report is a statement which may have relevance to primary preventionists:

The constituted objects of the Association are scientific, and this places it at a partial disadvantage in the maintenance of professional standards. Scientific men are predominantly schizoid, and while commonly energetic and at times heroic in the pursuit of personal aims and ideals, seldom exhibit the capacity for resolute common action which is observable in professional and more markedly in industrial groups. It is an open question whether the corporate resolution of a scientific group such as this one, without strong personal or professional interests at stake, can be counted on for effective opposition to the energy and resources which would be mustered by a colleague charged with misconduct and his professional life to fight for.

It might be supposed that primary preventionists would, by necessity, be attuned to the group or community level, but the diversity of backgrounds, values, goals, and activities may work against the formation of a shared sense of identity and common purpose necessary for " resolute common action" in this area.

Recognition of Need

A second condition necessary to the development of a formal system of ethical accountability is a shared recognition of the need for standards of behavior and ways of ensuring that those standards are met. Primary prevention in the area of human development, behavior, and experience is such a laudable, altruistic goal that it seems as if any efforts in that direction should be welcomed. To some (but by no means a majority of) primary preventionists, ethical lapses by those trying to lessen the occurrence of such phenomena as depression, mental retardation, violence, child abuse, homelessness, etc., might seem a small price to pay for preventive action in those areas, even smaller in contrast to the effects of so many people neglecting these causes of human suffering. But focusing on the supposed welfare of the many cannot freely justify the harm that may come to the few through ethical violations.

Moreover, it is the very worthiness of the goal -- the elimination of human suffering -- which tends to blind us to the possible harmful consequences of our well-intentioned behavior. We naturally tend to view our interventions from our own limited perspective as primary preventionists in terms of the consequences which we intend. Unintended harmful consequences may become more apparent if, on one hand, we move to various larger contexts or, on the other hand, if we examine the effects of our projects from the perspective of certain individuals. A formal system of ethical accountability that includes a set of explicit ethical principles can be useful in broadening our perspective and in increasing our awareness of the range and impact of unintended consequences.

It may be useful to cite two specific instances of strategies for primary prevention which might benefit from an examination from perspectives other than those implicit or explicit in the description provided.
The first instance is an eloquent defense of and authorization for the involuntary sterilization of Carrie Buck to prevent "mental in competence."

The judgment finds the facts that have been recited and that Carrie Buck " is the probable potential parent of socially in adequate offspring, likewise afflicted, that she may be sexually sterilized without detriment to her general health and that her welfare and that of society will be promoted by her sterilization," and thereupon makes the order. . . . We have seen more than once that the public welfare may call upon the best citizens for their lives. It would be strange if it could not call upon those who already sap the strength of the State for these lesser sacrifices, often not felt to be such by those concerned, in order to prevent our being swamped with incompetence. It is better for all the world if, instead of waiting to execute de generate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind. The principle that sustains compulsory vaccination is broad enough to cover cutting the fallopian tubes. . . . Three generations of imbeciles are enough. (Buck v. Bell, 1927)

This decision was written by Justice Oliver Wendell Holmes for the United States Supreme Court, upholding the sterilization law in the State of Virginia.

Buck v. Bell illustrates the dangers of embracing in principle a seemingly safe and effective preventive strategy (e.g., one that is " without detriment to her general health" as well as one that pro motes both "her welfare and that of society") without the careful examination from the full range of perspectives which systematic ethical review encourages. It also illustrates the dangers of embracing such a strategy in practice. Carrie Buck was already a mother to one child, the supposed " third generation of imbeciles." Yet the labeling of this child as an imbecile seems to have been an error (Kindregan, 1966). When she was one month old, the child was labeled by a Red Cross nurse as mentally defective. By the time she died of measles, she had graduated from second grade and had turned out to be quite bright.

The second instance is provided by the work of two Harvard professors (Mark & Ervin, 1970). They set forth a strategy for preventing violence. First, it would be necessary to develop ways of identifying potentially violent people. They hope that "psychological test scores" might be a promising avenue, and that studies "would give us a simple test to help predict accurately whether a given person has a dangerously low threshold for impulsive violence" (p. 158). Persons who score in the critical range on such psychological tests could then be treated before any episodes of violence could occur. "Improved techniques in behavior therapy" (p. 158) might be among the effective interventions. They set forth clearly the logic of their approach:

In other words, we peed to develop an "early warning test" . . . to detect those humans who have a low threshold for impulsive violence, and we need better and more effective methods of treating them once we have found out who they are. Violence is a public health problem, and the major thrust of any program dealing with violence must be toward its prevention -- a goal that will make a better and safer world for us all. (p. 160)

These two instances highlight an issue which is especially important in primary prevention. By its very nature, primary prevention tends to involve populations that are in some way "at risk." Once labeled "at risk," members of the population then may be the recipients of an intervention. But who is to make the judgment that certain people are indeed "at risk," and what methods will be used in making that judgment? Red Cross nurses (as in Carrie Buck's case) and psychological tests (as recommended by Mark and Ervin) have doubtless done much good for many people, and yet who among us wouldn't feel at least a little nervous when, for instance, we show up for second grade and find out that today we will be taking the "violence prediction test"?

When we are developing methods for assessment and intervention in the area of primary prevention, we may, by virtue of perspective, be less than optimally sensitive to the ethical implications of our work. A formal system of ethical principles and accountability can help us become more aware of other perspectives and unintended consequences. But first we must, as a community of primary preventionists (or people who aspire to primary prevention), recognize the need for such help.

Active Participation

If primary preventionists form an association in which they share a sense of identity and community and if the need for a system of ethical accountability is recognized and acknowledged, a third pre requisite is active participation. Such a system must be created by the members. All of us lead such busy lives, and the creation of a system of ethical accountability tends to loom as such daunting, unrewarding work, that it is tempting to wait. And wait. Surely someone will publish an ethical code soon. Perhaps a code from an existing professional association could be copied, with the words "primary prevention" to replace the activity of the other association.

Not only must a "critical mass" of members make a decision to participate actively in the creation of a formal system of ethical accountability, but there must also be a careful and honest determination of the resources necessary to develop, implement, and maintain the system. How much money must be budgeted? Is clerical staff support necessary? How much time will the participants need to devote to the system? And, not least important, what politics will be involved in the emergence of this system?
Any system of accountability will be weak to the degree that it lacks the participation of the full range of the association's member ship. It must represent the association's best efforts to formulate and enforce standards for itself. It is a form of self-regulation, of self-government. In discussing democracy as a form of self-government, Alinsky (1972) illuminates this requirement:

From the beginning the weakness as well as the strength of the democratic ideal has been the people. . . . The price of democracy is the ongoing pursuit of the common good by all the people. One hundred and thirty-five years ago Tocqueville gravely warned that unless individual citizens were regularly involved in the action of governing themselves, self-government would pass from the scene. Citizen participation is the animating spirit and force in a society predicated on voluntarism. (p. xxv)

Unless a full range of the association's membership is actively involved in the system of ethical accountability, the system itself will begin to generate resistance and resentment. It will be perceived by the nonparticipants as alien and intrusive even though it originated within the association. A small minority of the association cannot propose a system and expect it to gain automatic acceptance. The principles of consensus building, political persuasion, the sense of community participation, etc., are as relevant here as they are in the other activities of the profession.


What general issues would a formal ethics code for primary preventionists address? Redlich and Pope (1980; see also Pope, Tabachnick, & Keith-Spiegel, 1987; Borys & Pope, 1989) suggest seven general principles for applying some of the fundamental con tent of ethical codes across a variety of human service disciplines or professions. The first five are ancient and are found in, among other sources, the Hippocratic Oath. The sixth and seventh have been developed more recently, express the rights of the recipients of human services, and have not yet been universally accepted. These general principles are: (1) above all, do no harm, (2) practice only with competence, (3) do not exploit, (4) treat people with respect for their dignity as human beings, (5) protect confidentiality, (6) act, except in the most extreme instances, only after obtaining informed consent, and (7) practice, insofar as possible, within the framework of social equity and justice.

Do No Harm

Few if any primary preventionists would deliberately cause harm. And yet, life being so complex, none of us is free of causing harm in some ways, however unintended. The heart of this principle asks if all reasonable methods have been used to identify the hidden, the unexpected, the unintentional harm -- both direct and indirect -- which may occur as a result of a particular act or failure to act. To fulfill this principle, systematic methods must be developed for identifying such possible harm before it is produced (an approach familiar to primary preventionists).

The principle that interventions should cause no harm was obviously important in the Buck v. Bell decision, which emphasized that the intervention would not be detrimental to Ms. Buck's general health and would promote her welfare. Similarly, Mark and Ervin's approach is viewed by them as doing no harm. One of their colleagues reported on the success of psychosurgery to eliminate not only problems of violence but also loud and self-destructive behavior, apparently with no harm whatsoever. One of his case studies, presented in its entirety, follows:

A seven-year-old, mentally retarded child had sudden attacks of screaming, yelling, running and beating the head against the wall. The walls were actually indented by the blows. Following thalamotomy three years ago, the patient did not display the wild, aggressive and screaming behavior. The improved behavior was an enjoyment for both the child and the parents. (Staff of the Subcommittee on Constitutional Rights, 1974, p. 648)

In these instances, the main goal was accomplished (i.e., Carrie Buck had no more children and the seven-year-old boy ceased his distressing behavior), but harm might be found in the costs or side-effects. Yet the harm in interventions can also be more directly related to the failure to accomplish the goal. McCord (1978), for example, presented a 30-year follow up study comparing 253 men who had received treatment to prevent juvenile delinquency to 253 "matched mates" assigned to the control group. McCord described the origins of the program:

In 1935, Richard Clark Cabot instigated one of the most imaginative and exciting programs ever designed in hopes of preventing delinquency. A social philosopher as well as physician, Dr. Cabot established a program that both avoided stigmatizing participants and permitted follow-up evaluation. (p. 284)

Unfortunately, "none of the objective measures confirmed hopes that treatment had improved the lives of those in the treatment group" (p. 288). Moreover, those randomly assigned to the treatment group seemed to fare significantly worse than those in the control group.

The objective evidence presents a disturbing picture. The program seems not only to have failed to prevent its clients from committing crimes -- thus corroborating studies of other projects. . . -- but also to have produced negative side-effects. As compared with the control group,

1. Men who had been in the treatment program were more likely to commit (at least) a second crime.

2. Men who had been in the treatment program were more likely to evidence signs of alcoholism.

3. Men from the treatment group more commonly manifested signs of serious mental illness.

4. Among men who had died, those from the treatment group died younger.

5. Men from the treatment group were more likely to report having had at least one stress-related disease; in particular, they were more likely to have experienced high blood pressure or heart trouble.

6. Men from the treatment group tended to have occupations with lower prestige.

7. Men from the treatment group tended more often to report their work as not satisfying. (McCord, 1978, p. 288)

The methods used to identify possible harm will differ according to the population, the strategies of intervention being considered, and the problems being addressed. But four primary levels of
analysis may be crucially important in fulfilling this principle of not inflicting harm.

First, what are the possibilities for direct harm to the people being treated and to those indirectly affected (e.g., families, communities)? Did Carrie Buck and the seven-year-old boy, for example, foresee any harm in the interventions? Harm, of course, is not limited to physical damage. The emotional, developmental, interpersonal, educational, economic, employment, and a host of other aspects must be taken seriously. The methods developed for assessing potential damage must somehow transcend crucially limited perspectives. Those who are planning the intervention may, in their eagerness to get a project underway, deny, discount, or minimize any factors which might cause delays. Parents, neighbors, and others who associate with people who might be labeled as disruptive, deviant, or harmful, may be preoccupied with the anticipated relief at having such target populations "handled."

Second, if a particular community is the focus of an intervention, in what way could the community itself suffer harm through the intervention? For example, if a group of primary preventionists move into a community and set up programs to prevent certain phenomena (such as depression, violence, poverty), how might that intervention affect the social ecology of the community? How will it affect the natural leadership which has developed and is developing? How will it affect the community's social cohesiveness? How will it affect the community's sense of self-determination and ability to identify and address its own problems? If the group of primary preventionists differs significantly from the community in terms of such factors as social class, race, religion, politics, etc., what will be the effect upon the community?

Third, to what degree can we anticipate damage which might have a delayed onset? Almost by definition, primary preventionists are concerned with the future. "Seed projects" and similar interventions may be created which admittedly have little effect upon present conditions but which are designed to blossom sometime down the line. Problems can hopefully be prevented for second and third generations by virtue of interventions taken in the present. To the extent that such interventions are held to produce such long-term effects, it is reasonable to assume that harmful consequences may also be passed along to future generations.

Fourth, what effects which might be considered harmful could occur in the context of the community's relationship with the larger society? For example, a project might be planned to minimize the incidence of serious depression, anxiety, and impulsive behavior in an economically-disadvantaged neighborhood. Yet the disorders to be prevented might be viewed by others than those undertaking the project as a natural response to severe poverty. Attempting to eliminate such reactions to poverty might be a subtle, perhaps unintended form of social control, helping people to learn to adapt and adjust to desperate conditions. Such efforts may tend to "quieten" a community or "keep the lid on." They may hinder the community's ability to identify the true source of its suffering and take effective action.

One possible approach to taking seriously the effects of primary prevention projects on these four levels would involve the concept of zoning. We zone communities for a variety of reasons. Some communities zone out billboards for aesthetic reasons. Residential communities often zone out commercial enterprises (many of us would be distressed to return home to find that the neighbor on our left had just started a sheep farm and our neighbor on the right had opened an adult movie house and sensual encounter center). Perhaps this concept might make sense where primary prevention projects are being considered. Rather than simply moving into a community and setting up shop, a primary prevention team might announce their plans and then formally listen to the community's response before proceeding. This general approach was carried out in a very positive way in the Model Cities Program where specific zones were set aside for improvement efforts.

As part of this concept, something like a mandatory environmental impact report might be a prerequisite to beginning operations in any zone. Preventionists would formally discuss, in a systematic manner, the impact on all phases of community life. Certainly, if we are willing to delay huge projects in order to consider the habits, safety, and security of the snail darter, primary prevention projects can be delayed while a full investigation of their impact upon a community is carried out.

If such a "community impact report" (or "human impact report") were indeed seen as part of an ethical approach to primary prevention, it would be important that the committee which evaluates the impact report not be part of the organization which is advocating the project. The conflict of interest is apparent.

All four of these levels resist reflexive, simple solutions. The issues are complex and may seem overwhelming. When fully considered, they can exert an almost paralyzing sense that nothing can be done for fear of causing some harm somewhere, sometime. Yet their daunting nature cannot serve as an excuse for denying that they exist and deserve to be considered.

Practice with Competence

Practicing only with competence is a principle which tends to be recognized and embraced by a profession relatively late in its development. In the early, pioneering stages, new approaches and techniques -- many of them created and tried with enthusiasm and then quickly discarded when they prove to be unproductive -- form a quickly changing norm and there is no set of knowledge and skills which is generally recognized as a prerequisite to action.

Yet even without a formally agreed-upon set of special competencies, primary preventionists seeking to meet this standard can analyze a particular prevention or research project and identify the information and skills likely to be involved in the competent planning, initiation, management, and review of that project. Because primary prevention programs often focus on the community level, and because the ecology of the community is likely to involve economic, political, psychological, social, educational, religious, and other diverse aspects, a team approach is almost a necessity, each member of the team bringing complementary sets of competencies.

The challenges which must be faced in implementing such an ethical ideal include forming a consensus on what represents the body of knowledge for primary prevention, finding ways to deter mine who possesses the requisite expertise, and developing effective ways to surmount what seems dauntingly paradoxical: anticipating "unexpected" consequences.

The heart of this principle is the question: do the people who are implementing a project have the requisite expertise?

Do Not Exploit

The ways in which certain individuals and populations can be exploited by those who "know best" or "only want to help" are endless. As a purely hypothetical example, consider Professor Phame. His university is adjacent to one of the poorest neighbor hoods in the city. By almost any indicator, the residents of the community are desperate. The professor spends Tuesday and Thursday afternoons, and an occasional weekend, learning about the neighborhood. He visits community centers, churches, schools, bars, and homes, establishing trusting relationships so that he can learn the stories of the people who live there. He becomes a friend to many and, as the bond of trust deepens, learns " secrets" of the neighborhood which would not be apparent to the casual outsider.

One day Professor Phame disappears from the neighborhood. Some of the residents are concerned, wondering if something terrible has happened to him. Most are confident that he will soon return. He has become an important part of the community.

The professor's disappearance happens to coincide with the end of the spring semester. That summer he secludes himself in his summer home to write a book which will become a best seller: Secrets of Poverty and How They Can Be Solved. Many of the people in the neighborhood, upon which his book is based, cannot read, but if they could, and if they read his book, they would be surprised to find their life stories in full detail (though fictional names were used). The royalties from the book allow Professor Phame to pay off the mortgage on his summer home. The book tour enables him to visit several university campuses which he finds much more attractive than his current setting. He soon accepts a "moonlighting" consulting job for the Federal government advising them how the problems of poverty neighborhoods can be solved. He never quite finds the time to revisit his friends in the old neighborhood.

One of Professor Phame's recommendations to the government is to eliminate the type of center run by Ms. Monet. The center, originally part of a primary prevention project, houses a full-time staff of 20 who provide a variety of services to a neighborhood of extreme poverty. All 20 live in other parts of town, and make sure they are out of what is a very dangerous neighborhood before sundown. After its first year of operation, the program evaluation and community liaison aspects of the program were eliminated due to budget constraints. Over the last ten years, more and more of the staff's time has been devoted to desperate fund-raising to keep the center functioning. The funds come from federal, state, and local government, and from charitable foundations. As Executive Director of the Center, Ms. Monet has an annual salary of $68,000. The lowest-paid Center employee makes twice the mean annual income of the residents of the neighborhood.

Doubtless some will have no ethical qualms about the activities of either Professor Phame or Ms. Monet, while others will raise questions about potential or actual exploitation of the communities. The ethical principle of avoiding exploitation calls for a careful and disinterested examination of such issues.

Respect and Dignity

In one sense, all ethical principles can be seen as expressions of fundamental respect for the human dignity of others. But this principle places this concern in special focus.

Scrupulous attention must be paid those aspects of our education and training, of our institutional structures, of the language and content of our theories, research, and interventions which tend to diminish the degree to which we can appreciate, hold as fundamentally important, and respond appropriately to the full human dignity of others. When the people who are affected by our primary prevention strategies become primarily known as "research subjects," " populations-at-risk," variables whose behavior is influenced by environmental contingencies, case studies, etc., we may lose sight of the fact that they are all full human beings struggling with life just as we are.

The degree to which care and compassion are present in our interactions with those with whom we work is a crucial point. Sarason (1985), having explicitly defined clinical work to include " opportunities for prevention (primary, secondary, and tertiary)" (p. 6), stresses the importance of care and compassion in his discussion of clinical training issues.

On the surface, trainees accept the need for objectivity -- it does have the ring of science, and its importance can be illustrated with examples of the baleful consequences of "emotional over-involvement" -- but internally there is a struggle, as one of my students put it, " between what your heart says you should say and do and what theory and your supervisor say you should say and do." Many trainees give up the struggle, but there are some who continue to feel that in striving to maintain the stance of objectivity they are robbing themselves and their clients of something of therapeutic value. The trainee's struggle, which supervisors gloss over as a normal developmental phase that trainees grow out of, points to an omission in psychological-psychiatric theories. Those theories never concern themselves with caring and compassion. What does it mean to be caring and compassionate? When do caring and compassion arise as feelings? What inhibits or facilitates their expression? Why do people differ so widely in having such feelings and the ways they express them? It is, of course, implicit in all of these theories that these feelings are crucial in human development, but the reader would be surprised how little attention is given to their phenomenology and consequences (positive and negative). (p. 168)

Many of us were trained as clinicians in traditional programs. Unfortunately, some aspects of those programs may tend, however unintentionally, not only to discount caring and compassion but also to restrain friendliness and human spontaneity in their interactions with those whom they serve. Thompson (1950), for example, noted that

because of the stress on the unfortunate aspects of the analyst's involvement, the feeling grew that even a genuine objective feeling of friendliness on his part was to be suspected. As a result, many of Freud's pupils became afraid to be simply human and show the ordinary friendliness and interest a therapist customarily feels for a patient. In many cases, out of a fear of showing counter-transference, the attitude of the analyst became stilted and unnatural. (p. 107)

Fortunately, current programs in primary prevention training new practitioners and re-training former clinicians seem relatively free of such unfortunate constraints.


The issue of confidentiality is particularly important for primary preventionists because the nets cast by their projects tend to be so wide and to involve so many people. Often the kind of information collected is extremely sensitive (e.g., deeply personal information about individuals; potentially damaging information about individuals or groups who are supposedly at risk for depression, violence, child abuse, etc.).

The first task is to identify the sorts of information which are or ought to be treated as confidential. The second is to check carefully any legislation or case law which might govern confidentiality. For example, are school records, membership lists of various civil and religious organizations, personal information obtained through interviews by primary preventionists, and participation in primary prevention programs (to prevent child abuse, alcoholism, violence, depression, etc.) considered confidential through legislation or case law? The third is to make sure that all involved clearly understand the boundaries between what is and isn't confidential. The fourth is to develop effective mechanisms for handling documents to ensure their confidentiality. And the fifth is to develop procedures (including training procedures) to guard against the accidental disclosing of confidential information through casual conversation or at times when one is likely to be "off guard."

The final task is particularly important in light of recent research indicating that over half (62%) of clinical psychologists acknowledge having unintentionally disclosed confidential data (Pope, Tabachnick, & Keith-Spiegel, 1987; see also Pope & Vasquez, 1999; Pope & Vetter, 1992).

Acting Only With Informed Consent

The legal and ethical right of individuals to informed consent to treatment or informed refusal of treatment has become well established in assessment and treatment interactions in which there is a clearly defined "patient" or "client." The legal and ethical rights regarding informed consent of individuals who are part of a larger community which will be the recipient of primary prevention efforts have not yet evolved clearly.

Even if a form of the "community impact report" described above were utilized and a majority of the community welcomed the intervention, what ethical rights do the minority (those who dissent from the majority position, who want no part of the project, who do not want the intervention to disrupt the ecology of the community and their individual lives) have?

Relevant to the issue of agreement or disagreement about goals is the landmark article on "baby steps toward primary prevention" (Cowen, 1977). Cowen explores the problems which clinicians and primary prevention professionals have in agreeing upon what goals are to be achieved. And yet he maintains that there are a few goals upon which almost everyone should be able to agree. The first two, for example, are adjustment and adaptation.

Yet even in the cases of these "general agreement" goals, are we not ethically responsible for examining the implications of what we're asking people to adjust and adapt to? What are the values implicit in this adjustment and adaptation? What are we influencing people to give up and to move toward, and at what personal and social costs? Some methods must be developed for ensuring that the individual's right "to be left alone" is given due weight.

The principle of informed consent affirms an individual's right to understand a proposed intervention and then to give or refuse consent freely. Primary preventionists face considerable difficulty in respecting this principle when an intervention involves a community. The minority in the community who are opposed to the intervention may nonetheless be subjected to the indirect effects of the project. Methods of recognizing and weighing the rights of these individuals must be developed.

Promoting Equity and Justice

At a minimum, efforts toward primary prevention must not directly affirm or contribute to inequality and injustice. But a truly ethical approach must go beyond the minimum. Does the project actively promote equity and justice? Alinsky (1972) emphasizes this concept.

My aim here is to suggest how to organize for power: how to get it and use it. I will argue that the failure to use power for a more equitable distribution of the means of life for all people signals the end of the revolution and the beginning of the counterrevolution. (p. 10)

As with the other ethical areas, there are no simple answers which are useful. If, for instance, a project has as its goal the empowerment of a neighborhood, an unanticipated result may be that the residents, once empowered, may use that power to enforce discrimination against others. Thus the primary preventionists may be caught in a clash of competing values: self-determination vs. social justice.

Ethical Accountability

A formal and explicit ethical code cannot provide answers to such questions. What it can do is to ensure that we do not deny or discount such dilemmas, and that we do not spare any effort to resolve them carefully, practically, and constructively. An ethics code is not a conclusion and set of answers but rather a starting point and a guide.


Thinking through these substantive issues lays the groundwork for developing a system of professional ethics for primary preventionists. The creation of a useful and effective system of ethical accountability involves at least three major processes.

The Creation and Revision of Standards

An initial set of standards and the subsequent revisions should, as mentioned earlier, draw upon the experience and expertise of as many members of the association as possible. The approach of the American Psychological Association (APA) is a useful model. APA began by surveying its membership, asking them to describe ethical dilemmas they had encountered in their own work and the ways they had gone about addressing these issues (Pope & Vasquez, 1999; Pope & Vetter, 1992). Using an empirical, inductive, critical-incident, content-analysis approach, an initial comprehensive and detailed set of ethical standards was developed (American Psychological Association, 1953). General guidelines were derived from this initial code (American Psychological Association, 1959). Subsequent revisions leading to the current code were then formulated.

An association of primary preventionists might begin by conducting a similar survey of its membership. And yet the APA model neglects a potentially valuable source of information: those who are recipients of primary prevention efforts. A thorough approach might include surveying --through questionnaires, interviews, etc. -- those who reside in various communities which have been the focus of diverse primary prevention projects. What misgivings, concerns, regrets, disappointments, injuries, etc., did the consumers experience or fear? What ethical issues can they identify? Once these cases have been gathered and organized, they might be submitted to ethicists in various fields for review, to see if additional issues could be identified. The database could then serve as a basis for the creation of an ethical code.

Implementing the Standards

It is here that the models of other associations, such as the American Psychological Association, may be less helpful. The attention of the APA Ethics Committee is primarily devoted to adjudicating complaints against APA members. Some attention is also devoted to issues of education and prevention, but -- despite intentions -- the work which directly addresses the primary prevention of unethical behavior is relatively rare.

By the nature of their interests and day-to-day work, primary preventionists are aware of the importance and benefits of preventing misfortune, if at all possible, rather than waiting for it to occur and then attempting alleviation through crisis intervention, remediation, rehabilitation, etc. The individuals, committees, and activities of an association of primary preventionists must develop effective methods for intervening, where possible, prior to the occurrence of un ethical behavior. What the association attempts to do for others (prevention of harmful occurrences) it must also attempt to do for itself, developing and drawing upon its expertise in this area.

Program Evaluation

A third crucial aspect of the process of implementing ethical standards is program evaluation. Comprehensive and explicit methods must be developed to monitor the degree to which the efforts in this area are helpful, hurtful, or simply irrelevant. As rigorous and sophisticated monitoring methods evolve, objective data become available for assessing the impact of the specific primary prevention programs as well as the formal system of ethical accountability. What is learned from this monitoring can then be used to improve the ethical standards themselves, the ways in which the association seeks to implement them, and the primary prevention strategies used by the profession.


Human service workers generally acknowledge the importance, benefits, and perhaps even necessity of primary prevention. But all too often the acknowledgement does not lead to action. As Sarason (1985) notes: "The fact is that in practice, and the ways clinicians are prepared for practice, the preventive stance is conspicuous by its absence" (p. 202). The challenge to primary preventionists is to avoid placing ethical accountability in the same debilitating category: universally affirmed "in principle" but conspicuously absent in practice.



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