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ETH2228 - SECTION 6: BEST PRACTICE MODELS OF ETHICAL DECISION MAKING (PART 1)

From the previous review of the different codes it is clear that attempting to resolve ethical dilemmas in social work or counseling practice will generally result in resolutions that are more gray than black and white, it is therefore important for clinicians to have a decision making process at which they are skilled to resolve the dilemmas that they will encounter, sometimes on a daily basis.

This course will now present a number of ethical decision making modes, covering current and best practices strategies from the social work and counseling arena, as well as from the private business sector. It is less important and relevant which of these approaches a clinician uses. What is most important is that the clinician choose one of the best practices models, apply it with integrity and skill, and carefully document their work.

Trainees may print out each of these models by clicking on the "Print this Page" button on the right side of the page.

Elaine Congress ETHIC Model of Decision Making

In her article, What Social Workers Should Know About Ethics: Understanding and Resolving Practice Dilemmas, (Advances in Social Work Practice, Vol. 1 No 1 Spring 2000, pgs 1 – 25), Congress discusses the major tenets of the newly revised NASW Code of Ethics.

In addition to her review, Congress also presents the ETHIC model of decision making: “This easy to use five step process includes examining personal, agency, client, and professional values, thinking about ethical standards and relevant laws, hypothesizing about consequences, identifying the most vulnerable, and consulting with supervisors.” This model, described in more detail below, is meant to be a quick and as effective as possible approach to resolving ethical dilemmas.

E – Evaluate relevant personal, societal, agency, client and professional values

T – Think about what ethical standard of the NASW Code of Ethics applies, as well as relevant laws and case decisions

H – Hypothesize about possible consequences of different decisions

I - Identify who will benefit and who will be harmed in view of social work’s commitment to the most vulnerable

C – Consult with supervisor and colleagues about the most ethical choice


Congress, Elaine P., What Social Workers Should Know About Ethics: Understanding and Resolving Practice Dilemmas, Advances in Social Work Practice, Vol. 1 No 1 Spring 2000, pgs 1 – 25

Model II: American Counseling Association Approach to Ethical Decision Making

In its statement of purpose, the ACA Code of Ethics states that counselors are expected to use a credible decision making approach to resolving dilemmas:

“When counselors are faced with ethical dilemmas that are difficult to resolve, they are expected to engage in a carefully considered ethical decision-making process. Reasonable differences of opinion can and do exist among counselors with respect to the ways in which values, ethical principles, and ethical standards would be applied when they conflict. While there is no specific ethical decision making model that is most effective, counselors are expected to be familiar with a credible model of decision making that can bear public scrutiny and its application.”

A Practitioner’s Guide to Ethical Decision Making (2006) developed by Holly Forester-Miller and Thomas Davis for the American Counseling Association presents an ethical decision making model for ACA members. This model is summarized below.

ACA Ethical Decision Making Model

1. Identify the problem.
2. Apply the ACA Code of Ethics.
3. Determine the nature of the dimensions of the dilemma.
4. Generate potential courses of action.
5. Consider the potential consequences of all options, choose a course of action.
6. Evaluate the selected course of action.
7. Implement the course of action.

Forester-Miller and Davis conclude that: “It is important to realize that different professionals may implement different courses of action in the same situation. There is rarely one right answer to a complex ethical dilemma. However, if you follow a systematic model, you can be assured that you will be able to give a professional explanation for the course of action you chose.”

Citing Van Hoose and Paradise (1979) they go on to say: “a counselor ‘is probably acting in an ethically responsible way concerning a client if: (1) he or she has maintained personal and professional honesty, coupled with (2) the best interests of the client, (3) without malice or personal gain, and (4) can justify his or her actions as the best judgment of what should be done based upon the current state of the profession.’”

Forrester-Miller, H. and Davis, T. (1996). A practitioner’s guide to ethical decision making. Alexandria, VA. American Counseling Association.

Van Hoose, W. H. and Paradise, L.V. (1979). Ethics in counseling and psychology: Perspectives in issues and decision-making. Cranston, RI: Carroll Press.


Model III: Essential Steps for Ethical Problem-Solving – Frederic Reamer and Sr. Ann Patrick Conrad

The following approach, discussed by Reamer and Conrad, was included in a video developed by the NASW Office of Ethics and Adjudication and produced by NASW Press and the NASW Insurance Trust as a tool for use by practitioners, faculty members and students, agency administrators, and licensing boards.

1. DETERMINE whether there is an ethical issue or/and dilemma. Is there a conflict of values, or rights, or professional responsibilities? (For example, there may be an issue of self-determination of an adolescent versus the well-being of the family.)

2. IDENTIFY the key values and principles involved. What meanings and limitations are typically attached to these competing values? (For example, rarely is confidential information held in absolute secrecy; however, typically decisions about access by third parties to sensitive content should be contracted with clients.)

3. RANK the values or ethical principles which - in your professional judgment - are most relevant to the issue or dilemma. What reasons can you provide for prioritizing one competing value/principle over another? (For example, your client's right to choose a beneficial course of action could bring hardship or harm to others who would be affected.)

4. DEVELOP an action plan that is consistent with the ethical priorities that have been determined as central to the dilemma. Have you conferred with clients and colleagues, as appropriate, about the potential risks and consequences of alternative courses of action? Can you support or justify your action plan with the values/principles on which the plan is based? (For example, have you conferred with all the necessary persons regarding the ethical dimensions of planning for a battered wife's quest to secure secret shelter and the implications for her teen-aged children?)

5. IMPLEMENT your plan, utilizing the most appropriate practice skills and competencies. How will you make use of core social work skills such as sensitive communication, skillful negotiation, and cultural competence? (For example, skillful colleague or supervisory communication and negotiation may enable an impaired colleague to see her/his impact on clients and to take appropriate action.)

6. REFLECT on the outcome of this ethical decision making process. How would you evaluate the consequences of this process for those involved: Client(s), professional(s), and agency (ies)? (Increasingly, professionals have begun to seek support, further professional training, and consultation through the development of Ethics Review Committees or Ethics Consultation processes.)

From discussion by Frederick Reamer & Sr. Ann Patrick Conrad in Professional Choices: Ethics at Work (1995), video available from NASW Press, Retrieved 1/21/08 from: http://www.socialworkers.org/pubs/code/oepr/steps.asp


Model IV: Steinman, Richardson and McEnroe Ethical Decision-Making Process

The Ethical Decision-Making Manual for Helping Professionals, by Steinman et al. states that before you can begin a decision making process you need to identify the problem. Once the problem is identified, their model includes the following steps:

Step 1: Identify the Ethical Standard Involved
- What are the codes or laws that apply? If there are none, then why is it a problem?

Step 2: Determine the Ethical Trap Possibilities
- Possible Ethical Traps to avoid include:
a. a belief that there is an easy “commonsense, objective” solution
b. conflicting values, such as between personal or religious values and professional values
c. the circumstances are so unique they must be taken into consideration, and
d. confusion about who will benefit from a decision

Step 3: Frame a Preliminary Response
– What do the code and the law say you should do; what circumstances, if any, should influence the response; and what is your preliminary response?

Step 4: Consider the Consequences
– What will happen if you take that action? What are the short and long term consequences? Could there be any unintended consequences? Are the consequences ethically defensible?

Step 5: Prepare Ethical Resolution
a. What is the situation, including possible relevant circumstances?
b. What ethical codes or laws are involved?
c. What do these codes or laws suggest I or others do?
d. If I have consulted with colleagues, supervisors, or professional ethics boards, at this point, what do they suggest I or others do?
e. What are the consequences of taking this action on the client, on me, on my employer, and on others in the community?
f. In light of these considerations, here is what I propose…….

Step 6: Get feedback
– Discuss with your supervisor, respected peer, and/or attorney if legal issues involved

Step 7: Take Action
– Use feedback to amend the resolution as needed and then take action.

Steinman, Sarah, Richardson, Nan Franks and McEnroe, Tim, The Ethical Decision-Making Manual for Helping Professionals, Brooks/Cole Publishing Company, New York, 1998


Model V: Dolgoff, Loewenberg and Harrington – A General Decision Making Model

In presenting his model for making ethical decisions, Dolgoff states that “Ethical decision making is far too complex to permit the development of a simple “how-to” problem-solving model…… A model is a permissible didactic devise as long as it is understood that in real life every decision is preceded and followed by other decisions, many of which have a direct bearing on the matter under consideration.” (pgs. 57 – 58)

A General Decision-Making Model

Step 1. Identify the problem and the factors that contribute to its maintenance

Step 2. Identify all of the persons and institutions involved in this problem, such as clients, victims, support systems, other professionals and others

Step 3. Determine who should be involved in the decision making

Step 4. Identify the values relevant to this problem held by the several participants identified in Step 2, including the client’s and worker’s

Step 5. Identify the goals and objectives whose attainment you believe may resolve (or reduce) the problem

Step 6. Identify alternate intervention strategies and targets

Step 7. Assess the effectiveness and efficiency of each alternative in terms of the identified goals

Step 8. Select the most appropriate strategy

Step 9. Implement the strategy selected

Step 10. Monitor the implementation, paying particular attention to unanticipated consequences

Step 11. Evaluate the results and identify additional problems

To assist social workers using Dolgoff’s Decision Making Model, he offers the Ethical Assessment Screen to “help social workers further clarify and integrate the ethical aspects of decision making in social work practice.” (pg 58)

Ethical Assessment Screen

1. Identify your own relevant personal values in relation to this ethical dilemma
2. Identify any societal values relevant to the ethical decision to be made
3. Identify the relevant professional values and ethics

What can you do to minimize conflicts between personnel, societal, and professional values?

4. Identify alternative ethical options that you may take
5. Which of the alternative ethical actions will protect to the greatest extent your client’s and others’ rights and welfare?
6. Which alternative action will protect to the greatest extent possible society’s rights and interests?

What can you do to minimize conflicts between your client’s, others’ and society’s rights and interests?

7. Which alternative action will result in your doing the “least harm” possible?
8. To what extent will alternative actions be efficient, effective and ethical?
9. Have you considered and weighed both the short and long term ethical consequences?

Ethical Rules Screen

With the Ethical Rules Screen, Dolgoff provides a step to help social workers understand that the Code takes precedent over their own personal values. This concept is relevant to counselors and marriage and family therapists, as well.

A social worker who has done an ethical self- assessment, such as the one provided above, will have a better appreciation of the values they hold that are personal versus those that they hold as a professional. The Ethical Rules Screen suggests that if one or more provisions of the Code apply, the Code should be followed.

If the Code does not cover the specific issue or if conflicting provisions of the Code apply, Dolgoff offers the social worker a way to rank the provisions of the Code as they apply to that particular situation in the Ethical Principles Screen provided below. Since the NASW Code of Ethics does not place any one particular value, principle or standard above another and recognizes that there will be reasonable differences of opinion, it is important that social workers attempting to apply any decision making model have a justifiable approach for how they have ranked the principles.

Ethical Rules Screen

Examine the Code of Ethics to determine if any of the Code rules are applicable. These rules take precedence over the worker’s personal value system.

If one or more of the Code rules apply, follow the Code rules.

If the Code does not address the specific problem, or several Code rules provide conflicting guidance, use the Ethical Principles Screen.

Ethical Principles Screen (EPS)

1. Protection of life
2. Equality and inequality
3. Autonomy and freedom
4. Least harm
5. Quality of life
6. Privacy and confidentiality
7. Truthfulness and full disclosure

Dolgoff, Ralph, Loewenberg, Frank, and Harrington, Donna, Ethical Decisions for Social Work Practice, Brooks/Cole – Thompson Learning, Belmont, CA, 2005


A Six-Stage Model for Ethical Decision Making

In yourceus.com's introductory course on ethical decision making: Ethical Decision Making: A Primer for Mental Health Clinicians, a six-stage model was introduced that integrated and expanded on many of the components of the ethical decision making models presented so far.

This model was designed to clarify the steps or stages involved in making a good decision, and expand on information about how a clinician can make informed decisions about how to weigh various principles and interests that conflict in complex ethical dilemmas. This section will be concerned with looking at these stages and principles in some detail.

The Steps or Stages of the Ethical Decision Making Process

The Knowledge Stage

The Identification Stage

The Evaluation Stage

The Selection Stage

The Assessment Stage

The Adaptation Stage


Stage One: The Knowledge Stage

The first stage is the knowledge stage. It begins before you are faced with the ethical decision. This is the stage that appears to be omitted from many of the other models that describe a sequence of steps, yet it is in some ways the most important aspect of the ethical decision making process. As is implied by the name, this stage is concerned with knowing a number of things that are involved in clinical practice and in the ethical decision making process. Below are listed the items that must be known by every clinician.

Knowledge Stage: What Clinicians Must Know

Key expert clinical knowledge
Key expert ethical knowledge
Oneself, including one's biases, prejudices, and blind spots
Codes of ethics
Who the client is and when the client is a client
Competing ethical principles and interests
Ethical decision making models
What the mission and goals of treatment are
How to use professional authority
Distinctions between the Legal, Ethical, Moral realms of practice
Legal codes related to privacy and confidentiality, such as Federal Law 42 CFR part 2, 34 C.F.R. Part 99; and HIPAA regulations, the Hi-Tech Act of 2010 and the Final Omnibus Rule of March 2013
State statutes on reporting responsibilities for suicidality, homicidality, child and elder abuse
Other laws and statutes related to clinical work, e.g., with minors and multiple clients


There will be two items of importance that will be addressed from the list above. First, in order to practice ethically, a clinician must know one's self: one's biases and prejudices, one's blind spots and trouble spots, and situations in which self-interest will make it hard to make the right ethical choices.

Apart from not fully understanding the code of ethics, this area is the most likely to cause the clinician to make poor ethical decisions. Clinicians, like all other people, will at times be confronted by their own tendencies to engage in decision making based upon their emotional needs and impulses, instead of a full and clear reckoning of the issues involved.

The call of self-interests clouds good judgment, whether the call is set in motion by one's attraction to a client, the promise of improving one's financial situation, a need to avoid the discomfort of looking outside one's own value system, or fatigue and burn out. Clinicians are intimately involved in the business of helping other people come to know themselves, bringing forth clarity out of the confusion. This same process of seeking clarity must be turned on oneself if the clinician wishes to work at the highest level of ethical decision making.

The second item that will be covered will concern the competing interests and principles. We will return to this after we address the other stages of the ethical decision making process.

Stage Two: The Identification Stage

The second step or stage is the identification stage. There are three important things to identify in this stage: 1) who the client is; 2) the various ethical principles and interests in operation within the actual situation that is before the clinician; 3) potential options for solving the problem.

Stage Three: The Evaluation Stage

The evaluation stage is next. It is concerned with taking the principles and interests that have been identified as being at stake in the situation, and evaluating which are the most important to consider. This will incorporate knowledge of the codes of ethics, and understanding of the principles and interests themselves. As noted, we will examine the principles and interests later in this chapter.

The evaluation stage is also concerned with evaluating the options for resolving the situation. There may be a limited number of options available to the clinician, as is the case in many counseling situations. In other cases, there may also be a great number of possible solutions to the ethical problem. The more options that are available, the more work is required of the clinician to evaluate each option fully.

However, it is also true that the more options the clinician examines, the wider is the range of possibilities for finding an option that offers the best balance of all the principles and interests at stake, including those which support and protect the interests of the clinician.

There is a series of tests of moral perspectives that should be performed during the evaluation stage, tests that view the ethical decision from a number of different angles. We have noted these below:

Fairness Test – Is the ethical decision fair to all involved parties?
Ethical Principles Test - Is the ethical decision consistent with the most important ethical principles?
Universality Test – Is the ethical decision right from the point of view of universally held values?
Light-Of-Day Test – If the ethical decision were to be known by family, friends, colleagues, or printed in the newspaper, would you be comfortable with the decision that had been made?
Consequentialist Test – Which ethical decision will create the best consequences or results?

In the evaluation stage, it is important that the clinician be completely clear about how his or her personal self-interests, biases, emotional reactions and blind spots are being factored into whatever options are being considered. Where such clarity does not exist, it is often helpful for the clinician to seek a consultation from another trusted professional, who can lend an objective perspective on the situation.

In still other instances, it must be determined whether the client can and/or should be brought into the process of evaluating the ethical situation. While this is not an invitation to transfer responsibility for these difficult decisions to the client, the client's input can often be helpful in keeping clear the real potential outcomes from some of the decisions to be made.

This can be particularly complicated in situations in which the client comes from a culture other than the dominant culture. Ethical codes, which are connected to legal and moral systems of belief in complex ways, have arisen from ideas and beliefs that hold sway in Western culture.

While professional codes of ethics make note of the need to consider cultural difference in clinical work, there are times when the clinician will be forced to choose between respecting the client’s cultural values and beliefs, and operating in a way that is consistent with their own profession’s code of ethics and the ethos from which that code arises.

This issue represents one of the most difficult areas within the arena of ethical decision making and cannot be covered in full detail here. For clinicians who wish to engage in a fuller examination of this subject, we recommend yourceus.com’s course entitled, “Cultural Diversity, Value Conflict and Complex Ethical Decision Making for More Senior Clinicians”.

Stage Four: The Selection Stage

The fourth stage or step is the selection of the best option or solution, and the putting of the option or solution into effect. If the clinician has selected well, the choice will hopefully operate effectively in the real world. To assure that this is the case, the clinician will continue this process with the two final stages.

Stage Five: The Assessment Stage

The fifth stage is the assessment stage, in which the clinician assesses the real life effects of the selection that has been made to solve the ethical dilemma. The real life effects must be evaluated both from the perspective of the clinician and the ethical obligations the clinician holds, and from the perspective of the client, whose life will be affected by the ethical choice that has been made.

If the results or consequences of the selection have not led to the anticipated resolution of the problem, the clinician moves to the last stage or step of this process.

Stage Six: The Adaptation Stage

The last stage of this process is the adaptation stage. In this stage, the clinician will look to adapt the selection or solution of the ethical dilemma by refining it, or by returning to the evaluation and selection stages to find and choose a better solution.

With this section completed, we will now turn to an examination of the principles and interests at stake in the decision making process.

The Principles and Interests Involved in Ethical Decision Making


The First Principle: Do No Harm

Evaluate whether the decision will either bring direct harm to the client, or insufficiently protect the client or the public from harm.

In order of importance:
1) Does the decision threaten the life or physical safety of the client or others?
2) Does the decision threaten the client with profoundly damaging and non-therapeutic emotional consequences?
3) Does the decision threaten the client with life altering and irreversible social, material or monetary hardships?
4) Does the decision exploit the client in ways that harm his/her well being?

If the degree of harm is too great, it outweighs all other considerations and determines your ethical course to follow.


The Second Principle: Protect the Integrity of the Profession

Evaluate whether the decision will harm or preserve the integrity of the counseling profession.

1) Does the decision harm the professional or ethical reputation of the mental health professions?
2) Does the decision harm the capacity of other mental health professionals to perform their tasks successfully?
3) Does the decision hinder the larger public from profiting from the benefits of the mental health profession?

Elements of Protecting the Integrity of the Profession

No inhumane or discriminatory treatment towards groups or persons.

No dishonesty, fraud, deceit, or misrepresentation while performing professional activities.

No exploitation, sexual or otherwise, of clients, trainees, or students.

No practicing under the influence of non-prescribed drugs or alcohol.

No practicing outside one's area of competence.

No misuse of personal or professional relationships either to solicit clients, or request fees for making referrals.

No participating in dual relationships that create conflicts of interest that harm the client or compromise the counseling.

No continuing a treatment relationship when it is clear that the treatment is no longer helpful to the client.

No allowing an individual or agency that is paying for services to influence treatment decisions to the detriment of the client.

No making claims or guarantees that promise more than the counselor can realistically provide.

No withholding information about treatment alternatives that are different from those practiced by the counselor.

No misuse of confidential information.


The next two principles that should be looked at in evaluating any ethical decision are considered at almost the same time, and are accorded just about the same weighting in the decision making process.

The Third Principle/Component One

Evaluate whether the decision serves to promote or hinder autonomy in the client.

1) Does the ethical decision include involving the client in important decisions at all times, an important consideration called "informed consent"?
2) Does the ethical decision include consideration for the values, goals, needs, wants, ideas, and choices of the client at least equal to consideration for the same items of the counselor?
3) Does the ethical decision promote increased responsibility for the client, except where such responsibility may harm the client?


 

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