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In'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’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?

Elements of Protecting the Autonomy of the Client

No formulating treatment decisions, plans or goals without the participation and informed consent of the client.

No engaging in treatment with foreseeable risks without informed consent for the client of those risks.

No charging a fee for anything without informed consent for the client in advance of the fee.

No taking action for nonpayment of fees without advising the client first and providing an opportunity to settle the debt.

Except in those instances excepted by law, no releasing of confidential information without obtaining a release.

No recording counseling sessions without written, informed consent.

The Third Principle/Component Two

Evaluate whether the decision serves to promote the well being of the client and/or advance the course of treatment.

1) Does the decision promote the physical/emotional/spiritual health and well being of the client?
2) Does the decision help the client to reach the agreed to treatment goals?
3) Does the decision protect the integrity of the therapeutic relationship and the treatment process?

The Fourth Principle

Evaluate whether the decision serves to promote the well being and autonomy of the clinician.

While the primary purpose for the clinician to engage in counseling may be to take care of his or her self-interests, from the point of view of the state and the mental health professions, the well being of the clinician will be considered a secondary purpose, not a primary one.

This is to say that when there is a conflict between the needs and interests of the clinician, and the well being of the client or the integrity of the profession as a whole, there will tend to be more weighting on the side of the well being of the client than on the well being of the clinician.

The principles form a kind of flow chart, where the clinician begins by analyzing the first principle, working his/her way down towards the fourth principle, as shown below:

First Principle: Best interests and welfare of the client: At the very least, do no harm

Second Principle: Responsibilities of the clinician to the integrity of the profession

Third Principle, part 1) Autonomy of the client, including the right to make decisions and the responsibility for decisions made

Third Principle, part 2) Best interests and welfare of the client: Promote growth

Fourth Principle) Autonomy and best interests of the clinician, including the right to make decisions

Foundation Element Underlying Process: The responsibilities of the clinician towards the client, including the obligations agreed to concerning the counseling relationship

The responsibilities not to bring the client harm (First Principle) are most heavily weighted the greater the degree of harm with which the client is threatened.

As the potential harm that can come from the decision decreases, the clinician can pay attention to other ethical issues, beginning with the protection of the integrity of the counseling profession (Second Principle).

As the threat to the integrity of the profession decreases in the decision, then the clinician pays increasing attention to the autonomy of the client (Third Principle, part 1) and the promotion of the well being of the client (Third Principle, part 2).

When the most important concerns about the client's autonomy and promotion of the client's well being are less involved in the ethical decision, then the clinician can look to his or her own well being, and his or her own autonomy (Fourth Principle).

The clinician's responsibilities towards the client and towards the profession as a whole overlie the entire ethical decision making process.

When a clinician is presented with an extreme example of one of these interests or principles at a decision making time, it will usually lead to a fairly easy and straightforward decision. Other times - most times - things will not line up so conveniently. It is in the subtle details, the degrees, the grey area of ethics, that the counselor is presented with his or her most difficult decisions.

For trainees who would like further description of this model, please refer to's introductory course on ethical decision making: Ethical Decision Making: A Primer for Mental Health Clinicians