ETH5559 - SECTION 2: EXAMINATION OF SCENARIOS
21ST CENTURY MENTAL HEALTH ETHICS
by Charles D. Safford, LCSW
Charles D. Safford, LCSW is President of yourceus.com, Inc., with guidance and input from other senior yourceus.com, Inc. course developers and from NASW GA. Mr. Safford has over 20 years of post-master’s experience as a clinician, and has over fifteen years of experience as a training developer and trainer in business and clinical settings. A live version of this course was presented at the 2001 annual conference of NASW GA.
This course is the copyrighted property of yourceus.com and may not be copied in part or in entirety without the express written permission of yourceus.com. For information on how to secure permission to use this course or any part of this course, contact us at: firstname.lastname@example.org.
The objective of this introductory course on ethics is to help the mental health clinician understand the key components of the process of making ethical decisions, using a number of scenarios to highlight some of the common ethical dilemmas that clinical professionals are likely to face. When the trainee completes this course, he or she will know:
-The principles of ethical decision making
-The steps and stages of making an ethical decision
-What principles and interests are being balanced when making an ethical decision
-How these principles and interests work in the complex relationships that are created when a clinician works with clients
This course is primarily designed for clinicians early in their career, or for clinicians reviewing basic concepts of ethical decision making.
5 contact hours: Ethics
Section I: Introduction
There are three questions to be answered as an introduction to this course.
What are ethics?
Why do clinicians need them?
Why do clinicians need to study them?
The first question is the easiest to answer. As defined by the American Heritage Dictionary:
"Ethics are the study of the general nature of morals and the specific moral choices to be made by the individual in his relationship with others."
Morals are concerned with what is right and what is wrong. Therefore, generally speaking, ethics are concerned with right and wrong behaviors in your dealings with other people. In fact, most states have ethical codes that describe various right and wrong behaviors for clinicians to follow when they are dealing with their clients, their peers and other parties with whom they interact.
The second question is a little more complex. Not all professions have formal codes of ethics, and not all professionals face such serious consequences for violations of their code of ethics. What is different about mental health clinicians, and why is it so important for them to have a clear code of ethics that is understood and followed?
The mental health profession is different from most other professions in several important - and connected - ways:
-The nature of counseling is such that great and lasting harm can be done to clients if the clinician engages in the wrong behaviors.
-Because harm can be done to clients, most states restrict the mental health profession. The only people who can practice are those who meet certain criteria and follow certain guidelines.
-The capacity to do harm exists side by side with the capacity to do good. The mental health profession is defined - and thus sanctioned - as a profession whose primary purpose is to promote the well-being of its clients and the public at large, not to take care of the personal or financial well-being of the clinician.
This is different than most businesses. For most businesses, the primary responsibility is to take care of the financial well-being of the business and its stakeholders. In most businesses, the well-being of the client does not really come first. Companies may lose customers for not looking out for the interests of the client, but they will not lose their right to engage in that business. Clinicians can.
This speaks to a fundamental conflict that not only affects the study of ethics, but, more importantly, affects the practice of ethics. In a situation where there is ethical conflict, how much does the clinician need to put aside his or her own interests, including the right to follow one's own values and principles, in order to sufficiently take care of the best interests of the client and the public?
Later in this course, in the presentation of the ethics scenarios, many clinicians will not only see this conflict, but will also feel its effects on their own ethical decision making processes. Even clinicians who feel they have a clear understanding of ethics, can find themselves in very confusing territory.
Because states and the various mental health professions work together to oversee the definition of who can practice counseling, they also involve themselves in the clarification process around this important issue. In fact, the states continue to clarify new understandings about what constitutes ethical behavior, and make demands upon clinical professionals to know these changes and apply them in their practice.
In addition to making these demands, the state and its sanctioning bodies, like state licensing boards, also acknowledge the different nature of the clinician's job by conferring certain special rights and privileges to the clinical professional. The first special right has already been discussed. It is the right to practice as a licensed clinician, with the state acting as a kind of guarantor of the clinician's training, skills, experience, and ethical orientation.
In essence, the state says that the licensed clinician can be trusted because he or she has fulfilled a certain set of standards and has agreed to act in certain ways that protect the safety of his or her clients and the public at large. If the clinician does not meet these standards, or does not act in ways that protect the safety of clients or the public, the state can take away the clinician's legal right to practice.
The second right that is usually given to the clinician is the right to maintain privileged information, in the same way and with largely the same expectations as are granted to doctors, lawyers and clergy. This right has an important purpose: it allows clients to trust the clinician in handling important, and sometimes compromising, information.
The state has a stake in creating this trust, because confidentiality allows the goals and tasks of counseling to proceed in a more effective way. But the state again becomes the guarantor of the client's trust, saying that the clinician will demonstrate the right behaviors in the use of confidential information.
The third right given by the state is the right to join insurance provider networks, in a way that is overseen by the state, and to file third party insurance claims. In this way, the state acts as a guarantor to insurance panels of the clinician's ability to provide competent service. The state may also act as an advocate for the clinician by instructing third party payers that they must offer payment for these counseling services.
The rights and privileges of counseling, and the demands and responsibilities placed upon the clinician, are intricately intertwined.
One cannot have the rights and privileges without also accepting the demands and responsibilities.
Clinicians frequently struggle with the demands that are created from the responsibilities of the profession, as these demands place burdens and restrictions upon the personal life of the clinician. For example, clients may sometimes call in crisis in the middle of the night, exhibiting the potential to harm themselves or others. When a clinician chooses to become licensed to perform clinical services, he or she accepts the requirement of handling such crises, instead of simply going back to sleep.
The personal right to privacy (and sleep) can be superseded by the professional obligation to protect the safety of the client. These kinds of obligations exist as a condition of receiving the privileges of professional practice, as they do for doctors, safety personnel and many other service professionals for whom the state has guaranteed to the public the professionalism of the practitioners involved. This brings us to our final question: why is it necessary to study ethics?
The first reason is because ethics are complicated. Some of the scenarios in this training will demonstrate this fact. The second reason is that ethics continue to change and evolve over time. As time moves forward, knowledge increases, thus changing our collective understanding of what is right and what is wrong in our actions in this profession.
The third reason is that as we study ethics, we help each other, and the whole profession, to develop and redefine our collective understanding of what ethical behavior is. In so doing, we help the whole mental health profession to come to increasingly useful positions on ethics as we study, discuss and practice what we learn. Each clinician can contribute to the pool of collective knowledge and wisdom to improve the profession for all of us.
In this specific training program, this process has occurred and can continue to occur. Feedback from participants who took a live version of this training programs helped shape the knowledge and understandings presented here. Likewise, feedback from you and other trainees who complete this course will help shape the understandings that go into later versions of this training.
This ends the introductory section. We will now proceed to an examination of several scenarios that will test your knowledge of ethics by asking some complicated questions related to each scenario. This will lead to an examination of the process of ethical decision making - what factors are involved, and how these factors interact as the ethical decision making process proceeds.
This will be followed by detailed discussion of each scenario. It will be based upon feedback received from a panel of experts: experienced clinicians who will have been given the same scenarios to study. The discussion of each of the scenarios will show the ethical decision making process in action.
You will be asked to write down your responses to the scenarios so you can compare them with the answers from our panel. See if you come to the same conclusions for the same reasons. Later in the training, as part of the test section, you will be presented with new scenarios that will re-test your knowledge and understanding of the principles involved in making good ethical decisions.
Post-test Preparation: Review questions
At this point in the training, the trainee should be able to answer the following questions:
What is the difference between the primary purpose of the clinician's work and the primary purpose of other businesses, and how is this important in terms of ethical decision making?
In what ways does the state operate as a guarantor of the clinician’s skills, services and ethical behavior?
What three rights are clinicians usually granted as a balance to the responsibilities asked of the clinician?
What is the fundamental relationship between rights and responsibilities in ethical decision making?