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ETH8283 - SECTION 3: LEADERSHIP, AUTHORITY AND THE ETHICAL DECISION MAKING PROCESS: SETTING THE STAGE

 

Mental health clinicians who are willing to work from a position of leadership must have a great deal of clarity on several subjects when confronting complicated ethical situations. First, they must be able to differentiate three separate - but connected - arenas that professionals must consider when they are engaged in complex decision making.


These three arenas are the legal, the moral, and the ethical. Let's look at these three areas in diagrammatic form.


Moral
Pertaining to personal behavior as measured by prevailing standards of behavior as defined by a specified (usually spiritual) group.

Consequences for moral lapses are generally the domain of individual and group conscience.

 

Ethical
Pertaining to accepted principles of right and wrong as defined by a specified (usually professional) group.

Consequences for ethical lapses are generally the domain of the profession and keepers of the profession.


Legal
Pertaining to accepted principles of right and wrong as defined by the law, rather than by equity (fairness, justice impartiality).

Consequences for legal lapses are generally the domain of the legal system.

It is possible for a clinician to act in a manner that is legal, but not ethical; or ethical, but not moral; or moral, but not legal or ethical.

Since, these three different dimensions in decision making are mentioned in codes of ethics for mental health clinicians - sometimes on the same page, within the space of a few paragraphs, it may be helpful to examine the differences. This will further our understanding of how leadership is involved in ethical decision making, as we will see later.

Let's start with the legal dimension of decision making. Laws are defined by people in legislative positions, and courts (and juries) that interpret and issue rulings based upon their understanding of what those laws mean. The laws are not necessarily written by people who are most knowledgeable about a subject, nor by people who are interested in being fair and equitable in writing the law.

As we know from the history of the civil rights movement, laws, in fact, can be written and enforced in ways that are unfair and inequitable. Conversely, some very moral and ethical people have expressed their moral and ethical stances by breaking the law.

The law is designed to be fluid and changing over time, but fixed and certain at any specific point in time. Law, in fact, oftentimes struggles to keep up with changes in ethics and morals. Leaders who are involved in helping ethics and morals to progress forward sometimes find themselves pushing the boundaries of the law - until the law can be rewritten to reflect the changes in understanding.

This tension exists in the field of mental health in many areas concerned with ethical behavior. We will see some of these tensions as we analyze our scenarios.

The second dimension we will look at is the moral dimension. The moral dimension is deeply involved in helping to shape both the legal and the ethical dimensions. Many laws, in fact, represent an attempt to codify and enforce commonly accepted moral understandings.

Ethical standards, like laws, are also at least partially derived from commonly accepted moral ideas about what is right and wrong behavior, but typically within areas relevant to specific professions.

The important feature to know about the moral dimension, however, is that it is personal in nature. Both legal and ethical lapses can set in motion the external imposition of consequences. Moral lapses that do not also break the law or violate ethical standards will not provoke any externally imposed consequences. The consequences for moral violations will play out between the person and his/her individual conscience.

This does not mean the moral dimension is less significant. In fact, the moral dimension is usually the dimension out of which leadership emerges - bringing both the legal and the ethical dimension to more evolved states of being.

The difficulty, of course, is that the moral dimension is personal in nature in negative ways, as well. When one's own personal moral standards are less evolved than the prevailing legal and ethical standards, then this moral dimension works to sabotage the establishment of better legal and ethical standards, instead of an element that leads law and ethics towards a better place.

The proponents of segregation earlier in this century, for instance, based many of their positions upon a moral code that lagged behind changes in the prevailing social norms and standards.

This issue leads, of course, to very tricky ground. Most persons who have deeply held moral standards feel that these standards are held for the right reasons, not the wrong ones. When they are right, the society at large benefits from their unwillingness to bend; when they are wrong, society is damaged by their inflexible attitude towards change.

The essential question in this issue, of course, is - what is right? This is not an inconsequential question for the mental health profession. It is deeply involved in the decisions that are made about the last of our three dimensions - the ethical dimension.

In general terms, each profession wrestles with the question of what is right on an ongoing basis. The governing bodies in each of the mental health professions attempt to create workable definitions of right and wrong behaviors in important areas related to the profession.

When individuals depart from the standards set by the profession - even if the departures are based upon deeply felt moral reasons - the profession may choose to implement sanctions against that individual. The individual must evaluate this potential risk when a moral decision is made that is in conflict with the ethical standards set forth by the profession.

Each profession, of course, attempts to make their difficult judgments about which behaviors are right or wrong in well-reasoned ways. It is a complicated process which may involve seeking consensus from a number of members of the profession, guidance from core groups of wise and experienced leaders, and input from relevant outside parties who have a stake in the outcomes of these decisions.

It is neither a perfect nor an easy process, and the conclusions that are reached are often neither clear nor fixed. This leaves individual clinicians room for both flexibility . . . and uncertainty.

This sets the stage for opening some discussion on a concept that is essential to both ethical decision making and leadership: humility.

Because these complicated decisions occur in complex processes in which individuals, professions, and a society at large are weighing legal, moral and ethical aspects of each situation, it is sensible for all parties to approach the decision making process with a certain measure of humility and open-mindedness.

There is in humility a willingness to acknowledge that one does not have all the answers, as well as a willingness to be open to feedback from others who may help define the right decision.

There is also, in humility, a willingness to suppress one's own personal agenda - to accept that there may be things of a higher nature than the self, including a greater good that asks that the self be put aside. This, as we will see, is an essential aspect of leadership. This concept should also be familiar to mental health clinicians, although in another form.

The suppression of one's own personal agenda for the fulfillment of a more important mission is related to the concept of countertransference. Ethical practice requires that mental health clinicians have - as a primary purpose - an orientation towards forwarding the mental health of their clients, and keeping their own emotional agenda under control so that it does not interfere with this primary mission.

If we are to practice ethically, then, we must be careful - and humble - in terms of inflexibly placing our own moral codes above the primary goals and purposes of the business in which we are engaged.

This is because one's own moral code is tied to a personal agenda - held in place by our own personal values, and subject to whatever limitations we may have in our own ability to see and understand the great expanse of a very complicated universe.

The mental health professions involve working with other people - who may see and understand the world very differently. Our own personal values and agendas must, therefore, be applied very carefully and very humbly.

While, at a personal level, clinicians may strive to fully integrate their deeply held beliefs with their actions, at a professional level, we will almost always be split. We usually will not be able to hold absolutely firmly to our own moral code, and simultaneously stay absolutely focused on the well-being and purposes of the client.

This holds profound complications for the responsibilities of leadership as they pertain to ethical considerations. This will lead us into the next section of our training, where we look at the topic of leadership in more detail.


Post-test Preparation: Review questions

At this point in the training, the trainee should be able to answer the following questions:

What are the essential differences between the legal, the moral and the ethical realms and why is this important for clinical practice?

What three major groups have input into decisions about the legal, ethical and moral realms?

What problems can arise from placing our individual moral code above the ethical framework of our profession?

Why is humility considered important to ethical practice?


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