Posted: July 25th, 2024
5320: U8 D1 When Ethics and Legalities Collide
Please see attached.
5320: U8 D1 When Ethics and Legalities Collide
Each professional code of ethics includes a requirement to define limitations of
confidentiality that are not always required by law. Legal mandates in some
states can result in dilemmas when they conflict with standards in the code of
ethics. For example, standards of confidentiality might conflict with a court order
or a duty to protect a third party.
In your initial post, consider a situation such as the disclosure of HIV status or
adolescent privacy standards for disclosure to parents without consent. Use the
Tarvydas (2012) integrative approach to decision making (described in your
textbook) to discuss how you would arrive at a decision about confidentiality or
disclosure related to potential ethical dilemmas caused by conflicts between the
code of ethics and legal requirements.
Note: Must me a minimum of 250 words and 1 Scholarly Journal
105
PART II
Ethics and Standards of
Practice: The Professions’
Response
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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107
CHAPTER 5
Ethics and the Law
Mr. Harolds: Hi, Michelle. What’s up?
Ms. Wicks: Tom, could I talk to you about some legal concerns?
Mr. Harolds: Legal concerns? Certainly, but I’m not a lawyer.
Ms. Wicks: No, I know that—but you seem to stay current with laws
and regulations regarding counseling and to tell you the truth, I’m not
sure if it is a problem or not.
Mr. Harolds: Well, you certainly sound concerned. What’s up?
Most mental health practitioners enter the profession intending to
employ their knowledge and skills to assist those in need—not
concerning themselves about the legal complications of the issues
and the people with whom they work. The reality is that, just as there are
ethical principles and guidelines that need to be considered when making
professional decisions, there are also legal mandates and implications of
which the ethical practitioner must be fully aware.
Laws, including legislation, court decisions, and regulations, have grown
both in presence and importance in the practice of human service. Many
federal statutes, such as those requiring the reporting of suspected abuse
or the protection of confidential records and HIPAA laws as well as case
law, have impacted practitioners’ ethical judgments involving informed con-
sent, conflicts of interest, dual relationships, practitioner competence, and
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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108–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
termination of services (Reamer, 2013). Issues defining the rights of clients,
the rights of the practitioner, the way in which services are selected and
provided, and the nature of the relationship between the practitioner and
client are a1l being shaped by the professional codes of conduct and now
by extension of those codes into law. Some complain that law has made prac-
titioners more concerned for personal liability than client welfare. Bergantino
(1996), for example, states: “In our current psycholitigious world . . .
we only have left brains, and . . . only what is ‘appropriate’ is thought to
constitute therapy. Forget ‘excellence’ . . . Our profession is now defined by
those who want to make the world safe for mediocrity!” (p. 31).
The sad truth is that practitioners are vulnerable to legal action, and
many have opted to play it safe at the expense of providing the best ser-
vice for their clients. While litigation is a reality that now must be placed
within the mix of professional decision-making, laws are not meant to
make practitioners feel threatened. Quite often the law parallels and fur-
ther codifies sound ethical practice and as such, need not induce anxiety
or concern within the ethical practitioner. But there are times when the
relationship between ethics and legality is not clear or in fact may appear
in conflict. At those times, the question becomes, what’s the ethical helper
to do?
The current chapter focuses upon the unique and ever-evolving relation-
ship between professional codes of conduct and the law, in hopes of helping
practitioners find an answer to this question.
● OBJECTIVES
The relationship of professional ethics and the laws governing professional
practice is the focus of the current chapter. After reading this chapter, you
should be able to do the following:
• Describe the obligations incurred by a helper who has established a
“special relationship” with a client.
• Explain what is meant by “duty to care” and what defines that
obligation.
• Describe how licensure and/or certification may lend legal power to
the professional codes of conduct.
• Provide examples of ethical practice that may be i1legal and the legal
requirements that may violate professional codes of ethics.
• Describe one model for identifying and resolving conflict between
ethics and legality.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 5. Ethics and the Law–●–109
THE HELPING PROCESS AS A LEGAL CONTRACT ●
As a result of malpractice suits and legal actions, it is generally recognized
that a professional relationship or even the perception that the relationship
is a professional one constitutes the basis of the existence of legal duty to
provide appropriate care for a client. The professional help giver, by the very
nature of holding himself or herself out in practice, implies that he or she
will conduct himself or herself in a skillful and responsible manner and will
follow the dictates of that profession’s code of ethics.
The issue of whether helping is contractual and thus a minimum duty
of care is established rests with the courts’ decision as to whether a “special
relationship” existed that would be sufficient to create a “duty of care.” Such a
special relationship can certainly be created with the use of formal treatment
contracts in which the “duties” of each party are specified (see Exercise 5.1).
However, the establishment of a formal contract articulating the relationship
between client and practitioner or the rendering of a bill and exchange of
money for services is not necessary in order to provide evidence of a special
relationship and a duty to care.
A special relationship between helper and client can be established as
a result of implicit acts. Courts, for example, may determine that a special
relationship and thus a duty to care was established by the helper’s action
of taking notes, scheduling formal appointments, and even advertising as
one who can provide unique, helping services. These actions can be inter-
preted as reflecting an intent to render service and thus constitute a basis of
establishing the intent to form a special relationship and thus a contract to
provide the care. As with many areas of law and ethics, there is no singular
court case or clear directive that determines what actions, beyond a formal
contract, can be used to demonstrate an intent to form a special relationship
and thus a duty to provide care.
While there has not been a single court definition and ruling that
provides a universal standard regarding implicit contract or duty to care,
numerous state rulings have begun to give shape to this contract of profes-
sional service. In what now stands as a classic case, the Supreme Court of
Wisconsin (Bogust v. Iverson, 1960) ruled against the parents of a student,
Jane Dunn filed suit against the director of student personnel services
at Stout State College. The parents alleged there was negligence, because
the director failed to provide proper guidance or protection for the student,
who committed suicide. In the ruling against the parents, the Wisconsin
Supreme Court referred to the defendant as a teacher and not a counselor
and as such reported no special relationship had been established. “To hold
that a teacher who has no training, education, or experience in medical
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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110–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Exercise 5.1
The Use of Contracts: Formal and Informal
Many mental health practitioners, as a reflection of their concern to
assist clients to be fully informed, have begun to provide clients with
“contracts” of service. These contracts can be more or less formalized,
ranging from simple information sheets with identified fees, cancella-
tion policies, and so forth, to a formal statement requiring signatures
and witnesses from all parties involved.
Directions: Contact each of the following: (a) a residential treatment
program or hospital, (b) a free clinic, (c) a private practitioner, (d) a
university counseling center, (e) an elementary or high school counseling
center, and (f) a local church or religious organization. For each of these
service providers identify each of the following:
• Do they employ some form of agreement or contract when pro-
viding services (counseling, mental health) to their clients? If so,
why, and what is included? If not, why not?
• Do they provide informational brochures or materials? Do these
describe any special services that are offered and any require-
ments or responsibilities of the clients?
• When they see a client, do they maintain records? Collect a fee?
Schedule appointments (versus simply walk-in service)?
• Do they feel that their clients perceive that the services they
offer are professional in nature, even if no fees are collected?
Share your data with your colleagues or classmates. Discuss which of
the service providers appear to employ contracts or actions that would
characterize them as establishing “special relationships” with their
clients and therefore incurring a duty to care.
fields is required to recognize in a student a condition the diagnosis of which
is in a specialized and technical medical field, would require a duty beyond
reason” (Bogust v. lverson, 1960). A later ruling that suggested specialized
training and credentialing were needed prior to the establishment of a
special helping relationship and the duty to care was Nally v. Grace Com-
munity Church. In Nally v. Grace Community Church (1988), the parents
of a 24-year-old, Kenneth Nally, sued the Grace Community Church and its
pastors for negligence when their son committed suicide after receiving
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 5. Ethics and the Law–●–111
several years of informal counseling. Kenneth also saw secular psychologists
and psychiatrists during these years, and following an unsuccessful attempt
at suicide in 1979, his parents rejected the recommendations of a psychia-
trist to have him committed. This recommendation was also made by one
of the pastors of the church and similarly rejected. The California Supreme
Court ruled in favor of the church and its pastors because it found that there
was no duty of care that was breached by them and no special relationship
that would create such duty. In this case, the California court made a distinc-
tion between non-therapists, counselors, and professional therapists—such
as psychiatrists or certified psychologists and counselors. Since the pastors
were non -therapists without the requisite special relationship, the court did
not find or impose the duty of care. These two rulings appear to point to the
essential need to be recognized as a professional helper as defined by one’s
credentials, such as licensure, as the basis for a special relationship and to
identify that duty to care has been established. However, in Eisel v. Board
of Education of Montgomery County (1991) new legal precedent was set.
As noted, previously the courts did not find a duty of care in situations
in which a non-professional attempted to provide help to a client. This was
true even in situations in which an outpatient client who may have been
suicidal was seen by a school counselor. However in the Eisel case, the
court noted a special relationship sufficient to create a duty of care when an
adolescent in a school setting expresses an intention to commit suicide and
the counselor becomes aware of such intention. In Eisel, the court noted
that the school, as a result of standing in loco parentis, does have a special
duty to exercise reasonable care to protect a pupil from harm. Further, the
relationship of school counselor and pupil is not devoid of therapeutic over-
tones, as suggested by the counselor’s job description. Thus in addition to
pointing to special training, licensing, and certification, the existence of a
special relationship and the duty to care can be established based simply on
the job definition from which one provides service. Eisel (1991) strength-
ened counselors’ legal obligation to students by satisfying for the first time
the first element of negligence and declaring that school counselors have
a special relationship with students and owe a duty to try to prevent a stu-
dent’s suicide (Stone, 2003).
Another approach to the definition of a special relationship between
helper and client bases it on the principle of fiduciary responsibility.
Anytime an individual places his or her trust in a party who has the potential
to influence his or her action, a fiduciary relationship exists (Black, 1991).
In the case of mental health provision, the counselor or therapist becomes
a “fiduciary,” in that the helping relationship requires that the client have
confidence and trust in the recommendations that are being made by the
practitioner (Simon & Shuman, 2007).
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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112–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
When a fiduciary relationship exists, a practitioner has these obliga-
tions (a) to act with good faith and loyalty toward a client (McInerney v.
MacDonald, 1992); (b) to not abuse the power imbalance by exploiting the
client (Norberg v. Wynrib, 1992); and (c) to act in the best interest of the
client (Hodgkinson v. Simms, 1994).
While the anxiety surrounding the possibility of litigation may serve as
a motive for practitioners to be more fully aware of the law applicable to
their practice, knowledge and awareness of the law is a professional respon-
sibility regardless of anxiety. Professional codes of conduct direct practitio-
ners to know and practice in ways consistent with the law. For example,
“psychologists’ fee practices are consistent law” (APA, 2010, 6.04.b).
● THE LEGAL FOUNDATION OF ETHICAL PRACTICE
The process and relationship between health and human service profession-
als and their clients is increasingly shaped by law. Issues such as informed
consent, confidentiality, and competency as well as mandates, such as the
mandated reporting of child abuse and duty to warn, are significant influ-
ences on the practice of human service (see Case Illustration 5.1). In addi-
tion, courts of law can employ regulatory and ethical standards for health
and human services professionals as ways of identifying negligence, malprac-
tice, and liability.
Case Illustration 5.1
The Changing Face of School Counseling
The following was the result of an interview with Mr. L., an elementary
school counselor. Legal precedents relative to Mr. L.’s comments have
been inserted.
Well, I’ve been an elementary school counselor now for over
23 years, and I can tell you my job and my strategies in working with
children have changed dramatically as a result of litigation. I mean, there
was a time when I first started that if a kid was acting out or causing
a real disruption in a classroom, we could simply have him removed,
suspended, as a way of providing a “wake up call.” Try that now and
you will find yourself sued. Everything requires DUE PROCESS now.
In 1975, the Supreme Court ruled in Goss v. Lopez: “Due process
requires, in connection with a suspension of 10 days or less, that the
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 5. Ethics and the Law–●–113
student be given oral or written notice of the charges against him and,
if he denies them, an explanation of the evidence the authorities have
and an opportunity to present his side of the story’’ (p. 581). This even
gets to the point that you start to worry about using “time out” proce-
dures, because it may be argued that you are excluding a child from
his right to have an education. I don’t know, I feel like I should have
become a lawyer rather than a counselor.
Goss v. Lopez (1975) focused on exclusion from an education, and
while it did not define or give examples of de minimis punishments that
would not require due process, they probably would include practices
like after school detentions or “time outs” or even temporary exclusion
from extracurricular activities.
And another area that you have to be super cautious about is
record keeping. I mean, it used to be that my records were confidential,
and no one had access. Now I feel like any one can waltz in and see
my files, since they are school files. Where’s the privacy? A lot of the
counselors in our district simply keep special files or school-only files
that parents don’t have access to.
The Family Educational Rights and Privacy Act (FERPA) provides
parents and students 18 and older with certain rights with regard to the
inspection and dissemination of “education records.” As a federal law,
it applies to school districts and schools that receive federal financial
assistance through the U.S. Department of Education. FERPA makes
clear that all education records, no matter where they are stored or
how they are identified (i.e., “school only”) must be made available.
However, not all information obtained by a counselor need be dis-
closed. The legislative history of FERPA clarifies that education records
do not include the “personal files of psychologists, counselors, or
professors if these files are entirely private and not available to other
individuals” (120 Cong. Rec. 27, 36533 (1974).
Codes of ethics provide guidelines for practice decisions; however, they
are not binding unless they are otherwise codified or incorporated into law.
Granted, professional associations have the power to sanction their mem-
bers for unethical practice, via admonishment, suspension or expulsion. But
the extent of the sanctions is limited, and such sanctioning does not auto-
matically imply legal action. The professions’ codes of conduct, however, do
often provide the basis or at a minimum a standard for developing laws and
regulations that govern the practice of that profession. In most states, the
ethical principles and standards of practice have been incorporated into laws
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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114–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
or regulations that not only govern requirements for certification or licensure
but serve as consumer laws governing the practice of mental health services
(Bennett, Bryant, VandenBos, & Greenwood, 1990). While this may vary state
by state, it is important for all engaging in mental health services to under-
stand the relationship of ethical code to legal mandate (see Exercise 5.2).
Exercise 5.2
State Laws Codifying Professional Ethics
Directions: Licensed psychologists, in some states, will find that a
violation of their code of ethics places them at risk not only of facing
sanction of the board, but also of prosecution by the state in which
they practice.
Contact the department of state, the attorney general’s office, or
the department of license and measurements for your state and do the
following:
• Inquire if your state licenses mental health professionals. If so,
which professions?
• What does the law say about the practice of those within that
profession who are not licensed or about those from other pro-
fessions who practice within that state?
• Request a copy of the licensing law within your state.
• Inquire if the code of ethics for your profession has the force of
law within your state.
While the professional codes of conduct have been incorporated into
laws, in some cases, the reverse has been true; that is, the legal system has
stimulated mental health professions to develop and enhance their ethical
standards. Mental health professionals employ sensitive and careful ethical
practices to ensure that clients will not hurt themselves or others. The steps
taken to warn and protect potential victims of dangerous clients are clearly
integrated into all professional standards of conduct and were stimulated
by the landmark decision surrounding the Tarasoff v. The Regents of the
University of California (1976) court case (see Chapter 9). An illustration of
how case law has given shape to ethical principles of practice can be found
in Case Illustration 5.2.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 5. Ethics and the Law–●–115
Case Illustration 5.2
The Issue of Duty to Warn
Jonathan was referred to Dr. Ranklin, a licensed psychologist who pro-
vided services to employees of Company L. as part of its Employment
Assistance Program. In the initial session, Dr. Ranklin explained his role
and the fact that he was contracted by Company L. to provide employ-
ees with brief, solution-focused counseling and referral. Dr. Ranklin
also described the conditions of confidentiality and provided Jonathan
with an information sheet about the services available.
During the initial session, Jonathan revealed his intent to “get even
with Alex” (his immediate supervisor). When asked what “get even”
meant, Jonathan stated, “Alex has been on my case ever since he
became a supervisor. He thinks he’s hot stuff, better than the rest of us.
He keeps calling me lazy and asks if I’ve seen the shrink yet; he told me
he made the referral to you. Anyway, he does this stuff in front of the
other guys and I have had it. I’m just going to wait for him one night
this winter, when it’s dark, and get him out in the parking lot.”
When asked if he could provide more information about what it
was he was planning, Jonathan went into great detail: “I know where
he parks and he always leaves just around 5:45, after most of the
guys have cleared out of the lot. I’m going to be waiting for him. I’ll
just hide in the dark and when he goes to get into the car, I will whip
him terribly. I’ve got an ax handle with his name all over it. I’ll crack
that dumb head of his and then we’ll see who’s crazy. If he dies, that’s
his problem.”
Throughout the session, Dr. Ranklin attempted to gain a guaran-
tee that Jonathan really wouldn’t do what he was saying, but each
time Jonathan insisted that he would and that Alex deserved it. When
reminded of the “limits of confidentiality” that Dr. Ranklin explained
and that were listed in the handout, Jonathan said, “I don’t care. You
can tell him or anyone. He deserves it and I’m going to give it to him.”
Since all attempts to persuade Jonathan to commit to not harming
Alex were unsuccessful, Dr. Ranklin felt duty bound to protect his cli-
ent (Jonathan) from legal action and his identified victim (Alex) from
potential harm. Thus, he made an appointment to meet with Alex to
disclose this information.
(Continued)
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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116–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Dr. Ranklin’s actions were stimulated by the now famous Tarasoff
(1976) case and subsequent state case laws in Nebraska where he
practiced. Dr. Ranklin knew that while confidentiality was an ethical
directive, in Nebraska, therapists are required to initiate whatever
precautions are necessary to protect the potential victims of the patient
(Lipari v. Sears, Roebuck & Co., 1980).
(Continued)
Many of the ethical principles to be discussed and illustrated within
the upcoming chapters have strong legal foundations. Thus, in addition to
providing a review of the principles, some of the laws and court decisions
that tint or give further shape to the application of these principles will be
discussed. Table 5.1 provides a thumbnail view of a couple of these legal
decisions and their impact on professional practice.
Ethical Does Not Always Equal Legal
While codes of ethics most often overlap with legal requirements, they
are distinct from them and in some cases, may be in conflict. The potential
for conflict has been recognized within the American Psychological Associa-
tion code of ethics (2010), which states:
Table 5.1 Examples of Laws as Foundation for Ethical Practice
Ethical Issue Legal Rulings
Boundary
Violations
A number of rulings (e.g., Mazza v. Huffaker, 300 S.E. 2d 833, [1983];
Horak v. Biris, 474 N. E. 2d 13 [1985]) argue that due to the power
differentials within the relationship and the potential for abuse of power,
sexual relationships between client and practitioner are actionable as
malpractice.
Competence The foundation for negligence is based, in part, on the failure to use
knowledge, skill, and care ordinarily exercised in similar localities (Carlton
v. Quint, 77 Cal. App. 4th 690, 699 (2000) [91 Cal. Rptr. 2d 844]).
Confidentiality Duty to break confidence in service of the duty to warn was established
in Tarasoff v. The Regents of the University of California 551 P.2d 334
(Cal. Sup. Ct., 1976).
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 5. Ethics and the Law–●–117
If psychologists’ ethical responsibilities conflict with law, regulations,
or other governing legal authority, psychologists clarify the nature
of the conflict, make known their commitment to the Ethics Code,
and take reasonable steps to resolve the conflict consistent with the
General Principles and Ethical Standards of the Ethics Code. Under no
circumstances may this standard be used to justify or defend violating
human rights. (APA, 2010, Principle 1.02)
Unethical, Yet Legal
Conflict can occur when a practitioner’s decisions are unethical and
yet remain legal. For example, in most states it is not legally mandated that
a practitioner inform a client of the limitations to confidentiality or how
confidential information may be used, but many professional codes of ethics
require that such limitations be clearly described to the client (see Table 5.2).
Ethical, Yet Illegal
There are times when a practitioner’s actions may be considered illegal
yet fall within the codes of ethical conduct. Consider the situation in which a
client with AIDS refuses to inform an identified sexual partner about the AIDS
or take steps to protect that partner. Although disclosure of a client’s status as
having AIDS or being HIV positive without that client’s permission is illegal,
in many states, the ethical duty to protect third parties from harm may direct
the practitioner to disclose this information to the current sexual partner.
Table 5.2 Notification of Limits to Confidentiality
Professional Ethical
Standards Statement of Notification
American
Psychological
Association (2010)
4.02.a. Psychologists discuss . . . (1) the relevant limits of
confidentiality and (2) the foreseeable uses of the information
generated through their psychological activities.
b. Unless it is not feasible or is contradicted, the discussion
of confidentiality occurs at the outset of the relationship and
thereafter as new circumstances may warrant.
(Continued)
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118–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Professional Ethical
Standards Statement of Notification
National
Association of
Social
Workers (2008)
1.07 Privacy and confidentiality
d. Social workers should inform clients, to the extent possible,
about disclosure of confidential information and the potential
consequences, when feasible before the disclosure is made. This
applies whether social workers disclose confidential information on
the basis of a legal requirement or client consent.
e. Social workers should discuss with clients and other interested
parties the nature of confidentiality and the limitations of clients’ right of
confidentiality. Social workers should review with clients circumstances
where confidential information may be requested and where disclosure of
confidential information may be legally required. This discussion should
occur as soon as possible in the social worker–client relationship and as
needed throughout the course of the relationship.
American
Counseling
Association (2014)
A.2.b. Types of information needed
Counselors explicitly explain to clients the nature of all services
provided. They inform clients about issues such as, but not limited to,
the following: the purposes, goals, techniques, procedures, limitations,
potential risks, and benefits of services; the counselor’s qualifications,
credentials, relevant experience, and approach to counseling;
continuation of services upon the incapacitation or death of the
counselor; the role of technology; and pertinent information. Counselors
take steps to ensure that clients understand the implications of diagnosis
and intended use of tests and reports. Additionally, counselors inform
clients about fees and billing arrangements, including procedures for
nonpayment of fees. Clients have the right to confidentiality and to be
provided with an explanation of its limits, including how supervisors
and/or treatment or interdisciplinary team professionals are involved,
to obtain clear information about their records, to participate in the
ongoing counseling plans, and to refuse any services or modality
changes and to be advised of the consequences of such refusal.
A.2.d. Inability to give consent
When counseling minors, incapacitated adults, or other persons
unable to give voluntary consent, counselors seek the assent of clients
to services and include them in decision making as appropriate.
Counselors recognize the need to balance the ethical rights of clients
to make choices, their capacity to give consent or assent to receive
services, and parental or familial legal rights and responsibilities to
protect these clients and make decisions on their behalf.
Table 5.2 (Continued)
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Chapter 5. Ethics and the Law–●–119
Professional Ethical
Standards Limitations to Confidentiality
American
Psychological
Association (2010)
4.05.b.
Psychologists disclose confidential information without the consent of
the individual only as mandated by law, or where permitted by law for
a valid purpose, such as to (1) provide needed professional services;
(2) obtain appropriate professional consultations; (3) protect the client/
patient, psychologist, or others from harm; or (4) obtain payment for
services from a client/patient, in which instance disclosure is limited
to the minimum that is necessary to achieve that purpose.
National
Association of
Social Workers
(2008)
1.07. Privacy and confidentiality
c. Social workers should protect the confidentiality of all
information obtained in the course of professional service, except
for compelling professional reasons. The general expectation that
social workers will keep information confidential does not apply
when disclosure is necessary to prevent serious, foreseeable,
and imminent harm to a client or other identifiable person. In
all instances, social workers should disclose the least amount of
confidential information necessary to achieve the desired purpose;
only information that is directly relevant to the purpose for which
the disclosure is made should be revealed.
American
Counseling
Association (2014)
B.2. Exceptions
The general requirement that counselors keep information
confidential does not apply when disclosure is required to protect
clients or identified others from serious and foreseeable harm or
when legal requirements demand that confidential information must
be revealed. Counselors consult with other professionals when in
doubt as to the validity of an exception. Additional considerations
apply when addressing end-of-life issues.
American
Association for
Marriage and
Family Therapy
(2015)
2.2. Written authorization to release client information
Marriage and family therapists do not disclose client confidences
except by written authorization or waiver, or where mandated
or permitted by law. Verbal authorization will not be sufficient
except in emergency situations, unless prohibited by law. When
providing couple, family, or group treatment, the therapist does not
disclose information outside the treatment context without written
authorization from each individual competent to execute such a
waiver. In the context of couple, family, or group treatment, the
therapist may not reveal any individuals’ confidences to others in the
client unit without the prior written permission of that individual.
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120–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
It is clear that the relationship between law and ethics is not always
clear-cut. In the most desirable state, our professional ethics and the law
are in concert, as is the case when maintaining confidentiality is protected
under the law. And while it is clear that actions that are both illegal and
unethical must be avoided, clarity is blurred in situations where one’s ethi-
cal directive runs contrary to a legal mandate, as might be the case where a
professional feels it is essential to a client’s welfare to maintain confidential-
ity even when confronted with a court order.
Ethical and legal standards are by their very nature broad in spirit and
language, thus open to situational interpretation. As a result, practitioners
must remain informed about the legal interpretations of the applications
and misapplication of the ethics of practice and practice decisions as they
continue to unfold through legislation and court decisions.
● WHEN ETHICS AND LEGALITIES COLLIDE
When ethics and law collide, the practitioner will need to use his or her
own sense of judgment about the issues and directions to be taken. Such
judgment should be formed on accurate understanding of the specific ethi-
cal principles involved and the laws governing practice decisions. As noted
previously, psychologists confronted by such a conflict are directed to
“clarify the nature of the conflict, make known their commitment to the Eth-
ics Code, and take reasonable steps to resolve the conflict consistent with
the General Principles and Ethical Standards of the Ethics Code” (APA, 2010,
Principle 1.02). While the mental health practitioner is not called upon to
be a legal expert, it is important that the practitioner have some knowledge
of court rulings (local, state, and federal), since such rulings provide the
precedents for future actions by the courts. Clearly, the better informed a
practitioner is, the more likely conflicts between legal and ethical principles
can be resolved.
It is generally believed that mental health professions have an obligation
to abide by the legal requirements of the situation. This obligation is most
often considered as prima facie, meaning that the legal obligation needs to
be considered in every case and only set aside when ethical and/or legal
reasons of greater importance compel such action. However, the unique-
ness of each situation and the characteristics of each client complicate the
decision to be made.
There may be situations in which, even with the greatest understand-
ing of both the law and the ethical principles, a clear path resolving the
conflict cannot be found. It is possible that the action mandated by law
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Chapter 5. Ethics and the Law–●–121
may not appear to be in the best ethical interest of the client. Such a con-
flict places the mental health practitioner in quite a moral and professional
dilemma. This would certainly be the case for the counsellor attempting to
protect confidentiality of her client with HIV/AIDS while at the same time
being sensitive to her duty to warn a third party of potential harm (Alghazo,
Upton, & Cioe, 2011). Under these situations, it is the responsibility of the
professional to review all of the pertinent information, discerning which
avenue both upholds the intent of the law and essence of the profes-
sions ethics while providing the maximum benefit to the client. It will be
essential for the mental health practitioner confronted by such dilemmas
to employ a well-developed decision-making model. While this topic of
ethical decision-making and models that serve that purpose is presented in
Chapter 7, it is worthwhile to review one somewhat classic approach as
offered by Remley (1996).
Remley (1996, p. 288) provides four steps for counselors to take when
confronted by an apparent conflict between ethics and the law. These steps
have been adapted and are listed below:
1. The practitioner should identify all of the forces that are impacting
issues regarding the professional decision and behavior. While the
conflict may certainly be the result of an ethical principle or a legal
mandate, other forces, such as policies and procedures within a
specific workplace, accreditation rules or requirements, and even
parameters for funding, may be the source of the conflict rather than
the law.
2. When the question is one of law, legal advice should be obtained.
Quite often the state or national associations may provide legal con-
sultants who are trained in both the mental health field and the legal
profession. Another source of legal advice may be obtained through
one’s liability insurance company.
3. If there is a problem in applying an ethical standard or in understand-
ing the requirements of an ethical standard, the practitioner should
consult with a colleague and those perceived as experts within the
field. Again, it is also useful to contact the local, state, or national
associations and speak to members of the ethics board.
4. If a force other than law or ethics (for example, employment require-
ments) is suggesting that a practitioner take some action he or she
perceives as illegal, the counselor should obtain legal advice to deter-
mine whether such action is indeed illegal and what form of recourse
or protection is available should the counselor refuse to follow the
directive to perform this illegal act (see Chapter 6).
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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122–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
The need for ethical practitioners to remain informed as evolving ethics
receive the force of the law through court decisions and/or evolving law
gives new shape to codes of conduct cannot be overemphasized. Fortu-
nately, practitioners are not alone in their concern and their quest. State
and national associations, along with liability insurance companies, provide
continuing education programs to update the practitioner’s knowledge and
may even provide consultation services in case of conflict. The final exercise
(Exercise 5.3) is provided to help increase your awareness of the supports
available to assist you in becoming both an ethical and legal practitioner.
Exercise 5.3
Resources in Support of the Ethical-Legal Practitioner
Directions: It is essential to remain informed about the changing face of
law and codes of professional conduct as you continue to develop and
practice as a helper. Ongoing information and continuing education pro-
grams are often provided by state and national associations along with
the various companies providing liability insurance for your profession.
Similarly, these same resources oftentimes provide “hotline” consultation
for their members who may feel conflicted about a practice decision.
• Contact your state organization and inquire about its website
or ways that you can be informed about state legal decisions
that may impact your own professional practice. Ask if you can
be placed on a mailing list or list-serve announcing continuing
education programs geared to updating practitioners on relevant
law and ethical principles of practice.
• Contact your national organization and inquire about its
website or ways that you can be informed about recent legal
decisions impacting your practice and continuing education
programs geared to updating practitioners on relevant laws and
ethical principles of practice.
• Contact your liability insurance carrier and inquire whether it
provides continuing education programs on issues of ethics and
legality and if it provides a discount for those who attend.
• Contact each of the above and inquire about the availability of
legal assistance or ethical-legal consultation should you have
a question or conflict. Identify the process for connecting with
this service as well as any fees that may be involved.
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Chapter 5. Ethics and the Law–●–123
CONCLUDING CASE ILLUSTRATION ●
Returning to the scene with which we opened the chapter, we find
Ms. Wicks (Maria’s counselor) sharing concerns with a colleague. As you
read the exchange, look for issues of an ethical nature, issues or concerns
that may, in your opinion, have legal foundation and/or implications, and
the existence of conflict between Ms. Wicks’s ethical standards and the law.
Mr. Harolds: Hi, Michelle. What’s up?
Ms. Wicks: Tom, could I talk to you about some legal concerns?
Mr. Harolds: Legal concerns? Certainly, but I’m not a lawyer.
Ms. Wicks: No, I know that, but you seem to stay current with laws and
regulations regarding counseling, and to tell you the truth, I’m
not sure if it is a problem or not.
Mr. Harolds: Well, you certainly sound concerned. What’s up?
Ms. Wicks: Well, I’m not sure actually. I’ve been counseling a student who
shared with me that she is currently dating and having unpro-
tected sex with a boy whom she reports as having AIDS. She’s
18, and the information was revealed to me in my role of coun-
selor. I am not sure if I am legally responsible to report this.
Mr. Harolds: Did you share your concern with your client?
Ms. Wicks: Yes, and she simply states that she doesn’t care. You know, this
is love, and God wouldn’t punish her by letting her get AIDS.
Mr. Harolds: Wow, that’s sad. Michelle, when you first met with her, what
instructions did you give her regarding the limits to confidentiality?
Ms. Wicks: Tom, I know I explained about disclosing information if she
informed me of her intent to harm her herself, but I’m not sure
how this fits.
Mr. Harolds: This is tough. After all, she’s your client, not the boy. I know
individuals with AIDS have a right to privacy, but she is placing
herself in harm’s way. I don’t really know. Why don’t we call
the state board and ask to speak to one of their ethical-legal
consultants? Remember, I told you I wasn’t a lawyer!
Ms. Wicks: Tom, I just appreciate you hearing me out and confirming for
me that this is not so clear-cut. I agree that calling may be the
thing to do.
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124–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Reflections
1. Do you feel that Ms. Wicks should have gotten Maria’s consent to
speak with Tom?
2. Do you feel that the specific information shared with Tom was a viola-
tion of Maria’s right to confidentiality?
3. Do you feel that the potential for conflict between law and ethics
exists in this case? If so, where? If not, why not?
4. How do you feel about the fact that Ms. Wicks contacted a colleague
in a situation like this? Is there anything else she should have done
instead or in addition?
● COOPERATIVE LEARNING EXERCISE
The purpose of the chapter was to familiarize you with the unique and
sometimes conflicting relationship between law and professional codes of
ethics. Because they are broadly stated, both ethical and legal standards are
open to situational interpretation. The remaining chapters provide more
detailed information about specific, ethical principles and laws applying to
those guidelines.
Below you will find three scenarios. Along with your colleagues, read
each scenario and identify whether you feel they present issues that are
free of conflict or represent a conflict of law and ethics. Where conflict
exists, identify the nature of the conflict. Is it legal and unethical, illegal
and ethical, or unethical and illegal? Next, contact a professional practitio-
ner in your area and ask him or her for an opinion about the nature of the
situation. Finally, as you read more about specific ethical principles in the
upcoming chapters, return to these scenarios to see if your initial opinions
change.
Scenario 1: A girl, age 13, comes to a school counselor and asks for
advice and direction on where and how to go about securing an abortion.
The school counselor gives her the names and numbers of a number of agen-
cies that counsel women seeking an abortion. The school counselor also
promises the student not to inform her parents. Was the decision a conflict
of law and ethics? If so, what was the nature of the conflict? Which part of
the counselor’s behaviors or decisions were conflictual?
Scenario 2: A Vietnam War veteran voluntarily contracted for coun-
seling with a licensed social worker for what was determined to be post-
traumatic stress disorder. In the process of therapy the vet reported his
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 5. Ethics and the Law–●–125
intention to kill some college students who, according to the vet, prolonged
the war through their protests. When asked to identify the specific students,
the client simply said, “It doesn’t matter as long as they are in college.” The
therapist did not take steps to inform anyone about this threat. Should he? Is
there a conflict of law with ethics? If so, what is the nature of that conflict?
Scenario 3: Dr. Ortez works in the counseling center at a local univer-
sity. Dr. Ortez had provided career counseling for a graduate student named
Liz. It has been a year since Liz has graduated and over 15 months since her
last session with Dr. Ortez. Dr. Ortez calls Liz to inquire how she is doing
and, while on the phone, asks her on a date. Did Dr. Ortez violate any ethical
principles? Any laws?
SUMMARY ●
• In performing one’s practice, the helper provides implicit agreement
of his or her duty to the client.
• The issue of whether helping is contractual and thus a minimum duty
of care is established rests with the court’s decision as to whether a
“special relationship” existed that would be sufficient to create a duty
of care.
• Anytime an individual places his or her trust in a party who has the
potential to influence his or her action, a fiduciary relationship exists
(Black, 1991).
• Given this definition, it could be reasonably argued that all profes-
sional helping relationships have this fiduciary responsibility.
• In most states, the ethical principles and standards of practice have
been incorporated into laws or regulations that not only govern
requirements for certification or licensure but also serve as consumer
laws governing the practice of mental health services.
• While codes of ethics most often overlap with legal requirements,
they are distinct from them and in some cases may be in conflict.
• When ethics and law collide, the practitioner will need to use a good
decision-making model to guide decisions and directions.
• Remley (1996) provided four steps that counselors should take when
confronted by an apparent conflict between ethics and the law:
(1) Identify the forces that are at issue, (2) obtain legal advice,
(3) consult with colleagues or experts in the field of professional eth-
ics, and (4) seek legal advice, when forces other than law and ethics
are at the core, in order to understand available options.
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126–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
● IMPORTANT TERMS
Bogust v. Iverson implicit acts
contractual legal precedent
duty beyond reason Nally v. Grace Community Church
duty to care prima facie
Eisel v. Board of Education principle of fiduciary responsibility
ethical, yet illegal unethical, yet legal
● ADDITIONAL RESOURCES
Corey, G., Corey, M., Corey, C., & Callanan, P. (2015). Issues and ethics in the helping
professions with ACA 2014 Codes (9th ed.). Stamford, CT: Cengage Learning.
Fischer, L., & Sorenson-Paulus, O. (1996). School law for counselors, psychologists
and social workers (3rd ed.). White Plains, NY: Longman Publishers.
Pope, K. S., & Vasquez, M. J. T. (2016). Ethics in psychotherapy and counseling:
A practical guide (5th ed.). John Wiley & Sons.
Stone, C. (2013). School counseling principles: Ethics and law (3rd ed.). Alexandria,
VA: American School Counselors Association (ASCA).
Swenson, L. C. (1997). Psychology and law for the helping professions. Pacific
Grove, CA: Brooks/Cole.
Woody, R. H. (1997). Legally safe mental health practice: Psycholegal questions and
answers. Madison, CT: Psychosocial Press.
Web-Based
American Counseling Association. (n.d.). NEW ACA 2014 code of ethics: A 6-part
webinar series. Retrieved from https://www.counseling.org/continuing- education/
webinars/new-aca-2014-code-of-ethics-a-6-part-webinar-series
American School Counselor Association. (n.d.). Legal and ethical specialist training.
Retrieved from http://www.schoolcounselor.org/school-counselors-members/
professional-development/asca-u/legal-specialist-training
Counseling Today. (2015). Tag archives: Ethical and legal issues. Retrieved from
http://ct.counseling.org/tag/ethics-legal-issues/
Social Work Ethics and Law Institute. (n.d.). http://socialworkers.org/sweli/default.asp
Stone, C. B., & Zirkel, P. A. (2010). School counselor advocacy: When law and ethics may
collide, 13(4), 244–247. Retrieved from: http://www.jstor.org/stable/42732954
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Chapter 5. Ethics and the Law–●–127
REFERENCES ●
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confidentiality: Ethical and legal considerations relative to individuals with AIDS/
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American Psychological Association. (2010). Ethical principles of psychologists and
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Association.
Bergantino, L. (1996, Fall). For the defense: Psychotherapy and the law. Voices,
29–33.
Black, H. C. (1991). Black’s law dictionary (Abridged, 6th ed.). St. Paul, MN: West
Publishing.
Bogust v. Iverson, 102 N.W.2d 288 (Wis. 1960).
Carlton v. Quint, 77 Cal.App.4th 690, 699 (2000) [91 Cal.Rptr.2d 844].
Eisel v. Board of Education of Montgomery County, 68, 130,135.
Goss v. Lopez, 419 U.S. >565 (1975).
Hodgkinson v. Simms, 117 DLR (4th) 161 (1994).
Horak v. Biris, 474 N. E. 2d 13 (1985).
Mazza v. Huffaker, 300 S.E. 2d 833 (1983).
McInerney v. MacDonald, 93 DLR (4th) 415 (1992).
Nally v. Grace Community Church, 47 Cal.3d 378 (1988).
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129
CHAPTER 6
Conflict: The Reality
of “Being Ethical” Within
the Real World
Ms. Wicks: Hi, Tom it is me again.
Mr. Harolds: Hey, how are you? Did you get that information from the
state association?
Ms. Wicks: Not yet. They are supposed to call me. But, things are getting
more confusing . . .
Mr. Harolds: Really?
Ms. Wicks: Ms. Armstrong, the principal at the school, informed
me that it is understood in the district that we are not to counsel
students regarding sexual issues. She said it is not a formal policy, just
something that “we” all know not to do. So, I’m not sure if I broke a
law or violated a code of ethics or may have stepped over the line in
terms of my job definition. I am so confused!
When working with a client, a helper needs to be aware of and
sensitive to the many individual issues and concerns presented
by the client. In addition, the helper also needs to be fully cog-
nizant of the ethical and legal implications of his or her own professional
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130–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
decisions in relationship to these client concerns. Now, to complicate mat-
ters even more for those practitioners working within an organization or a
system, be it a school, a hospital, an agency, or a company, individual prac-
tice decisions must also reflect and be congruent with policies, procedures,
and informal standards and values operating within that system.
The current chapter looks at the ethical culture of social systems and
the influence it exerts on the practice decisions of those helpers working
within that system. The chapter will discuss the impact of working for and
within an organization. Further, in this chapter we will look at situations in
which conflicts arise when what the professionals feel is best for the indi-
vidual client falls outside of or even runs contrary to policies, procedures,
or values of the organization. Under these conditions, what’s a practitioner
to do?
● OBJECTIVES
The chapter will review the process and implications of making ethical
practice decisions within an organizational or system context. Attempting
to balance the needs of the individual client with the requirements of the
employing organization and other interested parties (e.g., managed care
organizations) is not an easy or clear-cut process. After reading this chapter
you should be able to do the following:
• Define what is meant by “system culture.”
• Discuss the impact of system culture on ethical decision-making.
• Identify possible points of ethical conflict when working in a man-
aged care environment.
• Identify possible points of ethical conflict when working with third-
party payees.
● SERVING THE INDIVIDUAL WITHIN A SYSTEM
Professional practice does not occur within a vacuum. At a minimum, pro-
fessional practice occurs within the social context of a client and a helper.
But for those working within an organization, professional practice and
ethical decision-making occurs not only within this dyadic system but also
within the context of the larger system or organization in which the helper
works. Ethical problems in professional practice are often the result of the
confluence of context, setting, and standards of practice. Practitioners who
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 6. Conflict–●–131
work in schools, clinics, or hospitals, and/or those who serve as providers
for managed care can find themselves in conflict with these competing cli-
ent systems (see Case Illustration 6.1).
Case Illustration 6.1
A Diagnostic Dilemma
Linda Alfreds is a new school psychologist, the first ever employed
by the Hallstead School District. Linda’s job involves performing all
psycho-educational assessments, especially those required for special
education placement. Linda was informed, however, that with the excep-
tion of a few “slower” children, the district really didn’t have children
with special needs, which according to the superintendent was a blessing,
since they have very limited monies for providing such services.
Linda was asked to see Marquis, a transfer student, who was
reported as having difficulty keeping up with the work in a number of
his classes. The test data presented Marquis as an impulsive child, with
a significant receptive language problem. From her work at a previous
school district, Linda knew that Marquis would benefit from placement
in a resource room with a special education teacher trained in learning
disabilities and language disorders.
Linda discussed the situation with her department chairperson and
was told that the district did not have resource room personnel. However,
the other middle school in the district did provide a classroom for “slow
learners.” The chairperson directed Linda to record Marquis as being
retarded rather than as having a language disability, since this would at
least get him some special services. It was clear to Linda that the data
would not support this diagnosis, but identifying the child with a language
disability might fail to provide any special teaming assistance to Marquis.
Certainly the school psychologist presented in Case Illustration 6.1 is
confronted with a serious ethical and potentially legal dilemma. As in this
case, practice decisions must clearly reflect not only the needs of the client
as well as the characteristics and orientation of the helper but also the
unique characteristics and demands of the context or organization in which
the helping occurs. Balancing all of these unique needs is not always easy or
clear-cut. The ethical practitioner needs to be aware of the system and the
subtle and often times not so subtle influences that a system can exert. Such
an awareness begins with an understanding of the nature of systems.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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132–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
As used here, a system is “an entity made up of interconnected parts
with recognizable relationships that are systematically arranged to serve a per-
ceived purpose” (Kurpius, 1985, p. 369). As one of the interconnected parts
within a work setting, the human service provider needs to fully understand
the roles enacted, the relationship that exist, the values and assumptions that
support these relationships, and the degree to which all of these exert pres-
sure on the performance of one’s duties. One cannot be an ethical-effective
provider of service without full awareness of the system and system dynamics
in which he works
It is not unexpected that when working in a system with multiple con-
stituents that conflict in performance of one’s duties may emerge. This may
occur in a situation of a school counselor who feels that what is best for the
student may be contrary to the policy or procedures of the school, for whom
they work. Or it is possible that one working in an employee assistance pro-
gram (EAP) might experience the pressure of a divided loyalty. When under
contract to provide employees services, one might feel a strain between
the desire to maintain employee confidentiality while understanding that
the contract exists with the employee’s place of business, and there may be
a legitimate need to know on the part of that employee’s manager. Under
these conditions, information regarding the client’s treatment as related to
job performance may be within the need to know and thus conflicts with the
client’s right of privacy and confidentiality. The practitioner, while respect-
ing the confidentiality of the information gathered, needs to be sensitive to
the obligations agreed to in contracts with the organization. The EAP coun-
selor described in Case Illustration 6.2 appears to have developed a plan for
balancing the needs of the organization with the rights of the client.
Case Illustration 6.2
Balancing the Needs of the System and the Client:
A Case of Confidentiality
Hanna Johannsen was a private practicing mental health counselor
who was certified as an EAP counselor. In addition to seeing clients for
a fee, Hanna provided EAP services to the members of a local school
district. In this EAP capacity, Hanna received a contracted fee and was
to provide three to five sessions free of charge to any school district
employee who desired such counseling. In addition, should additional
counseling be desired or required, Hanna would make a referral to
another provider, and the employee would then be responsible to con-
tinue on a fee-for-service basis.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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ETHICAL CULTURE OF SOCIAL SYSTEMS ●
As part of the contract with the school superintendent, the EAP
counselor was to provide monthly reports that included (a) the number
of people seen, (b) the specific school in which the employee worked,
(c) the job class (i.e., teacher, administrator, staff, etc.), (d) the type of
problem presented, (e) the number of sessions utilized, and (f) and
evaluation of the outcome. While the specific names of clients and any
details of the nature of the problem presented were not to be disclosed,
Hanna felt that the information requested was such that it could
jeopardize the confidentiality of those who utilized this EAP service.
Hanna worked out a compromise with school administration so
that all first sessions could be made completely confidential. In that
first session, as part of setting the boundaries of confidentiality, Hanna
explained to each client the types of data she would reveal to the
superintendent and asked the client for their informed consent before
making additional appointments. If the client would not give that
consent, Hanna would provide a referral list and share no information
about the contact with the central office.
Organizations—or for that matter, any social system (e.g., families)—develop
their own values or standards that guide decision-making and practice within
that system. These values, which may take form explicitly in an organization’s
value statement or implicitly as behavior guiding day-to-day decisions, serve as
a core to what has been described as systems culture (Schein, 2010). Schein
described system culture as a “pattern of shared basic assumptions that the
group learned as it solved its problems of external adaptation and internal inte-
gration, that has worked well enough to be considered valid and, therefore,
to be taught to new members as the correct way you perceive, think, and feel
in relation to those problems” (Schein, 2010, p. 18). The assumptions that
serve as the base for the development and maintenance of a system’s culture
form the unquestioned, non-debatable truths and reality of people within the
system. These develop when a solution or procedure works repeatedly. As a
result, those involved begin to take it for granted to the point where what was
once only a hunch or possibility starts to get viewed and treated as a reality.
These basic assumptions then serve as the foundation from which the system
defines structures and processes to guide its operations. This is an important
concept for the ethical practitioner to grasp, because when members of an
organization embrace these assumptions, they in turn shape what the mem-
bers value and the form these values take (see Exercise 6.1).
Chapter 6. Conflict–●–133
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134–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
The cultural values of a system become enacted in the way mem-
bers prioritize and function-shaping policies, decision-making, and other
operations. Practice decisions, therefore, may begin to reflect institutional
values and organizational ethics more than they represent “best practice”
or codes of professional conduct. While it is possible that organizational
ethics can parallel those of the profession, in view of the fact that the
purpose of an organization may be different than the purpose of any one
helping relationship, the organizational ethics may not only be conflictual
but may act to undermine the values and ethics of the practitioner (see
Exercise 6.2).
While it is clear that the ethical practitioner must be aware of the often-
times subtle influence of a system’s culture on his or her practice decision,
Exercise 6.1
Making Culturally Compatible Choices
Directions: Below is a table that provides a social context, a focus for
a practitioner, and two practice decision options. Along with a col-
league, select the options that you feel would most likely be encour-
aged and/or supported by that particular social context and provide
your rationale for your selection.
Social-
Organizational
Cultural
Context
Focus for
Practice
Decision
Practice
Decision
Options
Selection
and
Rationale
(sample)
Catholic High
School
Increased evi-
dence of stu-
dent
pregnancy
1. Guidance
unit on sex-
ual behavior,
safe sex,
and sexually
transmitted
diseases
2. Guidance
unit on self-
esteem and
value of
abstinence
Option 2,
given the
school’s
belief that
sex outside
of marriage
is unaccept-
able and
immoral
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Social-
Organizational
Cultural
Context
Focus for
Practice
Decision
Practice
Decision
Options
Selection
and
Rationale
A free-standing
clinic that is
funded primar-
ily through
managed care
contracts
A client diag-
nosed as
depressed, with
the possibility
of having an
early history of
sexual abuse
1. Referral for
anti-depres-
sant medica-
tion
2. Contract for
long term,
“recovered
memories’’
therapy
A military
industrial com-
plex, making
“sensitive’’
technical
equipment
A personnel
director who is
approached by
an upper level
manager experi-
encing extreme
financial pres-
sures and who
has had fantasies
of “selling tech-
nology” to other
governments
1. Respect the
confidential-
ity of the rela-
tionship and
work with the
employee on
stress reduc-
tion
2. Report the
fantasies to
his supervisor
A public
school, with
limited spe-
cial education
facilities and
funding
A school psy-
chologist who
believes a
student is in
serious need of
ongoing indi-
vidual psycho-
therapy
1. Recommend
therapy to
his family
as part of an
Individual
Education
Program
2. Suggest that
his family
may find it
useful to con-
tact an out-
side therapist
Chapter 6. Conflict–●–135
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136–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Exercise 6.2
Goals: Values and Decisions
Directions: As noted within the chapter, decisions are made that not only reflect the values
held, but the goals desired. Below you will find a scenario, system and practitioner goals,
and decision options. Your task is to identify the decisions preferred by the system along
with those preferred by the practitioner. Next identify the situations in which these are
parallel or in conflict.
Scenario
System
Goals
Practitioner
Goal
Decision
Preferred
by System
Decision
Preferred by
Practitioner
Parallel or
Conflict
1. (sample) Star
football player
has a very bad
sprained ankle.
Win
the big
game
Rest the
ankle
Allow the
student to
play
Sideline the
student for
one game
Conflict
2. The top
salesman for a
corporation has
embraced his
alcoholism and
is committed
to a treatment
program.
Maintain
sales
Maintain
salesman’s
health
Adjust
sales region
to allow
salesman
to attend
meetings
while
continuing
sales
Encourage
and support
in attending
meetings
3. A social worker
noted that a fifth
grade teacher
who is approach-
ing retirement
has a number of
physical prob-
lems, has been
falling asleep in
class, and often
verbally abuses
the children for
making noise.
Educate
children
in fulfil-
ment
of the
schools
mission
Protect
children
from
verbal
abuse and
show
concern for
an aging
teacher
with ill
health
Try not to
make too
public for
the remain-
der of the
semester
and then
provide
the teacher
with an
early retire-
ment pack-
age
Work with
the teacher
in develop-
ing some
cooperative
learning
units while
providing
supportive
counseling
around the
benefits of
retirement
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Scenario
System
Goals
Practitioner
Goal
Decision
Preferred by
System
Decision
Preferred by
Practitioner
Parallel or
Conflict
4. A residential
setting for
individuals
with severe
emotional
problems
To
provide
therapy
while at
the same
time
reducing
patient
disruption
To provide
therapy
geared at
empower-
ing individ-
uals to take
responsi-
bility for
their own
actions
Reliance on
medication
including
sedatives
Using the
minimum
amount of
medication
in order
to support
the client’s
development
of cognitive/
behavioral
methods of
control
the question remains: “If enculturated, how does one identify the operating
assumptions, values, and culture?” It has been suggested that the use of inter-
pretation of the artifacts and values reveals basic assumptions (Schein, 2010).
Artifacts would include the visible, tangible, or concrete manifestations, be
they the physical surroundings and their appointments, the stories or oral
histories still shared, and even the rituals and ceremonies practiced, whereas
a system’s values are revealed in what the system views as important in terms
of goals, activities, relationships, and feelings (Schein, 2010)). By review-
ing the way those within the system traditionally and continually address
specific problems posed by the situations they face in common, the ethical
practitioner can begin to understand the system’s values.
WHO IS THE CLIENT? ●
One seminal question that needs to be addressed when working within an
organization is “Who is the client?” While this at first may appear to be a simple
question to answer, balancing a practitioner’s responsibility to the employing
organization while at the same time servicing the individual helper seeker is not
always that clear-cut or easy. The various professional organizations are aware
of this potential confusion and area of conflict and have attempted to provide
practitioners with guidelines for their practice decisions (see Table 6.1).
Chapter 6. Conflict–●–137
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138–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Table 6.1 Ethics of Practice Serving Client and Organization
Professional Ethical
Standards Statement on Serving Client and Organization
American Counseling
Association (2014)
C.2.g. Counselors monitor themselves for signs of impairment
from their own physical, mental, or emotional problems and
refrain from offering or providing professional services when
impaired. They seek assistance for problems that reach the
level of professional impairment, and, if necessary, they limit,
suspend, or terminate their professional responsibilities until it is
determined that they may safely resume their work. Counselors
assist colleagues or supervisors in recognizing their own
professional impairment and provide consultation and assistance
when warranted with colleagues or supervisors showing signs of
impairment and intervene as appropriate to prevent imminent
harm to clients.
American
Psychological
Association (2010)
1.03. If the demands of an organization with which psychologists
are affiliated or for whom they are working are in conflict
with this Ethics Code, psychologists clarify the nature of the
conflict, make known their commitment to the Ethics Code, and
take reasonable steps to resolve the conflict with the General
Principles and Ethical Standards of the Ethics Code. Under no
circumstances may this standard be used to justify or defend
violating human rights.
National Association of
Social Workers (2008)
3.09.a. Social workers generally should adhere to commitments
made to employers and employing organizations.
3.09.b. Social workers should work to improve employing
agencies’ policies and procedures and the efficiency and
effectiveness of their services.
3.09.c. Social workers should take reasonable steps to ensure that
employers are aware of social workers’ ethical obligations as set
forth in the NASW Code of Ethics and of the implications of those
obligations for social work practice.
3.09.d. Social workers should not allow an employing
organization’s policies, procedures, regulations or administrative
orders to interfere with their ethical practice of social work.
Social workers should take reasonable steps to ensure that their
employing organizations’ practices are consistent with the NASW
Code of Ethics.
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Although the various professional organizations address the issue of
serving individuals and organizations, it is still for the individual practitioner
to resolve questions such as, does the ethical practitioner, when working
with individual members of an organization, make decisions that are best
suited for the goals and objectives of the institution, even if not in the best
interest of the individual care seeker? Or does the individual and the indi-
vidual’s well-being take primacy? (See Case Illustration 6.3.)
Case Illustration 6.3
Who Is the Client?
Col. R. J. Wipps was a clinical psychologist working in service of the
U.S. Army’s Special Service Division. Col. Wipps provided testing and
individual counseling to those involved with Special Services.
Col. Wipps was approached by D. L. Kingsley, an officer in
charge of a highly sensitive military project. D. L. came to Col. Wipps
because of what he reported to be extreme stress as a result of financial
difficulties that he was currently experiencing. D. L. noted that he was
concerned that his wife would leave him if something didn’t happen
soon to improve their lifestyle. When asked what he was attempting
to do to resolve the financial problems, D. L. was quick to note that
“nothing short of something illegal” could help. When confronted
directly about whether he had considered illegal activities, D. L. stated:
“Of course not . . . but I’ve been drinking a lot lately and God only
knows what I could do if I get drunk!”
Col. Wipps recommended that D. L. take a medical leave while he
went into a treatment program for the alcohol and also received some
individual and marital counseling. D. L. said he would think about it but
really did not feel that was necessary. D. L. asked if he would be able
to see Col. Wipps for some counseling during this really stressful time.
D. L. also wanted to be sure that the relationship would be confidential.
For Col. Wipps (see Case Illustration 6.3), questions existed about
whether individual confidentiality should be respected or whether this
individual posed a significant security risk and thus should be identified to
appropriate personnel. In part, the answer to this question rested on whom
Col. Wipps identified as his client, D. L. Kingsley or the U.S. Army. Most
guidelines, like that of the American Counseling Association (ACA) (see
Chapter 6. Conflict–●–139
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140–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Table 6.1) indicate that the client is the primary concern for the ethical
helper and the institution secondary. But it could be argued that accepting
a position within an organization is a tacit agreement to serve as its agent
and to embrace its values and standards of practice. In fact, the ACA Code of
Ethics (2014) advised that acceptance of employment is essentially an agree-
ment with the principles and policies of the institution, and that “counselors
strive to reach agreement with employers regarding acceptable standards
of client care and professional conduct . . . ” (ACA, 2014, Principle D.1.g).
It would appear, therefore, that the ethical practitioner needs to be account-
able and responsive to both the system of employment and the individual
clients served within that system. As such, it is essential that the practitioner
not only understand but also commit to the mission of the organization as
well as the specific values underlying that mission and the ways it becomes
manifested in the procedures, policies, and decision-making processes. This
does not mean to suggest a blind allegiance to the organization at the cost of
the individual. In fact, it can be argued that the ethical helper will attempt to
change organizational policies and procedures that are not healthy for those
within the system. For example, the ACA Code of Ethics states: “Counselors
alert their employers of inappropriate policies and practices. They attempt
to effect changes in such policies through constructive action within the
organization. When such polices are potentially disruptive or damaging to
clients or may limit the effectiveness of services provided and change can-
not be affected, counselors take appropriate further action” (ACA, 2014,
D.l.h). In a similar vein the American Psychological Association (APA) directs
its members that “if the demands of an organization with which psycholo-
gists are affiliated or for whom they are working are in conflict with this
Ethics Code, psychologists clarify the nature of the conflict, make known
their commitment to the Ethics Code, and take reasonable steps to resolve
the conflict with the General Principles and Ethical Standards of the Ethics
Code. Under no circumstances may this standard be used to justify or defend
violating human rights” (APA, 2010). The significance of this responsibility
to confront organizational policies and practices that are deemed damag-
ing to clients or in some way forcing practitioner unethical behavior is high-
lighted by the ACA directive that if there is an irreconcilable conflict between
the institution’s practices and those standards established by the code, resig-
nation from employment should be considered (ACA, 2014, Principle D.1.h).
Thus, while some practitioners find themselves feeling responsible for
championing the client’s right to confidentiality in the face of the organi-
zation’s rules and regulations, in some situations, this is neither legal nor
ethical. For example, in the military, confidentiality is guided by federal
statutes, Department of Defense regulations, and the specific service (i.e.,
Army, Navy, Air Force) regulations, a point that needs to be considered
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by Col. Wipps (see Case Illustration 6.3). While supporting respect for
the privacy of the individuals, these directives also mandate access to
confidential materials by federal employees on a “need to know” basis
(Neuhauser, 2011).
An ethical practitioner attempts to resolve conflicts between organiza-
tional need and individual need in a way that not only reflects the desire
of the practitioner to be supportive of his or her organization but also
upholds the professional code of ethics. Thus, when confronted by the
desire to protect the care seeker’s privacy while abiding by the rules and reg-
ulations of the organization in which one is employed, the use of advanced
warning on the limits of confidentiality would be essential as a means of
serving both the organization of employment and the care seeker.
When There Are Multiple Masters
Ethical practitioners will not only know the mission, objectives, and val-
ues of the organizations within which they work, but will also make known
to their employers the nature of their own professional ethical commit-
ments. Beyond this, it appears that an ethical practitioner will also share with
his or her clients the obligations of fidelity and conditions of employment
and how these may flavor the helping relationships and the practitioner’s
decisions. This is especially important when an organization’s disclosure
policy places additional limits on the confidentiality between client and
helper (see Case Illustration 6.2).
Recently, the issue of multiple clients or conflicts between the needs of
an employing organization with those of the client has taken on a new dimen-
sion with the introduction of managed care. Managed care is a term applied
to a widespread set of attempts to contain health care costs. The term has
been used to describe “any type of intervention in the delivery and financing
of health care that is intended to eliminate unnecessary and inappropriate
care and to reduce costs” (Langwell, 1992, p. 22). Under managed care, third-
party payers review requests for the initial delivery of services, determine the
volume of services to be provided, and review any subsequent requests for
service. Given the level of involvement in the professional decision process,
it could be argued in managed care situations the practitioner has in fact two
clients, the primary client being the person seeking assistance and the second-
ary client being the managed care company. The potential for conflict can arise
in that the needs and goals of these two clients may not always be congruent.
Managed care is essentially an economic strategy designed to provide
care of or better quality for less money. While the concept of cost contain-
ment is noble, the reality is that the goals of managed care can be in conflict
Chapter 6. Conflict–●–141
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142–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
with those of the practitioner (Meyers, 1999). Metzl (2012), for example,
argues that managed care’s desire to create a homogenous cost effective
product or template for treatment planning, while perhaps working with
the administration of EKGs to patients with chest pain are not applicable
to the nonhomogenous client base presenting with depression, personality
disorders, or other form of mental health conditions.
Under these conditions, the question that can arise is, at what point
does the cost containment interfere with the client’s needs and the helper’s
ethical practice?
Managed care may challenge the practitioner’s ability to provide ethical
practice. Managed care stresses time-limited interventions, cost-effective treat-
ment, toward preventive rather than remedial processes (Metzl, 2012). Profes-
sional literature raises several concerns about the impact of managed care on
the effectiveness of treatment provided (Roberts & Hurley, 2012). As noted by
these authors (Roberts & Hurley, 2012), managed care could result in clients
receiving undertreatment, in that they may go underdiagnosed, experience
restricted referral, and have insufficient follow-up. Thus, the policies of man-
aged care may conflict with the practitioner, especially when utilization review
decisions are contrary to professional judgment or when short-term or limited
interventions are inadequate forms of treatments. Ethical rules and standards
are often incongruent with the realities of treatment situations. In a managed
care environment with restrictions to the number of sessions allowed, adher-
ing to professional guidelines for risk management and standard of care service
may simply be unrealistic.
In addition to potentially restricting treatment choice, the third party
review can also compromise client privacy. Given these potential areas of
conflict, what is the ethical practitioner to do?
At a minimum, the ethical practitioner needs to inform clients how their
delivery of services may be influenced by managed care policies and restric-
tions. Our professional codes have addressed this concern by directing
clinicians to provide clients information needed to understand the potential
conflict and the limits imposed on practice. For example, APA directs its
members as follows:
When psychologists agree to provide services to a person or entity
at the request of a third party, psychologists attempt to clarify at the
outset of the service the nature of the relationship with all individuals
or organizations involved. This clarification includes the role of the
psychologist (e.g., therapist, consultant, diagnostician, or expert wit-
ness), an identification of who is the client, the probable uses of the
services provided or the information obtained, and the fact that there
may be limits to confidentiality. (APA, 2010, Principle 3.07)
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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A point echoed in the codes of ethics presented by the American Asso-
ciation for Marriage and Family Therapy (AAMFT, 2015, Principle 1.13),
beyond informing clients of the third-party relationship, practitioners are
directed to gain client permission prior to any disclosure to that third party
(e.g., ACA, 2014, B.3.d; AMHCA, 2010, 2.q; NASW, 2008, 1.07.h).
Another concern that can arise when working within a managed system
is that of balancing the requirements of managed care’s cost containment
principle with the ethical concern of providing quality of care, when such
care requires extending services beyond that sanctioned by the managed
care agency. How it is accomplished is truly the dilemma faced by all man-
aged care providers. Do therapists continue pro bono? Do they challenge the
managed care gatekeepers about artificial limits to needed care?
While the limitations to the number of sessions to be paid by insurance
may make good economic and business sense for the insuring body, the
question remains: What happens to the client once these limits are reached?
Should the client continue to need care, the helper is ethically bound not
to abandon him or her. The helper could refer the client needing additional
treatment or provide pro bono services. Both strategies invite complication.
How does one refer if referral sources are limited? How does one provide
pro bono services to so many and survive financially? The answer may lie
in the decisions an ethical practitioner makes before engaging in managed
care service. Haas and Cummings (1995) advise therapists to consider the
question of how to provide service to the client and how to avoid abandon-
ing clients without going bankrupt before one joins a managed care plan.
Understanding the nature of the managed care contract and resolving areas
of professional standards of practice and care with those of economic neces-
sity is a must for the ethical helper (see Exercise 6.3).
Exercise 6.3
Serving Clients in a Managed Care Environment
Directions: Contact two private practitioners who provide clinical
services and are part of a managed care organization. Ask the practi-
tioners each of the following questions:
• What are the limits to the types and/or length of services you can
provide to your managed care clients?
• Are there are any unique limitations to the confidentiality of your
records when working with managed care clients?
(Continued)
Chapter 6. Conflict–●–143
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144–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
● BEYOND PROFESSIONAL STANDARDS:
A PERSONAL MORAL RESPONSE
• What, if any, avenues of appeal do you have regarding the deci-
sions made by the managed care utilization review boards?
• How do you inform your clients of the special conditions regard-
ing type and length of service, utilization review, confidentiality,
and so forth, that may exist by the nature of providing managed
care services?
• Have you turned down any opportunities to join a particular
managed care group because you found it too restrictive?
• Have you been able to change any policies, procedures, or
requirements in the managed care organization of which you are
a part as a way of better servicing your clients?
• As a provider in managed care, what do you find to be the most
challenging factor to your ability to provide ethical, professional
care for your clients?
(Continued)
While it is easy to grasp and comprehend the dilemmas one may face as
the varying demands, needs, and responsibilities of client, profession, and
system of employment converge on a practitioner, positioning oneself to
make the ethical decision may be quite another story. The existence and
potential impact of these forces is not a simple intellectual or academic
issue. It is a real-life dilemma that has the potential to impact the client, the
practitioner, and the therapeutic relationship. Restrictions of modes and
duration of treatment not only have the potential to undermine effective-
ness but also can erode the professional’s personal and professional values.
The limited autonomy on professional decision-making may increase the
stress experienced in practice and contribute to conditions of burnout and
empathy fatigue (See Chapter 14). Confronted with these conditions, the
ethical practitioner may find herself confronted by a conflict between the
institution’s practices and the standards established by her professional
code. Such conflicts will require ethical practitioners to clarify and resolve
these conflicts in a way that maximizes adherence to ethical dictates of
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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their profession. This can be facilitated by establishing a preplan of resolv-
ing potential conflicts between organization and professional ethics and
values, including adjusting contracts and contract demands so that they are
in line with system goals AND professional standards. When this is not pos-
sible, then it is the contention of these authors that the ethical practitioner
should consider resignation. Exercise 6.4 is provided as a stimulus for your
own development of such a preplan.
Exercise 6.4
Recontracting or Resigning
Directions: Part 1: Below you will find a number of organizational poli-
cies or procedures that a practitioner would need to follow. Identify
those you find objectionable. How would you attempt to rework these
policies/procedures before you would resign your post?
Organizational
Directive (Policies/
Procedures) Rework or Recontract Resign?
All clinical records,
including notes, are
open to inspection
by anyone identified
as an executive
administrator within
the organization.
Attempt to specify the
specific types of data
open for review and tie
each level of data to a
specific administrator
with a “need to know.”
Further, all clients
would be informed
as to the access to
records.
Yes, if not
modified
Allowed only to
utilize a brief therapy
form of service.
Therapy restricted
to eight sessions
maximum.
(Continued)
Chapter 6. Conflict–●–145
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146–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Organizational
Directive (Policies/
Procedures) Rework or Recontract Resign?
Prior to providing ser-
vice, all intake infor-
mation must be shared
with a review board in
order to achieve per-
mission to continue.
Further, a specific
treatment plan and
progress reports must
be completed after
every four sessions.
As an employee,
you are required
to provide service,
in-house, for all
the clients you see,
regardless of their
needs and your level
of training.
You are required to
acquire a minimum
of 30 continuing
education credits
in your professional
field every 2 years.
Part 2: Ask an individual care provider who is a member of a managed
care program to show you his or her contract and statement of
responsibilities, policies, and procedures governing service delivery.
Review this contract and identify areas that you feel may potentially
compromise your ability to provide ethical practice.
(Continued)
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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CONCLUDING CASE ILLUSTRATION ●
Returning to the scene with which we opened the chapter, we find Ms. Wicks
(Maria’s counselor) expressing her felt conflict among the informal values and
rules of conduct held within the system in which she works, her concern for
her client, and her understanding of her professional code of ethics. As you
read the continuing dialogue, try to identify some of the values and/or under-
lying assumptions existing within that school’s culture and begin to identify
where and how these may conflict with this particular counselor’s under-
standing of her professional code of conduct. The questions in the reflection
section that follows the exchange should help you in this process.
Ms. Wicks: Hi, Tom, it is me again.
Mr. Harolds: Hey, how are you? Did you get that information from the state
association?
Ms. Wicks: Not yet, they are supposed to call me. But, things are getting
more confusing . . .
Mr. Harolds: Really?
Ms. Wicks: Ms. Armstrong, the principal at the school, informed me that it
is understood in the district that we are not to counsel students
regarding sexual issues. She said it is not a formal policy, just
something that “we” all know not to do. So now I’m not sure if
I broke a law, or violated a code of ethics, or may have stepped
over the line in terms of my job definition. I am so confused!
Mr. Harolds: Well, Michelle, this is a very conservative community, and the
truth is that with so many of our students having Latino back-
grounds, we rea1ly don’t want to impose mainstream cultural
values where they don’t belong.
Ms. Wicks: But, Tom, it is not like I’m going to promote a particular position
here. I am just very concerned that she is making some decisions
that could prove harmful and even potentially lethal to her.
Mr. Harolds: It is clear you are concerned about your client, but you need to
understand something. In the past, we attempted to help the
students make what we thought were value decisions. In fact,
in health class we used to have a unit on sexuality and sexually
transmitted diseases. Well, 5 years ago a parent group took the
Chapter 6. Conflict–●–147
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148–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
health teacher, the principal, and the school superintendent
all to court for supposedly “imposing moral values” on their
children. As a result, we removed health from our curriculum,
replaced it with something on career choices, and created a
parent supervisor board for the school that reviews curriculum
decisions. So the superintendent is likely to be extremely sensi-
tive about anything that may be interpreted as promoting a set of
values or beliefs. I guess Ms. Armstrong is simply trying to avoid
pressure from the central office. No sense rocking the boat.
Reflections
1. Assuming that Mr. Harolds’s depiction of the way the system operates
is accurate, what would be the primary value or motive driving deci-
sions around controversial topics?
2. When it comes to decision-making, which of the following would
you suspect takes primacy in the culture of that school: Do what’s
expedient? Avoid conflict at all costs? Be politically correct? Do what
is best for the students?
3. Could you identify an artifact that reflects the operating values and
assumptions within that school?
4. What do you feel Ms. Wicks should do? In relationship to her client?
Future clients? Her principal? Her job definition and contract?
● COOPERATIVE LEARNING EXERCISE
Directions: With a colleague, review each of the following scenarios and
• Identify potential areas of conflict
• Decide if the behavior of the practitioner is ethical
• Identify decision options available for the practitioner
• Discuss possible preplan options that could have been implemented
to reduce the potential of conflict.
Scenario 1: High School Counselor
A high school counselor has been working with a student athlete who
was self-referred, because of his concern about his tendency to attend under-
age drinking parties on the weekends and become intoxicated. The student
expressed genuine concern over these tendencies and appeared willing to
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work with the counselor in order to curtail both the desires and the actions.
He is particularly concerned with changing his behaviors, as the basketball
season has just begun and he is the starting center for the team. There is a
zero-tolerance policy for student athletes engaging in illegal activities, such
as underage drinking. The counselor feels that he should warn the basketball
coach about the student’s tendencies toward attending parties and drinking
on the weekends.
Scenario 2: An Employee Assistance Provider (EAP)
Dr. Livingston is a licensed social worker working in private practice.
Dr. Livingston also provides short-term counseling to employees of a local
manufacturing plant. In this capacity as an employee assistance counselor,
she has agreed to provide short-term (maximum of five visits) counseling to
all employees and offers referral services for those needing more extended
care. Further, her contract calls for her to consult with managers in order to
increase their effectiveness when working with their employees.
In working with Helen, Dr. Livingston discovered that Helen and her
coworkers have been punching in and out for one another and, as a result,
have developed a system where they can cut approximately 8 hours a week
off their actual work while recording and receiving pay for a full 40-hour
week. Helen is a little troubled by this procedure but reports this is what
everybody does. Dr. Livingston feels that she should report this information
to Mr. Hansen, the owner of the company, since it is he with whom she has
a contract.
SUMMARY ●
• Practice decisions made must reflect not only the needs of the client
and characteristics and orientation of the helper but also the unique
characteristics and demands of the context or organization in which
the helping occurs.
• A professional role as well as the expectations of professional behav-
ior is shaped in response to the organization’s expectations and
needs; therefore, these expectations are incorporated as standards
and guides for practice decisions.
• System culture is a pattern of basic assumptions invented, discovered,
or developed by a given group as it learns to cope with its problems of
external adaptation and internal integration. The pattern has worked
well enough to be considered valid and is taught to new members as
Chapter 6. Conflict–●–149
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150–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
the correct way to perceive, think, and feel, in relationship to those
problems.
• Once enculturated within a system, it is easy for the cultural values
to become enacted in the way members prioritize and function—
shaping policies, decision-making, and other operations. As such,
practice decisions may begin to reflect institutional values and
organizational ethics more than they represent “best practice” or
codes of professional conduct.
• Most guidelines, like that of the ACA, indicate that the client is the
primary concern for the ethical helper and the institution secondary.
But it could be argued that accepting a position within an organiza-
tion is a tacit agreement to serve as its agent and to embrace its values
and standards of practice.
• The ethical practitioner needs to be accountable and responsive to
both the system of employment and the individual clients served
within that system.
• Ethical practitioners will share with their clients the obligations of
fidelity, conditions of employment, and how these may flavor the
helping relationships and the practitioners’ decisions. One special
situation in which it is clear there may be more than one client is in
the case of managed care.
• Managed care is essentially an economic strategy designed to provide
care of equal or better quality for less money. The policies of managed
care may conflict with the decisions of an ethical practitioner, espe-
cially when utilization review decisions are contrary to professional
judgment or when short-term or limited interventions are inadequate
forms of treatments.
• Understanding the nature of the managed care contract and resolv-
ing areas of professional standards of practice and care with those of
economic necessity is a must for the ethical helper.
• Acceptance of employment is essentially an agreement with the prin-
ciples and policies of the institution. When conflict exists between the
institution’s practices and the standards established by the code, the
ethical practitioner needs to clarify and resolve conflicts in a way that
maximizes adherences to ethical dictates of his or her profession. This
can be facilitated by establishing a preplan of resolving potential con-
flicts between organization and professional ethics and values, including
adjusting contracts and contract demands so that they are in line with
system goals AND professional standards. When this is not possible,
then it is the contention of these authors that the ethical practitioner
will consider resignation.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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IMPORTANT TERMS ●
artifacts managed care
basic assumptions need to know
client organizational ethics
cultural values preplan
ethical culture of social systems system
limits of confidentiality utilization review
ADDITIONAL RESOURCES ●
Houser, R., Wilczenski, F. L., & Ham, M. (2006). Culturally relevant ethical decision-
making in counseling. Thousand Oaks, CA: Sage.
Sperry, L. (2007). The ethical and professional practice of counseling and psycho-
therapy. New York, NY: Pearson.
Thompson, R. (2012). Professional school counseling: Best practices for working in
the schools. New York, NY: Taylor & Francis.
Web-Based
Daniels, J. A. (2001). Managed care, ethics, and counseling. Journal of Counseling
and Development, 79, 119–122. doi: 10.1002/j.1556-6676.2001.tb01950.x
Glosoff, H. L., & Pate, R. H., Jr. (2002). Privacy and confidentiality in school counsel-
ing. Professional School Counseling, 6(1), 20–27.
Kremer, T. G., & Gesten, E. L. (1998). Confidentiality limits of managed care and cli-
ents’ willingness to self-disclose. Professional Psychology: Research and Practice,
29(6), 553–558. Retrieved from http://dx.doi.org/10.1037/0735-7028.29.6.553
Mappes, D. C., Robb. G. P., & Engels, D. W. (1985). Conflicts in ethics and
law in counseling and psychotherapy, Journal of Counseling and Devel-
opment, 64(4), 246–252. Retrieved from http://onlinelibrary.wiley.com/
doi/10.1002/j.1556-6676.1985.tb01094.x/abstract
Reamer, F. G. (2008). When ethics and the law collide, Social Work Today, 8(5).
Retrieved from http://www.socialworktoday.com/archive/EoESepOct08.shtml
Stone, C. (2006, January). Confidentiality and the need to know. ASCA school-
counselor. Retrieved from http://schoolcounselor.org/magazine/blogs/
january-february-2006/confidentiality-and-the-need-to-know
Chapter 6. Conflict–●–151
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152–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
● REFERENCES
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153
CHAPTER 7
Ethical Decision-Making
Ms. Wicks: You know, this job seemed easier when I was in school.
All the case examples used in class were so clear-cut. It was easy to
understand what was ethical and what was not.
Mr. Harolds: You would think there would be clear-cut answers to
what you are supposed to do, and when you are supposed to do it.
Ms. Wicks: That’s certainly not the case in my fieldwork! Professional
practice in real life is not always that clear.
The student’s reflection of how real life differs from the somewhat
“artificial” life of the textbook or academic setting highlights the fact
that ethics and ethical practice are not as simple or as clear-cut as
may be assumed or certainly desired. As one in the early stage of your pro-
fessional life, the thought of committing a violation against your professional
ethics may seem foreign and remote. Sadly, violations or at least behavior
approaching ethical violations are neither foreign nor remote. As reported
by one organization, nearly 5,000 ethical inquiries regarding counselor deci-
sions and practices were made in 2011 (ACA, 2012).
Our professional codes are “guidelines,” neither recipes nor clear direc-
tives. While it is essential to understand and embrace our ethical codes, it is
equally important for each professional and professional-in-training to under-
stand, embrace, and employ a process that will facilitate the application of
these codes, especially in those situations where clear, ethical pathways are
less than evident.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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154–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
● OBJECTIVES
The current chapter will review models for ethical decision-making and
provide an integrated model that helps clinicians move from the recogni-
tion and assessment of an ethical dilemma through planning, implementing,
and evaluating the impact of their practice decisions. Case illustrations and
guided exercises are provided to not only add to the clarity of understand-
ing but to facilitate, your valuing of the need for an ethical decision-making
process to guide your own practice decisions.
After reading this chapter you should be able to do the following:
• Not only understand but also value the need and importance of
employing ethical decision-making models to guide practice decisions;
• describe a number of step-wise and value-based models of ethical
decision-making;
• identify and explain common elements that can be crafted into a more
generic, integrated model for ethical decision-making; and
• apply an integrated model of ethical decision-making to illustrated cases.
● CODES OF ETHICS: GUIDES NOT PRESCRIPTIONS
A set of rules and directives that would result in efficient and ethical pro-
fessional practice would be something clearly welcomed by student and
professional alike. However, as should be clear by now, such prescriptions
or recipes for professional practice do not exist, nor does every client and
every professional condition provide clear-cut avenues for progress.
Professional practice is both complex and complicated. The issues pre-
sented are often confounded and conflicting. The process of making sense of
the options available and engaging in the path that leads to effective, ethical
practice cannot be preprogrammed but rather needs to be fluid, flexible,
and responsive to the uniqueness of the client and the context of helping.
The very dynamic and fluid nature of our work with clients prohibits the
use of rigid, formulaic prescriptions or directions. Never is this so obvious
as when first confronted with an ethical dilemma.
Consider the subtle challenges to practice decisions presented in Case Illus-
tration 7.1. The case reflects a decision regarding the release of information and
the potential breach of confidentiality. The element confounding the decision,
as you will see, is that the client was deceased and it was the executrix of the
estate providing permission to release the information to a third party.
As noted, the main question to be considered in this case is, does con-
fidentiality extend into the grave and if not, under what conditions can
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 7. Ethical Decision-Making–●–155
Case Illustration 7.1
Conditions for Maintaining Confidentiality
While all clinicians have been schooled in the issue of confidential-
ity and the various conditions under which confidentiality must be
breached (e.g., prevention of harm to self or another), the conditions
of maintenance of confidentiality can be somewhat blurred when the
material under consideration is that of a client who is now deceased.
Consider the case of Dr. Martin Orne, MD, PhD.
Dr. Orne was a psychotherapist who worked with Anne Sexton,
a Pulitzer Prize winner. Following the death of Ms. Sexton, an
author, Ms. Middlebrook, set out to write her biography. In doing her
research, Ms. Middlebrook discovered that Dr. Orne had tape-recorded
a number of sessions with Ms. Sexton in order to allow her to review
the sessions, and he had not destroyed the tapes following her death.
Ms. Middlebrook approached Linda Gray Sexton, the daughter
of the client and the executrix of the estate, seeking permission to access
these tapes of the confidential therapy sessions as an aid to her writing.
The daughter granted permission for release of the therapeutic tapes.
A number of questions could be raised around this case, includ-
ing the ethics of tape-recording or the ethics of maintenance of the
tapes following the death of the client. However, the most pressing
issue involves the conditions under which confidentiality should be
maintained. The challenge here is, should Dr. Orne release the tapes
in response to the daughter’s granting of permission, or does his client
have the right to confidentiality even beyond the grave?
(should) it be violated? You may find it informative to discuss that question
with your classmates or colleagues, and to aid in that discussion, you may
want to consult the following website for additional information on the case
(http://www.dianemiddlebrook.com/sexton/tpg12-91.html).
While our standards and professional codes of practice can help us in
resolving questions, such as that found in Case Illustration 7.1, they do not
(nor do they purport to) provide clear direction and solution in any and all
situations. Even principles such as informed consent, confidentiality, and
boundaries, while appearing clear and easily applied, can be challenging
to enact in professional practice. Consider these principles in light of some
challenging practice conditions (see Table 7.1).
Clearly, as a human service provider, you will encounter situations in which
you are confronted by an ethical dilemma. The situation may include if and when
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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156–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Table 7.1 Challenges to Clarity
Issue/Code Challenge
Real Life Challenge:
Case Scenario
Direction?
Decision?
Confidentiality
Keep information
confidential unless legal
requirements demand
that confidential
information be revealed
or a breach is required
to prevent serious and
foreseeable harm to the
student. (ASCA, 2016,
A.2.e)
To act or not to
act requires the
counselor to
interpret the
meaning of serious
and foreseeable
harm and
judge a client’s/
student’s behavior
as serious
enough to break
confidentiality.
A 17-year-old high
school senior discloses
the fact that she is
trying to “secretly” get
pregnant as a way of
making her boyfriend
make a commitment to
her.
A 12-year-old middle
school student has
shared that she is
actively engaging
in sexual activity,
including intercourse,
with one of her eighth-
grade peers.
How might
you apply
the concept
of “prevent
serious and
foreseeable
harm to the
student”?
Could a case be
made in either
illustration
for breaking
confidentiality?
How about
maintaining
confidentiality?
Boundaries
A psychologist refrains
from entering into a
multiple relationship if
the multiple relationship
could reasonably be
expected to impair
the psychologist’s
objectivity, competence,
or effectiveness
in performing his
or her functions
as a psychologist,
or otherwise risks
exploitation or harm
to the person with
whom the professional
relationship exists.
APA, 2010, 3.05)
The challenge is
to define those
conditions where
the multiple
relationships
could be expected
to impair one’s
objectivity,
competence, or
effectiveness.
While some
situations are
clear, as in having
a romantic
relationship with
a current client,
others may fall in
those shades of
gray.
A clinical psychologist in
private practice is invited
to serve as head coach
for the high school girls’
soccer team. To her
surprise, she arrived at
the first team meeting to
discover that the team’s
star player is also her
client.
While participating in
a single-parents group
at her local church, a
practicing psychologist
is approached by a
previous client who
“invites” her out for a
drink following one of
the meetings.
Can the
clinician
engage in both
roles—as coach
and therapist?
Is “socializing”
with this
previous client
allowable?
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 7. Ethical Decision-Making–●–157
Issue/Code Challenge
Real Life Challenge:
Case Scenario
Direction?
Decision?
Informed Consent
Clients have the
freedom to choose
whether to enter into or
remain in a counseling
relationship and need
adequate information
about the counseling
process and the
counselor. (ACA, 2014,
A.2.a)
Challenges could
include the
following:
Are there
conditions that
inhibit a client’s
ability to provide
informed consent?
Do all clients have
the ethical right of
freedom to choose
or are there
conditions (e.g.,
age, diagnosis,
court mandate,
etc.) that limit that
freedom?
The client, who is 26
years old, came to the
session having been
driven by his father.
During the initial
intake, it became clear
to the counselor that
the client had some
form of neurological
impairment not
previously disclosed.
The client is an 8-year-
old, third-grade student
who was referred by
his teacher because
of what she felt was
unusually aggressive
drawings and stories in
his journal.
How might
this issue of
neurological
damage
influence the
clinician’s
approach to
“informed
consent”?
Does age,
issue, or
context (i.e.,
school) affect
the client’s right
of freedom to
choose?
to disclose confidential information without a client’s consent (e.g., a suicidal
client) or the ethics of limiting a client’s right to self-determination (e.g., when
involuntary hospitalization is required) or even the appropriateness of engaging
in nonprofessional relationships with a former client. These ethical dilemmas
are difficult to resolve, because by one definition, that of Kitchener as cited in
Shiles (2009), an ethical dilemma occurs when “there are good but contradic-
tory ethical reasons to take conflicting and incompatible courses of action”
(p. 43). As such, the ethical dilemmas we encounter are by definition often subtle
and always, by definition, without a singular clear path to resolution. Consider
the findings of one study assessing 450 members of the American Psychological
Association’s Division 29 (Psychotherapy) by Pope, Tabachnick, & Keith-Spiegel
(1987). Of the 83 separate behaviors the members were asked to rate according
to ethicality, very few—for example, having sex with a client or breaking confi-
dentiality if clients are suicidal or homicidal—were clear-cut. Most of the 83 fell
in what the authors termed “gray areas” between being ethical and unethical.
Such data highlights the difficulty one experiences when faced with an ethical
dilemma and the need for a sound model of ethical decision-making.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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158–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
● ETHICAL DECISION-MAKING: A RANGE OF MODELS
Life—at least our professional lives—would be easier if all practice deci-
sions and ethical dilemmas were black or white. As should now be evident,
the ethical nature of our practice decisions are most often colored in many
shades of gray, and thus the path to follow is not always clear.
For some, the goal is to follow the ethical codes from a mandatory per-
spective and thus be true to the letter of the law. While this is a basic level of
ethical functioning and may serve to protect the human service provider to
avoid legal trouble, this should not be the main focus of our ethical choices.
We are called to embrace our ethics on an aspirational level. For one embrac-
ing aspirational ethics, the goal is not self-protection but rather client welfare.
While it is our duty, our responsibility, to understand and embrace our codes
of ethics (i.e., mandatory ethics), the execution of these codes in practice
demands that we engage in self-reflection and the employment of a decision-
making process that results in what is best for each of our clients (i.e., aspi-
rational ethics). Reliance on one’s “gut-feelings” or intuition, in the absence
of reflection on that which is both mandatory and aspirational, presents an
ethical problem in itself, given the greater risk to the public (Welfel, 2010).
In complex situations, the American Counseling Association’s (ACA)
Ethics Committee, for example, recommends that counselors explore pro-
fessionally accepted decision-making models and choose the model most
applicable to their situation (Kocet, 2006). This position has even been
codified in the ACA Code of Ethics where it is noted: “When counselors
are faced with an ethical dilemma, they use and document, as appropriate,
an ethical decision making model . . . ” (ACA, 2014, Code I.1.b).
While there is no one specific ethical decision-making model that has
been identified as most effective and globally embraced, it is important, as
noted by the ACA (2014, p. 3), for practitioners to be familiar with a credible
model of decision-making. To this end, numerous authors have offered models
for ethical decision-making, a sampling of which is offered in the next section.
Each model offers a unique perspective or lens through which to view prac-
tice decisions and ethical dilemmas and as such are worthwhile, considering as
each may reflect your style of practice and/or the context in which you work.
Ethical Justification Model
Kitchener (1984) has provided what some feel is the foundation for ethi-
cal decision-making (see Sheperis, Henning, & Kocet, [2016]). In fact, many
of the ethical decision models use Kitchener’s virtues as a springboard for
their development (Urofsky, Engels, & Engerbretson, 2008).
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 7. Ethical Decision-Making–●–159
Kitchener (1984) was aware of the then existing limitations to ethical
codes and thus directed psychologists to consider the fundamental ethical
principles that not only serve as the foundation for professional codes but pro-
vide a conceptual vocabulary for analyzing ethical issues when direction is less
than clear. Kitchener invited practitioners to employ the values of autonomy,
nonmaleficence, beneficence, fidelity, and justice (see Chapter 3) as reference
points when making ethical decisions. From this perspective, clinicians would
ensure that their decisions not only treated each client equally given equal cir-
cumstances (justice) but also supported client freedom to choose (autonomy).
Further, based on these principles, a practitioner’s ethical decisions would be
made in a way that not only avoided harming the client (nonmaleficence) but
promoted help and health (beneficence).
For example, while having a sexual relationship with a client is clearly
unethical, the question of ethics when applied to other nonsexual, multiple-
role relationships with former clients may be less obvious (Anderson &
Kitchener, 1998). In these situations, the codes may not be clear and direc-
tive. Kitchener (1984) would suggest that clinicians allow their concern
about not undoing therapeutic gains (i.e., nonmaleficence) along with their
desire to refrain from affecting client self-determination (i.e., autonomy) to
guide their decision to engage or not to engage in these nonsexual, multirole
relationships. To further clarify this perspective, we invite you to engage in
Exercise 7.1, applying foundational values.
When exploring an ethical dilemma, reflection on these moral values or
principles may offer insight into the path best chosen. However, it has been
suggested (e.g., Forester-Miller and Davis, 1996) that in complicated cases the
employment of a step-wise decision-making model may be useful.
Step-Wise Approach
Forester-Miller and Davis (1996) detailed one step-wise approach that
was presented in the ACA document “A Practitioner’s Guide to Ethical
Decision Making” (http://counseling.org/docs/ethics/practitioners_guide
?sfvrsn=2). The authors presented a practical, seven-step process for
ethical decision-making. The steps included the following:
Step 1: Identify the problem articulating the ethical concern. During this
step, the practitioner needs to gather information that sheds light on the
depth and breadth of the situation. The authors suggest that the practitioner
consider questions such as, is this an ethical, legal, professional, or clinical
problem or perhaps some combination? Is the issue a reflection of me,
the client, others in the client’s life, and/or the system in which I work?
Answering these questions helps focus the targets for resolution.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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160–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Exercise 7.1
Applying Foundational Values
Directions: The task is to review the following situations confronting a therapist. Your task is to
first decide what you would do. Next—and this may be best done in consult with a classmate,
colleague, or professor—view your decision through the values of autonomy, nonmaleficence,
beneficence, fidelity, and justice. Would this process alter your initial decision?
Situation
Your
Decision Autonomy Nonmalefi cence Beneficence Fidelity Justice
An 8-year-
old, third-
grade student
attempts
to hug the
school
counselor
upon
entering the
office.
In a group
session,
which is
working on
social skills,
a client
diagnosed
with autism
offers a
hug to the
therapist.
The client,
a 74-year-
old religious
sister (nun)
brings a
hand-knit
scarf as a
gift to the
therapist.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 7. Ethical Decision-Making–●–161
Step 2: Apply the ACA Code of Ethics. While developed for use by
counselors and thus the reference to ACA Code of Ethics, this decision-
making process could be employed by all mental health professionals
by making reference to the appropriate professional standard and code
at this step in the process. It is important to review the codes in order
to identify all standards that may apply to the situation. If the codes
do not provide clear and direct insight into the path of resolution,
additional steps of the decision-making process will be necessary.
Step 3: Determine the nature and dimensions of the dilemma, noting
the scope of the issue engaging the current professional literature,
colleagues, and even professional associations to ensure the most
current perspective on this type of problem is incorporated.
Situation
Your
Decision Autonomy Nonmalefi cence Beneficence Fidelity Justice
At a fund
raising
dinner, the
chair of
the event
introduces
himself to the
guest speaker,
a psycho-
therapist
within the
community.
He then
asks how his
brother is
progressing
in his therapy,
noting that
his brother
is under his
care and it
is he who is
paying for the
therapy.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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162–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Step 4: Generate a possible course of action that could result in resolution.
During this step, be creative; brainstorm in order to develop the widest
possible selection of options.
Step 5: Consider the potential consequences of all options. It is
important to identify all possible implications of each course of
actions as it may impact the client, others, and even yourself. Identify
the option or combination of options that best serve the situation.
Step 6: Evaluate the selected course of action. At this step, it is especially
important to be sure that the path selected will not create additional
ethical concerns.
Step 7: Implement the course of action. Once the pathway has been
selected and implemented, it is important to assess to ensure that the
desired impact or outcomes were achieved.
The employment of such a step-wise approach DOES NOT ensure that
each practitioner, in similar situations, would arrive at the same path or
outcome. However, the use of this or similar systematic models allows each
clinician to not only give evidence of their valuing of ethics and ethical
decision-making but to be able to articulate and explain their deliberations
and reflections in the selection of a course of action.
Case Illustration 7.2 highlights the use of this approach and Exercise 7.2
invites you to employ the model on simulated case dilemma.
Case Illustration 7.2
Confidentiality Violation?
The client, Mr. E., left a message on Dr. Ellis’s voicemail asking that
the therapist send a bill summarizing all contact over the past year. As
noted on the voicemail, Mr. E. was going to submit the summary to his
insurance for possible reimbursement. Mr. E. left no further instructions.
In order to expedite the process Dr. Ellis decided to send the sum-
mary to his client’s office fax machine. While the cover sheet accompa-
nying the bill had a large, very clear statement of confidentiality, it also
included the doctor’s name, practice name, and address at the bottom.
After faxing the summary, Dr. Ellis began to be concerned, because he
was unclear as to whether the fax machine was in a public place or
available only to this client. As such, he attempted to call the client to
inform him of the sent fax only to find that he was out sick.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 7. Ethical Decision-Making–●–163
Step 1: Identify the problem articulating the ethical concern. Clearly,
while the client directed him to assemble a summary statement, the
manner and medium for delivery could cause concern for the client. The
summary not only contained specific dates of the individual sessions but
also included codes indicating the diagnosis as well as codes indicating
the form of treatment (i.e., individual psychotherapy). The private and
sensitive nature of this material was not for public consumption, and the
doctor questioned whether the cover sheet noting the information was
confidential was sufficient to protect the client’s privacy.
Step 2: Apply the code of ethics. Dr. Ellis was a licensed profes-
sional counselor and member of the ACA, so he consulted the ACA
2014 Code of Ethics. In reviewing the code, he became concerned that
he may have violated the following:
A.1.a. Primary responsibility. The primary responsibility of counselors
is to respect the dignity and promote the welfare of clients.
B.1.c. Respect for confidentiality. Counselors protect the confidential
information of prospective and current clients. Counselors disclose
information only with appropriate consent or with sound legal or
ethical justification.
B.2.e. Minimal disclosure. To the extent possible, clients are
informed before confidential information is disclosed and are
involved in the disclosure decision-making process. When circum-
stances require the disclosure of confidential information, only
essential information is revealed.
B.6.b. Confidentiality of records and documentation. Counselors
ensure that records and documentation kept in any medium are
secure and that only authorized persons have access to them.
B.6.f. Assistance with records. When clients request access to their
records, counselors provide assistance and consultation in inter-
preting counseling records.
Step 3: Determine the nature and dimensions of the dilemma. Dr. Ellis
consulted with a colleague and attempted to research information on the
use of electronic media and faxes in mental health practice. It became clear
that while the use of fax transmissions is always dangerous, it should clearly
be used only when the intended party has sole access to the fax or is stand-
ing by the machine and ready to retrieve it, a point that would require veri-
fication via telephone. Further, in considering ACA ethics, Dr. Ellis realized
(Continued)
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164–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
that he should have consulted with the client, clearly identifying potential
risks and costs to faxing this information and then gained written permis-
sion for the client. The other issue raised by way of his consulting was
the possibility that sending billing information could be a violation of the
client’s company policy regarding use of company fax or even a possible
violation of debt collection laws, since an outstanding balance was listed.
Step 4: Generate possible courses of action. Dr. Ellis began listing
possible courses of action that included the following:
1. Go to the client’s office and retrieve the fax.
2. Call the office and ask a receptionist to retrieve and destroy the fax.
3. Contact the client and after describing the dilemma ask what he
would like to have done.
4. Wait, do nothing and see what happens.
Step 5: Consider the potential consequences of all options. In
reviewing the first two ideas, Dr. Ellis concluded that his very presence
and need to introduce himself and explain why retrieving the fax was
necessary would in fact be a public disclosure of his client’s engage-
ment in therapy. Further, Option Number 4, given the potential for dam-
age to the client’s reputation and even work status, was not viable. As
such, he chose to track down the client in order to discuss the situation.
Step 6: Evaluate the selected course of action. Upon reflection, Dr. Ellis
realized that contacting his client and disclosing what has occurred could
at minimum shake the strength of his therapeutic alliance and level of trust
and even invite client legal action. However, having worked with the client
for more than 8 months, Dr. Ellis felt secure that the relationship was strong
enough to weather this situation and thus proceeded to call.
Step 7: Implement the course of action. On contacting the client,
Dr. Ellis was relieved to find out that his client was not ill but rather
taking a “mental health day” and that the only other person in the office
was his personal secretary, whom he had already instructed to look for
a fax and to file his insurance claim.
While any damage to the therapeutic relationship had been averted
in this situation, the potential damage to future clients and client
relationships remained, and as such, Dr. Ellis developed a very clear,
specific policy regarding the use of social media, e-mail, and faxing,
which he would distribute and discuss to all current and future clients.
(Continued)
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Chapter 7. Ethical Decision-Making–●–165
Exercise 7.2
Applying a Step-Wise Model
Directions: Exercise 7.1 presented a number of situations that may
place a practitioner in an awkward situation and potentially an ethical
bind. Your task in this exercise is to select one of these scenarios and
employ the steps identified by Forester-Miller and Davis (1996) in order
to decide on the action you would ultimately take. It would be useful
to share your thinking and your decision with a colleague/classmate to
gain their perspective.
Situation: (select one situation presented in Exercise 7.1)
Apply Forester-Miller and Davis Step-Wise Approach
● Step 1: Identify the problem articulating the ethical concern.
● Step 2: Apply the ACA Code of Ethics (or employ the code that
best reflects your profession).
● Step 3: Determine the nature and dimensions of the dilemma.
● Step 4: Generate possible courses of action.
● Step 5: Consider the potential consequences of all options.
● Step 6: Evaluate the selected course of action.
● Step 7: Implement the course of action.
Values-Based Virtue Approach
Jordan and Meara (1990, 1995) introduced a rather unique perspective
on the issue of ethical decision-making. Their virtue ethics model focuses
not on what the counselor should DO but rather on HOW as well as on WHO
the counselor should be. Advocates of virtue ethics argue that practitioners
should not merely seek to conform to codes but should aspire to an ethical
ideal. For example, consider the situation in which a therapist approaches
a termination session with a Chinese American couple. They have worked
together for over a year, and the therapy has helped the couple achieve their
goals. At the end of this last session, the couple presented the therapist with
an original pen-and-ink drawing of their parents’ village back in Mainland
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166–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
China. The questions that flooded the therapist included, is it appropriate to
take the gift? Is something in reciprocation required? Are boundaries being
threatened? Would it be disrespectful not to take the gift?
Turning to his code of ethics, the therapist can clearly see that taking a gift
as a form of bartering (AAMFT, 2015, Principle 8.5) is something that a thera-
pist should ordinarily avoid. However, when it comes to simple reception of
gifts from clients, there is not clear directive as to its appropriateness, and
there even seems to be a general reluctance to discuss the issue (Zur, 2007).
While turning to one’s code of ethics may help direct the clinician’s
response, it is, according to this model, important for the therapist to reflect upon
his own personal values as they reflect his desire to both respect the persons of
the clients and their culture. From this perspective and understanding that the
gifts came from a desire to celebrate their success and give thanks for the profes-
sional assistance, the therapist decided to gracefully and gratefully accept this gift.
Jordan and Meara’s emphasis on the values, the virtues, and the person
of the therapist certainly fits with the primary theme of this text, a theme
that encourages BEING ethical rather than simply knowing ethics. Jordan
and Meara’s approach appears to these authors as a valuable addition to
any step-wise model of ethical decision-making. Further, with its emphasis
on ever-increasing self-awareness and ongoing reflection and development,
their model offers valuable direction for each of us as we continue to grow
and evolve both personally and professionally.
Integrating Codes, Laws, and Personal-Cultural Values
Tarvydas (2012) offers an integrative approach to decision-making that
highlights the need for the practitioner to view all decision- making in light
of not just ethical codes and laws but cultural and social values and con-
text. The Tarvydas Integrative Decision-Making Model of Ethical Behavior
comprises four stages: (a) interpreting the situation through awareness
and fact finding; (b) formulating an ethical decision; (c) weighing compet-
ing non-moral values and affirming course of action; and (d) planning and
executing the selected course of action. Each of these stages is described
below as applied to the following brief scenario (Case Illustration 7.3).
Stage I. Interpreting the Situation Through Awareness and Fact
Finding
During this stage, the counselor will reflect upon the client’s unique
circumstances and characteristics as well as the nature of the specific
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Chapter 7. Ethical Decision-Making–●–167
Case Illustration 7.3
Boundary Violation?
The client’s response came as totally unexpected, truly catching the thera-
pist off guard. It was a very productive yet emotionally draining and intense
session. Dr. Thwarp helped to facilitate the client’s review of a long-standing
history of abuse, both emotionally and, in two situations, physically.
While emotionally draining, the session appeared productive. The
client gave evidence of feeling empowered, no longer blaming herself
as being responsible and even “deserving” of the abuse. This was truly
a significant therapeutic breakthrough.
As the session came to an end and Dr. Thwarp stood to walk the
client to the door, the client suddenly turned and threw both arms
around Dr. Thwarp’s neck, holding her tightly for a few seconds and
then exiting the office saying, “Thank you for all of your support.”
concerns and claims of all stakeholders. In addition, the clinician will
engage in a fact-finding process that unearths all the facts reflecting the
situation and the dimensions of ethical concern. For example, in review-
ing the case of Dr. Thwarp (Case Illustration 7.3), she would want to
process the event through her knowledge of the content and dynamic of
the session; her reflections on her own responses prior to, during, and
after the event; as well as the client’s unique familial, cultural, and perhaps
religious values.
Stage II. Formulating an Ethical Decision
An initial step in the formulation process is to review and clearly identify
the various levels or elements of potential ethical concern.
Continuing our brief illustration of the unexpected hug, the therapist
in this situation may identify potential concerns around issues of power,
transference and countertransference, and most clearly boundary viola-
tions. Clearly, the theme of abuse and its implication of power and trust
needs to be considered. Each of these concerns would then be viewed
through relevant ethical codes, laws, and principles as well as institutional
policies and procedures that apply to the situation.
With this clarity of situation, as contrasted to the standards and
codes, the therapist would next consider both the positive and negative
impacts of various potential courses of action. Perhaps in our scenario,
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168–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
the therapist is considering the following potential courses of action:
(a) to immediately contact the client to define boundaries of their rela-
tionship; (b) to engage in a dialogue around boundaries at the beginning
of the next session; (c) to invite the client to reflect upon her actions
and the meaning they may have; (d) to increase her own sensitivity to
the potential for such action and to be sure to preempt it in the future
with this or any client; or (d) to simply accept the hug as a reflection of
a deep sense of appreciation. As directed by the model, she would then
consider the positive and negative impacts of each. During this process,
it is recommended that a clinician confer with a colleague or supervisor
before selecting a course of action.
Stage III. Selecting an Action by Weighing Competing, Non-Moral
Values, Personal Blind Spots, or Prejudices
The model reminds us that we all have blind spots and personal preju-
dices that can impact our decisions, and as such, it is important to engage in
reflective recognition and analysis of personal, competing non-moral values
and personal biases. Our illustrative therapist would need to be open to the
possibility of her own seductive behavior or countertransference. She would
want to consider what, if any, impact the lack of an intimate relationship in
her own life may have on her feelings and her behaviors around this client
and this experience. In addition, she may want to reflect on own personal
experience with hugging: Was it always and only in a sexual context or was
hugging a common form of social greeting?
In addition to reflecting on personal values and biases, it is important to
filter the experience through an awareness of contextual influences, includ-
ing institutional, cultural, and societal, before determining the best course of
action.
Stage IV. Planning and Executing the Selected Course of Action
In the final stage, the clinician identifies a sequence of specific actions
to be taken, with awareness of the potential personal and contextual barri-
ers to effective implementation. For example, Dr. Thwarp recognizes that
her schedule and the fact that she has a client waiting prevents an immedi-
ate reaction or follow-up response to the client. Further, as she reflected
on the session in light of the client’s history, she believes that any quick,
impersonal response to her, like a phone call, may be received as evidence
of her rejection and may result in the client’s developing feelings of shame.
As such, she decided to assess the nature and strength of their relationship
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Chapter 7. Ethical Decision-Making–●–169
at the time of her next session, and if it appeared to be of therapeutic
value, she would invite the client to review the hug in light of the previ-
ous session and her needs and feelings at that time. Should the nature of
the next session be such that review of this incident did not seem produc-
tive, Dr. Thwarp would be aware of future attempts of physical contact, at
which time she would invite the reflection while establishing a boundary.
With the implementation of a plan of action, the clinician is now invited
to evaluate and document the ultimate impact and effectiveness.
Readers interested in seeing a more detailed application of this model
as applied to a complex case should go to http://www.counseling.org/docs/
default-source/vistas/why-can-t-we-be-friends-maintaining-confidentiality
?sfvrsn=11 and review the presentation by Heather A. Warfield, Stephen
D. Kennedy, and Megan Hyland Tajlili, Winners of the 2012–2013 ACA Doc-
toral Student Ethics Competition.
COMMON ELEMENTS: AN INTEGRATED
APPROACH TO ETHICAL DECISION-MAKING
●
The previous section provided brief descriptions of a number of ethical
decision-making models. These are but a few of the numerous models
suggested throughout the literature. While each of these models provides
a unique perspective, a number of common elements seem to run through
each and as such have been extracted and presented as the following “Com-
mon Elements Integrated Approach.”
The common, recurring elements found within the various ethical
decision-making models include the following: awareness of the existence
and nature of the dilemma along with personal values and biases; ground-
ing in both knowledge of the professional codes of practice, laws, and insti-
tutional policies and procedures; support, which is found via consultation
with all parties involved and professional colleagues and supervisors; and
finally, implementation, including documentation and evaluation. Each of
these elements is described in detail below and applied to the following case
scenario (Case Illustration 7.4).
Awareness
As the first step to resolving an ethical dilemma, one must first note the
existence and specific nature of the dilemma. An ethical dilemma occurs
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170–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
when a practitioner is confronted with a situation that offers multiple courses
of action, where any one decision is less than perfect and will result in a com-
prise to some ethical principle. Recognition of the situation as presenting an
ethical dilemma may occur as a result of the practitioner’s reflection on the
experience and the cognitive dissonance it creates when contrasted to his
knowledge of the elements of his code of conduct (Johnson, 2012).
In addition to the identification of the principles being compromised, it
is important for the practitioner to be aware of personal values and biases
Case Illustration 7.4
How Much Do I Share?
John Kelly, PhD, a licensed psychologist, was asked to assess an
8-year-old third-grade student in a local school district because of her
parents’ concern over her recent withdrawal from social interaction
and her failing grades. The parents’ explicit concern was in ruling out
a possible learning disability and in developing some strategies for
returning her to her previous level of academic and social functioning.
The psycho-educational assessment included an extensive clinical
interview, a developmental history, as well as the administration of a
battery of tests including the following: achievement tests, behavioral
observational scales, and cognitive and personality assessments. The
data suggested that Tina was functioning within the normal range in
achievement and cognitive functioning but did give evidence of gen-
eral anxiety that appeared to be in response to parental marital discord
and the occurrence of parental arguing about an issue of “infidelity.”
In his report, Dr. Kelly noted the hypothesized interfering impact
of Tina’s current anxious state and, in addition to suggesting the family
engage in family therapy, provided a number of specific psycho-
educational recommendations aimed at increasing her social engagement
and academic performance.
A month after his contact with Tina, her school counselor sent a
request, with an appropriately signed parental release for any and all
information regarding his work with Tina. The request sought not only
the psychologist’s report but the raw data and any “working notes” the
psychologist had made during his meetings with the client and client’s
family.
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Chapter 7. Ethical Decision-Making–●–171
that may be operative in this situation. It is possible that one’s personal
values could run contrary to the ethical standards of her profession. How-
ever, as a member of a profession, one has agreed to comply with the stan-
dards of that profession as articulated within its code of ethics. As such, it
is important to distinguish between personal and professional dimensions
and as noted by the Council on Social Work Education (2008), “manage
personal values in a way that allows professional values to guide practice”
(EPAS 1.1).
In terms of our case illustration, Dr. Kelly was very aware of his discom-
fort with the request for information that he received. While valuing the
school counselor’s interest in helping Tina and even appreciating the fact
that some of the information he had gathered would be useful in guiding
the counselor’s work with Tina, he “felt” uncomfortable with releasing all
of his data as requested. The discomfort seemed to arise from his awareness
that some of the “family” information that might be disclosed focused more
on the marital discord without direct translation to education programming
or intervention. In addition, he had concerns over releasing raw test data,
being unsure of the counselor’s qualifications for interpreting such data. He
was further concerned about sharing the hypotheses and speculations that
may be listed in his working notes, all of which were not fully developed or
completely supported by data.
Grounding
When confronted with a “sense” that we are entering or even in danger-
ous territory, the next step is to find grounding in the ethical codes, orga-
nizational policies, and legal standards that should guide our practice. As
noted in the ACA Code of Ethics (2014, Section I.1.a), “Lack of knowledge
or misunderstanding of an ethical responsibility is not a defense against a
charge of unethical conduct.” Thus, listing the specific codes being called
into play along with any policies that may exist or laws established that
have relevance to the situation provides the data and the grounding one
needs to choose a path forward. Take note of how Dr. Kelly uses his code
of ethics.
As a licensed psychologist in private practice, Dr. Kelly was aware
of HIPPA regulations that specify patients’ access rights to their health
and mental health files. While HIPPA provides for the release of psycho-
therapy notes, it does so only under a special designation in the release
or waiver signed by the client. A general request for medical records does
not automatically allow for the release of these notes. Further, when it
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172–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
comes to “working notes,” their impressionistic nature makes them rela-
tively meaningless other than for the clinician drafting them. It is gener-
ally agreed that these should be temporary in nature, taking form in a
more formal summary or report and subsequently destroyed. This is not
the type of information that should be released to anyone, or maintained
as a permanent file.
In reviewing his profession’s code of ethics (APA, 2010), Dr. Kelly was
struck by the following:
“Psychologists may refrain from releasing test data to protect a client/
patient or others from substantial harm or misuse or misrepresentation of
the data or the test, recognizing that in many instances release of confidential
information under these circumstances is regulated by law (APA 2010, 9.04).
He also found that his code directed that disclosure of information should
be “only to the extent necessary to achieve the purposes of the consultation”
(APA 2010, 4.06).
Support
The very fact that our codes are not always clear and prescriptive to
every situation and that they may even be in conflict with existing organiza-
tional policies or legal standards calls practitioners to seek out support and
consultation when confronted with an ethical dilemma. As noted in the ACA
Code of Ethics (2014), “Counselors strive to resolve ethical dilemmas with
direct and open communication among all parties involved and seek con-
sultation with colleagues and supervisors when necessary” (Sec. I, Introduc-
tion). This same code further directs that “when uncertain about whether a
particular situation or course of action may be in violation of the ACA Code
of Ethics, counselors consult with other counselors who are knowledgeable
about ethics and the ACA Code of Ethics, with colleagues or with appropriate
authorities, such as the ACA Ethics and Professional Standards Department”
(Sec. I.2.c).
The provision of another perspective can serve to not only bring
increased clarity to the situation and the applicability of an existing code but
may help to counteract our own bias.
Returning to Case Illustration 7.4, Dr. Kelly’s understanding of HIPPA
law and of professional code led him to conclude that neither the raw data
nor his working notes should be released as per request. However, prior to
making that decision he wanted to consult with someone more schooled
in and familiar with this type of issue. As such, he called the chair of his
state ethics committee, who in turn consulted with the ethics committee.
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Chapter 7. Ethical Decision-Making–●–173
The response he received supported his decision to be selective in the infor-
mation released. The committee’s response did note, however, that its posi-
tion was not intended to serve as legal advice and was educational in nature
based on members’ understanding of the APA code of ethics.
Implementation
Ethical decision-making is not merely an intellectual activity, it is a pro-
cess that results in action. As is evident from our previous discussion on
ethical decision-making models, the implementation stage requires (a) the
generation of possible pathways to resolving the dilemma; (b) an assessment
of the potential positive and negative consequences for all involved parties
for each of the possible pathways; (c) the selection of the path to follow; and
(d) documentation and evaluation of the ultimate impact.
So in Case Illustration 7.4, Dr. Kelly considered a number of options
ranging from ignoring the request to sending all the data requested. Upon
reflection and consultation, he felt that the most prudent and beneficial
approach would be to contact his client’s parents to inform them of his
reception of a request for information and explain to them his plan to
respond. In talking with the parents, he explained that while his notes and
actual test data were important to his understanding and assessment that
these, even though requested, would be of little value to the school coun-
selor. He suggested that it would be more productive if he sent an abbrevi-
ated report with specific focus on the educational recommendations that
could be implemented within the school setting. Further, he suggested that
rather than sending this report directly to the counselor, he would provide
the parents with the report, and they in turn could share the information, if
they so desired, with the school.
Both parents were appreciative of the suggestion. Both admitted that
they had not completely thought through the implications of what was being
requested when they signed the release and were very happy that Dr. Kelly
was aware of the possible negative effects of releasing all of his data to the
school. Also, given the fact that he had previously gone over the entire report
and recommendation with them, they both felt comfortable with sharing the
sections relevant to the school and the counselor’s work with their daughter.
Dr. Kelly invited the parents to come into the office to once again
review the recommendations, but neither felt that was necessary. Finally, he
asked if they would send him a written request for the release of this “edu-
cational report” so that he could have it in his records. He also documented
the telephone conversation as well as the suggested and agreed upon plan.
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174–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
● CONCLUDING CASE ILLUSTRATION
Throughout the past chapters, you have seen Ms. Wicks, our school coun-
selor, experience a number of ethical concerns while engaging with Maria.
None of these seem to be as disruptive to the relationship as evidenced by
Maria’s disclosure regarding her boyfriend having AIDS and the couple being
engaged in unprotected sex. Ms. Wicks has concerns about both the legal
mandate and ethical concerns that should guide her response to this infor-
mation. In addition, she now has information that the district “prohibits”
her from talking to students about sexual issues, which arouses her concern
that she has violated some boundary. The situation is complicated, and the
options are not completely clear.
Reflections
1. Has Ms. Wicks given any evidence of employing one of the many
models of ethical decision-making described in this chapter?
2. What one specific step discussed within the chapter as contrib-
uting to ethical decision-making do you feel Ms. Wicks needs to
employ?
3. From your perspective, which of the models discussed within the
chapter provides the best guidance for ethical decision-making when
applied to this case?
● COOPERATIVE LEARNING EXERCISE
As noted in the beginning of the chapter, it is our responsibility to not
only know and embrace our professional code of ethics but also to employ
a process that will facilitate our application of these principles within
our professional practice. The failure to do so is in and of itself an ethical
problem (Welfel, 2010). As such, you are now invited to close this chapter
by engaging in the following learning exercise (Exercise 7.3). It is hoped
that engaging in this exercise will help your understanding, valuing, and
employment of our common elements integrated approach.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 7. Ethical Decision-Making–●–175
Exercise 7.3
Making a Decision
Directions: Read the following case scenario and then respond to ques-
tions posed under each of the stages of ethical decision-making listed
below. As with each of these cooperative learning exercises, benefit
is accrued through personal reflection and the sharing of perspectives
among your colleagues.
Dr. Mattison is a retired clinical social worker who had a large pri-
vate practice for over 35 years. In retirement, she was hired as an adjunct
professor to teach one graduate course a semester and also volunteered
as an intake worker at the local community mental health center.
The center operated more like a crisis and referral agency seeing
clients for a maximum of three sessions and making referrals when
additional sessions were necessary. During the month of August,
the agency experienced a high number of staff taking vacations.
Dr. Mattison was asked to step in to provide direct service to new
clients seeking support during the month.
In the week prior to her stepping back into the clinical chair, she
remained on the phone as intake worker. The intakes she was complet-
ing were on clients whom she would see in the following week.
One caller, Kathy, was clearly very upset, crying to the point
where gathering the basic information was difficult. Dr. Mattison gen-
tly calmed the caller and identified that the initial source of crisis was
the fact that she had just been terminated at her job and gotten into
a major argument with her boyfriend. While the caller felt as if the
“world was collapsing,” Dr. Mattison was able to assess her level of cri-
sis and the possibility of her harming herself or another. Both possibili-
ties were felt to be of very low probability, and the caller had numerous
supports in her life, living at home with her family. After setting up the
appointment to meet with Kathy, Dr. Mattison did a final assessment to
see how she was feeling and what her plans for the night and the days
to follow were. Kathy’s response provided Dr. Mattison with the data
she needed to feel that Kathy was okay and was not at risk.
After hanging up and as she was taking the next call, Dr. Mattison
realized that in her focusing on the “crisis” she forgot to get Kathy’s last
name or address. She felt that she could gather that information at the
time of her first session, which was scheduled that coming Monday.
(Continued)
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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176–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
● SUMMARY
On Monday, as Dr. Mattison enters the office, she becomes aware
that the young woman waiting is not only Kathy, her first appointment,
but that Kathy is actually a student in her Tuesday night class.
Awareness: Does the case present any possible ethical or legal
challenges? If so, what are they?
Grounding: Using your profession’s code of ethics, what, if any,
principles may be compromised or called into play given this
situation?
Support: What do your colleagues or classmates see is operating
in this situation? How about your professor or supervisor? Are their
perspectives different from yours? If so, what is the impact of mul-
tiple perspectives on your own awareness of the situation or your
own biases and values?
Implementation: Generate at least three possible paths to follow
in response to this situation. Further, identify the potential positive
and negative impacts of each? Which would you select to imple-
ment? Discuss with your colleagues to gain further perspective as
to whether they identified similar paths, impacts, and implementa-
tion plans.
(Continued)
• As professionals, it is our duty, our responsibility, to not only under-
stand and embrace our codes of ethics but to also engage in self-
reflection and the employment of a decision-making process.
• Our professional organizations direct us to employ accepted decision-
making models that are most applicable to our situations (e.g., ACA,
2014, I.1.b).
• One approach (Kitchener, 1984) invites practitioners to employ the
values of autonomy, nonmaleficence, beneficence, fidelity, and jus-
tice as reference points when making ethical decisions.
• A more sequential approach to ethical decision-making was pre-
sented by Forester-Miller and Davis (1996) and included seven steps:
(a) identifying the problem, (b) applying the code of ethics, (c) deter-
mining the nature and dimensions of the dilemma, (d) generating
possible courses of action, (e) considering potential consequences of
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 7. Ethical Decision-Making–●–177
all options, (f) evaluating the selected course of action, and (g) imple-
menting the course of action.
• Jordan and Meara (1990, 1995) introduced a rather unique perspec-
tive on the issue of ethical decision-making. Their virtue ethics model
focuses not on what the counselor should DO but rather on HOW as
well as on WHO the counselor should be.
• Tarvydas (2012) offers an integrative approach to decision-making that
highlights the need for the practitioner to view all decision-making in
light of not just ethical codes and laws but cultural and social values
and context. The Tarvydas Integrative Decision-Making Model of
Ethical Behavior comprises four stages: (a) interpreting the situation
through awareness and fact finding; (b) formulating an ethical decision;
(c) weighing competing non-moral values and affirming course of
action; and (d) planning and executing the selected course of action.
• Identifying recurrent themes or elements found within the various
models of ethical decision-making can direct us to a “common ele-
ments integrated approach” that includes awareness of the existence
and nature of the dilemma, along with personal values and biases;
grounding in both knowledge of the professional codes of practice,
laws, and institutional policies and procedures; support that is found
via consultation with all parties involved and professional colleagues
and supervisors; and finally implementation including documenta-
tion and evaluation.
IMPORTANT TERMS ●
American Counseling
Association (ACA)
American Association for
Marriage and Family Therapy
(AAMFT)
American Psychological
Association (APA)
aspirational ethics
autonomy
beneficence
common elements approach
ethical decision-making
ethical justification model
fidelity
Integrative Decision-Making
Model of Ethical Behavior
justice
mandatory ethics
nonmaleficence
step-wise approach
virtue ethics model
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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178–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
● ADDITIONAL RESOURCES
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