Corey, G., Corey, M. S.., Corey, C., & Callanan, P. (2015). Moral principles to guide decision making. In Issues and ethics in the helping professions (9th ed.) (pp. 17-24). Brook/Cole.
Building on the work of others, especially Kirchener (1984), Meara and colleagues (1996) describe six basic moral principles that form the foundation of functioning at the highest ethical level as a professional: autonomy, non-maleficence, beneficence, justice, fidelity and veracity. Applying these ethical principles and the related ethical standards is not as simple as it may seem, especially when dealing with culturally diverse populations. (See Chapters 4 and 13 for more on the issue.) These moral principles involve a process of striving that is never fully complete. We describe each of these six basic moral principles, cite a specific ethical guideline from the ACA, APA, or NASA, and provide a brief discussion of the cultural implications of using each principle.
Autonomy refers to the promotion of self-determination, or the freedom of clients to be self-governing within their social and cultural framework. Respect for autonomy entails acknowledging the right of another to choose and act in accordance with his or her wishes, and the professional behaves in a way that enables this right of another person. Practitioners strive to decrease client dependency and foster client empowerment. The ACA’s (2005) introduction to Section A states it this way:
Counselors encourage client growth and development in ways that foster the interest and welfare of clients and promote formation of healthy relationships. Counselors actively attempt to understand the diverse cultural backgrounds of the clients they serve. Counselors also explore their own cultural identities and how these affect their values and beliefs about the counseling process.
The helping services in the United States are typically based on traditional Western values of individualism, independence, interdependence, self-determination, and making choices for oneself. It often appears as though Western cultures promote individualism above any other cultural value. However, many cultures follow a different path, stressing decisions with the welfare of the family and the community as a priority. As the ACA standard described here implies, ethical practice involves considering the influence of cultural variables in the counseling relationship.
We cannot apply a rigid yardstick of what is a value priority in any culture without exploring how a particular client views priorities. For instance, what are the implications of the principle of autonomy when applied to clients who do not place a high priority on the value of being autonomous? Does it constitute an imposition of values for counselors to steer clients toward autonomous behavior when such behavior could lead to problems with others in their family, community, or culture? What about promoting autonomy for those incapable of it (for example, dependent youths)?
Non-maleficence means avoiding doing harm, which includes refraining from actions that risk hurting clients. Professionals have a responsibility to minimize risks for exploitation and practices that cause harm or have the potential to result in harm. The APA (2010) principle of beneficence and non-maleficence states:
Psychologists strive to benefit those with whom they work and take care to do no harm.
What are the cultural implications of the principle of non-maleficence? Traditional diagnostic practices can be inappropriate for certain cultural groups. For instance, a therapist may assign a diagnostic label to a client based on a pattern of behavior the therapist judges to be abnormal, such as inhibition of emotional expression, hesitation to confront, being cautious about self-disclosing, or not making direct eye contact while speaking. Yet these behaviors may be considered normal in certain cultures. Another example may be a school counselor who inappropriately labels a boy ADHD, which may color the perceptions of other staff members in a negative way so they pressure the parents to put the boy on medication. Practitioners need to develop cultural awareness and sensitivity in using assessment, diagnostic, and treatment procedures.
Beneficence refers to doing good for others and to promoting the well-being of clients. Beneficence also includes doing good for society. Ideally, counseling contributes to the growth and development of clients within their cultural context. Whatever practitioners do can be judged against this criterion. The following ACA (2005) guidelines illustrates beneficence:
The primary responsibility of counselors is to respect the dignity and to promote the welfare of clients (A.1.a)
Consider the possible consequences of a therapist encouraging a Vietnamese client to behave more assertively toward his father. The reality of this situation may be that the father would refuse to speak again to a son who confronted him. Even though counselors may be operating with good intentions and may think they are being beneficent, they may not always be doing what is in the best interest of the client. Is it possible for counselors to harm clients unintentionally by encouraging a course of action that has negative consequences? How can counselors know what is in the best interest of their clients? How can counselors determine whether their intervention will work for their clients? As we have previously stated, there are no simple answers for complex questions.
Justice means to be fair by giving equally to others and to treat others justly. Practitioners have a responsibility to provide appropriate services to all clients. Everyone, regardless of age, sex, race, ethnicity, disability, socioeconomic status, cultural background, religion, or sexual orientation, is entitled to equal access to mental health services. An example might be a social worker making a home visit to a parent who cannot come to the school because of transportation, child care matters, or poverty. NASW’s (2008) guideline illustrates this principle:
Social workers pursue social change, particularly with and on behalf of vulnerable and oppressed individuals and groups of people. Social workers’ social change efforts are focused primarily on issues of poverty, unemployment, discrimination, and other forms of social injustice. These activities seek to promote sensitivity to and knowledge about oppression and cultural and ethnic diversity. Social workers strive to ensure access to needed information, services, and resources; equality of opportunity; and meaningful participation in decision making for all people. (Ethical Principles, Social Justice.)
Traditional mental health services may not be just and fair to everyone in a culturally diverse society. If intervention strategies are not relevant to some segments of the population, justice is being violated. How can practitioners adapt the techniques they use to fit the needs of diverse populations? How can new helping strategies be developed that are consistent with the worldview of culturally different clients?
Fidelity means that professionals make realistic commitments and keep these promises. This entails fulfilling one’s responsibilities of trust in a relationship. ACA’s (2005) code encourages counselors to inform clients about counseling and to be faithful in keeping commitments made to clients:
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. Counselors have an obligation to review in writing and verbally with clients the rights and responsibilities of both the counselor and the client. Informed consent is an ongoing part of the counseling process and counselors appropriately document discussions of informed consent throughout the counseling relationship. (A.2.a)
Fidelity involves creating a trusting and therapeutic relationship in which people can search for solutions. However, what about clients whose culture teaches them that counselors are experts whose job is to provide answers to specific problem situations? What if a client expects the counselor to behave in this way? If the counselor does not meet the client’s expectations, is trust being established?
Veracity means truthfulness, which involves the practitioner’s obligation to deal honestly with clients. Unless practitioners are truthful with their clients, the trust required to form a good working relationship will not develop. An example of the principle of veracity is found in Code of Ethics of the National Association of Alcohol and Drug Abuse Counselors (NAADAC, 2008):
I understand that effectiveness in my profession is largely based on the ability to be worthy of trust, and I shall work to the best of my ability to act consistently within the bounds of a known moral universe, to faithfully fulfill the terms of both personal and professional commitments, to safeguard fiduciary relationships consistently, and to speak the truth as it is known to me. (Principle 4.)
The six principles discussed here are a good place to start in determining the degree to which your practice is consistent with promoting the welfare of the clients you serve. To the list above, Barnett (2008) adds self-care, which involves taking adequate care of ourselves so that we are able to implement the moral principles and virtues that are fundamental ethical concepts. If mental health professionals fail to practice self-care, their ability to effectively implement the other principles will be impaired (Barnett, Johnston, & Hillard, 2006).
Counselors may be faced with a conflict between ethical principles such as the client’s autonomy and self-determination versus the counselor’s duty to take action to protect the client from harm. For example, hospitalizing a client against his or her wishes is a restriction of freedom, yet not taking action could result in the client’s death (Wheeler & Bertram, 2012). At times, therapists may need to balance other ethical principles (especially non-maleficence) with autonomy. Rosenfeld (2011) has written about problems associated with overly respecting client self-determination and autonomy when harmful religious beliefs and practices are not challenged. Rosenfeld’s point may be well-taken, yet it does raise the fundamental question, “Who decides what constitutes harmful religious beliefs and practices?”
When making ethical decisions, ask yourself these questions: “Which values do I rely on and why? How do my values affect my work with clients?” When making ethical decisions, the National Association of Social Workers (2008) cautions you to be aware of your clients’ as well as your own personal values, cultural and religious beliefs, and practices. Acting responsibly implies recognizing any conflicts between personal and professional values and dealing with them effectively. The American Counseling Association’s (2005) Code of Ethics states that when counselors encounter an ethical dilemma they are expected to carefully consider an ethical decision-making process. To make sound ethical decisions, it is necessary to slow down the decision-making process and engage in an intentional course of ethical deliberation, consultation, and action (Barnett & Johnson, 2010). Although no one ethical decision-making model is most effective, mental health professionals need to be familiar with at least one of the following models or an amalgam that best fits for them.
Ethical decision making is not a purely cognitive and linear process that follows clearly defined and predictable steps. Indeed, it is crucial to acknowledge that emotions play a part in how you make ethical decisions. As a practitioner, your feelings will likely influence how you interpret both your client’s behavior and your own behavior. Furthermore, if you are uncomfortable with an ethical decision and do not adequately deal with this discomfort, it will certainly influence your future behavior with your client. An integral part of recognizing and working through an ethical concern is discussing your beliefs and values, motivations, feelings, and actions with a supervisor or a colleague.
In the process of making the best ethical decisions, it is also important to involve your clients whenever possible. Because you are making decisions about what is best for their welfare, it is good to strive to discuss with them the nature of the ethical dilemma that pertains to them. For instance, ethical decision making from a feminist therapy perspective calls for involving the client at every stage of the therapeutic process, which is based on the feminist principle that power should be equalized in the therapeutic relationship (Brown, 2010).
Consulting with the client fully and appropriately is an essential step in ethical decision making, for doing so increases the chance of making the best possible decision. Walden (2015) suggests that important therapeutic benefits can result from inclusion of the client in the ethical decision-making process, and she offers some strategies for accomplishing this goal at both the organizational and individual levels. When we make decisions about a client for the client rather than with the client, Walden maintains that we rob the client of power in the relationship. When we collaborate with clients, they are empowered. By soliciting the client’s perspective, we stand a good chance of achieving better counseling results and the best resolution for any ethical questions that arise. Potential therapeutic benefits can be gained by including clients in dealing with ethical concerns, and this practice represents functioning at the aspirational level. In fact, Walden questions whether it is truly possible to attain the aspirational level of ethical functioning without including the client’s voice in ethical concerns. By adding the voice and the unique perspective of the consumers of professional services, we indicate to the public that we as a profession are genuinely interested in protecting the rights and welfare of those who make use of our services. Bringing the client into ethical matters entails few risks, and both the client and the professional may benefit from this collaboration.
The social constructionist model of ethical decision making shares some aspects with the feminist model but focuses primarily on the social aspects of decision making in counseling (Cortone, 2001). This model redefines the ethical decision-making process as an interactive rather than an individual or intrapsychic process and places the decision in the social context itself, not in the mind of the person making the decision. This approach involves negotiating, consensualizing, and when necessary, arbitrating.
Garcia, Cartwright, Winston, and Borzuchowska (2003) describes a transcultural integrative model of ethical decision making that addresses the need for including cultural factors in the process of resolving ethical dilemmas. They present their model in a step-by-step format that counselors can use in dealing with ethical dilemmas in a variety of settings and with different client populations. Frame and Williams (2005) have developed a model of ethical decision making from a multicultural perspective based on Universalist philosophy. In this model cultural differences are recognized, but common principles such as altruism, responsibility, justice, and caring that link cultures are emphasized.
Barnett and Johnson (2010) remind us that many of the ethical dilemmas we will encounter do not have a readily apparent answer. Keeping in mind the feminist model of ethical decision making, Walden’s (2015) views on including the client’s voice in ethical concerns, a social constructionist approach to ethics, and a transcultural integrative model of ethical decision making, we present our approach to thinking through ethical dilemmas. Following these steps may help you think through ethical problems.
- Identify the problem or dilemma. It is important to determine whether a situation truly involves ethics. The distinction between unorthodox and poor professional practice may be unclear (Koocher & Keith-Spiegel, 2008). To determine the nature of the problem or dilemma, gather all the information that sheds light on the situation. Clarify whether the conflict is ethical, legal, clinical, professional, or moral – or a combination of any or all of these. The first step toward resolving an ethical dilemma is recognizing that a problem exists and identifying its specific nature. Because most ethical dilemmas are complex, it is useful to look at the problem from many perspectives. Consultation with your client begins at this initial stage and continues throughout the process of working toward an ethical decision, as does the process of documenting your decisions and actions. Frame and Williams (2005) suggest reflecting on these questions to identify and define an ethical dilemma: “What is the crux of the dilemma? Who is involved? What are the stakes? What insight does my client have regarding the dilemma? How is the client affected by the various aspects of the problem? What are my insights about the problem?” Taking time to engage in reflection is an essential first step.
- Identify the potential issues involved. After the information is collected, list and describe the critical issues and discard the irrelevant ones. Evaluate the rights, responsibilities, and welfare of all those who are affected by the situation. Consider the cultural context of the situation, including relevant and cultural dimensions of the client’s situation such as culture, race, socioeconomic status, and religious or spiritual background. Other relevant variables include the client’s age and the client’s relationship with other family members. It is important to consider the context of power and privilege and also to assess acculturation and racial identity development of the client (Frame & Williams, 2005). Part of the process of making ethical decisions involves identifying and examining the ethical principles that are relevant in the situation. Consider the six fundamental moral principles of autonomy, non-maleficence, beneficence, justice, fidelity, and veracity and apply them to the situation, including those that may be in conflict. It may help to prioritize these ethical principles and think through ways in which they can support a resolution to the dilemma. Reasons can be presented that support various sides of a given issue and different ethical principles may sometimes imply contradictory courses of action. When it is appropriate, and to the degree that it is possible, involve your client in identifying potential issues in the situation.
- Review the relevant ethics codes. Consult available guidelines that could apply in your situation. Ask yourself whether the standards or principles of your professional organization offer a possible solution to the problem. Consider whether your own values and ethics are consistent with, or in conflict with, the relevant codes. If you are in disagreement with a particular standard, do you have a rationale to support your position? It is imperative to document this process to demonstrate your conscientious commitment to solving a dilemma. You can also seek guidance from your professional organization on any specific concern relating to an ethical or legal situation. Most of the national professional organizations provide members with access to a telephone discussion of ethical and legal issues. These consultations focus on giving members guidance in understanding and applying the code of ethics to a particular situation and in assisting members in exploring relevant questions. However, these consultations do not tell members what to do, nor does the organization assume responsibility for making the decision.
- Know the applicable laws and regulations. It is essential for you to keep up to date on relevant state and federal laws that might apply to ethical dilemmas. In addition, be sure that you understand the current rules and regulations of the agency or organization where you work. This is especially critical in matters of keeping or breaching confidentiality, reporting child or elder abuse, dealing with issues pertaining to danger to self or others, parental rights, record keeping, assessment, diagnosis, licensing statutes, and the grounds for malpractice. However, realize that knowledge of the laws and regulations are not sufficient in addressing a dilemma. As Welfel (2013) aptly puts it: “Rules, laws, and codes must be fully understood to act responsibly, but they are the starting point of truly ethical action, not the end point” (p. 24).
- Obtain consultation. One reason for poor ethical decisions stems from our inability to view a situation objectively because of our prejudices, biases, personal needs, or emotional investment (Koocher & Keith-Spiegel, 2008). You do not have to make ethical decisions alone, but it is important to maintain client confidentiality when consulting others. It is generally helpful to consult with several trusted colleagues to obtain different perspectives on the area of concern and to arrive at the best possible decision. Wheeler and Bertram (2012) suggest that two heads are better than one, and that three heads are often even better! Do not consult only with those who share your viewpoint. If there is a legal question, seek legal counsel. If the ethical dilemma involves working with a client from a different culture or who has a different worldview than yours, it is prudent to consult with a person who has expertise in this culture. If a clinical issue is involved, seek consultation from a professional with appropriate clinical expertise. After you present your assessment of the situation and your ideas of how you might proceed, ask for feedback on your analysis. Are there factors you are not considering? Have you thoroughly examined all of the ethical, clinical, and legal issues involved in the case? It is wise to document the nature of your consultation, including the suggestions provided by those with whom you consulted. In court cases, a record of consultation illustrates that you have attempted to adhere to community standards by finding out what your colleagues in the community would do in the same situation. In an investigation the “reasonable person” standard may be applied: “What would a professional in your community with 3 years’ experience have done in your situation?”
- Consider possible and probable course of action. At this point, take time to think about the range of courses of actions. Brainstorm to identify multiple options for dealing with the situation. Generate a variety of possible solutions to the dilemma (Frame & Williams, 2005). Consider the ethical and legal implications of the possible solutions you have identified. What do you think is likely to happen if you implement each option? By listing a wide variety of courses of action, you may identify a possibility that is unorthodox but useful. Of course, one alternative is that no action is required. As you think about the many possibilities for action, discuss these options with your client as well as with other professionals and document these discussions.
- Enumerate the consequences of various decisions. Consider the implications of each course of action for the client, for others who are related to the client, and for you as the counselor. Examine the probable outcomes of various actions, considering the potential risks and benefits of each course of action. Other potential consequences of a decision include psychological and social costs, short- and long-term effects, the time and effort necessary to implement a decision, and any resource limitations (Koocher & Keith-Spiegel, 2008). Again, collaboration with your client about consequences for him or her is most important, for doing this can lead to your client’s empowerment. Use the six fundamental moral principles (autonomy, non-maleficence, beneficence, justice, fidelity, and veracity) as a framework for evaluating the consequences of a given course of action. Realize that there are likely to be multiple outcomes, rather than a single desired outcome in dealing with an ethical dilemma. A useful strategy is to continue brainstorming and reflecting on other options as well as consulting with colleagues who may see possibilities that have not occurred to you (Remley & Herlihy, 2014).
- Choose what appears to be the best course of action. To make the best decision, carefully consider the information you have received from various sources. The more obvious the dilemma, the clearer the course of action; the more subtle the dilemma, the more difficult the decision will be. After deciding, try not to second-guess your course of action. You may wonder if you have made the best decision in a given situation, or you may realize later that another action might have been more beneficial. Hindsight does not invalidate the decision you made based on the information you had at the time. Once you have made what you consider to be the best decision, evaluate your course of action by asking these questions (Frame & Williams, 2005): “How does my action fit with the code of ethics of my profession? To what degree does the action taken consider the cultural values and experiences of the client? How might others evaluate my action? What did I learn from dealing with this ethical dilemma?” Once you have decided on a course of action, remain open to the possibility that circumstances may require that you make adjustments to your plan. Wheeler and Bertram (2012) recommend careful documentation of the ethical decision-making process you used in arriving at a course of action, including the options you considered and ruled out. It is important to document the outcome and to include any additional actions that were taken to resolve the issue. Review your notes and follow up to determine the outcomes and whether further action is needed. To obtain the most accurate picture, involve your client in this process.
The goal of any ethical decision-making process is to help you take into account all relevant facts, use any resources available to you, and reason through the dilemma in a way that points to the best possible course of action. Reflecting on your assessment of the situation and on the actions you have taken is essential. The procedural steps we have listed here should not be thought of as a simple and linear way to reach a resolution on ethical matters. However, we have found that these steps do stimulate self-reflection and encourage discussion with clients and colleagues. Using this process, we are confident that you will find a solution that is helpful for your client, your profession, and yourself.
