Ethics in Psychology

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Ethical Dilemma

Jane is a licensed psychologist in private practice. In addition to her private therapy practice, she has been working as an instructor at a local college. She enjoys teaching and sharing her expertise with her students.

On the first evening of the Introduction to Psychology course she is teaching, she is surprised to see Carlene, a former client. After two years, Carlene had abruptly ended her therapy sessions approximately six months earlier.

When Jane sees Carlene in class, she does not acknowledge knowing Carlene, doing so to protect her former client's privacy. She treats her no differently than any other member of the class. After class, Jane wonders if she should talk to Carlene or talk to the chair of the psychology department to decide whether or not Carlene should continue in her course. She decides not to talk to the chair or Carlene and hopes for the best.

Carlene is excited to see that her former therapist is her teacher. It helps her to feel comfortable in the class, and she hopes that it might also give her a special place in the class because she knows the teacher. However, Carlene is confused about why Jane does not acknowledge her. When Carlene receives her first assignment grade, she is surprised by how low it is. She is upset with Jane, believing she has not treated her with the special considerations that she believes she deserves because of their therapy work.

Jane notices that Carlene, who at first participated actively in class, now appears to be withdrawn and not engaged in class discussions.

Think about the APA guiding principles or standards that would have helped Jane know what to do in this situation. Describe how these principles or standards are applicable.

To help guide you in your discussion and support your thinking on the areas of ethical concern, use the APA's "Ethical Principles of Psychologists and Code of Conduct" (http://www.apa.org/ethics/code/index.aspx) and the chapter by Nagy, "Thinking Critically About Ethics" (attached) from this unit's studies.

Your post to the discussion dilemma should include the following:

  • A description of at least two potential ethical dilemmas for Jane in this situation.
  • Arguments to support your position (case information and APA ethical principles and standards).
  • Evidence (information from APA ethical principles and standards or other professional sources) to support your arguments.

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Copyright American Psychological Association. Not for further distribution. Thinking Critically About Ethics 1 The psychologist believes in the dignity and worth of the individual human being. He is committed to increasing man’s understanding of himself and others. While pursuing this endeavor, he protects the welfare of any person who may seek his service or of any subject, human or animal, that may be the object of his study. He does not use his professional position or relationships, nor does he knowingly permit his own services to be used by others, for purposes inconsistent with these values. While demanding for himself freedom of inquiry and communication, he accepts the responsibility this freedom confers: for competence where he claims it, for objectivity in the report of his findings, and for consideration of these interests of his colleagues and of society. (American Psychological Association [APA], 1967) E thical awareness in psychological practice and research has long been in the consciousness of practitioners and researchers, even predating the publication of the first APA Ethics Code in 1953. However, formal education in ethics as a part of psychologists’ formal training and supervision has evolved only relatively recently, with most graduate and professional schools of psychology currently requiring at least a fundamental knowledge of the subject. When attempting to exercise good judgment in the course of carrying out professional work, a psychologist is generally confronted with a range of choices. The psychologist is guided http://dx.doi.org/10.1037/12345-001 Essential Ethics for Psychologists: A Primer for Understanding and Mastering Core Issues, by T. F. Nagy Copyright © 2011 American Psychological Association. All rights reserved. 9 Copyright American Psychological Association. Not for further distribution. 10 ESSENTIAL ETHICS FOR PSYCHOLOGISTS by a variety of factors, such as (a) formal education and training, (b) life experience, (c) previous experience with the situation at hand, (d) ethical rules, (e) relevant state and federal laws, and (f) other conscious or unconscious factors that make his or her own unique contributions to the decision-making process. This book focuses on the assistance provided by ethical rules in resolving these dilemmas, fundamentally, how to avoid harming others and facilitate helping them by meeting stated goals while in the role of psychologist. The challenge of an ethics code is to be instructive and provide guidance to psychologists in whatever setting they may work or professional responsibilities they may assume. However, an ethics code is also a dynamic document; it is constantly evolving, reflecting continual changes in the nature of psychological work concerning technology (e.g., computers, videoconferencing), the emergence of new human problems, (e.g., compulsive behavior involving the Internet), new areas of specialization (e.g., lesbian and gay lifestyles), legal requirements (e.g., state and federal laws), and changes in the culture (e.g., increase in racial/ethnic diversity, changing religious orientation and lifestyles). In view of the diversity of roles played by psychologists today—therapist, researcher, supervisor, professor, and management consultant, to name a few—it is unlikely that a single set of decision rules could provide guidance in sufficient detail to be practical. On the other hand, a document that would anticipate each and every scenario likely to be encountered by psychologists would be hopelessly long and legalistic in nature, allowing for the exercise of little independent judgment on the part of professionals. It would be more akin to a “paint-by-numbers” compendium of hypothetical scenarios that would spell out various courses of action for each situation. As a result, the various revisions of the Ethics Code governing the conduct of psychologists for over half a century have attempted to strike a balance between being overly general, resulting in language that would be too be too vague and lacking in operational definitions, and overly explicit, resulting in such a narrow a focus that psychologists would likely miss the forest for the trees—obscuring the general ethical principle and providing mainly individual solutions. Although this type of vignette-driven document may indeed be useful, it is not sufficiently broad to teach ethics to those specializing in a variety of different areas (e.g., therapist, researcher, supervisor). This chapter introduces the reader to various ethical concepts and issues. The remaining sections discuss the following: ethical problems that can be encountered by psychologists in different settings, intentionality in ethical conduct, ethics codes as a compendium of “musts” and “must nots,” attributes of ethical actions, deontology and teleology as bases for developing codes of ethics, aspirational and mandatory sections of the APA Ethics Code, the relationship between ethics codes and laws, and complaints against psychologists. Thinking Critically About Ethics A Sampling of Ethical Violations Copyright American Psychological Association. Not for further distribution. The following scenarios describe four different ethical issues that can challenge a psychotherapist, researcher, and professor. The subject areas are (a) multiple-role relationship, (b) competence, (c) informed consent, and (d) privacy. MULTIPLE-ROLE RELATIONSHIP The following vignette describes the development of a multiple-role relationship in which a competent psychologist feels a sexual attraction to his patient. A therapist experienced a physical attraction to his new patient—a female high school teacher seeking treatment for obsessive–compulsive disorder. Nevertheless, he provided competent treatment for her disorder, ultimately concluding her treatment in 5 months. One year later, he encountered the woman at a workshop on attention-deficit disorder in children and adolescents. They were pleased to see each other again in this new setting, acknowledged their mutual attraction for one another, and tentatively began to explore a romantic relationship. As their personal relationship became stronger, the teacher experienced a relapse of her obsessive–compulsive symptoms but was confused about whether to discuss this with her former therapist now that their affection for one another had begun to include a physical component. The therapist also recognized the return of her compulsions, noticing that she was spending much time checking up on herself and having increased periods of anxiety and worry. He attempted to help by reviewing his original therapy interventions with her but found that he had much less patience now and began to be irritable with her and even sarcastic at times. He realized, belatedly, that the relationship had not turned out the way he thought it might and that he had harmed his former patient by beginning a romantic relationship with her. COMPETENCE In this vignette a psychologist experiences the conflict between his motivation to rapidly build his practice yet provide competent treatment to a needy patient. A therapist who had recently moved to a metropolitan area was treating a young woman for substance abuse and depression. After several weeks of therapy the patient informed her that there were really “four of her” living in the same body and that “the others” would like to talk with the therapist as well. The therapist hypothesized that this patient might meet the diagnostic 11 Copyright American Psychological Association. Not for further distribution. 12 ESSENTIAL ETHICS FOR PSYCHOLOGISTS criteria for dissociative identity disorder. She had never encountered a patient with this degree of severe psychopathology. However, because she had recently opened her independent practice and did not want to turn away new patients, she arrived at the rationalization that she had the competence to continue treating this woman. Unfortunately, because of her busy schedule, she failed to augment her competence by consulting those who were knowledgeable about this disorder, attending workshops, or sufficiently researching the literature on dissociative disorder. After several weeks of treatment, one of the violent alternate personalities of this patient made a suicide attempt by driving her car into a tree, and the patient was hospitalized in critical condition. This was enough of a warning to the therapist about her inadequate skills in offering therapy to a patient with this diagnosis, and she promptly contacted a colleague who was experienced in the treatment of dissociative disorders for consultation. INFORMED CONSENT This vignette presents an inexperienced researcher who has not paid attention to important elements of informed consent before proceeding with her study. A researcher was conducting an investigation on the effects on adults’ mood and behavior from playing computer games that have violent graphic imagery. He was not affiliated with an institution and therefore was not required to submit his research protocol to an institutional review board for evaluation. Unfortunately, he failed to accurately describe the amount of time that would be required as a participant in the study, and he failed to fully disclose that the images viewed by participants would actually include excerpts from movies depicting acts of torture and brutality. After the study began, four participants decided to drop out when they realized that they would be spending hours more in the study than they had originally planned. Several other participants became panicky or physically ill during the exposure to the imagery and decided to withdraw from the study at that point. Another participant, a veteran of the Iraq war, experienced a flashback during one of the screenings and needed emergency therapeutic intervention with medication to treat his psychotic symptoms. It was apparent to the researcher that he had failed to provide adequate informed consent at the outset about the intended experiences of the participants and that he had also failed to adequately screen for evidence of posttraumatic stress disorder or other diagnoses among them. PRIVACY This vignette demonstrates how easy it is for a well-meaning psychologist to breach a patient’s privacy when playing the role of both therapist and professor. Copyright American Psychological Association. Not for further distribution. Thinking Critically About Ethics A psychologist was teaching a course on marital therapy to graduate students and used examples from her clinical practice to illustrate various theoretical approaches. To protect their anonymity, she changed the names and ages of the husbands and wives in her examples. Unfortunately, in describing one of the husbands as “a well-known lawyer” and in accidentally revealing his specialty area, intellectual property, she divulged too much information to protect the husband’s anonymity. Furthermore, it so happened that one of the graduate students in the class was acquainted with this particular man because her husband had graduated from the same law school. Some others in the class simply knew the man by his local reputation because there was only one lawyer in town who specialized in intellectual property matters. Intentionality in Ethical Conduct As can be seen in each of these ethical lapses, the psychologist made a decision or a series of decisions that might be conceived of as unethical based on the psychologist’s ignorance or lack of experience— an “accidental” unethical act. A decision was made in the course of carrying out professional work that resulted in harm or potential harm to another person. None of the psychologists intended to be exploitative of others at the outset; in fact, each might have considered his or her professional conduct to be above reproach, and each might have thought of him- or herself as having the highest regard for ethical conduct in the role of therapist, researcher, or instructor. However, in each case the psychologist made a decision that ultimately led to an ethical infraction. How could this happen, and how does an ethics code anticipate these situations? Before directly addressing this question, I briefly examine the nature of ethics codes and two fundamental models—deontology and teleology—that determine the bases of ethical decision making. Ethics Codes: Musts and Must Nots One might consider a code of professional conduct as a list of rules that both mandates and prohibits certain behavior while one is functioning in the role of psychologist. This is fundamentally a way of assisting in decision making about day-to-day behavior that will presumably prevent harming others and ideally also serve to further the task at hand, 13 Copyright American Psychological Association. Not for further distribution. 14 ESSENTIAL ETHICS FOR PSYCHOLOGISTS whether it is carrying out psychotherapy, clinical supervision, research, management consulting, or teaching. Referring to any code of professional conduct as a list of “shoulds” and “should nots” would mitigate the mandatory nature of the code to that of guidelines or recommendations. It would be more accurate to conceive of the code as a list of “musts” and “must nots,” that is, absolute rules that leave little to the imagination yet still are sufficiently generic to address a broad range of situations and variables. A rule involving informed consent for treatment, for example, must be able to address the specific problems of providing adequate consent for the psychologist who is about to offer psychotherapy to an outpatient, treatment for bipolar disorder to an inpatient, therapy to a committed couple living together, biofeedback to a patient with chronic back pain, hypnosis for a patient who wants to stop smoking, or any other type of intervention. The language of the rule must strike a balance between being sufficiently precise and detailed to be useful in providing informed consent in a specific situation while at the same time sufficiently broad to generally address a variety of different situations. For example, a rule of conduct must apply with equal relevance and clarity for each of the following groups: ❚ ❚ ❚ ❚ ❚ psychologists who have different theoretical orientations (a cognitive–behavioral therapist, a psychoanalyst, a therapist carrying out in vivo desensitization), psychologists who work in various settings (e.g., outpatient clinic, hospital, independent practice, high school or college counseling center, the military, forensic setting, industrial and organizational setting, university—teaching or doing research), psychologists who provide a broad variety of interventions (e.g., neuropsychological assessment, individual psychotherapy, family and marital therapy, group therapy, hypnosis, biofeedback, behavioral interventions, business consultation), psychologists who intervene and specialize with various populations (e.g., men or women and their special issues, lesbian and gay clients, those of particular developmental ages ranging from childhood to the elderly, battered women, divorcing couples, patients with chronic illness, those seeking midlife vocational changes), and psychologists who intervene with clients and patients of certain diagnostic categories (e.g., anxiety disorders such as phobias, obsessive–compulsive disorder, posttraumatic stress disorder; depression including bipolar disorder, major depression; eating disorders such as anorexia or bulimia; schizophrenia and other psychotic disorders; substance-related disorders for alcohol, cannabis; personality disorders including paranoid, borderline, narcissistic; sexual and gender identity disorders). Thinking Critically About Ethics Copyright American Psychological Association. Not for further distribution. What is the rationale for creating these rules, and what is the basis on which the actual rules themselves are founded? To answer these questions I turn briefly to the nature of ethical acts themselves and then to two concepts that underlie the evolution of ethical standards as they are today. Attributes of Ethical Actions Actions are generally held to be ethical if they possess the following three attributes: (a) They must be principled; (b) they must result from the reasoned outcome of applying the principles; and (c) they must be generalizable (Hass & Malouf, 1995). An action is said to be principled when the actor bases his or her actions on some specific and generally acceptable moral principle (e.g., avoiding harming others or protecting patient autonomy). The reasoned outcome consists of the actor executing the logical implementation of the principle, such as telling the truth to a patient about the impending treatment, as based on the principle honesty, instead of misrepresenting what the treatment will consist of. And, this course of action must be generalizable; it must be able to be recommended to others in comparable situations, such as requiring every researcher to debrief research participants after their participation has ended as part of an ethical principle of avoiding harming others. These three attributes form the basis of ethical standards in the health care professions currently, as they did with the first ethics code written by the physician Hippocrates approximately 2,500 years ago. Over the centuries, as the practice of medicine evolved, and much later, as the practice of psychology emerged as a separate and distinct discipline, ethics codes have also been able to address specific topics of concern. For example, issues as diverse as sexual harassment, bartering with patients and clients, and media presentations are included in the most recent APA Ethics Code; these were certainly not in evidence in the first edition of the Ethical Standards of Psychologists: A Summary of Ethical Principles (APA, 1953b). Conversely, topics have been removed from ethics codes over the years, as committees performing revisions saw that a particular topic was overly narrow, too general in nature, or otherwise inappropriate (such as the requirement that psychologist “show sensible regard for the social codes and moral expectations of the community in which he [sic] works” in the 1953 code or a prohibition against teaching hypnosis to laypeople in the 1992 revision). Over the years, the Ethics Code became a more useful and richer document by including a broad array of topics that had surfaced as problem areas in the course of psychologists’ work. It became increasingly 15 Copyright American Psychological Association. Not for further distribution. 16 ESSENTIAL ETHICS FOR PSYCHOLOGISTS clear as complaints against psychologists surfaced which areas needed to be addressed and what kinds of guidance psychologists needed to avoid the pitfalls of inflicting harm in the course of carrying out their work— harm to others (clients, patients, colleagues), harm to the psychological knowledge base (shoddy or fraudulent research), or harm to the profession of psychology itself (eroding confidence and the public perception of psychologists by their public actions). How this diversity and how these rules evolved is the focus of the next section through the examination of the concepts of deontology and teleology as two fundamental ways of conceptualizing ethical standards. Deontology and Teleology: Two Bases for Ethical Decision Making Deontology is defined as “ethics based on the notion of a duty, or what is right” (Blackburn, 2008). This important concept was first articulated by Immanuel Kant (1724–1804), whose “categorical imperative” required that individuals should act only according to that maxim whereby they can at the same time will that it should become a universal law (Schneewind, 1993). Hence, a deontological means of justifying the ethical quality of one’s actions focuses on a small or narrow set of moral values or characteristics. It does not consider specific exceptions or outcomes, mitigating circumstances, or the subjective judgment of the individual pondering which course of action to take. Rather, it is rigidly dichotomous in nature—engage in this behavior always, in every situation, regardless of factors or variables that might cause one to consider a different course of action. An example of a deontologically justified ethical principle might be “Always be honest.” Incorporating such a rule into one’s professional conduct could be interpreted as “Always tell the truth” or never deliberately make factual misrepresentations or “spin” the facts in oral or written communications. Another example, in the case of medical ethics, might focus on valuing life. This might be manifested in medical practice as “Always preserve life under any circumstances,” such as always choosing to engage in medical interventions that would support prolonging the patient’s life, regardless of its quality or the patient’s wishes. Unfortunately, ethical rules can come into conflict with each other when an ethics code is based solely on a deontological foundation. It is useful to consider the dilemma of a medical doctor who believes that he or she (a) must always state the literal truth and (b) must always preserve Copyright American Psychological Association. Not for further distribution. Thinking Critically About Ethics life whenever possible. How would this individual resolve the dilemma posed by the following scenario? The setting is a German hospital in World War II, and a Nazi soldier inquires of a physician who is the chief administrator of the hospital if there are any Jewish patients inside. Such a question immediately places the physician in conflict because he cannot simultaneously comply with both ethical rules; he cannot tell the truth and preserve life if, in fact, there is a Jewish patient inside. Similarly, there could be conflicting rules for the psychologist who is committed to (a) always telling the truth and (b) always protecting the welfare of patients and clients. It is useful to consider the following scenario. A marital therapist met with a high-conflict couple one time and observed during the session that the husband was intoxicated and loudly castigated his wife for her “shortcomings.” The next day, the therapist received an urgent telephone call from the wife, who told him that she had fled her home in the middle of the night for the safety of a women’s shelter because her husband had started beating her with his fists. Several hours later the repentant husband also telephoned the marital therapist inquiring if she knew where his wife had gone, that he was concerned about her and about to file a missing persons report with the police. Again, it is impossible to simultaneously comply with both mandates— providing an honest reply to the violent husband’s question concerning his wife’s whereabouts and protecting the wife’s welfare. Disclosing information about the wife’s location could jeopardize her safety; however, preserving her safety and welfare by telling a lie or refusing to answer would violate the requirement to honestly respond to all questions. There is no clear way for the psychologist to honor both mandates in an ethics code that is wholly deontologically based—to always preserve the welfare of all clients and patients and to always tell the absolute truth.1 The gray areas present problems that intuitive reasoning alone cannot always solve. This brings psychologists to another model for constructing ethical standards and helps resolve these intrinsic contradictions. Teleology is defined as “the study of the ends or purposes of things” (Blackburn, 2008). This utilitarian philosophy on which to base ethical decision making was developed by the British philosopher Jeremy Bentham (1748–1832), also a legal scholar and linguist, and elaborated 1In point of fact, the APA Ethics Code does not require absolute honesty in every situation, and the standard addressing public statements is defined by the code in such a way as to allow for a variety of situations in which absolute truth telling would not necessarily always be in the best interest of the patient (e.g., providing a diagnostic assessment of a paranoid patient prematurely before the therapy relationship has had a chance to develop or refusing to release the patient’s clinical record to the patient because it could ultimately result in harm to the patient). 17 Copyright American Psychological Association. Not for further distribution. 18 ESSENTIAL ETHICS FOR PSYCHOLOGISTS on later by John Stuart Mill (1806–1873), also an economist and political theorist (Callan & Callan, 2005). Bentham promulgated the philosophical concept that ethical decision making should rest on the concept of aspiring toward realizing the greatest good and happiness for the greatest number of people. Hence, a teleological or utilitarian justification for an ethical rule focuses on the results or endpoints (greatest good and happiness) as a consequence of the action completed; it attempts to link cause and effect by creating a rule that would facilitate or prevent certain outcomes. How did the framers of the first APA Ethics Code ascertain whether a certain behavior of a psychologist would hurt or harm another person? Absent any database, a code of ethics would necessarily be founded on broad philosophical concepts such as beneficence and maleficence, autonomy, and social justice, but they would not necessarily be closely linked to the actual work that psychologists perform in their various roles. It was necessary to develop an ethics code that closely tracked the day-to-day activities of psychologists and provided needed guidance in a variety of situations. As is discussed in more detail in Chapter 2, the first APA Ethics Code was based on a scientific method of systematically gathering data from 1,000 psychologists concerning ethical dilemmas that they had experienced in the course of their work (Canter, Bennett, Jones, & Nagy, 1994). Such a database allowed for a distillation of topical areas—competence, confidentiality, client welfare, and informed consent, to name a few. Each of these topical areas contained specific rules that informed the choices of an ethically compliant psychologist. An example is Principle 8, Client Relationship, Paragraph c: “Psychologists do not normally enter into a clinical relationship with members of their own family, intimate friends, close associates, or others whose welfare might be jeopardized by such a dual relationship” (APA, 1953a). Another example is Principle 6, Confidentiality, Paragraph a: “Information received in confidence is revealed only after most careful deliberation and when there is clear and imminent danger to an individual or to society, and then only to appropriate professional workers or public authorities.” In these rules there are specific musts and must nots. The first rule forbids entering into a dual-role relationship and then proceeds to define how one would identify such a situation. The second rule states that information obtained in confidence must remain so, except under a very specific circumstance, in which case psychologists must break confidentiality and even then in a narrowly defined way. These rules evolved because of negative consequences that resulted from engaging in prohibited activities. For example, the practice of attempting to provide individual psychotherapy to a family member or close friend would have resulted in possibly harming that person because Copyright American Psychological Association. Not for further distribution. Thinking Critically About Ethics the psychologist’s objectivity would have been impaired, calling into question his or her competence and customary good judgment in providing treatment. Or, revealing a client’s disclosures in therapy to friends, associates, or family members might irrevocably damage trust in the therapeutic relationship, likely inhibiting the honest exchange that is so essential to the process or simply bringing an end to treatment. Hence “operating rules” evolved to avoid such harmful consequences to those who interacted with psychologists. There was a close connection between the rule and the outcome, cause and effect; this is the very nature of a teleologically based code of ethics. Evolution of the APA Ethics Code As the Ethics Code evolved, additional standards were added. Some of these were driven by technology. As electronic recording of therapy patients or research participants became possible, a standard was developed requiring that formal consent by the individual be acquired before recording. Some additions were driven by questionable practices of psychologists, such as soliciting testimonials from their current clients to be used in advertisements. This capitalized on the undue influence held by the therapist over the client and was exploitative; hence a rule was developed to prohibit this practice. And some additions were driven by changes in the culture of patient care, including, among other things, managed health care and litigiousness on the part of patients who felt wronged by their health care providers. The requirement for psychologists to document their clinical work with patients was considered to possibly enhance treatment on a weekto-week basis (charting the patient’s history, diagnosis, goals, progress, setbacks, and plans) and provide better continuity of care if there was an interruption to treatment, such as the patient or therapist leaving the area or the therapist becoming ill. Case managers for health insurance companies came to rely on therapists’ clinical records to document progress in treatment or to substantiate requests for allocating additional sessions above and beyond those originally allowed. Good record keeping was also considered an invaluable resource in the event of patient dissatisfaction or failure by the therapist to meet the standard of care as prescribed by ethics codes, laws, professional guidelines, and professional standards published by the APA or other professional associations of which the therapist might be a member. In these cases, a psychologist’s clinical record would ideally provide a chronology of treatment events, sometimes over a period of many years (far longer than memory would adequately 19 Copyright American Psychological Association. Not for further distribution. 20 ESSENTIAL ETHICS FOR PSYCHOLOGISTS serve) that would best be relied on in the case of an ethics complaint or lawsuit by a patient. Such a record increased accountability and responsibility of the therapist by documenting important interventions, significant changes in the patient, and milestones and benchmarks that otherwise would be lost as the years progressed. It would also serve as a primary means by which psychologists could defend themselves against charges of incompetent practice, negligence, abuse, or other forms of malpractice. Educational settings also offered a similar opportunity for documentation that was omitted in the earlier editions of the Ethics Code. Those who provided individual supervision of psychology trainees were now required to provide informed consent at the outset as well as document the course of supervision in some way (APA, 2002, 2010). This was felt to improve the quality of supervision by (a) letting trainees know in advance exactly what they were to expect in the course of supervision and (b) putting supervisors on notice that they should carry out their work according to some theoretical model that included didactic and experiential elements considered to be relevant, useful, and ultimately evidence based. Indeed, some state licensing boards required that psychologists functioning as supervisors must take continuing education in clinical supervision at regular intervals if their supervision was to be considered legally valid. Aspirational and Mandatory The APA Ethics Code underwent a major change in 1992, resulting not only in revising the mandatory ethical standards (i.e., the actual nuts and bolts of the document) but also adding another section at the beginning of the code titled General Principles (Nagy, 1992). They were (a) Competence, (b) Integrity, (c) Professional and Scientific Responsibility, (d) Respect for People’s Rights and Dignity, (e) Concern for Others’ Welfare, and (f) Social Responsibility. The general principles were reduced to five in number in the 2002 revision and contain a descriptive paragraph for each. These general principles, some of which have long been held as important values in health care work, are couched in language that is broad ranging in nature, yet lofty in aspiration; their purpose is to inspire, not to set minimal standards of compliance. The general principles are discussed more fully in Chapter 3. The opening sentence of the first principle of the 2002 Ethics Code, Beneficence and Nonmaleficence, states: “Psychologists strive to benefit those with whom they work and take care to do no harm.” Although lofty in its objective, this statement is so general in concept and lacking in an operational definition that it offers little guidance about how to Copyright American Psychological Association. Not for further distribution. Thinking Critically About Ethics actually execute it. The remainder of the paragraph is similarly wideranging in scope, as it should be. The specific musts and most nots occur later in the document, in the form of the actual ethical standards. These are essentially a list of specific behavioral rules about a broad array of topics, such as competence, record keeping, advertising, providing informed consent for research, and maintaining patient privacy. Clearly, these two sections of the Ethics Code—general principles and ethical standards—although all part of the same document, are fundamentally different in nature. The general principles may be seen as largely deontologically based, as described in the previous section. They focus mainly on a narrow set of moral values or characteristics, such as integrity, justice, or respect for people’s rights and dignity, helping psychologists set their sights high while in their professional role. However, the ethical standards themselves are more teleologically based. They clearly link actions and outcomes. By providing good informed consent at the outset of therapy or research, a psychologist has prepared a particular client, patient, or research participant for the experience that lies ahead. Such actions directly contribute to the person’s autonomous decision making and could be said to potentially add to their own good or happiness in some way. On the contrary, foisting an experience on an unprepared recipient of psychological services (e.g., aversive experiences in treatment, unusually high fees) would likely be perceived as diminishing the individual’s good or happiness and contributing to feelings of being harmed or exploited. The natural outcome of diminishing the welfare of others might include complaints to a licensing board or ethics committee or attempts to gain compensation from the offending psychologist. A teleologically based code of ethics, then, offers protection to both psychologist and recipients of their services. By complying with each ethical standard, the psychologist not only contributes to the welfare of those with whom the psychologist works but also, ultimately, protects him- or herself from costly repercussions that can result from a consumer who feels hurt, angry, or exploited in some way. Options available to consumers for dealing with offending psychologists are discussed in the last section of this chapter. I turn now to another utilitarian means of limiting and mandating how psychologists behave when interacting with others. Ethics Codes and Laws In addition to observing ethical standards, psychologists who render services to consumers (e.g., psychological assessment, psychotherapy, management consulting) must also observe the laws of the land. Why 21 Copyright American Psychological Association. Not for further distribution. 22 ESSENTIAL ETHICS FOR PSYCHOLOGISTS do we need both, and is there not a risk of redundancy or confusion by conflicting rules? To answer these questions I first examine the nature of laws and ethics and the purpose and jurisdiction of each. Law may be defined as “a rule or system of rules recognized by a country or community as regulating the actions of its members and enforced by the imposition of penalties” (Compact Oxford English Dictionary, 2009). Every psychologist who holds a license to practice is required to comply with relevant state and federal laws as well as state psychology licensing regulations. Compliance with laws such as reporting child or elder abuse, taking appropriate action when there is a serious threat that a patient will harm himself or others, abstaining from sexual relations with patients, or permitting clients to view their own clinical record forms the legal skeleton of professional conduct on which all psychologists base their decision making in addition to complying with codes of ethics. The configuration of this skeleton varies from state to state because psychologists are licensed by the state in which they practice, and some states may not address such practices as informed consent or record keeping as fully as others. Conflicts between the Ethics Code and state law have been treated differently by the APA over the years. In the 1992 edition of the APA Ethics Code, psychologists were obliged to follow the “higher standard” of the two rules, ethical and legal (APA, 1992). If the ethical standard actually conflicted with a requirement of law, then psychologists were obliged to “make known their commitment to the Ethics Code and take steps to resolve the conflict in a responsible manner” (APA, 1992). An example is breaking confidentiality in response to receiving a subpoena ordering the release of a patient’s clinical record, although the Ethics Code specifically states that psychologists must only do so with client authorization. This is addressed more fully in Chapter 7. If psychologists’ attempts to resolve the conflict were unsuccessful, then they were supposed to consider other professional materials (e.g., published practice guidelines, official white papers of the ethics committee, or other documents), the dictates of their own conscience as well as consultation with other psychologists. The 2002 revision of the code took quite a different approach to conflicts by allowing psychologists to “adhere to the requirements of the law, regulations, or other governing legal authority” if the conflict was found to be unresolvable, as stated in Standards 1.02 and 1.03 (APA, 2002, 2010). This change was criticized by some as being a woefully inadequate solution to the problem of conflicting mandates, essentially allowing psychologists to engage in ethically questionable practices and justifying their conduct by claiming that they are merely following the Ethics Code, as delineated in the previously quoted sentence (Olson, Soldz, & Davis, 2008; Copyright American Psychological Association. Not for further distribution. Thinking Critically About Ethics Pope & Gutheil, 2009).2 Dissenting psychologists were passionate about this matter, with some acting on their objection by withdrawing their membership from the APA. In response to the persistent outcry about these standards, 8 years after the revision of the Ethics Code, the APA took the rare action of amending the two standards, the amendments taking effect in June 2010 (APA, in press). The APA adopted new wording that required psychologists to “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” (italics indicate amended wording; APA, in press). A final sentence stated unambiguously that “under no circumstances may this standard be used to justify or defend violating human rights.” This new rule applied to any situation in which ethical standards conflict with law, regulations, or other governing legal authority (Standard 1.02), or any situation in which ethical standards conflict with organizational demands (Standard 1.03). This was a momentous change that now clearly prohibited psychologists from using their own discretion to comply with an employer who expected them to violate human rights in the course of their work. It is possible that these new standards could lead to some confusion, as they are the only standards in the Ethical Standards section of the Ethics Code that cite or even mention the general principles and require psychologists to act in accordance with them while resolving an ethical dilemma.3 However, the introductory paragraph that precedes the general principles in the code clearly states that “General Principles, in contrast to Ethical Standards, do not represent obligations and should not form the basis for imposing sanctions. Relying upon General Principles for either or these reasons distorts their meaning and purpose.” To their credit, these changes firmly established the concepts articulated by the 2 Following the publication of the 2002 revision of the APA Ethics Code and the series of events following the September 11, 2001, terrorist attacks, a question was raised about the participation of psychologists in possibly unethical acts, primarily in military settings. This included such behaviors as allegedly participating in some aspects of interrogation and/or torture of prisoners who were held in the Guantanamo Bay prison or other prisons where inmates were allegedly exploited with the knowledge (and some would say with the assistance) of psychologists on site. 3 As mentioned previously, the general principles are considered to be aspirational in nature, and the ethical standards are mandatory. However, this new standard now could be interpreted by some as making the general principles “mandatory,” possibly eroding the distinction between the two sections of the code. Requiring psychologists to comply with the general principles may cause some uncertainty about possible exposure of psychologists to increased liability as well because the “minimal standards” implicit in the ethical standards are now being raised considerably to a much higher level—to that of the general principles. 23 Copyright American Psychological Association. Not for further distribution. 24 ESSENTIAL ETHICS FOR PSYCHOLOGISTS general principles as relevant to the daily work of psychologists, and they placed the responsibility squarely on the shoulders of psychologists to be aware of human rights and not just “follow orders” when carrying out their work if discharging their professional responsibilities could abrogate others’ human rights and be harmful to them. Infractions of laws pertaining to psychological practice may range from a misdemeanor to a felony. Penalties could include a monetary fine, a temporary suspension of license with certain requirements (e.g., taking training in ethics, consulting with a supervisor, undergoing psychological treatment), permanent loss of license to practice, and even prison for the most egregious offenses. Of course, federal laws pertaining to both therapists and researchers have uniform application across states. One example is the Health Insurance Portability and Accountability Act of 1996, which requires that therapists comply with certain rules involving clinical practices, such as informed consent, confidentiality, record keeping, and grievance procedures. Researchers are also governed by the principles of the Health Insurance Portability and Accountability Act as they bear on the recruitment of research participants and documentation. The National Institute of Mental Health also has policies regulating the conduct of researchers, concerning informed consent, voluntariness, and other matters. If a researcher has received funding from the National Institute of Mental Health (or any other government agency), the researcher must comply with all of the regulations, including such fundamental protections of participants’ welfare as informed consent, avoiding harm, maintaining privacy, and debriefing. As mentioned previously, ethical standards (or codes of conduct) are fundamentally a list of rules, as are laws—the musts and must nots that control what psychologists do. However, they do not have uniform applicability. Only those psychologists who belong to a professional association must comply with its ethics code or code of conduct. For example, the jurisdiction of the APA or the Association for Applied Psychophysiology and Biofeedback consists of the association’s members only. If one does not belong, one need not comply with the rules of that association. Although it may appear to be a simple dichotomy that laws regulate the actions of every licensed psychologist and ethical standards of professional associations regulate the behavior of their members, it is not quite that simple. Even codes of conduct have found a way into state laws. Well over half of the states in this country have chosen to incorporate the APA Ethics Code into their laws, thereby effectively endowing each of its regulatory standards with the force of law. It is likely that as the Ethics Code continues to undergo further revisions that will better address the welfare of both individuals and society, these revisions will also be incorporated into the laws of additional states. Thinking Critically About Ethics Copyright American Psychological Association. Not for further distribution. Complaints Against Psychologists It is a serious matter when psychologists violate an ethical standard or a state or federal law, and their actions have a variety of consequences. Patients, clients, supervisees, and others who interact with psychologists generally have at least three standard ways of complaining against a psychologist who they think has broken a regulation or harmed them in some way in addition to or instead of directly confronting the psychologist. Psychologists may choose to use the services of an attorney in their own defense in responding to the complaint. The three ways in which a complainant might seek redress are (a) initiating a complaint with the APA or state psychological association ethics committee,4 (b) initiating a complaint with the state licensing authority (also called board of psychology or licensing board), or (c) initiating a lawsuit against the psychologist. In some cases there would be a fourth option to initiate an in-house process if the hospital, clinic, university, or institution has a patient advocate office, grievance committee, ombudsman, department chair, institutional review board, or some other entity that is known to receive and adjudicate complaints against psychologists. This method may be the most accessible option for the complainant and has the possibility of providing excellent outcomes unless the problem behavior is pervasive within the system, spawning conflicts of interest for those attending to the complaint or the problem behavior is egregious, necessitating a legalistic remedy. I examine the other three methods in the sections that follow. INITIATING A COMPLAINT WITH THE APA OR STATE ETHICS COMMITTEE This choice would only be available to a complainant if the psychologist were a member of APA or the adjudicating state association.5 Even if a potentially offending psychologist belongs, he or she is given the choice of withdrawing membership when contacted by the ethics office to begin a preliminary investigation to determine whether an ethics case should be formally initiated. The APA Ethics Office has full clerical and legal support and depends on a panel of psychologists and one public member who volunteer their time to participate in adjudication of complaints. 4 It should be noted that the ethics committees of the APA and state psychological associations have no connection whatever with each other; they have different rules and procedures, different jurisdictions, and a different range of sanctions that are imposed on offenders. 5 Very few state associations continue to adjudicate complaints. 25 Copyright American Psychological Association. Not for further distribution. 26 ESSENTIAL ETHICS FOR PSYCHOLOGISTS It has well-established rules and procedures governing such things as statute of limitations on complaints, time limits on responding to complaints, failure to cooperate, appealing a decision, and the range of available directives and sanctions (APA, Ethics Committee, 2001). A complaint brought to the Ethics Office may take many months to resolve, and it is not uncommon for some complaints to go on for a year or more, allowing for the careful gathering of data from multiple parties. Due process in adjudicating ethics complaints always involves informing the psychologist of the issue that has been raised and providing him or her an opportunity to respond. The committee ultimately makes a decision whether to impose a sanction (punitive order) on the psychologist. Possible sanctions are ❚ ❚ ❚ ❚ reprimand, issued when there clearly has been a violation of a particular ethical standard but no harm came to an individual or the profession of psychology (e.g., making a false statement on one’s résumé); censure, administered when an ethics violation has resulted in harm to someone, but not in a substantial way (e.g., deliberately providing erroneous informed consent about the nature, course, and duration of treatment to engage the patient in psychotherapy); expulsion, administered for egregious acts resulting in harm to another or to the profession (e.g., having sex with a patient, fabricating data on a major research project, committing a felony); and stipulated resignation, also for serious violations but allowing the psychologist to resign from the APA for a period of time, comply with certain stipulations or directives (listed previously), and then reapply for membership following full compliance (e.g., engaging a patient in a multiple-role relationship resulting in harm or failing to comply with directives that had been issued previously). It should be noted that even if one is expelled from the APA, one may continue to practice, because one’s license remains intact unless the state licensing authority chooses to investigate and decides to suspend or permanently revoke a license. The APA ethics committee has the option of imposing a directive as well, if warranted. They are as follows, from least to most serious: ❚ ❚ ❚ ❚ cease and desist order requiring the psychologist to immediately stop the unethical conduct (e.g., advertising that guarantees results of treatment, or violating the code in some other way); other corrective actions; supervision requirement mandating that the psychologist submit to a period of supervision in ethics, clinical work, or some other area; education, training, or tutorial requirement requiring a range of didactic experiences; Thinking Critically About Ethics ❚ Copyright American Psychological Association. Not for further distribution. ❚ evaluation and/or treatment requiring a formal psychological evaluation and, if warranted, treatment for a mental disorder; and probation mandating a period of monitoring by the ethics committee to ensure that the psychologist is complying with the directives that were mandated. INITIATING A COMPLAINT WITH THE STATE LICENSING AUTHORITY The state licensing authority or board of psychology is a consumer agency that regulates the practice of psychology and offers useful information to the public, such as a patient’s “bill of rights,” licensure status of particular individuals, recent board actions, or the status of a particular complaint, among other things. If an individual thinks that a psychologist has broken a state law pertaining to psychological practice or an important ethical rule (e.g., failure to remain within the standard of care by using an inappropriate therapeutic technique that harmed a patient, having a sexual relationship with a supervisee), that individual may initiate a formal complaint. The complaint is filed with the state licensing department whose disciplinary supervision of psychologists is handled by its psychology board. States vary with regard to the range of disciplinary actions they may take when warranted, but the major categories of sanctions are letter of warning, probation, suspension, and revocation of license. LAWSUITS, CIVIL CHARGES, AND CRIMINAL CHARGES Clients, patients, trainees, or anyone else who feels that they have a serious cause of action against a psychologist for the harm they believe the psychologist has caused them (e.g., sexual relationship with the patient or a close family member, gross incompetence) after consultation with an attorney may bring an action for damages (lawsuit) against a psychologist. Another reason for initiating a lawsuit could be a dispute about fees, such as obtaining money from a patient by misrepresentation. This might include billing the patient for services that the psychologist knew or should have known had no therapeutic value for the patient. A patient may sue the psychologist in addition to bringing an ethics complaint and/or notifying the licensing board of any concerns. Suing a psychologist may initially exert a significant financial toll on the complainant, and it could have serious financial repercussions for the therapist too. Sometimes, unethical, harmful behavior that provides grounds for a civil suit may rise to the level of criminal conduct under the criminal statutes of the state. If so, the state might independently bring criminal charges against the offending psychologist. 27 Copyright American Psychological Association. Not for further distribution. 28 ESSENTIAL ETHICS FOR PSYCHOLOGISTS Psychologists commonly defend themselves by notifying their malpractice insurance carrier, and they are then assigned an attorney who participates in their defense in the pending suit. This is generally a lengthy procedure and could easily last several years until it is settled, either in court or out of court. It is true that clients and patients may feel harmed or disappointed at times and occasionally bring ethics complaints even when the psychologist has done nothing wrong. Under these circumstances, after close scrutiny by an ethics committee or licensing board, the psychologist is usually exonerated and accepts this as a learning experience. By understanding aspirational and mandatory ethical concepts, as described in the chapters ahead, psychologists reduce the likelihood of ever receiving an ethics complaint of any kind, unfounded or not.
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Running Head: ETHICS IN PSYCHOLOGY

Ethical dilemma in psychology
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Running Head: ETHICS IN PSYCHOLOGY

Psychologists are professionals who believe in upholding the dignity and the self-esteem
of his clients or of all people who come across them. He achieves this by protecting their welfare
and trying to learn them more than they may understand themselves. However, in his line of
duty, the psychologist cannot allow or permit his own services to be misused for inconsistent
values. The psychologist's main objectivity is to attain competency as he helps all people who
come along his way (American Psychol...


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