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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.
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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
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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
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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.
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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,
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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
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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
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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
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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).
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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
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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
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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
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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
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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;
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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.
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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
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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.
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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
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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:
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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
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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.
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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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