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Ethics is More than a Code: Ethical Foundations, Positive Ethics, and Ethical Decision-Making

Ethics is More than a Code: Ethical Foundations, Positive Ethics, and Ethical Decision-Making

This was a day-long, 6 hour CE course.

Not for the faint of heart.

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Ethics is More than a Code: Ethics is More than a Code: Presentation Transcript

  • Ethics is More than a Code: Ethical Foundations, Positive Ethics, and Ethical Decision-Making John Gavazzi, Psy.D., ABPP
  • Learning Objectives
    • Describe positive ethics
    • Differentiate between remedial ethics and positive ethics
    • Identify ways that positive ethics can maximize professional effectiveness
  • Learning Objectives
    • Illustrate how a positive ethics approach can enrich your career
    • Explain one ethical decision-making model
    • Analyze one ethical dilemma and reflect on the personal and professional ethical values that led to the decision.
  • What is the “take home?”
    • Reflect on personal ethical values
    • Discern practical applications
    • Resources for future consideration
  • Remedial Ethics compared to Positive Ethics
  • Remedial Ethics
    • Mandatory “floor” or minimum standards of the profession
    • Focus on the law or standards to protect the public
    • Can lead to an overemphasis on legal rules and an incomplete view of ethics
  • Remedial Ethics
    • Why do we sometimes overemphasize remedial ethics?
    • “Bad is stronger than good,” but, we have an internal moral grammar.
    • Are we so afraid of doing something wrong that we lose opportunities to do good?
  • Positive Ethics
    • Ethics moves away from the punishing and anxiety-producing components of ethics
    • Fulfill their highest ideals
    • A means to help interpret and apply ethics standards
  • Positive Ethics
    • Positive ethics influenced by positive psychology or the effort to focus on uplifting and fulfilling aspects of human existence.
  • Precursors of Positive Ethics
    • Lee VandeCreek
    • Patricia Bricklin
    • Sam Knapp
    • Richard Small
    • Alan Tjeltveit
  • Competence
    • Remedial: Acquiring and maintaining minimal formal qualifications
    • Positive: Striving for highest standards
    • Includes self-awareness and
    • self-care
    • Emotional competence
  • Relationships
    • Remedial: Avoiding boundary violations Focus on sexual boundaries
    • Adhere to strict interpretation
    • Positive: Striving to enhance quality of all professional relationships
    • Understand issues related to multiple relationships
  • Patient Empowerment
    • Remedial: Fulfilling legal responsibilities
    • to get consent forms or Privacy Notices signed
    • Positive: Working to maximize client participation with goals and treatment processes
  • Trust
    • Remedial: Avoiding prohibited disclosure
    • Emphasis legal requirements
    • Positive: Striving to enhance trust Understanding nuances when
    • working with families
  • Positive Ethics is NOT
    • An avoidance of ethical codes, case law, regulations, and statutes
    • A rationalization to explain inappropriate behaviors or decisions
  • Benefits of Positive Ethics
  • Benefits of Positive Ethics
    • Sensitizes psychologists to:
    • Ethical implications of their “habits of practice”
    • Opportunities for creative decision making
    • Abilities to help difficult patients
  • Benefits of Positive Ethics
    • Appreciate the moral values on which the APA code is based
    • Assist psychologists in balancing competing ethical demands
    • Help psychologists to address systemic social problems
    • Ethics autobiography
    • Ethics genograms or charts
    Self-Reflection on Values
  • Self-Reflection on Values
    • Are you a classical radical?
    • Radical means “root”
    • Do you fully consider the root or basic assumptions by which you live?
  • Classical Radicals
    • Have a moral foundation or vision
    • Are committed to the community
    • Have a goal for a more positive future
  • ML King was a classical radical
    • Moral foundation on Christianity and influenced by other religious traditions
    • Commitment to entire American community
    • Positive vision of “somebodyness” in a “beloved community”
  • Are you a classical radical?
    • Do you look at your habits of practice and consider ways that you can make them more consistent with your values?
  • Meet some Classical Radicals
    • Rebecca– “Love your neighbor as yourself”
    • Jewish upbringing and community
    • Goal– more attention to helping pts with life style issues– diet, exercise, etc.
    • Challenge– “I can be too rigid at times, I need to loosen up.”
  • Meet Some Classical Radicals
    • Robert- “On earth as in heaven;” Christian upbringing and community
    • Goal- integrate spirituality in therapy for persons of different faith backgrounds.
    • Challenge. “I tend to form opinions too quickly. I need to listen more.”
  • Meet Some Classical Radicals
    • Jennifer- “All religions are true.” Agnostic background, but studying Eastern religions
    • Goal– help high conflict families as consultant in collaborative divorce project.
    • Challenge– “I tend to get overloaded. I need to make more time for family and self.”
  • Reflections on Values
    • Ethical traditions, such as foundational religious writings?
    • Your ethical community?
    • Your personal insights or inspirations?
  • Reflections on Values
    • Traditions– The Holy Bible, other religious writings; “science of morality”; Existential Phenomenology; philosophy; ethics
    • Community- family, “ethics buddies”, Psychology in PA
    • Personal
  • An Acculturation Model One Application of Positive Ethics
  • Acculturation
    • A process to change the cultural behavior of an individual through contact with another culture. The process of acculturation occurs when there is an adaptation into an organization or society.
  • Ethics Acculturation Model
    • This model is a natural outgrowth of positive ethics in that it shows how to integrate personal ethics into context of professional obligations.
  • Ethical Culture of Psychology
    • Our system of common beliefs, shared meanings, norms and traditions that distinguish psychologists as professionals.
    • It is a learned set of skills, bases of knowledge and ethical beliefs, as described in our ethics code.
  • Ethical Culture of Psychology
    • You cannot understand the laws of a society without understanding the society.
    • You cannot understand the ethics of psychology without understanding the profession of psychology
  • Ethical Culture of Psychology
    • Some rules may appear to be counter intuitive:
    • Do you loan money to patients?
    • Do you engage in routine mutual self-disclosure?
    • Do you place your welfare on an equal basis as your patients?
  • Acculturation as a Process
    • Can be a complex process
    • Some parts of a psychologist’s practice and lifestyle may be easily acculturated while others not
    • Process that may continue throughout the education or career as a psychologist
  • Ethical Acculturation
    • Identification with personal value system
    • (high vs. low)
    • Identification with value system of psychology
    • (high vs. low)
  • Acculturation Model of ethical training Hi Professional Ethics Low Professional Ethics Hi Personal Ethics Low Personal Ethics Integration Separation Assimilation Marginalization
  • Marginalized
    • Matrix: Low on professional ethics
    • Low on personal ethics
    • Risks: Greatest risk of harm
    • Lack appreciation for ethics
    • Motivated by self-interest
    • Less concern for patients
  • Assimilation
    • Matrix: High on professional ethics
    • Low on personal ethics
    • Risks: Developing an overly legalistic stance
    • Rigidly conforming to individual rules while missing broader issues
  • Separation
    • Matrix: Low on professional ethics
    • High on personal ethics
    • Risks: Compassion overrides good
    • professional judgment
    • Fail to recognize the unique role of psychologists
  • Integrated
    • Matrix: High on professional ethics
    • High on personal ethics
    • Reward: Implement values in context of professional roles
    • Reaching for the ethical ceiling
    • Aspirational ethics
  • Integration- Example Separation : Treating a patient like a friend Assimilation : Maintain rigid boundaries at times, to the point of being cold and distant Integration : Cordial and friendly within the boundaries of a professional relationship
  • Integration
    • The integration strategy is used by “classical radicals” in that they look to ways to adhere to their foundational ethical beliefs in the context of their professional lives.
  • Understanding the Ethical Foundation of the APA Code
    • The Ethics Code does not equal ethics.
    • Ethics = ethics ?
  • APA Ethics Code
    • Introduction and Applicability
    • Preamble and General Principles
    • (Aspirational and based on principle-based ethics)
    • Ethical Standards (Enforceable and represent minimum standards)
  • APA Ethics Code
    • The ethics code does not include federal laws, such as HIPAA
    • The ethics code does not include case law, though influence is noted
    • The ethics code is distinct and separate from guidelines approved by the APA Council of Representatives (e.g., Child Custody Evaluation Guidelines)
  • The enforceable portion of the APA Code is based on principle-based ethics
    • Respect for Autonomy
    • Beneficence
    • Nonmaleficence
    • Fidelity
    • Justice
  • Respect for Autonomy
    • Does not mean promoting autonomy (individuation or separation)
    • Means respecting the autonomous decision making ability of the patient
  • Autonomy
    • It encompasses freedom of thought and action. Individuals are at liberty to behave as they chose.
    • - Determining goals in therapy
    • - Making life decisions (e.g., marriage, divorce)
    • - Scheduling appointments and terminating treatment
  • Beneficence
    • The principle of benefiting others and accepting the responsibility to do good underlies the profession.
    • - Providing the best treatment possible
    • - Competency
    • - Referring when needed
  • Beneficence
    • Basis of foundational standard 2.01
    • “Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence.”
  • Nonmaleficence
    • The principle is doing no harm.
    • - Demonstrating competence
    • - Maintaining appropriate boundaries
    • - Not using an experimental technique as the first line of treatment
    • - Providing benefits, risks, and costs
  • Nonmaleficence
    • Foundational Standard 3.04
    • “Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm when it is foreseeable and unavoidable.”
  • Fidelity
    • This principle refers to being faithful to commitments. Fidelity includes promise keeping, trustworthiness, and loyalty.
    • - Avoiding conflicts of interests that could compromise therapy
    • - Keeping information confidential
    • - Adhering to therapeutic contract (e.g., session length, time, phone contacts, etc.)
  • Fidelity
    • Foundational Standard 4.01
    • “Psychologists have a primary obligation and take reasonable precautions to protect confidential information.”
  • Justice
    • Justice primarily refers to treating people fairly and equally.
    • In their work-related activities, psychologists do not engage in unfair discrimination based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, socioeconomic status, or any basis proscribed by law. (3.01)
  • Principles and APA Ethics Code
    • The standards in the APA Ethics Code
    • state the principle (“foundational standards”);
    • amplify or apply the principle; or
    • balance it with competing moral obligations.
  • Principles and APA Ethics Code
    • Beneficence—
    • Foundation– Standard 2.01
    • Amplification example– Standard 2.03
    • “Psychologists undertake ongoing efforts to develop and maintain their competence.”
  • Principles and APA Ethics Code
    • Beneficence-
    • Balancing example- Standard 2.02
    • Psychologists provide services in emergencies even in areas where they are not ordinarily competent
  • APA Aspirational Virtues
        • Competence
        • Integrity
        • Responsibility
        • Respect
        • Welfare
        • Social Responsibility
  • Ethics Across Cultures
    • Relativism– the practices and beliefs of all cultures are equally ethical
    • Universalism– the practices and beliefs of all cultures must be evaluated according to universal principles
    • Soft universalism- although the practices and beliefs of all cultures must be evaluated according to universal principles, cultures may differ in the interpretation and manifestation of these universal principles
  • Supererogatory Question
    • What must I do to fulfill my ethical ideals?
    • As compared to:
    • What must I do to fulfill the minimum requirements of the ethics code?
  • Supererogatory Question
    • Supererogatory obligations are those that we voluntary choose for ourselves. Once they are chosen, certain expectations follow.
    • Example– no one makes you become a parent, but if you are a parent there are certain minimal expectations of you.
  • Some Supererogatory Activities
    • Engage in political advocacy for better access to mental health care
    • Serve on a prison committee addressing needs of mental health population
    • Putting effort into being the best clinician that you can be
  • Some Supererogatory Activities
    • Becoming proficient in a new area of practice in psychology
    • Applying psychological knowledge to a growing area of public concern (such as helping impaired drivers)
  • Some Supererogatory Activities
    • Give a public presentation on the signs and symptoms of adolescent depression and suicide
    • Write an op-ed article for a local paper on the problems with mental health care
    • Join a political action committee that advances the causes of psychology
  • Some Supererogatory Activities
    • Provide information to business leaders about psychologically healthy workplace principles
    • Volunteer with local, state, national psychological associations
    • Provide volunteer presentations to other psychologists on positive ethics
  • Some Supererogatory Advice
    • Supererogatory obligations require prudence and balance
    • If you adopt too many obligations, you may fail or fall short of your primary obligations
    • Supererogatory obligations may be combined with personal obligations (e.g., involve the family with Humane League)
  • Patient Focused Risk Management Patient-Focused Risk Management Strategies Adapted from Bennet et al.
  • Positive Ethics and Difficult Patients
    • What patients are most difficult?
    • Chronic dysphoria
    • Interpersonal hostility
    • Threaten selves or others
    • Unresponsive to treatment
  • Difficult Patients
    • Often useful to look at ethical principles to guide our relationships with these patients.
    • “BANJO:” Beneficence, autonomy, nonmaleficence, justice, and others
    • Often require us to engage in creative decision making
  • Managing the Risks
    • No psychologist can eliminate all risks
    • Risk management principles are designed to minimize legal risks by identifying ways in which patients have been injured
    • There is no fixed or predetermined risk management strategies for every situation
  • Patient Focused Risk Management Strategies
    • Informed Consent
    • Consultation
    • Increased documentation
    • Redundant systems of protection
  • Patient Focused Risk Management Strategies
    • Relationship to moral principles
    • Informed consent related to respect for autonomy
    • Consultation, documentation, redundant protections related to beneficence and nonmaleficence
  • Patient Focused Risk Management Strategies
    • Should be done to maximize transparency
    • Generally be open with patient about goals and procedures
    • Be candid with consultants
    • Document decision making accurately
  • A Suicidal Patient
    • The strategies should increase when the risk of harm increases
    • Utilizing these “integrated” strategies fulfill both the legal obligations as well as aspire to your highest ethical standards
  • A Suicidal Patient
    • Informed Consent– do you maximize their involvement in treatment plan?
    • Documentation–
    • Do you use 8 th grade algebra teacher method of documentation?
    • Do you address all factors that influence your decision making?
  • A Suicidal Patient
    • Consultation– do you routinely seek consultation with highly suicidal patients?
    • Redundant Protections– do you seek second or third sources of information if possible and helpful?
  • False Risk Management Strategies
    • Avoid any risk management strategy that appears to harm patients
    • Avoid any risk management strategy that violates deeply held moral principles
  • False Risk Management
    • Always have suicidal patients sign “no suicide” contracts
    • Never take detailed notes when treating a client who threatens to harm others
    • Never touch a patient
    • Informed consent only consists of having patients sign the paper
  • False Risk Management
    • Psychologists may believe that they are following the laws or protecting themselves
    • Actually, the psychologist may be distorting laws and standards at the expense of generally accepted moral values or patient welfare
    • Psychologist may risk alienating the client
  • Good risk management strategies involve a “culture of safety” which attempt to:
    • Minimize mistakes
    • Provide high quality of service
    • Maximize ethical ideals
  • Developing a Culture of Safety
    • Remaining alert to subtle clues with patient and office dynamics
    • Proactively taking steps to address issues
    • Psychologist to monitor his/her own behavior
  • Origins of the Safety Culture
    • Retrospective look at commercial disasters (Titanic, airplane crashes, etc.)
    • Medical errors research
  • Positive Ethics and Professional Development Emotional Competence, Self-care, and Social Responsibility
  • Emotional Competence
    • The ability to reflect critically upon one’s own behavior and to withstand the many stresses that occur when working with adolescents in the mental health system
  • Importance of Self Care
    • Well-being is associated with high levels of self-awareness, self-awareness, strong social relationships, and a balanced life
    • Resilient psychologists turn toward social support in order to cope effectively
    • High functioning psychologists take time for personal and family activities
  • Importance of Self-Care
    • Self-care is both an instrumental and intrinsic goals
    • Performance improves when we care for ourselves
    • Our own well-being is intrinsically important
  • Challenges to Self-Care
            • Personal Professional
    • Stressors chronic illness difficult patient
    • Events serious accident patient suicide
  • Challenges to Self-care
    • Work with challenging patients
    • Our own unique psychological limitations and vulnerabilities
    • Patients that threaten, attempt, or commit suicide
    • Being threatened, assaulted, or stalked by patients
    • Taking on too much at work
  • Challenges to Self-care
    • Family tensions, separation, and divorce
    • Illness or death of a loved one
    • Financial difficulties
    • Societal traumas (e.g., 9/11 and VT)
    • Major life transitions
  • Reducing the Negative Impact
    • Familiarity with ethics codes, laws, and regulations (“before the fact” controls)
    • Self-monitoring for stress, distress, and impairment
    • Join a professional peer support or peer consultation group
  • Reducing the Negative Impact
    • Develop a healthy social network as a source of support
    • Work with a mentor or supervisor to monitor your work
    • Psychotherapy
  • Increasing Positive Experiences
    • Continuing education and ongoing professional development
    • Joining and being active in a professional organization
    • Pursuing healthy non-work interests
  • Increasing Positive Experiences
    • Making time for friends and family
    • Religious or spiritual practice
    • Psychotherapy
  • Broad and Build Theory
    • Positive emotions help to broaden our behavioral repertoire and make us more effective in our work.
    • Positive emotions build emotional resources and increase resilience to difficult times or traumas.
  • Civic Virtue Social Responsibility (versus Social Loafing)
  • Social Responsibility
    • There is no group outside of psychology that advocates for our patients or our profession
    • General beneficence is to strengthen the mental health system so that our society as a whole is healthier
  • Social Responsibility
    • Using knowledge to benefit society
    • Volunteer for non profit organization or for community project
  • Political Advocacy
    • The legislative process governs many aspects of our lives – what we eat and breathe
    • The legislative process is how we change the practice of psychology for the better
  • State Political Advocacy
    • Recognition for psychologists’ role in hospital settings (Act 28)
    • Limited immunity for custody evaluators
    • Mandated reporting requirements
    • Curbing outpatient authorization for routine mental health care
  • Federal Level
    • Restoring the Medicare reimbursement rates for psychological services
    • Mental Health parity
  • Review
    • Are you a classical radical?
    • Do you use integrative strategies?
    • Do you rely on your ethical foundations when engaging in creative decision making?
    • Do you think of the acronym “BANJO” when faced with difficult patients?
  • Review
    • Do you rely on patient focused risk management strategies?
    • Do you see the value of self-care in helping you to fulfill your professional obligations?
    • Do you identify your supererogatory obligations and how to fulfill them?
  • Lunch Break
  • Positive Ethics and Ethical Decision-making
  • Ethical Decision-Making Some initial lecture Some group exercises
  • The APA Ethical Principles and Code of Conduct do not include a model of ethical decision-making
  • Why is this a problem?
    • The means to comply with a standard may not always be readily apparent
    • Two seemingly competing standards may appear equally appropriate
    • Application with of a single standard or set of standards appear consistent with one or more aspirational principle, but not another
  • In certain situations, we need to construct or create a solution instead of looking up the enforceable standards in the APA Ethics Code.
  • Common Dilemmas
    • Often ethical dilemmas involve apparent conflicts between respect for patient autonomy versus beneficence
    • Or
    • Respect for autonomy versus general or public beneficence
  • 5 Step Decision Making Model
    • S Scrutinize
    • H Hypothesize
    • A Analyze
    • P Proceed
    • E Evaluate
  • Decision Making Factors
    • What are the moral principles / personal values
    • Clinical / Cultural values
    • What are the relevant ethical codes / standards
    • Statutes / regulations
    • What are the agency policies
    • What is the applicable case law
  • Some Limiting Cognitive Factors
    • Trait Negativity Bias : The tendency for negative traits to weigh more heavily than positive traits when forming impressions
    • Fundamental Attribution Error : The tendency to see others’ behavior as reflective of internal traits and dispositions, while overlooking or minimizing the influence of external or situations factors
  • Some Limiting Cognitive Factors
    • Availability Heuristic : The tendency to base probability judgments on how easily examples come to mind
    • Representative Heuristic : The tendency to make a decision based on the extent of the perceived similarity with prototypical cases from a certain category
  • Counteracting Errors in Thinking
    • Afford time for self-reflection
    • Examine the role of internal/dispositional issues as well as external/situational factors
    • Generate a number of alternatives to the dilemma (overconfidence can be reduced)
    • Ask why could this decision be wrong
  • Some Limiting Emotional Factors
    • High Anxiety : Making a decision, any decision, will usually help reduce anxiety. However, the quickest solution is not always the best
    • “Just Good Enough” solutions: Taking the first halfway decent idea as a means to move to the next task
    • Too much or too little emotion hampers effective decision-making skills
  • Strategies for Emotional Issues
    • Create the time needed to calm down and/or focus on the dilemma
    • Reflect on how this dilemma affects your practice and sense of self
    • Seek consultation
  • Positive Ethics encourages…
    • Increase awareness of ethical issues
      • Know the code
      • Know the laws, regulations
      • Participate on the listserv
    • Self-reflect on ethical decisions
    • Develop insight into your emotional and cognitive styles when under pressure and making difficult decisions
  • Positive Ethics encourages…
    • Acculturation process
      • Becoming part of the community of psychologists
      • Awareness of ethical issues through ongoing continuing education
    • Judicious use of consultations
  • Benefits of Consultations
    • Provide new information
    • Reduce emotional reactance
    • Provide feedback on decision making ability
  • Group Exercise
  • Evaluations