Ethical Decision Making 1

Ethical Decision Making Exercise Lara Nestman University of Calgary

Vignette You have been asked to counsel an 11-year old aboriginal youth who is withdrawn in school and spends a lot of time alone. He is accompanied by his grandmother who says that they need each other very much because her husband has died recently. The youth describes feeling alone, remembering times when he has been abandoned, and hearing voices singing and the voice of an old man speaking to him in the tribal dialect. The grandmother is not eating or sleeping well and she thinks a lot about traumatic events experienced in residential school. You are uncomfortable about counselling without first obtaining a psychiatric assessment to evaluate what may be psychotic symptoms. A psychiatric assessment would require a trip some 100 miles away to a large urban centre.

____________________________________________________________________________ Using the Canadian Code of Ethics for Psychologists decision making steps, I will resolve and arrive at a decision regarding the vignette above. Step 1: Identification of the Individuals and Groups Potentially Affected by the Decision The primary individuals that could be affected by any decision I make are the 11 year old aboriginal youth, the grandmother, and the counsellor. As the counsellor, I think that the clients are both the boy and his grandmother. Both the boy and the grandmother are experiencing difficulty with grief and sorrow, being abandoned, and trauma from prior experiences experienced as a family. The secondary individuals/groups affected are the community in which they reside, and public trust. Step 2: Identification of Ethically Relevant Issues and practices, including the interests, rights, and any relevant characteristics of the individuals and groups involved and of the system and circumstances in which the ethical problem arose Using the chart that outlines the Code (The Four Ethical Principles with their respective Values and Standards), I can identify nineteen ethical values that I think are key to my current dilemma: six under Respect for the Dignity of Persons, seven under Responsible Caring, three under Integrity in Relationships, and three under Responsibility to Society.

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The Four Ethical Principles with their Respective Values and Standard
*Those typed in RED indicate those that apply to the Vignette I. Respect for the II. Responsible Dignity of Persons Caring 1.General Respect 1. General Caring 2. General Rights 3. NonDiscrimination 4. FairTreatment/Due Process 5. Informed Consent 6. Freedom of Consent 7. Protection for Vulnerable Persons 8. Privacy 9. Confidentiality 10. Extended Responsibility Principle I: Respect for the Dignity of Persons Principle/Value
General Respect I.I. Demonstrate appropriate respect for the knowledge, insight, experience, and areas of expertise of others. I.2.Not engage publicly (e.g., in public statements, presentations, research reports, or with clients) in degrading comments about others, including demeaning jokes based on such characteristics as culture, nationality, ethnicity, colour, race, religion, sex, gender, or sexual orientation. I.3 Strive to use language that conveys respect for the dignity of persons as much as possible in all written or oral communication.

III. Integrity in Relationships 1. Accuracy/Honesty 2. Objectivity/Lack of Bias 3.Straightforwardness/Openness 4. Avoidance of Incomplete Disclosure 5. Avoidance of Conflict of Interest 6. Reliance on the Discipline 7. Extended Responsibility

2. Competence and Self-Knowledge 3. Risk/Benefit Analysis 4. Maximize Benefit 5. Minimize Harm 6. Offset/Correct Harm 7. Care of Animals 8. Extended Responsibility

IV. Responsibility in Society 1. Development of Knowledge 2. Beneficial Activities 3. Respect for Society 4. Development of Society 5. Extended Responsibility

My thoughts Whatever decisions I make, I need to convey respect for the boy and the grandmother as a family unit, and their community in my contacts with them. Should I decide to offer counselling services, in order to demonstrate further respect for all parties, I will ask if the grandmother is willing to consider and participate in family therapy sessions with the boy. As with all human beings, I will consistently need to use language that demonstrates respect about their concerns and problems, striving to develop a trusting, collaborative working alliance.

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Non-discrimination I.9 Not practice, condone, facilitate, or collaborate with any form of unjust discrimination Informed Consent

Am I being discriminatory in possibly deciding to refer them to a professional in their community because of their culture? This value suggests that I cannot refer based on culture to do so would be unintentionally disrespectful of their worth as human beings.

This value suggests that I should work with others collaboratively to establish informed consent. Firstly, I need to establish the legal I.16 Seek as full and active participation as possible guardianship of the boy. Are there parents? In from others in decisions that affect them, this case, I am making the assumption that the respecting and integrating as much as possible their parents are not the legal guardians so I will need opinions and wishes. to involve the grandmother and the boy in working out what is best for both of them. I I.17 Recognize that informed consent is the result of a process of reaching an agreement to work could offer to counsel both the grandmother and collaboratively, rather than of simply having a boy together in family therapy sessions and consent form signed. would hope to get informed consent from the grandmother on behalf of herself and the boy. I.18 Respect the expressed wishes of persons to The boy is considered a minor in this case and involve others (e.g., family members, community therefore, the grandmother has the legal right to members) in their decision making regarding consent for him. However, it is important that informed consent. This would include respect for the boy consent to counselling as well. By written and clearly expressed unwritten advance creating a trusting relationship initially, I would directives. hope that this is not an issue.
I.24 Ensure, in the process of obtaining informed consent, that at least the following points are understood: purpose and nature of the activity; mutual responsibilities; confidentiality protections and limitations; likely benefits and risks; alternatives; the likely consequences of non-action; the option to refuse or withdraw at any time, without prejudice; over what period of time the consent applies; and, how to rescind consent if desired. (Also see StandardsIII.23-30.)

I need to respect the expressed wish of the grandmother to involve others in their aboriginal community if she decides to do so. I will also disclose as much information as possible to the grandmother and boy about the purpose and nature of counselling activities, risks and benefits, alternatives, option to refuse or withdraw from services at any time. Because the grandmother is vulnerable and under stress, it is important that the family freely consent to counselling services. They cannot be forced, or coerced into consent. The grandmother and boy also need to be aware that she has the right to discontinue participation or service at any time on behalf of her grandson and herself.

Freedom of Consent
I.27 Take all reasonable steps to ensure that consent is not given under conditions of coercion, undue pressure, or undue reward. (Also see Standard III.32.) I.29 Take all reasonable steps to confirm or reestablish freedom of consent, if consent for service is given under conditions of duress or conditions of extreme need.

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I.30 Respect the right of persons to discontinue participation or service at any time, and be responsive to non-verbal indications of a desire to discontinue if a person has difficulty with verbally communicating such a desire (e.g., young children, verbally disabled persons) or, due to culture, is unlikely to communicate such a desire orally.

Protection for vulnerable persons

I.33 Seek to use methods that maximize the understanding and ability to consent of persons of diminished capacity to give informed consent, and that reduce the need for a substitute decision maker. I.34 Carry out informed consent processes with those persons who are legally responsible or appointed to give informed consent on behalf of persons not competent to consent on their own behalf, seeking to ensure respect for any previously expressed preferences of persons not competent to consent.

Because the grandmother is legally responsible for her grandson, I am worried about her vulnerable state given her presented symptoms and possible trust issues given her past traumatic experiences. I will need to be particularly cautious about how I communicate my counselling services so that she truly understands the nature and purpose of counselling, its risks and benefits, alternatives. I will need to respect any decisions she makes. This will build trust in our relationship. Because the boy is a minor, it is important that I assist the grandmother to understand that she is consenting for her grandson. Both members of this family are vulnerable right now. It is important to act immediately. To wait for a psychiatric assessment for the boy might cause more harm than good.

Confidentiality
I.44 Clarify what measures will be taken to protect confidentiality, and what responsibilities family, group, and community members have for the protection of each others confidentiality, when engaged in services to or research with individuals, families, groups, or communities. I.45 Share confidential information with others only with the informed consent of those involved, or in a manner that the persons involved cannot be identified, except as required or justified by law, or in circumstances of actual or possible serious physical harm or death. (Also see Standards II.39, IV.17, and IV.18.)

It is important to communicate the measures that will be taken to protect the confidentiality of their information and results, and that information will only be shared with others (school, aboriginal community members, etc) with the informed consent of the grandmother and grandson if the need should arise.

Principle II: Responsible Caring

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Principle/Value General Caring

II.1 Protect and promote the welfare of clients, research participants, employees, supervisees, students, trainees, colleagues, and others. II.3 Accept responsibility for the consequences of their actions. II.5 Make every reasonable effort to ensure that psychological knowledge is not misused, intentionally or unintentionally, to harm others.

My thoughts I need to be concerned about protecting the welfare of the boy, the grandmother, and the aboriginal community. I need to accept responsibility for the decisions they make regarding counselling services. I am also conscientious about protecting this family particularly if I decide to refer them to another professional. For example, I do not want anyone to abuse her trust that she has gained from our relationship. I am concerned about whether or not I have the knowledge and skills to counsel this family. This standard conveys that I should only offer to carry out those activities for which I am qualified. I might need to obtain consultation with another appropriate professional from the aboriginal community (aboriginal counsellor, spiritual healer/elder) so that the client receives competent service. I also need to evaluate how my own culture and experiences might influence my interactions with the boy and the grandmother.

Competence and self-knowledge

II.6 Offer or carry out (without supervision) only those activities for which they have established their competence to carry them out to the benefit of others. II.8 Take immediate steps to obtain consultation or to refer a client to a colleague or other appropriate professional, whichever is more likely to result in providing the client with competent service, if it becomes apparent that a clients problems are beyond their competence. II.9 Keep themselves up to date with a broad range of relevant knowledge, research methods, and techniques, and their impact on persons and society, through the reading of relevant literature, peer consultation, and continuing education activities, in order that their service or research activities and conclusions will benefit and not harm others.

Risk/Benefit analysis
II.14 Be sufficiently sensitive to and knowledgeable about individual, group, community, and cultural differences and vulnerabilities to discern what will benefit and not harm persons involved in their activities.

This value asserts that I need to assess whether or not they are receiving support from other individuals, family groups, and community and if so, if this support is positive or negative. I also need to be knowledgeable about the cultural differences and vulnerabilities of the boy and the grandmother so that I do not harm them. I am worried that I do not have the knowledge or experience which are relevant to the needs of this family. I am concerned that I will not be able to provide the best possible service to this family because I do not know their cultural needs and

Maximize benefit
II.21 Strive to provide and/or obtain the best

Ethical Decision Making 6 possible service for those needing and seeking psychological service. This may include, but is not limited to: selecting interventions that are relevant to the needs and characteristics of the client and that have reasonable theoretical or empirically-supported efficacy in light of those needs and characteristics; consulting with, or including in service delivery, persons relevant to the culture or belief systems of those served; advocating on behalf of the client; and, recommending professionals other than psychologists when appropriate.

characteristics. From my own clinical perspective, I think the boy needs a psychiatric assessment. However, I must keep in mind that providing the best possible service I can for both the boy and his grandmother essential. Is a psychiatric assessment really warranted before counselling begins? I am aware that a psychiatric assessment might be geographically and financially unrealistic and that it might not be in the absolute best interest of the boy given that I have not had the opportunity to work with him. I will need to get over feeling uncomfortable. If I decide to counsel this family, to maximize benefit, I will need to selfeducate and seek resources. I am concerned about the welfare of all clients so I will communicate with the boy and his grandmother that I will provide, if needed and desired, reasonable assistance so that they can afford counselling should we agree that I counsel them. I will also need to communicate that I will help them seek other resources, and activities if they would like or need them. If I do think that there is a medical issue for the boy, it will be important to communicate this to the grandmother so as to minimize possible future harm and to establish the best possible course of action (e.g. possible psychiatric assessment) Should the family decide to accept a referral to another professional, I will need to make sure that I maintain contact and responsible caring until that counselling service begins.

Minimize harm
II.31 Give reasonable assistance to secure needed psychological services or activities, if personally unable to meet requests for needed psychological services or activities. II.32 Provide a client, if appropriate and if desired by the client, with reasonable assistance to find a way to receive needed services in the event that third party payments are exhausted and the client cannot afford the fees involved. II.33 Maintain appropriate contact, support, and responsibility for caring until a colleague or other professional begins

Offset/correct harm
II.42 Be open to the concerns of others about perceptions of harm that they as a psychologist might be causing, stop activities that are causing harm, and not punish or seek punishment for those who raise such concerns in good faith.

Because the grandmother has expressed trauma as a result of residential school education, I am making the assumption that she might feel distrustful or feel concerned about perceptions of harm and/or oppression that I might cause during the counselling process to the family. If this is the case, I need to be open, caring, honest

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and straightforward about these concerns, stop activities if they do cause harm, and respect the boy and/or grandmothers concerns if these concerns are raised.

Extended responsibility
II.49 Encourage others, in a manner consistent with this Code, to care responsibly.

I need to help the grandmother understand my perception of the grandsons needs in this situation, and encourage her to act primarily in the interest of the childs welfare. However, because I believe that both boy and grandmother should participate in counselling together as a family, they both need to understand my perceptions of each others needs.

Principle III: Integrity in Relationships Principle/Value Objectivity/lack of bias

III.10 Evaluate how their personal experiences, attitudes, values, social context, individual differences, stresses, and specific training influence their activities and thinking, integrating this awareness into all attempts to be objective and unbiased in their research, service, and other activities.

My thoughts I need to consider how my own personal experiences, attitudes, values might influence my counselling services with this family. I will need to ascertain whether or not particular counselling interventions are appropriate given their circumstance. For example, for me to assume that the child is exhibiting psychotic symptoms may in fact be going against what his culture believes about hearing an old man speaking to him in his tribal dialect. The medical model may not fit this particular case at all. The cultural or social belief might be that he has the ability to communicate with the dead or that the boy is in a stage of grief. Failure to integrate an appreciation for the families belief system would be violating the ethical principle of beneficence.

Straightforwardness/Openness III.14 Be clear and straightforward about all information needed to establish informed consent or any other valid written or unwritten agreement

This value communicates that I need to disclose information to the family regarding possible counselling services in an honest, open, warm and caring manner.

Ethical Decision Making 8 (for example: fees, including any limitations imposed by third-party payers; relevant business policies and practices; mutual concerns; mutual responsibilities; ethical responsibilities of psychologists; purpose and nature of the relationship, including research participation; alternatives; likely experiences; possible conflicts; possible outcomes; and, expectations for processing, using, and sharing any information generated).

Reliance on the discipline

III.38 Seek consultation from colleagues and/or appropriate groups and committees, and give due regard to their advice in arriving at a responsible decision, if faced with difficult situations.

I have the time to consult with other professionals about my perceptions of this situation and possible courses of action and will do so. With consent from the grandmother and the boy, consultation with aboriginal counsellors or spiritual leaders/elders is important. However, this could also be difficult if the community is isolated and expertise is lacking.

Principle IV: Responsibility to Society Principle/Value Beneficial Activities

IV.4 Participate in and contribute to continuing education and the professional and scientific growth of self and colleagues. IV.6 Participate in the process of critical selfevaluation of the disciplines place in society, and in the development and implementation of structures and procedures that help the discipline to contribute to beneficial societal functioning and changes.

My thoughts It is important to participate in professional growth in areas of grief, bereavement, aboriginal customs and traditions, and residential schools in order to understand the issues that the family are presenting. It is also important that I self-evaluate my practice while counselling my client(s) so that I contribute positively to the welfare of the family, their community and to society in general.

Respect for society

IV.15 Acquire an adequate knowledge of the culture, social structure, and customs of a community before beginning any major work there. IV.16 Convey respect for and abide by prevailing community mores, social customs, and cultural expectations in their scientific and professional

Should I decide to counsel this family, I will need to ensure that I have acquired enough knowledge about the culture of their aboriginal community before I begin services with them. The role of legal caregiver, the grandmother, in our society includes the legal right to decide what is in the best interest of the child. I will need to convey respect for this role. I will also

Ethical Decision Making 9 activities, provided that this does not contravene any of the ethical principles of this Code.

need to respect the aboriginal community in which they reside by respecting their social and cultural customs and expectations.

Step 3: Consideration of how personal biases, stresses, or self-interest might influence the development of or choice between courses of action My initial reaction to this situation was one of concern, sadness, and lack of confidence. I felt great concern for the welfare of both the boy and the grandmother, who are both grieving for losses they have both incurred as a result of death, abandonment and residential school trauma. I also felt upset not knowing if there was any support for them in their own aboriginal community. Given the fact that I am Caucasian and European by descent, I felt to be at a great disadvantage not knowing if I could help them to the point of perhaps wanting to walk away from this situation. Step 4: Development of alternative courses of action My analysis seems to rule out one particular course of action which is to obtain a psychiatric assessment before counselling services begin. Having not counselled the family yet, I think that it would show great disrespect by making the assumption that this assessment is needed prior to service. Furthermore, obtaining a psychiatric assessment might take months. I could do more harm to the family than good by waiting for the results. They will continue to suffer if we wait. Furthermore, this is clearly not practical or realistic because of the geographical distance they would need to travel. Overall, I think that this is unfair to the boy and could possibly be a waste of their time and money. I need to get over feeling uncomfortable.

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However, there are two initial courses of action that would be consistent with my analysis. I think they are reasonably ethical and I should consider further. Alternative 1: First, if there is a cross-cultural/aboriginal counsellor in their community, then I would speak to the grandmother about the possibility of a referral. I would communicate my concerns of accepting the proposal to counsel the boy and/or the family given the lack of expertise with their issues of grief and bereavement. I would also communicate that I do not know if the medical model is best suited to their problems. If she agrees that the needs, interests and welfare of both are being served best by being referred to an aboriginal/cross-cultural counsellor, then I would call the cross-cultural counsellor to refer the family to him/her. I would ensure that the family received a referral and appointment date and time to ensure that they receive services. Until their appointment, I would act responsibly and maintain contact to ensure that they were coping well. Then, I would do a follow-up to ensure that counselling services are in progress with the crosscultural counsellor. Alternative 2: First, I would ask the grandmother if she is interested in participating in family counselling with her grandson. Should she accept, I would do my best to counsel the family using the constructivist narrative family therapy model and if there are community elders and cross-cultural counsellors with whom I could collaborate, I would do so with informed consent from the grandmother and boy. If during the counselling process I continue to feel uncomfortable about the boy hearing voices, I would ask the grandmother and boy about the possibility of a psychiatric assessment. If this is something they both think needs to be done, we would work together as a team to realize it. Lastly, if, after the first several meetings, it is clear that the interests of this

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family would best be served by someone from their community, I would suggest a referral to an aboriginal or cross-cultural counsellor. Step 5: Analysis of likely short-term, ongoing and long term risks and benefits of each course of action on the individual(s)/group(s) involved or likely to be affected (e.g. client, clients family or employees, employing institution, students, research participants, colleagues, the discipline, society, self) Alternative 1 Possible Positive Consequences Gives the grandmother a sense of control about the choices she has and enables her to share in the decision making. Possible Negative Consequences Grandmother could end up feeling resentful that the whites created the problem and now they want us to fix it ourselves. That the whites do not want to take responsibility for their actions regarding residential school survivors. This could end up being a political issue. Referring could cause more harm. It may compromise my credibility as a counsellor. She cannot help. That I will look like I am too discriminating. That I can only help those of my own cultural background. The child may actually need medical attention because of an underlying psychosis.

Engaging in discussion with the grandmother is respectful, helps her understand my concerns for receiving competent counselling services. The community in which they reside will feel empowered and respected by the psychological community at large, knowing that they are able to help members of their community. The aboriginal counsellor will have a clear understanding of issues and concerns, which might result in quicker changes to lifestyle for the family. Interventions might be more suitable.

Alternative 2 Possible Positive Consequences Consultation and counselling this family will greatly improve my competency. Working with Possible Negative Consequences I may have difficulty building a relationship due

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the family as a unit is an important skill to develop. Because they share many of the same experiences, the boy and grandmother would benefit by working as a family unit. If I was to refer them to another counsellor in their community, this may not happen. On a personal note, I will benefit from counselling this family. I will listen and learn.

to power differentials. I may feel uncomfortable about the boy hearing voices. There may be spirituality differences.

As a collective, if we decide that the boy does need a psychiatric assessment, the cost of transportation and testing could be an issue. Also, the boy could face the stigma and labelling that comes with being tested and diagnosed as having a psychosis.

The family will benefit from working from outside and within their community. They will have two models from which to draw resources and support rather than one.

Should the boy need medical attention because of a possible psychosis, he will receive it. The grandmother will feel respected and empowered knowing that I want to help them. This alternative also allows her to share in the decision making.

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Step 6: Choice of course of action after conscientious application of existing principles, values and standards Although I think that either course of action is reasonably ethical, I think that the second alternative more clearly supports the values included in Principle I (Respect for the Dignity of Persons) and Principle II (Responsible Caring) and therefore, reflects more closely with the spirit of the Code. Firstly, the second alternative is more respectful of the family and it does not discriminate based on their culture. Furthermore, because I was asked to counsel the boy, it is my responsibility to protect the dignity and rights of the boy and his grandmother particularly given that both are in a vulnerable position. This alternative maximizes the possible benefits of services and minimizes much harm to the family. In addition, I think that the second alternative has more of a chance of having a beneficial outcome because the family has been explicitly included in the ethical decisions making process and because the counsellor and the family will work together and with other professionals in and outside of their community to ensure that they get the support they need through this difficult time. As the counsellor, this alternative offers me the opportunity to grow as a person and as a professional. Furthermore, this decision fits me emotionally and rationally. It seems to meet everyones needs, including mine. I would wish to be treated in the same way. This decision is open, honest and straightforward for those affected. Step 7: Action with a commitment to assume responsibility for the consequences of the action I will carry out the second alternative. There is no possible resolution of the dilemma unless I try out what I consider to be the best course of action. I need to act, monitor and evaluate. Step 8: Evaluation of the results of the course of action

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Evaluation will need to be on-going. I will need to consistently re-evaluate the counselling process and the nature of possible interventions with the family to ensure they feel that they are starting to feel better. I will need to evaluate with the family whether or not the desired goals are being achieved or whether further action is necessary. I may need to re-adjust my thinking or adjust my decision. I will need to constantly re-evaluate my confidence, attitudes and effectiveness in working with this family. I will need to consistently consult with others who are more familiar with particular issues in order to continue to provide competent services. I will also need to evaluate whether or not negative consequences are arising or are occurring. Step 9: Assumption of responsibility for the consequences of action, including correction of negative consequences, if any, or re-engaging in the decision-making process if ethical issue is not resolved. It is possible that my chosen decision will not work. If that is the case, I might need to refer to Alternative One or I might need to refer back to the Code of Ethics for help again to resolve this dilemma or any others that arise. If there are unanticipated negative consequences, they must be addressed in a very timely fashion. I will need to involve the family, and other colleagues and counsellors in open and honest discussions. Step 10: Appropriate action, as warranted and feasible, to prevent future occurrences of the dilemma (e.g., communication and problem solving with colleagues, changes in procedures and practices) In future, I need to avoid making assumptions about a particular situation and I need to overlook the medical model knowing that it may not fit everyone with whom I will work. Also, I immediately assumed that the family might be better off if they were counselled by a cross-cultural counsellor. While this might be the case, I need to be careful that I do not discriminate unintentionally based on culture. All individuals have the right to be treated as appreciated human beings and this worth is not dependent upon their culture. I need to be more confident about my

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abilities as a counsellor so that I do not feel intimidated or helpless when asked to counsel others who have problems with which I have not had much experience. Lastly, I need to communicate and problem solve with other colleagues with the hopes that that this does not happen again.

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References: Canadian Psychological Association (2000). Canadian code of ethics for psychologists (3rd ed.). Ottawa: Author College of Alberta Psychologists. (1998). Guidelines for non-discriminatory practice. Edmonton, AB: Author. Sinclair, C., & Pettifor, J. (Eds.). (2001). Companion manual to the Canadian code of ethics for psychologists (3rd ed.). Ottawa: Canadian Psychological Association.