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CHAPTER 4

ETHICAL DECISION MAKING


IN MENTAL HEALTH CONTEXTS:
REPRESENTATIVE MODELS AND
AN ORGANIZATIONAL FRAMEWORK
R. Rocco Cottone

No degree of preparation can fully insulate a psy- workers and not laborers, but professionals who
chologist from facing an ethical dilemma or a charge apply both historical and scientific knowledge to
of unethical conduct. Professional savvy or ethical complex circumstances. The ethical practice of psy-
sensitivity, although helpful, will not suffice. Psy- chology must not be just about avoiding punish-
chology practice is challenging. New situations arise ment, it also must be about establishing a means and
that require intelligent educated action. method for high-level decision making in the best
Even with good intentions, sometimes psycholo- interests of clients, society, and the profession of
gists make choices they may later regret. Some psychology itself. Knowing how to act ethically,
choices may have serious repercussions. Some being willing to act, and not just knowing how to
choices have ethical implications. Of course, some avoid being unethical, is a critical element in each
psychologists may be confronted by clients who psychologists personal development and accultura-
have malicious intent, and it is difficult to protect tion in the profession (Handelsman, Gottlieb, &
against a manipulative client in search of a legal set- Knapp, 2005).
tlement. Prevention is a psychologists first line of When mental health professionals are surveyed
defense against ethical challenges. Once challenged, on issues of importance related to ethical practice,
however, psychologists should address the challenge decision making typically is highly ranked. Knapp
competently and ethically, ideally by means of a for- and Sturm (2002) cited a study that ranked decision
mal decision process. making second in a long list of potential needs in
As a best practice, the decision making of psy- ethics continuing education. Practitioners must
chologists should be guided by a formal decision- know how to apply a decision-making model in a
making process and a positive ethic (Handelsman, competent and professional way. Knowing when to
Knapp, & Gottlieb, 2009), meaning that psycholo- apply this decision-making model also is important.
gists should know how to act when confronted by The Ethical Principles of Psychologists and Code of
an ethical dilemma, not just how not to act. Ethical Conduct (the Ethics Code; American Psychological
dilemmas, those quandaries all psychologists face in Association [APA], 2010) does not provide guidance
practice that place psychologists in positions requir- on such matters; it also does not recommend a deci-
ing choices about how to act, are not only a sign of sion-making model, unlike its Canadian counterpart
conflict (at some level) but also are the sign of a (Canadian Psychological Association [CPA], 2000).
mature profession. Psychologists have arrived at a The Ethics Code, however, does define five general
professional place and time that speaks to their ethical principles to guide decision making (more
membership in an established profession. Psycholo- on ethical principles in the section Major Intellec-
gists, in this regard, are intellectuals, not just trade tual Movements in Decision Making in Psychology).

Special thanks to Hsin-hsin Huang for her assistance in producing this chapter.

DOI: 10.1037/13271-004
APA Handbook of Ethics in Psychology: Vol. 1. Moral Foundations and Common Themes, S. J. Knapp (Editor-in-Chief)
99
Copyright 2012 by the American Psychological Association. All rights reserved.
R. Rocco Cottone

As a general rule, psychologists should apply a the most ethically mature and experienced profes-
decision-making model when they are faced with an sional psychologist.
ethical dilemma. An ethical dilemma is a circum-
stance that stymies or confuses the psychologist DEFINING ETHICAL DECISION MAKING
IN PSYCHOLOGY
because (a) there are competing or
conflicting ethical standards that apply, As used in this chapter, the term ethical decision
(b) there is a conflict between what is making (sometimes referred to by others as ethical
ethical (e.g., professional standards) and problem solving or ethical choice making) relates to
moral (e.g., religious standards), (c) the the use of formal models or processes to address
situation is such that complexities make professional ethical dilemmas within a mental health
application of ethical standards unclear, context. Ethical choice and moral choice philosophy
or (d) some other circumstance prevents often address decisions, but those decisions are
a clear application of standards. (Cottone & focused on choices that involve a moral dilemma
Tarvydas, 2007, p. 2) (whether stealing to survive is justified, or whether
one should kill in self-defense, as examples). Litera-
In these situations, knowledge must be applied,
ture also addresses decision making on matters of
and judgment is involved. Knapp and VandeCreek
choices that have little to do with mental health
(2006) made a similar case; they argued that deci-
practicelike choosing to buy a certain product
sion making is necessary when judgments must be
when alternatives are available. The literature
made regarding conflicting principles, laws, or insti-
addressed in this chapter is limited to those publica-
tutional policies. A formal decision-making process
tions or works that specifically attend to choices
will help the psychologist discern the best course of
mental health professionals must make when facing
action when there are competing possibilities and in
a professional ethical dilemma. Literature outside of
cases in which the application of a single standard is
the mental health realm may be relevant to profes-
not clear-cut.
sional ethical decision making, but readers must be
This chapter addresses ethical decision making
alerted to the specific contexts within which certain
in psychology. It gives a brief overview of several
models or terminology apply. Also, because ethical
intellectual movements that have affected decision-
decision making is so important that it permeates all
making models in psychology, and it provides a cat-
specialties of psychology, decision-making models
egorization of models on several theoretical,
are briefly mentioned in other chapters in this text,
philosophical, and practical criteria. It provides
including Volume 2, Chapter 2, this handbook, on
example models to help the reader understand the
older adults, and Volume 2, Chapter 8, this hand-
complexity of decision making and the choices pro-
book, on industrialorganizational psychology. In
fessionals may make in addressing different con-
this chapter, the focus is clearly on professional ethi-
cerns though different models. It also addresses
cal decision making in a mental health context, and
issues related to willingness and resoluteness of the
when specific publications are referenced that veer
psychologist to take action to address an ethical
from that focus, special notation is made.
dilemma, and it explores the question as to whether
individual conscience is an adequate arbiter of deci-
MAJOR INTELLECTUAL MOVEMENTS
sion implementation. This chapter does not provide
IN DECISION MAKING IN PSYCHOLOGY
an exhaustive review on the topic of ethical deci-
sion making, but hopefully the reader will have a Three major intellectual movements are relevant to
broad understanding of the literature and of how the ethical decision making in psychology. An intel-
decision theory relates to practice at the most basic lectual movement, as defined here, refers to a
levels. This chapter provides information to facili- unique philosophical framework that excludes easy
tate competent management of challenging clinical application of ideals from another competitive phi-
circumstancesthose situations that will defy even losophy. For example, relying on a decision maker

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who rationally applies accepted standards is differ- and she elevated Beauchamp and Childresss ethical
ent than relinquishing a decision to someone based rule of fidelity to an ethical principle in psychology
primarily on his or her character. Similarly, commit- (following the lead of Drane, 1982). (Beauchamp
tee decision making and individual decision making and Childress later defined professionalpatient rela-
are mutually exclusive. As applied to decision mak- tionships as a principle, addressing concerns such as
ing, an intellectual movement must have a unique fidelity, privacy, and confidentiality.) Kitchener fur-
philosophy upon which decision making stands. ther heralded the works of Hare (1981) applying his
Given this definition, the three major intellectual two levels of moral thinking: intuition and critical
movements in the area of ethical decision making in evaluation. Kitcheners work is highly cited, and she
psychology are principle ethics, virtue ethics, and succeeded in establishing the foundation for what can
relational ethics. Additionally, the theme of multi- be called principle ethics in psychology. Principle eth-
cultural sensitivity represents an overarching frame- ics is the logical application of identified and highly
work within which decisions may be generated. accepted principles (overarching standards) that are
Multicultural sensitivity does not rise to the level of crucial to any decision in psychology. Kitchener
a full-fledged movement, but it does provide a gen- defined the ethical principles as prima facie, meaning
eral theme within which decisions are framed. The they hold weight and should be set aside only for
next sections address the three intellectual move- compelling reasons. (See Ross, 1930, seminal analysis
ments and the theme of multicultural sensitivity as of prima facie responsibility.) Kitchener stated,
applied to ethical decision making in psychology.
While the problems of applying ethi-
cal principles in decision making need
Principle Ethics: The First
to be acknowledged, this does not keep
Intellectual Movement in Psychology
them from being useful or important. By
Decision Making
accepting them as prima facie valid, we
Some outstanding works on ethics in the health pro-
imply that their relevance always needs
fessions have influenced decision making in psy-
to be considered in ethical situations.
chology. One of the most influential is a text entitled
(Kitchener, 1984, p. 53)
Principles of Biomedical Ethics by Beauchamp and
Childress (2009) now in its sixth edition. The first Kitcheners work (1984), specifically, and princi-
edition was published in 1979. In keeping with the ple ethics, in general, lay the groundwork for defin-
foundational work of R. W. Ross (1930) on princi- ing one philosophical framework for understanding
ple ethics, Beauchamp and Childress defined four ethical decision making in psychology. Decision
ethical principles to guide medical professionals in making is viewed as a process of an individual who
decision making. The principles were autonomy considers ethical principles while deliberating an
(the patients right to make choices on his or her ethical dilemma. Principle ethics fits nicely within
own), beneficence (the idea that medical profession- the context of a psychology that views the individual
als should primarily be concerned with the well-being as a decision makera singular person who weighs
of patients), nonmaleficence (the idea that medical options and makes choices.
professionals should do no harm), and justice (the
idea that professionals should treat people fairly and Virtue Ethics: The Second
without discrimination). They also defined an ethi- Intellectual Movement in Psychology
cal rule (not as prominent as a principle) entitled Decision Making
fidelity, meaning that medical professionals A competitor view to principle ethics is virtue ethics.
should be faithful to their patients. It was Kitchener, Initially, virtue ethics (which focuses on the charac-
in 1984, who firmly brought psychologys attention ter of the decision maker) was viewed as a comple-
to the biomedical ethical standards defined by Beau- ment to principle ethics. In the 21st century, virtue
champ and Childress. Kitchener (1984) in a seminal ethics often is described in general textbooks on
work, embraced the biomedical ethical principles, ethics as a different or as an alternative approach to

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R. Rocco Cottone

ethical judgment (Sommers-Flanagan & Sommers- at least a certain amount of exposure


Flanagan, 2007; Sperry, 2007; Welfel, 2006). to specific values and often a personal
Originally, Meara, Schmidt, and Day (1996) pro- investment in those values. Factors such
posed that the virtue of the ethical agent (the deci- as gender, ethnicity or race, religious
sion maker) is crucial in decision making and background, geographic location, and so
worthy of study in tandem with the study of ethical forth, are even more obviously related
principles. They proposed that personal character to values. The therapists personal expe-
should be a major component in the decision pro- riences of oppression and the uses of
cess. The issue of virtue raises the discussion of power, (e.g., through race, sexual orien-
making decisions from the simple means of defining tation, gender, size, disability, class, and
right and wrong (e.g., means to avoid punishment age) will sensitize that individual in cer-
for breaching an ethical standard or principle) to the tain ways. Those same factors and others
means of an ethical ideal (virtuous professional psy- (such as religious background, family or
chologists). The proponents did not propose that living situation, or geographic location)
virtue ethics should replace principle ethics, but will influence the therapists priorities
they did make the case that virtue ethics comple- and assumptions. In order to make a fem-
ment principle ethics, and they even went so far as inist model for decision making, these
to call for an expansion of ethics research to encom- aspects of who the therapist is cannot
pass the character of the decision maker. They dem- be separated from the decisions that she
onstrated that one cannot fully understand an or he makes. If therapists turn to ethi-
ethical decision on the basis of principles alone: cal decision-making models that do not
Some people will do the minimum only to avoid address these factors, they then run the
punishment or will not act ethically at all, whereas risk of making these factors invisible and
other people will embrace an ethical lifestyle regard- thus not open to scrutiny. (1995, p. 25)
less of ethical dictates. In either case, the decision
maker is the crucial variable. This helps to explain Hill et al. made a case for consideration of the
why people bound by the same code of ethics act socialcultural context in decision making, particu-
differently in similar circumstances. larly as it relates to issues of power (1995, p. 36).
They provided a stepwise model for decision mak-
ing, which they called a feminist model for ethical
Relational Ethics: The Third
decision making. The steps are as follows: (a) rec-
Intellectual Movement in Psychology
ognizing a problem, (b) defining the problem,
Decision Making
(c) developing solutions, (d) choosing a solution,
A third philosophical or theoretical movement that
(e) reviewing process, (f) implementing and evaluat-
has affected the decision-making literature is what
ing the decision, and (g) continuing reflection. They
can be identified as relational ethics. Relational eth-
argued that through the decision-making process
ics, which focuses on social context, has put princi-
the feminist must consider the emotional-intuitive
ple ethics in perspective, just as virtue ethics
responses of the therapist; the sociocultural context
provided another way to view the decision process.
of the therapist, client, and consultant particularly
One of the first publications to address contextual
as it relates to issues of power; and the clients par-
factors was a chapter by Hill, Glaser, and Harden
ticipation in the decision making process (1995,
(1995). In that chapter, the authors argued that con-
p. 36). The call for a feminist ethics is a call for plac-
sideration of contextual factors enters into value
ing principle ethics in the context of social (and spe-
judgments, and therefore context affects decision
cifically social power) considerations.
making. They stated,
Betan (1997) also made a significant contribution
Time in a particular setting or working to the decision-making literature by introducing a
from a certain theoretical base represents hermeneutic model of ethical decision making.

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Hermeneutics is a philosophical framework through the section Philosophically Grounded Models of


which knowledge is viewed as residing in the context Relational Influence.)
of human relationships. Betan stated, Hermeneutics
involves an awareness that the process of inquiry is MULTICULTURAL SENSITIVITY:
affected by and in turn affects the person seeking A DECISION-MAKING THEME
knowledge (1997, p. 352). Therefore, all historical,
Multiculturalism may not constitute a fourth intellec-
personal, and circumstantial factors are involved in
tual movement affecting ethical decision-making
every decision. Even ethical principles are viewed as
models in psychology, but it certainly represents a
historical and circumstantially situatedthey are
theme that has major implications for decision-
not standards that come from some objective source
making processes. Viewing ethics through the lens of
of knowledgethey are reflective of the cultural
multiculturalism places emphasis (even prominence)
context from which they emerge and the situation in
on the identification and analysis of established cul-
which they are applied. Betan did not provide a step-
tural traditions that may affect the relationship
wise model for decision making. He attempted, how-
between the psychologist, the client, and other stake-
ever, to demonstrate that hermeneutics allows the
holders affected by a decision. Multicultural sensitiv-
therapist to remain part of the situation, and it places
ity, for example, can be an overarching theme for
authority not in abstract, externally imposed princi-
decision making that applies principle ethics, virtue
ples but rather in the connection between therapist
ethics, or relational ethics (or some combination).
and patient (1997, p. 362). Social and relational
In this way, multicultural factors are fully acknowl-
considerations are prominent in this model. Still, in
edged. For example, Knapp and VandeCreek (2007)
hermeneutics, there is an individual decision maker.
framed the problem of cultural conflicts in decision
The decision is not made by a committee. In other
making as a tension between application of universal
words, the model is not so extreme as to situate the
standards (such as ethical principles) and acceptance
mind of the individual in the social matrix. Some
of the plural truths that are present when addressing
(one) person does weigh the social factors that are
culturally situated behaviors (i.e., behaviors that may
involved in a decision, and the decision is still a psy-
be counter to ethical principles). They used the
chological process for the decision maker.
example of child discipline, which may be harsher
Cottones (2001) model is much more extreme.
in a foreign culture than is acceptable in U.S. society.
Guided by social constructivism as a philosophical
In the case described by Knapp and VandeCreek, an
movement in the human services, Cottone took an
immigrant East Asian family in the United States used
extreme relational stance, claiming that decisions
extreme physical punishment of their children to
are not made in the head of the apparent decision
ensure obedience and conformity (2007, p. 660).
makerrather they reflect a consensualizing pro-
According to Knapp and VandeCreek, defining the
cess that is culturally, socially, and interpersonally
fine line between discipline and abuse, in this case,
imbedded. He built on the works of Gergen (1985)
required a decision process that involved respectful
on the constructionist movement in modern psy-
dialogue and application of soft universalism (no
chology, and he used the works of Maturana (1980)
hard line, black-or-white logic in defining principles
on the biology of cognition (as lauded by Dell,
of acceptable behavior). They stated,
1985) as representing a fully relational view of the
human condition. Using these foundational works, We suggest that psychologists engage
Cottone developed a social constructivism model of in a respectful dialogue to help patients
ethical decision making, which is completely inter- clarify their values and goals, and that
personal. Decisions are taken out of the decision they look for areas of agreement between
makers head and placed within the social interac- the value systems. If this fails to pre-
tive context. Decision making involves negotiating, vent a serious threat to a fundamental
consensualizing, and arbitrating, rather than indi- ethical principle, we suggest that it is
vidual deliberation. (There is more on this model in appropriate, as a last resort, to confront

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R. Rocco Cottone

the patients values from the perspective ideas from three of the most culturally sensitive
of soft universalism, which may mean approaches known to that date (Cottone, 2001;
allowing the ethical principles of benefi- Davis, 1997; Tarvydas, 1998) to build a formal
cence or nonmaleficence to temporarily model of ethical decision making they called the
override respect for autonomy. Even so, transcultural integrative model. Their model thor-
the psychologist should only override oughly integrates cultural factors with social and
autonomy to the minimal extent possible, psychological factors into the decision-making pro-
consistent with the overarching goal of cess, and the model uses Tarvydass stages as a
beneficence or nonmaleficence. (Knapp framework. Garcia et al. made the case that the tran-
& VandeCreek, 2007, p. 663) scultural integrative model allowed cultural factors
to play an important and perhaps definitive role
This suggestion implicitly defines the role of the (Garcia et al., 2003, p. 275) in the decision-making
psychologist as a transcultural negotiator responsi- process. As with Knapp and VandeCreek (2007),
ble to facilitate solutions to problems that are both Garcia et al. argued for prominent consideration of
true to overarching values in psychology and multicultural factors in the decision-making process.
respectful of cultural differences. Multicultural sensitivity, as it is described here,
Hanson and Kerkhoff (2007) addressed similar is more thematic than philosophical. Models devel-
concerns specific to ethical decision making in reha- oped around multicultural sensitivity typically
bilitation psychology. After providing a detailed depend on one or more of the intellectual move-
example representing a failure to acknowledge ments to define crucial steps or processes in the
Latino cultural factors in medical decision making, decision effort. Models based on multicultural sensi-
the authors stated, tivity can draw from the other intellectual move-
Failing to aspire to become a culturally ments without conflict, whereas the intellectual
proficient psychologist is to ignore the movements appear to be more circumscribed, theo-
evolving social landscape within which retically distinct, and even mutually exclusive. One
psychologists practice. As the United can appeal to principles, virtues, or relationships in
States grapples with its founding history defining a culturally sensitive way to address an eth-
and contemporary views of immigration, ical dilemma. But to move from principle ethics to
so too is the discipline of psychology try- relational ethics, for example, may require a Gestalt-
ing to find its voice in the social dialogue like shift in perspective, as ethical principles are
on diversity and the impact of multicul- held as established truths, whereas relational ethics
tural approaches on education, practice, are always context specific and historically situated
research, and advocacy. (Hanson & truths. Therefore, the intellectual movements in eth-
Kerkhoff, 2007, p. 418) ical decision making, when viewed from a pure or
absolute point of view, are mutually exclusive, and
A psychologist must at least recognize the ten- they may not be reconciled easily.
sion that arises with an automatic application of
prevailing standards at the expense of cultural tradi-
CLASSIFYING MODELS ON
tions. A decision may be different if cultural factors
PHILOSOPHICAL, THEORETICAL, OR
are understood and addressed through the decision-
PRACTICAL GROUNDS
making process.
Garcia, Cartwright, Winston, and Borzuchowska The three intellectual movements (principle ethics,
(2003) presented a similar multicultural theme: In virtue ethics, and relational ethics) and the theme
examining the available ethical decision-making of multicultural sensitivity have influenced ethical
models published in the field, we found minimal ref- decision making in psychology, and together they
erence to culture or how to integrate culture into constitute a framework for classifying and analyzing
ethical decision-making (p. 269). Garcia et al. used existing decision-making models. These models,

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Ethical Decision Making in Mental Health Contexts

however, also may be classified on other philosophi- duty or which intuition ought to carry
cal, theoretical, or practical grounds. the day, we need some means other than
Beyond the intellectual movements that have intuition, some higher kind of thinking
affected the field, an additional philosophical, theo- (let us call it critical moral thinking) to
retical, and practical taxonomy offers another way of settle the question between them. (Hare,
looking at the models and analyzing their validity. 1991, p. 35)
Models can be classified on the basis of philosophy,
empirical formulations, or anecdotal evidence. They Hare (1991) argued that at the bottom level, the
can be based on specific theories. They can be intuitive level, a decision can be absolutist, meaning
focused on the individual decision maker, or they that there can be a concrete application of a princi-
can focus on a group of individuals who are influen- ple to a problem. But at the higher level of decision
tial in the final outcome. They can be a mixture of making (when intuition fails), absolute thinking
any number of such factors. Several categories will must give way to utilitarianism. He summarized
be defined, and at least one example model will be utilitarian philosophy by stating, A utilitarian is
presented for each category. In every case, however, one who thinks that when faced with a moral deci-
it will be obvious which intellectual movement is at sion he ought to act in whichever way is best for the
its base. Individually oriented approaches will tend interests of those affected (1991, p. 34). He used
to be based in principle or virtue ethics, or both. Kants example of a madman in search of a known
Models that involve interaction will be relationally individual he plans to kill; when confronted, should
focused. So the models will tend to be offshoots of someone reveal the potential victims location, or
the intellectual movements with some specific and lie? Hare stated,
unique philosophical, theoretical, or practice-rele- Most of us, as well as the duty to speak
vant ingredient added to the recipe. the truth, acknowledge a duty to preserve
innocent people from murderers, and here
Philosophically Grounded Models the duties are in conflict. An absolutist
of Individual Choice will have to resolve the conflict by calling
Hare (1991), in The Philosophical Basis of Psychiat- one of the duties absolute and assigning
ric Ethics, provided one of the most philosophically some weaker status to the other. A
grounded models of ethical decision making. Hare utilitarian, by contrast, is likely to say that
argued that there are two levels of ethical decision neither duty is absolute; what we have
making, the intuitive level and the critical evaluative to do is to decide what would be for the
level. At the intuitive level, an application of ethical best in the particular case. In this case, it
principles is in order. Mental health professionals are will presumably do most good to all con-
taught principles as guides to professional behavior, cerned, considering their interests impar-
and when confronted with a dilemma, they use their tially, if I tell a lie. (1991, p. 36)
intuition to apply the principles. Hare argued that, in
most cases, dilemmas will be adequately addressed Effectively, Hare (1991) proposed a two-stage
by means of the intuitive application of principles. model of moral decision making. At the first level,
He also raised concerns about the problem of con- one is intuitive and can apply absolutist standards
flicts between principles. How should those conflicts of right and wrong. At the second level, one must
be negotiated? He stated, apply utilitarian philosophy, engaging a critical eval-
uation of utilitarian values to the situation at hand.
That we have a duty to serve the interests Recently, research has supported Hares (1991)
of the patient, and that we have a duty to contention that decision making is a two-tiered pro-
respect his rights, can both perhaps be cess. Kahneman (2003), in a review of the literature
ascertained by consulting our intuitions on judgment and choice, defined two levels of judg-
at the bottom level. But if we ask which ments. In the first level (System 1), judgments and

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preferences are called intuitive in everyday language Their model was presented in a text on decision
if they come to mind quickly and effortlessly making as applied to psychiatry. They designed a
(Kahneman, 2003, p. 716). More deliberate thought model using probability theory as a basis for formu-
is applied at the second level (System 2), which can lating a decision. They described two quantitative
modify or override what occurs in System 1. The paradigms in sciencethe mechanistic and the
research supports a two-layered decisional process, probabilistic paradigms. Historically, quantitative
and Hares intuitive and critical evaluation levels analysis was reflective of defining absolute truths in
mirror decision levels defined by empirical findings nature through mechanistic approaches to research.
on the process of decision making. In this case, the- Gutheil et al. (1991), however, defined a shift from
ory built on philosophy coincides with theory built mechanistic analysis to analysis of probability,
on empirical findings. which involves not only the search for truth, but
So when a psychologist is confronted with an acknowledgment of variables that may influence
ethical dilemma, for examplea suicidal client outcomes, including the variable of the observer
following Hares two-stage process, he or she first (experimenter). They made the case for decision
must intuitively apply ethical principles (typically analysis, a means to apply statistical probabilities to
beneficence and nonmaleficence) and may decide to a decision tree to define the likelihood of an out-
seek hospitalization for the client. But if a conflict- come. They stated,
ing circumstance exists (the autonomy of a client
Decision analysis can also be used to
who refuses to be admitted to a hospital), then utili-
build logic and rationality into our intui-
tarian values come into play, and may require iden-
tive decision makingto educate our
tifying an option that values the clients autonomy,
intuition about probabilities and about
safety, and well-being. The utilitarian will ask,
the paths of contingency by which our
What is best for all concerned on this case? And a
actions, in combination with chance
decision will involve weighing hospitalization and
or outside events, lead to outcomes.
alternative actions to find a suitable course of action
(Gutheil et al., 1991, p. 41)
so that the needs of all are summed (and a decision
in the service of the greatest number is discerned). A decision is structured around a decision tree.
The client, in this case, may desire to go home, but a They described how a decision sets in motion a
decision may be made to send the client home only chain of controllable and uncontrollable, predictable
under the strictest of supervision by a mutually and unpredictable, events (Gutheil et al., 1991,
agreed-on party or parties (involved loved ones). In p. 43). Each outcome is connected with what came
this way, others may rest assured of the clients before and with the choices that followeffectively
safety short of hospitalization, while respecting the building a decision tree or visual representation of
clients autonomy. the path of the decision. They stated, A decision
Hares (1991) model provides a good example of a tree can be drawn to capture this sequence of chosen
philosophically grounded approach to decision mak- actions and chance events (Gutheil et al., 1991,
ing in which an individual makes a decision. In this p. 43), so that actions, uncontrollable events, and
case, an individual must assess choices on the basis of outcomes (intended and unintended) can be out-
utilitarian values when intuition fails or when con- lined in terms of contingencies. Probabilities on
flicts arise between agreed-on standards of ethical each branch of the decision tree can be estimated.
behavior. Hares model is an excellent example of a According to Gutheil et al. (1991), estimating
philosophically grounded model of individual choice. probability is complicated, but one way is to calcu-
late the relative frequency with which the event in
Quantitative Models of question occurs over a large number of trials in sim-
Individual Choice ilar circumstances (p. 46). This is problematic
Gutheil, Bursztajn, Brodsky, and Alexander (1991) when trying to estimate the outcome of unique
provided a unique perspective of decision making. events, in which case the authors acknowledge that

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Ethical Decision Making in Mental Health Contexts

subjective judgment must be used. They stated, models describe an initial step of problem identifica-
Psychologists have found that subjective probabil- tion. Problem identification is followed by another
ity estimates can be reasonably accurate when the step of information gathering. Consultation with
people making them are knowledgeable about what codes, laws, or experts may be a separate step or part
they are estimating as well as experienced in proba- of the information-gathering effort. Options are
bility estimation (Gutheil et al., 1991, pp. 4647). identified; options are weighed. Finally, an option
The intention is to quantify, to whatever degree is chosen for action, and the decision is finalized.
possible, the likelihood of decision outcomes by Table 4.1 provides a comparison of several text-
anticipating and enumerating probable choices book models of ethical decision making. The table
along the way. does not produce a line-by-line comparison, but it
Gutheil et al. (1991) made a compelling argu- does provide a visual picture of some of the com-
ment that even in cases in which measurement is mon textbook models of decision making, and how
not precise, decision analysis makes decision mak- their steps compare. Also, the table illustrates the
ing conscious, methodical, and critical, thereby overlap across the models (as with many models
rendering the decision analysis process beneficial described in this chapter). For example, the Corey
(p. 48). They finalized their arguments by compar- et al. (2007) model shares common steps or stages
ing decision analysis to conscious gambling, with with other models listed on and off the table. Typi-
the latter being less formal and systematic. Although cally, this overlap occurs in steps defining the prob-
conscious gambling may be more haphazard than lem, fact finding, defining alternative courses of
decision analysis, it still provides an opportunity for action, and making a choice.
decision makers to hone their decision-making skills In all of the models in Table 4.1, an individual
in a stepwise fashion. In the end, they took a posi- makes a decision after following the steps of the
tion that quantification is valuable in decision mak- decision process. It is not clear how the decision is
ing whenever some individual makes a choice. finally made. One must conclude that the decision
Decision analysis cannot happen outside a prin- maker applies logical principles to determine the
ciple ethics context. For example, if a psychiatrist is final outcome, and few of the models acknowledge
faced with a suicidal patient, decision analysis will the process of weighting the cognitive, intuitive,
show that there is nearly a 100% probability that the or emotional aspects involved in a decision. Few
patient will survive over night if he or she is hospi- address interpersonal involvement in the process,
talized in a safe room. In this case, decision analysis except as related to expert consultation. Some mod-
provides a quantitative means of defining an out- els do encourage an analysis of probability before a
come, but the value of the outcome does not derive decision is made (e.g., Keith-Spiegel & Koocher,
from the decision analysis; rather the value of the 1985).
outcome derives from the ethical principles of Overall, these models are more mixed than those
beneficence (client well-being) and nonmaleficence that are more purely theoretically derived. One can
(do not harm). So decision analysis based on proba- find principle ethics, a focus on the character of the
bility still is guided by a principle ethics and is car- decision maker, and even acknowledgment of the
ried out by an individual decision maker. influence of interpersonal consultation on the final
decision. So practice-based models tend to draw on
Practice-Derived Models of a number of sources and apply concepts across the
Individual Choice intellectual movements, even in ways that are con-
Almost every major textbook on ethics in psychol- tradictory or mutually exclusive at times.
ogy practice provides a model for decision making. Consider the example from the prior section
Some of the earliest texts (e.g., Corey, Corey, & the suicidal patient. Applying the well-known Corey
Callanan, 2007, now in its 7th edition) provided a et al. (2007) model (described in Table 4.1), the
stepwise approach that was logical and supported by problem is first identified. Other issues then are
anecdotal evidence of its usefulness. Typically, these identified, and in this case, the safety of the client is

107
TABLE 4.1

Comparison of Textbook Models of Ethical Decision Making

Corey, Corey, and Forester-Miller and Hass and Malouf Keith-Spiegel and
Callanan (2007) Davis (1996) (2005) Koocher (1985) Sperry (2007) Welfel (2006)
1. Identify the 1. Identify the problem 1. Identify the 1. Describe the 1. Enhance ethical 1. Develop ethical
problem ethical problem parameters sensitivity and sensitivity
anticipation
2. Identify potential 2. Identify 2. Define the 2. Identify the 2. Identify relevant
issues involved legitimate potential issues problem facts and
stakeholders stakeholders
3. Review relevant 2. Apply the American 3. Identify relevant 3. Consult legal and 3. Identify 3. Define central
ethical guidelines Counseling standards ethical guidelines participants issues in dilemma
Association Code affected by the and available
of Ethics decision options
4. Know applicable 3. Determine nature of 4. Review the 4. Evaluate 4. Identify courses 4. Examine relevant
laws and dilemma relevance of the the rights, of action and ethical standards,
regulations existing standard responsibilities, benefitsrisks for laws, and
and welfare of participants regulations
involved parties
5. Obtain 4. Generate potential 5. Evaluate the 5. Generate alternate 5. Evaluate benefits 5. Search out ethics
consultation; courses of action ethical dimensions decisions risks context scholarship
consider possible of the issue and considerations
and probable specify a primary
courses of action ethical dimension
if possible
6. Consider possible 5. Consider potential 6. Consult and 6. Enumerate the 6. Consult with peers 6. Apply ethical
and probable consequences; review codes of consequences of and experts principles to
courses of action determine course of ethics; review each decision situation
action literature;
consider ethical
principles
7. Enumerate 7. Generate a list of 7. Estimate 7. Consult with
consequences of possible actions probability for supervisor
various decisions. outcomes of each and respected
decision colleagues
8. Decide on best 8. Do costbenefit 8. Make the decision 7. Decide the most 8. Deliberate and
course of action analysis and feasible option decide
choose based and document the
on optimum decision process
resolution for
greatest number
6. Evaluate selected 9. Evaluate the
course of action new course of
action for effect
on people and
unforeseen
ethical problems
7. Implement course of 10. Judge whether 8. Implement, 9. Inform supervisor
action course of evaluate, and and take action
action can be document the
implemented decision
11. Implement the 10. Reflect on the
chosen course of experience
action

Note. Adapted from Ethical Decision Making Models: A Review of the Literature, by R. R. Cottone and R. E. Claus,
2000, Journal of Counseling and Development, 78, p. 279. Copyright 2000 by the American Counseling Association.
Reprinted with permission. No further reproduction authorized without written permission from the American
Counseling Association.

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Ethical Decision Making in Mental Health Contexts

prominent. Ethical principles direct the psychologist and the Hare (1991) model, therefore, provide use-
to consider the best interest of the client and to pre- ful examples of how individual decision making is
vent harm, which would mean the psychologist to be conceptualizedit is theoretically grounded
should act in some way to prevent suicide. Relevant and explains the process; other models of individual
laws and other standards must be considered. Corey choice appear to leave the decision maker without a
et al. (2007) then encourage the mental health pro- means of weighing optionsthe decision appears to
fessional to seek consultation to consider possible just happen, perhaps out of individual conscience
and probable courses of action. In this case, a psy- (which will be explored in the section Is Autono-
chologist can be directed by colleagues or supervi- mous Decision Making Problematic?).
sors to consider the safety of the client first. The
consequences or repercussions of possible choices Philosophically Grounded Models
must be defined. If the client hurts him or herself, of Relational Influence
then the psychologist faces serious repercussions, The social constructivism movement in psychology
especially if the psychologist had an opportunity to may represent the emergence of a body of knowledge
act in a way to prevent harm. Finally, the psycholo- that constitutes a full-fledged paradigm of counseling
gist is directed to decide on the best course of and psychotherapy (Cottone, 2007). Its implications
action. As can be gleaned from the scenario, individ- are pervasive for the psychology and the mental
ual and social factors come into play, but the deci- health enterprise both theoretically and practically.
sion, in the end, is defined by the individual The practical aspect of the social constructivism
psychologist who must in some way consider and movement is clearly exemplified in the social con-
weigh the pros and cons of the situation and negoti- structivism model of ethical decision making
ate through consultations on the matter. The model (Cottone, 2001, 2004; Cottone & Tarvydas, 2007),
is stepwise, logical, and practical; however, it does which provides a purely philosophically directed
not offer guidance on the value associated with fol- model of decision making. The constructivism model
lowing simple standards versus addressing other is a decision-making model with a clear focus on
issues or concerns raised by consultants. For exam- relationshipsthere is no individual decision maker
ple, how does a psychologist react when a consul- decision making occurs outside of ones head (so to
tant recommends a course of action that is counter speak) and in the social matrix. Building on the
to the psychologists initial impressions or ethical works of a cognitive biologist (Maturana, 1978, 1980,
choice? Viewing the model positively, it is easy to 1988; Maturana & Varela, 1980) and expanding the
apply. From a negative point of view, it provides lit- ideas of Gergens (1985) constructionism movement
tle guidance on the weight to be given to consultant in modern psychology, I defined an extreme rela-
opinion, especially when the opinion is contrary to tional framework for decision making. As Gergen
the decision makers position. This same criticism is (1991) stated, When individuals declare right and
valid for any model that mixes individual decision wrong in a given situation they are only acting as
making with a step involving consultation. In the local representatives for larger relationships in which
end, the decision risks are the decision makers to they are enmeshed. Their relationships speak
bear, and little explanation is given as to what hap- through them (pp. 168169). Likewise, I defined
pens (or what is to happen). This is contrasted by decision making as a process of addressing conflicts
the Gutheil et al. (1991) model, which provided a between people as relationships speak through
means for final decision determination through themconflicts of consensualitieswhere a con-
decision analysis and probability; in that case, the sensuality is a socially constructed truth. Consensual-
decision maker must individually compute the ities generally are considered absolute truths within
probabilities and follow the statistically most likely the confines of the relationship system within which
positive result. It also contrasts to Hares (1991) the truth is distinguished and defined; but consensu-
position, in which the utilitarian must sum what is alities may appear as relative to outsiders who view
best for all involved. The Gutheil et al. (1991) model other alternatives as equally valid. As an example, the

109
R. Rocco Cottone

acceptability of drugs within the drug culture may be all of the relationships of significance from the per-
viewed as a truth to those in the culture, but to out- spective of the patient. The psychologist also might
siders, drug use may be viewed as unacceptable. Pro- explain the process of hospitalization and explore
fessional ethical conflicts derive from conflicting the implications of hospitalizations for the clients
consensualities, where at least two people disagree current and future relationships. In cases in which
on the nature, harm, or intent of an act of a mental the opinions of others are valued by the client,
health professional. especially from a multicultural perspective, consul-
The social constructivism model involves tation would occur (as legally permitted) with other
three interpersonal processes: consensualizing (the stakeholders in the decision about how to address
process of acting with others according to some the suicidal intent. Then, using his or her training
socially agreed on definition), negotiating (discuss- and past supervision as a guide, the psychologist
ing and debating through disagreements while would consult other professionals about the cir-
making distinctions and attempting to reconcile dif- cumstance. He or she might consult a supervisor,
ferences), and arbitrating (the process whereby a hospital emergency physician, or a colleague for
negotiators in a stalemate seek the judgment of a such matters. Discussion of options or even negoti-
consensually acceptable individual to resolve a con- ation with stakeholders and involved professionals
flict). All three processes are social; no individual may occur while developing an agreement on the
(internal) decision making is involved. The decision best course of action. Their counsel would be valu-
is processed in the interaction with stakeholders and able in determining whether some action should be
others who potentially can contribute to an out- taken. The psychologist in this social context will
come. The model is represented graphically in agree or disagree with the emerging or historical
Figure 4.1. Individuals involved in the decision- (learned in prior circumstances) consensualities,
making process obtain information from involved which are viewed as socially defined truths. The
parties, assess the nature of relationships (are they psychologist might facilitate hospitalization of the
conflicting or adversarial?), and consult valued col- client, or perhaps he or she would act otherwise to
leagues and expert opinion (including ethical and ensure safety consistent with ethical imperatives,
legal standards). The decision makers then attempt social factors, cultural standards, legal standards,
to reach a consensus about what should happen or and best practice in the field. What appears to be a
what occurred. If a difference of opinion exists, then decision of an individual actually is an action con-
continued negotiating and ultimately arbitrating are sistent with an operative consensus (currently or
necessary. The model also allows for a period of historically situated) that looks like an individual
interactive reflection, during which time stakehold- choice. If there is impasse, then arbitration likely
ers define whether they can modify their stance and will occur in the courts (e.g., involuntary hospital-
reenter negotiation to avoid arbitration. ization), where a judge or jury will decide the oper-
In the case of a suicidal patient, the psychologist ative truth. The legal system is viewed as the final
following the social constructivism model would arbiter (as both clients and counselors operate
first address the issue of suicide with the patient. within the constraints of a sociolegal consensus).
Assuming that the client is not incapacitated, and On matters that are not adversarial, the social con-
using knowledge of suicidal factors, the psycholo- structivism model encourages agreements between
gist would evaluate and address the risk factors parties on problem arbitration in advance. For
with the client. The client would either agree that example, a psychologist-in-training and a supervi-
the factors were or not. The psychologist might ask sor ideally would agree that unresolved ethical or
the patient who the patient believes would be most clinical disagreements would be presented to a con-
negatively affected by the patients suicide. The psy- sulting psychologist (or ethicist) and that both par-
chologist might also explore the patients thoughts ties would defer to the judgment of the consultant.
on who might be viewed as benefiting from the sui- Whereas arbitration may be defined legally by the
cide. The intent of questioning is to clearly define contract of services between a psychologist and a

110
Ethical Decision Making in Mental Health Contexts

Obtain Information From Assess the Nature of Consult Consult Valued Colleagues
Those Involved Relationships and Expert Opinion
Conflicting Opinions? (Including Ethical Standards)
Adversarial?

Negotiate
(if Necessary)

Consensualize

Interactive
Reflection
(When Consensualizing Fails)

Arbitrate
(if Necessary)

FIGURE 4.1. The interactive process of socially constructing an outcome to an ethical


dilemma. From A Social Constructivism Model of Ethical Decision Making in Counseling,
by R. R. Cottone, 2001, Journal of Counseling and Development, 79, p. 43. Copyright 2001 by
the American Counseling Association. Reprinted with permission. No further reproduction
authorized without written permission from the American Counseling Association.

client, professional relationships may establish theory or philosophythe social constructivism


alternative means of arbitration (short of legal movement in mental health services. Decisions are
recourse) in their daily practices. The legal system removed from the individual decision makers head
is viewed as a consensual system in which judges and instead are defined within the social interaction
apply case law and juries socially construct a deci- that ensues around a dilemma. The decision is in
sion within rules of law. the social matrix. The psychologist, according to
The social constructivism model of ethical deci- this model, acts in accord with an operative consen-
sion making is an example of a purely relational sus and not as an isolated individual decision
decision-making process that is derived solely from maker.

111
R. Rocco Cottone

Mixed Models of Individual and there. There are two more stages. In Stage 3, there is
Relational Influence reconsideration of the choice around context and
Probably the most comprehensive model that for- nonmoral or other values are considered that might
mally addresses both psychological and social pro- in some way blind the psychologist from the right
cesses in decision making is the Tarvydas integrative choice. Maybe hospitalization is just an easy way to
model of ethical decision making (Cottone & Tarvy- unload ones responsibility to a hospital staff physi-
das, 2007; Tarvydas & Cottone, 1991). Tarvydass cian (a psychology blind spot). Perhaps hospitaliza-
model incorporates the best of theory from a num- tion may engage the client in a medical model of
ber of original sources. She draws on the works of treatment when the problems leading to suicidal
Hare (1981), Rest (1984), Kitchener (1984), and threat were more relational than psychological. Per-
Beauchamp and Childress (2009) representing prin- haps hospitalization may lead to stigmatization that
ciple ethics. She included the concept of virtue eth- in the end will brand the client negatively and cause
ics (Meara et al., 1996). She also carefully built a problems within the social network within which
contextual component in her model, so that rela- the client operates. It might be harder for the psy-
tional influences are addressed. And she added a chologist to come up with another option, but in
reflective component, consistent with recommenda- this case, it might be justified. Stage 3, then, might
tions of Hill et al. (1995) and Welfel (1998), so that lead to a decision to seek some other means of
selecting the best ethical course of action is not the safety, short of hospitalization. That may be the pre-
final step in the decision process. Tarvydass model ferred course of action. The final stage (Stage 4) of
is a comprehensive model of decision making. The the Tarvydas model requires definition of the exact
model is understandably complex, but, at the same steps to be taken to implement the decision, possible
time, it uses the best of theory to the point of its barriers to execution of the decision, and possible
development. counter measures if something prevents the pre-
The Tarvydas model is a four-stage model: ferred option. Finally, the decision is carried out and
Stage 1, interpreting the situation through aware- evaluated.
ness and fact finding; Stage 2, formulating an ethical At specific stages in the Tarvydas model, a num-
decision; Stage 3, selecting an action by weighing ber of components reflect the contributions of theo-
nonmoral values, personal blind spots, or preju- rists at the foundation of her model. Her model
dices; and Stage 4, planning and executing the skillfully addresses context, involves a degree of col-
selected course of action. laboration, and encourages reflection before a final
Considering the suicidal patient and applying the determination. It engages principle ethics, but it also
Tarvydas model, one can see the models ability to recognizes that the decision makers intuition and
address multiple layers of theory and context. The character may be crucial factors in the decision.
first two stages are much like any logical decision- Relationship factors are weighed heavily, and her
making process in which an individual makes a model is truly integrative. Although it is vulnerable
choice. One is sensitive and aware of the dilemma, to criticism on the basis of its merging what may be
defines involved parties (stakeholders), goes viewed as mutually exclusive philosophies (rela-
through a process of fact finding (all in Stage 1). In tional versus individual), her model will stand as an
Stage 2, one reviews the data; applies relevant codes, historical marker of the status of the field at the time
laws, and institutional policies; and generates possi- of its development.
ble courses of action, considering the consequences
of each. Consultation with supervisors or other
A BRIEF SUMMARY OF MODELS APPLIED
knowledgeable professionals occurs in Stage 2, and
TO SPECIFIC ETHICAL DILEMMAS
then the best course of action is selected. In the case
OR POPULATIONS
of the suicidal client, the best course of action may
be to act to prevent suicide by facilitating hospital- The complexity of professional mental health prac-
ization. However, the Tarvydas model does not stop tice is reflected in the number of publications that

112
Ethical Decision Making in Mental Health Contexts

present guidelines or models that apply to special- HIV. She provided three levels of action that will
ized ethical dilemmas. These publications are found lead to a logical decision. The first level involves
not only in psychology journals, but also in social engaging the client in services to help in recognizing
work, marriage and family therapy, behavioral sci- the unacceptable behavior and addressing the denial
ence, and counseling journals. A number of publica- process. The second level involves physician contact
tions address specific challenges when serving and advice to encourage appropriate behavior. The
clients who have faced such issues as (a) domestic third level involves contact with agencies to inform
violence or battered women (e.g., Edwards, Merrill, authorities of the behavior of the resistant client.
Desai, & McNamara, 2008; Koenig, Rinfrette, & Costa and Altekruse (1994) provide a list of duty-to-
Lutz, 2006), (b) end-of-life care (e.g., Werth, 2002), warn guidelines to direct mental health profession-
(c) geriatric neuropsychology (e.g., Martin & Bush, als addressing clients who have made a threat. The
2008), and (d) HIV and AIDS. There also have been guidelines include preventative measures and spe-
models or guidelines developed for serving clients cific steps to be taken once a threat has been made.
within specific contexts, such as (a) religious com- If one follows both the preventative measures and
munities (e.g., Hill & Mamalakis, 2001), (b) man- the steps following a threat, the act of warning an
aged care (e.g., Belar, 2000; Tjelveit, 2000; endangered party is a justifiable outcome. Garfat
Younggren, 2000), (c) child clinical psychology and Ricks (1995) described a self-driven model of
(e.g., Mannheim et al., 2002), (d) outpatient care decision making when working in child and youth
(Truscott, Evans, & Mansell, 1995), and (e) play care. The decision is self-driven and involves criti-
therapy (Seymour & Rubin, 2006). And there are cal and reflective analysis (1995, p. 395). Like
recommendations for psychologists who counsel many more general individual-focused models, the
specific populations of clients, such as Asian Ameri- decision somehow happens in the logical part of the
cans (e.g., Littleford, 2007) or those vulnerable to self, as data are weighed in some way and a defensi-
exploitive dual relationships (Gottlieb, 1993). These ble outcome emerges. The intention is to engage an
are just a few of any number of publications that aware and responsible self in ethical practice, as
address specific ethical challenges in mental health opposed to practice moderated or driven by exter-
practice. nal variables (Garfat & Ricks, 1995, p. 397).
Most publications addressing ethically challeng- Another example is the P3 model presented by Sey-
ing specialized circumstances direct mental health mour and Rubin (2006) as related to ethical play
professionals on matters that are specific to the issue therapy. The P3 model incorporates principles,
at hand; few actually provide a formal model of deci- principals, and process (P3) (p. 101). The princi-
sion making. Some examples of publications that ples referred to in the article are those that were
formalize a decision process are Erickson (1990); addressed by Kitchener (1984), with the addition of
Chenneville (2000); Costa and Altekruse (1994); veracity or truthfulness. The principals are essen-
Garfat and Ricks (1995); Gottlieb (1993); Knapp, tially the decisional stakeholders, and include the
Gottlieb, Berman, and Handelsman (2007); Truscott client, counselor, collaterals, and community (the
et al. (1995); and Seymour and Rubin (2006). Two four Cs); these individuals voices are heard in
publications address HIV and provide stepwise deci- the process (the third P), which is an inclusive col-
sional processes. Chenneville (2000) specifically laborative process of recursive interaction. Knapp
addressed confidentiality and the duty to protect, et al. (2007) provided a structured format for
and provides three steps in a decision-making addressing conflicts between laws and ethical stan-
model: (a) determine whether disclosure is war- dards. Steps in the decision-making process follow
ranted, (b) refer to professional ethical guidelines, questions that must be asked, such as What does
and (c) refer to state guidelines. Erickson (1990) the law require? or What are your ethical obliga-
provided a set of guidelines for working with irre- tions? After answering a set of questions, the psy-
sponsible AIDS clients, those who are involved in chologist must discern whether either the law or
behavior that could potentially lead to spread of ethical standard must be breached, that is, that the

113
R. Rocco Cottone

conflict cannot be resolved. In these cases, the psychology or professional practitioners are unwill-
authors recommended a set of steps to take if a deci- ing in certain cases to take ethical action. Scenarios
sion is made not to obey the law. They also provide a presented in such research typically involve a deci-
guideline for minimizing harm resulting from offend- sion to report a peer who was behaving unethically.
ing ethical values. Truscott et al. (1995) provided In as many of 50% of responses, participants admit
four decisional cells (two levels of therapeutic alli- that they would do less than what they realized
ance versus two levels of violence risk) to address they should do (Bernard et al., 1987, p. 490).
dangerous clients in outpatient settings. Assessments In effect, the psychologists (or trainees) who
are made to place clients in the scheme of four deci- responded to these surveys were blinded by personal
sional cells. Finally, Gottlieb (1993) provided a factors. Betan and Stanton (1999) stated,
three-dimensional model of decision making to avoid
Ethical decision making and willingness
exploitive dual relationships. The three dimensions
are not simply a matter of implementing
are power, duration of the relationship, and clarity of
principles. We suggest that psychologists
termination. A stepwise analysis is then carried out,
are making inadequate decisions about
much as with a decision tree, so that the psychologist
ethical dilemmas in part because they are
has an answer to concerns on any one dimension. In
not well attuned to the influential role
all of these publications, the authors provide the
of emotions, values, and contextual con-
reader with specific guidelines or steps to take when
cerns in ethical discourse. Consequently,
confronted with the respective ethical dilemma.
anxiety or other concerns can impede the
ability to implement the ethical course of
WILL THE APPLICATION OF A action. By contrast, those who are more
DECISION-MAKING MODEL ENSURE aware of personal emotions and values
AN ETHICAL ACTION? may be better able and willing to inter-
vene ethically. Awareness of competing
With ethics education of psychologists and with the
factors can enable one to override barri-
attention on ethical issues and ethical decision mak-
ers, as well as to integrate emotional sensi-
ing in the literature, one would think that using an
tivity with rational analysis of a dilemma,
ethical decision-making model automatically would
in order to act ethically and protect the
lead to an ethical decision, and a defensible decision
welfare of the affected parties. (p. 299)
as well. This may be true in many cases, but not in
all cases. So knowledge, in and of itself, is not enough.
It certainly is likely that professional psycholo- Motivational factors enter the equation, and emo-
gists will follow decision-making processes with tion and personal values play a role. In effect,
action, especially in cases where (a) the well-being research is supporting the virtue ethics and rela-
of clients is in danger, or (b) there is serious profes- tional ethics movements, as studies are showing that
sional or legal repercussion for not addressing a the decision maker is responsible to address per-
dilemma. But research has shown that some intui- sonal blind spots (often relationship-based) to
tive (ethical) judgments may be overridden or even ensure that nothing prevents the just application of
blocked under certain circumstances (Kahneman, ethical standards. It speaks to the character of the
2003). And what about blind spots, those dilemmas decision maker and the influence of relational
prone to bias or that may be confused by personal allegiances.
feelings (Cottone & Tarvydas, 2007)? In those Detert, Trevino, and Sweitzer (2008) were able to
cases, it becomes a question of ethical willingness show that some individuals are capable of moral dis-
and resoluteness (cf. Bernard & Jara, 1986; Ber- engagement (a term originally defined by Bandura,
nard, Murphy, & Little, 1987; Betan & Stanton, 1999), which means those individuals are able to
1999). Typically, publications that address ethical deactivate moral self-regulatory processes and in
willingness document empirically that students of cases in which they make unethical decisions, they

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Ethical Decision Making in Mental Health Contexts

are able to do so without apparent guilt or self- her choices and consequent actions, documentation
censure (Detert et al., 2008, p. 374). Personal fac- of the use of a formal decision-making process will
tors are associated with moral disengagement, and likely serve the psychologist well. Defense of a deci-
the authors found that moral disengagement pre- sion will always be easier when a formal and recog-
dicts unethical decision making. So there appears to nized process has been utilized. If one is able to
be a subset of professional psychologists who are defend ones decisions beyond intuition, then it is
capable of unethical action on the basis of personal less likely one can be found negligent or guilty of
factors or some weakness of characteran issue that malpractice. The problem for adjudicators is the
must be taken into account when admitting and possibility that the psychologist charged with uneth-
training individuals in professional psychology. The ical conduct claims to have operated on individual
profession must not be blind itself. It must assume conscience without evidence of consultation,
that there will be professional psychologists, who, thereby relegating the decision process nonobjective
for whatever reason, will choose to be unethical, or or immune to corroboration.
will not choose to be ethical, no matter how much At face value, it seems likely that a psychologist
training on ethical matters they receive. would choose to act on an ethical dilemma if others
have been consulted during the process (Betan &
Stanton, 1999). If there has been acceptable and eth-
IS AUTONOMOUS DECISION MAKING
ical consultation with colleagues or ethics experts
PROBLEMATIC?
on a case, it is likely that sharing the dilemma will
When decisions are left to an individual autonomous help to ensure follow-through on a decision. No
decision maker without specific guidance as to what guarantee of ethical action in such a situation exists,
is suppose to happen in the decision makers head, and there is always the slight possibility of conspir-
then the decision appears to rely on subjective fac- acy (where the psychologist and consultants
tors of individual conscience. In such cases, there is together decide to act unethically), but the likeli-
always the concern that the psychologist will lack a hood of decisive ethical action would seem
conscience. Nonrelational approaches to decision enhanced by collaboration. Research is lacking in
making have traditionally relied on the willingness this regard. Will a psychologist more likely follow
and resoluteness (Betan & Stanton, 1999) of the through with a report of a colleagues questionable
mental health professional to do the right thing. This practice if a decision-making model requires consul-
is an assumption of questionable validity because it tation with other colleagues as a formal part of the
appears that, in certain circumstances, psychologists process (versus a model that does not require inter-
can have blind spots that will prevent or inhibit ful- action)? This is an area that warrants further study
fillment of ethical responsibility (as discussed in and may be significant to the training on and devel-
Will the Application of a Decision-Making Model opment and implementation of future models of
Ensure an Ethical Action?). Typically, the ethical ethical decision making.
dilemma associated with vulnerability involves alle- Psychologists have traditionally viewed auton-
giances where acting ethically is at the potential omy as a valuable ethical imperative (an ethical
expense of an established relationship. principle); but in the area of ethical decision making
Two good reasons exists to have and to use a for- of professional psychologists, autonomous decision
mal ethical decision-making model. First, the obvi- making may allow for secrecy, inaction, or noncom-
ous reason is that a model will guide a practitioner pliance with ethical directives.
through an ethical dilemma. In effect, models are
guides that help to ensure ethical practice when pro-
THE ETHICAL DECISION MAKERS
fessionals are faced with a quandary. A second rea-
DECISION-MAKING DILEMMA
son for having a formal decision-making model
relates to adjudication. If a psychologists ethics are Beyond the issue of autonomy, the profession of
challenged, and the psychologist must defend his or psychology must also be alert to another issue that

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R. Rocco Cottone

may compromise easy application of standards. Pro- distinctions that may serve researchers well, as they
fessional psychology has arrived at a place at which begin to define real and measurable differences in
a psychologist, confronted with an ethical dilemma, the processes involved in decision making. For
must not only address the dilemma, but also make a example, Cottones (2001) social constructivism
decision as to which ethical decision making model model provides an opportunity to measure observ-
to apply. able interpersonal processes in the decision process,
For Canadian psychologists, the CPAs Canadian in contrast to the isolated weighing of options
Code of Ethics for Psychologists (CPA, 2000) provides (based on some criterion) of the typical model of
a recommended decision-making model. The CPA individual choice. In effect, the decision-making
model is clearly a model of individual choice knowledge base has expanded to the degree that
providing logical steps for applying the CPA ethical empirical studies may prove fruitful.
standards. It is not attuned to the influence of rela- A question that logically flows from this analysis
tional or multicultural factors (group influence is is, Does it really matter what model is chosen? It
given lip service) or to the relative weight applied to is fair to ask, Arent most decision-making models
professional consultation (which is addressed only going to lead to the same conclusions? The answer
as a postscript to the model). Although there are is that it does matter because decisions may be quite
weaknesses in the model, at least Canadian psychol- different depending on the model. For instance, a
ogists know what is expected of them when apply- model that operates on the extreme of one of the
ing standards from their code of ethics. Members of intellectual movements of psychology decision mak-
the APA comparatively have much more flexibility ing (principle, virtue, relational) or that takes a pur-
in applying decision-making models to an ethical ist philosophical position (utilitarianism, social
dilemma, for better or for worse. constructivism) likely will produce outcomes that
It is ironic that the profession of psychology, are different and perhaps unique to the model.
which prides itself on its scientific foundation, has Those models that are less extreme or that combine
little in the way of scientific data to offer the practi- elements of differing philosophies or movements
tioner attempting to discern which decision-making may produce less distinguishable outcomes. Take,
model to use. Only a few studies have empirically for example, the case of an adult client being coun-
assessed ethical decision-making models (e.g., seled about adjustment to disability issues who
Dinger, 1997; Garcia, McGuire-Kuletz, Froehlich & reveals he is participating in sexual online commu-
Dave, 2008; Garcia, Winston, Borzuchowska & nications with individuals identified as underage
McGuire-Kuletz, 2004). The number of published children. Assume also that this person is operating
studies is surprisingly small; this may be true, in in a state or province where electronic communica-
part, because ethical decision-making processes tions of sexual content with individuals identified as
have derived their meaning from the study of ethics, under age is not a crimethat the communications
which is a branch of philosophy. It is easy to see that must be followed by action to engage the children in
the nature of decision-making models is aligned personal contact for there to be criminal activity.
with the study of moral philosophy and the litera- The law in this case is clearthe clients actions are
ture of moral choice. Theories of philosophy not illegal, and the client communicates no intent to
underpin some of the best known models (e.g., utili- make personal contact with any identified child con-
tarianism). The application of logic (another branch tacted electronically. A psychologist might, regard-
of philosophy) also pervades existing decision- less of the law, find the clients actions offensive and
making models. There is, therefore, more of a abhorrent. The psychologist might use a utilitarian
philosophical than empirical basis for decision- model of decision making and conclude that the
making model development. Decision-making mod- greatest number are served (the children) if the
els, only recently and by means of virtue ethics and client stops such action and a firm request is made
the relational movements, are breaking from the to the client in that regard. The client adamantly
classic philosophical mode. The newer models offer refuses to stop his electronic contact with children

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Ethical Decision Making in Mental Health Contexts

on sexual matters, states firmly that his purpose for would include the therapeutic context. So the psy-
seeking counseling has nothing to do with his elec- chologists actions would be quite different. In the
tronic contact with children, and asserts he is not first case, using a point-in-time utilitarian model of
doing anything illegal and that it is his choice to individual choice, refusing to continue counseling on
continue. The psychologist then may refuse to coun- moral grounds is defensible because the psychologist
sel the client unless the client ceases such communi- first acted firmly to stop the unacceptable and mor-
cation. The psychologists intent, by taking a strong ally reprehensible behavior. In the second case, the
stand, would be to stop the clients activity. But relationally oriented decision maker might continue
since the client continues to communicate no will- counseling justifiably (at least for a short while) in
ingness to stop or intention of stopping, the psy- hopes of influencing the client therapeutically at the
chologist may decide to withdraw services on moral risk of impingement of strongly held personal values.
grounds. This decision would be defensible on the Decision-making models do make a difference in
basis of the actions of the client, the values of the defining outcomes, especially if competing models
psychologist, and the decision-making model are grounded in unique and distinct philosophies
employed. Because decision making is an individual and applied in a purist fashion. Either model or out-
choice based on personally defined standards, both come may be viewed as right or wrong. Both are
the counselor and the client are justified in their laudable, and both are vulnerable to criticism. What
choices. Choice, in this case, is based on the individ- is important, however, is the fact that the psycholo-
ual conscience of the decision maker. gist used a model, was thoughtful in application of
By way of contrast, a psychologist using a more the model, and followed the model to a defensible
relational model of decision making, such as Betans outcome; this is evidence of an educated professional
hermeneutic model, might act differently in a similar competently applying theory to practice.
circumstance. Even though the clients actions are It is recommended that professional psycholo-
not illegal, the psychologist may find the behavior gists consider their own theoretical and philosophi-
immoral, offensive, or abhorrent. But considering the cal biases as they consider which model to use. For
relational ramifications of the psychologists actions, those with a philosophical bent, for example, the
the psychologist might consider the consequences if choice of a model grounded in philosophy may
the therapeutic relationship is terminated on moral serve them well, such as Hares (1991) or Kitchen-
groundswill society be benefited by an untreated ers (1984) models. For those with interest in rela-
Internet abuser, even though the purpose of counsel- tional theory, Betans (1997) or Cottones (2001)
ing is unrelated or tangential to the moral issue? The model may be of interest. The culturally sensitive
psychologist might ask, Could the influence of the models (e.g., Garcia et al., 2003; Knapp & Vande-
psychologistclient therapeutic relationship poten- Creek, 2007) likely will appeal to those who value
tially result in a remedy over time so that the psy- the identification and study of multicultural tradi-
chologists values are not compromised and the tions as factors in decision making. For those who
clients behaviors may be affected? In this case, rela- want to incorporate the best of known theory, an
tionship factors would prevail, and a decision to con- integrative model will be attractive (e.g., Cottone &
tinue with the client for a specified time (even Tarvydas, 2007, model). And for those just inter-
though a number of children might continue to be ested in the application of logic to solve a problem,
contacted in the interim) to attempt to remedy the the use of stepwise models with anecdotal support is
behavior or to replace it with harmless behavior logical, whether it is a comprehensive model (as
would be the preferred course of action. An underly- presented in textbooks) or a model for a specialized
ing philosophy directs such action, because the psy- ethical circumstance. Regardless of which approach
chologist is operating from an assumption that the is chosen, the profession has advanced to the degree
clients choice is not based on character or individual that a psychologist who makes a crucial ethical deci-
conscience; rather, it is the result of the relational sion without the use of a model will appear nave,
context within which the client operates, which uneducated, or potentially incompetent. When faced

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R. Rocco Cottone

with defending a decision, if a psychologist can his or her own, discern a course of action. A purist
show (especially in a way that can be corroborated) relational theorist would argue that such a scenario
that a formal decision-making approach was taken, (the independent decision maker) is not theoreti-
it is likely that the decision will be viewed as cally possible and must be undergirded by social
thoughtful, grounded, and reasonable. factors. Such a criticism has credence when one crit-
ically analyzes, for example, the process of applying
ethical principles to a dilemma. For example, Beau-
ADVANCED ANALYSIS OF PREMISES
champ and Childress (2009) relied heavily on the
The identification of major intellectual movements work of Ross (1998), as Ross challenged utilitarian
in decision making in psychology has a benefit decision-making processes in favor of intuitive
in addition to delineation of a classification induction (Beauchamp & Childress, 2009,
frameworkthe cross-evaluation of the tenets p. 362). But an examination of Rosss position
underlying each movement. For example, virtue eth- reveals that his arguments are grounded on some-
ics provides a framework for analyzing both princi- thing close to a consensual ethic. Ross (1998) stated,
ple ethics and relational ethics because, in the end,
The existing body of moral convictions of
a professional psychologist will act (or fail to act)
the best people is the cumulative product
when confronted with an ethical dilemma. Virtue
of the moral reflection of many genera-
ethics provides a unique perspectiveone that
tions, which has developed an extremely
focuses on the traits of the decision maker rather
delicate power of appreciation of moral
than the nature of the dilemma. Virtue ethics also
distinctions; and this the theorist cannot
requires an analysis of social factors that may affect
afford to treat with anything other than
the willingness and resoluteness of a psychologist to
the greatest respect. The verdicts of the
act, which places a decision within a relational con-
moral consciousness of the best people
text, much like the hermeneutic model of Betan
are the foundation on which he must
(1997). Likewise, principle ethics will challenge the
build; though he must first compare
relational theorist to concretize the interpersonal
them with one another and eliminate any
processes that lead to an action. Just as individual
contradictions they may contain. (p. 285)
decision making may be criticized because, in many
cases, the decision making disappears into the deci- So just thinking about a dilemma, as Ross would
sion makers head, the process of consensualizing recommend, does not happen outside a socially
may, at its worst, appear to be a simple majority vote established framework, which is exactly what a
of stakeholders. Decision making is a complex pro- social constructivist would argue.
cess, and the identification of the three intellectual Identification of the intellectual movements in
movements and the theme of multicultural sensitiv- psychology decision making allows for a high level
ity helps to place models in historical, philosophical, cross-evaluation of precepts and assumptions and
and theoretical contexts, providing a new framework provides an enriched understanding of models. It
for core analysis and critique of existing models. becomes obvious, no matter where a psychologist
A good example of how identification of the begins the decision process, decision making is com-
intellectual movements in psychology ethical deci- plex and may be viewed from a number of perspec-
sion making leads to advanced analysis would be a tives. Those perspectives may be mutually exclusive.
relational critique of principle ethics. As a relational They may intersect. Or one perspective may super-
theorist, my critique here is both convenient and sede or reframe the others. The debate is open.
defensive, as I clearly and comfortably operate from
a relational bias. Principle ethics fits nicely within
CONCLUSION
the mold of a psychology of an individual deliberator.
It identifies the psychologist as a decision agent, one A number of ethics decision-making models apply
that (to the extreme) can analyze a decision, and on to the practice of psychology. There is also enough

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Ethical Decision Making in Mental Health Contexts

variability among models to begin to classify them ethical principles. Professional Psychology: Research and
according to several movements in the field (princi- Practice, 17, 313315. doi:10.1037/0735-7028.17.4.313
ple ethics, virtue ethics, and relational ethics and the Bernard, J. L., Murphy, M., & Little, M. (1987). The
theme of multicultural sensitivity) and to analyze failure of clinical psychologists to apply understood
ethical principles. Professional Psychology: Research
them on theoretical, philosophical, and practical and Practice, 18, 489491. doi:10.1037/0735-7028.
grounds. 18.5.489
When it comes to training psychologists or accul- Betan, E. J. (1997). Toward a hermeneutic model
turating them (Handelsman et al., 2005), it is becom- of ethical decision-making in clinical practice.
ing important not only to address ethical issues, Ethics and Behavior, 7, 347365. doi:10.1207/
s15327019eb0704_6
values, and dilemmas, but also to address formal mod-
els for decision making and the willingness and reso- Betan, E. J., & Stanton, A. L. (1999). Fostering ethical
willingness: Integrating emotional and contex-
luteness of the psychologist to make a decision. As tual awareness with rational analysis. Professional
ethical decision-making models become more preva- Psychology: Research and Practice, 30, 295301.
lent and sophisticated, it also will be important for doi:10.1037/0735-7028.30.3.295
psychologists to study and to assess them. This may be Canadian Psychological Association. (2000). Canadian
especially important on the issue of consultation and code of ethics for psychologists (3rd ed.). Ottawa,
Ontario, Canada: Author.
the importance of sharing ethical dilemmas with oth-
ers as a means to ensure that the decision-making pro- Chenneville, T. (2000). HIV, confidentiality, and duty
to protect: A decision-making model. Professional
cess may be corroborated. Psychology has advanced to Psychology: Research and Practice, 31, 661670.
a degree at which competitive models of decision mak- doi:10.1037/0735-7028.31.6.661
ing exist, presenting a quandary (in addition to an eth- Corey, G., Corey, M. S., & Callanan, P. (2007). Issues
ical dilemma itself) as professionals may be faced with and ethics in the helping professions (7th ed.). Pacific
an additional decision as to which model to apply. The Grove, CA: Brooks/Cole.
dearth of empirical studies on ethical decision-making Costa, L., & Altekruse, M. (1994). Duty-to-warn
models and processes in psychology is alarming, and guidelines for mental health counselors. Journal of
Counseling and Development, 72, 346350.
hopefully this chapter will be a catalyst for the applica-
tion, study, and research of ethical decision making in Cottone, R. R. (2001). A social constructivism model of
ethical decision-making in counseling. Journal of
psychology, especially related to cross-evaluation of Counseling and Development, 79, 3945.
models from the perspective of different intellectual
Cottone, R. R. (2004). Displacing the psychology of
movements in the field. the individual in ethical decision making: The
social constructivism model. Canadian Journal of
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