● Review—Define the dilemma based on standards or principles, review ethical and legal standards, and review literature. ● Intrapersonal—Self-reflection of personal values and beliefs and boundaries of competence are assessed. ● Interpersonal—Discuss with the client, get consultation with a colleague, and/or seek out additional training or supervision. ● Prediction—Consider possible outcomes, estimate the probability of consequences for each option, and determine if the solution is feasible. ● Deliberation—Identify and interpret the problem, consider possible courses of action, identify the ideal desired outcome, assess values, and determine if the action is acceptable. ● Self-monitoring—Monitor the outcome, review the process, and document the process. ● Perspective thinking—Consider all parties affected, consider cultural factors, identify competing values, and adopt the perspective of each party involved. Brownlee and colleagues (2019) evaluated social workers’ strategies for ethical decision making. They found that the study participants reported experiencing frequent dilemmas related to boundary concerns but seldom used formalized step-by-step decision-making models to guide their response in those boundary situations. Clinicians more often tended to use intuitive approaches based on personal or cultural value systems. They stress that although this may allow sensitivity to the specific context, this process is highly vulnerable to being influenced by personal attitudes, values, beliefs, and needs. By extension, it would then become more difficult for the clinician to justify their decision if it is challenged. They recommend that the clinician put in place, and document, a more formal decision-making process when faced with dilemmas such as boundary crossings.
3. The objective awareness of the limits of one’s knowledge and competence and the willingness to practice within the boundaries of competence. 4. The ability to recognize high-risk situations proactively before an ethical dilemma arises. 5. The willingness to seek consultation and information when a situation arises that is clinically difficult or ethically challenging, as well as the willingness to use the guidance offered. 6. The ability to proactively put into place ethical safeguards. They note that clinicians tend to use an eclectic approach that utilizes their intuitive sense of principles, their past clinical experiences, lessons they have learned from their colleagues, and inductive and deductive reasoning. This loose, informal strategy typically does not yield one answer or path of behavior but rather identifies a host of possible responses that may be ethically acceptable. This process often ends up being of limited benefit in making a decision in day-to-day practice. They advocate for the use of a more formal and systematic approach to ethical decision-making. Johnson and colleagues (2022) reviewed the current literature on the use of ethical decision-making models by mental health professionals. They found that the use of a model has many benefits including improved quality of a decision and better preparation for dealing with difficult situations. They identified 38 unique models for ethical decision-making, reviewed the individual steps in the models, and categorized them into common themes. Based on this, they identified core components of ethical decision-making models which could then be used by the professional to evaluate the model and select the one that fits them best. ● Action—Select a course of action, implement the action, modify practices based on the action, and accept responsibility for the action.
DECISION-MAKING MODELS
● Stage Three: Consultation—Consult with supervisors, colleagues, and current literature. Brainstorm potential solutions and evaluate each. Develop a list of possible solutions and what the repercussions would be. Involve the client in the decision-making process if appropriate. ● Stage Four: Balance—Consider the balance between personal beliefs and values and the accepted code of ethics. These must be balanced with the values of the client, or the client may be minimized and/or boundary crossings may occur. ● Stage Five: Action—The course of action is prepared and implemented. ● Stage Six: Reflection—Self-reflection, mindfulness, and documentation are completed. Document the details of the dilemma, the procedures followed, the reasoning for choosing a particular solution, and the final effect of the course of action. Determine if something different should have been done. Another popular model is the ETHICS model introduced by Ling and Hauck (2017). It is based on the ethics literature, and it uses the ACA’s suggestions for ethical decision-making models and strategies included in the ACA Code of Ethics (2014). This model strives to simplify the ethical decision-making process into six steps, which can be applied to a broad range of ethical dilemmas. ● E—Evaluate the dilemma. This is the most critical aspect of the model. The clinician applies the Ethics Code and any applicable laws to help define the dilemma. Possible courses of action and the ethical codes that support or violate each option are evaluated. There are three possible categories of action: 1. The course of action may not violate any ethical code. In this situation there is no dilemma and no need to apply the decision-making model.
An ethical dilemma is defined as a situation in which there are competing values, conflict between ethics and law, conflicts between ethics and organizational requirements, knowledge of substandard practice of other professionals, and/or conflict between professional ethics and personal morals. A quick literature review shows that there are numerous decision-making models available which have various numbers of steps and areas of focus designed to help the clinician navigate these situations to come to a course of action. Choosing a model to use should be in line with the clinician’s personal ethics, theoretical orientation, and values and should fit with their own professional identity, personality, and risk tolerance. It should be appropriate for practitioners of all experience levels, and the provider should be able to apply it to a wide range of ethical situations, for example, when considering a boundary crossing. Riggin and Lack (2018) note that decision-making models have traditionally failed to take into account the affective components of ethical problem solving. They propose a virtue-driven decision-making model which takes into account the values and morals of the clinician. The congruence of the model with the clinician is then increased, and this fosters a stronger sense of internalized ethical behavior. Their values model incorporates themes of openness, benevolence, justice, and commitment, during six stages when making a decision on a course of action. This type of model, which focuses on values, is popular with the helping professions. ● Stage One: Observation—Recognize and define the situation which requires decision-making. Research codes of conduct and local laws to see if the appropriate action is specified. Explore personal affect including feelings, values, and biases. ● Stage Two: Identification—Identify the culture, value systems, and relevant ethical principles to help clarify how they all influence the potential course of action.
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