Decisions in day-to-day practice are often not clear cut and have a level of ambiguity. Grace and colleagues (2020) appropriately note that, leaving aside serious boundary violations, ethical dilemmas like decisions about boundary crossings are part of the day-to-day practice of clinicians. Although knowledge of one’s professional code of conduct is essential, it is often not sufficient when considering a boundary crossing or when faced with an ethical dilemma. At these times the clinician needs a framework for determining the most ethical course of action. Ethical decision-making models are designed to guide the clinician in a systematic way to determine an acceptable and defensible decision or course of action. Several professional codes of ethics require the clinician to use a formal decision-making model and to document that in the client’s chart. Other codes do not specifically require use of a formal model, but all direct the clinician to evaluate ethical situations critically. ● ACA (2014) states that when faced with ethical dilemmas, such as a potential boundary crossing, counselors use and document an ethical decision- making model that may include consultation, consideration of relevant ethical standards and laws, generation of potential course of action, deliberation of risks and benefits, and selection of an objective decision (1.1.b). The counselor is expected to use a credible model of decision making that can bear public scrutiny of its application. ● NBCC (2023) states that when confronted by ethical dilemmas, the counselor shall engage in an ethical decision-making process and consult available resources. ● APA (2017) does not specifically address the use of a decision-making model. However, the principles are in the process of being updated through the APA Ethics Code Task Force, and they will include a formal decision- making tree. Roberts and Termuehlen (2021) identified six core skills that are used by mental health professionals, which affect their ability to recognize and manage ethical issues: 1. The ability to identify ethical issues as they arise. This is intuitive for some, a feeling or sense that something is not right, and for others it is a more logical analysis. 2. The ability to understand how one’s own values and beliefs impact their care of patients. This includes implicit bias, the understanding of how one’s attitudes and social stereotypes affect access to health care and equity in quality. Implicit bias can adversely affect quality, safety outcomes, and health system policies. 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. ● 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.
DECISION-MAKING MODELS
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.
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Book Code: PYTX1325
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