Essential ethics for psychologists nagy pdf

3

49

The General Ethical Principles of Psychologists

Dr. Johnson was invited by a television journalist to participate in a documentary on eating disorders in women, an area in which he had recently published a book for the general public. The journalist also requested that he bring one of his current patients who was willing to describe the ups and downs of treatment and how she had improved over time. The journalist’s motive was to dispel the stigma attached to eating disorders and provide hope to the thousands in the television audience with a similar problem.

Dr. Johnson was deliberate in his response. He considered the issues of patient privacy, exploitation, coercion (could she easily decline her therapist’s request?), informed consent, and the ultimate impact on treatment. He then discussed the matter with a senior clinician, who advised against it, stating that inviting a patient to participate in a media event creates a multiple-role relationship: (a) current psychotherapy patient and (b) copresenter with Dr. Johnson describing treatment successes. Dr. Johnson decided to accept the journalist’s invitation to discuss his treatment of eating disorders but declined, on ethical grounds, to bring a patient. The journalist was disappointed but understood his rationale and proceeded with the interview.

http://dx.doi.org/10.1037/12345-003 Essential Ethics for Psychologists: A Primer for Understanding and Mastering Core Issues, by T. F. Nagy Copyright © 2011 American Psychological Association. All rights reserved.

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

Introduction

This chapter focuses on the general principles of psychologists, ethical topics that have been a part of the Ethics Code in one form or another since it was first published in 1953. “The Ethical Principles of Psychologists and Code of Conduct” (American Psychological Association [APA], 2010) consists of two sections: General Principles and Ethical Standards. The general principles may be compared to the prologue of a play, reviewing the general themes, whereas the ethical standards constitute the play itself in all of its rich detail. They consist of five broad concepts, undergirding the ethical standards: (a) Beneficence and Nonmaleficence, (b) Fidelity and Responsibility, (c) Integrity, (d) Justice, and (e) Respect for People’s Rights and Dignity. The selection of these five principles reflects in part the work of Karen Kitchener, who served on the original 1986 task force that produced the 1992 revision (Kitchener, 1984).1

As noted in Chapter 2 of this volume, the purpose of the general principles, as originally conceived by the Ethics Code Task Force in 1992, was twofold: (a) to identify the general ethical concepts that form the philosophical foundation of all the ethical standards, or rules, of the Ethics Code of psychologists; and (b) to physically separate them from the rest of the Code so that there would be no question about which sections were aspirational and which parts required mandatory compli- ance (Nagy, 1992).

The general principles are voluntary in nature; that is, psychologists should ideally set their sights on these as guidelines while serving in their professional roles, but they are far too general to require compli- ance. The ethical standards, on the other hand, constitute the specific rules of conduct for all psychologists who are functioning in a variety of professional roles. The general principles could be thought of as “what psychologists believe,” whereas the ethical standards could be thought of as “what psychologists must do.” It is important to note that under- standing the values and goals outlined in the general principles provides the contextual keys to unlocking the meaning and rationale for each ethical standard.

In this chapter, I first discuss the importance of using general prin- ciples to resolve possible conflicts between ethical standards. Then, I describe each of the general principles in depth.

50 E S S E N T I A L E T H I C S F O R P S Y C H O L O G I S T S

1Following the work of Beauchamp and Childress (1979), Kitchener suggested that autonomy, beneficence, nonmaleficence, fidelity, and justice constitute the general concepts on which psychologists should base ethical decision making at the evaluative level.

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

Using General Principles to Resolve Conflicting Ethical Standards

A common problem for psychologists attempting to comply with the many ethical standards is encountering rules that seem to contradict each other. Occasionally ethical rules do conflict, creating a dilemma for the psychologist attempting to apply them in real-life situations. For example, psychologists are obligated to respect the autonomy of clients and at the same time protect them from harm. In the following two scenarios this causes a dilemma for the therapist.

A 56-year-old commercial airline pilot with chronic neck pain continues to fly even though his pain medication clouds his judgment and makes him sleepy. He has not informed his employer or copilots of his medical problem but has told his psychotherapist. He refuses to acknowledge that continuing to fly may well endanger the lives of others.

A psychotherapist makes a decision to break confidentiality to preserve the safety of his patient. The psychotherapist contacts the police to hospitalize a physically healthy patient with major depression who has just revealed his serious intention and detailed plan to drive his car over a cliff at midnight tonight.

Are there potential conflicts among the ethical standards, and if so, how are psychologists to understand and balance the values and protec- tions inherent in them? The suicidal patient may feel that his privacy is being violated by the disclosure of his intent to kill himself to the police or the psychiatric emergency team. He may also feel that he is being harmed by having his freedom restricted by involuntary hospitalization, even though the intent of the psychologist was to preserve his life. The resolu- tion of conflicting ethical standards is not always as immediately apparent as in this example. However, conflicts can frequently be resolved by focus- ing on the concept of the greater good, either to the individual or to society.

In the case of the suicidal patient, it is clearly more urgent to take steps that would prevent an imminent suicide than it is to protect patient confidentiality in psychotherapy, despite the patient’s right to privacy and autonomous decision making. The first case is more complex, however, because it involves a psychologist’s duty or right to break confidentiality when his or her patient’s conduct is likely to endanger others and involves legal statutes and contractual issues as well. This becomes more apparent in later chapters, as I focus on the specific ethical standards and how they complement or, at times, contradict each other.

Psychologists rely heavily on the Ethical Standards section of the APA Ethics Code because it articulates the actual rules that they must

51General Ethical Principles of Psychologists

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

follow. These are divided into 10 sections: (a) Resolving Ethical Issues, (b) Competence, (c) Human Relations, (d) Privacy and Confidential- ity, (e) Advertising and Other Public Statements, (f) Record Keeping and Fees, (g) Education and Training, (h) Research and Publication, (i) Assess- ment, and (j) Therapy. Each section consists of the specific “musts” and “must nots” that direct psychologists in carrying out their work. Although this section of the document is titled Ethical Standards, it is something of a misnomer, and it should be thought of instead as a code of conduct. The actual rules that make up this section are directives, such as documenting clinical work, cooperating with an ethics committee investigation, or maintaining patient confidentiality. They are not true ethical concepts as psychologists have come to think of them, however, such as integrity, justice, or respect for people’s rights and dignity. Those are within the realm of the general principles and, as mentioned, pro- vide the general context and guidance for the code of conduct. Thus, the general principles are a means of assisting in ethical decision making and serve as general guidelines in the face of conflicting ethical standards.

Although some psychologists may not be aware of this, when joining the APA they immediately become duty bound to comply with every ethical standard and are so notified on their annual billing statement. Furthermore, well over half of the states have incorporated the APA Ethics Code in the body of their mental health code or practice rules and regulations, requiring every licensed psychologist to abide by them, whether or not they are members of the APA. I now examine the general principles and how they orient psychologists to the overall topics that are so important in the profession of psychology.

General Ethical Principles of Psychologists

The ethical standards might be thought of as the “floor” in the house of ethics, stating the minimal standards of compliance, whereas the general principles can be seen as the “ceiling.” In the general principles that follow, it is interesting to note the nature of the language used, which asks psychologists to “exercise reasonable judgment,” “take care,” be “concerned,” and be “alert to,” words and phrases that rarely appear in the ethical standards themselves.

PRINCIPLE A: BENEFICENCE AND NONMALEFICENCE

Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they

52 E S S E N T I A L E T H I C S F O R P S Y C H O L O G I S T S

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

interact professionally and other affected persons, and the welfare of animal subjects of research. When conflicts occur among psychologists’ obligations or concerns, they attempt to resolve these conflicts in a responsible fashion that avoids or minimizes harm. Because psychologists’ scientific and professional judgments and actions may affect the lives of others, they are alert to and guard against personal, financial, social, organizational, or political factors that might lead to misuse of their influence. Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work. (APA, 2010)

The first general principle, Beneficence and Nonmaleficence, has long been a tenet of ethical codes in the helping professions. Loosely translated from Latin, beneficence means helping or assisting from the Latin bene, meaning well or favorably, and facere, to make or do—literally, to do good. Nonmaleficence means avoiding harming others in the course of carrying out one’s professional work from the Latin non, meaning not, and male, meaning badly or ill. Beginning with the Hippocratic oath in the 4th century BCE, health care practitioners have been attempting to balance competing demands in helping their patients and clients and avoiding harming them.

An example is training a psychotherapist to competently establish a working alliance with a patient while at the same time prohibiting a friendship or romantic relationship from developing, lest the psycholo- gist lose his or her objectivity and, ultimately, his or her competence. In this case, it is important for the therapist to always balance the personal relationship with the professional one. This is an ongoing part of clinical work that could be said to form the essence of the artistry and science of psychotherapy. Or consider the supervisor who must balance train- ing his or her supervisee with the welfare of the client being treated in psychotherapy. In some cases the patient might be better served by con- sulting a more experienced therapist, but with competent supervision of the training therapist, the treatment will likely progress satisfactorily. However, if the supervisor is lax in his or her duties, then both the train- ing therapist and the client could be harmed.

Psychologists are supposed to be aware of personal, financial, social, organizational, or political factors that might lead to misusing their power or influence. In most professional settings there is a power differential— those on the receiving end are clients, patients, supervisees, students, or research participants, to name a few. Psychologists may, at times, be tempted to use their power or authority unfairly under the guise of helping or training, for example.

Returning to the vignette at the start of this chapter, the inherent power differential in the therapist–patient relationship could result in the psychologist easily persuading a current patient with an eating dis- order to appear on a television talk show. However, he may be unfairly leveraging his authority if he makes no attempt to disguise her identity

53General Ethical Principles of Psychologists

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

or discuss the potential risks of such an appearance at the outset. These risks might include such things as feeling pressure to perform in front of the camera; losing her anonymity and exposing her private thoughts to family members, neighbors, friends, and coworkers who might be watching; and experiencing a change in the relationship with her therapist that lasts long after the on-camera interview, perhaps permanently changing the therapy dynamics. However, the patient may feel she has little choice in the matter if her therapist asks her to “volunteer” to participate in the broadcast. Although the apparent motive might be to educate the public about this difficult disorder, the psychologist’s additional motive might also be to promote his own clinical practice, thereby obtaining free publicity for his eating disor- ders practice.

Psychologists are also supposed to be mindful of problems with their own physical and mental health and how their problems could impact others. It is useful to consider the therapist with chronic back pain necessitating medication that tends to dull the person’s awareness. How effective will the therapist be in carrying out diagnostic testing or listening carefully to the more challenging therapy client, such as a divorced father with major depression who is having difficulty parenting his autistic child? Psychologists are subject to the same human frailties as anyone else. The competence of an otherwise excellent supervisor, teacher, or therapist could be significantly affected by a chronic medical condition, medication, sleep deprivation, or major life stress, such as the death of a family mem- ber, divorce, or financial adversity. Therapist competence and personal impairment are discussed more fully in Chapter 4 of this volume.

PRINCIPLE B: FIDELITY AND RESPONSIBILITY

Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior, and seek to manage conflicts of interest that could lead to exploitation or harm. Psychologists consult with, refer to, or cooperate with other professionals and institutions to the extent needed to serve the best interests of those with whom they work. They are concerned about the ethical compliance of their colleagues’ scientific and professional conduct. Psychologists strive to contribute a portion of their professional time for little or no compensation or personal advantage. (APA, 2010)

The second general principle, Fidelity and Responsibility, consists of two concepts. Fidelity, from the Latin fidelis, meaning faithful, refers to the trust and commitment that psychologists hold toward those with

54 E S S E N T I A L E T H I C S F O R P S Y C H O L O G I S T S

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

whom they work. It may also refer to how faithfully psychologists trans- late the ethical principles into their every day professional conduct as therapists, teachers, and researchers. The concept of responsibility, from the Latin respondere, meaning to answer, refers to individual accounta- bility on the part of psychologists. Psychologists must ultimately answer for the consequences of their actions in the various roles they play with consumers, students, and supervisees.

Fidelity and responsibility may also include the notion of informed consent. This has long been an important concept for psychologists, requiring them to explain in advance to clients, patients, and other recipients of their services how they intend to intervene in their lives. Those who are about to consult a psychologist for the first time generally have a minimal concept of what to expect concerning such basics as fees, an approximate duration of treatment, and theoretical orientation, and they would welcome some clarification and information.

Psychologists consulting with school systems or business entities are also expected to provide some manner of informed consent about their intended services. They are responsible for making good on their word, that is, for carrying through on commitments, usually spelled out in a letter of agreement or contract, explaining the nature of the fiduciary relationship.

Also included in Fidelity and Responsibility is managing conflicts of interest, lest individuals, groups, or society be harmed by psychologists’ actions or failure to act. It is useful to consider the situation in which a man experiencing depression and rage because he has recently lost his job confides to his therapist that he has an impulse to get revenge on his former boss by murdering him. Must the therapist protect the client in treatment and shield him from any consequences of revealing his dis- closures to a third party such as the police or the intended victim? Or does the psychologist owe a duty to society when such destructive intentions are revealed, and should the psychologist take some action that would risk ending the therapeutic relationship and potentially harming the patient? This kind of conflict of interest is regulated by law in many states, and therapists have specific rules, which they must follow to resolve such a conflict. This is further examined in Chapter 6.

Other conflicts may be less clear. It is useful to consider the marital therapist who is treating a real estate agent and her husband and is also in the market for a new house. By relying on the wife’s occasional input and assistance in the local realty market, the therapist may be tempted to form an alliance with her that might decrease his objectivity with this couple and make him less able to accept the husband’s point of view in the therapy sessions. Clearly the husband could feel harmed in this instance by being in a “one-down” situation.

This general principle also advises therapists to serve the best interests of others and be ready to refer them to other professionals and

55General Ethical Principles of Psychologists

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

institutions as needed. This includes other health care professionals (e.g., psychopharmacologist, neuropsychological examiner) or other resources (e.g., group therapy, Alcoholics Anonymous) as needed.

Part of serving the best interests of others involves monitoring one’s professional colleagues’ adherence to high ethical standards. In this sense, psychologists are “their brother’s keepers” and should make an attempt to address ethical infractions by others, either by directly contacting the psychologist or possibly by some other means. Choosing the right intervention, particularly with a colleague who may be unapproachable, feel threatened, be self-righteous, or be adversarial, may be particularly challenging. Yet failing to take any action would likely not be in keeping with the spirit of this principle and might result in harm to patients and clients later on. If Dr. Green discovered that a colleague was going online to a social networking site and revealing some details of his successful therapy experiences with certain clients, then Dr. Green should tell him about the significance of these potential breaches in confidentiality and potential harm to those clients.

Finally, serving the best interests of clients might at times include offering services to consumers at no cost. Although this is not an absolute requirement (true of all these general principles), it is recommended that in certain situations psychologists offer their professional contribution without regard to fee or personal compensation. This is of great potential benefit to financially disadvantaged clients and patients, schools with less financial resources, nonprofit organizations, and other entities that could benefit from psychological services but do not have the ready means to pay for them.

PRINCIPLE C: INTEGRITY

Psychologists seek to promote accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology. In these activities psychologists do not steal, cheat, or engage in fraud, subterfuge, or intentional misrepresentation of fact. Psychologists strive to keep their promises and to avoid unwise or unclear commitments. In situations in which deception may be ethically justifiable to maximize benefits and minimize harm, psychologists have a serious obligation to consider the need for, the possible consequences of, and their responsibility to correct any resulting mistrust or other harmful effects that arise from the use of such techniques. (APA, 2010)

Integrity is defined as “the quality of being honest and morally upright” (Compact Oxford English Dictionary, 2009). It is derived from the Latin integritas, meaning soundness, purity, honesty, or innocence. The original Ethical Standards of Psychologists published in 1953 contained a standard that included some of these concepts; it was titled Moral and Legal Standards, and it emphasized psychologists’ adherence to “the social codes and

56 E S S E N T I A L E T H I C S F O R P S Y C H O L O G I S T S

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

moral expectations of the community in which he works” (APA, 1953a). It warned psychologists that failure to do so could “involve his clients, students, or colleagues in damaging personal conflicts” that might “impugn his own name and the reputation of his profession.” It is inter- esting that the word moral can no longer be found in the 2002 psychology Ethics Code.

As this principle elaborates, the concept of integrity includes pro- moting accuracy, honesty, and truthfulness in every psychological role, whether in the area of teaching, carrying out research, or applied psychol- ogy (e.g., assessment, psychotherapy, management consulting). Practicing with integrity means avoiding deceiving others or misrepresenting facts that psychologists are aware of or should be aware of in the course of carrying out their duties. This principle also prohibits subterfuge, such as deliberately using deception to achieve a private goal. It is useful to consider the psychologist who bills a patient’s insurance company for a psychotherapy session that did not happen (the patient forgot), claiming that it occurred. He might feel entitled to extra payment because there had been many telephone calls from the patient between office visits that did not qualify for reimbursement. However, this general ethical princi- ple would prohibit such a fraudulent practice because the psychologist deliberately misstates the facts, which is unethical to be sure, and this case also constitutes insurance fraud, which is illegal.

In some cases, a breach of the principle of integrity might result in harming others. An example is the researcher who at the outset with- holds information from prospective participants in a research study. The protocol may involve experiences that could provoke feelings of anxiety or anger, such as viewing graphic or violent images, with a hypothesis regarding the impact of limbic system arousal on memory and cognitive functioning. However, the investigator might neglect to include a statement in the informed consent document describing the possible range of visual stimuli to which participants would be exposed or the possible emotional reactions that might be elicited, fearing that such information might discourage people from volunteering. The possibility of harm from this deliberate deception would increase if a participant happened to have a preexisting mood disorder, a history of childhood abuse, or some other traumatic experience (e.g., experience as a soldier who fought in a war) that could elicit panicky feelings or dissociative reactions during the exposure to such powerful visual stimuli. Investi- gators have an obligation to provide accurate informed consent at the outset of psychological research, and to deliberately omit or misrepresent facts that would make a difference to one’s decision to participate is in violation of the spirit of this ethical principle. Research conducted in universities, hospitals, and other institutional settings usually afford pro- tections against these abuses by requiring approval of research protocols by the institutional review board.

57General Ethical Principles of Psychologists

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

Psychologists must also keep their promises and avoid commitments that are unwise or vague in nature. If a psychotherapist working in a group practice agrees to be on call for a particular weekend, the psychol- ogist has a fiduciary responsibility to both his or her colleagues in the practice and the needy clients and patients who might require services on that particular weekend. The psychologist must honor this obliga- tion or delegate the responsibility to another once he or she has made the commitment. An example of an unclear commitment follows.

A psychologist who also happens to be a Catholic priest has agreed to see a member of his congregation who has admitted to molesting a 9-year-old child over the past few years. He reassures the man that he will consult with him in confidence and that a religious approach to pederasty offers the highest chances of success.

It is also clear, however, that as a licensed psychologist he is required by state law to notify the child protective services of the county in which he practices within 24 hr of learning that his patient has sexually molested a child.

It may be unclear whether he is planning to work with the man as his priest, who has learned of the molestation in the confessional, or as his psychologist, who learned of it in the consulting office. In any case, vague or unclear reassurances at the outset, particularly if the man relapses into old patterns of child sexual assault, are not helpful to the client, his future victims, or ultimately, the priest-psychologist himself. Fully clarifying one’s role at the beginning of treatment, including confidentiality and its exceptions, is essential in maintaining clear commitments.

The principle of integrity also addresses situations in which it is eth- ically justifiable to use deception to maximize benefits and minimize harm. For example, a psychologist may wish to preserve the naiveté of research participants to maximize the robustness of research findings. This is done by deceiving research participants about the research hypothesis being tested while providing informed consent, lest they consciously or unconsciously provide biased responses in their role as subjects. An example is informing participants that the purpose of an investigation is to measure the effects of fatigue on short-term memory and varying the amount of sleep they are allowed to have the night before. However, the research might actually be assessing how social pressure by an authority figure impacts on decision making. It could employ the services of a confederate research assistant (an actor) who administers the test items and then behaves differently with different subjects, according to the protocol, to influence their responses to test items. The research participants would thus remain naive until the end of the data gathering and be debriefed at that point.