Fisher decoding the ethics code

CHAPTER 3

The APA Ethics Code and

Ethical Decision Making

The APA’s Ethics Code provides a set of aspirational principles and

behavioral rules written broadly to apply to psychologists’ varied roles

and the diverse contexts in which the science and practice of psychology

are conducted. The five aspirational principles described in Chapter 2

represent the core values of the discipline of psychology that guide members in

recognizing in broad terms the moral rightness or wrongness of an act. As an

articulation of the universal moral values intrinsic to the discipline, the aspirational

principles are intended to inspire right action but do not specify what

those actions might be. The ethical standards that will be discussed in later

chapters of this book are concerned with specific behaviors that reflect the

application of these moral principles to the work of psychologists in specific

settings and with specific populations. In their everyday activities, psychologists

will find many instances in which familiarity with and adherence to specific

Ethical Standards provide adequate foundation for ethical actions. There

will also be many instances in which (a) the means by which to comply with a

standard are not readily apparent, (b) two seemingly competing standards

appear equally appropriate, (c) application of a single standard or set of standards

appears consistent with one aspirational principle but inconsistent with

another, or (d) a judgment is required to determine if exemption criteria for a

particular standard are met.

The Ethics Code is not a formula for solving these ethical challenges. The

Ethics Code provides psychologists with a set of aspirations and broad general

rules of conduct that must be interpreted and applied as a function of the unique

scientific and professional roles and relationships in which they are embedded.

Psychologists are not moral technocrats simply working their way through a

maze of ethical rules. Successful application of the principles and standards of the

Ethics Code involves a conception of psychologists as active moral agents committed

to the good and just practice and science of psychology. Ethical decision

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30——PART I INTRODUCTION AND BACKGROUND

making thus involves a commitment to applying the Ethics Code to construct

rather than simply discover solutions to ethical quandaries.

This chapter discusses the ethical attitudes and decision-making strategies that can

help psychologists prepare for, identify, and resolve ethical challenges as they continuously

emerge and evolve in the dynamic discipline of psychology. An opportunity to

apply these strategies is provided in the 10 case studies presented in Appendix B.

Ethical Commitment and Virtues

The development of a dynamic set of ethical standards for psychologists’

work-related conduct requires a personal commitment and lifelong effort to

act ethically; to encourage ethical behavior by students, supervisees, employees,

and colleagues; and to consult with others concerning ethical problems.

—APA (2010c, Preamble)

Ethical commitment refers to a strong desire to do what is right because it is right

(Josephson Institute of Ethics, 1999). In psychology, this commitment reflects a

moral disposition and emotional responsiveness that move psychologists to creatively

apply the APA’s Ethics Code principles and standards to the unique ethical

demands of the scientific or professional context.

The desire to do the right thing has often been associated with moral virtues or

moral character, defined as a disposition to act and feel in accordance with moral

principles, obligations, and ideals—a disposition that is neither principle bound

nor situation specific (Beauchamp & Childress, 2001; MacIntyre, 1984). Virtues are

dispositional habits acquired through social nurturance and professional education

that provide psychologists with the motivation and skills necessary to apply the

ideals and standards of the profession (see, e.g., Hauerwas, 1981; Jordan & Meara,

1990; May, 1984; National Academy of Sciences, 1995; Pellegrino, 1995). Fowers

(2012) describes virtues as the cognitive, emotional, dispositional, behavioral, and

wisdom aspects of character strength that motivates and enables us to act ethically

out of an attachment to what is good.

Focal Virtues for Psychology

Many moral dispositions have been proposed for the virtuous professional

(Beauchamp & Childress, 2001; Keenan, 1995; MacIntyre, 1984; May, 1984). For

disciplines such as psychology, in which codes of conduct dictate the general

parameters but not the context-specific nature of ethical conduct, conscientiousness,

discernment, and prudence are requisite virtues.

A conscientious psychologist is motivated to do what is right because it is right,

diligently tries to determine what is right, and makes reasonable attempts to

do the right thing.

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Chapter 3 The APA Ethics Code and Ethical Decision Making——31

A discerning psychologist brings contextually and relationally sensitive

insight, good judgment, and appropriately detached understanding to determine

what is right.

A prudent psychologist applies practical wisdom to ethical challenges leading

to right solutions that can be realized given the nature of the problem and the

individuals involved.

Some moral dispositions can be understood as derivative of their corresponding

principles (Beauchamp & Childress, 2001). Drawing on the five APA General

Principles, Table 3.1 lists corresponding virtues.

The virtues considered most salient by members of a profession will vary

with differences in role responsibilities. Benevolence, care, and compassion are

often associated with the provision of mental health services. Prudence, discretion,

and trustworthiness have been considered salient in scientific decision

making. Scientists who willingly and consistently report procedures and findings

accurately are enacting the virtue of honesty (Fowers, 2012). Fidelity,

integrity, and wisdom are moral characteristics frequently associated with

teaching and consultation. Across all work activities the virtue of “self-care”

enables psychologists to maintain appropriate competencies under stressful

work conditions (see the Hot Topic “The Ethical Component of Self-Care” at

the end of this chapter.

“Openness to the other” has been identified as a core virtue for the practice of

multiculturalism (Fowers & Davidov, 2006). Openness is characterized by a personal

and professional commitment to applying a multicultural lens to our work

motivated by a genuine interest in understanding others rather than reacting to a

new wave of multicultural “shoulds” (Gallardo, Johnson, Parham, & Carter,

2009). It reflects a strong desire to understand how culture is relevant to the identification

and resolution of ethical challenges in research and practice, to explore

cultural differences, to respond to fluid definitions of group characteristics, to

recognize the realities of institutional racism and other forms of discrimination

on personal identity and life opportunities, and to creatively apply the profession’s

APA General Principles Corresponding Virtues

Principle A: Beneficence and

Nonmaleficence

Compassionate, humane, nonmalevolent, and

prudent

Principle B: Fidelity and Responsibility Faithful, dependable, and conscientious

Principle C: Integrity Honest, reliable, and genuine

Principle D: Justice Judicious and fair

Principle E: Respect for People’s Rights

and Dignity

Respectful and considerate

Table 3.1 APA Ethics Code General Principles and Corresponding Virtues

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32——PART I INTRODUCTION AND BACKGROUND

ethical principles and standards to each cultural context (Aronson, 2006; Fisher,

in press; Fowers & Davidov, 2006; Hamilton & Mahalik, 2009; Neumark, 2009;

Riggle, Rostosky, & Horne, 2010; D. W. Sue & Sue, 2003; Trimble, 2009; Trimble &

Fisher, 2006).

Can Virtues Be Taught?

No course could automatically close the gap between knowing what is

right and doing it.

—Pellegrino (1989, p. 492)

Some have argued that psychology professors cannot change graduate students’

moral character through classroom teaching, and therefore ethics education should

focus on understanding the Ethics Code rather than instilling moral dispositions to

right action. Without question, however, senior members of the discipline, through

teaching and through their own examples, can enhance the ability of students and

young professionals to understand the centrality of ethical commitment to ethical

practice. At the same time, the development of professional moral character is not to

simply know about virtue but to become good (P. A. Scott, 2003). Beyond the intellectual

virtues transmitted in the classroom and modeled through mentoring and

supervision, excellence of character can be acquired through habitual practice

(Begley, 2006). One such habit is that the virtuous graduate student and seasoned

psychologist are committed to lifelong learning and practice in the continued development

of moral excellence.

Ethical Awareness and Moral Principles

In the process of making decisions regarding their professional behavior,

psychologists must consider this Ethics Code, in addition to applicable

laws and psychology board regulations.

—APA (2010c, Introduction)

Lack of awareness or misunderstanding of an ethical standard is not itself

a defense to a charge of unethical conduct.

—APA (2010c, Introduction)

Ethical commitment is just the first step in effective ethical decision making. Good

intentions are insufficient if psychologists fail to identify the ethical situations to

which they should be applied. Psychologists found to have violated Ethical Standards

or licensure regulations have too often harmed others or damaged their own careers

or the careers of others because of ethical ignorance. Conscientious psychologists

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Chapter 3 The APA Ethics Code and Ethical Decision Making——33

understand that identification of situations requiring ethical attention depends on

familiarity and understanding of the APA Ethics Code, relevant scientific and professional

guidelines, laws and regulations applicable to their specific work-related

activities, and an awareness of relational obligations embedded within each context.

Moral Principles and Ethical Awareness

To identify a situation as warranting ethical consideration, psychologists must

be aware of the moral values of the discipline. Although the Ethics Code’s General

Principles are not exhaustive, they do identify the major moral ideals of psychology

as a field. Familiarity with the General Principles, however, is not sufficient for good

ethical decision making. Psychologists also need the knowledge, motivation, and

coping skills to detect when situations call for consideration of these principles and

attempt to address these issues when and if possible before they arise (Crowley &

Gottlieb, 2012; Tjeltveit & Gottlieb, 2010; see also the Hot Topic “The Ethical

Component of Self Care” at the end of this chapter). Table 3.2 identifies types of

ethical awareness corresponding to each General Principle.

APA General

Principles Corresponding Ethical Awareness

Principle A:

Beneficence and

Nonmaleficence

Psychologists should be able to identify what is in the best interests of

those with whom they work, when a situation threatens the welfare of

individuals, and the competencies required to achieve the greatest

good and avoid or minimize harm.

Principle B: Fidelity

and Responsibility

Psychologists should be aware of their obligations to the individuals

and communities affected by their work, including their responsibilities

to the profession and obligations under the law.

Principle C: Integrity Psychologists should know what is possible before making professional

commitments and be able to identify when it is necessary to correct

misconceptions or mistrust.

Principle D: Justice Psychologists should be able to identify individual or group

vulnerabilities that can lead to exploitation and recognize when a

course of action would result in or has resulted in unfair or unjust

practices.

Principle E: Respect

for People’s Rights

and Dignity

Psychologists must be aware of special safeguards necessary to protect

the autonomy, privacy, and dignity of members from the diverse

populations with whom psychologists work.

Table 3.2 APA Ethics Code General Principles and the Ethical Awareness Necessary to Apply

the Principles

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34——PART I INTRODUCTION AND BACKGROUND

Ethical Awareness and Ethical Theories

Ethical theories provide a moral framework to reflect on conflicting obligations.

Unfortunately, ethical theories tend to emphasize one idea as the foundation for

moral decision making, and illustrative problems are often reduced to that one idea.

Given the complexity of moral reality, these frameworks are probably not mutually

exclusive in their claims to moral truth (Steinbock, Arras, & London, 2003).

However, awareness of the moral frameworks that might help address an ethical

concern can also help clarify the values and available ethical choices (Beauchamp &

Childress, 2001; Fisher, 1999; Kitchener, 1984).

Deception Research: A Case Example for the

Application of Different Ethical Theories

Since Stanley Milgram (1963) published his well-known obedience experiments,

the use of deception has become normative practice in some fields of psychological

research and a frequent source of ethical debate (Baumrind, 1964, 1985; Fisher &

Fyrberg, 1994). Deceptive techniques in research intentionally withhold information

or misinform participants about the purpose of the study, the methodology, or roles

of research confederates (Sieber, 1982). The methodological rationale for the use of

deception is that some psychological phenomena cannot be adequately understood if

research participants are aware of the purpose of the study. For example, deception has

been used to study the phenomenon of “bystander apathy effect,” the tendency for

people in the presence of others to observe but not help a person who is a victim of an

attack, medical emergency, or other dangerous condition (Latane & Darley, 1970). In

such experiments, false emergency situations are staged without the knowledge of the

research participants, whose reactions to the “emergency” are recorded and analyzed.

By its very nature, the use of deception in research creates what Fisher (2005a)

has termed the consent paradox. On the one hand intentionally deceiving participants

about the nature and purpose of a study conflicts with Principle C: Integrity

and with enforceable standards requiring psychologists to obtain fully informed

consent of research participants prior to study initiation. On the other hand by

approximating naturalistic contexts in which everyday behaviors take place, the use

of deception research can reflect Principle A: Beneficence and Nonmaleficence by

enhancing the ability of psychologists to generate scientifically and socially useful

knowledge that might not otherwise be obtained.

Below are examples of how different ethical theories might lead to different conclusions

about the moral acceptability of deception research. Readers should refer to

Chapter 11 for a more in-depth discussion of Standard 8.07, Deception in Research.

Deontology

Deontology has been described as “absolutist,” “universal,” and “impersonal”

(Kant, 1785/1959). It prioritizes absolute obligations over consequences. In this

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Chapter 3 The APA Ethics Code and Ethical Decision Making——35

moral framework, ethical decision making is the rational act of applying universal

principles to all situations irrespective of specific relationships, contexts, or consequences.

This reflects Immanuel Kant’s conviction that ethical decisions cannot vary

or be influenced by special circumstances or relationships. Rather, a decision is

“moral” only if a rational person believes the act resulting from the decision should

be universally followed in all situations. For Kant, respect for the worth of all persons

was one such universal principle. A course of action that results in a person being

used simply as a means for others’ gains would be ethically unacceptable.

With respect to deception in research, from a deontological perspective, since we

would not believe it moral to intentionally deceive individuals in some other context,

neither potential benefits to society nor the effectiveness of participant

debriefing for a particular deception study can morally justify intentionally deceiving

persons about the purpose or nature of a research study. Further, deception in

research would not be ethically permissible since intentionally disguising the nature

of the study for the goals of research violates the moral obligation to respect each

participant’s intrinsic worth by undermining individuals’ right to make rational

and autonomous decisions regarding participation (Fisher & Fyrberg, 1994).

Utilitarianism

Utilitarian theory prioritizes the consequences (or utility) of an act over the

application of universal principles (Mill, 1861/1957). From this perspective, an ethical

decision is situation specific and must be governed by a risk–benefit calculus that

determines which act will produce the greatest possible balance of good over bad

consequences. An “act utilitarian” makes an ethical decision by evaluating the consequences

of an act for a given situation. A “rule utilitarian” makes an ethical decision

by evaluating whether following a general rule in all similar situations would

create the greater good. Like deontology, utilitarianism is impersonal: It does not

take into account interpersonal and relational features of ethical responsibility. From

this perspective, psychologists’ obligations to those with whom they work can be

superseded by an action that would produce a greater good for others (Fisher, 1999).

A psychologist adhering to act utilitarianism might decide that the potential

knowledge about social behavior generated by a specific deception study could

produce benefits for many members of society, thereby justifying the minimal risk

of harm and violation of autonomy rights for a few research participants. A rule

utilitarian might decide against the use of deception in all research studies because

the unknown benefits to society did not outweigh the potential harm to the discipline

of psychology if society began to see it as an untrustworthy science.

Communitarianism

Communitarian theory assumes that right actions derive from community

values, goals, traditions, and cooperative virtues. Accordingly, different populations

with whom a psychologist works may require different conceptualizations of

what is ethically appropriate (MacIntyre, 1989; Walzer, 1983). Unlike deontology,

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36——PART I INTRODUCTION AND BACKGROUND

communitarianism rejects the elevation of individual over group rights. Whereas

utilitarianism asks whether a policy will produce the greatest good for all individuals

in society, communitarianism asks whether a policy will promote the kind

of community we want to live in (Steinbock et al., 2003).

Scientists as members of a community of shared values have traditionally

assumed that (a) the pursuit of knowledge is a universal good and that (b) consideration

for the practical consequences of research will inhibit scientific progress

(Fisher, 1999; Sarason, 1984; Scarr, 1988). From this “community of scientists”

perspective, the results of deception research are intrinsically valuable, and standards

or regulations prohibiting deceptive research would deprive society of this

knowledge. Thus, communitarian theory may be implicitly reflected, at least in

part, in the acceptance of deception research in the APA Ethics Code (Standard 8.07,

Deception in Research) and in current federal regulations (Department of Health

and Human Services [DHHS], 2009) as representing the values of the scientific

community. At the same time little is known about the extent to which the “community

of research participants” shares the scientific community’s valuing of

deception methods (Fisher & Fyrberg, 1994).

Feminist Ethics

Feminist ethics, or an ethics of care, sees emotional commitment to act on behalf

of persons with whom one has a significant relationship as central to ethical decision

making. This moral theory rejects the primacy of universal and individual rights in

favor of relationally specific obligations (Baier, 1985; Brabeck, 2000; Fisher, 2000;

Gilligan, 1982). Feminist ethics also focuses our attention on power imbalances and

supports efforts to promote equality of power and opportunity. In evaluating the

ethics of deception research, feminist psychologists might view intentional deception

as a violation of interpersonal obligations of trust by investigators to participants

and as reinforcing power inequities by permitting psychologists to deprive

persons of information that might affect their decision to participate.

Ethical Absolutism, Ethical Relativism,

and Ethical Multiculturalism

The movement known as multiculturalism is reshaping moral dialogue in psychology

through its emphasis on inclusion, social justice, and mutual respect (Fowers &

Davidov, 2006).

Psychologists with high levels of ethical commitment and awareness are often

stymied by moral complexities that surface when psychological activities are conducted

in diverse contexts, cultures, or communities. For example, when applied to

ethical decision making across different contexts, the universal perspective of the

deontic position is indifferent to particular persons and situations. It therefore

rejects the influence of culture on the identification and resolution of ethical problems

in a manner that can lead to a one-size-fits-all form of ethical problem solving

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Chapter 3 The APA Ethics Code and Ethical Decision Making——37

(Fisher, 1999). In sharp contrast, ethical relativism, often associated with some

forms of utilitarianism and communitarianism, denies the existence of universal or

common moral values characterizing the whole of human relationships, proposing

instead that the identification and resolution of ethical problems are unique to each

particular culture or community.

Ethical contextualism (Fisher, 1999, 2000, in press; Macklin, 1999) blends the two

approaches assuming that moral principles such as beneficence and respect for

autonomy are universally valued across diverse contexts and cultures, but the expression

of an ethical problem and the right actions to resolve it can be unique to the

cultural context. From this perspective, universal moral principles can mediate our

understanding of ethical meaning across diverse contexts without placing a priority

on the principles themselves over the moral frameworks of others (Walker, 1992).

Culture and Informed Consent: A Case Example

Take the example of the ethical challenge of obtaining informed consent for

mental health treatment for women suffering from posttraumatic stress disorder

(PTSD) in war-torn countries where cultural mores require that permission is

obtained from fathers, husbands, or brothers before a practitioner can offer services

to women.

A psychologist who is an ethical absolutist might refuse to obtain permission from

a male relative prior to obtaining consent from a female living in this culture on the

grounds that any action that privileges the opinion of a third party in a treatment or

research decision is a violation of a universal principle of respect for individual

autonomy. The cultural relativist, on the other hand, might interpret the cultural

mores dictating male privilege as evidence that respect for individual autonomy is not

a moral value in this particular culture; consequently, any action consistent with the

cultural norm (e.g., obtaining the male relative’s permission) is ethical.

The ethical contextualist would see the problem as one that requires consideration

of both a universal valuing of individual autonomy and its traditional expression

within this particular culture. A psychologist adopting this position would

seek to resolve the ethical problem in a manner consistent with both. For example,

examining the cultural meaning of this tradition, a psychologist might find that

women in this culture value the male gatekeeper role and see it as beneficial to

themselves and/or the stability of their families and communities. In this scenario,

principles of justice and respect for personhood might result in an ethical resolution

in which psychologists seek permission from a male relative before they obtain

informed consent from potential female clients/patients—at the same time making

it clear to both parties that the psychologist would respect the woman’s right to

refuse treatment irrespective of male permission.

Alternatively, the ethical contextualist might find that women living in this particular

cultural community view this tradition as repressive and fear harsh retaliation

if they disagree with the decision of their husbands or other male relatives. In

this scenario, drawing on the principles of beneficence and nonmaleficence

and respect for personhood, the psychologist might create a safe and confidential

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38——PART I INTRODUCTION AND BACKGROUND

opportunity for women to learn about and then consent or refuse the treatment on

their own without male involvement. For further discussion of these and related issues,

readers are referred to the Hot Topics in Chapter 5, on multicultural ethical competence,

and in Chapter 13, on the integration of religion and spirituality in therapy.

Ethical Competence and Ethical Decision Making

Too often, psychologists approach ethics as an afterthought to assessment or treatment

plans, research designs, course preparation, or groundwork for forensic or

consulting activities. Ethical planning based on familiarity with ethical standards,

professional guidelines, state and federal laws, and organizational and institutional

policies should be seen as integral rather than tangential to psychologists’ work.

Ethical Knowledge and Planning

Ethical Standards

Familiarity with the rules of conduct set forth in the Ethical Standards enables

psychologists to take preventive measures to avoid the harms, injustices, and violations

of individual rights that often lead to ethical complaints. For example, psychologists

familiar with the standards on confidentiality and disclosure discussed in

Chapter 7 will take steps in advance to (a) develop appropriate procedures to protect

the confidentiality of information obtained during their work-related activities;

(b) appropriately inform research participants, clients/patients, organizational

clients, and others in advance about the extent and limitations of confidentiality;

and (c) develop specific plans and lists of appropriate professionals, agencies, and

institutions to be used if disclosure of confidential information becomes necessary.

Guidelines

Good ethical planning also involves familiarity with guidelines for responsible

practice and science. The APA and other professional and scientific organizations

publish guidelines for responsible practice appropriate to particular psychological

activities. Guidelines, unlike ethical standards, are essentially aspirational and

unenforceable. As a result, compared with the enforceable Ethics Code standards,

guidelines can include recommendations for and examples of responsible conduct

with greater specificity to role, activity, and context. For example, Standard 2.01,

Boundaries of Competence, requires psychologists to limit their services to populations

and areas within their boundaries of competence, but as a general standard it

does not specify what such competencies are in different work contents. By contrast,

guidelines such as those for multicultural education, training, research, practice,

and organizational change for psychologists (APA, 2003) describe the specific

areas of training, education, or supervision that psychologists must have to perform

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Chapter 3 The APA Ethics Code and Ethical Decision Making——39

their jobs competently. The Guidelines for Assessment of Dementia and Evaluation

of Age-Related Cognitive Change (APA, 2012a) provides a list of necessary competencies,

including memory changes associated with normative aging and the broad

range of medical, pharmacological, and mental health disorders (e.g., depression)

that can influence cognition in older adults. The crafters of guidelines developed by

APA constituencies usually attempt to ensure that their recommendations are consistent

with the most current APA Ethics Code—readers should be alert to instances

in which the 2010 Ethics Code renders some guideline recommendations adopted

prior to 2010 obsolete. Specific Guidelines are discussed throughout this book

where their relevance to ethical standards can be applied.

Laws, Regulations, and Policies

Another important element of information gathering is identifying and understanding

applicable laws, government regulations, and institutional and organizational

policies that may dictate or limit specific courses of action necessary to resolve

an ethical problem. There are state and federal laws and organizational policies

governing patient privacy, mandated reporting, research with humans and animals,

conduct among military enlistees and officers, employment discrimination, conflicts

of interest, billing, and treatment. Psychologists involved in forensically relevant

activities must also be familiar with rules of evidence governing expert testimony.

Readers may wish to refer to the Hot Topic in Chapter 12 on the implications of case

and federal law on the use of assessments in expert testimony.

As discussed in Chapter 2, only a handful of Ethical Standards require psychologists

to adhere to laws or institutional rules. However, choosing an ethical path that

violates law, institutional rules, or company policy can have serious consequences for

psychologists and others. Laws and policies should not dictate ethics, but familiarity

with legal and organizational rules is essential for informed ethical decision making.

When conflicts between ethics and law arise, psychologists consider the consequences

of the decision for stakeholders, use practical wisdom to anticipate and take

preventive actions for complications that can arise, and draw on professional virtues

to help identify the moral principles most salient for meeting professional role obligations

(Knapp, Gottlieb, Berman, & Handelsman, 2007).

Stakeholders

Ethical decision making requires sensitivity to and compassion for the views of

individuals affected by actions taken. Discussions with stakeholders can clarify the

multifaceted nature of an ethical problem, illuminate ethical principles that are in

jeopardy of being violated or ignored, and alert psychologists to potential unintended

consequences of specific action choices. By taking steps to understand the

concerns, values, and perceptions of clients/patients, research participants, family

members, organizational clients, students, IRBs or corporate compliance officers,

and others with whom they work, psychologists can avoid ethical decisions that

would be ineffective or harmful (Fisher, 1999, 2000).

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40——PART I INTRODUCTION AND BACKGROUND

Steps in Ethical Decision Making

Ethical commitment and well-informed ethical planning will reduce but not eliminate

ethical challenges that emerge during the course of psychologists’ work. Ethical

problems often arise when two or more principles or standards appear to be in

conflict, in unexpected events, or in response to unforeseen reactions of those with

whom a psychologist works. There is no ethical menu from which the right ethical

actions simply can be selected. Many ethical challenges are unique in time, place,

and persons involved. The very process of generating and evaluating alternative

courses of action helps place in vivid relief the moral principles underlying such

conflicts and stimulates creative strategies that may resolve or eliminate them.

Ethical decisions are neither singular nor static. They involve a series of steps,

each of which will be determined by the consequences of previous steps. Evaluation

of alternative ethical solutions should take a narrative approach that sequentially

considers the potential risks and benefits of each action. Understanding of relevant

laws and regulations as well as the nature of institutions, companies, or organizations

in which the activities will take place is similarly essential for adequate evaluation

of the reactions and restraints imposed by the specific ethical context.

A number of psychologists have proposed excellent ethical decision-making

models to guide the responsible conduct of psychological science and practice (e.g.,

Barnett & Johnson, 2008; Canter et al., 1994; Kitchener, 1984; Koocher & Keith-

Spiegel, 2008; Newman, Gray, & Fuqua, 1996; Rest, 1983; Staal & King, 2000).

Drawing on these models and the importance of ethical commitment, awareness,

and competence, an eight-step model is proposed:

Step 1: Develop and sustain a professional commitment to doing what is right.

Step 2: Acquire sufficient familiarity with the APA Ethics Code General Principles

and Ethical Standards to be able to anticipate situations that require ethical planning

and to identify unanticipated situations that require ethical decision making.

Step 3: Gather additional facts relevant to the specific ethical situation from

professional guidelines, state and federal laws, and organizational policies.

Step 4: Make efforts to understand the perspective of different stakeholders who

will be affected by the decision and consult with colleagues.

Step 5: Apply Steps 1 to 4 to generate ethical alternatives and evaluate each alternative

in terms of moral theories, General Principles and Ethical Standards,

relevant laws and policies, and consequences to stakeholders.

Step 6: Select and implement an ethical course of action.

Step 7: Monitor and evaluate the effectiveness of the course of action.

Step 8: Modify and continue to evaluate the ethical plan if feasible and necessary.

Appendix B contains 10 case studies that provide readers with the opportunity

to creatively apply to ethical challenges across a broad range of psychological work

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Chapter 3 The APA Ethics Code and Ethical Decision Making——41

the ethical decision-making model described above and the knowledge they gain in

reading chapters throughout this book. The next section provides an example of

how the eight ethical decision-making steps can be applied to an ethical dilemma.

An Example of Ethical Decision Making

Dr. Ames conducts outpatient individual and group therapy for young adults with dual

diagnosis (substance dependence and anxiety disorders). Although Dr. Ames was careful

not to enter into the group those of her patients who were friends, partners, or relatives,

she has recently learned that two group members (James and Angela) have started to date

one another. In her next individual therapy session, Angela excitedly tells Dr. Ames that she

is pregnant and is planning to move in with James, the father of her baby. When asked if

she has seen a doctor, Angela replies that she does not have health insurance and has

nothing to worry about since neither she nor James have any diseases. Dr. Ames knows

from previous individual sessions with James that he is HIV positive. She asks Angela’s

permission to speak with James about their new situation and Angela agrees. During his

next session James tells Dr. Ames that he does not plan to tell Angela that he is HIV positive

because she would leave him. He also angrily reminds Dr. Ames that she is “sworn to

secrecy” because she promised that everything he told her, except child abuse or hurting

someone, would be confidential.

Step 1. Dr. Ames is committed to doing the right thing. She thinks of herself as honest,

judicious, respectful, and compassionate. She struggles with her desire to maintain

James’s confidentiality about his HIV status and her concern about the health

risks to Angela and her pregnancy (Standards 2.01, Maintaining Confidentiality;

3.05, Avoiding Harm).

Step 2. Dr. Ames reviews the Ethics Code standards. She realizes that because two of

her group therapy patients have unexpectedly entered into a romantic relationship

discussed only in their individual sessions that she is confronting an unforeseen

potentially harmful multiple relationship (Standard 3.05b, Multiple Relationships).

She realizes that her concerns regarding the health risks to Angela and her baby and

her conflict over maintaining James’s confidentiality can potentially compromise her

objectivity and effectiveness in performing her job. According to Standard 3.05b, she

must take reasonable steps to resolve the problem with due regard for the best interests

of all the affected persons.

Dr. Ames also recognizes that while it is important to protect James’s confidentiality

(Standard 4.01, Maintaining Confidentiality), the Ethics Code permits her to disclose

confidential information to protect others from harm (Standard 4.05, Disclosures). She

had thought that her informed consent procedure was consistent with ethical standards

since she did inform James and all her individual and group clients/patients of her legal

obligation to report child abuse and the possibility that disclosure could also occur to

protect others from harm (Standard 4.02, Discussing the Limits of Confidentiality).

However, although she was prepared to address issues of group members fraternizing

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42——PART I INTRODUCTION AND BACKGROUND

outside of group, she had not anticipated that this type of situation would arise and she

was unsure about the answers to the following questions. Should James’s decision to

intentionally keep his HIV status secret and to continue to have unprotected sex with

Angela be considered “harm” to another person? Did the consent language adequately

inform Dr. Ames’s clients/patients that the risk of transmitting HIV would meet criteria

for disclosure? Are there prohibitions in state law against revealing a non-medical

client’s/patient’s HIV status? Is exposing a fetus to HIV infection included in the legal

definition of child abuse in Dr. Ames’s state?

Dr. Ames also reviews the Ethics Code’s aspirational principles. She recognizes

that she has a fiduciary responsibility to both James and Angela that rests on

establishing relationships of trust (Principle B: Fidelity and Responsibility) and

worries that the therapeutic alliance with James may be jeopardized if she discloses

his HIV status to Angela and that her therapeutic alliance with Angela may

be compromised if she is perceived to be colluding with James in a secret that

could be harmful to the health of Angela and her baby (Principle A: Beneficence

and Nonmaleficence, Principle C: Integrity, and Principle E: Respect for People’s

Rights and Dignity).

Step 3. Dr. Ames consults with legal counsel at her state psychological association

and discovers that her state does not have a “duty to protect” law requiring clinicians

to take steps to protect identified others from harm (see Chapter 7) and that

mandatory child abuse–reporting laws are not extended to pregnancies. There are

also no laws requiring or preventing mental health providers from disclosing information

on HIV obtained in a nonmedical context. She reviews relevant publications

and discovers that conditions requiring disclosure remain under debate

within the discipline (Donner, VandeCreek, Gonsiorek, & Fisher, 2008).

Step 4. She consults with medical colleagues regarding the probability that James

will transmit the virus to Angela and the risks to her fetus and learns that infectivity

rates are highly variable ranging from 1 per 1,000 to 1 per 3 contacts (Powers,

Poole, Pettifor, & Cohen, 2008) and mother to child transmission is 15% to 30%

occurring mostly in the last trimester (Orendi et al., 1999). She also speaks to the

prenatal department of the community clinic and finds out that they routinely

provide pregnant women with information regarding HIV risk protection. To

ensure that she is sensitive to the cultural context from which James and Angela’s

reactions to her decision may be embedded, she consults with her community advisory

board (CAB) composed of former drug users and social service workers with

experience serving this community. Some board members express the belief that

the risk of HIV is well-known in the community and that Angela is responsible for

protecting herself. Others believe that James is violating community standards and

that he has therefore given away his right to confidentiality (see Fisher et al., 2009).

Still, others point out that Dr. Ames may lose the trust of the rest of her group

therapy members if she violates James’s confidentiality (Standard 10.03, Group

Therapy). Through all of these discussions, Dr. Ames is careful not to reveal the

identities of James and Angela (Standard 4.06, Consultations).

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Chapter 3 The APA Ethics Code and Ethical Decision Making—Step 5. Dr. Ames begins to contemplate alternative actions. From a Kantian/deontic

perspective, by not disclosing the HIV risk information to Angela, she would fulfill

her confidentiality commitment to James, on which his autonomous consent to

participate was based. At the same time, Kant’s idea of humanity as an end in itself

might support taking steps to protect Angela and her fetus from harm. From a

utilitarian perspective, the importance of protecting Angela and her fetus from a

potentially life-threatening health risk must be weighed against the unknown probability

of HIV infection to Angela and her fetus as well as Angela’s reaction to the

disclosure. Dr. Ames also considers what type of decision would preserve the trust

she has developed with her other group therapy clients/patients. The advisory

board consultation suggested that there was not a broadly shared common moral

perspective that would suggest a specific communitarian or multicultural approach

to the problem. From a feminist ethics perspective, failing to disclose the information

to Angela might perpetuate the powerlessness and victimization of women in

this disenfranchised community. At the same time, disclosure might undermine

Angela’s autonomy if in fact she is aware of HIV risk factors in general and knows

or suspects James’s HIV positive status.

Step 6. On the basis of the previous steps, Dr. Ames decides that she will not at this

point disclose James’s HIV status to Angela. She concludes that her promise of

confidentiality to James was explicitly related to his agreement to participate in

treatment, while her sense of obligation to protect Angela from James’s behavior

was not a requisite or an expectation of Angela’s participation. The community

board’s comments suggest that Angela is most likely aware of the general risks of

HIV transmission among drug users, as do some of Angela’s comments in Dr. Ames’s

notes from previous sessions. In addition, Dr. Ames’s visit to the clinic indicated

that there are community health services that routinely advise pregnant women

about these risks and provide HIV testing. Dr. Ames decides that at her next individual

session with Angela, and during subsequent sessions, she will encourage her

to visit the free prenatal clinic, as well as discuss prenatal risks and the value of

prenatal care. She will also tell James of her decision not to disclose his HIV status

to Angela, continue to encourage him to do so, and provide him with written information

regarding prenatal risk and safer sexual practices.

Step 7. Dr. Ames will monitor and evaluate the effectiveness of her course of action.

She will keep apprised of whether Angela visits the prenatal clinic, including

whether Angela is tested for HIV. She will also monitor whether James begins to act

in ways that will be protective of Angela, especially as Angela enters her third trimester.

Dr. Ames will also continue to evaluate whether the unexpected multiple

relationship with James and Angela compromises her ability to maintain objectivity

in her individual and group sessions and seek consultation if necessary.

Step 8. Whether or not monitoring over the next few months leads Dr. Ames to

modify her decision to maintain James’s confidentiality, her evaluation of the effect

of her course of action will influence her confidentiality and disclosure policies in

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44——PART I INTRODUCTION AND BACKGROUND

the future. She plans to convene a meeting of community drug users and community

practitioners to develop procedures that can anticipate and best address this

type of issue in the future.

Doing Good Well

Ethical decision making in psychology requires flexibility and sensitivity to the

context, role responsibilities, and stakeholder expectations unique to each work

endeavor. At their best, ethical choices reflect the reciprocal interplay between psychological

activities and ethical standards in which each is continuously informed

and transformed by the other. The specific manner in which the APA Ethics Code

General Principles and Ethical Standards are applied should reflect a “goodness of

fit” between ethical alternatives and the psychologist’s professional role, work setting,

and stakeholder needs (Fisher, 2002b, 2003b; Fisher & Goodman, 2009; Fisher &

Ragsdale, 2006; Masty & Fisher, 2008). Envisioning the responsible conduct of

psychology as a process that draws on psychologists’ human responsiveness to those

with whom they work and their awareness of their own boundaries, competencies,

and obligations will sustain a profession that is both effective and ethical.

Ethics requires self-reflection and the courage to analyze and challenge one’s

values and actions. Ethical practice is ensured only to the extent that there is a personal

commitment accompanied by ethical awareness and active engagement in the

ongoing construction, evaluation, and modification of ethical actions. In their commitment

to the ongoing identification of key ethical crossroads and the construction

of contextually sensitive ethical courses of action, psychologists reflect the highest

ideals of the profession and merit the trust of those with whom they work.

HOT TOPIC

The Ethical Component of Self-Care

The professional practice of psychology can be rewarding as well as stressful. Psychological treatment often

involves working with clients/patients who express acute or chronic suicidality, engage in self-harm, are victims

of abuse or assault, or are coping with the death of loved ones or with their own chronic or fatal disease.

Clinicians treating veterans or others with posttraumatic stress disorder (PTSD) are regularly assessing and

treating patients struggling with repetitive aggressive or homicidal episodes that may place the client/patient,

their families, and the treating psychologist in physical danger (Voss Horrell, Holohan, Didion, & Vance, 2011).

The Emotional Toll of Professional Practice

The emotional toll and precarious nature of this work makes psychologists vulnerable to occupational

stress, including emotional exhaustion, depersonalization and lack of personal accomplishment that lead

to burnout, overcompensating efforts to “save” clients/patients or participants, boundary violations, and

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Chapter 3 The APA Ethics Code and Ethical Decision Making——45

other behaviors that impair job performance (APA Committee on Colleague Assistance, 2006; Lee, Lim,

Yang, & Lee, 2011; Webb, 2011). For example, military psychologists with extended deployments to war

zones who are practicing in life-threatening contexts risk direct trauma-related distress and vicarious

distress working with traumatized military personnel (W. B. Johnson et al., 2011). Psychologists working

with patients or research participants graphically describing child or partner abuse, homelessness and

hunger, drug abuse and violence, or death and dying may also experience vicarious or secondary trauma,

guilt, or a sense of powerlessness for which there is little institutional support (McGourty, Farrants, Pratt,

& Cankovic, 2010; Simmons & Koester, 2003). Psychologists who have a client/patient die from suicide,

an accident, or fatal disease may not recognize or receive social support for their own grief reactions

(Doka, 2008).

Psychologists working in schools, military hospitals, or correctional facilities may experience the painful

feelings and psychological disequilibrium that characterizes moral distress—lack of professional control to do

what they believe is right (Corely, 2002) in response to institutional constraints on caseload, resources, use of

evidence-based practices (EBPs), up-to-date assessment instruments, or trained personnel (Maltzman, 2011;

O’Brien, 2011; Voss Horrell et al., 2011). Or in response to work-related stressors, psychologists may develop

compassion fatigue or begin to process client/patient experiences on a purely cognitive level, a syndrome

W. B. Johnson et al. (2011) describe as empathy failure.

“Wounded Healer”

Competent treatment of fatally ill, violent, or suicidal clients/patients may require extensive patient contact,

behavioral monitoring, interactions with family members, and significant flexibility in identifying

appropriate treatment strategies. Not surprisingly, many ethical dilemmas for psychologists working with

these patients revolve around decisions regarding maintaining an appropriate balance between personal

and professional boundaries (e.g., Standards 3.04, Avoiding Harm; 3.05, Multiple Relationships; 7.07,

Sexual Relationships with Students and Supervisees; and 10.05, Sexual Intimacies with Current Therapy

Clients/Patients).

Working in emotionally charged therapeutic contexts can lead to work-related exhaustion, sense of

urgency, and worries that may compromise competent therapeutic decisions (Standard 2.06, Personal Problems

and Conflicts). On the other hand, such experiences can lead to unique professional growth. Jackson (2001)

introduced the term wounded healer to describe how the emotional experience of working with such clients/

patients can later serve to enhance psychologists’ therapeutic endeavors. Voss Horrell et al. (2011) have

described similar positive developments in compassion satisfaction and posttraumatic growth in response to

the challenges of treating veterans with PTSD.

Mindfulness-Based Stress Reduction

Research and clinical scholarship on the potential for and diminished work competence associated with

burnout, social isolation, compassion fatigue, depression, and vicarious traumatization among psychologists

working with high-risk populations have led to a widening endorsement of self-care practices as an

essential ethical tool in ensuring competence in psychological work. Discerning when stress becomes

impairment is difficult in the present moment (Barnett, 2008) and thus requires a proactive approach to

self-care that mitigates the effect of stressors on professional competence (Tamura, 2012).

One such approach is mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1993) adapted for the practice

of psychology. MBSR is rapidly becoming a popular approach for maintaining appropriate competencies

under stressful work conditions. MBSR is a technique for enhancing emotional competence through attention

to present moment inner experience without judgment. It is seen as an effective means of reducing emotional

reactions toward and identification with clients’/patients’ problems that can lead to therapeutic deficits

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46——PART I INTRODUCTION AND BACKGROUND

(Christopher & Maris, 2010; D. M. Davis & Hayes, 2011; S. L. Shapiro, Brown, & Biegel, 2007). Several recent

studies have demonstrated positive effects of MBSR training on counseling skills and therapeutic relationships

(Christopher, Christopher, Dunnagan, & Schure, 2006; McCollum & Gehart, 2010), including self-care educational

materials in graduate courses and modeling and mentoring self-care habits in supervisory relationships.

Practical Guidelines for Self-Care

While there are empirical studies on effective approaches such as MBSR for maintaining and developing the

competencies required, several psychologists have generously shared their own experiences and hardearned

professional insights on personal and professional approaches to such challenging cases (Barnett,

Cornish, Goodyear, & Lichtenberg, 2007; O’Brien, 2011; Tamura, 2012; Webb, 2011).

Specific self-care strategies for competent practice include the following:

Minimize risks posed by the social isolation of working in individualized therapeutic settings through

formal (peer consultation or supervision) and informal (professional conferences, lunch with peers)

activities

Schedule activities that are not work related and develop daily strategies for transitioning from work

life to home life

Develop healthy habits of eating, sleeping, and exercise

Set appropriate boundaries for work-related activities such as beginning and ending sessions on time,

limiting work-related phone calls or e-mails to specific times of the day or early evening

Diversify work activities and/or caseload

Utilize personal psychotherapy as a means of addressing psychological distress and enhancing professional

competence through increased self-awareness, self-monitoring, and emotional competence

Preparing Psychology Trainees for Work-Related

Risks and Self-Care

Self-care strategies should be included in graduate education and training and encouraged as lifelong

learning techniques (Barnett & Cooper, 2009). Trainees and young professionals may be particularly susceptible

to stressors associated with clinical work, especially when programs have not provided training in selfawareness

and self-regulation techniques to balance self and other interests and to maintain emotional

competence (Andersson, King, & Lalande, 2010; S. L. Shapiro et al., 2007; Tamura, 2012). W. B. Johnson et al.

(2011) propose that psychologists must acknowledge the ethical obligation to routinely assess their colleagues’

performance. This is especially important in graduate and internships programs in which students

may rely on peer and faculty reactions as measures of their own competence. Programs should thus strive to

create a culture of community competence that encourages trainees to recognize themselves as vulnerable

to work-related stress and reduced competence, to recognize personal and professional dysfunction, and to

develop professional self-care habits that support emotional and professional competence.