Ethical Decision-Making

VERGÉSCONTEXT IN ETHICAL DECISION MAKING

Integrating Contextual Issues in Ethical Decision Making

Alvaro Vergés Department of Psychological Sciences

University of Missouri-Columbia

Many issues in ethics arise in relation to the contexts in which psychologists work. However, most ethical decision-making models reproduce the way in which psychologists tend to approach ethics by focusing on ethical dilemmas and proposing a step-by-step response to deal with them. Although these models might be useful, their emphasis on reactive approaches and their lack of contextualiza- tion constitute significant limitations on their applicability. In this article, an approach to ethical deci- sion making that highlights the importance of the context in developing proactive strategies to solve ethical issues is proposed. This approach is further explained through its application to medical and rural settings. The implications of these suggestions to the training in ethics are finally discussed.

Keywords: ethics, ethical decision making, ethical dilemmas, training

Many conflicts in ethics arise in direct relation to the contexts in which psychologists work. For example, problems with boundaries in rural settings where overlapping relations are common or with confidentiality in medical settings where records of patients are shared by different profes- sionals, emerge before the psychologist has even started to work. Clinical psychologists, as well as other mental health professionals, tend to think about ethics as a circumscribed problem related to their specific work in the treatment room. However, their responsibility goes beyond the time and space of the therapeutic process, and their ethical concerns should begin in the moment they start to know the contexts in which they will work.

Most ethical decision-making models reproduce the way in which psychologists tend to ap- proach ethics. The major concerns of these models are the ethical dilemmas and the sequence of steps necessary to deal with them. Although these models are useful, they emphasize reactive ap- proaches to ethical issues and overlook preventive measures that might help solving ethical prob- lems before they arise. Moreover, ethical decision-making models tend to be abstract statements about how psychologist should behave and do not take into account the different contexts in which they might be applied.

Attempts have been made to modify existing ethical decision-making models in a way that in- corporates these issues. For example, ethical decision-making models to be used in contexts as di- verse as military operations (Stephenson & Staal, 2007) or the work with AIDS patients (Erickson, 1990) have been proposed. In this article, the limitations of these kinds of models are

ETHICS & BEHAVIOR, 20(6), 497–507 Copyright © 2010 Taylor & Francis Group, LLC ISSN: 1050-8422 print / 1532-7019 online DOI: 10.1080/10508422.2010.521451

Correspondence should be addressed to Alvaro Vergés, 200 South Seventh Street, Department of Psychological Sci- ences, University of Missouri-Columbia, Columbia, MO 65211. E-mail: avhz6@mail.mizzou.edu

addressed, together with the suggestion that a different approach should be implemented to inte- grate the context into ethical decision making. Examples of the application of this approach to medical and rural settings are provided. Finally, the implications of these suggestions to training in ethics are discussed.

ETHICAL DECISION-MAKING MODELS

Ethical decision-making models originally emerged as a response to the limitations of mandatory ethics, centered in the creation of universal principles and standards that guide the ethical behav- ior of psychologists in the most diverse situations (Tymchuk, 1982). As stated by Stephen Behnke (Barnett, Behnke, Rosenthal, & Koocher, 2007), the idea that the correct answer to an ethical di- lemma comes from external prescriptions was considered both impossible and undesirable. It was impossible because the complexity of situations in which psychologists are involved make it im- practicable to create a standard for every single ethical problem. It was also undesirable because it implied the idea of psychologists as passive appliers of ethical prescriptions. In contrast, ethical decision-making models promoted an active processing of ethical principles and standards in or- der to generate a creative response to a particular ethical problem (Seitz & O’Neill, 1996). More- over, ethical decision-making models analyze ethical behavior in the light of the process through which a course of action is selected, instead of just considering the final action. This implies that a “right action” is discerned not only by its consequences but also by reviewing the steps that led to it (Garfat & Ricks, 1995).

In a review of the ethical decision-making models proposed between 1984 and 1998, Cottone and Claus (2000) analyzed theoretically and empirically based models. Among the models in- cluded in their review, there are some that consider contextual issues in the process. For example, the feminist model of Hill, Glaser, and Harden (1998) considers the social context in which the ethical dilemma arises. Similarly, Betan (1997) developed a model based on hermeneutics, incor- porating the context in which the therapeutic relationship occurs into the narrating process that characterizes ethical decision making according this author. Furthermore, Cottone’s (2001) social constructivist approach states that the process of solving an ethical dilemma takes place in the in- teraction among people and not in the individual mind of the psychotherapist. However, none of these models provide explicit guidelines on how the context should be incorporated in the process. Moreover, with the exception of Welfel’s (2006) model, which includes a first step of developing ethical sensitivity, most models reviewed by Cottone and Claus start with the identification of rel- evant aspects of the problem, that is, they consider the ethical dilemma as the starting point for ethical deliberation and do not mention preventive steps to impede the occurrence of the ethical dilemma.

One of the models reviewed by Cottone and Claus is the one proposed by Garfat and Ricks (1995) for clinical work in child and youth care, which deserves special attention here. In this model, the activity of the self is the core of ethical behavior. The self processes the influences of contextual values, codes of ethics, and standards through a critical and reflective analysis that gen- erates a decision given a context of ethical practice. Once the action is taken, its consequences are evaluated and integrated as feedback to the process and the self. Thus, the whole process is said to be driven by the self, implying a more personalized interpretation and application of general stan- dards that takes into account the context in which the decision must be made. However, in this

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model the context is still considered after the dilemma has arisen, so that contextual issues are not incorporated in a proactive analysis. Like other models of ethical decision making, Garfat and Ricks’s model seems to describe the self as being activated by the ethical problem, rather than be- ing active before the problem.

In recent years, new models of ethical decision making have emerged, most of them focusing in one area, setting, or ethical dilemma, so that the new tendency seems to be the development of an ethical decision model for every specialty in clinical psychology (e.g., Gottlieb, 1993; Knapp & VandeCreek, 2007; Stephenson & Staal, 2007). However, this line of work, although useful in guiding the application of general principles to specific contexts, does not teach how to do the ap- plication by oneself. Do we have to wait until a new ethical decision-making model for a specific setting is published before we start to work in that setting? With the rapid changes that we witness every day in psychology and the reasonable expectation for the emergence of new areas of devel- opment in the near future, it seems more wise to develop skills in the thoughtful examination of new settings to identify as soon as possible the ethical challenges and dilemmas that we are likely to encounter. To identify those skills, it might be useful to consider the influences that affect ethi- cal decision making.

INFLUENCES IN ETHICAL DECISION-MAKING PROCESSES

One of the first studies that highlighted the role of contextual factors in ethical decision making was conducted by Kurtines (1986). Sixty-four undergraduate students were asked to report their course of action in six different scenarios, categorized as behavioral (involve the analysis of possi- ble consequences) and distributive (don’t involve analysis of consequences) decision-making sit- uations. Individual differences in the use of justice, benevolence, and pragmatism as moral princi- ples and situational factors were included as predictors in regression equations in which the ethical decision was the dependent variable. The results indicate that, although both individual and situational factors significantly predicted ethical decision making, the situational factors tended to be better predictors (i.e., accounted for more variance).

In a study involving 258 students of 59 clinical psychology programs, Betan and Stanton (1999) examined the discrepancy between the ability to identify a proper response to an ethical di- lemma and the willingness to act in accordance to that identification. Their results show that only 37% of participants who identified the appropriate response according to the American Psycho- logical Association (APA) Ethics Code (APA, 2002), said that they would actually do what they believed they should do. Furthermore, Betan and Stanton identified emotional and contextual pre- dictors of this discrepancy. They found that participants who stated their willingness to act as they should reported less anxiety and more compassion in relation to the ethical dilemma. Also, these participants reported that their decision was more influenced by ethical and professional concerns, ethics code and education, and clinic-related concerns and less influenced by personal and friend-related concerns. The authors concluded that “psychologists are making inadequate deci- sions about ethical dilemmas in part because they are not well attuned to the influential role of emotions, values, and contextual concerns in ethical discourse” (p. 299). That is, although psy- chologists may know the principles and standards that regulate the profession, their implementa- tion of those principles and standards can be interfered by emotional and contextual issues, espe- cially when they are not aware of those factors. For this reason, “any ethical model used in training

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must incorporate these contextual factors in order to awaken therapists’ sensibilities” (p. 299). However, Betan and Stanton’s proposal focuses mainly in the interpersonal context and doesn’t take into account the specific features of the setting in which the ethical problem arises.

In a review of the literature on ethical decision making in business environments, O’Fallon and Butterfield (2005) found good empirical support for individual and contextual factors affecting the process of ethical decision making. Among the contextual factors, O’Fallon and Butterfield reported that the existence of a code of ethics tends to be associated with positive measures of ethi- cal decision making. Also, the creation of an ethical climate or culture in an organization fosters the ethical decisions of individuals. Finally, the existence of rewards and sanctions that are consis- tent with ethical behaviors is positively related to ethical decision making. Another contextual factor that according to O’Fallon and Butterfield requires more investigation is the influence of peers.

Although these findings apply to the field of business, there is some research suggesting their generalizability to other situations. For example, Mumford et al. (2007) examined the responses of 102 graduate students in programs in biological, health, and social sciences to different scenar- ios reflecting conflictive ethical situations in research. Their results show that some dimensions of both environmental experiences and perceptions of climate in the workplace are associated with ethical decision making.

In summary, the accumulated evidence shows that there are contextual factors that systemati- cally influence the processes and results of ethical decision making. If we take these results seri- ously, we should consider taking these factors into account whenever we are confronted by ethical dilemmas and engage in a deliberative decision making process. That implies the use of an ethical decision-making model in combination with an awareness of all the factors that might influence the steps prescribed by the model. However, if this is the case, ethical decision-making models be- gin to appear more overwhelming than useful. A different approach might involve trying to iden- tify and, if possible, modify the contextual factors that influence ethical decisions before the model is applied, that is, applying the model when there is no ethical dilemma to focus on. The next section provides some ideas on how contextual issues might be incorporated into formal ethi- cal decision making.

INTEGRATING CONTEXT TO ETHICAL DECISION-MAKING MODELS

Traditional ethical decision-making models are useful to avoid impulsive responses to an ethical dilemma. However, this statement can be slightly reframed saying that these models are useful only if they avoid impulsive responses, because once an impulsive response has occurred, there is little more to take from the model. This problem is solved in part if psychologists take a time prior to any ethical conflict to apply a model to their distinctive context and think of alternative solu- tions to problems that have not yet occurred. Thus, if the worse scenario happened and the psy- chologist could not avoid an impulsive response, at least that response would more likely be one that has been considered before, in a better state of mind.1

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1A reasonable reader could think at this point that this is what most (or at least some) people already do. That is true. However, the same can be said about most ethical decision-making models. One of the most important goals of an ethical decision-making model is to systematize the best practices in dealing with ethical issues.

A more formal exposure of such a process is presented by Kitchener (1984) in a very influential article. She developed a hierarchy of justification for ethical judgments composed of two levels: an immediate, intuitive level and a critical, evaluative level. The intuitive level corresponds to the set of personal beliefs and knowledge (including knowledge about ethics codes) that are applied in most situations when we need to make a moral judgment that does not involve a conflict between different principles. However, when such a conflict arises, or when we need to evaluate or justify decisions made on the basis of intuitive judgment, a more elaborated process for ethical judgment is needed. Here is when the evaluative level is required. This level is, in turn, composed of three tiers of moral justification, namely, ethical rules (including professional codes and laws), ethical principles, and ethical theory. These tiers are also hierarchically organized, so that we move to a more abstract tier when a given situation cannot be solved through the application of a previous tier (Kitchener, 1984).

The importance of this model for the present discussion resides in two aspects that appear to be overlooked in most of the subsequent models of ethical decision making. First is the inclusion of an immediate, intuitive level of justification that is conformed by personal values and general knowledge but is also influenced by formal training in ethics and personal reflection about every- day practice. This level of justification is not a primitive or secondary aspect of ethical behavior that can be dismissed from further analysis. On the contrary, it must be a central matter in our ethi- cal concerns, and we should take responsibility for the development of a good moral intuition. This involves developing moral awareness and sensitivity, increasing the familiarity with ethics codes and laws and, as we insist here, being aware of the relevant features of the contexts of work in order to develop a set of strategies to address potential conflicts before they emerge.

The second aspect of Kitchener’s model to be highlighted here is that the constant application of the critical, evaluative level of moral judgment is assumed to improve our moral intuitions. Moreover, this application does not need an ethical dilemma to be exercised. As Kitchener (1984) stated,

Hopefully, by doing the best critical thinking possible when we are not pressed by the immediacy of a situation, we can build up an improved set of ethical rules and principles which will ultimately become part of our redefined intuitive sense. (p. 45)

The suggestion made in this article is that “the best critical thinking possible” involves the ap- plication of ethical rules, ethical principles, and ethical theory to the particular context in which professionals work.

There are several reasons for including the context in this process of critical thinking. First, the power of the context in influencing the decision-making process, which has been already exam- ined, requires psychologists to pay attention to those sources of interference. Also, although codes, laws, and principles are stated as universally applicable, the demands of an ethical dilemma occur in a very specific situation that sometimes makes the general norms inapplicable. Between the universality of the general norms and the specificity of the particular situation we can identify the context as the relatively stable place where some ethical problems are more or less likely to oc- cur. That is, the context is the natural field where proactive ethical judgment should be applied. If professionals are able to identify the features of their context of work that make the application of general norms more difficult, and use that identification as a starting point to think of potential sit- uations of ethical conflicts, the moment in which those conflicts emerge will not be a moment of

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despair and improvisation. Although it is unlikely that this proactive thinking will prevent ethical dilemmas from occurring, the possibility of anticipating some (or most) of the ethical dilemmas in a given context makes the process of ethical decision making a more straightforward and less stressful one. Furthermore, the analysis of the context can also be helpful to identify unethical contexts (e.g., a context where torture is applied) in which there is no possible ethical behavior ex- cept for resigning and denouncing (Lira, 2008). Finally, the integration of contextual consider- ations to ethical decision making has the potential to change the way we think about ethical issues. As we learn to consider the particular aspects of our context of work before we encounter any ethi- cal problem, we will develop a greater awareness of ethical issues, which in turn will help us to make better decisions.

Because the absence of specific guidelines to analyze contexts might still discourage some psychologists from considering these suggestions, it may be helpful to present concrete examples of how contextual issues have been identified in the literature and have been used to modify the clinical practice.

EXAMPLES

The following examples are presented to give an idea of the incorporation of context in ethical de- cision making. It should be noted that these examples are still too general, comprising very differ- ent situations. However, they provide an idea of how the analysis of more particular contexts should be addressed. It should also be mentioned that the analysis of these contexts does not imply that there is something unethical about them, but that they are different from the usual context of psychological practice in relation to which most of the literature on ethics has been developed. Finally, although the context is understood in these examples as the setting in which psychologists work, there are other dimensions that could also be considered as “contextual,” such as the activi- ties in which clients are involved (e.g., sport psychology), the way in which psychologist and cli- ent communicate (e.g., Internet-based psychotherapy), the financial context in which services are provided (e.g., managed care), or the legal dispositions that regulate psychological practice (i.e., differences in laws among states).

Ethical Issues in Medical Settings

Practicing psychology in medical settings involves several ethical issues that emerge due to the specific features of this context. For instance, the patients who are most likely to receive services in medical settings are different from patients seen in mental health settings. Patients in medical settings tend to have more limited knowledge about the process of psychotherapy or the role of psychologists, are usually referred by other professionals without a good explanation of the rea- sons for the referral, might be referred as a “last option” when more traditional treatments have failed, and might present limitations in movement (which implies the need for services in their hospital room) or in their ability to make decisions (Belar & Deardorff, 2009; Cooper-Patrick, Crum & Ford, 1994; Pope, 1990).

Some characteristics of the organizational culture are also particular in medical settings, where different professionals with a diversity of theoretical frameworks, ways to understand disease, and ways to approach team work can be found, which can lead to difficult situations. Also, the

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presence of differences in professional codes of ethics might be problematic, as well as the exis- tence of different ways to cope with emotional distress among professionals (Belar & Deardorff, 2009). An environment that behaves in a way that is so different from how psychologists usually behave might affect their ethical decisions unless they anticipate the problems that are likely to emerge (Pope, 1990). To avoid this, psychologists working in medical settings should ask them- selves, for example, What would I do if I have to meet with a patient who cannot move and needs to be seen in a multiple bed room? (issues with confidentiality) or what would I do if there is a con- flict between my patient and the treatment team with regard to the most appropriate treatment? (conflicts of interest).

Does this mean that an ethical decision-making model for psychologists in medical settings is necessary? Maybe. But the rapid changes in medical practices and law, as well as the new devel- opments in health psychology (Rozensky, 2006), would probably make such a model obsolete in a few years. A better solution would be to provide training to psychologists who work in medical settings to assist them to analyze their context and anticipate possible ethical conflicts.

Ethical Issues in Rural Settings

The literature on ethical issues in rural settings constitutes an excellent example of how the analy- sis of contextual issues can lead to a particular and coherent set of ethical guidelines for practice. The features of rural contexts have been described by a number of authors (e.g., Helbok, 2003; Roberts, Battaglia, & Epstein, 1999; Stockman, 1990). Roberts et al. (1999) stated than in com- parison to urban population, rural residents have higher rates of alcohol-related accidents, sui- cides, chronic illnesses, and environmental hazards. Furthermore, they are less likely to seek pro- fessional help and tend to distrust outsiders from the community (Stockman, 1990). On the other hand, rural psychotherapists are more likely to provide care without necessary support or re- sources, address clinical issues outside their competence, and make difficult decisions without consultation or support from specialists. Moreover, therapeutic relationships tend to be compli- cated by the fact that overlapping relations are almost inevitable in rural settings. This implies that psychotherapists have to deal with a constant balancing between their personal life and their duty to their patients, or even the balancing between being accepted in the community and avoiding multiple relationships (Helbok, 2003). In a national survey of 447 psychologists in urban and rural areas, Helbok, Marinelli, and Walls (2006) found that rural psychologists encounter more issues with multiple relationships, have more problems related to their visibility in the community, and are less likely to discuss their work with other professionals.

However, the existence of these problems does not mean that psychologists should dismiss their commitment with ethical codes. As Helbok (2003) stated,

Even though some ethical considerations may be different in rural areas than urban areas, it does not mean the ethical codes should be abandoned or loosely interpreted. On the contrary, it is because of the fact that multiple relationships are inevitable, or anonymity impossible, that the psychologist needs to be even more diligent in working within the ethical codes and principles. (p. 370)

As we have noted, this is not a simple task, and several guidelines have been proposed to help deal with these issues. For example, Stockman (1990) applied Kitchener’s (1988) guidelines to multiple relationships to the context of practice in rural settings. She made a number of useful sug-

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gestions, among which we find addressing with patients their expectations regarding their relation with the psychotherapist, discussing in advance potential role conflicts, meeting with other pro- fessionals in the community to explain issues related to confidentiality, and considering consulta- tion with community members to learn more about the community. Roberts et al. (1999) sug- gested educating patients about ethical standards and involving them in the process of identifying potential conflicts and solutions related to boundary violations. They also encouraged profession- als to work together in order to translate ethical standards to the reality in rural contexts. Coyle (1999) proposed providing documents explaining conflictive issues and reviewing them with the patient to facilitate informed consent. During this process, patient and psychotherapist could even anticipate problematic situations that are likely to occur and think together about possible ways to deal with them. Turchik, Karpenko, Hammers, and McNamara (2007) provided suggestions for how to deal with difficulties in assessment in rural settings. They presented some criteria to select and apply useful assessment tools and emphasized working with test developers, test publishing corporations, third-party payers, the profession of psychology, and legislators to prevent difficul- ties derived from lack of accessibility to quality assessment in rural areas.

It is interesting to note how these suggestions share a preventive perspective that is more re- lated to proactive measures than to reactive steps to follow after a problem has been identified. Al- though some useful models for ethical decision making in rural contexts have been proposed (e.g., Gottlieb, 1993), it is clear that most efficient measures involve working with the context to pre- vent ethical dilemmas in a proactive way.

In summary, a psychologist taking a job in a new context (even if the context is supposed to be “traditional” as opposed to “emergent”) should be able to examine the main features of that con- text, including—but not limited to—characteristics of the potential clients (including cultural is- sues, developmental issues, and psychopathology), characteristics of other professionals and ser- vices in the context (including knowledge of psychology and differences in ethics codes), characteristics of the general community (broadly defined to include professionals and public in- stitutions), and characteristics of the job (does it—or should it—involve assessment, coordination with other professionals, interventions at different levels, etc.?) to determine the potential ethical issues that might arise. This analysis should be done with the assistance of experts in the context (i.e., other professionals or members of the community) in a dialogue that involves an explanation of psychological services and ethical issues in psychology. Furthermore, the examination of the context should take into account the fact that a single job might involve different contextual di- mensions at the same time (e.g., working with adolescents from a rural community through the Internet).

The ability to engage in this examination of ethical issues in a given context certainly requires appropriate training. The implications that the approach to ethical decision making presented in this article has for training in ethics are presented in the next section.

IMPLICATIONS FOR TRAINING IN ETHICS

In an article titled “Beyond Ethical Decision Making,” Newman, Gray, and Fuqua (1996) com- pared two different models of ethical judgment. The first, “ethical and moral judgment,” is related to mandatory ethics in that the focus is centered on the ethical dilemma or question, and the step-by-step process of reaction to the dilemma. The second model, “ethical and moral inquiry,” is

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more related to virtue ethics, so the emphasis is on a proactive attitude that is directed toward the achievement of the best possible ethical practice instead of the avoidance of ethical violations. The ethical and moral inquiry is thus a long-term process of growth in which the professional at- tempts to answer the question “who shall I be” as opposed to the more reactive question “what shall I do” that is characteristic of decision making as understood by traditional models. The in- corporation of this aspirational model of ethical judgment associated with virtue ethics has been repeatedly proposed by many authors (Jordan & Meara, 1990; Knapp & VandeCreek, 2007). Al- though the focus of this article is not intended to address these issues, it should be noted that an in- corporation of the context in the ethical decision-making process could contribute to the integra- tion of these two models of ethical judgment, as the ethical and moral judgment starts to be more proactive and involved in the search for the best practices. However this goal might require differ- ent models of training in ethics.

The recommendations that can be derived from the previous sections for teaching ethics are straightforward. Learning about models of ethical decision making and their application to differ- ent ethical dilemmas should still be a central part of the training. However, the analysis of contex- tual issues and the application of ethical decision-making models to those issues should definitely be encouraged to foster a proactive attitude toward the resolution of ethical problems.

With coming changes in health care, it is likely that the whole model of mental health service delivery that we have learned and practiced will change dramatically. The context in which we learned the ethics of our profession will be different than the context in which we will have to ap- ply them.

These changes will require a new set of skills that allow for a flexible but rigorous application of the APA Ethics Code (APA, 2002) to situations that have not been even considered by those who wrote it. In this situation, a reactive ethical decision-making approach is likely to be insuffi- cient, so that students should be trained to be constantly aware of changes in their context of work in order to anticipate future problems. As Koocher (2003) stated, planning is the key to effectively address changes in professional practice. However, planning without paying attention to the changes in context might be as ineffective as not planning at all.

A similar approach to what is proposed here was taken by Mumford et al. (2008) in providing research integrity training to graduate students. Their results showed that an application of general principles to the particular context of research involving case examples and practical strategies was effective and that results were maintained after 6 months. Although the effectiveness of a training model for ethics in clinical practice based on contextual analyses is still to be tested, there are reasons to be optimistic about its potential results.

ACKNOWLEDGMENTS

Gratitude is expressed to Jeffrey Barnett, PsyD, and Nan Presser, PhD, for their comments on ear- lier versions of this article.

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