Psychologists contact APA's Ethics Office with a wide range of questions. Certain questions repeat, such as whether to file a child-abuse report and whether to inform a client that confidential information may have been compromised. Less frequent but nonetheless recurring questions involve adopting a child whom a psychologist has met in a professional setting or consulting with a contestant on a reality television program who might benefit from psychological expertise.
These calls challenge the Ethics Office staff and serve as a humbling reminder for us of the depth and richness of what psychologists do.
An especially poignant question involves what happens after a client dies. Consider this scenario:
A client with whom I had been working for nearly 25 years recently passed away. He suffered from a psychotic disorder, yet managed to have a good and productive life. Over the course of our work together, we sometimes saw each other as much as three times a week when times were difficult, but other times met once a month or even less. I charged him a small portion of my full fee. (I met him while I was a trainee and never considered charging full fee when he asked to stay with me after I completed my postdoc.) I was deeply saddened when I received a notice of his death — we hadn't seen one another for several weeks, which was unusual although not unheard of. I was utterly stunned, though, when I learned he had left me a piece of property worth a rather sizable (six-figure) sum of money. He lived quite simply and I never imagined he had any significant assets. Accepting the property cuts against everything I feel I ought to do as an ethical psychologist, but I live in an expensive city, have two children nearing college age, and when I told my spouse I thought I should refuse the property on ethical grounds the temperature in the room rose precipitously. The reality is that the amount of money the bequest is worth is not terribly far off what I would have earned had I charged full fee the entire time. What are the ethics of my situation?
This situation touches on a host of challenging and complex issues, perhaps most centrally how we as psychologists deal with a client's death. The question in this instance, however, is more specific: The psychologist is asking what to do. It can be helpful to consider this question from legal, clinical, risk management and ethical perspectives.
Most risk managers — people who work for insurance carriers, for example, whose primary goal is to lower a psychologist's exposure to risk — will advise the psychologist to decline the property. This advice makes good sense. The situation invites a claim that the psychologist exercised undue influence over the client, which is a relevant legal standard for overturning the bequest. The likelihood that a claim of undue influence will be made against the psychologist rises exponentially if the client had heirs, or potential beneficiaries of the estate who are found. If a complaint is made to an ethics committee or licensing board, the psychologist will bear the burden of demonstrating that there has been no exploitation:
3.08 Exploitative Relationships
Psychologists do not exploit persons over whom they have supervisory, evaluative or other authority such as clients/patients, students, supervisees, research participants and employees.
From a risk-management perspective, based on the psychologist having a fiduciary duty to the client and facts that provide fertile ground for a claim of undue influence, the situation is problematic.
To consider the situation only from a risk-management perspective, however, seems disrespectful both of the client and of the work the psychologist and the client did together. Autonomy is a core value in the Ethics Code:
Principle E: Respect for People's Rights and Dignity
Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision-making.
Psychologists have an unfortunate disposition to view client behavior through the lens of deficit. It may be tempting in this situation to label the client's bequest as acting out transference. That characterization, however, risks minimizing what it may have meant to the client to include the psychologist in his will.
The challenge for the psychologist is that assessing the role of the client's autonomy and examining whether the psychologist did anything in the treatment to unduly influence the client presents a potential conflict of interest:
3.06 Conflict of Interest
Psychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial or other interests or relationships could reasonably be expected to (1) impair their objectivity, competence or effectiveness in performing their functions as psychologists or (2) expose the person or organization with whom the professional relationship exists to harm or exploitation.
The conflict of interest literature is clear: The psychologist in the situation/conflict is in the worst (or least best) position to determine the effects of the conflict. If the psychologist explores keeping the bequest, a consultation is appropriate, even necessary.
A consultant will help the psychologist explore what role the treatment may have played in the client's decision and how the psychologist may have contributed to the particular outcome. If it appears that the psychologist unduly influenced the client, the ethics of the situation are clear: The psychologist should not accept the bequest. A consultant will also be mindful that the client may have engaged in a thoughtful decision-making process and made a considered decision, unaware of the ethical quandary he was creating for the psychologist.
An ethical dilemma arises for the psychologist if the consultant concludes that the psychologist provided competent and ethical treatment. In that case, the psychologist is left with a set of values to balance. These may include how accepting the client's bequest comports with the psychologist's own sense of what an ethical psychologist should do, and/or how accepting the bequest may affect the public image of psychologists, may influence other treatments the psychologist offers, and may affect how colleagues view the psychologist.
The psychologist will balance these professional considerations with his or her personal interests. Although some may argue that the psychologist's personal interests should have no role whatsoever in resolving this dilemma, that position seems far removed from life as we live it and is not required by the Ethics Code.
What is required is for the psychologist to consider the relevant ethical principles — do good, do no harm; respect the client's autonomy — and perhaps to struggle with how psychologists integrate doing right by our clients while respecting the ethical commitments we have in our personal lives.
Stephen Behnke, JD, PhD, MDiv, directs APA's Ethics Office.
