Ethics Rounds

"Ethics" and "ethical" are words that people use in different ways. For some, to say that a psychologist has behaved "unethically" means that the psychologist has violated a rule of conduct, perhaps a licensing board regulation or a standard in the APA Ethics Code. This way of thinking about ethics focuses on the unethical, the absence of what is ethical, a breach in the minimum standards of our profession's behavior. The "Code of Conduct" aspect of the Ethical Principles of Psychologists and Code of Conduct sets forth 89 such standards, a violation of which constitutes "unethical" behavior.

A different orientation toward ethics derives from the "Ethical Principles" aspect of the Ethical Principles of Psychologists and Code of Conduct. This orientation, which focuses on the principles to which we aspire, raises an important question for every member of our profession: What does it mean to be an ethical psychologist? A satisfying response will not come from a rule-based approach. Abiding by enforceable rules is necessary, but by no means sufficient for becoming an ethical psychologist. How, then, do we pour content into this aspirational concept of ethics?

Ethics can be defined as thinking about reasons in terms of values. The five ethical principles in the Ethics Code set forth psychology's core values: Beneficence and Nonmaleficence; Fidelity and Responsibility; Integrity; Justice; and Respect for People's Rights and Dignity. While it is entirely appropriate that other values, such as earning a living and developing professionally from our work, inform and motivate our behavior, the values in the five ethical principles play a fundamental role in setting the ethical parameters of our profession.

An ethical dilemma arises when two or more of the values found in the ethical principles conflict. Such a dilemma is an ethical dilemma because its resolution must appeal to values. Since, by definition, more than technical expertise is at issue in an ethical dilemma, even the most skilled practitioner cannot resolve an ethical dilemma by appealing to technical expertise alone. Resolving an ethical dilemma requires identifying the relevant values and weighing those competing values against one another to determine which receives priority.

In Tarasoff v. Regents of the University of California (see Judicial Notebook, page 112), a young man, Prosjenit Poddar, in treatment with a psychologist, threatened to harm a young woman, Tatiana Tarasoff. The psychologist did not break confidentiality to tell the young woman or her family of Poddar's threat, and Poddar did indeed kill Tatiana. In reviewing the case, the Supreme Court of California stated "The protective privilege ends where the public peril begins." This statement, found in a legal case, resolved an ethical dilemma that pitted confidentiality ("the protective privilege") against safety ("the public peril"). To resolve the ethical dilemma, the California court identified the values at stake--confidentiality and safety--and concluded that, in California, safety receives priority when these values conflict: Psychologists break confidentiality to protect the safety of a third party, such as Tatiana, from a patient's harm.

The California court emphasized that in giving priority to safety over confidentiality, confidentiality nonetheless remains important to preserve. According to the court, psychologists disclose confidential information only to the extent necessary to protect safety. Psychologists thus keep both values--safety and confidentiality--in mind at all points during the process of protecting. To say that one value receives priority is not to say that the other value is unimportant or may be neglected.

The California court's reasoning provides an excellent place to begin reflecting on one way of thinking about what it means to be an ethical psychologist. Elaborating on the court's analysis, an ethical psychologist is one who recognizes ethical dilemmas and strives to keep all of the competing values in mind as the dilemma unfolds. Encountering and engaging in ethical dilemmas, far from being a sign that a psychologist is somehow falling short, is rather an indication that what we do is subtle, complex and important. Holding on to multiple values simultaneously can be a significant challenge in our work and often requires courage in the face of uncertainty.

An area of practice that especially illustrates the call to be an ethical psychologist is working with individuals who struggle with chronic suicidal feelings. Such individuals, who sometimes meet the diagnostic criteria for borderline personality isorder, can place the question of values into bold relief because what these clients want may not be in their best interests. On one side of this dilemma is the Preamble to the Ethics Code, which states that the code "has as its goals the welfare and protection of the individuals...with whom psychologists work." On the other side of this dilemma is Principle E, "Respect for People's Rights and Dignity," which begins "Psychologists respect the dignity and worth of all people...and the rights of individuals to...self-determination." This dilemma may make itself felt throughout an entire treatment with a chronically suicidal patient, as a treating psychologist attempts to protect the patient's safety and welfare while at the same time respecting the patient's treatment wishes and life choices.

Marsha Linehan, PhD, a psychologist who developed dialectical behavior therapy (DBT) for individuals who meet criteria for borderline personality disorder, gives the profession a wonderful example of a treatment that integrates competing values. DBT clients engage in impulsive and sometimes very high-risk behaviors. Linehan's clinical approach takes both protecting the client's welfare and respecting the client's autonomy seriously. The foundation of DBT is informed consent: Clients work toward their own concept of "a life worth living," with the understanding that hospitalization, even in times of crisis, may hinder rather than help them on their way to that life. In good DBT treatment, there will be a tension between protecting the client from harm and enhancing the client's autonomy. Linehan welcomes that tension. Seeing an intervention too far in either direction--toward protecting the client or toward autonomy--as missing an opportunity for growth, a skilled DBT clinician uses the tension that arises in a particular moment with a particular client to push the client forward toward health. Ideally, such a melding of solid clinical and ethical thinking will help fashion the standard of care, so that good law, good ethics and good clinical care will come together and go hand-in-hand.

There is no single, definitive way of thinking about what it means to be an ethical psychologist. To say that an ethical psychologist does more than abide by our rules and standards by no means diminishes the importance of rules and standards, which are the bedrock that protects those with whom we work, and us, from harm. Thinking through what "more" characterizes an ethical psychologist, over and above obeying rules of conduct, is a fruitful exercise for all who are part of a profession that touches so many lives in such a profound manner.

Further Reading

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