Ethics Rounds

This past July, I had the opportunity to spend a day discussing ethics with faculty members from the Chicago School of Professional Psychology. This very thoughtful group of psychologists had extensive experience in forensic practice and several had taught ethics courses. I had with me a fairly detailed plan for the day, which was soon abandoned as our discussion turned from my planned material to how we teach ethics in the classroom and at our training sites. As our discussion unfolded, I found myself wondering whether my ways of teaching ethics were sometimes off the mark.

The issue that sparked my thinking was a question commonly brought up in ethics and risk-management workshops: An HIV+ client continues to be sexually active, refusing to disclose the status to a partner or partners and refusing to allow the treating psychologist to make any such disclosure. Is the psychologist either permitted, or required, to notify a partner or some other party of the client's health status? Most often the discussion centers on the jurisdiction's duty-to-protect (Tarasoff) law and how that law applies (or not) to the HIV+ scenario; on the jurisdiction's level of protection of HIV status; and on the relative risks and benefits of disclosing or not disclosing the material, given factors such as the likelihood that a disclosure will have the intended result of protecting a partner and the possible effect of the disclosure on the therapeutic relationship. These discussions press for an "either-or" resolution: The psychologist should either disclose the client's status or maintain the client's confidentiality. As the discussion progressed, I wondered whether this way of talking about ethical dilemmas--as important as these considerations are to the process of determining a course of action--missed something central to the ethics of our profession.

The exercise of judgment and discretion is the defining feature of a profession. Remove judgment and discretion from an ethics code and one is left with a simple laundry list of required and prohibited behaviors. This approach to ethics hardly befits a group of highly skilled and dedicated professionals and is ultimately unworkable, since it would be impossible to address the myriad circumstances that arise in a profession as broad, complex and nuanced as psychology. Consistent with its stature as a profession, psychology has an ethics code that allows, indeed requires, psychologists to exercise their judgment and discretion in arriving at an ethical course of action.

Arriving at an ethical course of action for a psychologist implies first, that the decision-making process involves ethics--that is, entails weighing and balancing the values of our profession--and second, that the psychologist relies on professional skills as an essential part of that process. The scenario above implicates values central to our profession. Principle A, "Beneficence and Nonmaleficence," exhorts psychologists to "safeguard the welfare and rights of those with whom they interact and other affected persons." Principle E, "Respect for People's Rights and Dignity," says that psychologists respect "the rights of individuals to privacy, confidentiality, and self-determination." A tension arises in the scenario between the psychologist's concern for "the welfare of...other affected persons," and the psychologist's respect for the client's rights to confidentiality and self-determination. Principle A states, "When conflicts occur among psychologists' obligations or concerns, they attempt to resolve these conflicts in a responsible fashion that avoids or minimizes harm." In thinking through the dilemma to arrive at an ethical course of action, the psychologist will weigh and balance these values against one another, in the context of the laws that govern, among other things: HIV status, the duty to warn or protect, and confidential communications between a psychologist and a client.

A discussion that ends here, however, is incomplete because it leaves the psychology out of the decision-making process. To have a professional code of ethics means that psychologists use their background, training and expertise as members of our profession to arrive at an ethical course of action. Identifying and weighing competing values against one another in the context of a legal landscape is essential, but represents only half of the decision-making equation. Remaining is to examine the client's psychology, an understanding of which will almost certainly affect, perhaps profoundly so, what course of action the psychologist ultimately decides upon.

Consider four clinical presentations regarding the scenario above. First, the client is a 45-year-old businessman who has contracted HIV through unprotected sex with prostitutes on business trips. He and his wife have two young children and plan for no more. They are affluent, live in a conservative part of the country and regularly attend church. While this man says he loves his wife and does not want to harm her, he is terrified that if his wife learns of his health status she will leave him and take the children, and that he will lose everything he has worked his entire life to achieve. Second, the client is a very immature 18-year-old male who comes from a culture that attaches great shame to homosexuality. To refute rumors among his peer group that he is gay, he begins to have unprotected sex with a girl his age whom he tells "protection is the female's business." Third, the client is a 30-year-old woman with bipolar illness who goes off her mood-stabilizing medication and becomes hypomanic, a usual prelude for her to a full-blown mania. She becomes convinced that any man who contracts the virus through a sexual contact with her will become, like her, invincible. Fourth, the client is a 25-year-old man whom you suspect has psychopathic features. He announces that he got tested and has HIV, probably from IV drug use "when people didn't know you could get it from needles." Asked whether he intends to tell his partner, whom he has been dating several weeks, he replies, "No way--we probably won't stay together, and I don't want word out on the street that I got the virus."

Each of these four presentations calls for a unique clinical response requiring a high degree of skill and nuance. The "either-or" approach to ethical decision-making risks missing what role psychology plays in arriving at an ethical course of action--that is, risks leaving out what lies at the heart of our ethics: that we have the benefit of extensive training and experience as psychologists. Equally important, framing the question as "either to disclose or not" and thus failing to discuss the clinical aspects of the scenario, including the very strong feelings that these issues generate in us as treaters, artificially removes the question from its clinical context, where psychologists inevitably confront their ethical dilemmas, apply their clinical skills and implement their decision-making processes.

I felt fortunate for the opportunity to think about these challenging issues with faculty members so clearly concerned with their students becoming ethical psychologists. The faculty's reflections gave me pause, by impressing upon me the importance of how we present ethics in the classroom, at clinical sites and in the lab. When we leave what is psychological out of our ethics presentations and discussions, we neglect the unique contributions we are poised to make by virtue of our background, training and experience as members of our profession, and so miss an essential aspect of our ethics. I left the workshop with an obvious but perhaps for that very reason all the more valuable lesson to keep in mind: Being a psychologist is an integral part of being an ethical psychologist.

Further Reading

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Previous "Ethics Rounds" columns can be found at the APA Ethics Web page in the "From the Director" section.