How to Make Ethical Decisions
When Faced With Real World
Ambiguities
Marna S. Barrett, Ph.D.
Department of Psychiatry
Support
 The Thomas Scattergood Behavioral Health
Foundation, Philadelphia, PA
University of Pennsylvania
 Dominic Sisti, PhD and the Department of Medical
Ethics & Health Policy
 Mood & Anxiety Disorders Treatment & Research
Program
Overview
 Why decision-making
 Strategies for confronting and resolving ethical
dilemmas
 Application in real world scenarios
Ethical Decision-Making
Cases
Case #1. BPD
Matthew, 37 year old male, presents after recently being fired from a
job and a history of 10 job losses. He has been off and on social
assistance throughout his life due to lack of career goals and interests.
Matthew reports that he has been fired for “no reason”- when
questioned further it appears that inability to get along with coworkers
is the root of the problem. Matthew reports being mistrustful and
jealous of his coworkers. He tells you that he is really angry at a
former coworker whom he doesn’t name and says he is so angry he
could just snap and kill someone. What do you do?
Cases
Case #2: Trauma
Stephanie, 48 year old widowed accountant, has just begun to talk
about her husband’s murder (during a household robbery) and how
scared, vulnerable, and alone she feels. She tearfully describes the loss
of his physical and emotional support---- “He would be comforting me now
if this had happened to anyone else.” At the end of session, she wipes her
tears away with a tissue and asks you for a hug.
Cases
Case #3: Depression
Alice, is a 45 year old mother of three, who presents a year after her
third failed marriage. Despite having been a “stay-at-home” mom, she
struggles with her identity. She reports feeling lost and not knowing
who she is or what purpose there is in life. Alice reports feelings of
chronic emptiness. She has tried a number of antidepressant
medications with little symptomatic relief. After a few sessions, she
reports wanting to die and is thinking of driving off a bridge with her
three children in the car. She is the sole caregiver for her children and
has no family support nearby. What do you do?
Decision-making
What is decision-making?
 Identifying and choosing alternatives based on
values and preferences.
 Process of sufficiently reducing uncertainty and
doubt about alternatives to allow a reasonable
choice to be made.
Decision-making
How is moral decision-making different?
 Process for dealing with moral uncertainties
 Introduces a degree of rationality and rigor
into our moral deliberations
Decision-making
Why do we need a model specific to psychiatry?
 Ethical problems require examination through
filters: organizational, personal, social, legal
 Mental health has unique issues:
- authority over others
- determine social policy
- legal influence
Ethical Decision-making
Why do I need a model for making ethical
decisions?
 Professional guidelines often fail us
 The “right” decision is not always clear
 Most of the ethical dilemmas we face do not
come with clear resolutions
Organizing Principles
Autonomy: right to noninterference, self-determination
(confidentiality, treatment options, records)
Beneficence: mercy, kindness, charity to others
(competent, identify/report abuse & neglect,
community service)
Nonmaleficence: avoid harm or risk of harm
(know limits, keep current, refer, consult)
Organizing Principles
 Justice: benefits, risks, costs distributed fairly
(treat fairly, non-prejudicial care, emergency care)
 Fidelity: faithfulness to duties or obligations
(honest, trustworthy, overbilling, waiver of co-payment)
 Empathy: experience the experience of others
Ethical decision-making
Ethical Principles inform decisions
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Ends -based
Rule-based or Kantian principle
Justice or fairness-based (Aristotle)
Care-based principle (i.e., Golden Rule)
Virtue-based
Ethical decision-making
Most dilemmas are not right vs. wrong but right vs. right
dilemmas.
- It is right to respect autonomy,
it is right to prevent harm
- It is right to uphold confidentiality,
it is right to protect the welfare of others
How Good People Make Tough Choices
Rushworth M. Kidder, 1995
Ethical decision-making
Dilemmas often represent competing moral paradigms
▪ Truth vs. Loyalty
duty to paying parents vs. duty to minor patient
▪ Individual vs. Community
patient needs vs. family needs
▪ Short-term vs. Long-term goals
work demands vs. family demands
▪ Justice vs. Mercy
respect for autonomy vs. respect for others
How Good People Make Tough Choices
Rushworth M. Kidder, 1995
Ethical decision-making
Models to guide us in making decisions
 Standards-based
 Principle-based
 Virtues-based
 Practice-based
Ethical decision-making
I. Standards-based model
Based on the assumption that rules, laws, & policies provide
the best basis for determining action.
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Determine primary dilemma
Spell out ethical standards for response
Determine if there is a reason to deviate
Decide on course of action
Ethical decision-making
When would following rules be the best
choice?
What difficulties might arise if we followed
rules/policies for all ethical dilemmas?
Ethical decision-making
II. Principles-based model
Clarify
▪ Determine dilemma
▪ Key ethical principles and values involved
Evaluate
▪ Any ethical principle violated?
▪ Facts vs. beliefs, theories, opinions
▪ Consider credibility of sources
▪ Weigh benefits, burdens and risks
Ethical decision-making
II. Principles-based model (cont’d)
Decide
▪ Evaluate alternatives & determine consequences
▪ Prioritize ethical principles/values
Consider worst case scenario & Apply principles
▪ Implement
▪ Maximize benefits & minimize costs & risks
Monitor and modify
Ethical decision-making
How does the principles-based model
improve upon the standards based model?
Where does this model fall short in
addressing ethical dilemmas in your work?
Ethical decision-making
III. Virtues-based model
Dispositions and habits allow us to act to the highest
potential of our character and on behalf of our values.
▪ Virtue ethics asks of any action:
What kind of person will I become if I do this?
Is this action consistent with my acting at my best?
▪ Use virtues in considering options
▪ Make decision
Ethical decision-making
How does reliance on virtues improve our
decision-making?
What difficulties might arise if we followed
only our virtues in resolving ethical
dilemmas?
Ethical decision-making
IV. Integrated or practice-based model
1. Recognize there is a dilemma
2. Determine the actor(s)
3. Gather the relevant facts
4. Test for right-versus-wrong issues
5. Test for right-versus-right paradigms
Ethical decision-making
6. Determine resolution principles involved
▪
▪
▪
▪
▪
Ends-based
Rule-based or Kantian principle
Justice or fairness-based
Care-based principle
Virtue-based
7. Investigate possibilities for action: “trilemma”
8. Consult
9. Weigh benefits & burdens
Ethical decision-making
10. Consider additional dilemmas
11. Make the decision
12. Formulate a justification for the decision
▪ List reasons & arguments
▪ Recognize shortcomings
▪ Anticipate objections
▪ Recognize limitations in perspective
13. Document
14. Review and reflect on decision
Ethics in Psychotherapy and Counseling: A Practical Guide (4th edition), Pope & Vasquez, 2011
Conclusions
What does your model look like?