Ethical Dilemmas: Analysis of ethical case scenario 

Ethical dilemmas require a complex decision making process which is informed by; the relevant code of ethics; federal, state and or territory law; advice from colleagues; ethical principles which guide the practitioner and; the relevant decision making model. The author will argue that there are four main options to consider based on six moral principles to guide decision making using the feminist model for ethical decision making. The ethical dilemma is whether the practitioner should or must disclose confidential information arising from counselling sessions with the client. This model will inform the body of this paper to guide the reader in a practical way through this ethical dilemma. This paper is based on the case study which can be found in appendix 1. 

An ethical dilemma can be defined as a situation where there is only a decision which is “’more right’ than the alternatives” (Hill, Glaser, & Harden, 2008, p.102). In effect it is a situation where either decision is going to be difficult for the client and practitioner. Referring to the Australian Psychological Society (APS) Code of Ethics under the general principle of  “respect for the rights and dignity of people and peoples” (APS Code of Ethics, 2007, p.11) a practitioner should consider the rights of the survivor of child sexual assault. The practitioner should also consider their responsibility to the client in reference to the ACA Code of Ethics where “counsellors must take all reasonable steps to be aware of current law as it applies to their counselling practice”(ACA, 2012, 3.2.f.i, p.6). This is especially important when recording information which the client discloses as it may be subpoenaed later.

Of most relevance is an analysis of the ethical dilemma from a teleological perspective taking the utilitarian approach where the greatest good for the greatest number of people is valued. By exposing the teacher’s actions there would be a number of people affected including the school, other teachers, other students, and family of the teacher. Additionally one must consider the impact of disclosure on Graham’s family and the inevitable impact it would have on his relationships with colleagues, family, friends and students. This is consistent with the feminist perspective on ethics – ethic of care states that “all individuals interact with, rely on, and are depended on by others, and the complex webs of values and interactions and the contexts in which problems arise, cannot be ignored when applying other principled approaches” (Freegard & Isted, 2006, p.16). Due to these reasons, a feminist model for ethical decision making could be the most appropriate as it “includes the client in the decision making process wherever possible”(Hill et al., 2008, p.102). This reduces the power differential between the client and practitioner where appropriate. This model also takes into consideration the context and the intuitive emotions of the practitioner as well as the client’s place in society. In addition it would be helpful if Claudia had an understanding of the ethical framework/s which guides Graham’s decision making process. Tjeltveit (2005) has argued that if the practitioner can understand this then she can be more effective when talking through the major issues which have brought him to counselling.

Model – Part 1. Recognising a problem. The client (Graham) is presenting with symptoms of depression, anxiety, substance use issues and is a survivor of sexual assault. In addition the client is a staff member for the organisation Claudia works for fulfilling the role of pastoral care officer working with young people and children. Using a rational evaluative process as outlined by Hill et al., Claudia might choose to discuss disclosure with the client in that they may wish to get legal advice for both the sexual assault and the possible manslaughter(2008). From a feeling-intuitive perspective she may have doubts as to the benefit of going through the court system and bringing up issues from the past. She may feel that this is beyond her level of competence and being guided by the principle of nonmaleficence may wish to refer the client.

Model – Part 2. Defining the problem. The rational evaluation should lead to a review of the relevant ethical codes as mentioned previously. From an intuitive perspective Claudia would be asking herself why she feels uncomfortable about the situation and “what are the client’s feelings about the dilemma”(Hill et al., 2008). As a survivor of sexual assault Graham may have a negative view of himself which could be perpetuated as a result of this disclosure. (Dunmore, Clark, & Ehlers, 2001, p.1079). This process will highlight the ethical dilemma.

Model – Part 3. Developing solutions and choosing a solution.  There are four main scenarios and six moral principles to guide decision making: autonomy;  nonmaleficence;  beneficence;  justice, fidelity; and veracity as stated by Meara and colleagues (as cited in Corey, Corey, & Callahan, 2011, p.19). In particular the principles of autonomy, nonmaleficence, justice and beneficence will be discussed here whilst further explanation can be found in table 1. Underpinning these ethical principles are the values of the practitioner (Corey et al., 2011, p.16) and practitioners need to ensure they don’t teach the client these values as this can have a negative effect on client autonomy. The dilemma regarding justice is whether Claudia should disclose this information for the good of society, weighing this up against the harm it may do to the client. This takes into account the principle of beneficence not only to the client but “also includes doing good for society”(Corey et al., 2011, p.20). If there are others who have suffered, this could also be a positive process for them to go through.

The first option Claudia discusses with her supervisor is to continue the treatment and tell Graham that the information does not need to go further as the incident was a long way in the past and no good could come from raising it again.  The second option is to refer Graham to the Service Assisting Male Survivors of Sexual Assault (SAMSSA) as their counsellors are specifically trained to assist men who are in Graham’s situation. The third option is to seek legal advice regarding disclosure and whether she is breaking any law by keeping this confidential (see Table 1). The fourth option is to encourage Graham to seek his own legal advice so he can be aware of his rights and make an informed decision from there.

Whilst researching online she discovers that she will need to disclose as:

If a person has committed a serious indictable offence and another person who knows or         believes that the offence has been committed… fails without reasonable excuse to bring that    information to the attention of a member of the Police Force or other appropriate authority, that other person is liable to imprisonment for 2 years.(NSW CRIMES ACT 1900, 2012)

Mcmahon (1998) found that there is no law privilege applying to therapy though the “law has not been used against youth workers and other welfare workers in NSW.”

Model -Part 4. Choosing a solution. Claudia decides that three of the four solutions are in the best interests of the client. She felt intuitively that covering this up any further could lead to further guilt and shame for Graham.  Whilst making this decision she considers the following points; what the likelihood of reoffending; his age at the time of the crime; the context and; the likelihood that a jury would convict him once all the evidence was obtained.

Identifying with the principle of nonmaleficence, Lievore states the practitioner needs to understand that the client’s disclosure is quite often “primarily motivated by the need for safety, protection and support; not wanting to be alone; or were seeking information to help them clarify their understandings about the nature of the assault”(as cited in Quadara, 2008, p.3). So whilst there is a need to explore the issue of sexual assault and subsequent death of the client’s attacker the first priority is the wellbeing of the client.

Model – Part 5. Reviewing Process. Claudia has the weekend to think about her decisions and is conflicted by her need to ensure she doesn’t break the law versus the need to do no harm to the client. She checks the policies of the University she works in and cannot find any reference to wrongdoing by not disclosing particularly as Graham has not been charged with any offence. She reviews the PACFA guidelines and considers the values and principles “Respect for the essential humanity, worth and dignity of all people” (2012, 2.1 A.) is the most relevant part of the code in helping make her decision.

Model – Part 6. Rechoosing a solution. After long deliberation she decides that the most important consideration is the wellbeing of the client. She thinks that Graham can go to SAMSSA and discuss the sexual assault and work through those issues. As far as she is aware there is no proof that Graham caused the teachers death and Graham was acting in self-defence. She decides to refer due to the possibility of a dual relationship in the organisation given that Graham often refers students to her counselling service though not directly to her as she is responsible for staff.

Model – Part 7. Implementing and evaluating the decision. Claudia works with Graham over two more sessions to encourage him to seek help from SAMSSA and to work through the issues of guilt. She also referred him to Legal Aid for confidential advice.

Model – Part 8. Continuing reflection.

Claudia reflects on the decisions she has considered after Graham has moved on to SAMSSA. She feels that she could have worked with Graham and kept the death a secret because she has children of her own and she considered what she might do if she had known about one of them being abused. She struggles with her moral values in this case and was glad she made the best decision for her client. 

Conclusion

Counsellors face a wide range of ethically challenging situations on a weekly or daily basis. It is not enough for them to be aware of their values and those of the client. Practitioners have a wide range of resources to draw on whilst considering ethical dilemmas including the relevant ethics code, colleagues and decision making models. Disclosure of past crimes in relation to homicide must be reported to police and decision making models can be a useful framework to assist especially when there are legal obligations for the practitioner.  

References

Australian Counsellors Association. (2012). Code of Ethics and Practice (pp. 1–16). Retrieved from http://www.theaca.net.au/documents/ACA Code of Ethics v8.pdf

Australian Psychologists Society. (2007). Code of Ethics. Melbourne, Australia. Retrieved from http://www.psychology.org.au/Assets/Files/APS-Code-of-Ethics.pdf

Corey, G., Corey, M. S., & Callahan, P. (2011). Issues and Ethics in the Helping Professions (8th ed., pp. 1–587). Belmont: Brooks/Cole.

Dunmore, E., Clark, D. M., & Ehlers, A. (2001). A Prospective investigation of the role of cognitive factors in persistent Posttraumatic Stress Disorder (PTSD) after physical or sexual assault. Behaviour Research and Therapy, 39, 1063–1084.

Freegard, H., & Isted, L. (Eds.). (2006). Ethical Practice for Health Professionals (2nd ed.). Melbourne, Australia.

Hill, M., Glaser, K., & Harden, J. (2008). A Feminist Model for Ethical Decision Making. Women & Therapy, 21(3), 101–121.

Manning, N. (2006). Is it OK? Duty of care, law & ethics in NSW youth work: A guide to common legal and ethical dilemmas. Youth Action & Policy Association NSW. Retrieved from http://www.yapa.org.au/youthwork/facts/ok/privacy.php

McMahon, M. (1998). Confidentiality & disclosure of crime related information. In-Psych. Retrieved November 20, 2012, from http://www.psychology.org.au/Assets/Files/crime_related_confidentiality_ethics.pdf

NSW CRIMES ACT 1900 (2012). SECT 316. Retrieved from http://www.austlii.edu.au/au/legis/nsw/consol_act/ca190082/s316.html

Quadara, A. (2008). Responding to young people disclosing sexual assault: A resource for schools. Australian Centre for the Study of Sexual Assault, 6, 1–11. Retrieved from http://www.aifs.gov.au/acssa/pubs/wrap/acssa_wrap6.pdf

Tjeltveit, A. (2005). Ethics and Values in Psychotherapy (1st ed., pp. 1–331). New York: Routledge.

Appendix A

Case scenario

Claudia is a counsellor at a University in Canberra. She had been working with a staff member Graham for 4 sessions now in her role as staff advisor. Graham had been experiencing chronic anxiety and symptoms of depression which he was dealing with by self-medicating with alcohol. Claudia had been focusing on the substance use and anxiety using CBT and Graham was not interested in considering medication. During the 6^th session Graham revealed that he was sexually assaulted by one of his teachers whilst residing at boarding school in NSW. This went on for a number of months until one time the teacher tried it on him again and, in a rage Graham pushed him causing him to fall, hitting his head on the brick fireplace in the teachers room. Graham ran back to his own room quickly and it was never known to anyone else what had happened. The teacher never regained consciousness. Graham broke down as he told this story, sobbing uncontrollably then realising what he had said he looked up at Claudia in fear and told her that he had never told anyone else. His pallor was pale as he asked Claudia not to tell anyone.

Table 1.

Description of Ethical Dilemma Based on Ethical Principles

principlesOption 1

Continue treatment. No disclosureOption 2

Referral to SAMSSAOption 3

Practitioner legal adviceOption 4

Client legal adviceAutonomyLeaves the decision to the client.Refer client to SAMSSA to assist in self-determination after sexual assault.Can then discuss options with client. May need to disclose regardless of client’s wishes.Client makes own decision about disclosure.NonmaleficenceClient does not face extra distress. Guilt may need to be worked on.Less risk to client due to underqualified treatment.Client & Practitioner relationship determined by external factors.Client & Practitioner relationship determined by external factors.BeneficenceNeeds of the client are met.

Practitioner may be breaking the law.Client receives more specific treatment.Practitioner can inform client of important external factors.Practitioner can discuss options with client.JusticeClient does not go through the justice system. Client may not get closure.Client’s rights will be looked after based on years of organisational experience at SAMSSA.High likelihood client would not be charged.High likelihood client would not be charged. FidelityClient should have been made aware of the limits of confidentiality.Client informed that client notes will be passed on as well.Practitioner is in a dilemma regarding disclosure of a crime.Client is truthful with practitioner about the information received.VeracityPractitioner does not provide enough information for autonomous decision making.Counsellor should provide information about the risks and benefits of disclosure to SAMSSA.Counsellor should provide information about the risks and benefits of disclosure.Ensure the client knows their rights. Ensure the client knows the practitioners obligations.