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Morality Values Duties
Morality Personal Morals Societal Morals Group Morals
Morals vs. Ethics Ethics = systematic reflection on
morality Ethics = applied morals Ethical Decisions - most difficult
when ethical dilemmas exist
Ethics - Definition “Do the right thing” (Spike Lee)
Categorization of Moral Theories Relativism vs. Absolutism Micro ethics vs. Macro ethics Deontological vs. Teleological
Relativism vs. Absolutism Relativism
What is right and wrong varies from person to person and culture to culture
There are no absolute moral standards Absolutism
There are absolute moral standards that are both universal and objective
Micro ethics vs. Macro ethics Micro ethics
The happiness of the individual is the highest good
The good of the group = the good of the individuals who comprise the group
Macro ethics The happiness of the group itself (city,
state, nation or race) is the highest good
Deontological vs. Teleological Theories Deontological Theories
The correct way to proceed is to learn basic duties and rights of individuals or groups and act accordingly• e.g. Kant’s Categorical Imperative
Teleological Theories Sometimes adherence to duty leads to
consequences contrary to well-being. • E.g. Utilitarianism ( Bentham, Mill)
Ethical Principles Beneficence Autonomy Nonmaleficence Justice Fidelity
Beneficence Comes with risks General Societal Obligations? Strength of Duty Factors
Significant need Ability to assist probability of success Benefit outweighs risk
Role-related obligation
Risks of Beneficence: Paternalism Undermines dignity promotes dependence conflicts with rights to autonomy When is paternalism justified?
Competency is seriously limited C has ability to promote Cl’s best interests Cl’s interests are considered primary Risk for loss must be real & significant
Autonomy 3 conditions necessary for autonomy
Voluntariness Competence Full Disclosure
What & how much should one disclose? The “reasonable person” standard Individualized standard
Does client/patient truly understand?
Informed Consent enables client to make autonomous
choices minimizes harm/risk by enabling cl
to protect self encourages c & cl to discuss issues
openly & plan together
Promoting Autonomy Assess Teach Encourage choice wherever &
whenever possible
Nonmaleficence Beneficence vs. Nonmaleficence
Beneficence: Doing Good Nonmaleficence: Avoiding Harm to another by
• not directly causing harm• avoiding placing others at risk for harm
“Above all, do no harm” - role obligations Obligation to prevent harm is stronger than
obligation to do good In rehab, must take some risks for later
benefit
Negligence: Failure to act or to exercise due care Failure to exercise due care toward
another Due Care = Proper training + Proper skills +
Diligence Includes both deliberately & carelessly
imposed risks Types of Negligence
Culpable ignorance Personal Incompetence Environmental factors
Justice Most problem in conditions of
scarcity and competition Actions based on justice (examples)
avoiding discrimination avoiding exploitation distributing resources fairly
Material principles of Justice Equal shares need motivation/effort contribution free market exchange fair opportunity
FUNDAMENTAL NEED: person will be harmed if need is not met - takes priority
Quantitative criteria of Distributive Justice Cost-effectiveness Limitations:
Quantity isn’t everything (can’t quantify human dignity & worth
Efficiency ignores common values e.g. hospice, etc.
Fidelity Focuses on relationships Caregivers make implicit promises of
trustworthiness Asymmetric relationship increases
duty to fidelity
Confidentiality Assumed by your willingness to enter into
therapist-patient relationship Circumstances under which confidentiality
can be broken clear & imminent danger to self or others others as determined by law (e.g. child abuse,
elder abuse) court actions/subpoena
Importance of disclosure
Dual Relationships Sexual, family, friend, business,
supervisor, etc. Pt. Needs to be free of your
problems may impair objectivity &
professional judgement
Fidelity in Professional Relationships Fidelity to employer Fidelity to profession Fidelity to colleagues/team
Principles vs. Standards Principles: General Guidelines to
govern one’s actions Standards: Generally derived from
principles and prescribe appropriate behavior in a given circumstance Rules Laws Codes
Ethical Codes Assist counselors in deciding what to do
when situations of conflict arise Help clarify the counselor’s responsibility
to the client and protect the client from the counselor’s failure to fulfill these responsibilities
Give the profession a means of self governance
Ethical Codes of Interest to Rehabilitation Counselors Code of Professional Ethics for Rehabilitation
Counselors (CRCC) American Counseling Association (ACA) International Association of Rehabilitation
Professionals (IARP) American Psychological Association (APA) National Association of Social Workers (NASW) American Association for Marriage & Family
Therapy (AAMFT) Association for Specialists in Group Work (ASGW)
Code of Professional Ethics for Rehabilitation Counselors
CRCC Ethics Committee initiated 2001 update due to
• Changes in practice• Changes in technology• Experience of Ethics Committee
Code Structure Table of Contents Preamble Enforceable Standards of Ethical
Practice 11 Sections (A-K) Rules within each Section
Sections of Code A The Counseling Relationship B Confidentiality C Advocacy and Accessibility D Professional Responsibility E Relationships with Other
Professionals F Evaluation, Assessment and
Interpretation
Sections of Code continued G Teaching, Training, and
Supervision H Research and Publication I Electronic Communication and
Emerging Applications J Business Practices K Resolving Ethical Issues
Consultation Model Code of Ethics Supervisor Colleagues Experts Licensure &/or Certification Boards
Questions to Ask Have I Consulted with the Code?
Others? Have I Documented Everything? What if this was the Newspaper
Headline? What if this was the one I most love?
Ethical Dilemma Choice must be made between two or
more courses of action Significant consequences for any course
of action Each action can be supported by ethical
principle(s) Ethical principle supporting unchosen
course of action is compromised
Ethical Decision Making Model for Rehabilitation Counselors Review the situation & determine the
possible courses of action List the factually based reasons
supporting each course of action Identify the ethical principles that support
each action List the factually based reasons for not
supporting each course of action Identify the ethical principles that would
be compromised if each action were taken
Ethical Decision Making Model continued Formulate a justification
Rubin et al. (1990)
The Eclectic Decision-Making Model of Ethical
Behavior
Tarvydas (1998)
Stage I: Interpreting the Situation through Awareness and Fact-Finding
>Enhance sensitivity and awareness>Dilemma vs. issue?>Determine major stakeholders & their ethical claims in the situation>Engage in the fact-finding process
Stage II: Formulating an Ethical Decision Review the dilemma Determine what ethical codes, laws,
principles, and institutional policies and procedures apply
Generate possible and probable courses of action
Consider potential positive and negative consequences
Select the best ethical course of action
Stage III: Selecting an Action by Weighing Competing, Nonmoral Values
>Engage in Reflective Recognition and Analysis of Personal Competing Values>Consider Contextual Influences on Values Selection at the Collegial, Team, Institutional, and Societal Levels
Stage IV: Planning and Executing the Selected Course of Action
Figure out a reasonable sequence of concrete actions to be taken
Anticipate & work out personal & contextual barriers to effective execution of the plan, and effective counter-measures for them
Carry out and evaluate the course of action as planned
Processing Ethical Complaints
The CRCC Ethics Committee Process and Procedures for Processing Ethical Complaints
Commission on Rehabilitation Counselor Certification (CRCC)
CRC Credential Assures certified RCs meet minimum
ed, experience and competency standards
Consumer protection Accountability
CRCC Ethics Committee Promotes Ethical Practice among
Certified Rehabilitation Counselors CRCC Code of Ethics Education Advisory Opinions Self Governance/Judicial Function
Reporting Ethical Violations Who Reports? The Ethics Complaint Form
Steps in the Process The Ethical Complaint Process
Flowchart Details actions of Ethics Committee and
Administrative Office Blueprint for processing complaints
Suggested Procedures for Initial Case Review (Tarvydas)
Summarize charge If true, as alleged, would there be an
ethical violation? Identify specific Ethical Canon(s) and
Rule(s) Accept complaint if violation may have
occurred What additional info/evidence is needed?
Ethics Committee Actions Letter of Instruction Reprimand Probation Suspension Revocation
Legal/Ethical Interface
Understanding the Legal Issues impacting Rehabilitation Counselors
Types of Procedural Law Civil Law Criminal Law Mental Health Law
Civil Law Lawsuits brought by private parties
against each other Losing means financial loss Burden of Proof:
Fair preponderance of the evidence Burden is on Plaintiff
Criminal Law Disputes between state & persons Losing means loss of liberty Burden of Proof:
Beyond a reasonable doubt Burden is on the State
Mental Health Law Regulates how state helps mentally ill
persons (commitment hearings) Considered type of Civil Law Conflict: right to freedom vs. state’s resp.
to protect those unable to protect selves Burden of Proof
Because psych is too inexact to meet reasonable doubt, must meet level of reasonable medical certainty test
Clear & convincing evidence Burden is on those bringing the proceedings
Case Law Tarasoff v. Regents of the University of
California Requires therapists to protect foreseeable victims
of dangerous clients (Duty to Warn or Duty to Protect).
Wyatt v. Stickney, Donaldson v. O’Connor & O’Connor v. Donaldson: Duty to treat involuntarily confined mental patients
or release them Caesar v. Mountanos
The client is the sole holder of the psychotherapist-client privilege
Therapists are regulated by Laws at three levels: Federal State
Statute Regulations
Local County/City
Florida Law Themes Confidentiality
Allowable Exceptions to Confidentiality
Mandated Reporting of Abuse or Neglect of: Aged persons Disabled adults Children
Children & Families (confidentiality, custody,etc)
Psychotherapist-Patient Privilege
Involuntary Admission (Baker Act)
Guardians and Substitute decision-making
Ethics and The Law
Mandatory ReportingDiscretionary ReportingDuty to Protect
Ethics and The Law Linda R. Shaw, Ph.D., CRC, LMHC Associate Professor & Graduate
Coordinator University of Florida Dept. of
Rehabilitation Counseling
This presentation provides general guidance only. All questions related to Florida Law should be directed to an attorney specializing in mental health law.
Presumption of Confidentiality Confidentiality is necessary to preserve:
Client privacy, dignity & respect A relationship characterized by trust Client Autonomy (freedom to decide with
whom information will be shared) Florida LMHCs are included in Testimonial
Privilege Law – Cl. has right to keep confidential communications from being disclosed in a legal proceeding (Fla Statute 90.503).
Rationale for Exceptions to Confidentiality Must balance client’s right to privacy &
autonomy with competing societal interests
Exceptions may be either Mandatory – Counselor shall report Permissive – Counselor may report
Whether an exception is permissive or mandatory depends on the importance of the societal interest at stake
Mandated Exceptions to Confidentiality Reporting Generally referred to as “Mandated
Reporting” Requires that certain information
applying to particularly vulnerable groups be disclosed to ensure their safety & well-being
Mandated Reporting Required of all persons who, in a
professional capacity, come into contact with individuals comprising three groups:
Groups include: Children Elderly Disabled Adults
Mandated Reporting Children (Fla. Statutes 39.01 and 827.03)
Must report any incident of known or suspected abuse, abandonment or neglect
Definitions:• Abuse: “any willful act or threatened act that results
in a physical, mental or sexual injury or harm that causes or is likely to cause the child’s physical, mental, or emotional health to be significantly impaired” (Fla. Statute 39.01) Also includes the active “encouragement of any person to commit an act that results or could reasonably be expected to result in physical of mental injury to a child” (Fla Statute 827.03)
Mandated Reporting Children (Fla. Statutes 39.01 and 827.03)
Must report any incident of known or suspected abuse, abandonment or neglect
Definitions:• Neglect: a caregiver’s failure to (1) provide a child
with necessary care, supervision, and services and (2) to make a reasonable effort to protect a child from abuse, neglect or exploitation (Fla Statutes 39.01 and 827.03).
• Abandonment: when a parent sufficiently fails to support and nurture a child so as to evince a willful rejection of parental obligations (Fla. Statute 39.01[1]).
Mandated Reporting Children
Fla. Statutes 39.01 and 827.03 list specific examples of situations that would constitute abuse and/or neglect – e.g.• Cuts, bites, burns, scalding• Excessively harsh discipline likely to result
in physical injury• Failure to provide child with adequate food
or clothing
Mandated Reporting Elders and Disabled Adults (Fla. Statute 415) Definitions:
Abuse: the “nonaccidental infliction of physical or psychological injury or sexual abuse” (Fla Stat. Ch. 415.102[1])
Neglect: “the failure or omission . . . To provide care, supervision, and services necessary to maintain the physical and mental health of the disabled adult or elderly person.”(Fla. Stat. Ch. 415.101[2]).
Exploitation includes “financial exploitation and misuse of funds” (Fla. Stat. Ch. 415.101[2]).
Mandated Reporting Standard for reporting
Must report if the mandated reporter “knows or has reasonable cause to suspect” that harm is occurring or has occurred.
Timing of report As soon as mandated reporter has
reasonable cause to suspect
Florida Abuse Hotline Department of Children and Famlies Contact Information:
ServicePhone: (850) 487-4332 Suncom: 377-4332 Toll Free: (800)962-2873
Liability Failure to report (e.g. Fla. Statute 491)
Possible criminal sanctions – “knowingly & willfully”
Civil sanctions Professional discipline
Release from liability (Fla. Statute 39.203, 415.111) No civil or criminal sanctions attach when
report is made in good faith
Permissive Reporting
Allows counselor to exercise discretion and to violate confidentiality under certain conditions:
Permissive Exceptions to Confidentiality Client consent Treatment emergencies Facilitation of Treatment Provision of mental health services
Peer & administrative review The legal system Research Public safety
Exceptions to Confidentiality to Protect the Public Safety
Florida and the Tarasoff Decision Tarasoff v. California Board of
Regents Created a duty to protect identifiable 3rd
party Florida is not a Tarasoff state
Florida Laws related to public safety Confidentiality may be waived when
“there is a clear and immediate probability of physical harm to the patient or to the society”(Fla. Statute 491.0147)”
Psychiatrists have the option to to disclose when the patient has made an “actual threat” to “physically harm” an “identifiable victim” (Fla Statute 455.671)
Florida Laws related to public safety Mental health counselors may
disclose to a HIV positive patient’s sexual or needle-sharing partner when Patient has disclosed the identity; and Patient has refused to notify the partner
nor will he/she refrain from high-risk activity (Fla Statute 455.674)
Protections against Malpractice Abide by the Law of No Surprises
Informed Consent Professional Disclosure
Professional Disclosure The nature & purpose of the services provided Risks and Benefits Alternatives to service provision Information about the procedures and duration of
counseling Limitations on confidentiality Client’s right to make complaints and/or
discontinue services Logistics of counseling (Making & canceling
appointments, etc.) What to do in an emergency Policies and procedures regarding fees
Protections against Malpractice Know your legal and ethical
responsibilities Codes of Ethics Statutes & Regulations
Consult Allows for “reality testing” Establishes standard for
“reasonable” care Establishes evidence for reasonable
& prudent action
Document If its not written down, it didn’t
happen Never alter documentation!
Insure against malpractice Anyone can be sued at any time Institution liability insurance may
not be adequate Available through professional
associations
Professional Disclosure
Professional Disclosure: The act of sharing the information
needed to understand the nature and characteristics of the counseling process, toward the goal of furthering informed, autonomous decision making
Professional Disclosure: Informed Consent:
The obligation to ensure that the consumer understands all information pertinent to any choices he or she must make throughout the course of treatment
Counseling Guidelines Describes the logistics of how the
rehabili5tation process works
How to approach Disclosure Individual vs. Group Written vs. Oral or Both Low Tech vs. High Tech Information Imparting vs. Information
Sharing A one-way street or a two-way street? When/how does the consumer orient you?
Ensuring understanding – short term and long term
What to include? Varies by agency, state law, needs
of consumer How much is enough? Too much? Accessibility of Information
What to include? Goals of the Agency The Rehabilitation Process Services available
What the agency can do What the agency can’t do
Eligibility Criteria & Process Financial Obligations/Limitations Timelines General Logistics (Appointments, etc)
What to include? The role of the Counselor Education – Credentials - Special Skills Contact Information Values – Approach - Philosophy What your counselor expects from you What you may expect from your
counselor Right to ask about treatment/progress Right to complain
What to include? Benefits & Risks of Participation Alternatives Purposes & Uses of Testing Release of Information
Procedures Limitations on Confidentiality
Disclosure Checklist Non technical &
easily understood? Length? Enough
info? Too much? Personal? Too
personal? General tone?
Does it convey what you want to convey?
Inclusive of critical information?
Inviting format? (white space, font size, etc.)
Decisions at the End of Life
Introduction Increasingly, Americans die in medical
facilities 85% of Americans die in some kind of
healthcare facility (hospitals, nursing homes, hospices, etc.)
Of this group, 70% (60% of the population as a whole) choose to withhold some kind of life-sustaining treatment
The Right to Die Do we have a right to die?
Negative right (others may not interfere Positive right (others must help
Do we own our own bodies and our lives? Do we have the right to do whatever we want with them?
Isn’t it cruel to let people suffer pointlessly?
The Sanctity of Life Life is a “gift from God” Importance of ministering to the sick
and dying See life as “priceless” (Kant)
Compassion for Suffering The larger
question in many of these situations is: how do we respond to suffering?
Hospice and palliative care
Aggressive pain-killing medications
Sitting with the dying
Euthanasia
What are we striving for? Euthanasia
means “a good death”, “dying well”
What is a good death? Peaceful Painless Lucid With loved ones
gathered around
Some Initial Distinctions Active vs. Passive Euthanasia Voluntary, Non-voluntary, and
Involuntary Euthanasia Assisted vs. Unassisted Euthanasia
Assisted vs. Unassisted Euthanasia Many patients who want to die are
unable to do so without assistance Some who are able to assist
themselves commit suicide with guns, etc. - - ways that are much harder and difficult for those who are left behind
Voluntary, Non-voluntary and Involuntary Euthanasia Voluntary: Patient chooses to be put
to death Non-voluntary: Patient is unable to
make a choice at all Involuntary: Patient chooses not to
be put to death, but is anyway
Active vs. Passive Euthanasia Active euthanasia
Occurs in those instances in which someone takes active means, such as a lethal injection, to bring about someone’s death
Passive euthanasia Occurs in those
instances in which someone simply refuses to intervene in order to prevent someone’s death
Active Euthanasia Typical case for active euthanasia
There is no doubt that the patient will die soon
Passive measures will not bring about the death of the patient
The option of passive euthanasia causes significantly more pain for the patient (and often the family as well) than active
Criticisms of the Active/Passive Distinction in Euthanasia
Conceptual Clarity – vague dividing line between active and passive, depending on notions of “normal care”
Moral Significance – does passive euthanasia sometimes cause more suffering?
Health Care Advance Directives
Planning Ahead for End of Life Decisions
Health Care Advance Directive A document in which you give instructions
about your health care if, in the future, you cannot speak for yourself Living Will: State wishes about life-sustaining
medical treatments Health Care Power of Attorney: Appoint
another to make medical treatment decisions for yo if you cannot make them for yourself
Health Care Advance Directives Should provide specific guidance
regarding your wishes about: Artificial respiration Nutritional support & hydration Medication use for
• Pain relief• Prolonging life
Organ Donation
Legally Binding? Legal document in most states Medicaid requires discussion for
admission to healthcare facilities Durable Power of Attorney Most courts tend to honor wishes
expressed in living will
The Slippery Slope Worrisome examples from history:
Nazi eugenics program Chinese orphanages
Special danger to undervalued groups in our society The elderly Minorities Persons with disabilities Groups that are typically discriminated against
Supervision Clinical Supervision
Developing and enhancing the clinical competencies of supervisees
Providing oversight/Protecting the safety and well-being of clients
Administrative Supervision Facilitating the activities of supervisees Ensuring competent performance of job duties
and implementing corrective action, as necessary
Complex Overlapping Roles Teacher Counselor Consultant Evaluator
Conflicting Roles Power differential/therapy-like
relationship Fidelity to client, employer and
supervisee, and protection of self
Dual Relationships Danger of impaired judgment and
exploitation Is a sexual relationship appropriate? A close friendship?
Competence Supervisory Skills
Development of Counselor Skills Implementing Corrective Action Providing meaningful evaluation
Confidentiality Client information/Informed Consent Supervisee information
Ethical Issues in Research
Themes Honesty Integrity Objectivity
Protection of Human Subjects Historical Violations of Human Rights Need for Informed Consent Nonmaleficence
Informed Consent Voluntariness Confidentiality Full disclosure
Multicultural Diversity
Implications for Ethical Practice
Diversity Issues in Ethics Discrimination/Bias Multicultural
Competence Sue & Sue (1990)
Counselors have a responsibility to: (1)Become aware of
biases, stereotypes & assumptions based on culture
(2)Become aware of client values & world view
(3)Develop culturally appropriate intervention strategies
Misperceptions Based on Different Worldviews
• Non-verbal behavior• Directness vs.
indirectness • Individualism vs.
Collectivism• Change vs.
acceptance• Cultural mistrust
Diversity Issues in Ethics (continued) Sensitivity to Cultural Issues in
Test Selection & Interpretation Diagnosis Treatment Planning Service Provision/Counseling Electronic Communication/Web Counseling
Advocacy Recruitment & Retention in Education
Programs Research
Purposes of Professional Associations Represent members in lobbying,
professional advocacy efforts Provide networking opportunities Provide opportunities for professional
development Promote professional practice
Support accreditation, certification Promote ethical practice & self-regulation
Advocate for PWD
Exercise Name of Association Structure
Divisions State/Regional/Local Governance Structure Committee
Benefits to membership
Licensed Mental Health Counselor (LMHC) Administered by the Board of Clinical
Social Work, Marriage & Family Therapy and Mental Health Counseling
http://www.doh.state.fl.us/mqa/491/soc_home.html
Mental Health Counseling: Definition Broad definition Includes “methods of a psychological
nature used to evaluate, assess, diagnose & treat
“Includes counseling, behavior modification, consultation, advocacy, crisis intervention, client education, research . . .”
“individuals, couples, families, groups, organizations, & communities”
Academic Preparation Generally based upon CACREP
requirements Major revision, effective Jan 1, 2001 Requires: 60 hr. masters program 1,000 hours of practicum &/or
internship Specified coursework
Required Coursework – 3 hrs of: Counseling Theories & Practice Human Growth & Development Diagnosis & Treatment of
psychopathology Human sexuality Group theories & practice Individual evaluation and assessment Career and Lifestyle Assessment
Required Coursework – 3 hrs of: Research and program evaluation Social & cultural foundations Counseling in community settings Substance abuse Legal ethical and professional standards
IT IS ESSENTIAL THAT YOU KEEP COURSE SYLLABI!!
Supervised Experience A minimum of:
2 years =1500 face to face over at least 100 weeks
100 hrs. of supervision per 1500 hrs. of face to face
1 hr. of supervision q 2 wks. 1 hr. of supervision per 15 hrs. of face
to face Focus on raw data
Supervised Experience No more than 50% group supervision (2-6
supervisees) Post-masters experience can commence
when 7 of 11 required courses, including diagnosis & treatment has been completed.
IT IS ESSENTIAL THAT YOU PROPERLY DOCUMENT SUPERVISION!!
Supervisor Qualifications LMHC,LMFT, LCSW or equivalent in
another state M.D. Psychiatrist, Board Certified Licensed Psychologist + 3 yrs. Of
experience providing psychotherapy (incl. 750 hr. face to face)
AAMFT-approved or NCC-ACS supervisor
Supervisor Qualifications cont. Supervisors must have completed 5
years clinical experience & training in supervision in one of the following: Graduate level supervision course Continuing Education course (16 hr) Meet AAMFT or SW supervision course
requirements
Registered Intern Requirement Before beginning supervised
experience, must apply for intern registration
Includes review of coursework and I.d. of qualified supervisor
Title: Registered Mental Health Counselor Intern
Provisional License For individuals who have satisfied
clinical experience Allows individuals to work under
supervision while completing additional coursework or exam requirements.
Exam Taken at conclusion of 2 years of
supervised experience National Clinical Mental Health
Counseling (NCMHC) Exam
Laws & Rules HIV/AIDS Laws & Rules
Must complete 8 hr. course covering• Specified Fla. Laws & rules• Integration with competencies required for clinical
practice & interactive discussion of case examples
HIV/AIDS Must complete course by time of licensure (or
within 6 mos. In extenuating circumstances)
Additional Approved Training Domestic Battery Medical Errors
