at all, has the dominant discourse in which this family is situated oppressed their self-agency? Their self-determination? A family practitioner adopting participatory ethics might invite and emphasize the family’s experience and meaning-making processes in interactions with the dominant culture or the stories told by the court system about child neglect and how such stories influence the preferred view of the family. As participatory ethics attends to the marginalized, the voice of the 14-year-old child might be encouraged and amplified. The family counselor could work with the parents to help them imagine themselves through the eyes of their child, to imagine what the experience of the situation might be like and what the child’s preferred choices might be. The postmodern shift to participatory ethics can be quite powerful: In this model, the family practitioner’s position of power is counterbalanced by honoring the family’s own power in their process of living.
We have introduced three perspectives on ethics: principle, virtue, and participatory ethics. Take a moment to reflect on the essence of each of these perspectives and your emotional reaction to them. With principle ethics, you have externally derived guidelines based on at least six principles to guide your professional actions. Virtue ethics calls on you and the helping professions to examine the character traits essential to family practice and how these characteristics may impact ethical processes. Last, participatory ethics takes you to the space between you and your clients, to the relationship in which clinical decisions are coconstructed and negotiated with families. What are the potential positives in each that you see? What are the problems? What does your gut tell you about your thoughts and feelings about each? Now look at your answers to these questions. What do they say about you and your work with families? If you are not satisfied by one and only one perspective on ethics, then which blend fits for you? How would you integrate that blend into a functional model? Continue to ponder such questions as we now move through various models of decision-making.
Ethical Decision-Making
Understanding principles and virtues alone does not resolve an ethical dilemma. Some process is necessary that uses these principles and virtues. What follow are descriptions of three models of ethical decision-making related to the three ethics models we have already presented. These three models do not represent all available models of ethical decision-making. They are simply used to demonstrate how different perspectives might be applied.
Models of Ethical Decision-Making
The ACA Code of Ethics (ACA, 2014) states “when counselors are faced with ethical dilemmas that are difficult to resolve, they are expected to engage in a carefully considered ethical decision-making process” (p. 3). This same code goes on to note that “counselors are expected to use a credible model of decision making that can bear public scrutiny of its application” (p. 3). None of the other helping profession codes state the importance of understanding and using models of ethical decision-making so explicitly. Because no model of decision-making has been shown to be better than any other, the responsibility is on the practitioner to demonstrate and justify publicly the value of solving an ethical dilemma in a particular way.
The Critical-Evaluation Model
Kitchener’s (1984) critical-evaluation model is based on the ethical principles of autonomy, beneficence, nonmaleficence, and justice. Today we would include the principles of fidelity and veracity in this list and use eight steps in the critical-evaluation model (Corey et al., 2019). They are as follows:
1 Identify the problem or dilemma: ethical, moral, and legal dimensions.
2 Identify potential issues, stakeholders, stakeholders’ responsibilities, and the competing principles involved in the situation.
3 Review ethical guidelines of the profession against your own moral perspective on the situation.
4 Know the applicable laws and regulations of the state in which you practice.
5 Consult.
6 Consider possible courses of action, and the actions of all parties involved.
7 Enumerate possible consequences of various decisions for all stakeholders.
8 Decide which option is the best choice. (pp. 19–23)
Wheeler and Bertram (2019) recommended careful documentation of the ethical decision-making process used to arrive at a course of action, including the options considered and ruled out. It is important to document the outcome and to include any additional actions that were taken to resolve the issue. This is where reviewing your notes can be particularly helpful in assessing the process. To obtain the most accurate picture, involve your client in this process when appropriate.
Let us walk through each step of the critical-evaluation model with the family whose child has leukemia that the parents are addressing with prayer. For the sake of brevity, we provide only brief examples here and not the complete process.
1 Step 1: Identify the problem. From an ethical standpoint, we have concerns regarding breaching client confidentiality and the welfare of the clients, including the child. Morally speaking you may be wondering about the safety and welfare of the child and about your tolerance for the parents’ autonomous decision-making.
2 Step 2: Identify potential issues involved. Do the parents know the potential legal consequences of their actions? Equally important, do you know the potential legal consequences of your actions as a family counselor or therapist? What legal responsibility do you have for any harm that befalls the child? Legally speaking, are there any other stakeholders? What about grandparents? The state is a stakeholder because it is acting on behalf of the child. What legal duty do you have as a family practitioner to the state?The principles of autonomy, beneficence, nonmaleficence, justice, fidelity, and veracity all seem pertinent here. Obviously, autonomy is very pertinent, as it relates to the principle of beneficence and the duties imposed by mandatory reporting laws in various states. Nonmaleficence is a primary concern in relation to the child. Justice is also a concern: What is fair and to whom? If fairness implies affirming that both parents have an equal say in the medical decision, does the child have a say? Would that not be fair? What actions might you take that demonstrate fairness in relation to the state’s interest? Who is involved in these discussions? In regard to fidelity, you have duties to both the parents and the child. As a licensed family practitioner, you would also have duties to the state. Feeling stretched in multiple directions yet? Veracity would require that you provide informed consent that spells out the relationships among the various constituents whom you must serve, including the family; its individual members, especially the child; and the state.
3 Step 3: Review ethical guidelines of profession. As we noted much earlier, ethics codes and standards of practice often contain conflicting guidelines and little that might help to resolve such a case easily. Family practitioners must respect the dignity and promote the welfare of the family; maintain cultural sensitivity, confidentiality, and privacy while respecting differing views on disclosing information; and uphold the professional laws of the state. In the end, it comes down to a very complex question: How does the family practitioner work with the family, demonstrate sensitivity for the family’s perspective, and decide what constitutes the family’s welfare?
4 Step 4: Know the applicable laws. From a legal standpoint, which again depends specifically on various state laws, the parents’ withholding of medical care for a life-threatening condition can be viewed as child neglect. If the child were to die, child abuse leading to death would most likely lead to a legal indictment. For the purpose of this example, let us make this step easy: The laws of your state define the parents’ religious beliefs as harmful to the child and therefore require you as the family
