Psychological Association.

http://dx.doi.org/10.1037/14670-003
Ethical Dilemmas in Psychotherapy: Positive Approaches to Decision Making, by S. J. Knapp, M. C. Gottlieb,
and M. M. Handelsman
Copyright © 2015 by the American Psychological Association. All rights reserved.

THE ETHICAL
DECISION-MAKING MODEL
26 ethical dilemmas in psychotherapy
In this chapter, we use the five-step model (identify relevant principles,
generate alternatives, select the optimal intervention, act, and review; Knapp
& VandeCreek, 2012) to review decision making from the perspective of
principle-based ethics. We describe principle-based ethics, identify the principles
important in problem analysis and resolution, give examples of how the
model may be applied, and pay special attention to creative ways to resolve
apparent ethical conflicts. We view ethics decision making as a process that
is more than a thought experiment—it is a process that also is influenced by
emotions and other nonrational factors. We contend that awareness of these
factors can improve the quality of decision making.
Almost every decision-making model is an example of slow, deliberate,
and effortful System 2 thinking (see Chapter 1). Here, we present the five-step
model of Knapp and VandeCreek (2012; see also Weinstein, 2000), which
borrows from others models, such as the IDEAL system (identify, develop,
explore, act, and look back; Bransford & Stein, 1993) and the SHAPE system
(scrutinize, develop hypothesis, analyze proposed solution, perform, and evaluate;
Härtel & Härtel, 1997). Our labels for the five steps include the mnemonics
of both Bransford and Stein (1993) and Härtel and Härtel (1997).
The IDEAL and SHAPE systems are general decision-making models
and are not specific to ethics. Many of the factors related to decision making
in general apply to ethical decision making, too (Elm & Radin, 2012). We
review the basics of principle-based ethics and then go through each of the
five steps to show how they are linked to principle-based ethics. We want to
emphasize right at the beginning, though, that ours is a dynamic model in;
depending on the circumstances of a problem, the decision maker may need
to skip steps, repeat steps, move backward, or otherwise alter the sequence of
decision making.
PRINCIPLE-BASED ETHICS
As noted in Chapter 1, the English philosopher William David Ross
(1930/1998) developed principle-based ethics, and American philosophers
Thomas Beauchamp and James Childress (2009) expanded and applied it to
health care. The influence of principle-based ethics is clear in APA’s (2010)
“Ethical Principles of Psychologists and Code of Conduct,” in which the
General (aspirational) Principles are modeled largely after W. D. Ross.
W. D. Ross (1930/1998) developed principle-based ethics after reflecting
on two of the dominant philosophies of his time: deontology and utilitarianism.
Deontological ethics focuses on the importance of following rules dealing with
obligations and prohibitions. W. D. Ross appreciated the emphasis that
the ethical decision-making model 27
deontological ethics gave to following overriding values, but he disliked that
it did not allow for exceptions under unique circumstances, and that it had
no ethical decision-making process to follow when two or more obligations
appeared to collide.
In contrast, utilitarianism focuses on the importance of looking at the
effect of behavior on all affected people. W. D. Ross (1930/1998) appreciated
utilitarianism, because it had an ethical decision-making process and
it emphasized the welfare of all people affected by the decision maker’s
behavior. But he disliked that utilitarianism weighed the effect on all people
equally—that is, in making moral judgments, the well-being of strangers
had the same weight as the well-being of families, friends, or others to
whom the moral agent has special obligations. As a result, W. D. Ross tried
to develop a philosophy that maximized the strengths and minimized the
limitations of deontological and utilitarian ethics. Thus, the principlebased
ethics that he developed retained an emphasis on moral obligations
as found in deontological ethics and included a decision-making process,
as did utilitarianism.
W. D. Ross (1930/1998) identified six prima facie duties, those that
people should generally follow and that represent a reasonable claim or
obligation that can be expected of an individual. He identified the duties in
no particular order or priority and without claiming “completeness or finality”
(p. 269): fidelity, gratitude, justice, beneficence, self-improvement, and nonmaleficence.
Later, Beauchamp and Childress (2009) identified those principles
that apply more directly to health care professionals, including beneficence
(to act to promote the well-being of another person), nonmaleficence (to avoid
harming another person), respect for patient autonomy (to respect the decisions
made by patients and to promote circumstances that help the patient
make informed decisions), justice (either procedural justice—treating people
fairly—or distributive justice—the notion that everyone in society has access
to some of the goods of society necessary for life), and physician–patient
relationships (dealing with the obligations to keep promises). Knapp and
VandeCreek (2012) added general or public beneficence (dealing with obligations
to the public). Brief definitions and examples of these principles
appear in Exhibit 2.1.
Authors vary slightly in how they formulate or discuss these overarching
ethical principles. For example, the General Principles of the APA
Ethics Code combine beneficence and nonmaleficence. However, we concur
with Beauchamp and Childress (2009) that nonmaleficence should
be separated from beneficence, because there is a human tendency to give
more weight to negative than positive events, even when they are of equal
valence.
28 ethical dilemmas in psychotherapy
FIVE-STEP DECISION-MAKING PROCESSES
In this section, we go through the five steps sequentially.
Step 1: Identify or Scrutinize the Problem123

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