maker seeks to minimize the negative effect of

infringing on the offended ethical principle.

the ethical decision-making model 33
According to these conditions, Dr. Yasuto must ask,
1. Is there sufficient justification to allow one ethical principle
(beneficence or nonmaleficence) to trump another ethical
principle (respect for patient autonomy)?
Typically, in the case of imminent suicide, beneficence/
nonmaleficence trumps respect for patient autonomy. However,
Dr. Yasuto needs to assess the imminence and potential lethality
of suicidal behavior with attention to many case-specific and
contextual factors. If the risk of suicide is low, Dr. Yasuto needs
to give greater deference to respecting the patient’s autonomous
decision making.
2. Does the proposed action have a realistic chance of success?
Dr. Yasuto may decide that the patient has to go to the
hospital, even if the admission is done involuntarily. In this
situation, Dr. Yasuto must first determine if the patient’s behavior
meets the statutory requirements for an involuntary hospitalization
in her state to determine whether an effort to obtain it
would be successful.
3. Can a morally preferable alternative be found?
From this brief vignette, it appears that no preferable alternative
to hospitalization can be found. However, the general
rule is that, whenever possible, psychologists should strive
assiduously to find useful alternatives that avoid a direct conflict
between two ethical principles.
In her search for a solution, Dr. Yasuto may consider
whether she can mobilize the healthy aspects of the patient, as
a matter of respect for his autonomy, to ensure his safety and
cooperation with the general treatment goals without the use
or threat of force. Because an involuntary psychiatric hospitalization
offends respect for patient autonomy so extensively,
Dr. Yasuto should only use it as a last resort when she can
find no other alternative to save the patient’s life. She also
would prefer a voluntary hospitalization to avoid making the
patient reluctant to seek treatment in the future. Nonetheless,
in some situations, no morally preferable alternative may be
available.
4. Can Dr. Yasuto minimize the harm to the offended ethical
principle?
If Dr. Yasuto decides to have beneficence/nonmaleficence
trump autonomy and institute an involuntary hospitalization,
she should attempt to involve the patient in the decision as
34 ethical dilemmas in psychotherapy
much as possible. For example, if possible, Dr. Yasuto could give
the patient a choice of hospital.
We find that the most common mistake graduate students make is their
failure to consider how to minimize harm to an offended moral principle.
Nonetheless, this is the feature that often distinguishes excellent ethical decisions
from minimally acceptable ones and may be the key to preserving the
therapeutic alliance.
A general strategy may be to select a solution that combines the best
elements of the different solutions proposed through a process akin to theory
knitting. In experimental psychology “theory development progresses through
the integration of the strongest features of the alternative theories with
one’s own ideas about the phenomenon under investigation” (Sternberg,
Grigorenko, & Kalmar, 2001, p. 107). Similarly, psychologists can knit solutions
by comparing alternatives, evaluating the conflicting properties of each,
and integrating the best aspects of each.
Step 4: Act or Perform
Step 4 can be quite complex because even the most thorough deliberation
does not necessarily lead to action. Here we consider whether and how
Dr. Yasuto will implement her solution.
Whether the Solution Will Be Implemented
Some studies have found that many psychology graduate students
(Bernard & Jara, 1986) and psychologists (Bernard, Murphy, & Little, 1987)
who reached the “right” solution to an ethical dilemma would not act on the
solution. The reasons for these findings are unclear. At times, the inability to
act may be due to shortcomings of psychologists