1

ETHICAL DECISION-MAKING

Ethical Decision-Making

Shane Brooks and Kyra Schmutz

Department of Recreational Therapy, University of Utah

RECTH 5350: Clinical and Professional Analysis

Professor Ashley Bowen

December 5, 2021
2
ETHICAL DECISION-MAKING

Abstract

Marines of the 3rd Combat Engineer Battalion were deployed to a combat zone overseas, where

the operating procedures stated not to give out food to locals. Hungry locals, primarily children,

approached their convoy begging for food. The Marines weighed the ethics of the situation and

had to decide whether to give these children food or not. When translated into a recreational

therapy context, this situation would look like a group session involving a community outing in

which a community member asks to join the group. This study analyzes this situation using the

Decision-Making Model for Ethical Situations in Professional Practice/Business, the American

Therapeutic Recreation Association’s (ATRA) Code of Ethics, and the ATRA Standards of

Practice (citation, citation, citation). The Marines chose to give food to the local children in their

situation, which was against operating procedures and the Marine's ethical standards. Based on

our analysis of personal and professional values in the recreational therapy situation, we decided

that denying the community member's participation in the group would be the most ethical

course of action. We would appease personal values by offering information about our facility

and how the community member can access these resources and sign up for this program

properly.

Keywords: ethics, community integration, recreational therapy, Marines

3
ETHICAL DECISION-MAKING

The Original Ethical Problem

In 2010 while deployed to Helmand Province, Afghanistan, the 3rd Combat Engineer

Battalion (CEB) Marines faced severe ethical and moral dilemmas. When they first arrived at

their operating area, they were required to sit down and go over the Standard Operating

Procedures (SOP) for the area. Those in command of the entire area determined these procedures

in conjunction with individuals within the first Obama Administration. During the briefing, the

Marines were told that their mission was one of route clearance and only that. For the 3rd CEB,

this meant that they were only to focus on finding the Improvised Explosive Devices and

escorting other units throughout the area. They were not to give any food or water to the locals

because that would encourage them to come up to every convoy and ask for supplies. The

command also told them that this was not to be done because their mission was not humanitarian

and that there were other Marines that would deliver these supplies to the locals.

When the Marines finally begin going out on their missions, they see hungry and thirsty

people everywhere. These are the people that the command said their mission would make their

lives better. Nevertheless, their SOPs said they could not give them food or water despite the

Marines having plenty of it and the ability to give it out. The ethical dilemma arose because of

these Marines' honor, courage, and commitment values. Their values made it, so the Marines

were torn between values and ethical principles of listening to the command when their honor

and courage were telling the Marines to go ahead and give the locals the supplies. At the same

time, the parts of honor and commitment are telling them to listen to the command and not hand

out the supplies. Ethically it is not right to keep food and water away from starving people when

an individual has the supplies to help. 3rd CEB went against the command at the end of the day
4
ETHICAL DECISION-MAKING

and handed out the food and water because they determined that regardless that was the right

thing to do.

The Ethical Problem Translated to a Recreational Therapy Context

Recreational therapy professionals could encounter similar situations in their practice,

and we have come up with a specific scenario with which we can analyze the ethical forces

involved. In this scenario, recreational therapists facilitate a program focused on community

integration for individuals with disabilities. As a part of this program, we bring our group into a

public setting and facilitate interventions there. While we facilitate a community intervention in a

public space, an individual with a similar disability to those in our group approaches us. This

individual expresses that they need to learn the skills we are teaching and want to participate in

the activity with our group.

The Decision-Making Model for Ethical Situations in Professional Practice/Business

It is best to follow a plan or model when dealing with ethical situations. The most fitting

model to follow is the Professional Practice/Business model. According to Norma Stumbo, the

model sets up six steps to resolve the situation. Those steps are identifying the behavior,

determining the professional relevance, differentiating personal and/or professional ideals and

values, considering legal duties, assessing legal obligations, and determining action (2017).

Identifying the Behavior

The first thing we have to do is identify the behavior causing the ethical problem. In the

Marines’ case, it was determining if giving out the food and water were appropriate. The

Marines were choosing to go against their command. When this gets translated over to a
5
ETHICAL DECISION-MAKING

recreational therapy setting, the behavior is similar. The recreational therapist is in a situation

where they have to determine whether or not to allow a community member access to services. If

they say yes and allow them to join, there is a whole new array of ethical behaviors that need to

be broken down. If they say no, withholding treatment is an ethical issue; however, this would

not be permanent.

Determining the Professional Relevance

This scenario has professional relevance on a few different levels. In a general sense, we

have a duty as recreational therapists to advocate for and serve individuals with disabilities. As

people who are not having the same experience as others who have disabilities, part of that

responsibility includes listening to the needs of individuals with disabilities and advocating for

those needs. This individual with a disability has approached us and voiced a need and a solution

they see as being part of our group.

We have professional duties to follow the agency’s policies at which we are employed.

While this scenario is fictional, and we do not have specific agency policies to cite, most

agencies will have a policy against allowing this person to participate in this group in which they

are not a member. As agency employees, we are expected to follow this policy, and we may face

professional consequences if we do not.

We have a professional duty to our clients. Whether clients are explicitly paying for

recreational therapy services; or a member of a treatment team at a facility providing services to

a client, we are being paid to meet the expectations defined in our job descriptions. As

professionals, we are entrusted to provide services to the clients referred to us and are under our

care and responsibility.

6
ETHICAL DECISION-MAKING

Differentiating Personal and Professional Ideals and Values

One of the most extensive obstacles when dealing with any ethical dilemma is

determining an individual’s personal and professional ideals and values; how much importance

to place on those. Like the Marines of 3rd CEB, recreational therapists sometimes have to

evaluate these on the fly in the case of someone approaching the group on an outing and feeling

that it would be a good fit for them. The recreational therapist has to evaluate quickly what their

personal values are. These might be things like their own personal safety and the safety of their

group members, believing that the right thing to do is to help everyone, feeling that they cannot

withhold the resources from the individual and worrying about the long-term impact if they are

to tell them they cannot join the activity right away. These can be seen as personal ideals and

values because they are areas where bias can influence decisions. If recreational therapists are

influenced too much by these values, they might go against their facilities' SOPs and the

American Therapeutic Recreation Association's (ATRA) standards of practice. The list of any

personal ideals and values can be prodigious and unique for every recreational therapist.

Professional ideals and values are a little different and can be viewed differently. They

can be considered things that will affect a recreational therapist's professional career or value the

facility that the individual is employed. The specific case discussed no information about the

facility. Therefore, the focus will be on ideals and values the can impact a career; ideals and

values like confidentiality for the individuals that are receiving treatment, violating the facilities

SOPs could cost the recreational therapist their job, and withholding treatment from the

individual would not best represent the facility in which the recreational therapist is employed.

The weight of these will often be higher than the personal values. However, these are still areas

where bias can be introduced into the equation when determining the proper action to take—
7
ETHICAL DECISION-MAKING

making sure that as recreational therapists, the action that we decide to take as influenced by the

biases as little as possible is the key.

Consider Legal Duties

There are a few laws that could play a role in this situation. First, informed consent is

required by law in any healthcare situation. Second, information privacy laws such as the Health

Insurance Portability and Accountability Act (HIPPA) are applicable because the group

members’ medical information could now easily be disclosed to the community member who

joins. Third, the therapist could now be held liable for the safety and outcomes of the community

member who joins the group and any adverse effects experienced by the current members

because of anything that community members do during the group—leaving the therapist

vulnerable to civil suits.

Assessing Ethical Obligations

The ATRA code of ethics defines ten ethics as the standards for recreational therapists.

These are beneficence, non-maleficence, autonomy, justice, fidelity, veracity, informed consent,

confidentiality and privacy, competence, and compliance with laws and regulations (ATRA,

2009).

Beneficence ensures that individuals are served in a way that maximizes their health and

well-being (ATRA, 2009). Other healthcare professionals could argue that refusing service to an

individual in the community would violate the ethic of beneficence. However, this beneficence is

owed first to the therapist’s clients, and allowing this individual to enter the group would not

maximize the current clients’ health or well-being.

8
ETHICAL DECISION-MAKING

Non-maleficence ensures that no harm comes to individuals served (ATRA, 2009).

Again, refusing service to the community member in this scenario could be harmful. However,

the potential damage that this individual could cause to the current clients remains the priority.

Autonomy is the right of each individual to determine their care plan (ATRA, 2009). The

community member in this situation has utilized their autonomy in expressing their desire to

participate in the group. However, the therapist has not been made responsible for this person’s

care plan and is not obligated to honor their decision unless they become an official client.

Justice is equitable distribution of services or services free of discrimination (ATRA,

2009). If services are refused, this individual may say that the refusal was unjust or unfair.

However, as long as they have not been denied the opportunity to apply for and join the group in

the same way the current group members did, there has been no injustice.

Fidelity is faith and loyalty to clients, colleagues, agency, and profession. One of the

essential ethical obligations in this situation (ATRA, 2009). Although this community member

has fundamental needs that joining this group could meet. A recreational therapist's loyalties and

priorities must first go to their current clients. Fidelity also involves a commitment to the agency

because to continue running; the agency needs to receive compensation from clients or their

insurance companies for services provided.

Veracity is a relatively straightforward ethical principle; it requires the recreational

therapist to be truthful and honest without deception (ATRA, 2009). With it being unequivocal,

it can get violated easily when the personal biases of recreational therapists get involved, when it

comes to the case of a community member approaching the group and wanting to join in. As

recreational therapists, the ethical obligations are to be truthful and forthcoming about the

activity and provide as much information as possible without violating the confidentiality of
9
ETHICAL DECISION-MAKING

those participating. The recreational therapist has to also provide them with enough information

that will not deceive them about the purpose of the group and where to find all of the remaining

information for the community member.

Informed consent is the next item on the ATRA code of ethics and is a pretty simple one.

The recreational therapist should provide all relevant information to the individuals they are

treating while respecting and sharing the decision-making. ATRA wants the individual to be

making the choices based on all of the knowledge; they do not want the recreational therapist

doing everything (ATRA, 2009). In the case of someone approaching the group activity, the

recreational therapist is not equipped to get informed consent from that individual at that time.

Instead, they should make sure that the individual knows where to go to get all of the information

needed. Due to the limited time, the recreational therapist needs to direct the individual to the

main facility to ensure that all information regarding the activity, benefits, length of treatment,

outcomes are covered before they participate.

Another ethical item that the recreational therapist needs to be concerned with is

confidentiality and privacy. As stated earlier, one of the laws that can impact the situation

discussed here is privacy and HIPPA. The confidentiality and privacy on the ATRA Code of

ethics mention how as a recreational therapist, there is a responsibility to disclose all relevant

information to individuals seeking services but not disclose private information to any 3rd parties

(ATRA, 2009). When any individual approaches wanting to join a group, the line that the

recreational therapist has to tread is delicate. The ethical obligation is to tell them all information

pertaining to the activity without disclosing private information to any 3rd parties. It is vital to

make sure they know what the activity is and what it is for and protect those on the outing from

being identified. This is because the individual can be considered a third party, and just telling
10
ETHICAL DECISION-MAKING

them what the activity works on could be considered private information from some. The best

option here is to be brief in the activity summary and refer them to the main facility to get further

information on it.

Competence might not seem to play a role in this situation. ATRA describes this in the

code of ethics as improving and maintaining knowledge related to the profession and

demonstrating current competent practice (2009), in this case, making sure that as the

recreational therapist, you are demonstrating the knowledge about the activity. While displaying

that knowledge, when you describe the activity to them, making sure that you abide by the

ATRA code of ethics will show your competent practice.

Lastly and certainly not least is the compliance with laws and regulations aspect of the

code of ethics. ATRA wants recreational therapists to abide by all local, state, federal laws and

regulations and ATRA policies (ATRA, 2009). In this case, some of the biggest things that the

recreational therapist needs to be aware of are local laws regarding the treatment of individuals

within the healthcare industry and federal laws like HIPPA. Also, making sure that despite

having them approach the group, they are not denying them access to any treatment. In order to

do this, the recreational therapist has to make sure that there is enough information provided to

the individual. All recreational therapists’ actions should follow the ATRA code of ethics and the

ATRA standards of practice.

Standards of Practice

As recreational therapists, the ATRA code of ethics is not the only set of guidelines we

should follow. ATRA has its standards of practice that they want all recreational therapists to

follow. There are 12 total items on the standards of practice that cover the entire recreational

therapy process. Not every item on the standards of practice will apply to every situation.
11
ETHICAL DECISION-MAKING

However, the recreational therapist must follow them as closely as possible in the case discussed

here, an individual approaching a group during an outing and wanting to join. The standards that

are in play are one through eight and 11. The first eight standards deal with the assessment,

treatment planning, plan implementation, re-assessment and evaluation, discharge/transition

planning, prevention, safety planning and risk management, and ethical conduct (ATRA, 2015).

All of these standards cannot be achieved if the individual were to be allowed to partake in the

activity due to their approaching the group. Not only does it interfere with the potential treatment

for that individual, but it interferes with the recreational therapist to properly perform all of these

standards with the individuals already enrolled in the group. Standard 11 deals with resource

management. Recreational therapists need to make sure they are managing things responsibly

(ATRA, 2015). Allowing the individual to join in it could take away resources from the

individuals enrolled in the group. On the other hand, the recreational therapist has to make sure

that the individual has enough information about the group to make the most out of the resources

available to them.

Determine Action

The most important ethical issues in this situation come down to showing fidelity

to our clients by protecting their privacy, honoring their informed consent, and protecting them

from potential harm. It is also in the best interest of this community member because of the

potential consequences of taking them into a therapeutic setting without first assessing them and

planning for them. To maintain a controlled therapeutic environment, protect clients’ sensitive

information, and demonstrate commitment and loyalty to those clients, refusing service to this

community member would be the best course of action. This is also the best way to protect this

individual and comply with the law and professional standards of practice.
12
ETHICAL DECISION-MAKING

One way to give this individual a more positive outcome would be to offer them

information about your facility and get involved with recreational therapy programming. If this

group is the best fit to meet their needs, they can access the same benefits that they see

happening by joining appropriately. It would be beneficial for recreational therapists to bring

brochures, handouts, or some form of informational materials on community outings if a member

of the public has questions. Suppose they provide a handout or information to a public member.

In that case, the therapist must ensure that this information is generic agency information that

does not disclose any sensitive client information. If it is not possible to inform this community

member about the agency without disclosing protected client information, the community

member still must be refused service.

Conclusion

After looking at a real-life experience in which the Marines of 3rd CEB were forced into

deciding between withholding resources or handing them out to the starving locals, the

correlation between that situation and a recreational therapy situation can be easily made when

looking at it from the aspect of going on a community outing. Many of the activities that we

provide are intriguing if someone who looks like those participating in the group were to see it.

They might approach and want to join in right away, thinking that it will help and be fun. It is the

ethical job of the recreational therapist not to deny them treatment or access to the resources.

However, it is also the job of the recreational therapist to make sure that they receive these

resources fairly and with full knowledge about them. All while protecting the privacy of

individuals participating currently in the group. To ensure this happens, recreational therapists

should follow the ATRA code of ethics during their career and as many of the ATRA standards

of practice applicable to the situation.

13
ETHICAL DECISION-MAKING

Ensuring that the individual is aware of the facility, activity, and all information about the

duration and outcomes is critical for the recreational therapist. On outings, there is not enough

time to educate a community member about all of these things properly while making sure the

appropriate attention is paid to the individuals enrolled in the group. The advice would be for the

recreational therapist to be equipped with brochures, information packets, flyers about the

facility, and quick handouts about registering for the group. The reasoning for having this is to

have a brief couple of minutes of discussion and then hand out the information bringing their

attention back to the individuals already enrolled in the group. Overall, as recreational therapists,

the key is making sure that we are aware of our personal biases and that they are not influencing

our decision-making when it comes to the treatment of individuals we serve or will serve.
14
ETHICAL DECISION-MAKING

References

ATRA. (2009, July). Code of ethics - American therapeutic recreation association. American

Therapeutic Recreation Association. Retrieved November 30, 2021, from

https://www.atra-online.com/general/custom.asp?page=Ethics.

ATRA. (2015). Standards of practice - atra-online.com. American Therapeutic Recreation

Association. Retrieved November 30, 2021, from

https://www.atra-online.com/general/custom.asp?page=SOP.

Stumbo, N. J., Wolfe, B. D., & Pegg, S. A. (2017). Professional issues in therapeutic recreation:

On competence and outcomes. Sagamore-Venture Publishing LLC.