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Ethical Decision-Making Process

David Leon & Adrian Portillo

Department of Occupational and Recreational Therapies, University of Utah

RECTH 5350: Advancement of Recreational Therapy: Clinical & Professional Analysis

Ashley Bowen

December 5, 2021
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Abstract

Over many years, different healthcare professions have set guidelines and standards of

practice to ensure the safety and well-being of all patients and consumers. These have been set

not just because of incidents that have occurred in the past, but also because of possible ethical

concerns that may arise. As for recreational therapy (RT), the literature has contained significant

information and discussion about ethical conduct in the profession (Stumbo et al, 2017). Ranging

from possible ethical concerns and how they play a role in this service that is being delivered.

This paper discusses an ethical incident, in particular, involving a children’s camp and a camp

counselor. The ethical concern was that a child was alone with a counselor for a short period of

time. Though nothing concerning occurred, the discussion will entail why this is an ethical

concern and how it can be addressed in the future, pertaining specifically to the field of RT. A

connection between the incident and the American Therapeutic Recreation Association (ATRA)

code of ethics and standards of practice was made to determine what was violated and what was

not.

Keywords: ATRA, ethical, profession

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Introduction

When a situation comes about, it may seem easy to label it as either a bad situation or a

good one. However, it may not be as easy when the decision that has to be made can have a wide

variety of possible outcomes that are not predictable. This is the idea of ethical practice, which is

a term used that covers the nature of morals and the specific moral choices that are made

(Varkey, 2021). “Ethical norms are so ubiquitous that one might be tempted to regard them as

simple common sense” (Stumbo et al, 2017, p. 558). What is viewed as common sense in one

field may be viewed differently in another. Take a physician, for example, who has endured

extensive training in medicine and may need to see a part of a patient’s physical body if they

have a health concern. This is not the same case for someone who may work as a teacher, as they

do not have the same training or scope of practice to observe an individual’s physical body.

Every profession has its regulations and standards of practice (SOP) that make this process of

determining ethical concerns easier. In recreational therapy (RT), ATRA’s code of ethics and

SOP do just that. There are many scenarios that can be reviewed using these resources, one that

will be discussed is regarding a camp counselor and a child camper. This particular scenario will

be discussed using The Decision-Making Model Ethical Situations in Professional

Practice/Business, a model that breaks down the behavior, concerns, and how it should be

resolved (Stumbo, 2009, p. 304). This model consists of 6 steps which consist of identifying the

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

and values, considering legal duties, assessing ethical obligations, and determining what action

should take place.

Identify the Behavior

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The first step of the model is to identify the behavior that is being questioned. At a

summer camp designed for children with cancer, an incident occurred where one of the children

at the camp woke up in the middle of the night after they had wet their bed and wanted to use the

restroom and get cleaned up. The child had to wake one of the counselors up and tell them that

they wanted to use the restroom. The camp policy is that if one camper wakes up needing to use

the restroom, they must wake up one counselor and let them know. The counselor then has to

wake up every other camper and see if any of them need to use the bathroom as well or if anyone

would like to join their fellow camper and counselor to the restroom. This ensures that a camper

is not alone with a counselor and that a camper also has the supervision of a counselor while they

go to the restroom. During this time, the co-counselor stays inside the cabin with the rest of the

campers.

However, the camper had requested for the counselor to not wake anyone else up because

they feared the possibility of the other campers finding out about his accident. The counselor,

taking the camper’s fear into consideration, decided that they would not wake up the other kids

or any other counselor and took the child to use the restroom alone. No one was aware that this

situation took place. Although nothing concerning happened, everyone was asleep throughout

the campground and no one noticed when they left for the restroom and returned to their cabin.

This not only violated camp policy, but it also brought up the concern of placing a child alone

with an adult, regardless of what the circumstance was.

Determining the Professional Relevance

The next step in the model is to determine how this ethical concern pertains to the

professional role and if it presents itself within the working relationship, specifically as a

recreational therapist (RT). RTs will often work at camps for children, either facilitating a
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program or running the camp itself. Because of this possibility, an RT may find themselves

having to engage with children in different aspects by providing instruction, leading a program,

offering assistance, or even conducting an interview. These all are ways than an RT can see this

ethical concern arise within the working relationship. Though they may not find this exact same

dilemma occurring in these settings, a similar one can still happen such as if a camper asks an RT

if they can speak with them privately in a separate room, or even if they happen to have a

concern during a group facilitation and prefer not to address it in front of everyone else. As an

RT professional, it is important to understand how this concern connects to the role of an RT,

even if it did or did not occur with one directly.

Differentiate Personal and/or Professional Ideas and Values

The next step of the model is to differentiate personal and/or professional ideas and

values within the dilemma. This individual’s personal belief was that they were doing the right

thing by not waking everyone up in the middle of the night in an attempt to not embarrass the

child who had wet their bed. Although this individual did not have any malignant intentions, it

was the wrong action to engage in. As an RT professional, there are protocols that need to be

followed as they have been implemented to ensure that the populations being served are

receiving the best and safest care. In this instance, the individual was thinking about the child as

to not embarrass them for wetting their bed and having the other children see it. However, this

situation could have had a completely different story if the camp counselor had participated in

this behavior with a different intention and no one would have found out about it since no one

else had witnessed it at the time. Procedures, protocols, and professional values should always be

in the back of professionals’ minds and they should triumph over personal beliefs. Although you

should not completely let go of your personal beliefs as they make you who you are, you should
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always remember the client comes first and the procedures in place are set to serve and protect

the clients and yourself.

Consider Legal Duties

The following step from the model is to determine if there was any law or judicial

violation that occurred within this dilemma. The only law that was found which pertains to this

dilemma is where registered sex offenders or child predators are not allowed to be with children

alone in this setting. However, this finding does not play a big role in this situation because the

camp runs a strict background check before hiring any volunteer camp counselors (Camp Hobe

Kids, n.d.). One additional legal concern that should be considered is the fact that a camp policy

was broken, which states that a counselor should never be alone with another camper. If this

policy was written up in the contract that the counselor had to sign, it was most likely issued in

the agreement that the campers’ parents had to sign as well. The parents of this camper may find

that if this agreement form is violated by the camp, they can choose to press legal charges on the

organization. This can not only blemish the camp’s name to the public but can also lead to less

funding for future camps.

Assess Ethical Obligations

The following step in the model is to evaluate the ethical obligations and if the behavior

in question violates the professional code of ethics. Regarding the RT profession, there is a set

code of ethics put together by the American Therapeutic Recreation Association (ATRA). These

code of ethics were evaluated to see if any of them were violated by the behavior between this

camper and counselor (American Therapeutic Recreation Association, n.d.).

Principle 1: Beneficence. This principle states how RTs should actively make efforts to

lessen or minimize possible harm. In this situation, the camp counselor in question failed this
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ethical code as instead of minimizing possible harm, they created a situation where the client was

in a very vulnerable position and could have been hurt.

Principle 2: Non-Maleficence. This principle talks about the obligation that RTs have to

use their knowledge, skills, and judgment while still respecting the decision of the client to

protect them from harm. In this situation, the camp counselor did respect the clients’ decision but

they did not use their judgment to take into account that this is a minor. By doing this, they were

put in a place where they could have been harmed without little assistance by another staff

member or counselor

Principle 3: Autonomy. This principle mentions how an RT must ensure the client has

the right to make their own choice and is given the opportunity to pursue that choice. If the client

is not able to exercise their autonomy, RT should respect the decision of their legal

representative. In this dilemma, the client is able to practice their autonomy but they are a minor

so the camp counselor needs to follow what the parents consented to. In this case, the parents

were under the impression that the camp policy was being followed, which stated that camp

counselors would not be alone with a camper.

Principle 4: Justice. This principle states that RTs should treat everyone fairly ensuring

that there is equity in the services provided. That the services provided are not based on race,

color, creed, gender, sexual orientation, age, disease/disability, social and financial status. The

camp counselor did not violate this code of ethics.

Principle 5: Fidelity. This principle focuses on the obligation that RT professionals have

on ensuring that the clients are receiving their services. Colleagues, agencies and the profession

come as secondary obligations after the client. The camp counselor in question did not violate

this principle either.

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Principle 6: Veracity. This principle expresses how RTs should be truthful and honest.

Deception and omitting information should be avoided. The camp counselor did violate this

principle as they did not report what they did to a supervisor which falls under omitting

information. If they had not told another counselor about this incident, no one would have ever

known about it.

Principle 7: Informed Consent. This principle expresses how staff and clients should be

informed on the services, benefits, outcomes, length of treatment, expected activities, risks, and

limitations, including the credentials of the professionals. This information and consent are

obtained when information is needed to help the client make the decision whether or not they

would like to accept the treatment. In the camp, this is done in the beginning when you sign the

contract and this would have been done by the child’s parent(s) and the camp. This was violated

as one of the items states that camp counselors are not to be alone with the campers.

Principle 8: Confidentiality & Privacy. This principle mentions how RTs have the

responsibility to disclose all the information needed to the person seeking treatment. They also

should not share any disclosed confidential information about the individual with a third party.

This principle was not broken by the camp counselor in this situation.

Principle 9: Competence. RTs should continue their education and improve it to stay

competent in the profession. They should also have an obligation to maintain their credential.

The camp counselor did not break this code ethic but hopefully from this incident, they learn so

that it does not happen again and can improve their knowledge as a caregiver.

Principle 10: Compliance with laws and regulations. RTs are responsible for abiding

by state and federal laws, regulations, and ATRA policies governing the profession of
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recreational therapy. Although the camp counselor did not break any state or federal laws. they

did break the policy of the camp.

Determine Action

The final step on the model is to determine the action of what happened as a result of this

situation, what should have actually been done, and what should be done in the future to avoid

this dilemma from occurring again. Nothing was actually done as a result of the issue because it

never raised questions to the staff or parents of the camper. However, one thing that should have

been done is a formal discussion between the camp supervisor and the counselor to find

alternative ways to handle the situation in the future. This will not only make higher-up staff

aware of the situation to better prepare for it themselves, but it also gives the counselor insight on

making decisions that may lead to unnecessary outcomes. To increase the possibility of avoiding

a similar issue in the future, a camp counselor or professional should critically think about ethical

decision-making before jumping to a solution that the camper opinionated. One alternative way

that this issue could have been avoided would have been to only wake up one camper that the

counselor found to be the most kind-hearted out of the cabin. However, making these decisions

are solely based on subjective information and can sometimes be hard on obtaining the desired

outcome. In this case, the camp counselor could have also gone to wake up another staff member

from a cabin and asked them if they could join them to the restroom. These are alternatives that

perhaps were not thought of at the moment, but with greater training and more insight, the

counselors could have thought out a solution with greater ethical decision-making.

The dilemma was resolved because no concern arose, but it would have also been

resolved if these actions would have been completed. As an RT, clinical reasoning is a big part of

decision-making during each stage of the RT process (assessment, planning, implementation, and
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evaluation/documentation). It is wise to remember that the ability to reason does not just take

part in treating clients, but also should be implemented when interacting or working with clients

away from therapy.

Connecting to the Standards of Practice (SOP)

Now that the scenario was discussed in detail regarding the ethical decision-making

model, it will be analyzed using the ATRA SOP. Despite the camp counselor not being an RT, the

SOP can apply in this situation as they hold very similar roles in terms of the population they

work with and the care they offer. Three standards that were analyzed and found important to this

situation were Standard 6: Prevention, safety planning, and risk management, Standard 7: Ethical

conduct, and Standard 10: Quality improvement (American Therapeutic Recreation Association,

n.d.).

Standard 6: Prevention, Safety Planning, and Risk Management. This standard

expects the RT to plan for prevention and reduction of risks to prevent injury and reduce the

potential of actual harm. Though no harm occurred from this dilemma, there is a greater potential

of injury or harm that could have happened since it was late at night and there was no other

individual present to help if something did happen. As an RT, it is important to think about this

possibility beforehand to better prepare and also, make a more ethical decision to ensure

whatever is about to happen will not increase the risk of the client or staff’s safety.

Standard 7: Ethical Conduct. This standard expects the RT to adhere to the ATRA code

of ethics when providing client treatment and care. As mentioned earlier, this dilemma did play a

role in violating some of the ATRA code of ethics as a camp counselor. The following principles

that were violated were principles 1, 2, 3, 6, 7, 9, and 10. This shows that the camp counselor’s
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decision violated the majority of the ATRA code of ethics and therefore, did not abide by this

standard. All the code of ethics must be followed in order to adhere to this standard.

Standard 10: Quality Improvement. This standard expects the RT to focus on

continuously improving client safety and identifying opportunities to improve RT treatment and

care. Though the dilemma did not demonstrate a lack of this, it does indirectly show that the

counselor was not focused on improving client safety and opportunities for improvement. This

was because they did something that was against camp policy and chose to leave it behind and

not bring it up to a higher staff member. This can prevent finding new ways to improve the

quality of safety and care because it would not have caused any attention if no one ever knew

about it. As an RT, it is important to do as much as you can to improve the quality of the service

that is being provided, even if it means reporting a situation that occurred on your behalf.

Conclusion

For the most part, this is a complex incident that occurred. At the end of the day, it is not

ethically correct and it does violate a couple of ATRA’s code of ethics and standards of practice.

Everyone has different moral and ethical beliefs, but as health care professionals there are rules

and standards in place to make sure the best service possible is being delivered. This situation

was evaluated using the Decision-Making Model Ethical Situations in Professional

Practice/Business and it was found that there are potential ways to solve this dilemma. In the RT

profession, it is important to understand not just the situation itself but also any potential

outcomes that can affect the service of care. As such, clinical reasoning and critical thinking are

two important skills that will help assist decision-making to ensure not just that services will

provide the best outcomes, but also that services will focus on providing ethically competent

care.
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References

American Therapeutic Recreation Association. (n.d.). Code of ethics.

https://www.atra-online.com/page/Ethics

American Therapeutic Recreation Association. (n.d.). Standards of practice.

https://www.atra-online.com/page/SOP

Camp Hobe Kids. (n.d.) Requirements & application.

https://www.camphobekids.org/home/volunteer/requirements/

Stumbo, N.J. (2009). Professional issues in therapeutic recreation: on competence and

outcomes. (2nd ed.). Sagamore Publishing LLC.

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

On competence and outcomes. (3rd ed.). Sagamore-Venture Publishing LLC.

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical

Principles and Practice, (30). 17-28. https://doi.org/10.1159/000509119