Ethics - Decision Making Process
Kardasz: Here are excerpts from an interesting article about ethical decision-making by Joseph Paliwoda. Although the article is written for behavioral health care workers the concepts are also applicable to other occupations.
From Behavioral Health Management, Sept-Oct 2002 v 22 i5 p44(2).
Seven ways to think about ethics: In behavioral healthcare, solutions to ethical problems might not be as clear-cut as they seem
Many organizations offer ethics training. This training typically deals with the extreme breaches in behavior. While codes of ethics are typically reviewed during training students can find themselves facing situations that need further clarification. In short, ethics is not always black and white.
Consider this hypothetical scenario:
John is a client at your behavioral health facility. He has a court date coming up and wants to sell his stereo in case he needs bail money to stay out of jail. A worker at your facility is shopping for a stereo. They begin to talk and the worker buys the stereo.
1. What issue(s) do you see arising from this situation?
2. Is there a breach of ethics?
3. If so, how do you address this with the worker?
Many would see a problem with creating a dual relationship with the client, but this situation is not so obvious to everyone. In fact, other factors could complicate the situation even further. For example, what if the worker is a secretary, i.e., a nonclinician? What if the client was about to leave the facility's care the next day?
As the vice-president of a rapidly growing behavioral health organization, I am constantly confronted with questions regarding ethical decisions like the example provided. And I've found that staff, while well intentioned, often need guidance in making appropriate decisions. What follows is the seven-step process (with explanations) that I go through to make decisions and to train my staff on the decision-making process:
1. Gather all the relevant facts of the situation/proposed action.
2. Identify key stakeholders and their interests.
3. Determine whether this action violates any laws, codes of ethics or organizational policies. If not, or if you're unsure, then ...
4. Identify the worst-case scenarios.
5. Brainstorm a solution with the stakeholders involved.
6. Conduct a "fairness test."
7. Develop a plan of action to resolve the current dilemma and prevent
future incidents.
To explain:
1. Gather all the relevant facts of the situation/proposed action. Whenever a situation is presented, it is usually missing some key facts or perspectives that could alter the decision. The manager/decision maker needs to gather as many of the relevant facts of the situation as possible. (For example,see the possible complications raised in the above scenario.)
2. Identify key stakeholders and their interests. Stakeholders might include
the client, the individual staff member, the organization, the client's family members, your organization's funding sources and society as a whole. Identifying their interests, and how they conflict, is crucial to resolving the dilemma fairly. In the example provided above, the client, worker and organization are all stakeholders. We know what the interests of the client (and possibly family members) and worker are. The organization's concern might be over its reputation (e.g., being potentially viewed as taking advantage of a client's vulnerable situation for self-gain).
3. Determine whether this action violates any laws, codes of ethics or organizational policies. Clearly, if an action violates the law, the code of ethics or an organizational policy, then it cannot be justified. However, the finding of a violation of the code of ethics might sometimes be disputed by those involved, such as the worker who doesn't understand why she can't buy the stereo, or the client who doesn't understand why he can't sell the stereo to assist himself or herself. This necessitates steps 4 through 7.
4. Identify the worst-case scenarios. This is where I let my imagination run amok. I, along with the staff member, identify the worst-case scenarios. In the example given earlier, some possible scenarios are: (a) the client is not the true owner of the stereo and is purveying borrowed or stolen equipment; (b) the stereo is faulty and not worth what the staff member is willing to pay for it (thus possibly causing animosity toward the client once this is discovered); (c) the transaction causes a perception that the facility's staff are "taking advantage" of clients; (d) the client complains after the sale that he or she wants the stereo returned. Together, with the staff member, identify and work through all such potential problems associated with the transaction.
5. Brainstorm a solution with the stakeholders involved. In the example given, some brainstorming ideas might include: (a) encouraging the client to identify buyers through different means (pawn shop, classified advertising, posting fliers at stores, making an announcement at support meetings); (b) identifying alternative ways for the staff member to obtain bargain stereo equipment (e.g., pawn shops, etc.); (c) establishing organizational policy on staff members' purchasing goods or services from clients.
6. Conduct a "fairness test." For a decision to pass the "fairness test," all stakeholders should perceive it to be fair, given all the circumstances.
Subparts of the fairness test include:
* Does it meet the Mission Test (i.e., does the decision fit comfortably with the organization's mission)?
* Does it meet the Pride Test (i.e., do you "feel proud" of the decision)?
* Does it meet the Explanation Test (i.e., would you feel comfortable explaining the decision to all stakeholders)?
* Does it meet the "Front Page of the Paper" test? This is one of my favorites: What is the worst headline you can make from the situation and resulting decision? In the example provided, how about "Program Buys Stolen PropertyFrom Clients" or "Counselors Prey on Cash-Strapped Clients"?
7. Develop a plan of action to resolve the current dilemma and prevent future incidents. This step will show how much you have learned from previous experiences and how well you explain it to all potential stakeholders.
I suggest that staff in your organization practice this approach in staff meetings devoted to training for ethical decision making. Keep in mind, process is important, even if the answer to some situations is obvious to some staff members. All will encounter "gray areas" sooner or later. Perhaps this will help your organization prepare for the inevitable.
Joseph Paliwoda, MBA, is president of Paragon Consulting Services, Pinckney, Mich. As a CARF surveyor, he provides consultation to mental health and substance abuse treatment providers. For further information, phone (734) 546-7020 or e-mail jspjoe@tir.com.