Running head: ETHICAL DECISION-MAKING EXERCISE

Ethical Decision-Making Exercise Jo Friesen University of Calgary

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Ethical Decision Making Exercise Step 1 In this situation, the individuals directly affected include the young boy and his grandmother. On a broader scale, there may also be other groups affected by the decision, including the staff and students at the school the boy attends, his peers, the aboriginal community the boy and his grandmother are a part of and professionals who I might call on to help with a psychiatric assessment. Step 2 I can identify 28 ethical values that I think are key to understanding this scenario: seven under Respect for the Dignity of Persons, eleven under Responsible Caring, six under Integrity in Relationships and four under Responsibility to Society. Principle/Value Principle I: Respect for the Dignity of Persons General Respect I.1 Demonstrate appropriate respect for the knowledge, insight, experience, and areas of expertise of others. Non-discrimination I.11 Seek to design research, teaching, practice, and business activities in such a way that they contribute to the fair distribution of benefits to individuals and groups, and that they do not unfairly exclude those who are vulnerable or might be disadvantaged. My Thoughts Regardless of my final decision, I need to ensure that I am paying attention to knowledge and expertise others may have around this decision, and respecting the input they have. One of my hesitations around seeking a psychiatric consult is the distance the family would have to travel. However, it is important that I not rule out this benefit simply because they dont have the advantage of living in a community were such an assessment would be easily accessible. This helps me to see that I need to work to ensure this boy has equal access to the services he needs. In this situation, I see the need to potentially consult with other experts, both in terms of better understanding the culture and in terms of possible mental illness. I need to be certain I take into account any arrangements I need to make in terms of compensation. Is this

Fair treatment/due process I.14 Compensate others fairly for the use of their time, energy, and knowledge, unless such compensation is refused in advance.

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something I have funds to consider? Is this an additional expense for the family? This may be a reason to work with the grandmother in finding cultural support, as she may have access to resources I do not. Informed Consent I.16 Seek as full and active participation as possible from others in decisions that affect them, respecting and integrating as much as possible their opinions and wishes. I need to be sure that I communicate with both the youth and his grandmother about the options and help to provide them with the right information to guide them to the best decision. Based on age alone, it would seem the grandmother is the one who would be making final decisions, but considering how she has described the team they are as a family, I think she will be relying a lot on his input. As above, I need to work with both the boy and his grandmother to help them to understand their options and what each course of action would entail. I need to ensure I take the time to build rapport in order to develop a relationship that is collaborative. I need to help them both to understand that this is a process and that while we can lay out a course of action, we will still need to work together as more information becomes available. They need to understand what role I can continue to play to co-ordinate, liaise and counsel as well as their own role in the decision making process. I think it is very important they understand the consequences of their decisions, but that they dont have to make them all at once we can seek more info first too. In a small community it might be hard to seek local counsel in a way that protects anonymity but is still specific to this situation. I think I would need to try to convince the grandmother to provide consent to share personal information, especially in regards to seeking advice from aboriginal elders. I need to keep in mind that although I will be expecting the youth and his grandmother to participate in the decision making process, I am responsible for this young man and his care.

I.17 Recognize that informed consent is the result of a process of reaching an agreement to work collaboratively, rather than of simply having a consent form signed. I.24 Ensure, in the process of obtaining informed consent, that at least the following points are understood: purpose and nature of the activity; mutual responsibilities; confidentiality protections and limitations; likely benefits and risks; alternatives; the likely consequences of non-action; the option to refuse or withdraw at any time, without prejudice; over what period of time the consent applies; and, how to rescind consent if desired. Confidentiality I.45 Share confidential information with others only with the informed consent of those involved, or in a manner that the persons involved cannot be identified, except as required or justified by law, or in circumstances of actual or possible serious physical harm or death. Principle II: Responsible Caring General Caring II.3 Accept responsibility for the consequences of their actions.

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This puts the onus on me to work through this process carefully and respectfully in order to ensure that I create a healthy environment for decision making. In this case, I also need to consider the grandmother and what support she may need personally in order to provide the support her grandson needs. Competence and self-knowledge II.6 Offer or carry out (without supervision) only those activities for which they have established their competence to carry them out to the benefit of others. This is a situation in which I am not confident of my competence. I am uncertain about the fact that the boy is hearing voices and whether this is something that is expected within his culture after a death, or if this is a symptom of mental illness. As someone who works with children and youth, I also dont feel competent to diagnose or treat the grandmother, especially as I know that depression can present itself differently in the elderly. Since I feel she also needs care, I will need to look for outside support for her as well. I believe I am confident to work with the family to develop stronger family support system within the home, to create a better learning environment for the boy and school and to consider certain other causes of concern for the son, such as depression. I also feel confident to work with the family to help them to find the services they need. II.8 Take immediate steps to obtain This value tells me I need to act however consultation or to refer a client to a colleague or some of those steps can be gathering the other appropriate professional, whichever is information I need to get the right kind of more likely to result in providing the client with consultation. Since I have already recognized competent service, if it becomes apparent that a my need for help, I need to seek it out. The clients problems are beyond their competence. question that remains is whether to seek advice myself, or to refer the boy to someone else. Risk/benefit analysis II.13 Assess the individuals, families, groups, I need to better understand the aboriginal and communities involved in their activities community this family is a part of, both to adequately enough to ensure that they will be better understand the significance of some of able to discern what will benefit and not harm these symptoms, and to be knowledgeable the persons involved. about the ramifications of some of the courses of action. I do not know if there would be any stigma associated with having a psychiatric assessment in either the aboriginal community or the larger community. I need to consider this as a part of the risk assessment. II 14 Be sufficiently sensitive to and If it would be a risk for the family to seek a

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knowledgeable about individual, group, community, and cultural differences and vulnerabilities to discern what will benefit and not harm persons involved in their activities. Maximize benefit II.18 Provide services that are coordinated over time and with other service providers, in order to avoid duplication or working at cross purposes. II.20 Make themselves aware of the knowledge and skills of other disciplines (e.g., law, medicine, business administration) and advise the use of such knowledge and skills, where relevant to the benefit of others.

psychiatric assessment, I need to consider how important it is and what other options there may be. I dont want to make life worse for this young man or more stressful for his grandmother in the course of supporting them. It looks like I will be seeking outside services, and I therefore need to take responsibility to coordinate those services and see this through. It is not enough to make a referral and leave it I need to make sure as many layers of support come together and work together. It would be helpful for me to read up on what the medical literature says about these symptoms and why I am concerned. I dont want to frighten the family, but I also dont want to promise them things that are unrealistic. Ideally, I want them to be willing to seek the correct diagnosis and the right type of support, so I need to be able to provide enough info to help them make a decision. If I want the best possible service, I need to help this family overcome obstacles to getting it, including not only helping them understand their options and how they relate to their culture, but also helping with logistics, such as how to travel to the city for the assessment if that is what they choose. I would like to put together a proposal where the travel is not a factor in the choice but rather just a step in the process. I need to consider that with the grandmothers history, she may be unwilling to send her grandson away so I need to be sure to include her in any transportation plans. As new information becomes available, I need to stay in contact with the family and help them to integrate this new info into future action steps. Again I think reasonable assistance in this case will need to include helping with transportation. I need to continue to follow up and work with this family, unless another professional takes on this co-ordinating task. It is not enough to make

II.21 Strive to provide and/or obtain the best possible service for those needing and seeking psychological service. This may include, but is not limited to: selecting interventions that are relevant to the needs and characteristics of the client and that have reasonable theoretical or empirically-supported efficacy in light of those needs and characteristics; consulting with, or including in service delivery, persons relevant to the culture or belief systems of those served; advocating on behalf of the client; and, recommending professionals other than psychologists when appropriate. II.22 Monitor and evaluate the effect of their activities, record their findings, and communicate new knowledge to relevant others. Minimize Harm II.31 Give reasonable assistance to secure needed psychological services or activities, if personally unable to meet requests for needed psychological services or activities. II.33 Maintain appropriate contact, support, and responsibility for caring until a colleague or other professional begins service, if referring a

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client to a colleague or other professional.

a couple of referrals and be done. They both already feel alone enough I think it is important I help them navigate the process as long as necessary. I need to be clear with the family about my lack of competence both in terms of cultural understanding and with mental illness. I also need to carefully and honestly explain what other professionals can offer that I cannot and be careful not to promise more than someone else would be able to deliver. Again, I think this comes down to not making promises about what we can accomplish, but rather helping them to see what I and my colleagues can offer. I need to be sure to consider my own need to be culturally sensitive and not allow that desire to cloud my judgement in terms of how serious these voices may or may not be. I dont know so I need to seek help and not make a decision about their severity or significance myself. In expressing my concern for both the youth and the grandmother, I need to be certain I am communicating well, so they understand my concerns, but dont think I have diagnosed them. For instance, I shouldnt tell them I think the son has a mental illness, but why hearing voices is a cause for concern. I need to be straightforward with the grandmother in terms of my concerns for her as well and how her situation may be affecting her grandson. Since I have areas of uncertainty here, I definitely need to seek advice from others colleagues and aboriginal community members, to ensure this family gets the best support possible.

Principle III: Integrity in Relationships Accuracy/honesty III.2 Accurately represent their own and their colleagues credentials, qualifications, education, experience, competence, and affiliations, in all spoken, written, or printed communications, being careful not to use descriptions or information that could be misinterpreted (e.g., citing membership in a voluntary association of psychologists as a testament of competence). III.8 Acknowledge the limitations of their own and their colleagues knowledge, methods, findings, interventions, and views. Objectivity/lack of bias III.10 Evaluate how their personal experiences, attitudes, values, social context, individual differences, stresses, and specific training influence their activities and thinking, integrating this awareness into all attempts to be objective and unbiased in their research, service, and other activities. III.11 Take care to communicate as completely and objectively as possible, and to clearly differentiate facts, opinions, theories, hypotheses, and ideas, when communicating knowledge, findings, and views. Straightforwardness/Openness III.16 Fully explain reasons for their actions to persons who have been affected by their actions, if appropriate and if asked. Reliance on the discipline III.38 Seek consultation from colleagues and/or appropriate groups and committees, and give due regard to their advice in arriving at a responsible decision, if faced with difficult situations.

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Principle IV: Responsibility to Society Beneficial activities IV.11 Protect the skills, knowledge, and interpretations of psychology from being misused, used incompetently, or made useless (e.g., loss of security of assessment techniques) by others. Respect for society IV.15 Acquire an adequate knowledge of the culture, social structure, and customs of a community before beginning any major work there. IV.16 Convey respect for and abide by prevailing community mores, social customs, and cultural expectations in their scientific and professional activities, provided that this does not contravene any of the ethical principles of this Code. Development of society IV. 25 Make themselves aware of the current social and political climate and of previous and possible future societal misuses of psychological knowledge, and exercise due discretion in communicating psychological information (e.g., research results, theoretical knowledge), in order to discourage any further misuse. Step 3: Biases

This could be a sensitive situation, especially if it is the case where the voices this boy is hearing seen as a good thing within his culture. Seeking a psychiatric assessment for this boy could cause others to be less trusting and honest with other members of my profession in the future. Since I am working in a community with aboriginal youth, I should have a better understanding of their culture. This is something I need to rectify not only for this client, but for future ones as well. If it becomes clear that the concerns I have with the voices are a common part of the culture, or expected after a death, I need to consider this in making my suggestions. I doesnt mean I should rule out a referral, but a different overall approach may be necessary if I am going to ensure the boy has long-term support and understanding. The fact that the grandmother is still dealing with her own traumatic experiences with residential schools is an important factor. This is an area of concern for her own well-being, as well as for how trusting she may be in terms of allowing me and the school to help her son. She suffered a great abuse of power and authority, and I need to be cognizant and respectful of that as I work with this family.

I need to consider how my own biases may affect my judgment in this scenario. Having worked a lot with a variety of cultures, I have learned to respect different traditions but I still do not understand them all of them very well. I need to ensure that in my desire to be understanding of culture, sensitive and respectful, I do not just assume that what the youth is experiencing is appropriate and overlook a medical or psychiatric condition. I also spend a lot of my time

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advocating for youth, and in this situation, I need to ensure that I am taking the grandmothers needs into account as well and being realistic about what kind of support she can offer in her current condition. I cannot just expect her to do whatever it takes to support her grandson, without ensuring she has support as well. It is clear that she would benefit from additional support as well, and while I might not be the best person to provide it, I cannot overlook it or disregard it in my considerations of how to best help her grandson. Step 4: Alternatives Alternative 1: One option is to offer the support I am capable of providing for the grandson. I can begin to work with the grandson in regards to his social withdrawal and provide support to help him to deal with his grief. As a part of the process, I could also find an aboriginal elder to consult with to better understand what the youth might be experiencing, and to help him understand it as well. As I work with him, I can see if other symptoms of mental illness arise or if the voices become more of an issue and then make a decision about referral for psychiatric assessment then. Alternative 2: Another option is to admit that this situation is beyond my expertise and arrange a referral to the psychiatric clinic in the city. If the family goes through with the assessment, I can be available to provide follow up support if I feel competent to do so based on the findings. If the family does not go through with the assessment, I would need to reassess my willingness to counsel the youth without the assessment. Alternative 3: A third option is to make a decision to work with the family to seek out the various types of support or expertise they may need that I am unable to provide, as well as offer the family and social counselling I feel competent to provide. I would sit down with the grandmother alone initially to discuss my concerns regarding the voices her son hears and ask for her level of

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concern surrounding them. I would also express my concern for her as a person and try to help her see that there are others she could rely on besides her grandson. I would also seek permission to meet with the grandson alone, to better understand the nature of the voices, how his grandmothers reliance on him affects him and what he would like to accomplish through our working together. I would then meet with both of them to discuss the grandsons situation specifically, including seeking consent to consult with others to better understand the significance of the voices and the options they have in terms of how to best move forward with understanding what is really going on with the grandson. I would include the psychiatric assessment as an important option, and help them to make the best decision regarding what to do, including clear information on the process and transportation to and from the city. I would also make it clear that as a part of my role I was committed to seeing them through the process. Step 5: Risks and Benefits Possible Positive Consequences Alternative 1: There would be immediate action with regards to some of the grandmothers concerns, as we wouldnt be waiting for further information to make decisions. Having an aboriginal elder consult could provide important insight and clarity in regards what is happening. Alternative 2: Someone with the correct expertise would be able to diagnose any mental illness and the youth could potentially get good care quickly. Possible Negative Consequences If there is a mental illness involved, we may just be wasting our time trying to find solutions without getting to the heart of what is going on. Things could get much worse with the youth. We could miss a window of opportunity to provide him with the support he needs, leading to more challenges down the road. The stigma involved in receiving an assessment, and potentially a diagnosis of mental illness could be an added burden if the community is not accepting of such types of treatments.

The grandmother may be relieved if she feels this is the way for her grandson to get the help he needs. It might help her to know that it The grandmother may not follow through, may not be something she is doing wrong and leaving me back where I started in terms of that there is help. decision making. Based on her background, it may have taken a great deal of courage to

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consult with me in the first place, and if I just pass her off, she may not be willing to seek help again, leaving them both feeling even more alone. Alternative 3: The family would have good information and guidance to make the best decision. This process itself could help them to feel less alone and on their own, and more ready to accept support. A more thorough process will allow me time to develop rapport and build up trust, especially with the grandmother. This may lead to additional, important information which might make action steps down the road more effective. A diagnosis of mental illness, while potentially frightening, also means that the youth could be that much closer to receiving the treatment and support he needs. It might make a significant difference for him to understand why he feels and/or acts different from his peers. The grandson seeking, receiving and benefiting from support may help encourage the grandmother to do the same for herself. Step 6: The best choice here is Alternative 3. It allows me to involve the family in the process, ensures that they receive the full benefit of support and is respectful of both of their needs, as well as their position within the larger community. It allows me to address both the immediate and long-term situation and works to ensure that there is support for each step of what could be a complex and lengthy process. It ensures I only operate in areas I feel competent and still provides the greatest amount of support for the family. Step 7: Being in a position to make the decision about seeking an assessment or not could be an added burden to the grandmother one that she may find difficult in her present condition. She may choose not to act out of fear or distrust. The delay in seeking a consult or referral necessitated by incorporating the family into the decision process could be a problem if the grandson does have a mental illness and it deteriorates before he is diagnosed. The family may still refuse to the psychiatric assessment even if it is still warranted after further investigation. This may mean I would need to reassess my decision model as I might still feel incompetent to work with the youth. There could be conflict with the aboriginal community if they believe the voices are welcome and/or normal and I still recommend psychiatric assessment. This could lead to distrust not only of myself, but of the profession.

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I need to take the first step and start to arrange meetings. I need to consider the timely nature of the concerns and the ramifications of waiting, and try and take care of the first meetings quickly, so that if psychiatric assessment is needed, it is not delayed an unreasonable amount. Step 8: Since the situation is complex and the process realistically lengthy, I will need to continue to evaluate as we move forward. What the next step should be will only become evident after my initial course of meetings once I see how the family responds and what their decisions are. I will need to continue to act and evaluate through each stage of the process. Step 9: Despite my careful consideration, I need to be aware that the possible negative consequences could come to pass. I need to be prepared to continue to work with the family to follow up with support and stay committed to advocating for this young man, even if I dont agree with every decision his grandmother makes. Step 10: Moving forward, it is clear that I need to develop better cultural understanding of the cultures represented in my community and how some of the beliefs or practices of those cultures might overlap, or conflict with, psychological practice. I think I also need to look into the situation regarding residential school trauma with the grandmother. If there are a number of adults in the community still affected by this, it may be appropriate to provide community support in terms of reconciliation and healing so that we can minimize any negative impact their children/grandchildren may feel and maximize the benefits of having trusting relationships within the school system.

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References Canadian Psychological Association. (2000) Canadian Code of Ethics for Psychologists (3rd ed). Ottawa, ON: Author. Sinclair, C., & Pettifor, J. (2001). Companion manual to the Canadian code of ethics for Psychologists, Third Edition. Ottawa, ON. Canadian Psychological Association.