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CAAP 603 – Ethics – Nina Valli

Ethical Decision-Making for a Hypothetical Case

Ethical Dilemma:

An 11-year old Aboriginal boy reports to his teacher at school that he is hearing voices. You are
a counsellor working outside of the Aboriginal community that has been asked by the school’s
administration to come in and meet with the boy and his grandmother, who is his guardian. You
have been told that his grandmother is strongly opposed to her grandson undergoing any
psychological assessments, but the teacher report that she thinks the boy would benefit form this
type of test. How do you proceed?

Ethical Model: Canadian Psychological Association Code of Ethics

Step 1: Identification of the Individuals and Groups Potentially Affected by the Decision.

Youth, grandmother, psychiatrist, colleagues, school board, myself

Step 2: Identification of Ethically Relevant Issues and Practices, Including the Interests,
Rights, and any relevant Characteristics of the Individuals and Groups Involved
and of the System or Circumstances in Which the Ethical Problem Arose.

The Four Ethical Principles with their

Respective Values and Standards
I. Respect for the II. Responsible Caring III. Integrity in IV. Responsibility
Dignity of Persons Relationships to Society
1.1 General Respect 2.1 General Caring 3.2 Honesty 4.15 Respect for
1.3 3.8 Society
4.16
1.9 Non- 2.2 Competence 3.10 Lack of Bias
Discrimination 2.6
2.8
2.10
1.12 Fair Treatment 2.14 Risk/Benefit 3.38 Reliance on
Analysis Discipline
1.16 Informed Consent 2.30 Minimize Harm
1.19 2.31
2.33
1.27 Freedom of
Consent

1.34 Protection for

Vulnerable
Persons
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1.45 Confidentiality

PRINCIPLE I: RESPECT FOR THE DIGNITY OF PERSONS

Value: General Respect

1.1 Demonstrate appropriate respect for the knowledge, insight, experience, and areas of
expertise of others.

I must consider the youth and grandmother’s knowledge of the aboriginal culture, including
rights, customs, insight, etc., due to the fact that the youth’s symptoms of hearing voices and
seeing an older man may be common place and a consequence of the grieving process. Also, I
must appreciate the inherent worth of others who are different from myself (East Indian).

1.3 Strive to use language that conveys respect for the dignity of persons as much as possible
in all written or oral communication.

Taking into consideration my own cultural, moral, social beliefs, and education, it is important
that I be sensitive to how my interactions with the youth and grandmother may interfere with
promoting their welfare. For example, I will make certain not to use language that sounds
authoritative (creating a power differential) or disrespectful, as well as be careful not to use
derogatory terms, conjecture, and make assumptions when writing documents pertaining to the
client’s files.

Value: Non-discrimination
1.9 Not practice, condone, facilitate, or collaborate with any form of unjust discrimination.

I must be careful not to make assumptions and label the youth’s symptoms with terms such as
“psychosis” or “delusions”. I need to be respectful of the Aboriginal culture and practices. Also,
I need to be aware that theories developed from dominant culture (western society) may apply
differently to people from non-dominant cultures and as such, I cannot impose the dominant
world view on the client.

1.10 Act to correct practices that are unjustly discriminatory.

I need to have a conversation with the school board (assuming this is the referral source?) about
their reasons for referring the youth and any attempts they made at understanding the youth’s
presentation due to cultural differences and grief for his grandfather’s death. This action will
contribute to building a society that is respectful and caring of all its citizens.

Value: Fair Treatment

1.12 Work and act in a spirit of fair treatment to others.

I need to make sure that the youth receives the appropriate services with respect to his needs. For
example, if a psychological assessment is needed and transportation is an issue, I would advocate
that the psychiatrist come to the town to see the client. Another possibility may be to access
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school board funding for the trip to the urban centre. I have an additional responsibility to make
sure that the youth has equal access to the benefits of psychological knowledge and services.

Value: Informed Consent

1.16 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 share all relevant decision making with the youth and grandmother, including the goals
of services, and proposed interventions in order to serve their best interests. I need to make an
effort to be open, honest, and straightforward, remembering that people from non-dominant
cultures may be distrustful or overly trustful to those in authority.

1.19 Obtain informed consent from all independent persons for any psychological services
provided to them except in circumstances of urgent need.

Consent for services needs to be obtained from the youth and grandmother. Since the youth is a
minor and grandmother is assumed to be the parental guardian, she would be the one to give
informed consent. I need to ensure that consent is truly informed, keeping in mind diversity
issues and cultural differences.

Value: Freedom of Consent

1.27 Take all reasonable steps to ensure that consent is not given under conditions of coercion,
undue pressure, or undue reward.

I will make sure that the youth and grandmother are not pressured by the school board or other
sources to seek psychological services.

Value: Protection for Vulnerable Persons

1.34 Carry out informed consent processes with those persons who are legally responsible or
appointed to give informed consent on behalf of persons not competent to consent on their
own behalf, seeking to ensure respect for any previously expressed preferences of persons
not competent to consent.

Since the youth is a minor and grandmother is assumed to be the parental guardian, she would be
the one to give informed consent. I need to be respectful of the youth’s wishes to obtain
treatment and factor this into the consent process with the grandmother, if she is pressuring the
youth to seek services.

Not related to any particular value, I need to make sure that I promote and protect the rights of
the youth due to his young age and his non-dominant cultural background. I am interested in
empowering vulnerable persons so that they have equal opportunities in mainstream society.

Also with respect to the grandmother mentioning that the youth and her “need each other right
now” due to the grandfather’s death, it is clear that the grandmother is not feeling well both
physically and mentally. In fact, there is concern that if she does not start feeling better and
resolving her childhood issues, she may negatively impact the youth’s development and well-
being. It is my duty to protect the youth and although I have only been requested to provide
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services for him, I it is important for me to offer counselling services to the grandmother as well.
I need to ensure that she is able to provide the best possible care for the youth.

Value: Confidentiality
1.45 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.

I need to make certain that I respect the client’s privacy according to their wishes, and fully
explain the limitations of confidentiality according to the federal legislation. I need to obtain
consent from the client before sharing information with colleagues, psychiatrist, school board,
and anyone else affected or involved, unless there is suspicion of child abuse, self-harm such as
suicidal tendencies, and homicidal thoughts.

PRINCIPLE II: RESPONSIBLE CARING

Value: General Caring

2.1 Protect and promote the welfare of clients, research participants, employees, supervisees,
students, trainees, colleagues, and others.

Recognize that for persons who are perceived as different in mainstream society, living among a
dominant culture is not easy and as such, vulnerable persons are affected with additional issues
and problems.

2.2 Avoid doing harm to clients, research participants, employees, supervisees, students,
trainees, colleagues, and others.

I need to be particularly aware of power differentials, unequal access to opportunities, and the
imposition of dominant culture world view on those who are different. In addition, I need to be
aware that if I am to insist that the youth travel to the urban centre for an assessment, that I may
exacerbate his tendency to isolate and withdraw from society. The stigma of seeing psychiatrist
and potentially be labeled with a mental illness will have negative repercussions. Also, visiting a
large urban centre may not be advisable in this case, due to the youth being accustomed to living
in a small town or reserve land.

Value: Competence
2.6 Offer or carry out only those activities for which they have established their competence to
carry them out to the benefits of others.

Be open and honest about limitations in my experience in working with Aboriginal clients and
ability in delivering psychological assessments. Do not provide the psych assessment myself due
to the client not having transportation to see the psychiatrist.

2.8 Take immediate steps to obtain consultation or to refer a client to a colleague or other
appropriate professional, whichever is more likely to result in providing the client with
competent service, if it becomes apparent that a client’s problems are beyond their
competence.
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If it is determined that the youth needs an assessment and his physical symptoms are of greater
concern, I would have to immediately refer him to the psychiatrist in order for him to receive
competent services.

2.10 Evaluate how their own experiences, attitudes, culture, beliefs, values, social context,
individual differences, specific training, and stresses influence their interactions with
others, and integrate this awareness into all efforts to benefit and not harm others.

Due to my limited experience and knowledge of Aboriginal culture, I need to be careful not
make assumptions regarding the youth’s physical presentation. I cannot let my own values,
attitudes, and biased/stereotypical perception of Aboriginals affect my work with the client.

Value: Risk/Benefit Analysis

2.14 Be sufficiently sensitive to and knowledgeable about individual, group, community, and
cultural differences and vulnerabilities to discern what will benefit and not harm persons
involved in their activities.

I need to better informed about Aboriginal culture. Due to my limited experience with
Aboriginal clients, I have not made an effort to learn more about this community. I would need
to take immediate steps to gain a better understanding of cultural differences by reading,
researching, talking to knowledgeable colleagues, and the family. This would prevent me from
unintentionally harming my client, make me aware of cultural sensitivities and important
practices, and understand the community’s philosophy and world view.

Value: Minimize Harm

2.30 Be acutely aware of the need for discretion in the recording and communication of
information, in order that the information not be misinterpreted or misused to the detriment
of others.

Due to the youth’s physical symptoms being interpreted as a presentation of “psychosis” in

dominant psychological theory, it is important that this is not misinterpreted as such in the
client’s documentation. Also, it is important that the client is able to read and easily understand
the information in their file pertaining to diagnoses, interventions, etc. The information must be
factual, not opinionated or assumed. There may be a language barrier present or inability to read,
accommodations must be made in order to effectively communicate the information.

2.31 Give reasonable assistance to secure needed psychological services or activities, if

personally unable to meet requests for needed psychological services or activities.

It is my responsibility to assure that the client receives services, if I am not competent to deliver
them. I will offer other options and resources available to assist the client.

2.33 Maintain appropriate contact, support, and responsibility for caring until a colleague or
other professional begins service, if referring a client to a colleague or other professional.

In the case of referral to a psychiatrist for assessment or further treatment, I need to maintain
support and responsibility for my client until the other professional is able to start service. Also, I
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need to follow-up after treatment with the referral has started for a reasonable period of time in
order to ensure that my client is receiving adequate care.

PRINCIPLE III: INTEGRITY IN RELATIONSHIPS

Value: Honesty
3.2 Accurately represent their own and their colleagues’ credentials, qualification, education,
experience, competence, and affiliations, in all spoken, written, or printed communications,
being careful not to use descriptions or information that could be misinterpreted.

As stated previously, I need to be open and honest about my own experience, qualifications, and
knowledge of Aboriginal culture in order to best serve the client. Once this information is
conveyed to the client, they can make an informed decision whether to receive services. I realize
that it may be difficult for the client to travel to the urban centre, due to lack of transportation as
well as the potentially stressful experience of visiting a large urban centre due to the client’s
diversity. In this case, it is important that I do not to deceive the client by embellishing my
qualifications to include services that I am not fully competent in.

Value: Lack of Bias

3.8 Acknowledge the limitations of their own and their colleagues’ knowledge, methods,
findings, interventions, and views.

I need to acknowledge the limitation of my knowledge of the Aboriginal culture and seek to
understand their views before I provide any major services or make any definitive conclusions.

3.10 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.

I need to acknowledge my own biases against the Aboriginal community in order to provide the
most objective service. This population is generally devalued in mainstream society. If my own
assumptions and interpretations prevent me from being objective, I am not maintaining honesty
and accuracy in my services. If I am not able to effectively manage these conflicts, it is crucial
that I refer the client to a service provider who does not have these biases and can effectively
serve the client with their best interests at heart.

Value: Reliance on Discipline

3.38 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.

In this case, it my responsibility to consult with Aboriginal colleagues, or those who are
knowledgeable of this culture, as I am limited in my understanding.

PRINCIPLE IV: RESPONSIBILITY TO SOCIETY

Value: Respect for Society

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4.15 Acquire an adequate knowledge of the culture, social structure, and customs of a
community before beginning any major work there.

It is my responsibility to constantly re-evaluate my competence, attitudes, and effectiveness in

working with diverse populations. In order to maintain a higher level of competence I must seek
to educate myself with knowledge of diverse cultures.

4.16 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.

Even though, I may not agree with social customs and expectations of a culture, I need to be
respectful and accepting of their views. By having this attitude, I can incorporate their cultural
values into suitable treatment goals and interventions.

Step 3: Consideration of how personal biases, stresses, or self-interest might influence the
development of or choice between courses of action.

My initial reaction was to feel very worried for the youth because my education in
psychotherapy tells me that the symptoms the youth is exhibiting are evidence of psychotic
behavior. Therefore, in order to prevent discrimination, I need to make an effort to understand
Aboriginal culture, particularly the way in which the community deals with the loss of a loved
one. Perhaps the youth is having visions of his grandfather due to extreme feelings of loss and
abandonment, which is not necessarily a sign on psychotic behaviour. In addition, I was upset
that the grandmother expressed her need to be close to the youth due to loss of the grandfather.
To me, it almost sounded like grandmother may be relying too heavily on the youth, further
compromising his mental health. Again, this perspective may stem from my value of autonomy,
rather than the collective mentality of non-dominant cultures. Another red flag was the fact that
the grandmother had unresolved issues from her past that were still affecting her mental health in
the present. It seemed to me that the grandmother might not be able to provide the best care for
the youth at this time and if her situation did not improve, the youth’s development and well-
being would suffer in the long-term. I immediately thought of the possible involvement of
childwelfare and offering counselling services to the grandmother. I need to seriously consider
the repercussions of separating the family and work to see the value in preserving it. Also,
perhaps the grandmother does not need formal counselling and can benefit from supportive
resources within her community that are more in line with her cultural values. Lastly, I need to
acknowledge my own biases against the Aboriginal community in order to provide the most
objective service. This population is generally devalued in mainstream society. If my own
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assumptions and interpretations prevent me from being objective, I am not maintaining honesty
and accuracy in my services. If I am not able to effectively manage these conflicts, it is crucial
that I refer the client to a service provider who does not have these biases and can effectively
serve the client with their best interests at heart.

Step 4. Development of alternative courses of action.

Alternative 1.

Establish whether the grandmother is the legal guardian. If she is, begin by explaining the
right to the client’s privacy and the limitations of confidentiality. Talk about the reason for
referral by the school board and the youth’s isolated and withdrawn demeanor, being cautious to
avoid discussing the youth’s symptoms in his presence. Explain my qualifications, experience,
and the goals and particulars of counselling services. Obtain informed consent for services from
the grandmother, since the youth is a minor. However, involve the youth by engaging him to
voice his opinion and show respect for his views. Make certain that the grandmother is not being
pressured into obtaining services. Politely ask the youth to leave the room temporarily.
To the grandmother, express concerns of the youth’s symptoms of seeing and hearing
voices of a man, without the youth present, in order to prevent causing more undue stress for
him. Explain that these symptoms may be a result of psychosis. Recommend to the grandmother
that the youth should have a psychological assessment before I can continue with services.
Explain my limitations in performing this evaluation and the benefits if having it done, including
obtaining immediate competent care for the youth’s mental health. Obtain consent to release
information to the psychiatrist and the school board in order to keep them involved. In addition,
explain concerns regarding the grandmother’s mental health and self-care, since she is not eating,
sleeping, and stressed about her past. Recommend that the grandmother also receive counselling
services in order to effectively care for the youth. Express long-term repercussions on the
youth’s health if the grandmother’s health does not improve. Explain the possibility of involving
childwelfare for assistance in caring for the youth appropriately at this time and in the future.
Have the youth return to the room. Explain the decision to conduct a psych assessment.
Describe the location and the travel required. Ask the youth’s opinion of this decision. Try and
accommodate the client by advocating for the psychiatrist to visit the client in order to prevent
the youth from experiencing further stress due to visiting a large urban centre.
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Alternative 2.

Establish whether the grandmother is the legal guardian. If she is, begin by explaining the
right to the client’s privacy and the limitations of confidentiality. Also provide the youth with the
option of having private discussions with me without the grandmother in order to have the youth
feel more comfortable expressing his true feelings. Talk only about the reason for referral by the
school board and the youth’s isolated and withdrawn demeanor. Explain my qualifications,
experience, my unfamiliarity with Aboriginal culture, and the goals and particulars of
counselling services. Request that the family help me in understanding the culture. Obtain
informed consent for services from the grandmother, since the youth is a minor. However,
involve the youth by engaging him to voice his opinion and show respect for his views. Make
certain that the grandmother is not being pressured into obtaining services.
Once informed consent is obtained, obtain the family’s understanding of the youth’s
behavior. Ask the grandmother about the grieving process in their culture, including behaviors
and coping mechanisms. Ask the youth for a translation of what is being said to him in tribal
dialect. Find out about resources available to them from their own community. If it seems that
the family is not particularly worried about the youth’s visions and ability to hear voices, I would
not convey my concerns just yet about these symptoms. I would spend this initial time building a
strong relationship and understanding the client’s concerns and needs. I would obtain consent to
discuss this case with colleagues knowledgeable of Aboriginal culture, a psychiatrist for
preventative measures and information, and the school board for their reasoning regarding
referral and follow-up. I would schedule another session with the family.
In between sessions, I would conduct an investigation of my own of Aboriginal culture,
by consulting with colleagues and researching literature in order to become educated in their
customs, social structure, and in particular the grieving process. I would also consult with
colleagues in making a decision regarding obtaining a psych assessment for the youth’s
symptoms as well as my concerns regarding the grandmother’s ability to care for the youth.
Step 5: Analysis of likely short-term, ongoing, and long-term risks and benefits of
each course of action on the individual(s)/group(s) involved or likely to be
affected

Alternative 1.

Possible Positive Consequences Possible Negative Consequences

Providing immediate options for competent Discriminating against the youth’s culture and
care for the youth’s “psychosis” encountering resistance/poor alliance
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Providing immediate assurance for the youth’s Guardian will become angry and defensive,
safety regarding a potentially “unfit” guardian resulting in resistance/poor alliance
Obtaining a professional assessment of the Causing the youth undue stress from the
youth’s mental state assessment, exacerbating his symptoms

Alternative 2.

Possible Positive Consequences Possible Negative Consequences

Discussing the issues in the open might lead to
a quick resolution conducive to the youth’s
welfare
Give the family a sense of control, leading to
better collaboration
Preservation of the family and their cultural
beliefs with respect to collectivism
Postponing the assessment and continuing
treatment might result in negligence, adversely
affecting the youth’s health and my credibility
Maybe the family’s understanding of what’s
best for the youth is actually harmful
Allowing the youth to remain in a potentially
harmful environment

Step 6: Choice of Course of Action

I think the actions for the second alternative more accurately support the values included in
Principle I- Respect for the Dignity of Persons as the family’s culture and beliefs are respected.
Alternatively, the actions of the first alternative support more clearly the values included in
Principle II- Responsible Caring due to the emphasis on providing immediate competent care.
With respect to Principle III- Integrity in Relationships, the second alternative more accurately
supports the values because the family is involved in the process of decision making. Lastly,
Principle IV- Responsibility to Society is also more highly supported in alternative two due to its
importance in obtaining knowledge of the Aboriginal culture. The conflicting principles in this
case are I and II. Obtaining more information regarding the family’s culture, not discriminating
by jumping to a conclusion of “psychosis”, and an “unfit” grandmother, conflict with providing
immediate competent care to the youth with respect to his mental health and safety. However,
Principle I is weighted more according to the code, so alternative two is my choice of action. The
concerns regarding Principle II will not be ignored, just kept in the background until the family
and I can come to a definitive conclusion.

Step 7. Action, with a Commitment to Assume Responsibility for the Consequences

I have chosen to proceed with counselling the client, even though I have concerns that I cannot
effectively deal with myself. However, I am respecting the general rights of the client by
attempting to obtain more information regarding cultural beliefs before I make a definitive
conclusion.

Step 8. Evaluation of the Results of the Course of Action

Evaluation of the results will consist of how the client responds to counselling services and my
findings of Aboriginal culture. If there is sufficient evidence that the youth’s response is
“normal” and that counselling surrounding his isolation, feelings of abandonment, and grief will
adequately treat his symptoms, then I know I made the correct decision. As well, the
grandmother receiving support from the community might be enough to put her negative state
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into remission. On the other hand, if she is not doing better, alternative action will have to take
place.

Step 9. Assumption of Responsibility for the Consequences of Action

Despite my best efforts to minimize negative consequences, there is a chance that my decision
was incorrect. The youth’s mental health could get worse and the situation at home with the
grandmother also suffering might escalate both their behaviors. I would assume responsibility for
the consequences and act to correct the situation immediately.

Step 10. Appropriate Action, as Warranted and Feasible, to Prevent Future Occurrences of
the Dilemma

In the future, I need to be more prepared initially to work with clients from diverse cultures. My
lack of understanding of the culture’s customs, etc., is what contributed to my uncertainty. Even
though I made the decision to research at that point and consult with colleagues, I wasted
precious time and potentially placed my client at risk of additional suffering.