Читать книгу Theory and Practice of Couples and Family Counseling - James Robert Bitter - Страница 93

Principle ethics can be seen as preexisting obligations a family practitioner embraces prior to any interaction with clients. The most commonly mentioned principles in the fields of counseling and family therapy reflect the Western values and themes first articulated by Plato, Aristotle, and Cicero: autonomy, beneficence, nonmaleficence, fidelity, justice, and veracity (Remley & Herlihy, 2020).

Autonomy is the principle underlying the individual’s freedom of choice. There are many ways in which the principle of autonomy can play out in family practice. At the outset of family consultation, you will describe to your client your preferred approach or model as part of what is called informed consent. Families have the right to say “no” to the services you offer if those services do not fit them. The principle of autonomy also favors the individual over the family or the group. In many Asian and Hispanic cultures, however, what is best for the individual is never considered above what is best for the family. It is important to keep in mind that autonomy is a decidedly Western value. Even in Western cultures, the principle of autonomy forces relational practitioners to articulate who they see as their client: Is it each individual in the couple or family, or is it the relationship or system as a whole? Will the practitioner support the needs and development of individuals or of the couple or family or attempt to do both? And how will conflicts in these areas be resolved? The ACA Code of Ethics (ACA, 2014) states that in couples and family counseling

counselors clearly define who is considered “the client” and discuss expectations and limitations of confidentiality. Counselors seek agreement and document in writing such agreement among all involved parties regarding the confidentiality of information. In the absence of an agreement to the contrary, the couple or family is considered to be the client [emphasis added]. (Standard B.4.b.)

The default position is that the relational system is the client when counselors do not indicate otherwise.

Beneficence is the promotion of the client’s welfare and well-being. Family practitioners take steps to consciously and consistently work toward the betterment of the couples and families with whom they work. Sounds simple, does it not?

Let us imagine a family that has come to you for support and guidance. (We use this family throughout the rest of this chapter to consider other ethical questions and concerns.) The family has recently been charged with child neglect. The specific charge of neglect involves the family’s 14-year-old child, who is suffering from leukemia. The parents hold religious beliefs that do not allow medical intervention to be given for any illness, even cancer. The parents want to gain your support for their freedom to choose the health care interventions they deem appropriate within their religious system. Prayer is their preferred form of intervention.

Supporting their freedom sounds like the right thing to do, but there in front of you is their 14-year-old child, suffering—and most likely dying—from cancer. So what actions do you take that would be seen as promoting the client’s welfare? And who exactly is your client: the parents, the child, the family as a whole? The answer to this question will be central to every move you make.

If promoting the 14-year-old child’s welfare seems clear to you, then you are viewing the child’s problem from the perspective of what is possible using Western medical procedures, a perspective clearly outside of the religious values that are informing the parents’ actions. As it turns out, even the child espouses the same religious convictions. If you support the family’s perspective, are you prepared to watch this young person die when everything within your own value system tells you the child has a chance with what you might deem proper medical care?

Nonmaleficence is the classic credo of doctors: Do no harm. This directive seems so simple, but the meaning of “harm” can be individual, contextual, cultural, or even historical. What the family practitioner means by harm can be quite different from the family’s definition, and even within a family differences may exist as to what constitutes harm for each family member.

In the early days of family therapy, Jay Haley (1963) used paradoxical interventions when certain client symptoms were thought to be maintaining a family’s problems: Haley would sometimes prescribe and augment the symptom as opposed to working directly to relieve it. For example, a father might exhibit great anxiety and worry about his family’s welfare, checking on his kids at school three, four, or five times a day. Haley might tell the father that he is not worrying enough. What about all of the hours of the night when other family members are asleep? Haley might even instruct the father to set his alarm clock to wake him every hour, on the hour. Upon awakening, he is to get out of bed and wake each of his children and ask whether they are okay. The father is directed to carry out this task for five nights in a row.

We already have noted that the definition of “harm” can differ across different periods in history. During the 1960s and 1970s, paradoxical interventions might have caught the scorn of some, but they would have been allowed to continue. Such interventions certainly brought about sudden, beneficial changes at times, even though their use raised the issue of whether the end justified the means. Today standing up in your agency’s case meeting and describing this intervention might very well lead to charges of an ethical violation.

Fidelity refers to the responsibility to maintain trust in the therapeutic relationship. Family practitioners must remain faithful to the promises they make to clients, especially when maintaining clients’ right to privacy. What does this principle mean in relation to family secrets? Building and maintaining trust is the cornerstone of an effective therapeutic alliance with clients. The codes of ethics for all of the helping professions recognize the importance of keeping individual family members’ private conversations with their counselor or therapist confidential unless that individual has given consent to share the content of the conversation. This right to privacy also is codified in law through the current HIPAA regulations and requirements.

Let us say that the 16-year-old daughter of a family speaks to you one on one prior to a family session about her recent experimentation with marijuana and her fear of her parents’ potential response. You listen intently and affirm the confidentiality of the conversation. During the family session, the father and the mother both indicate that they are worried about their daughter. Her grades in school are getting worse (“She has always been a good student”); she is hanging out with a different set of friends, and she sneaks out to see them at night, but she will not introduce any of them to her parents; and she is dressing differently. The parents ask her, “Are you doing drugs?” The girl denies that she is. The parents look to you: “Do you think she is doing drugs?” How do you reconcile the principles of beneficence, nonmaleficence, and fidelity in this case? What effect would disclosing this family secret have on the 16-year-old daughter? How might she view the counseling process and you as a family counselor? If you think this dilemma is hard, what will you do when you know that one of the parents is having an extramarital affair that is directly harming other members of the family? With each additional ethical principle, the professional waters muddy even more.

Justice refers to fairness, including equitable service for all clients. In 2004–2005, Counselors for Social Justice, a division of ACA, developed a website that specifically targeted issues of equity, oppression, discrimination, and injustice (see https://www.counseling-csj.org). Such a development highlights how valued this principle is within the counseling profession:

Counselors for Social Justice works to promote social justice in our society through confronting oppressive systems of power and privilege that affect professional counselors and our clients and to assist in the positive change in our society through the professional development of counselors. (Counselors for Social Justice, 2020)

In the teaching of ethics, the principle of justice has been the most misunderstood and debated. For many, equality and fairness mean equal treatment or the same treatment. Relational counselors understand equality to mean that all people have an equal right to be valued and respected even when they are different from one another. Both philosophy (Aristotle, 350 B.C.E./1985) and systems theory (Bateson, 1979) have noted that differences cannot be ignored: Being just means treating similar people similarly and different people differently.

For example, is working with a family with an only child and an income of more than $100,000 the same as working with a family of eight whose income is less than $25,000? Is the difference in incomes different enough to warrant a different way of providing family counseling? Do you think poverty has real effects on family life? If you are in private practice, and you have set a rate for your services at $100 per hour, will you even see the poorer family? How will you bill them? Will you see them for free or on a sliding scale? And how many poor families will you be able to accept in your practice and still make a living yourself? Justice requires that you wrestle with these issues before you even see your first family.

Veracity is the implementation of truthfulness: It is intimately related to personal and professional integrity. It has only been recently that veracity has been included in major ethical texts (Corey et al., 2019). One reason for including veracity in the list of ethical principles is the increasing requirements of managed care. Managed care dictates not only the treatment people receive from medical doctors but also the services delivered to individuals and families for mental health problems. In the name of controlling health care costs, managed care companies limit the type and duration of services offered to clients. To remain on a preferred provider list, family practitioners must agree to abide by the parameters set by such companies. This means that family practitioners within a managed care system must wrestle with split loyalties. Being truthful, an essential part of informed consent, is essential for resolving professional conflict in the managed worlds of hospitals and community agencies.

These six common ethical principles do not exist independent of one another. A. Hill (2004) suggested that they are present in any ethical dilemma; the family practitioner, however, needs to assess which principles are most relevant to any given situation and how other principles might also be addressed. Deciding which ethical principle is most pertinent in any given situation can be a difficult task. The decision often depends on your in-the-moment interpretation of the ethical principles, consultation with other professionals, and guidance from your profession’s code(s) of ethics.

What would be an action that you would define as promoting the clients’ welfare in the case of the 14-year-old child with leukemia? In reviewing your profession’s codes of ethics, you find no statement that begins with “When counseling a family whose child has leukemia and whose religious beliefs do not support medical intervention, you must …” What you will find in codes of ethics are statements such as “The primary responsibility of counselors is to respect the dignity and promote the welfare of clients” (ACA, 2014, Standard A.1.a.) or the indication that “couple and family counselors do not engage in actions that violate the legal standards of their community and do not encourage client or others to engage in unlawful activities” (IAMFC, 2017, p. 4), or the indication that marriage and family therapists participate in activities that contribute to a better community and society (AAMFT, 2015).

So what can we glean from these statements that might help? The ACA Code of Ethics (ACA, 2014) makes beneficence the primary ethical responsibility. Okay, what action(s) serve(s) to promote the family’s welfare? Respecting their welfare may mean respecting their autonomy to make decisions on their own. Yet respecting autonomy may contribute to the parents ending up in court facing either jail time or the removal of their child from their custody. Whose welfare is served then?

The IAMFC Code of Ethics (IAMFC, 2017) asks you to ponder the legal standards of the community within which you practice. At issue here is the community’s definition of “child neglect” (probably a state statute). For example, the state of Wisconsin defines child neglect as follows:

Any person who is responsible for a child’s welfare who, through his or her action or failure to take action, for reasons other than poverty, negligently fails to provide any of the following [necessary care, food, clothing, medical care, shelter, education, or protection from exposure to drugs], so as to seriously endanger the physical, mental, or emotional health of the child, is guilty of neglect. (Wisconsin Penal Code, 2005, §948.21[2])

If you are practicing in Wisconsin, respecting the parents’ autonomy may contribute to the death of their child, a Class D felony. A similar statute exists in the state of Idaho. It appears that in both states the most relevant principle is beneficence, in particular the beneficence of a child.

This family example shows the constructivist nature of ethical decision-making when viewing problems through principle ethics. The words and intent of the codes, together with relevant legislation, all carry various meanings. In such cases, the local interpretation of ethical principles significantly influences a family practitioner’s actions.

Freeman and Francis (2006) noted one significant problem with principle ethics: They have been given relevance and authority separate from and prior to their actual use in ethical decision-making. Autonomy, for example, is important in any given case, because autonomy is valued as a principled guide to action. In theory, it supersedes localized interpretations and applications of ethical standards. To be sure, principle ethics in some cases can remind family practitioners to be sensitive to diverse cultures when local interpretations and laws are not (e.g., in supporting the welfare of sexual and gender minority clients). In some cases, however, the principles themselves may not be culturally sensitive (e.g., autonomy in relation to non-Western cultures), and the practitioner is left to adapt them to fit the needs of the culture, thereby challenging the very foundation on which principle ethics is based (DuBois, 2004).

The family case we have presented highlights the potential impact of religion on the application of the ethical principles. Other cultural influences include race, ethnicity, nationality, age, gender, sexual and affectional orientation, ability and disability, and poverty. DuBois (2004) suggested that ethical principles may have universal relevance, but the focus should be on how the specific principles are enacted within a given culture. That is, the question is not whether autonomy is a relevant principle in Sri Lanka; rather, it is how Sri Lankans respect autonomy.