Ethics conundrum #2

This is taken from my Ethics formal assignment, Semester 1, 2015.

Context

A client has reached a point where they no longer wish to continue cancer treatments and instead wish to die.

Ethical dilemma

Do I take steps to notify relevant bodies of my client’s intentions to die, or do respect their wishes and assist them to live what remains of their life in as fulfilling a manner as possible?

Deontological perspective

The CCAA (2012) is clear on this:

3.5 The exception to maintaining confidentiality is a client threatening to harm self or another through suicide, homicide, or serious and imminent abuse. It is the duty of counsellors to disclose such information to their supervisors and to the authorities including, where relevant, the Police and the relevant Child Protection Authority in their jurisdiction.

PACFA (2014) is less clear on the topic and more open-ended and flexible. It refers to the need to keep the trust of the client:

3.1.3 Keeping trust

D. Situations in which clients pose a risk of causing serious harm to themselves or others are particularly challenging for the practitioner. These are situations in which the practitioner should be alert to the possibility of conflicting responsibilities between those concerning their client, other people who may be significantly affected, and society generally. Resolving conflicting responsibilities may require due consideration of the context in which the service is being provided. Consultation with a supervisor or experienced practitioner is strongly recommended, whenever this would not cause undue delay. In all cases, the aim should be to ensure for the client a good quality of care that is as respectful of the client’s capacity for self-determination and their trust as circumstances permit.

As can be seen, the PACFA-ethical practitioner could arguably leave the door open for the client to self-determine and respectfully be allowed to self-euthanise.

The Criminal Law Consolidation Act 1935 (1935) speaks to us of suicide. Section 13A(1) of the Act states that “It is not an offence to commit or attempt to commit suicide.” But it is, however, an offence under section 13A(5) to aid, abet or counsel someone else to commit suicide or attempt to commit suicide.

As Dale (2010, p. 31) puts it, “As counsellors our practices are governed firstly by the laws of the land, secondly through our adherence to ethical guidelines and codes of practice set out by the professional bodies to which we belong and thirdly to our own personal views of ethics and morality.” In this instance my membership of CCAA would mean that I would have to notify my supervisor as well as the police and any other relevant bodies.

Having been at the point that forces one to attempt suicide in order to alleviate one’s psychic pain, I have some personal sympathy and empathy with my client. I know that to consider taking one’s own life is not a selfish act, as some have suggested, but is instead an act of great courage. Every fibre of one’s being screams for life; to act upon oneself to draw a veil over one’s life takes immense fortitude and strength. Suicide, especially in a country like Australia where firearms are not easily obtainable, is a courageous and not easy act.

The law holds that I cannot physically do anything to help my client end their life, lest I be charged with manslaughter and being an accessory to manslaughter. But equally I know the pain of depression; also having been a first-hand witness to my wife’s and my mother’s painful, debilitating cancer treatments, I know the suffering that is inflicted upon the cancer victim. From their experiences I know too the feelings they had of being unwell and unable to do anything about it. It is a complete lack of quality of life (QOL) that my client is experiencing.

So do I, the counsellor, take ‘seeking to protect life’ as a supreme ethical cornerstone for my work, or, as Dale (2010) suggests, do I respect client autonomy, even if this means that the client may choose to die? “Do we empathise, explore the suicidal thoughts with our clients and take no action, or do we need (or want) to alert others, most usually the client’s GP, or other medical practitioner, of the perceived danger?” (Dale, p.32).

My own reading of the SA Mental Health Act 2009 (2009) seems to indicate, but I am not a lawyer, that notification is only required if the client has a mental illness; if my client does not, in my eyes, have a mental illness but is instead tired of the pain and lack of QOL and wishes to prolong it no longer, then there are two avenues open to me as I see it. One would be to work with their medical practitioner to increase the dosages and timings of painkiller medications for my client so that pain and discomfort no longer plague him. The other is to allow him autonomy, agency and confidentiality and keep his intentions to myself.

Virtue

Virtue ethics is not a stance I would have entertained before this course, principally because I had not heard of them. I would have classed myself as a Consequentialist before this course. But Virtue ethics are instructive in this instance of trying to decide what the ‘right’ thing to do is.

Virtue ethics are normative ethical philosophies that place their emphasis on ‘being’ rather than ‘doing’. Through ‘right being’ I am more likely to be ‘right doing’. As Aristotle said in the Nicomachean Ethics (2002), the chief human good is happiness, achieved through the development and display of wisdom and reason, and balancing the components of courage, moderation, open-handedness, munificence (i.e. spending in proportion to the occasion), greatness of soul, honour, mildness of temper, conversational excellence and technical skill-based excellences (Stewart, 2010). Progression towards these goals leads to general human excellence. For me as a counsellor to display the Aristotelian virtues would require of me the following:

  • Courage to possibly disagree with my supervisor and ignore the CCAA code of ethics 3.5 and not notify the police or other relevant bodies;
  • Moderation in balancing my responsibilities under CCAA’s code of conduct versus the needs of my client;
  • Open-handedness in my dealings with my client, my supervisor and me;
  • Somehow to display ‘megalopsychia’ (Aristotle, 2002) or greatness of soul which, according to Curzer (1990), is ‘greatness and self-knowledge’;
  • The display of Honour in my dealings with all of my clients, colleagues and others;
  • Mildness of temper;
  • Conversational excellence; and
  • Excellence in my tradecraft.

These are virtues worth striving for, in my humble opinion. They call on me to do my best in all circumstances, and to apply phronēsis, or ‘practical wisdom’ (Hinman, 2013).

What I would do

I would attempt to exercise and display the Aristotelian virtues by letting my client exercise autonomy. I would not encourage them to suicide, but would instead encourage them to seek out palliative care; such providers are better skilled than I in meeting the needs of the soon-to-be-deceased. I would of course discuss the case with my supervisor but I would not be swayed from allowing my client the respect due to them, which comes attached with notions such as autonomy and self-agency.

And as in the first case study, I would document everything.

 

Bibliography for both Ethics Conundrum #1 and #2

Aristotle. (2002). Nicomachean ethics: Translation, introduction, and commentary. Oxford: Oxford University Press.

CCAA. (2014). Code of ethics. Retrieved from: http://ccaa.net.au/images/documents/CODE_OF_ETHICS_Sept_2014.pdf

Curzer, H. J. (1990). A great philosopher’s not so great account of great virtue: Aristotle’s treatment of ‘Greatness of Soul’. Canadian Journal of Philosophy, 20(4), 517-537. doi: 10.1080/00455091.1990.10716503

Dale, S. (2010). Where angels fear to tread : An exploration of having conversations about suicide in a counselling context. Newcastle upon Tyne: Cambridge Scholars Publishing.

Government of South Australia. (1935). Criminal Law Consolidation Act 1935. Adelaide: Government of South Australia Retrieved from http://www.legislation.sa.gov.au/LZ/C/A/CRIMINAL%20LAW%20CONSOLIDATION%20ACT%201935.aspx.

Government of South Australia. (2009). Mental Health Act 2009. Adelaide: S.A. Government Retrieved from http://www.legislation.sa.gov.au/LZ/C/A/MENTAL%20HEALTH%20ACT%202009.aspx.

Hinman, L. M. (2013). Ethics: A pluralist approach to moral theory (Fifth ed.). Boston, USA: Wadsworth.

King, I. (2008). How to make good decisions and be right all the time: Solving the riddle of right and wrong (Kindle ed.). London: Bloomsbury Academic.

Miner, M. H. (2006). A proposed comprehensive model for ethical decision-making (EDM). In S. Morrissey & P. Reddy (Eds.), Ethics and professional practice for psychologists (pp. 25-37). South Melbourne: Thomson.

PACFA. (2014). Code of Ethics: The ethical framework for best practice in counselling and psychotherapy. Retrieved from: http://www.pacfa.org.au/wp-content/uploads/2014/10/PACFA-Code-of-Ethics.pdf

Stewart, A. E. (2010). Explorations in the Meanings of Excellence and Its Importance for Counselors: The Culture of Excellence in the United States. Journal of Counseling & Development, 88(2), 189-195.

Wikipedia. (n.d.). Ethical non-naturalism. Retrieved 28th May, 2015, from http://en.wikipedia.org/wiki/Ethical_non-naturalism

Ethics condundrum #1

This is taken from my Ethics formal assignment, Semester 1, 2015.

Context

I believe my client has reached the end of fruitful counselling and has been using me as a crutch rather than take responsibility for their own life. I believe I should terminate the relationship but my supervisor believes we should keep the relationship going as the client pays the full fee and on time.

Meta-ethical perspective

The author’s meta-ethical perspective is one of ethical non-naturalism (Wikipedia, n.d.). That is to say, ‘right’ and ‘wrong’ are self-evident and reached by either ‘common sense’ or rational, non-empirical, non-sensory processes, or by special revelation by a deity (Miner, 2006).

Ethical dilemma

Do I continue seeing a client just because they pay the full fee and on time? What of their needs?

Consequentialism

Drawing on a long heritage that goes back to ancient Greece and Aristotle, early Enlightenment philosophers John Locke and David Hume[1] laid the foundation for writer Jeremy Bentham in 1789 to propose a ‘calculus’ for determining right from wrong. The system was simple: do whatever is best.

This is simple—all one needs to do is to determine which action will bring about the best consequences and do it (King, 2008). There is a beguiling logic to this; after all, as John Stuart Mill asked in the Greatest Happiness Principle, how could anybody want anything but the best consequences?

There are, of course, some minor problems with such a system. For example, comparing what people want is fraught with difficulty: who is to say that one of my needs—to keep a full-fee paying client for the practice or agency—outweighs one of the client’s needs to move forward with their life?

Doing whatever brings about ‘the best consequence’ doesn’t offer any clear rules for behaviour. If I look for moral certainty with this calculus, I cannot find it. So at times, ‘seek the best consequence’ seems like a very empty sort of advice (King, 2008).

In addition, my intentions—as distinct from the outcomes from my act—may be deleterious to my client. I may intend to keep my client coming to see me for as long as I can in order to pay my rent, irrespective of the benefit to them of continuing therapy.

Deontological

Deontology places its emphasis on doing one’s duty, which is obedience to some predetermined higher moral absolute. It is in the following of predetermined ethical duties that the deontological decision can be reached.

To bring deontological principles to bear on the case study, I would only be acting ethically if I were following the prescribed rules for handling such situations, rules embedded either in workplace codes of conduct or the codes of any relevant professional bodies—in this instance, Christian Counsellors Association of Australia (CCAA) and Psychotherapy and Counselling Federation of Australia (PACFA).

The PACFA Code of Ethics (PACFA, 2014) doesn’t have any specific rules that dictate what to do in our current situation; but the CCAA Code of Ethics (CCAA, 2014) does. Code 2.6.3 states:

2.6 Counsellors shall not:-

2.6.3 Unnecessarily prolong therapy or continue counselling with high fee clients.

However, PACFA do have in their code some general principles that should guide ethical behaviour:

2.2.4 Non-maleficence: a commitment to avoiding harm to the client

Non-maleficence involves: avoiding sexual, financial, emotional or any other form of client exploitation;

Clearly here there is an imperative to not exploit the client financially by insisting on them continuing with their therapy. But there is a big gulf between ‘insisting’ and agreeing to see the client when they renew their appointment at the end of each session. One is coercive; the other is allowing the client freedom and agency. In considering the CCAA directives, the client may be still deriving benefit from the sessions (have we asked them?). The therapy room may be the only place they have where they can ‘vent’, or talk through decisions they need to make.

The CCAA have something further to say:

3.8 Counsellors should not abruptly cut off or end services without giving notice and adequately preparing the client for termination or referral. Termination or referral is indicated when:-

· 3.8.1 objectives have largely been achieved;

· 3.8.2 the client declines further counselling; and/or

· 3.8.3 the client no longer benefits from counselling.

Clearly, deontological principles can impact on our end decision about what to do in this instance, but a strictly rule-based approach doesn’t take into account the client’s views—we may think we have reached the end of the road with them, but the client may not agree. So a purely deontological approach to our case study is not sufficient in this instance.

What I would do

Both consequentialism and deontology have been examined and individually found wanting. So, bearing in mind Miner’s (2006) reminder that the goal of ethical decision-making is a fully-informed decision, I would take both approaches into account. I would firstly ask the client what they wanted to do, pointing out why I thought they had gone as far as they could with me as their counsellor. Armed with the knowledge of what the client felt was best for them, I would do my best to meet their needs. If they requested further counselling sessions, I would acquiesce.

And document everything.


[1] I can’t think of David Hume without thinking of Monty Python’s ‘The Philosophers Song’ [https://www.youtube.com/watch?v=xQycQ8DABvc]