Practice Guidelines and Position Statements in Ethical Decision Making

Bush, S. S. (2019). Use of practice guidelines and position statements in ethical decision making. American Psychologist, 74(9), 1151-1162.

Jacqueline Weber, MEd, BCBA and Mary Jane Weiss, PhD, BCBA-D
Endicott College

Professional organizations such as the American Psychological Association (APA) utilize an ethics code to help guide practitioners in navigating ethical challenges in the treatment of their clients. While professionals are likely very aware of the ethics code, they may be less familiar with practice guidelines and position statements provided by their respective professional organizations. Practice guidelines and position statements complement ethical codes by providing direction applicable to specific clinical situations. Whereas ethical guidelines are general and are developed to be applied to a wide variety of situations and clients, practice guidelines and position statements are more specific. The broad nature of ethics codes does not always help the professional arrive at a solution to a clinical dilemma. Position statements and professional guidelines may help to clarify professional behavior and may provide the practitioner with guidance. Ideally, such resources point out potential risks of various courses of action and aid in the development of a positive solution within a therapeutic context. Disseminating information on how to incorporate practice guidelines, position statements, and ethical codes into clinical treatment is essential to ensuring that the practitioner has all the resources needed to make ethical decisions.

Ethical decision-making is emphasized across disciplines as a means of systematizing judgments for complex ethical dilemmas. In his article, Use of Practice Guidelines and Position Statements in Ethical Decision Making, Bush (2019) presents several ways in which ethical decision making can be improved with the addition of practice guidelines, position statements, and other resources. A major recommendation is to utilize a structured decision-making model, such as CORE-OPT, which stands for “correct option.” CORE-OPT is comprised of 7 steps:

Clarify the ethical issue(s).
Consider Obligations owed to stakeholders.
Review and utilize ethical and legal Resources.
Examine personal beliefs and values.
Consider possible Options.
Put a plan into practice.
Take stock, evaluate outcome, and revise as needed.

This model guides the professional through a logical series of steps to incorporate practice guidelines and position statements into making an ethical decision. The utility of this model is applied to an example in a neuropsychology vignette in the article. A neuropsychologist, who has joined a practice, accepts a patient who has characteristics and issues that are outside of his scope of expertise. The patient is an 88-year-old Hispanic woman with cognitive decline. She has what is equivalent to an 8th grade education, her grandson must translate all interview and testing items for her, and she presents as highly anxious during testing. The neuropsychologist has no experience with older individuals and does not speak Spanish. During the lengthy testing, it is unclear if the grandson is translating accurately and assessment is frequently interrupted by break requests from the patient. The neuropsychologist and the psychometrist working on the case are unsure if the patient can complete the testing necessary, in the time afforded, to develop a treatment for her (Bush, 2019)

Bush (2019) walks the reader through a systematic application of the CORE-OPT model to arrive at a sound clinical and ethical outcome in this vignette. The neuropsychologist clarifies the ethical issue by acknowledging that he is practicing outside of his scope of competence and the potential harm that can be caused to the client by conducting an inappropriate evaluation. He then considers his obligations to multiple stakeholders; the referral source, his employer, and the patient. His main obligation is to the patient and in ensuring that she receives an appropriate and useful evaluation. The neuropsychologist has a number of ethical and legal resources from the ethical guidelines and position statements of his field to him to help make a decision. He can identify a more experienced neuropsychologist who can supervise his work and he can obtain a bilingual psychometrist and translator to assist with the evaluation. Additionally, he should obtain informed consent in the patient’s language. The neuropsychologist also examines his personal beliefs and values. He agreed to take this case because he wanted to please his new employer without thinking about his lack of experience with this population. He considers his options, solutions, and consequences which include rescheduling the testing and referring the patient to another neuropsychologist. The plan that he puts in place is to refer the client to a culturally competent geriatric neuropsychologist. Finally, he takes stock and evaluates the outcomes of his decision. The client received an appropriate evaluation and the neuropsychologist reviews his decision-making and client outcome with his employer. In this way, the author illustrates the implementation of the model, focusing on how resource consultation and a problem-solving approach can be used to arrive at a solid decision.

Notably, Bush (2019) presents the use of resources that contribute to what is considered best practice in a professional field. These resources include ethics committees, ethics codes, codes of conduct, jurisdictional laws, practice guidelines and position statements, scholarly journals, informed colleagues and workshops, and professional liability carriers. All these resources lend assistance when analyzing the unique ways in which dilemmas are encountered. While multiple resources are valuable, they may conflict with ethical guidelines. For example, a behavior analyst working for a public school district who may be required to expand their caseload beyond their capability, to serve a client who has a need that is outside of their scope of practice, or to refrain from implementing a restraint when a student is hurting himself due to a no-restraint policy. A behavior analyst may be required by a superior to replicate a treatment from a journal article with questionable ethical compliance and without proper support. Scenarios like these put practitioners in difficult ethical positions.

When a conflict arises, Bush (2019) recommends that one consider the reliability and significance of the source(s), any underlying general ethical principles, and one’s personal values, while adhering to the law in delivering ethical clinical treatment.

Bush (2019) refers to the “4 As” of ethical practice which can assist the professional in making best outcome decisions. Knowledge of practice guidelines and position statements helps the practitioner to anticipate, avoid, and address potential ethical issues. It is also consistent with clinicians’ aspirations to demonstrate sound practical and clinical judgement that represent the values and standards of one’s professional group.

The author concludes that an ethics code serves as a foundation for providing practitioners with guidance and knowledge. To provide the best standard of care for patients, practitioners should incorporate multiple resources including practice guidelines, position statements, and decision-making models. These resources not only help the clinician to anticipate and avoid ethical dilemmas, but also serve to fill in the gaps needed to treat diverse clients (i.e., clients from different backgrounds, nationalities, races, socioeconomic statuses and other relevant demographic and identity descriptors) with the most effective and ethical treatment that they can provide.

These same challenges exist for Applied Behavior Analysis (ABA) practitioners, and behavior analysts need guidelines for ethical decision making. Numerous resources exist within ABA that can serve to help practicing behavior analysts to navigate difficult decisions. Recently, the Behavior Analyst Certification Board (BACB), the governing organization that certifies practitioners of behavior analysis, incorporated a decision-making model into the Ethics Code for Behavior Analysts (2020). This model is located at the bottom of page 5 and consists of 11 steps. The model emphasizes many of the elements focused upon in Bush’s article (2019). In particular, the use of a decision-making model is emphasized. Steps of the model include the consultation of resources, both in the form of written resources such as articles and other professional standards, and in the form of valued mentors/colleagues. Familiarity with resources such as position statements (from within and outside the field of ABA) can also assist behavior analysts, especially in dilemmas surrounding evidence-based (and non-evidence-based) interventions.

While ethical decisions are made every day, some are more straight-forward than others. Where there is conflicting information, difficulty navigating diverse rules, or vagueness in how the rules should be applied, practitioners should feel more comfortable making ethical decisions by applying a decision-making model such as the one described by Bush (2019). In this way, practitioners can feel confident in their decision making process and may also be able to communicate with clients more effectively and clearly as to how they arrived at such a decision, and why it is the most ethical choice.

References

Behavior Analyst Certification Board. (2020). Ethics code for behavior analysts. Author.

Citation for this article:

Weber, J., & Weiss, M. J. (2021). Article review: Use of practice guidelines and position statements in ethical decision making. Science in Autism Treatment, 18(8).

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A review of Use of Practice Guidelines and Position Statements in Ethical Decision Making