Each year I train tens of thousands of mental and physical health care professionals on their ethical obligations. In most of my trainings, there are professionals from various professional groups.
Every professional group has a slightly different code of ethics that defines that profession’s responsibilities. Instead of getting into the details of each individual profession’s specific code of ethics, I ground my trainings in the understanding and application of four basic principles of ethics: Beneficence, Nonmaleficence, Autonomy and Justice. These four principles come from the ethics of medical and physical health professions, but are easily translated for use in all professions, which includes mental health and and behavioral health professionals.
Understanding Beneficence
The primary ethical principle of all professions is “beneficence”. The principle of beneficence is grounded in the idea that a professional’s primary purpose is to “do good” or “benefit” the client, patient, entity and/or communities that they serve. For mental and behavioral health professionals, like me, we come into our work so that we can help others, and make their lives better.
Distinguishing Nonmaleficence
Nonmaleficence relates to the professional’s obligation to minimize harm to the clients, patients, entities and communities they serve. The word “nonmaleficence” literally means “don’t do bad things”. Not doing “bad things” almost sounds like the same thing as “doing good things”, but it is NOT the same.
The ethical principle of nonmaleficence requires professionals to acknowledge that EVERYTHING they do to help/benefit their clients, etc. comes with a risk of harm to that client, or others, that must be minimized.
Mental health professionals struggle with the concept of nonmaleficence in their practice and often assume that since everything they do is based on their intention to “help”, that they can’t possibly be responsible for any resulting harm. And that’s where they’d be wrong.
Every intervention offered by a mental health professional comes with at least a risk of harm. The clients of mental health professionals are not likely to be seeking medical care because everything is great in their lives. And there aren’t many clients who would claim that their long term work with a therapist, or other mental health professional, was always fun or enjoyable.
The work with our clients can cause mental health issues including distress, trigger trauma, and destabilize interpersonal relationships. We risk these negative effects for our clients in the hopes that the ultimate outcome of our work will be “worth it”; that the benefits will outweigh the risks. It is our ethical duty, in fact, to conduct that assessment.
The Healthcare Professional & Patient’s Autonomy
All professionals have the ethical obligation to support autonomy. Autonomy is related to the right to make decisions. Patients and clients should have the right to make decisions about their care and the services they receive. To learn more about the conflict professionals face when it comes to autonomy, click here.
In order to support the making of informed decisions, professionals are ethically bound to explain to their patients and clients their options. We call that “informed consent”.
Professionals also have the right to autonomy. Professionals are not like other workers in society. Some workers in society are bound by specific procedures. For instance, baristas at a coffee shop are bound to provide to the customer what the customer asks for and pays for.
If a customer orders a “half decaf latte with oat milk”, the barista cannot expect to be paid if they provide the customer with a cup of green tea, right?
Professionals, however, are expected to provide their clients and patients with their options. They can make suggestions about what is the choice they recommend for the client, and if the client refuses to agree with their suggestions, the professional does not have to continue working with the client. In fact, clients seek out the work of professionals specifically for their expertise and recommendations.
Professionals should do whatever they can to support a client or patient’s right to make decisions for themselves, whenever beneficence and nonmaleficence would support such choice. And, professionals should support the right of other professionals to make decisions for themselves, as well.
The Ethical Principle of Justice
The ethical principle of justice relates to equity and fairness. Justice is not the least important ethical principle. In fact, it is arguably the MOST important ethical principle.
I discuss justice after introducing the other three principles of beneficence, nonmaleficence and autonomy for a reason: You cannot appreciate justice, nor be able to identify injustice, until you recognize ALL clients, patients, entities, and communities that we as professionals serve deserve our beneficence, nonmaleficence, and support of their autonomy. Then, if you see that certain people, groups, or communities are NOT getting access to those principles then we know there is a concern for justice that we must attend to.
Using the Principles in Practice
Working with Children
The law in all states provides that children have limited rights over the decisions made for their physical and mental health care, but that doesn’t mean we should ignore their right to beneficence, nonmaleficence and even autonomy.
Consider this example: A 12 year old is working with a private practice therapist due to a history of mental health disorder and self-harm. In the state in which the child is receiving counseling , the parent has the right to access the child’s mental health records.
After 6 months of therapy, the parent doesn’t think the child is “better, yet”, and demands the therapist’s notes. The child is nervous that the parent will see notes about the negative feelings they expressed about the parent to the therapist.
The parents have the legal right to access their child’s record, but the therapist has the ethical obligation to minimize the harm to the child that would come from sharing those records. The therapist should work with the child and parent to find another solution. The therapist can explain to the parent that their concerns are understandable, but that sharing the records might actually cause stress on the child that will result in regression of achievements made through therapy.
However, if the therapist is unable to convince the parent otherwise, they will need to provide the notes. In that case the therapist should do whatever they can to minimize the harm from that disclosure.
This situation is not uncommon, but is easier to avoid when the therapist effectively works with the family at the start of the clinical relationship, and regularly, to set expectations for disclosure and record sharing, through the informed consent process.
Ethical Evaluation of Mandated Reporting
The law in all 50 states requires certain professionals to make reports to child protective services when they meet a legal threshold related to their suspicions. We call this “mandated reporting”.
Beneficence: The beneficent intent of mandated reporting is to identify and protect children experiencing, or at imminent risk of experiencing, child abuse or neglect. However, there are MANY harms caused by mandated reporting that are, arguably, not outweighed by the benefits.
Non-Maleficence: For instance, more than ⅔ of all reports that are investigated fail to find evidence to substantiate the report. As a result, more than 3 million families and children are subjected to intrusive and traumatic investigations and CPS involvement every year. THREE MILLION!! That is why mandated reporters are ethically obligated to only make reports when they are legally necessary. When a report is not legally mandated, it causes unnecessary harm to children and families.
Autonomy
Parental Autonomy: Mandated reporting limits parental autonomy over their children and families. Every call to CPS means that parents will be forced to provide private information about their family to the government, even though fewer than ⅓ of reports will result in services to a family.
Professional Autonomy: Since the law requires these professionals to make these reports, professionals lose their right to choice. There are many situations where a professional mandated reporter believes that they could help the family more than any child protective services intervention could, but the law requires them to make the report.
Justice: Poor families and families of color are disproportionately reported to child protective services by mandated reporters. Research suggests that these families are over-reported, in part, due to implicit and explicit biases held by these professionals. Additionally, research shows that White families, and families of higher socioeconomic statuses are less likely to be reported, because mandated reporters fear repercussions from those communities that would impact the professional’s livelihood.
Takeaway for Mental Health Professionals
Professionals should use the four basic ethical principles: beneficence, nonmaleficence, autonomy and justice, to evaluate tough choices they need to make in their practice, instances of mandated reporting as well as to clarify the easy choices that they make on a regular basis.
For more information, resources and training opportunities check out www.makingthetoughcall.info and www.kraseconsulting.com