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Discussion: Ethical Principles and Dilemmas

What situations do psychologists find to be ethically challenging or troubling? The purpose of the study described in “Ethical Dilemmas Encountered by Members of the American Psychological Association” (Pope & Vetter, 1992) was to have a representative sample of then-current APA members describe incidents that they found ethically challenging or troubling. These incidents were collected to be used in possible revisions of the current APA’s Ethics Code. Participants in the study were asked to describe an incident that they or a colleague faced that was ethically challenging or troubling. Some of the incidents described also detailed the psychologist’s response to the particular dilemma.

For this Discussion, you will consider whether you agree with the action taken by the psychologist and support your stance using the current version of the APA’s Ethical Principles of Psychologists and Code of Conduct.

To prepare:

Read the APA’s Ethical Principles of Psychologists and Code of Conduct and the article “Ethical Dilemmas Encountered by Members of the American Psychological Associations,” which discusses real scenarios of ethical dilemmas. Then, think about two of the scenarios discussed in the article.

With these thoughts in mind:

By Day 3

Post  your answer to the following:

Choose two ethical dilemmas in the article. First, choose one in which you agree with the actions the psychologist took. Discuss why you agree with those actions. Next, choose an ethical dilemma in which you disagree with the actions the psychologist took. Explain why you disagree with those actions. Be sure to use the APA’s Ethical Principles of Psychologists and Code of Conduct to support both of your responses.

Ethical Dilemmas Encountered by Members of the American Psychological Association

A National Survey

Kenneth S. Pope Valerie A. Vetter

Los Angeles, CA Medical Board of California, San Bernardino, CA

A random sample of 1,319 members of the American Psy- chological Association (APA) were asked to describe in- cidents that they found ethically challenging or troubling. Responses from 679 psychologists described 703 incidents in 23 categories. This process of gathering critical inci- dents from the general membership, pioneered by those who developed APA’s original code of ethics, may be useful in considering possible revisions of the code and preserving APA’s unique approach to identifying ethical principles that address realistically the emerging dilemmas that the diverse membership confronts in the day-to-day work of psychology.

Founded in 1892, the American Psychological Association (APA) faced ethical problems without a formal code of ethics for 60 years. As the chair of the Committee on Scientific and Professional Ethics and Conduct in the early 1950s observed,

In the early years of the American Psychological Association, the problems of ethics were relatively simple. We were essentially an organization of college teachers. The only ethical problems which seemed to present themselves were those of plagiarism and of academic freedom. (Rich, 1952, p. 440)

The Committee on Scientific and Professional Ethics was created in 1938 and began handling complaints on an informal basis (“A Little Recent History,” 1952). By 1947, the committee recommended that APA develop a formal code. “The present unwritten code . . . is tenuous, elu- sive, and unsatisfactory” (“A Little Recent History,” 1952, p. 427).

The method used to create the formal code was in- novative and unique, an extraordinary break from the traditional methods used previously by more than 500 professional and business associations (Hobbs, 1948). Setting aside what Hobbs termed the “armchair ap- proach” (p. 82) in which a committee of those “who are most mature, in wisdom, experience, and knowledge of their fellow psychologists” (p. 81) would study the various available codes, issues, and literature and then submit a draft to the membership for approval, APA decided to create “an empirically developed code” based on an in- vestigation of the ethical dilemmas encountered by a

“representative sample of members”: “The research itself would involve the collection, from psychologists involved in all of the various professional activities, of descriptions of actual situations which required ethical decisions” (p. 83). A survey collecting examples of the ethical dilemmas encountered by APA members led to a draft code (APA Committee on Ethical Standards for Psychology, 1951a, 1951b, 1951c) that was refined and approved in 1952 (APA, 1953). APA had created a process through which it could produce “a code of ethics truly indigenous to psychology, a code that could be lived” (Hobbs, 1948, p. 84).

The 1959 revision, the result of nine drafts over a three-year period, was adopted for use on a trial basis (APA, 1959). The committee anticipated that future re- visions would be necessary to address changing conditions of practice:

The Committee on Ethical Standards hopes that these major principles stated in general form will weather considerable growth of psychology without drastic alteration. Unlike the gen- eral principles, the explanatory paragraphs which accompany them are quite specific and, therefore, subject to change or ex- tension as the need arises. They may serve the purpose fairly well for the present, but it would be a sad mistake indeed to assume that there is little left to say about the ethical behavior of psychologists! (Holzman, 1960, p. 247)

To maintain the unique nature and effectiveness of the code, future revisions were to be based not only on discussion among members but also on “additional crit- ical incidents of controversial behavior” (Holzman, 1960, p. 247). To base revisions on recommendations by ethics committees seemed inadequate because “the energies of ethics committees are so totally devoted to fire fighting that fire proofing or concern with problems that have not

Gerald P. Koocher served as action editor for this article. We are indebted to numerous colleagues who helped us pilot test

and refine this survey. We would especially like to thank Michael F. Enright and Philip S. Erdberg, who took time to review this manuscript and to offer valuable suggestions. We would also like to thank Gregory A. Kimble, a member of the original Ad Hoc Committee on Ethical Standards in Psychological Research, who provided us with information about the work of that committee.

Correspondence concerning this article should be addressed to Kenneth S. Pope, 11747 Sunset #325, Los Angeles, CA 90049-2988.

March 1992 • American Psychologist Copyright 1992 by the American Psychological Association, Inc. 0OO3-O66X/92/$02.0O Vol. 47, No. 3, 397-411

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yet emerged in the form of complaints must take a lower priority” (Golann, 1969, p. 454). Moreover, if the existing code neglected certain issues or dilemmas, individuals would obviously have no basis on which to file complaints relevant to those issues or dilemmas; thus there could be extreme discrepancies between the issues brought to the attention of an ethics committee and the issues encoun- tered by the diverse membership. Even if a committee of experts were to develop ethical standards for diverse areas, they would, according to the rationale of the original code, likely overlook problems in implementing those standards that would be obvious to someone whose day-to-day work was in one of those areas.

The conviction that revisions should be based on subsequent critical incident studies was also based on be- liefs about empowerment, management style, group pro- cess, and allegiance (e.g., Golann, 1969; Hobbs, 1948; Holzman, 1960). This conviction reflected the assumption that two ways of developing a revision would produce very different results. In the first approach, unique to psychology, the revision process would begin by actively soliciting through a formal mail survey the observations, ideas, and questions from those working “on the front lines” in diverse specialties, settings, and circumstances. A revision committee would then base its work on the primary data of this survey. In the alternate approach, used by virtually all other professional and business as- sociations, a committee would decide how the code should be revised. The draft would then be circulated or pub- lished along with an announcement inviting comments. The first approach, as a style for managing the revision process, was considered to empower individual members by involving them meaningfully at the beginning of the project. The process seemed likely not only to lead to a better revision but also to create and benefit from better group dynamics. The membership would be involved at ground level in the revision process, an involvement more likely to foster a psychological sense of community and a personal as well as professional allegiance to the revised code.

The unique nature of the code was that it was “based upon the day-to-day decisions made by psychologists in the practice of their profession, rather than prescribed by a committee” (Golann, 1969, p. 454). Basing revisions on recent critical incidents provided by the membership was believed necessary to maintain an ethical code “close enough to the contemporary scene to win the genuine acceptance of the majority who are most directly affected by its principles” (Holzman, 1960, p. 250).

Although studies in which investigators usually specified the dilemmas to be addressed have examined various ethical issues in specific topic areas by surveying speciality groups, APA never again conducted a mail sur- vey of a representative sample of the membership as the basis for revising the general code. However, the Ad Hoc Committee on Ethical Standards in Psychological Re- search, appointed by the Board of Directors in 1966, pat- terned its work in accordance with APA’s heritage as “the first society to develop a code of ethics by means of em-

pirical and participatory principles” (Committee for the Protection of Human Participants in Research, 1982, p. 10). They conducted an impressive pilot survey and two major mail surveys of APA membership as a foundation for the Ethical Principles in the Conduct of Research with Human Participants (Committee for the Protection of Human Participants in Research, 1982).

The purpose of the study reported in this article was to collect, from a representative sample of APA members, contemporary data of the type that provided the unique foundation for APA’s ethics code and was intended as a basis for revisions.

Method A cover letter and survey form were developed to invite APA members to provide examples of the ethical dilem- mas they faced in their work. A major objective of refining the survey form was to identify factors that would en- courage participation in light of the original APA study’s return rate of “approximately 15%,” which has tended to be the range of “all surveys that request actual incidents regarding problems of ethics” (Golann, 1969, p. 456). Brevity and simplicity emerged as salient factors. Con- sequently, all questions regarding the participant’s age, sex, and other related information were eliminated. Par- ticipants were asked only to “describe, in a few words or more detail, an incident that you or a colleague have faced in the past year or two that was ethically challenging or troubling to you.” They were asked to reply even if they had not encountered a troubling incident.

A table of random numbers was used to select 1,319 individuals listed as members or fellows in the APA (1989) membership directory. Each member was sent a cover letter, survey form, and stamped return envelope. When packages were returned as undeliverable, a replacement name was randomly selected from the directory.

Results Replies were received from 679 psychologists, for a return rate of 51%. Fourteen respondents reported that they were retired and 3 reported that they were not working as psy- chologists. There were 134 respondents who indicated that they had not encountered ethically troubling inci- dents in the past year or two, as the following examples illustrate.

Happily, I am able to report no ethical problems in the past several years. Which is not to suggest that military research psychology is without its frustrations. The challenge is to con- vince leadership of the value of advice and analysis provided. This has become easier, albeit not easy. My work has been in both social and instructional settings.

As an Industrial/Organizational psychologist I have not en- countered any issues that I believed were related to ethical chal- lenges. Specifically when the context of our work has been ex- plained to executives/managers relating to confidentiality/con- flict of interest etc no one has ever challenged me or asked me to do something that would compromise the ethical standards of the APA. Essentially I have been surprised that more incidents have not occurred! I also believe that the ethics issues are much

398 M a r c h 1992 • A m e r i c a n Psychologist

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more clear cut than colleagues would like to believe. Either you are conforming or you’re compromising. I believe the APA has set down very clear guidelines. If psychologists struggle with the guidelines then possibly their ability to form concise judgments in these areas are problems that should be examined.

Respondents provided 703 ethically troubling incidents in 23 general categories, as presented in Table 1. Examples of the ethical dilemmas are presented in the Discussion section.

Discussion The primary purpose of this discussion is to present ex- amples of the critical incidents, highlighting areas and instances in which psychologists find themselves con- fronting ethical challenges in their day-to-day work. These incidents may be useful as a basis for discussion in grad- uate courses, workshops, and other settings in which ethics are a focus of formal or informal learning and exploration. Discussion of the issues was limited in order to present as many incidents as possible; however, in some sections, the issues are discussed in light of not only emerging the- ory and research but also the current ethical code (APA, 1990) and the most recent draft revision (“Draft,” 1991).

In the following sections, percentages are used only when based on the total number (703) of incidents; simple frequencies are used to refer to subsets and trends within each of the 23 general categories.

Table 1 Categories of 703 Ethically Troubling Incidents

Category

Confidentiality Blurred, dual, or conflictual relationships Payment sources, plans, settings, and

methods Academic settings, teaching dilemmas,

and concerns about training Forensic psychology Research Conduct of colleagues Sexual issues Assessment Questionable or harmful interventions Competence Ethics (and related) codes and committees School psychology Publishing Helping the financially stricken Supervision Advertising and (mis)representation Industrial-organizational psychology Medical issues Termination Ethnicity Treatment records Miscellaneous

n

128 116

97

57 35 29 29 28 25 20 20 17 15 14 13 13 13

9 5 5 4 4 7

%

18 17

14

8 5 4 4 4 4 3 3 2 2 2 2 2 2 1 1 1 1 1 1

Confidentiality

The most frequently described dilemmas involved con- fidentiality. Of these troubling or challenging incidents, 38 involved actual or potential risks to third parties, 23 involved child abuse reporting, 8 involved individuals in- fected with human immunodeficiency virus (HIV) or suf- fering from acquired immunodeficiency syndrome (AIDS), 6 involved patients who threatened or had com- mitted violence, and 1 involved elder abuse.

An additional 79 dilemmas reveal that respondents are wrestling with agonizing questions about whether confidential information should be disclosed and, if so, to whom. The following were typical:

One girl underwent an abortion without the knowledge of her foster parents . . . I fully evaluated her view of the adults’ in- ability to be supportive and agreed but worried about our re- lationship being damaged if I was discovered to know about the pregnancy and her action.

A colleague withheld information about a client from the ther- apist to whom she transferred the case (within the same agency). She did so on the grounds of maintaining client confidentiality. This case raises questions not only about client confidentiality and professional relationships, but about the limits of confiden- tiality within an agency setting.

The executive director of the Mental Health Clinic with which I’m employed used his position to obtain and review clinical patient files of clients who were members of his church. He was [clerical title] in an church and indicated his knowledge of this clinical (confidential) information would be of help to him in his role as [clerical title].

Having a psychologist as a client who tells me she has commit- ted an ethical violation and because of confidentiality I can’t report it.

One of my clients claimed she was raped; the police did not believe her and refused to follow up (because of her mental history). Another of my clients described how he raped a woman (the same woman).

The remaining 11 incidents involved respondents’ concerns about the careless or unintentional disclosure of confidential information: for example, “A psychiatrist who leases me space and does some of my billing is care- less about discussing patient names in front of other pa- tients. What should I do about this?”

In 1990, confidentiality accounted for only 2% of the primary category of active cases before the APA ethics committee (“Report of the Ethics Committee,” 1991), yet participants in this research reported more struggles with confidentiality than any other category. This illus- trates what the creators of the initial APA ethics code emphasized—that there may be a significant discrepancy between the ethical dilemmas encountered by the mem- bership and the complaints received by the ethics com- mittee, and therefore revisions to the code should be in- formed by the former as well as the latter.

Perhaps it is not surprising that confidentiality is the most frequently reported ethical dilemma reported by the membership. Although confidentiality is considered

March 1992 • American Psychologist 399

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one of the most fundamental principles (Knapp & VandeCreek, 1987), and in some research has been en- dorsed by psychologists as the most important ethical duty (Crowe, Grogan, Jacobs, Lindsay, & Mark, 1985), national studies of psychologists have found that the most frequent intentional violations of formal standards in- volved confidentiality (Pope & Bajt, 1988) and that more than half of the respondents reported unintentionally vi- olating confidentiality (Pope, Tabachnick, & Keith-Spie- gel, 1987). So difficult is the task of formulating clear, useful, practical, and generally acceptable ethical prin- ciples in this area that in the late 1970s, at the end of nine years of work revising the code, APA was unable to agree on a revision of the confidentiality section.

Because the Council could not agree on several sections of Prin- ciple 5 (Confidentiality), the final action was to approve the final revised draft with the exception of this principle. The old prin- ciple (formerly Principle 6 in the Ethical Standards as printed in the 1975 Biographical Directory) will hold until a revision has been adopted by Council. (APA, 1979, p. 1)

Although the incidents raise a variety of concerns, they highlight two critical areas that the most recent draft revision does not address adequately. First, the boundaries of confidentiality when multiple caregivers (including ad- ministrators and supervisors) or clients are involved (e.g., clinics, therapy groups, and participants in couple or family therapy) need to be explicitly discussed.

Second, some of the incidents, especially about mandatory child abuse reporting laws, illustrate situations in which some psychologists believe it is better to break the law and act on that belief (Kalichman, Craig, & Fol- lingstad, 1989; Koocher & Keith-Spiegel, 1990; Pope & Bajt, 1988; Pope et al., 1987). Most psychologists are likely to have encountered dilemmas in which following legal requirements seemed clinically and ethically wrong, per- haps placing the client or third parties at needless risk for harm and injustice (Pope & Bajt, 1988). The current ethics code states that psychologists must adhere to the law “in the ordinary course of events” (APA, 1990, p. 391), implying that in extraordinary circumstances some form of resistance to a particular law might be an ethically acceptable course. The most recent draft revision, how- ever, specifies a solution to conflicts between the law and ethics that “complies with the law and yet most nearly conforms to the ethics code” (“Draft,” 1991, p. 35), im- plying that civil disobedience (Gandhi, 1948; King, 1958, 1964; Plato, 1956a, 1956b; Thoreau, 1849/1960) and re- lated approaches are unethical. This issue is in need of careful exploration and vigorous, informed debate. For a presentation of philosophical approaches, research data, and case law on this topic as they are relevant to psy- chology, see Pope and Bajt (1988) and Pope and Vasquez (1991).

Blurred, Dual, or Conflictual Relationships

The second most frequently described incidents involved maintaining clear, reasonable, and therapeutic boundaries around the professional relationship with a client. In some

cases, respondents were troubled by such instances as serving as both “therapist and supervisor for hours for [patient/supervisee’s] MFCC [marriage, family, and child counselor] license” or when “an agency hires one of its own clients.” In other cases, respondents found dual re- lationships to be useful “to provide role modeling, nur- turing and a giving quality to therapy”; one respondent, for example, believed that providing therapy to couples with whom he has social relationships and who are mem- bers of his small church makes sense because he is “able to see how these people interact in group context.” In still other cases, respondents reported that it was some- times difficult to know what constitutes a dual relation- ship or conflict of interest; for example, “I have employ- ees/supervisees who were former clients and wonder if this is a dual relationship.” Similarly, another respondent felt a conflict between his own romantic attraction to a patient’s mother and responsibilities to the child who had developed a positive relationship with him:

I was conducting therapy with a child and soon became aware that there was a mutual attraction between myself and the child’s mother. The strategies I had used and my rapport with the child had been positive. Nonetheless, I felt it necessary to refer to avoid a dual relationship (at the cost of the gains that had been made).

Taken as a whole, the incidents suggest, first, that the ethical principles need to define dual relationships more carefully and to note with clarity if and when they are ever therapeutically indicated or acceptable. For ex- ample, a statement such as “Minimal or remote rela- tionships are unlikely to violate this standard” (“Draft,” 1991, p. 32) may be too vague and ambiguous. A psy- chologist’s relationship to a very casual acquaintance whom she or he meets for lunch a few times a year, to an accountant who only does very routine work in filling out her or his tax forms once a year (all such business being conducted by mail), to her or his employer’s hus- band (who has no involvement in the business and with whom the psychologist never socializes), and to a travel agent (who books perhaps one or two flights a year for the psychologist) may constitute relatively minimal or re- mote relationships. However, will a formal code’s assur- ance that minimal or remote relationships are unlikely to violate the standard provide a clear, practical, valid, and useful basis for ethical deliberation to the psychologist who is serves as therapist to all four individuals? Research and the professional literature focusing on nonsexual dual relationships underscores the importance and implica- tions of decisions to enter into or refrain from such ac- tivities (e.g., Borys & Pope, 1989; Ethics Committee, 1988; Keith-Spiegel & Koocher, 1985; Pope & Vasquez, 1991; Stromberg et al., 1988).

Second, the principles must address clearly and re- alistically the situations of those who practice in small towns, rural communities, and other remote locales. Nei- ther the current code nor the current draft revision ex- plicitly acknowledges and adequately addresses such geo- graphic contexts. Forty-one of the dual relationship in-

400 March 1992 • American Psychologist

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cidents involved such locales. Many respondents implicitly or explicitly complained that the principles seem to ignore the special conditions in small, self-con- tained communities. For example, I live and maintain a . . . private practice in a rural area. I am also a member of a spiritual community based here. There are very few other therapists in the immediate vicinity who work with transformational, holistic, and feminist principles in the context of good clinical training that “conventional” people can also feel confidence in. Clients often come to me because they know me already, because they are not satisfied with the other services available, or because they want to work with someone who understands their spiritual practice and can incorporate its principles and practices into the process of transformation, healing, and change. The stricture against dual relationships helps me to maintain a high degree of sensitivity to the ethics (and potentials for abuse or confusion) of such situations, but doesn’t give me any help in working with the actual circum- stances of my practice. I hope revised principles will address these concerns!

Third, the principles need to distinguish between dual relationships and accidental or incidental extra- therapeutic contacts (e.g., running into a patient at the grocery market or unexpectedly seeing a client at a party) and to address realistically the awkward entanglements into which even the most careful therapist can fall. For example, a therapist sought to file a formal complaint against some very noisy tenants of a neighboring house. When he did so, he was surprised to discover “that his patient was the owner-landlord.” As another example, a respondent reported,

Six months ago a patient 1 had been working with for 3 years became romantically involved with my best and longest friend. I could write no less than a book on the complications of this fact! I have been getting legal and therapeutic consultations all along, and continue to do so. Currently they are living together and I referred the patient (who was furious that I did this and felt abandoned). I worked with the other psychologist for several months to provide a bridge for the patient. I told my friend soon after I found out that I would have to suspend our contact. I’m currently trying to figure out if we can ever resume our friendship and under what conditions.

The latter example is one of many that demonstrate the extreme lengths to which most psychologists are willing to go to ensure the welfare of their patients. Although it is impossible to anticipate every pattern of multiple re- lationship or to account for all the vicissitudes and com- plexities of life, psychologists need and deserve formal principles that provide lucid, useful, and practical guid- ance as an aid to professional judgment.

Payment Sources, Plans, Settings, and Methods

The third most frequently described incidents involved payment providers, plans, settings, or methods. Fifty-six focused on insurance coverage. Inadequate coverage for clients with urgent needs created a cruel ethical dilemma in which therapists felt forced either to breach their re- sponsibilities to clients (“Insurance companies force me to provide inadequate care for patients because of policy limitations and patients’ limited financial resources”) or

to be less than honest with what sometimes seems an adversarial provider of reimbursement (“I’m forced to lie about clients’ mental condition to obtain insurance cov- erage that is due them, while insurance company psy- chologists are struggling to deny their customers their rightfully due coverage”). As one respondent put it: “I feel caught between providing the best service and being truly ethical.” A vast range of troubling issues were de- scribed, including billing for no-shows, billing family therapy as if it were individual, distorting a patient’s con- dition so that it qualifies for coverage, signing forms for unlicensed staff, and not collecting copayments.

Fifteen focused on what are typically called managed health plans, such as health maintenance organizations (HMOs) and employee assistance plans (EAPs). Most of the dilemmas, such as those focusing on more general insurance, highlighted (a) the discrepancy between the needs of the client and the services covered, and (b) the tensions between the interests of clients and the interests of those providing, administering, or investing in the managed health plan. The following examples were typ- ical:

A 7 year old boy was severely sexually abused and severely, de- pressed. I evaluated the case and recommended 6 months treat- ment. My recommendation was evaluated by a managed health care agency and approved for 10 sessions by a nonprofessional inspite of the fact that there is no known treatment program that can be performed in 10 sessions on a 7 year old that has demonstrated efficacy.

[I am] a part-time psychologist in an HMO. Am I an insurance agent or a clinician? . . . The primary obligation of the HMO is towards stockholders, not clients.

A managed care company discontinued a benefit and told my patient to stop seeing me, then referred her to a therapist they had a lower fee contract with.

Twelve dilemmas focused on payment-related issues in hospital settings; again, the emphasis tended to be on the conflict between the needs of the patient and the fi- nancial needs of the hospital.

Need to meet admission quotas . . . for private hospital. Pres- sure to develop diagnosis for inpatients in private hospital that would support hospitalization.

Much of my practice is in a private hospital which is in general very good clinically. However its profit motivation is so very intense that decisions are often made for $ reasons that actively hurt the patients. When patients complain, this is often inter- preted as being part of their psychopathology, thus reenacting the dysfunctional families they came from. I don’t do this myself and don’t permit others to do so in my presence—I try to mit- igate the problem—but I can’t speak perfectly frankly to my patients and I’m constantly colluding with something that feels marginally unethical.

I have been concerned about the unnecessary hospitalization of teenagers, extensive and expensive testing (often farmed out to MFCCs or interns on commission), 10 minute visits in hospital at $80 to $100 a visit (also often farmed out on a fee splitting basis) with the teenager leaving hospital when medical insurance runs out and receiving no further treatment.

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As a clinical psychologist in a large metropolitan area, I have been frustrated on a few occasions recently by the apparent profit motive of the private psychiatric facilities. It appears that decisions to release patients are almost routinely delayed beyond that which I think is in the best interest of the patient. Psy- chologists appear to be pressured to “go along” with the system, or risk no referrals.

Similarly, in six dilemmas that focused on mental health clinics or centers and two that focused on individ- uals who paid for someone else’s therapy, there was an actual or potential conflict between the interests of the patient and the (generally but not always financial) in- terests of the party paying for or providing the therapy, as these examples illustrate.

As a psychologist working in a private clinic, I feel that the use of biofeedback to support individual therapy is inappropriately done as an extra billing device.

A woman who is married, but unemployed comes to a psy- chologist for therapy or counseling. The husband of the woman is paying the bills. After a few sessions, it becomes evident that the patient is planning on leaving or divorcing the husband, who is unaware of this. The psychologist is put in a position of helping the patient to carry through an adverse (to the husband) action, which the husband is unknowingly paying for.

Four dilemmas addressed billing issues with clients who were paying for their own therapy; they tended to involve questions about adjusting fees (e.g., “I worry about the ethics of varying fee scale but feel less concerned than I would if I denied services to those unable to pay the higher rate”). Finally, two focused on gifts or financial advantages offered by clients; for example, a consulting psychologist described how “I have had to deal with a number of offers to get expensive items for me ‘wholesale.’ (I’ve resisted because it would compromise the relation- ship but it is tempting).”

The Ethical Principles of Psychologists (APA, 1990) and the current draft revision (“Draft,” 1991) address many of these issues, such as organizational demands that are in conflict with the principles, the relationship of fi- nancial arrangements to a client’s best interests, and pro- longing a professional relationship beyond the point that it benefits the consumer. However, the growing influence and prevalence of third-party payment sources, from tra- ditional insurance to HMOs and EAPs, seem to have intensified the need for explicit ethical standards that ad- dress more directly, realistically, and helpfully the dilem- mas created by these payment sources (see, e.g., Cum- mings & Duhl, 1987; DeLeon, VandenBos, & Kraut, 1986; Dorken & DeLeon, 1986; Kiesler & Morton, 1988a, 1988b; Pope, 1990a; Zimet, 1989). Psychologists who find themselves working for organizations such as HMOs and for patients served by those organizations may be facing conflicts parallel to those faced by industrial-organiza- tional psychologists. An author of the 1959 standards noted the unavoidable question that the revision com- mittee confronted: “Can one really serve the needs of management in developing a more effective company while also doing what is always best from the point of

view of the man down the line who may be adversely affected by the outcome?” (Holzman, 1960).

Academic Settings, Teaching Dilemmas, and Concerns About Training

Twenty-five dilemmas focusing on teaching, training, and academia involved concern about lax or unenforced standards. Thirteen mentioned “grade inflation” and the pressures of to give “A”s, whether or not deserved. An additional 8 worried about the selection and graduation of unqualified students. Although some were worried about “diploma mills” (termed “a crisis” by one respon- dent), a majority were concerned about more mainstream programs, as the following examples illustrate.

My colleagues and I are concerned about the emotional insta- bility and intellectual deficits of several students who have been accepted by APA-approved educational institutions.

I employ over 600 psychologists. I am disturbed by the fact that those psychologists with marginal ethics and competence were so identified in graduate school and no one did anything about it.

Asked to comment to a search committee about a graduate student whom I feel is “ethically dubious” but has a good pub- lication record and is a top candidate for a job.

I have had students who were clearly emotionally disturbed, yet were completing programs in counseling psychology to become “therapists.”

One barrier to addressing the dilemmas associated with unsuitable students seemed to be the threat of lawsuits, mentioned by an additional four respondents.

Three dilemmas mentioned academic discrimina- tion on the basis of race, sex, or physical disability. An- other three mentioned psychology graduate programs’ failure to offer adequate coursework in the areas of ethics and values, the treatment of minorities, and psycho- pharmacology. The remaining dilemmas were extremely diverse, including such topics as exploitation of students, teaching group therapy using experiential participation by students, teachers using questions taken from licensing exams and distributing them to students, and misuse of power by professors or administrators.

Forensic Psychology

Some of the respondents’ most bitter language (e.g., “whores”) was used to describe psychologists who seem willing to present false testimony in court.

There are psychologists who are “hired” guns who testify for whoever pays them.

A psychologist in my area is widely known, to clients, psychol- ogists, and the legal community to give whatever testimony is requested in court. He has a very commanding “presence” and it works. He will say anything, adamantly, for pay. Clients/lawyers continue to use him because if the other side uses him, that side will probably win the case (because he’s so persuasive, though lying).

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the attorney’s pressures or inducements for this kind of testimony. Yet another four, although making no infer- ences concerning the psychologist’s motivation, expressed concern about testimony that is not founded on the data or established scientific principles (e.g., Huber, 1991).

Another psychologist’s report or testimony in a court case goes way beyond what psychology knows or his own data supports. How or whether I should respond.

Overstepping of professional knowledge; e.g., testifying in child abuse cases that the perpetrator is “cured” and that there is no chance of reabuse (crystal ball predictions).

An additional eight forensic dilemmas reflected these tendencies to go beyond the data or to respond to lawyers’ pressure specifically in child custody disputes (especially to provide custody recommendations based on interviews with only one parent).

Colleagues feel uncomfortable in courtroom settings, making recommendations of one parent over another in a custody dis- pute when the child clearly has a strong relationship with both. Subjective impressions of patients are used as fact.

An attorney wants me to see one patient and the children in a custody case, but won’t refer the case to me if I insist on seeing both parents.

Participating in a system in which false or misleading testimony is rendered confronts psychologists with trou- bling ethical challenges. However, five dilemmas revealed that, bogus testimony aside, psychologists are concerned that presenting accurate data in a forensic setting may have harmful consequences.

I find it difficult to have to testify in court or by way of deposition and to provide sensitive information about a client. Although the client has given permission to provide this information, there are times when there is much discomfort in so doing.

I felt compelled to go against a subpoena from a former client’s attorney in her divorce proceedings because I strongly believed my written case notes would be severely detrimental to her case. I explained that to her, and barely avoided contempt charges.

Unlike the current code (APA, 1990), which does not explicitly address forensic settings, procedures, and stan- dards, the draft revision (“Draft,” 1991) provides a sep- arate section (with seven subsections) on “Forensic Ac- tivities.” Readers may wish to compare this section with the “Specialty Guidelines for Forensic Psychologists” (Committee on Ethical Guidelines for Forensic Psychol- ogists, 1991).

Research

Twelve dilemmas focusing on research mentioned pres- sures or tendencies to misstate research procedures or findings.

I design, analyze and write up research reports that identify the advantages for one medium over the other media. Yet with large expenditures for the research, I feel constrained to report some- thing. . . . But there is a limit to how many unpleasant findings I come up with—Finally, I have to find some truthful positives or I start looking for another job.

A particular company . . . has been citing my research con- clusions . . . without considering my stated cautions, qualifi- cations, and so forth. That is, my work is cited out of the context of conflicting research and the conclusions are uncritically over- generalized or overstated. I am concerned that my name or my research may be associated with a kind of deceit.

I am co-investigator on a grant. While walking past the secre- tary’s desk I saw an interim report completed by the PI [principal investigator] to the funding source. The interim report claimed double the number of subjects who had actually entered the protocol.

I have consulted to research projects at a major university med- ical school where “random selection” of subjects for drug studies was flagrantly disregarded. I resigned after the first phase.

A colleague frequently distorts the results of poorly conducted collaborative research with students in order to gain recognition and material to present at conferences. He typically works in applied areas with considerable public interest.

Eight dilemmas reflected concern about the rights of re- search participants.

With some field experiments, it is unclear whether informed consent is needed and, if so, from whom it should be sought.

As a consultant at a speech clinic, the director wishes to use clinical data for research without informing or getting informed consent.

Deception that was not disclosed, use of a data videotape in a public presentation without the subject’s consent (the subject was in the audience), using a class homework assignment as an experimental manipulation without informing students.

The remainder of the dilemmas involved such diverse topics as mistreatment of animals, established researchers squelching new research, inadequate resources, and the difficulties of conducting research for large organizations in which many employees exert influence over how the research should be conducted.

The current draft revision addresses research issues in much more detail than the current code. Its combined section on “Teaching, Research, and Publishing” contains 15 subsections focusing primarily on research. This ex- pansion probably reflects increasing awareness of the ways in which research can, both intentionally and uninten- tionally, result in harm, violation of human rights, the dissemination of results in a misleading manner, and an erosion of professional integrity (Ceci, Peters, & Plotkin, 1985; Denmark, Russo, Frieze, & Sechzer, 1988; Helms, 1989; Johnson, 1990; Keith-Spiegel & Koocher, 1985; Koocher & Keith-Spiegel, 1990; Levine, 1988; Mulvey & Phelps, 1988; Scarr, 1988; Sieber, in press; Stanley & Sieber, 1991).

Conduct of Colleagues

Four percent of the responses described dilemmas created by disruptive (e.g., competitive) relationships with col- leagues or difficulties confronting colleagues engaging in unethical or harmful behavior.

As a faculty member, it was difficult dealing with a colleague about whom I received numerous complaints from students.