Ethical and Legal Decision-Making Processes

Clearly, counselors working with clients who have EDs would benefit from an ethical decision-making model to guide their decisions when they are faced with complex situations such as the ones described in this chapter. On the basis of recommendations from the ACA Code of Ethics (ACA, 2005) and common components of ethical decision-making models (Corey, Corey, & Callanan, 2007; Kitchener, 1984; Welfel, 2006), we present Remley and Herlihy's (2010) model here. The model incorporates steps drawn from principle and virtue ethics, feminist and multicultural ethics, and social constructivism. The model attends to both facts and counselor feelings (which is particularly important because EDs can produce strong countertransference reactions from the counselor) and tries to incorporate the client's perspective and involvement as much as possible. The steps of the model are presented next, followed by the application of the model to a case example.

Ethical Decision-Making Model (Remley & Herlihy, 2010)

Identify the Problem

The counselor should compile information related to the dilemma and determine relevant ethical codes and legal statutes that may apply, consulting an attorney, if necessary, concerning any legal matters. The counselor should consider the various aspects of the problem, because ethical and legal dilemmas are usually multifaceted and complex.

Consider Principles and Virtues

Of particular relevance in cases of EDs are the moral principles of nonmaleficence (to do no harm), beneficence (which goes beyond nonmaleficence by being a benefit to the client), and autonomy (clients' right to make their own choices). The counselor should evaluate what precedence each principle takes in a specific case.

Tune Into Feelings, Personal Values, and Emotions

As the counselor considers the situation and all possible interventions, he or she should attend to any emotions experienced such as fear, self-doubt, guilt, responsibility, or the need to rescue because awareness of emotions will help to inform the decision-making process. The counselor should also reflect on personal values and how they might affect his or her view of the client, problem, and judgment during the decision-making process.

Obtain Consultation With Colleagues and Other Professionals, Particularly the Treatment Team Members

To make the most effective decisions, counselors should consult with the treatment team and with other professionals as part of the process (ACA, 2005, Standard B.2.a.). Consultation can provide a different perspective on the problem, helping the counselor to discover aspects of the problem that may not previously have been visible. Consultation is also an important part of supporting the counselors actions in the event that he or she is brought before an ethical board or court of law.

Involve the Client in the Decision-Making Process

The client should be included in the process as much as possible. If there are non-life-threatening treatment decisions to be made, it is in the clients best interest to be part of the process because she will be more receptive to treatment and will be more motivated to achieve treatment goals. Although in general the “counselor should avoid making decisions for the client when those decision can be made with the client” (Remley & Herlihy, 2010, p. 15), an exception might be made in the case of an impaired and emaciated client who is no longer able to make competent treatment decisions because of her emaciated state. This situation may also be complicated when the client is a minor, and the parent or legal guardian has the right to make any decisions on the minors behalf. Even in these cases, offering the minor as much information as possible and providing her with choices whenever possible helps her to become more involved.

Identify Desired Outcomes

Generally, any ethical dilemma has more than one outcome, but brainstorming possible outcomes is helpful in recognizing the goal of the decision-making process.

Consider Possible Actions and Their Consequences, Enumerating the Consequences of Various Actions

As the counselor contemplates the desired outcomes, he or she should think about possible actions that might achieve those outcomes. Counselors should also anticipate the consequences of all potential actions, both positive and undesirable, and the implications those consequences might have for the client and for the counselor.

Decide on the Best Course of Action

Once the counselor has carefully considered the options available, he or she should decide on a course of action on the basis of an analysis of each option.

As a final assessment of the decision, the counselor should apply four self-tests to ensure that he or she has selected the best course of action to achieve the most desired outcomes for the client: (a) justice: Would I treat others the same in this situation? (b) universality: Would I be willing to recommend this action to other counselors who are in a similar situation?

(c) publicity: Would I be willing to have my actions come to light and be known by others? What if this decision were reported in the press? and

(d) moral traces: lingering feelings of doubt, discomfort, or uncertainty after the decision (Stadler, 1986; Remley & Herlihy, 2010).

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