Ethical decision-making is a cornerstone of mental health practice. This article introduces general ethical decision-making frameworks that mental health professionals can employ regardless of their specific disciplines or regional ethical codes.
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Introduction
Ethical decision-making is a cornerstone of mental health practice, guiding clinicians in handling dilemmas that arise across varied cultural, professional, and clinical contexts. Unlike “straightforward” decision-making, ethical decision-making requires balancing client welfare, professional integrity, and broader social responsibilities, often in complex and uncertain situations. This article introduces general ethical decision-making frameworks that mental health professionals can employ regardless of their specific disciplines or regional ethical codes, emphasising universal principles and practical applications.
Understanding ethical decision-making frameworks
Ethical decision-making frameworks provide structured approaches for mental health professionals to assess and address ethical dilemmas. These frameworks prioritise considerations like client autonomy, confidentiality, non-maleficence (avoiding harm), and justice. Though frameworks vary, most share a commitment to balancing client rights with professional duties in ways that are culturally respectful and clinically appropriate.
Below we explore five different frameworks: Principle-based approach; The seven-step decision-making model; Virtue ethics and relational ethics; The four-quadrant approach; and the integrative model of ethical decision-making.
Principle-based approach
One of the most widely recognised frameworks in mental health is the principle-based approach, which identifies key ethical principles to guide decision-making. These principles, derived from the medical ethics model, include autonomy, beneficence, non-maleficence, and justice:
- Autonomy: Respecting the client’s right to self-determination and informed consent.
- Beneficence: Acting in the best interest of the client.
- Non-Maleficence: Avoiding actions that could cause harm.
- Justice: Ensuring fairness and equality in service provision.
A case example: A counsellor faces an ethical dilemma involving a client, an adolescent who reveals a history of self-harm and intentions to continue. The principle-based approach guides the counsellor in weighing the adolescent’s autonomy against the duty to prevent harm. In this scenario, non-maleficence and beneficence support involving the client’s parents or school staff to ensure safety. However, confidentiality and autonomy must also be respected. Ultimately, the counsellor consults with a supervisor, emphasising non-maleficence and concluding that disclosure is necessary, though handled sensitively to minimise distress.
The seven-step decision-making model
The seven-step model is another common ethical decision-making approach, breaking down decision-making into practical steps:
- Identify the dilemma
- Consider the ethical principles involved
- Review applicable ethical guidelines
- Consult with colleagues or supervisors
- Identify potential courses of action
- Evaluate potential consequences for each option
- Document the decision and reflect on the process
This framework’s structured approach ensures comprehensive consideration of ethical issues and accountability through documentation.
A case example: A psychologist treating a culturally diverse client grapples with whether to disclose concerns about potential family pressure impacting the client’s progress. Following the seven-step model, the psychologist identifies the dilemma as a conflict between respecting the client’s confidentiality and addressing the impact of cultural factors on treatment. After reviewing ethical guidelines, consulting with a colleague, and evaluating potential outcomes, the psychologist decides to discuss the cultural issue directly with the client, respecting both confidentiality and the client’s cultural context.
Virtue ethics and relational ethics
Virtue ethics emphasises the professional’s moral character and values. In this framework, mental health practitioners rely on virtues like empathy, compassion, and integrity to make ethically sound decisions. Virtue ethics highlights the importance of relationship-based approaches, emphasising that ethical decisions should be driven by genuine care for the client’s wellbeing and respect for their experiences.
Relational ethics, a subset of virtue ethics, emphasises the role of relationships in ethical decision-making, particularly in multicultural or diverse settings. This approach advocates for mutual respect, dialogue, and understanding between the clinician and client, fostering an ethical commitment to shared decision-making.
A case example: A social worker in a community clinic is asked by a client, an undocumented immigrant, for help with legal advice. The social worker’s immediate inclination is to assist; however, boundaries and professional competencies restrict the type of support they can offer. By applying a relational ethics approach, the social worker listens empathetically and works collaboratively with the client to find an alternative resource within their network. In doing so, the social worker maintains ethical boundaries while ensuring the client feels heard and supported.
The four-quadrant approach
Developed primarily for medical ethics, the four-quadrant approach is a practical framework that mental health professionals can adapt. It divides decision-making into four quadrants, encouraging practitioners to assess:
- Medical indications: Does this intervention align with best practices?
- Patient preferences: What are the client’s values and desires?
- Quality of life: How does the decision impact the client’s well-being?
- Contextual features: What external factors (e.g. cultural, social, legal) influence the decision?
A case example: A psychiatrist treating a client with severe mental health symptoms that impair decision-making is concerned about potential coercion if they suggest a specific medication. The psychiatrist uses the four-quadrant approach to consider medical indications, client autonomy, the potential to improve quality of life, and cultural concerns around medication. By framing the options transparently and involving the client’s family in the conversation, the psychiatrist supports the client’s autonomy within ethical boundaries, ultimately leading to a jointly agreed-upon treatment plan.
Integrative model of ethical decision-making
The integrative model combines principles from various frameworks and is particularly valuable when mental health professionals encounter dilemmas that require flexibility. This model emphasises:
- Identification of ethical conflicts: Recognising conflicts between ethical principles.
- Cultural and contextual awareness: Acknowledging factors such as cultural background, socioeconomic status, and client-specific needs.
- Stakeholder perspectives: Considering the viewpoints of all individuals affected by the decision.
A case example: A psychotherapist discovers that a client is at risk of domestic abuse but expresses a desire not to involve law enforcement. Applying an integrative model, the psychotherapist identifies conflicting principles (non-maleficence versus autonomy), considers the client’s cultural and personal context, and weighs the perspectives of possible stakeholders, including the client’s family. By consulting with experts in domestic violence intervention and involving the client in safety planning, the psychotherapist maintains a balanced approach that respects the client’s autonomy while prioritising safety.
Conclusion
Ethical decision-making frameworks are indispensable tools for mental health professionals facing complex and nuanced dilemmas in their work. By employing structured approaches, clinicians can navigate ethical challenges with greater confidence, fostering client trust and ensuring professional accountability. These frameworks, when used thoughtfully, help professionals balance their ethical obligations across diverse cultural and clinical contexts, ultimately enhancing the quality of mental health care globally.
Key takeaways
- Ethical decision-making frameworks, such as the principle-based approach, seven-step model, virtue ethics, four-quadrant approach, and integrative model, guide clinicians in resolving dilemmas while honouring client welfare and professional values.
- Practical application of these frameworks requires flexibility, cultural awareness, and consultation, especially in diverse clinical scenarios.
- Effective ethical decision-making enhances client trust and reinforces professional accountability, supporting equitable and compassionate mental health care.
References
- Beauchamp, T. L., & Childress, J. F. (2019). Principles of Biomedical Ethics (8th ed.). Oxford University Press.
- Cottone, R. R., Tarvydas, V. M. and Hartley, M. (2021). Ethics and Decision-making in Counseling and Psychotherapy (5th ed.). Springer Publishing company.
- Fisher, C. B. (2022). Decoding the Ethics Code: A Practical Guide for Psychologists (5th ed.). Sage Publications.
- Knapp, S. J., Gottlieb, M. C., & Handelsman, M. M. (2015). Ethical dilemmas in psychotherapy: Positive approaches to decision making. American Psychological Association. https://doi.org/10.1037/14670-000
- Knapp, S. J., VandeCreek, L. D., & Fingerhut, R. (2017). Practical ethics for psychologists: A positive approach (3rd ed.). American Psychological Association. https://doi.org/10.1037/0000036-000