Introduction
Counselling practice is characterized by many ethical dilemmas where conflicting professional standards and moral prejudices hinder practitioners’ decision-making. The Psychotherapy and Counselling Federation of Australia (PACFA) and the Australian Counselling Association (ACA) code of ethics assist therapists in safeguarding the welfare of their clients and protect the counsellor from liability and disciplinary actions. However, there are instances where upholding a particular ethical code will adversely impact the application of the other, effectively presenting a therapist with an ethical dilemma. For example, a counsellor’s legal and professional responsibilities may necessitate the involuntary hospitalization of an imminently suicidal patient, impeding the client’s autonomy and desire to be discharged. Such decisions are anchored in the Kantian and Utilitarian ethical philosophies, which emphasize the motive and consequences of an action, respectively. Although the ethical principles in counselling are usually presented as discrete and equally occurring ideals, the relative contextual tension between autonomy and beneficence results in an ethical dilemma.
Code of Ethics in Counselling
Counsellors are trained professionals who work with individuals experiencing personal difficulties and assist them in attaining their optimal level of psychosocial functioning by making the appropriate adjustments to their lives. This obligates therapists to always act in clients’ best interest and undertake such functions that protect their rights, maximize the good, and minimize the potential for harm (Tapson, 2016). Counsellors are guided by an elaborate code of ethics, including PACFA and ACA, which function as a roadmap and enhance positive outcomes. While these tenets promote client welfare, standardize the practice, and foster self-regulation, they often create situations where practitioners are required to choose between equally undesirable options (American Occupational Therapy Association, 2020). In this regard, the counsellor is compelled to resolve the complex scenario in a manner inconsistent with the established guidelines. This implies that healthcare professionals use the ethical codes to guide their practice and demonstrate the degree and appropriateness of responsibility they may have to their clients. However, the principles do not prevent a counsellor from encountering situations with conflicting or competing moral imperatives where upholding one code will inherently mean the violation of another.
Mock Case Example
John is a 63-year-old male who sought treatment after his marriage failed. He recently lost his job due to heavy drinking and acknowledged feelings of hopelessness following the collapse of his 35-year marriage and dismissal from his job. He was admitted twice in a healthcare facility almost in comatose condition within the last month after a substance overdose combined with alcohol intoxication. After regaining consciousness, John confided to a nurse that he hoped a fatal illness would soon kill him. He noted that he started to contemplate suicide through drug overdose and intoxication since the disease he hoped would kill him was not forthcoming quick enough. Additionally, he regretted that the attempt failed and that the only relief would be suicide since no one cared about him anymore and that his death would not affect anybody. John also said he intends to use his savings to pursue that relaxing and pleasant feeling accompanying death since nobody can help him and sees no better alternative than death.
After several counselling sessions, he demands to be released to go back to his hobby of drinking. John also says that his continued stay at the facility will make him miss a drug refill from a peddler in his neighborhood. Further, he tells the counsellor that he is being involuntarily detained at the facility and that he should be allowed to permanently escape from life since it is not worth living anymore. However, the therapist is concerned that discharging John as would imminently lead to his death since he is actively suicidal at the present moment. He is unremorseful for his suicidal ideations and attempts, and he still asserts that death is his only relief since he has concluded that life is not worthwhile.
The Ethical Dilemma of Counsellor Responsibilities
Counsellors’ primary responsibility is to promote the overall wellbeing of their clients by assisting them in attaining an optimal degree of psychosocial functioning. To achieve their obligations to patients, the therapists make numerous decisions by using their professional knowledge and skills within the code of ethics as developed by PACFA and ACA. Often, the practitioners are faced with complex situations where ethical decision-making is inhibited by conflicting or inconsistent standards, implying that observing a particular code will inherently occasion the disregard of another. For instance, under the principle of autonomy, counsellors are obligated to encourage and support the client’s right to their decisions and actions without the external control or influence of the therapist (Fortune et al., 2016). Blease et al. (2020) contend that therapists acknowledge the benefits of relational autonomy in a counselling engagement and note that it empowers patients, fosters self-motivation, and maintains therapeutic change. However, a counsellor may encounter an ethical dilemma surrounding their responsibility on ensuring client autonomy when compelled to consider involuntary hospitalization of an imminently suicidal patient. Such a scenario will unavoidably necessitate limiting freedoms to promote beneficence.
Patient autonomy and beneficence rank among the critical ethical tenets that guide a practitioner when working with a patient. The code of ethics obligates counselling practitioners to uphold and respect the independent decisions of their clients and actively contribute to the overall wellbeing of their patients (Varkey, 2020). Khanahmadi (2020) contends that beneficence differs sharply from nonmaleficence since it entails the proactive engagement in actions and behaviors, which promote the client’s best interests instead of the latter’s passiveness and refraining from doing harm. From this perspective, autonomy and beneficence reflect therapists’ foremost roles and obligations as supportive pillars in the patient’s health-seeking journey and a promoter of all actions that enhance the attainment of optimal psychosocial functionality.
The essence of these principles is to uphold patients’ freedoms in decision-making, choice, and action and undertake all the necessary options to promote the client’s health and general wellness. According to Sedig (2016), a patient’s autonomy is the hallmark of medical ethics and requires a physician to respect their client’s liberties by supporting independent decisions. Notably, the respect for personal autonomy in medical care is a philosophical tradition anchored in Kantian ethics, which assigns profound value to a person’s inherent dignity and independence of thought (Genius, 2021; Jantos, 2016). However, autonomy and beneficence often create confounding situations for therapists, where their decision-making is impeded by the inconsistencies of the ethical codes or competing responsibilities. Reis-Dennis (2020) corroborates this view and opines that, in everyday clinical encounters, therapists are confronted with situations where respecting the independent decisions of the patient would impede the ability to ensure their wellbeing. Therefore, although beneficence and autonomy may be presented as discrete and equally occurring counselling ideals, they are often in relative contextual conflict with each other.
Decision-making in counselling is usually a multidimensional and complex undertaking requiring therapists to comprehensively observe the distinct contextual attributes of their situation and make the most rational judgment. In this regard, a counsellor’s decisions are generally determined by the specific patient characteristics. This implies that although they are obligated to observe the ethical standards, clinical situations may arise compelling therapists to uphold a particular code while disregarding the other to promote the patient’s overall wellbeing (Teven & Gottlieb, 2018). For instance, it is imperative for a therapist to curtail the autonomy of an imminently suicidal patient and impose involuntary hospitalization. In such a scenario, a counsellor’s responsibility for the client’s autonomy is overridden by the need to ensure that the patient does not engage in self-harming behaviors (Young & Everret, 2018). This implies that although deciding when to intervene in a patient’s independent decisions is challenging, healthcare practitioners can use a decision-making model to arrive at ethically justifiable judgments. While the risk for self-harm cannot be eliminated entirely, counsellors are obligated to place a premium on patients’ safety by minimizing the opportunities for inflicting harm instead of upholding client autonomy.
Conflicting Values in the Mock Case
The two conflicting values in the mock case above are the counsellor’s obligation to beneficence and upholding the patient’s autonomy. According to Bastemeijer et al. (2017), respecting clients’ freedoms of making independent decisions rank prominently among the valued elements of any healthcare engagement. From the patient’s perspective, practitioners should respect the client’s capacity for making decisions on various critical issues in their care and treatment. Lindberg et al. (2018) and Malcolm and Golsworthy (2018) posit that ultimately, it is the client who should decide whether to accept or disregard the suggested treatment or care options. Notably, allowing patients to make or participate in decision-making regarding the healthcare interventions they will or not receive significantly impacts the attainment of the desired outcomes (Gomez-Virseda et al., 2020; Zhu et al., 2020). From this perspective, patients have a right to make independent decisions, including resolving on whether or not to accept a suggested treatment.
Similarly, under the ethical code of beneficence, healthcare providers are always obligated to do good and undertake all the necessary actions to promote the welfare and general health of their patients. However, in the given mock case, the attainment of this tenet conflicts with the pursuit of the patient’s autonomy. Stone (2018) notes that high regard for autonomy without integrating beneficence may ultimately result in detrimental outcomes. For instance, in the given scenario, discharging John in his current status would be a dereliction of duty on the counsellor’s part since the patient is still at high risk of suicide. In this regard, the tenet of beneficence from the therapist’s angle is of greater significance than the patient’s autonomy. Conversely, John’s mental status and hopelessness crave for the permanency of death and values his autonomy more than the therapeutic intervention. Consequently, the patient’s liberty and the counsellor’s responsibility for beneficence are the two conflicting values in the mock case.
PACFA and ACA’s Guidelines
Counsellors are obligated to take all the necessary steps that protect their patients from physical, psychological, or emotional harm during the course of therapeutic sessions. According to PACFA (2017) and the Australian Counselling Association (2019), clients should be safeguarded when practitioners establish that they are at risk of inflicting self-harm or injury. In this regard, the counsellor’s primary responsibility is to always protect patient safety and their wellbeing (Mullen et al., 2017). Similarly, under the clause of counsellor’s responsibility to the client in ACA’s Code of Ethics and Practice, therapists are obligated to take all necessary steps to protect patients from any harm.
From a legal perspective, discharging a patient while their suicidal behaviors and ideations remain unaltered based on upholding autonomy constitutes maleficence due to the disregard of the inherent risk. Chung et al. (2017) and Bojanic et al. (2020) note that high suicide rates are reported after patients are released from healthcare facilities. This implies that a counselling practitioner should consider inpatient psychiatric care to mitigate the immediate risk of suicide until some therapeutic progress has been attained. In John’s case, the severity of suicide risk legally obligates confidentiality breach and disclosure of information to a third party who can mitigate the threat (Ordway & Casasnovas, 2019; Darby & Weinstock, 2018). The act of discharging John would fall below the expected legal and professional standards of care since it would increase his risk of harm. Therefore, holding a patient to improve their psychosocial wellbeing, despite their objection, is a legally justifiable recourse as opposed to discharging them and they up committing suicide.
Dealing with the Conflict
In addressing the conflict between beneficence and autonomy, a counsellor should make their decisions within the parameters of the ethical codes and the socio context in which they operate. In this regard, the resolution should reflect comprehensive contextualization instead of individual preferences. Sengkey et al. (2020) assert that therapists should enhance their effectiveness by contextualizing their practices within the society in which they operate. In this, counsellors’ decisions should mirror the social aspects and the broader environment in which they operate.
Conclusion
Ethical dilemmas in counselling are ordinary occurrences where the decision to be taken are equally undesirable. While their practice is guided by beneficence, nonmaleficence, autonomy, and justice, instances occur where upholding one ethical tenet will mean disregarding the other. Despite the conflict or inconsistency in the ethical codes, a counsellor’s course of action should primarily seek to safeguard the patient’s safety and promote their overall wellbeing.
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