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The Tension Between Ethical Principles: Nonmaleficence Vs Beneficence

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According to the Cambridge dictionary, the word ethics is the study of what is morally right and wrong or a set of beliefs about what is morally right and wrong. Ethics can be a difficult subject to define as it is closely related to one’s unique moral, spiritual or cultural values. Therefore, ethics are important in counselling because they are a means to protect the welfare of the client and counselors by clearly outlining what is appropriate. Besides, ethical codes offer counsellors an outline of what is considered acceptable and unacceptable behaviours.

Ethical guidelines cannot be addressed in all situations that a counsellor encounters. Reviewing these ethical principles which are at the foundation of the guidelines often helps to clarify the issues involved in a given situation. The ethical guidelines for counsellors are based on the five moral principles which are fidelity, autonomy, beneficence, nonmaleficence and justice. These principles enable a counsellor to have a better understanding of the conflict issues.

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The first ethical standard set by the American Counselling Association (ACA) is non-maleficence. As stated in 2014 American Counselling Association (ACA) Code of Ethics, counsellors act to avoid harming their clients to minimize or to remedy unavoidable or unanticipated harm. This is very important to ensure their clients are safe. When applying the ethical principles, a counsellor does not know which principles should come first. Therefore, non-maleficence is the priority that is to be considered more than other principles because a counsellor has to avoid clients from being endangered or harmed in various situations, especially in crucial situations like suicide and child abuse. Besides, (Adarsh and Karobi) a counsellor should not ask for any financial favour, help or aid from the client for their own needs. A counsellor should not take advantage of the weaker, dependent and at vulnerable position of the client. The Association of Cooperative Counselling Therapist of Canada (ACCT) code of ethics also stated that counsellor must refrain from actions that risk harm to the client. Besides, a counsellor should ensure that no harm is done in a counselling session and if a conflict arises, it should be resolved swiftly and cause the least amount of harm possible.

The next ethical guideline for counsellors is beneficence. The definition of beneficence is an action that is taken for the benefits of others. As discussed earlier, the primary objective for a counsellor is non-maleficence which is to do no harm. The counterpoint to this do no harm principle is beneficence. A counsellor has to be non-maleficence but he/she also has the obligation to help the client. Nurul et al (2017) stated that beneficence is described as a counsellor’s responsibility to do good, which includes the promotion of public welfare and duty to help the society. British Association for Counselling and Psychology (BACP) stated that beneficence is a commitment to promote the client’s wellbeing. Beneficence actions are meant to prevent and remove harms the client may encounter. A counsellor can also provide training or service just to improve the situation of the client. Counsellor promotes what is good for the client and expects the client will benefit from the counselling sessions. Forester-Miller and Davis explained that beneficence can come in many forms, such as early intervention actions that contribute to the betterment of the client. PERKAMA Code of Ethics (2008) clearly stated that counsellors should at all times evaluate and increase their knowledge, competencies and skills in the counselling profession. A counsellor must continue updating knowledge for professional development so that he/she is able to enhance the quality of services provided to the client. “It could be argued that the obligation of ordinary citizens in our society ends with doing no harm to others, whereas professionals have a higher obligation to provide a service that benefits society. Thus, counsellors actively do good or are helpful and work to promote the mental health and wellness of their clients”.

Theodore Remley and Barbara Herlihy

The following ethical guideline for counsellors is autonomy. Autonomy is client-based guideline where a counsellor shouldn’t interrupt. Australian Counselling Association (ACA), Code of Ethics and Practice discussed the importance of client autonomy. Counsellor is responsible for working in ways that respect and promote the client’s ability to make decisions in the light of his/her own beliefs, values and context. The essence of this principle is allowing an individual the freedom of choice and action. Forester-Miller and Davis (1996) mentioned that autonomy is the principle that addresses respect for independence and self-determination that provides freedom of choice and action to the client. The counsellor can assist the client to be autonomous by helping the client to analyse the decisions, values and circumstances that may occur upon the action taken. The final decision is up to the client and the counsellor is not supposing to judge. But for those clients that are not capable to make competent choices, such as children and individuals with mental disabilities, should not be allowed to make decisions that may harm them or others. As stated in the Australian Institute of Professional Counsellors (2008), a counsellor is ethically responsible to encourage the client to think independently and make a decision independently. A counsellor should discourage all forms of client dependency. A counsellor can only guide the client, not making a decision for the client because, in the end, the client should be the decision-maker.

Nurul et al (2017) defined fidelity as loyalty to the client. A counsellor must give priority to the client’s interest than their own interest. Trust and faithfulness play an important part in the fidelity principles. A counsellor must be honest to the client according to what they promise and must make a full commitment. Forester-Miller and Davis (1996) stated that fidelity involves the notions of loyalty, faithfulness, and honouring commitments. American Counselling Association (ACA) discussed that fidelity involves the notions of loyalty, faithfulness, and honouring commitments between the client and counsellor. The client must be able to trust the counsellor and have faith in the therapeutic relationship. Therefore, the counsellor must take care not to threaten the therapeutic relationship or to leave obligations unfulfilled. A counsellor must be honest with clients and faithfully honouring the counsellor’s commitment to the client’s progress. According to the Australian Institute of Professional Counsellors, (2010), fidelity deals with the trust relationship between the counsellor and their client.

The last principle is justice. Justice is defined as the responsibilities to be fair, to avoid bias and to be nondiscriminatory. American Psychologist Association (APA) mentioned that psychologists recognize that fairness and justice entitle to everybody to access. Besides that, the qualities in the processes, procedures, and services being conducted by psychologist have to be equal as well. A counsellor has to provide equal opportunity to the clients, no matter what are their personal and social characteristics which might lead to discrimination. American Counselling Association (ACA) discussed that justice does not mean treating all individuals the same. If an individual is to be treated differently, the counsellor needs to be able to offer a rationale that explains the necessity and appropriateness of treating the individual differently. For example, a counsellor will not ask a client that is blind to fill up a written form but go through the form orally. The counsellor will treat him the same as any other client in all other regards. PERKAMA Code of Ethics (2008) clearly stated that counsellor should have nature behaviours at all times in order to maintain the standard, integrity and professional identity of the counselling profession.

Case 1:

Charlene is a 10-year-old student. She came to see the school counsellor for the second time. In her first visit, she told the counsellor that her parents are divorced. Currently, she is staying with her mother, her younger brother and her grandparents. Her mother is under depression where she always scolds and beat Charlene for no reason. Only Charlene gets the scolding and beating from her mother but not her younger brother. According to Charlene, her younger brother will not get scolded just because he is a boy (traditional Chinese family gender bias). During her second visit, Charlene was crying. She told the counsellor that she cannot return her B.M. test paper to her teacher because her test paper was torn by her mother. The reason her mother tore that test paper was Charlene did not score A in her B.M. paper. Her mother tore the test paper after beat her up. She was terrified and did not know what to do.

The school counsellor suggested reporting this case to the Malaysia Association for the Protection of Children. But Charlene did not want that to happen because she believes it will probably make the situation worse at home. The counsellor was in the dilemma of autonomy and beneficence. She supposed to respect Charlene’s decision or remove the harm that Charlene was facing?

The counsellor decided to report the case to the Malaysia Association for the Protection of Children. The counsellor was worried because domestic violence can be psychologically damaging. The counsellor wants to protect Charlene of future anxiety, PTSD (post-traumatic stress disorder) and depression. Beneficence actions are meant to prevent and remove harms the client may encounter in the future. Charlene had to experience family violence. Basically, she was mentally and physically abused. Beneficence action is the most accurate for Charlene’s case.

Case 2:

Sally’s grandmother was diagnosed with late-stage of dementia. She was 70 years old. The symptoms of late-stage dementia were having difficulty swallowing, memory lost, needing help with most everyday activities, unable to walk, speech limited to single words or phrases and so on. Basically, she needs to be taken care of most of the time. According to the doctor, it is not easy to take care of a late-stage dementia patient. She may need 24 hours care, assisted living care and medical nursing care. Therefore he suggested sending her to the old folk’s home or hospice where she will be taken care off.

After discussion between Sally’s uncles and aunts, they were facing a dilemma of autonomy and beneficence. That was because her uncles and aunts wanted to send her grandmother to the old folk’s home so that she can be well-taken care off. In fact, Sally’s grandmother wished to live at home because she has the phobia of being tortured in the old folks home. In the end, they told the doctor that they would like to take care of her at home. That decision was made based on autonomy where it was Sally’s grandmother’s wish. They hired a carer and everyone in the family took a turn to take care of her. She managed to live for 2 more years. Then she passed away peacefully. Although the process of taking care of a late-stage dementia patient, but they get to spend precious time together with her grandmother. Autonomy is the principle that addresses respect for independence and self-determination that provides freedom of choice. My uncles and aunts respected the choice made by my grandmother. She believed that was the best choice which she was able to spend more time with her family.

Case 3:

Sean and Mikhail are close friends. Sean is the grandson of the school’s chairman while Mikhail is the son of a postman. Although both of them are from different background but that does not stop them to be good friends. Sean is a smart boy but he does not pay attention in class while Mikhail studies hard. One day, they were sitting for midyear examination. The paper they were sitting was Mathematics (paper I), the subject that Sean hates the most. During the exam, Sean was struggling with the questions. At the same time, he saw Mikhail had completed the exam paper. He was hoping his best friend may help him. He passed a small piece of paper to Mikhail asking for answers. Mikhail immediately wrote down the answers on the paper then pass it back to Sean. He did that because Sean is his buddy. Unfortunately, Puan Rina who was invigilating in the exam hall caught them passing a note.

Puan Rina sent Sean and Mikhail to the headmaster’s office. The headmaster called their parents and told them the incident. The headmaster also told them that they will be suspended for three days as a punishment because cheating in an exam is a serious offence in a school. Furthermore, they will get zero for Mathematics paper. Sean’s grandfather (the school’s chairman) called the school and requested the headmaster to withdraw the case. The headmaster was in a dilemma of justice and fidelity. He should be fair handling Sean and Mikhial or being loyal to the chairman?

The next day, the letter of suspension was sent to Sean and Mikhail’s parents. The chairman was very angry with the headmaster. The headmaster’s action may risk his appraisal at the end this year. According to the headmaster, the boys should receive equal punishment disregard your age, race, gender and background. Justice is defined as the responsibilities to be fair, to avoid bias and to be nondiscriminatory.

Case 4:

Dr Nurul is a sports medicine specialist in a group practice. While some of her patients compete in professional sports, she also serves many younger athletes. One day, an 18-year-old boy – Aiman came to see her. Aiman is a high school senior and a promising soccer player. Aiman has an impressive record as a centre forward, and his team was poised to enter a national championship. Aiman feels that his performance in this competition may also influence the scholarships he hopes to be offered when he enters college in the next academic year.

After a brief history and physical exam, Dr Nurul concluded that Alison had injured his anterior ligament. She told Aiman that he cannot play pivoting sport like soccer with a ligament-deficient knee because it could risk further and irreversible damage to the articular cartilage. Aiman requested Dr Nurul to write a note to the school so that he can play in the championship. Dr Nurul refused to write the note because she cannot recommend Aiman to return to play with his knee injury. This case demonstrates the tension between the ethical principles of autonomy and nonmaleficence. Autonomy refers to the principle that Aiman as an adult (18-year-old) has the right to make decisions about the treatment of his/her body. But Dr Nurul clearly understands that playing with a torn ligament puts his at risk for further injury. Dr Nurul, mindful of nonmaleficence (do no harm), did not leave the decision to Alison, because she concerned that Aiman will further damage his knee.

Case 5:

Alex is a finance manager in a listed company in Kuala Lumpur. He is married to a beautiful wife, Emily with 2 adorable kids. He is energetic, active and dedicated in his job and life. Lately, Alex experiences severe headache and the headache becomes more and more frequent. He went to the hospital for a checkup without acknowledging his wife. The result of his checkup gives him a shock. The doctor found a 1.5cm tumour in his brain. The treatment for this brain tumour is to remove it through an operation. According to the doctor, he should remove the tumor as soon as possible because he worries that the tumor may increase in size and then it will affect his eyesight. The doctor claims a 50 per cent of success rate for this operation.

Alex decided not to take the risk to operate his brain. He chooses not to tell his wife because he does not want her and the kids worry. He acts in front of his family as nothing happens to him. He hides his medicines and doctor appointment card well. One day, Emily found his medicines and appointment card. She was shocked to see the number of medicines that Alex consumes. She cannot imagine how sick Alex is. She knows that Alex will not tell her the truth if she confronted. The next day, she decided to find out from the hospital.

She found Cik Yani, the nurse who used to deal with Alex for the appointment. She told Cik Yani about what she found and request Cik Yani to tell her about Alex’s sickness. Cik Yani was unable to reveal a patient’s detail to anyone even to his wife. That is the ethic of a nurse. Therefore, she rejected Emily’s request. Emily was so mad and scolded Cik Yani for inconsiderate.

This case demonstrates the tension between the ethical principles of fidelity and nonmaleficence. Fidelity for nurses refers to remain true to professional promises made to provide quality and competent care to the patients. An ethical nurse will not reveal patients diagnosis to others. Although she has a mindful of nonmaleficence (do no harm), to reveal Alex diagnose so that he would remove his tumour as soon as possible.

Applying these moral principles to professional functioning of any fields is not an easy task, especially when dealing with culturally diverse clients. It is important to realize that different professionals may choose different courses of action for the same situation. There is rarely one right answer to a complex ethical dilemma. However, if you follow a systematic model, you can be assured that you will be able to give a professional explanation for the course of action you chose. Everyone should carry out their duties efficiently, responsibly, objectively, honestly and with dedication in line with the high standard of professionalism. However, with a culturally diversified society like Malaysia, the success of applying all these moral principles will definitely raise the professional level.

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