ethical decision making case study pdf

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Seven Step Method for Ethical Decision-Making

This ethical decision-making framework developed by Dr. Michael Davis of the Illinois Institute of Technology is useful in guiding discussions around case studies and other ethics courses and workshop activities.

• State the Problem

What is the main issue at stake in this case?

• Gather and assess relevant facts in the case

At this step it is important to address the non-ethical issues raised within the case. For example, one may need to know the legal constraints of the decision, technical aspects that loom large, or other issues. Since it is impossible to include all facts in a case-study, frequently you will have to make assumptions based on the information you do have.

• Identifying the stakeholders

At this step, all stakeholders in the decision should be identified. As with Step 1, think broadly and generate a list of all possible individuals, groups, or entities (e.g. the environment) that will be affected by the decisions to be made.

• Develop list of at least five options

(Be imaginative, try to avoid “dilemma” - not “yes” or ”no” but who to go to, what to say).

• Test options, using such tests as the following:
• Harm test - does this option do less harm than any alternative?
• Publicity test - would I want my choice of this option published in the newspaper?
• Defensibility test - could I defend my choice of this option before a Congressional committee, a committee of my peers, or my parents?
• Reversibility test - would I still think the choice of this option good if I were one of those adversely affected by it?
• Virtue test - what would I become if I choose this option often?
• Professional test - what might my profession's ethics committee say about this option?
• Colleague test - what do my colleagues say when I describe my problem and suggest this option as my solution?
• Organization test - what does the organization's ethics officer or legal counsel say about this?
• Make a tentative choice based on steps 1 -5.

Did you solve the problem with which you began?

• Make final choice (after reviewing steps 1- 6), act, and then ask:
• What could make it less likely you would have to make such a decision again?
• What precautions can you take as individual (announce policy on question, change job, etc.)?
• What can you do to have more support next time (e.g., seek future allies on this issue)?
• What can you do to change organization (e.g., suggest policy change at next dept. meeting)?
• What can you do to change larger society (e.g. work for new statute or EPA regulation)?

Adapted from Michael Davis, Ethics and the University (Routledge, London, 1999) pp. 166-67.

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This material is based upon work supported by the National Science Foundation under Award No. 2055332. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the National Science Foundation.

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• v.16(3); 2023 Sep
• PMC10480129

Examination of Ethical Decision-Making Models Across Disciplines: Common Elements and Application to the Field of Behavior Analysis

Victoria d. suarez.

1 Endicott College, Beverly, MA USA

Videsha Marya

2 Village Autism Center, Marietta, GA USA

Mary Jane Weiss

3 Behavioral Health Center of Excellence, Los Angeles, CA USA

Human service practitioners from varying fields make ethical decisions daily. At some point during their careers, many behavior analysts may face ethical decisions outside the range of their previous education, training, and professional experiences. To help practitioners make better decisions, researchers have published ethical decision-making models; however, it is unknown the extent to which published models recommend similar behaviors. Thus, we systematically reviewed and analyzed ethical decision-making models from published peer-reviewed articles in behavior analysis and related allied health professions. We identified 55 ethical decision-making models across 60 peer-reviewed articles, seven primary professions (e.g., medicine, psychology), and 22 subfields (e.g., dentistry, family medicine). Through consensus-based analysis, we identified nine behaviors commonly recommended across the set of reviewed ethical decision-making models with almost all ( n = 52) models arranging the recommended behaviors sequentially and less than half ( n = 23) including a problem-solving approach. All nine ethical decision-making steps clustered around the ethical decision-making steps in the Ethics Code for Behavior Analysts published by the Behavior Analyst Certification Board ( 2020 ) suggesting broad professional consensus for the behaviors likely involved in ethical decision making.

Ethical decision making is operant behavior involving a behavior chain of complex responses (Marya et al., 2022 ). As behavior analysts, we make difficult ethical decisions daily. Behavior analysts are typically taught to respond to ethical scenarios via vignettes or descriptions of real-world ethical dilemmas (e.g., Bailey & Burch, 2016 ; Sush & Najdowski, 2019 ). However, the variability in ethical dilemmas that behavior analysts contact can be extensive and often contains contextual information not included in past training. Such contextual variables (e.g., impact of and on stakeholders, organizational variables, perspective of the funding source) might alter one’s course of action. Ethical decision-making models can equip behavior analysts with the needed tools to navigate varied and complex dilemmas. Thus, behavior analysts can benefit from models that allow an analysis of contextual variables because those variables often impact solutions.

Ethical conduct of board certified behavior analysts is governed by the Behavior Analyst Certification Board (BACB) ethical codes. Since its inception, the BACB has disseminated three major codes— Guidelines for Responsible Conduct for Behavior Analysts (BACB, 2004 , 2010 ), the Professional and Ethical Compliance Code for Behavior Analysts (BACB, 2014 ), and most recently the Ethics Code for Behavior Analysts (BACB, 2020 ). Although versions prior to 2020 outlined specific ethical obligations and provided a framework and reference for considering paths of action when confronted with ethical challenges, no ethical decision-making tool was embedded until the most recent Code iteration.

Within applied behavior analysis (ABA), several ethical decision-making models have been published to guide behavior analysts to make optimal decisions (BACB, 2020 ; Bailey & Burch, 2013 , 2022 ; Brodhead, 2015 ; Brodhead, Quigley, & Wilczynski, 2018 ; Newhouse-Oisten et al., 2017 ; Rosenberg & Schwartz, 2019 ; Sush & Najdowski, 2019 ). These models unanimously share the common goal of providing readers with a systematic approach to ethical decision making, yet include unique elements that provide varying contextual recommendations. Some models offer a generalizable approach affording wider applicability to a variety of ethical situations (BACB, 2020 ; Bailey & Burch, 2013 , 2016 , 2022 ; Brodhead et al., 2018 ; Rosenberg & Schwartz, 2019 ; Sush & Najdowski, 2019 ), and other models provide guidance to navigate specific ethical situations (Brodhead, 2015 ; Newhouse-Oisten et al., 2017 ). Moreover, some models incorporate a problem-solving approach wherein multiple behaviors are considered along with their possible outcomes to aid decision making in ethical contexts (Rosenberg & Schwartz, 2019 ).

Existing models within the behavior analytic literature have all emerged in the last 7 years and offer a discipline-specific approach. However, many other allied disciplines (e.g., medicine, psychology) have published literature offering models for ethical decision making for a longer period than the field of behavior analysis. Recently, there have been calls to action where behavior analysts have been looking to and learning from related professions (LaFrance et al., 2019 ; Miller et al., 2019 ; Pritchett et al., 2021 ; Taylor et al., 2019 ; Wright, 2019 ). Learning from other disciplines may help the field of behavior analysis rule out ineffective approaches or derive novel effective solutions more quickly.

The purpose of this systematic literature review was to conduct a descriptive analysis of ethical decision-making models across behavior analysis and allied disciplines. This literature review aimed to identify similarities and differences in approaches to ethical decision making that could inform future ethical decision-making models and aid the development of ethical decision-making skills in behavior analysts.

Inclusion Criteria

Articles included in this systematic review met the following three criteria: published in peer-reviewed journals through June 2020, written in English, and the title or abstract included keywords from the search (described below). We began the review in July 2020 and completed it in August 2021.

Search Procedure

We conducted a systematic review of the literature on ethical decision-making models for the fields of applied behavior analysis, education, medicine, occupational therapy, psychology, social work, and speech language pathology using the Preferred Reporting Item for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff, Altman, & Prisma Group, 2009 ). We chose these fields because of their similarities to behavior analysis’ mission in serving vulnerable populations. The following procedures were completed in accordance with the PRISMA guidelines: (1) potential articles meeting inclusion criteria were identified; (2) the identified articles were comprehensively screened; (3) the eligibility of each article was evaluated across dependent measures; and (4) the included articles were analyzed.

The first and second authors completed primary database searches using PsycINFO and PubMed. The keywords used to identify potential articles to be included in this analysis were: applied behavior analysis, clinical psychology, counseling psychology, decision mak*, educat*, ethic*, model, medicine, nursing, occupational therapy, speech and language*, and social work. In particular, the key words “ethic*”, “decision mak*”, and “model” were used in combination with the terms “applied behavior analysis,” or “clinical psychology,” or “counseling psychology,” or “medicine,” or “nursing,” or “occupational therapy,” or “speech,” or “language.”

The initial PsycINFO and PubMed searches yielded 635 articles. Of these, 46 were duplicates. The titles and abstracts of the remaining 589 articles were read by the first and second authors to evaluate the inclusion of keywords. Full-text articles were retrieved for studies that included the words ethics or ethical , decision making , or model in their abstracts or titles ( n = 249). Of these, a total of 173 articles were selected for full-text review.

The articles selected for full-text review ( n = 173) were read in their entirety to evaluate whether they met these criteria: (1) included humans as the population of interest; (2) mentioned decision making; (3) mentioned ethics; (4) provided at least three identifiable steps to be followed as a part of a model in either a text or figure format; and (5) the provided model addressed how to respond to ethical dilemmas. The first and second authors scored each of the 173 articles across the aforementioned criteria to determine whether they would be included in the final analysis. Articles ( n = 27) for which it was unclear whether they met any of the criteria were coded as needing additional review, and the third and fourth authors completed an additional full-text review to determine whether they would be included in the final analysis. A total of 126 articles were removed for not meeting all five of the criteria. Thus, 47 articles remained to be included in the analysis.

Next, the first and second authors conducted a manual search (i.e., identification through other sources) of the references ( n = 1,354) for the remaining 47 articles. The screening criteria for this search was identical to the initial screening in which the title and abstract were searched for the inclusion of the words ethics or ethical , decision making , and model . Seventy-nine additional articles were identified through this process. Of these 79 articles, 16 were identified as duplicates from the initial PsycINFO and PubMed searches. Twelve articles were inaccessible to us online or through available library loans and were thus excluded. A list of these articles is not included in this article but is available upon request. Upon reviewing the full text of the remaining 51 articles, 26 additional articles met eligibility to be included in the analysis. In sum, a total of 60 articles met all inclusion criteria and were included.

Interrater reliability was scored using a consensus-based approach. In particular, all four authors collaboratively scored each of the models across the various measures described in the section below. If there was disagreement on scoring at any point, the authors collaboratively reviewed the model using figures provided within the article and any available text describing the model until consensus in scoring was reached.

Dependent Measures

Articles that met criteria for inclusion were evaluated across four dependent measures. First, we evaluated the steps included within the models from each article. Second, we categorized the model by the professional discipline or field of study. Third, we evaluated whether the model author presented the model in a specific order or sequence (i.e., linear or sequential model). Lastly, we scored whether the model included a problem-solving approach. We provide greater detail on each of these dependent measures below.

Decision-Making Steps

The models from each article were evaluated across nine steps (Table ​ (Table1). 1 ). These steps were developed during the process of data synthesis. We read the included articles and identified common themes based on their prevalence in the examined literature. Next, we began classifying articles by the inclusion of these steps, indicating whether each article contained each of the identified steps. Then, we began tracking additional steps that appeared in articles. If those steps appeared in multiple articles, we added them as official steps in the analysis. When this was done, all previously coded articles were recoded for these additional steps. For the purpose of the current review, we identified the following nine components of ethical decision making: (1) ethical radar; (2) urgent detour; (3) pinpoint the problem; (4) information gathering; (5) available options/behaviors; (6) ranking and weighing; (7) analysis; (8) implementation; and (9) follow-up. Details on scoring criteria for each of these steps can be found in Appendix Table ​ Table4. 4 . We scored models included in each article as either including or not including the steps listed above. This was done by using the text description of the model, if provided, or the figure representation of the model if descriptive text was not included.

Steps from the Decision-Making Model from the Ethics Code for Behavior Analysts ( 2020 ) and from the Current Literature Review

*Step 4 of the BACB model aligns with components from Step 6 of current literature review.

Decision-making Steps

Field of Study

The field of study of each article was recorded (e.g., psychology). Where possible, we also included a secondary field of study (e.g., school psychology). The primary field of study of the article was determined based on the journal that it was published in and the intended audience of the article. Secondary fields of study were coded to further gather information about the specific subfield. For example, if the article was published in a psychology journal and the audience of the article was specifically school psychologists.

Problem Solving

Models within each article were scored as including a problem-solving component or approach if the model author(s) guided the model users to identify two or more possible solutions and likely outcomes or consequences to the possible solutions. Models that did not include more than one possible solution and did not anticipate outcomes to solutions were scored as not including a problem-solving component.

Linear or Sequential

We coded whether the proposed model was linear or sequential in nature. That is, the model author(s) indicated that steps in the model followed a certain order or sequence wherein each preceding step in the model was to be considered prior to moving on to subsequent steps. If a model was not linear or sequential, this was also recorded.

Number of Models

A total of 55 ethical decision-making models across 60 peer-reviewed journal articles were analyzed. Models included in more than one article were counted as duplicates, and papers that included more than one model resulted in each unique model being coded.

Table ​ Table2 2 shows the number of models that included each of the nine steps. None of the steps were present in all models and the step that was included in the greatest number of models was ranking and weighing information ( n = 51; 93%). After ranking and weighing information, the steps found in the most-to-least number of models were: affected parties and available options/behaviors ( n = 49; 89%); reference other codes of ethics (e.g., personal, religious, organizational; n = 44; 80%); analysis ( n = 43; 78%), reference of professional codes ( n = 40; 73%); case specific information ( n = 38; 69%); implementation and pinpoint the problem (29 models each; 52%); follow up ( n = 26; 47%); ethical radar ( n = 21; 38%); urgent detour ( n = 16; 29%); and, information gathering ( n = 11; 20%).

Steps Included in Each Model

Figure ​ Figure1 1 shows a stacked bar chart of the primary and secondary fields of the ethical decision-making models. Medicine dominated the resulting set of models, followed by psychology, education, business, then child and youth care and organizational behavior management (OBM). Nevertheless, 23 different subspecialties were represented in the secondary field of the ethical decision-making models.

Stacked-Bar Graph Showing the Number of Ethical Decision-Making Models Based on the Primary and Secondary Literatures from which It Came

Table ​ Table3 3 presents a list of the synthesized models and their respective fields of study. The most common field of study across the 55 models was medicine ( n = 34; 62%). Seventeen of the models from medicine were specific to the subfield of nursing (50%) and three were specific to the subfield of psychiatry (9%). Of the remaining models from the field of medicine, one each was specific to critical care (3%), dentistry (3%), emergency medicine (3%), geriatrics (3%), internal medicine (3%), and oncology (3%). The remaining models from the field of medicine were coded as “general medicine” because they did not indicate a specific subfield.

Field of Study of Included Models

Thirteen models were specific to the field of psychology (24%). Four of the psychology specific models were from the subfield of counseling (31%) and two were specific to the subfield of school psychology (15%). Other specified psychology subfields included coaching ( n = 1; 8%), industrial/organizational psychology ( n = 1; 8%), pediatric psychology ( n = 1; 8%), and psychobiography ( n = 1; 8%). The remaining models were coded as “general psychology” because they did not indicate a specific subfield.

Three models were specific to the field of education (5%). Two of these were specific to the subfield of teaching (67%) and one was specific to the subfield of administration and leadership (33%). Two models were specific to the field of business (4%); one of these was specific to the subfield of management (50%) and the other to the subfield of leadership (50%). One model was specific to the field of child and youth care (2%), one was specific to engineering (2%), and one was specific to OBM (2%).

Figure ​ Figure2 2 shows the number of models that contained a problem-solving approach. A total of 23 models included a problem-solving approach (42%) and 32 did not (58%). Most of the models with a problem-solving component came from medicine ( n = 15; 65%), followed by psychology ( n = 7; 30%), and engineering ( n = 1; 43%). No models from the fields of business, education, or OBM included a problem-solving component.

Bar Graph Showing the Number of Decision-Making Models with and without a Problem-Solving Component, and Models that were Sequential or Nonsequential

Figure ​ Figure2 2 also shows the number of models that were sequential. A total of 52 models were linear or sequential in nature (95%), whereas 3 were not (5%). Most of the models that were sequential came from medicine ( n = 32; 62%), followed by psychology ( n = 14; 27%), education ( n = 3; 58%), business ( n = 2; 4%), engineering ( n = 1; 2%), and child and youth care ( n = 1; 2%).

The goal of this literature review was to identify and analyze published ethical decision-making models in behavior analysis and allied disciplines to determine consistency in recommended approaches. We examined 55 ethical decision-making models to collect data on what recommended steps were included and what approaches were most frequently emphasized. Three general themes within ethical decision-making models arose from our analysis. These include: (1) What steps were included within models; (2) Whether the steps were sequential (i.e., a behavior chain); and (3) Whether the entire process could be labeled as problem solving (i.e., Szabo, 2020 ). We discuss each of these findings in turn.

Behaviors Involved in Ethical Decision Making

The first main finding surrounds the variability in recommended steps of ethical decision making across models. We found that each of the nine steps coded appeared in an average (arithmetic mean) of 58% of the articles (range: 20%–93%). This suggests that some consistency exists in what behaviors various scholars recommend practitioners should engage in when faced with an ethical decision. However, the wide variability in how frequently each behavior appeared also highlights that ABA practitioners would benefit from researchers clarifying at least three important characteristics of ethical decision-making models. These are: (1) What behaviors are necessary and sufficient to make an optimal ethical decision in ABA contexts (i.e., component analysis)? (2) What are the conditions under which specific steps are and are not needed (i.e., conditional discrimination analysis)? (3) Is there an optimal functional result of ethical decision making that is more important than the specific topographies a practitioner uses to contact that outcome (i.e., functional analysis; see Cox, 2021 )? Practitioners and researchers may begin to explore some of these questions when engaging in ethical decision making.

More than half of the articles examined emphasized the need for consulting ethical codes. It is interesting that more ethical models recommended practitioners reference codes of ethics from outside their discipline ( n = 44; 80% of models; e.g., personal, religious, organizational) than their own discipline’s code of ethics ( n = 40; 73%). To our knowledge, the conflict between personal and professional codes of ethics is an underexplored topic in the ABA literature. Nevertheless, the slightly greater emphasis on other codes of ethics in addition to one’s own discipline suggests this might be an important area where practitioners could use guidance. Also, the field of ABA would likely benefit from future research and scholarship surrounding the conditions and functional outcomes of ethical decisions where personal and professional values conflict.

It is important to mention that our review was done prior to the publication of the BACB’s ( 2020 ) ethical decision-making model. The BACB’s model was published in the analysis and writing stage of this review. Our findings suggest a robust literature spanning 40+ years, 60+ articles, and 50+ models all clustered around similar ethical decision-making steps published by the BACB. Perhaps most intriguing is that we identified the nine steps from our review prior to the publication of the BACB’s model, and no previous models had incorporated all nine ethical decision-making steps until the BACB published their decision model (BACB, 2020). Practicing behavior analysts would benefit from future component analyses, conditional discrimination analyses, functional analyses, and empirical support surrounding the BACB’s ethical decision-making model.

Our analysis also suggests that behavior analysts and allied professionals approach ethical decision making similarly. Given the complexity of ethical decision making and the shared types of dilemmas human service professionals contact, some convergence is expected. However, there are many reasons that two professionals from different disciplines may come into disagreement (Boivin et al., 2021 ; Bowman et al., 2021 ; Cox, 2019 ; Gasiewski et al., 2021 ). Having familiar systems with empirical support for how to navigate ethical dilemmas might improve the likelihood that a positive resolution occurs. Further, such interprofessional similarities in ethical decision-making processes allows future interdisciplinary dialogue to focus more on specific areas of agreement because what and how information will be used to make a decision is already agreed upon.

Behavior Chains and Behavior Topography

We found that 95% of the ethical decision-making models could be described as a behavior chain (e.g., Catania, 2013 ). Framing ethical decision making as a behavior chain might be useful as it highlights the interrelated and sequential nature of ethical decision making. That is, completing one step in an ethical decision-making behavior chain leads to a context wherein the next response in the chain is more likely to contact reinforcement. For example, until you have gathered all relevant information about how the decision will affect all relevant parties, your ranking and weighing of information seems less likely to lead to the best outcome. That said, the temporally delayed nature of behaviors and consequences involved in ethical decision making is different than how behavior chains have been studied in laboratory settings (e.g., Baum, 2017 ; Cox, 2021 ; Slocum & Tiger, 2011 ). Future research will likely be needed to better understand the effects of temporal relations on behavior chains and thus determine what approach best provides a behavioral description of ethical decision making.

It is interesting that the order in which steps were proposed differed across models. We are unaware of any research that compares the effectiveness of different sequential ethical decision-making models to understand whether the order of behaviors recommended as a chain are more or less useful. Nevertheless, future research that identifies the extent to which rigid sequences of behaviors need to occur to optimize decision making would be helpful for the field of ABA. Such information would likely improve behavior analytic training programs and prove useful for clinical directors, ethics committee chairs, case supervisors (e.g., BCBAs), and direct staff (e.g., RBTs).

Ethical Decision Making as Problem Solving

Recent attention has been given to the common-sense problem-solving approach (Szabo, 2020 ), which we used to score models within the current analysis. This problem-solving approach may offer great utility and is observed across various fields (e.g., cognitive psychology; Szabo, 2020 ). Within behavior analysis, this problem-solving approach has increasingly been applied to teach complex skills (e.g., Suarez et al., 2021 ). Our review involves an interesting extension of this analysis to ethical decision making and indicates the steps of the models may also point to additional precurrent behaviors or mediating strategies that could prove to be important elements of the behavioral chain.

We found that 42% of the ethical decision-making models could be described as including problem solving (e.g., Kieta et al., 2019 ). Framing ethical decision making as involving problem solving is advantageous because of the existing empirical literature on how to teach problem-solving skills and recognition of the importance of verbal stimuli and verbal behavior (e.g., Kieta et al., 2019 ). However, this also might have the drawbacks of adding complexity and less empirical support specific from the behavior analytic literature on describing, predicting, and controlling problem solving. This suggests that there are either components of ethical decision making outside of problem solving or that there are components of problem solving that might be missing from current decision-making models. Future research using concept analysis (e.g., Layng, 2019 ) combined with laboratory experiments may help clarify which of the above scenarios is more likely (or if there’s an unknown third!).

We also found that 58% of the ethical decision-making models could not be described as including problem solving. We are unaware of any research that has directly compared the effectiveness of ethical decision-making models with and without problem-solving components. Nevertheless, a practically useful set of empirical questions might identify the conditions under which ethical decision-making models with and without problem-solving components are more helpful for practitioners. Behavior analytic training programs subsequently could teach fluency toward ethical decision making via problem solving under some conditions and ethical decision making without problem solving under other conditions.

Limitations and Final Thoughts

The current study included several limitations. One limitation centers on the procedures used for rater agreement. Article ratings were completed in a group format and by consensus among the authors. It is possible that reactivity to other members of the group affected overall ratings (e.g., Asch, 1956 ). It is also possible that the search terms we used failed to capture relevant ethical decision-making models or that additional search terms would have led to different results. Further, we also restricted our inclusion criteria to specific human service fields allied to ABA. Thus, it is possible that a more comprehensive search of ethical decision-making models across more varied professions would lead to different outcomes. Finally, we did not include ethical decision-making models published in books mainly due to access issues and a typical lack of peer-review for books. Regardless, these limitations may provide greater support for our primary findings that the existing variability in ethical decision-making steps and overall lack of empirical support suggest this area is ripe for future research.

The development of an ethical decision-making skill set is vital for behavior analysts and for other human service providers. Dilemmas present as complex circumstances, with specific and unique contextual variations that require nuanced assessment. The process of training behavior analysts to meet these demands is daunting. There is a need to identify strategies for navigating dilemmas and for making ethical decisions. Allied professions and behavior analysis have identified steps in this process. Many of these models use problem-solving techniques. The BACB’s Decision Making Model overlaps substantially with existing literature across professions, and uses a problem-solving, sequential approach. These results are especially interesting as we had completed identifying the decision-making steps scored in the current article before the BACB model was released. It seems that the field has built a model that is entirely aligned with and built upon this interprofessional database. It will be important to empirically evaluate this new model. It will also be important to explore other decision-making approaches, to compare models, and to (potentially) match models to the contextual variables embedded in the presenting dilemma. The field of behavior analysis has, at times, been insular, and this has been a source of internal and external criticism. However, this review of the literature supports the substantial overlap across fields and provides concrete hope for mutually beneficial interdisciplinary collaboration. So, although decision-making models can be field-specific, ethical dilemmas appear to be universal and so are the intended outcomes. As behavior analysis tackles this complex skill set, it is important to learn from colleagues in allied disciplines, examine the component skills likely to be crucial to the development of this behavioral repertoire, and develop procedures for measuring, teaching, and training clinicians to methodically approach ethical dilemmas.

Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

No funding was received to assist with the preparation of this manuscript.

Declarations

The authors do not have any potential conflicts of interest to disclose and have no relevant financial or nonfinancial interests to disclose.

No human participants were involved in this research, and therefore informed consent was not obtained.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

All articles with an asterisk indicate the final articles included in the review

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Videos Concepts Unwrapped View All 36 short illustrated videos explain behavioral ethics concepts and basic ethics principles. Concepts Unwrapped: Sports Edition View All 10 short videos introduce athletes to behavioral ethics concepts. Ethics Defined (Glossary) View All 58 animated videos - 1 to 2 minutes each - define key ethics terms and concepts. Ethics in Focus View All One-of-a-kind videos highlight the ethical aspects of current and historical subjects. Giving Voice To Values View All Eight short videos present the 7 principles of values-driven leadership from Gentile's Giving Voice to Values. In It To Win View All A documentary and six short videos reveal the behavioral ethics biases in super-lobbyist Jack Abramoff's story. Scandals Illustrated View All 30 videos - one minute each - introduce newsworthy scandals with ethical insights and case studies. Video Series

Case Studies UT Star Icon

Case Studies

More than 70 cases pair ethics concepts with real world situations. From journalism, performing arts, and scientific research to sports, law, and business, these case studies explore current and historic ethical dilemmas, their motivating biases, and their consequences. Each case includes discussion questions, related videos, and a bibliography.

A Million Little Pieces

James Frey’s popular memoir stirred controversy and media attention after it was revealed to contain numerous exaggerations and fabrications.

Abramoff: Lobbying Congress

Super-lobbyist Abramoff was caught in a scheme to lobby against his own clients. Was a corrupt individual or a corrupt system – or both – to blame?

Apple Suppliers & Labor Practices

Is tech company Apple, Inc. ethically obligated to oversee the questionable working conditions of other companies further down their supply chain?

Approaching the Presidency: Roosevelt & Taft

Some presidents view their responsibilities in strictly legal terms, others according to duty. Roosevelt and Taft took two extreme approaches.

Appropriating “Hope”

Fairey’s portrait of Barack Obama raised debate over the extent to which an artist can use and modify another’s artistic work, yet still call it one’s own.

Arctic Offshore Drilling

Competing groups frame the debate over oil drilling off Alaska’s coast in varying ways depending on their environmental and economic interests.

Banning Burkas: Freedom or Discrimination?

The French law banning women from wearing burkas in public sparked debate about discrimination and freedom of religion.

Birthing Vaccine Skepticism

Wakefield published an article riddled with inaccuracies and conflicts of interest that created significant vaccine hesitancy regarding the MMR vaccine.

Blurred Lines of Copyright

Marvin Gaye’s Estate won a lawsuit against Robin Thicke and Pharrell Williams for the hit song “Blurred Lines,” which had a similar feel to one of his songs.

Bullfighting: Art or Not?

Bullfighting has been a prominent cultural and artistic event for centuries, but in recent decades it has faced increasing criticism for animal rights’ abuse.

Buying Green: Consumer Behavior

Do purchasing green products, such as organic foods and electric cars, give consumers the moral license to indulge in unethical behavior?

Cadavers in Car Safety Research

Engineers at Heidelberg University insist that the use of human cadavers in car safety research is ethical because their research can save lives.

Cardinals’ Computer Hacking

St. Louis Cardinals scouting director Chris Correa hacked into the Houston Astros’ webmail system, leading to legal repercussions and a lifetime ban from MLB.

Cheating: Atlanta’s School Scandal

Teachers and administrators at Parks Middle School adjust struggling students’ test scores in an effort to save their school from closure.

Cheating: Sign-Stealing in MLB

The Houston Astros’ sign-stealing scheme rocked the baseball world, leading to a game-changing MLB investigation and fallout.

Cheating: UNC’s Academic Fraud

UNC’s academic fraud scandal uncovered an 18-year scheme of unchecked coursework and fraudulent classes that enabled student-athletes to play sports.

Cheney v. U.S. District Court

A controversial case focuses on Justice Scalia’s personal friendship with Vice President Cheney and the possible conflict of interest it poses to the case.

Christina Fallin: “Appropriate Culturation?”

After Fallin posted a picture of herself wearing a Plain’s headdress on social media, uproar emerged over cultural appropriation and Fallin’s intentions.

Climate Change & the Paris Deal

While climate change poses many abstract problems, the actions (or inactions) of today’s populations will have tangible effects on future generations.

Cover-Up on Campus

While the Baylor University football team was winning on the field, university officials failed to take action when allegations of sexual assault by student athletes emerged.

Covering Female Athletes

Sports Illustrated stirs controversy when their cover photo of an Olympic skier seems to focus more on her physical appearance than her athletic abilities.

Covering Yourself? Journalists and the Bowl Championship

Can news outlets covering the Bowl Championship Series fairly report sports news if their own polls were used to create the news?

Cyber Harassment

After a student defames a middle school teacher on social media, the teacher confronts the student in class and posts a video of the confrontation online.

Defending Freedom of Tweets?

Running back Rashard Mendenhall receives backlash from fans after criticizing the celebration of the assassination of Osama Bin Laden in a tweet.

Dennis Kozlowski: Living Large

Dennis Kozlowski was an effective leader for Tyco in his first few years as CEO, but eventually faced criminal charges over his use of company assets.

Digital Downloads

File-sharing program Napster sparked debate over the legal and ethical dimensions of downloading unauthorized copies of copyrighted music.

Dr. V’s Magical Putter

Journalist Caleb Hannan outed Dr. V as a trans woman, sparking debate over the ethics of Hannan’s reporting, as well its role in Dr. V’s suicide.

East Germany’s Doping Machine

From 1968 to the late 1980s, East Germany (GDR) doped some 9,000 athletes to gain success in international athletic competitions despite being aware of the unfortunate side effects.

Ebola & American Intervention

Did the dispatch of U.S. military units to Liberia to aid in humanitarian relief during the Ebola epidemic help or hinder the process?

Edward Snowden: Traitor or Hero?

Was Edward Snowden’s release of confidential government documents ethically justifiable?

Ethical Pitfalls in Action

Why do good people do bad things? Behavioral ethics is the science of moral decision-making, which explores why and how people make the ethical (and unethical) decisions that they do.

Ethical Use of Home DNA Testing

The rising popularity of at-home DNA testing kits raises questions about privacy and consumer rights.

Flying the Confederate Flag

A heated debate ensues over whether or not the Confederate flag should be removed from the South Carolina State House grounds.

Freedom of Speech on Campus

In the wake of racially motivated offenses, student protests sparked debate over the roles of free speech, deliberation, and tolerance on campus.

Freedom vs. Duty in Clinical Social Work

What should social workers do when their personal values come in conflict with the clients they are meant to serve?

Full Disclosure: Manipulating Donors

When an intern witnesses a donor making a large gift to a non-profit organization under misleading circumstances, she struggles with what to do.

Gaming the System: The VA Scandal

The Veterans Administration’s incentives were meant to spur more efficient and productive healthcare, but not all administrators complied as intended.

German Police Battalion 101

During the Holocaust, ordinary Germans became willing killers even though they could have opted out from murdering their Jewish neighbors.

Head Injuries & American Football

Many studies have linked traumatic brain injuries and related conditions to American football, creating controversy around the safety of the sport.

Head Injuries & the NFL

American football is a rough and dangerous game and its impact on the players’ brain health has sparked a hotly contested debate.

Healthcare Obligations: Personal vs. Institutional

A medical doctor must make a difficult decision when informing patients of the effectiveness of flu shots while upholding institutional recommendations.

High Stakes Testing

In the wake of the No Child Left Behind Act, parents, teachers, and school administrators take different positions on how to assess student achievement.

In-FUR-mercials: Advertising & Adoption

When the Lied Animal Shelter faces a spike in animal intake, an advertising agency uses its moral imagination to increase pet adoptions.

Krogh & the Watergate Scandal

Egil Krogh was a young lawyer working for the Nixon Administration whose ethics faded from view when asked to play a part in the Watergate break-in.

Limbaugh on Drug Addiction

Radio talk show host Rush Limbaugh argued that drug abuse was a choice, not a disease. He later became addicted to painkillers.

U.S. Olympic swimmer Ryan Lochte’s “over-exaggeration” of an incident at the 2016 Rio Olympics led to very real consequences.

Meet Me at Starbucks

Two black men were arrested after an employee called the police on them, prompting Starbucks to implement “racial-bias” training across all its stores.

Myanmar Amber

Buying amber could potentially fund an ethnic civil war, but refraining allows collectors to acquire important specimens that could be used for research.

Negotiating Bankruptcy

Bankruptcy lawyer Gellene successfully represented a mining company during a major reorganization, but failed to disclose potential conflicts of interest.

Pao & Gender Bias

Ellen Pao stirred debate in the venture capital and tech industries when she filed a lawsuit against her employer on grounds of gender discrimination.

Pardoning Nixon

One month after Richard Nixon resigned from the presidency, Gerald Ford made the controversial decision to issue Nixon a full pardon.

Patient Autonomy & Informed Consent

Nursing staff and family members struggle with informed consent when taking care of a patient who has been deemed legally incompetent.

Prenatal Diagnosis & Parental Choice

Debate has emerged over the ethics of prenatal diagnosis and reproductive freedom in instances where testing has revealed genetic abnormalities.

Reporting on Robin Williams

After Robin Williams took his own life, news media covered the story in great detail, leading many to argue that such reporting violated the family’s privacy.

Responding to Child Migration

An influx of children migrants posed logistical and ethical dilemmas for U.S. authorities while intensifying ongoing debate about immigration.

Retracting Research: The Case of Chandok v. Klessig

A researcher makes the difficult decision to retract a published, peer-reviewed article after the original research results cannot be reproduced.

Sacking Social Media in College Sports

In the wake of questionable social media use by college athletes, the head coach at University of South Carolina bans his players from using Twitter.

Selling Enron

Following the deregulation of electricity markets in California, private energy company Enron profited greatly, but at a dire cost.

Snyder v. Phelps

Freedom of speech was put on trial in a case involving the Westboro Baptist Church and their protesting at the funeral of U.S. Marine Matthew Snyder.

Something Fishy at the Paralympics

Rampant cheating has plagued the Paralympics over the years, compromising the credibility and sportsmanship of Paralympian athletes.

Sports Blogs: The Wild West of Sports Journalism?

Deadspin pays an anonymous source for information related to NFL star Brett Favre, sparking debate over the ethics of “checkbook journalism.”

Stangl & the Holocaust

Franz Stangl was the most effective Nazi administrator in Poland, killing nearly one million Jews at Treblinka, but he claimed he was simply following orders.

Teaching Blackface: A Lesson on Stereotypes

A teacher was put on leave for showing a blackface video during a lesson on racial segregation, sparking discussion over how to teach about stereotypes.

The Astros’ Sign-Stealing Scandal

The Houston Astros rode a wave of success, culminating in a World Series win, but it all came crashing down when their sign-stealing scheme was revealed.

The Central Park Five

Despite the indisputable and overwhelming evidence of the innocence of the Central Park Five, some involved in the case refuse to believe it.

The CIA Leak

Legal and political fallout follows from the leak of classified information that led to the identification of CIA agent Valerie Plame.

The Collapse of Barings Bank

When faced with growing losses, investment banker Nick Leeson took big risks in an attempt to get out from under the losses. He lost.

The Costco Model

How can companies promote positive treatment of employees and benefit from leading with the best practices? Costco offers a model.

The FBI & Apple Security vs. Privacy

How can tech companies and government organizations strike a balance between maintaining national security and protecting user privacy?

The Miss Saigon Controversy

When a white actor was cast for the half-French, half-Vietnamese character in the Broadway production of Miss Saigon , debate ensued.

The Sandusky Scandal

Following the conviction of assistant coach Jerry Sandusky for sexual abuse, debate continues on how much university officials and head coach Joe Paterno knew of the crimes.

The Varsity Blues Scandal

A college admissions prep advisor told wealthy parents that while there were front doors into universities and back doors, he had created a side door that was worth exploring.

Providing radiation therapy to cancer patients, Therac-25 had malfunctions that resulted in 6 deaths. Who is accountable when technology causes harm?

Welfare Reform

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• The PLUS Ethical Decision Making Model

Seven Steps to Ethical Decision Making –  Step 1: Define the problem  (consult  PLUS filters ) –  Step 2: Seek out relevant assistance, guidance and support  –  Step 3: Identify alternatives –  Step 4: Evaluate the alternatives  (consult  PLUS filters ) –  Step 5: Make the decision –  Step 6: Implement the decision –  Step 7: Evaluate the decision  (consult  PLUS filters )

Introduction Organizations struggle to develop a simple set of guidelines that makes it easier for individual employees, regardless of position or level, to be confident that his/her decisions meet all of the competing standards for effective and ethical decision-making used by the organization. Such a model must take into account two realities:

• Every employee is called upon to make decisions in the normal course of doing his/her job. Organizations cannot function effectively if employees are not empowered to make decisions consistent with their positions and responsibilities.
• For the decision maker to be confident in the decision’s soundness, every decision should be tested against the organization’s policies and values, applicable laws and regulations as well as the individual employee’s definition of what is right, fair, good and acceptable.

The decision making process described below has been carefully constructed to be:

• Fundamentally sound based on current theories and understandings of both decision-making processes and ethics.
• Simple and straightforward enough to be easily integrated into every employee’s thought processes.
• Descriptive (detailing how ethical decision are made naturally) rather than prescriptive (defining unnatural ways of making choices).

Why do organizations need ethical decision making? See our special edition case study, #RespectAtWork, to find out.

First, explore the difference between what you expect and/or desire and the current reality. By defining the problem in terms of outcomes, you can clearly state the problem.

Consider this example: Tenants at an older office building are complaining that their employees are getting angry and frustrated because there is always a long delay getting an elevator to the lobby at rush hour. Many possible solutions exist, and all are predicated on a particular understanding the problem:

• Flexible hours – so all the tenants’ employees are not at the elevators at the same time.
• Faster elevators – so each elevator can carry more people in a given time period.
• Bigger elevators – so each elevator can carry more people per trip.
• Elevator banks – so each elevator only stops on certain floors, increasing efficiency.
• Better elevator controls – so each elevator is used more efficiently.
• More elevators – so that overall carrying capacity can be increased.
• Improved elevator maintenance – so each elevator is more efficient.
• Encourage employees to use the stairs – so fewer people use the elevators.

The real-life decision makers defined the problem as “people complaining about having to wait.” Their solution was to make the wait less frustrating by piping music into the elevator lobbies. The complaints stopped. There is no way that the eventual solution could have been reached if, for example, the problem had been defined as “too few elevators.”

How you define the problem determines where you go to look for alternatives/solutions– so define the problem carefully.

Step 2: Seek out relevant assistance, guidance and support

Once the problem is defined, it is critical to search out resources that may be of assistance in making the decision. Resources can include people (i.e., a mentor, coworkers, external colleagues, or friends and family) as well professional guidelines and organizational policies and codes. Such resources are critical for determining parameters, generating solutions, clarifying priorities and providing support, both while implementing the solution and dealing with the repercussions of the solution.

Step 3: Identify available alternative solutions to the problem The key to this step is to not limit yourself to obvious alternatives or merely what has worked in the past. Be open to new and better alternatives. Consider as many as solutions as possible — five or more in most cases, three at the barest minimum. This gets away from the trap of seeing “both sides of the situation” and limiting one’s alternatives to two opposing choices (i.e., either this or that).

Step 4: Evaluate the identified alternatives As you evaluate each alternative, identify the likely positive and negative consequence of each. It is unusual to find one alternative that would completely resolve the problem and is significantly better than all others. As you consider positive and negative consequences, you must be careful to differentiate between what you know for a fact and what you believe might be the case. Consulting resources, including written guidelines and standards, can help you ascertain which consequences are of greater (and lesser) import.

You should think through not just what results each alternative could yield, but the likelihood it is that such impact will occur. You will only have all the facts in simple cases. It is reasonable and usually even necessary to supplement the facts you have with realistic assumptions and informed beliefs. Nonetheless, keep in mind that the more the evaluation is fact-based, the more confident you can be that the expected outcome will occur. Knowing the ratio of fact-based evaluation versus non-fact-based evaluation allows you to gauge how confident you can be in the proposed impact of each alternative.

Step 5: Make the decision When acting alone, this is the natural next step after selecting the best alternative. When you are working in a team environment, this is where a proposal is made to the team, complete with a clear definition of the problem, a clear list of the alternatives that were considered and a clear rationale for the proposed solution.

Step 6: Implement the decision While this might seem obvious, it is necessary to make the point that deciding on the best alternative is not the same as doing something. The action itself is the first real, tangible step in changing the situation. It is not enough to think about it or talk about it or even decide to do it. A decision only counts when it is implemented. As Lou Gerstner (former CEO of IBM) said, “There are no more prizes for predicting rain. There are only prizes for building arks.”

Step 7: Evaluate the decision Every decision is intended to fix a problem. The final test of any decision is whether or not the problem was fixed. Did it go away? Did it change appreciably? Is it better now, or worse, or the same? What new problems did the solution create?

Ethics Filters

The ethical component of the decision making process takes the form of a set of “filters.” Their purpose is to surface the ethics considerations and implications of the decision at hand. When decisions are classified as being “business” decisions (rather than “ethics” issues), values can quickly be left out of consideration and ethical lapses can occur.

At key steps in the process, you should stop and work through these filters, ensuring that the ethics issues imbedded in the decision are given consideration.

We group the considerations into the mnemonic PLUS.

• P  = Policies Is it consistent with my organization’s policies, procedures and guidelines?
• L = Legal Is it acceptable under the applicable laws and regulations?
• U  = Universal Does it conform to the universal principles/values my organization has adopted?
• S = Self Does it satisfy my personal definition of right, good and fair?

The PLUS filters work as an integral part of steps 1, 4 and 7 of the decision-making process. The decision maker applies the four PLUS filters to determine if the ethical component(s) of the decision are being surfaced/addressed/satisfied.

• Does the existing situation violate any of the PLUS considerations?
• Step 2:   Seek out relevant assistance, guidance and support
• Step 3: Identify available alternative solutions to the problem
• Will the alternative I am considering resolve the PLUS violations?
• Will the alternative being considered create any new PLUS considerations?
• Are the ethical trade-offs acceptable?
• Step 5: Make the decision
• Step 6: Implement the decision
• Does the resultant situation resolve the earlier PLUS considerations?
• Are there any new PLUS considerations to be addressed?

The PLUS filters do not guarantee an ethically-sound decision. They merely ensure that the ethics components of the situation will be surfaced so that they might be considered.

How Organizations Can Support Ethical Decision-Making  Organizations empower employees with the knowledge and tools they need to make ethical decisions by

• Intentionally and regularly communicating to all employees:
• Organizational policies and procedures as they apply to the common workplace ethics issues.
• Applicable laws and regulations.
• Agreed-upon set of “universal” values (i.e., Empathy, Patience, Integrity, Courage [EPIC]).
• Providing a formal mechanism (i.e., a code and a helpline, giving employees access to a definitive interpretation of the policies, laws and universal values when they need additional guidance before making a decision).
• Free Ethics & Compliance Toolkit
• Ethics and Compliance Glossary
• Definitions of Values
• Why Have a Code of Conduct?
• Code Construction and Content
• Common Code Provisions
• Ten Style Tips for Writing an Effective Code of Conduct
• Five Keys to Reducing Ethics and Compliance Risk
• Business Ethics & Compliance Timeline

A Framework for Ethical Decision Making

• Markkula Center for Applied Ethics
• Ethics Resources

This document is designed as an introduction to thinking ethically. Read more about what the framework can (and cannot) do .  

We all have an image of our better selves—of how we are when we act ethically or are “at our best.” We probably also have an image of what an ethical community, an ethical business, an ethical government, or an ethical society should be. Ethics really has to do with all these levels—acting ethically as individuals, creating ethical organizations and governments, and making our society as a whole more ethical in the way it treats everyone.

What is Ethics?

Ethics refers to standards and practices that tell us how human beings ought to act in the many situations in which they find themselves—as friends, parents, children, citizens, businesspeople, professionals, and so on. Ethics is also concerned with our character. It requires knowledge, skills, and habits. 

It is helpful to identify what ethics is NOT:

• Ethics is not the same as feelings . Feelings do provide important information for our ethical choices. However, while some people have highly developed habits that make them feel bad when they do something wrong, others feel good even though they are doing something wrong. And, often, our feelings will tell us that it is uncomfortable to do the right thing if it is difficult.
• Ethics is not the same as religion . Many people are not religious but act ethically, and some religious people act unethically. Religious traditions can, however, develop and advocate for high ethical standards, such as the Golden Rule.
• Ethics is not the same thing as following the law. A good system of law does incorporate many ethical standards, but law can deviate from what is ethical. Law can become ethically corrupt—a function of power alone and designed to serve the interests of narrow groups. Law may also have a difficult time designing or enforcing standards in some important areas and may be slow to address new problems.
• Ethics is not the same as following culturally accepted norms . Cultures can include both ethical and unethical customs, expectations, and behaviors. While assessing norms, it is important to recognize how one’s ethical views can be limited by one’s own cultural perspective or background, alongside being culturally sensitive to others.
• Ethics is not science . Social and natural science can provide important data to help us make better and more informed ethical choices. But science alone does not tell us what we ought to do. Some things may be scientifically or technologically possible and yet unethical to develop and deploy.

Six Ethical Lenses

If our ethical decision-making is not solely based on feelings, religion, law, accepted social practice, or science, then on what basis can we decide between right and wrong, good and bad? Many philosophers, ethicists, and theologians have helped us answer this critical question. They have suggested a variety of different lenses that help us perceive ethical dimensions. Here are six of them:

The Rights Lens

Some suggest that the ethical action is the one that best protects and respects the moral rights of those affected. This approach starts from the belief that humans have a dignity based on their human nature per se or on their ability to choose freely what they do with their lives. On the basis of such dignity, they have a right to be treated as ends in themselves and not merely as means to other ends. The list of moral rights—including the rights to make one's own choices about what kind of life to lead, to be told the truth, not to be injured, to a degree of privacy, and so on—is widely debated; some argue that non-humans have rights, too. Rights are also often understood as implying duties—in particular, the duty to respect others' rights and dignity.

( For further elaboration on the rights lens, please see our essay, “Rights.” )

The Justice Lens

Justice is the idea that each person should be given their due, and what people are due is often interpreted as fair or equal treatment. Equal treatment implies that people should be treated as equals   according to some defensible standard such as merit or need, but not necessarily that everyone should be treated in the exact same way in every respect. There are different types of justice that address what people are due in various contexts. These include social justice (structuring the basic institutions of society), distributive justice (distributing benefits and burdens), corrective justice (repairing past injustices), retributive justice (determining how to appropriately punish wrongdoers), and restorative or transformational justice (restoring relationships or transforming social structures as an alternative to criminal punishment).

( For further elaboration on the justice lens, please see our essay, “Justice and Fairness.” )

The Utilitarian Lens

Some ethicists begin by asking, “How will this action impact everyone affected?”—emphasizing the consequences of our actions. Utilitarianism, a results-based approach, says that the ethical action is the one that produces the greatest balance of good over harm for as many stakeholders as possible. It requires an accurate determination of the likelihood of a particular result and its impact. For example, the ethical corporate action, then, is the one that produces the greatest good and does the least harm for all who are affected—customers, employees, shareholders, the community, and the environment. Cost/benefit analysis is another consequentialist approach.

( For further elaboration on the utilitarian lens, please see our essay, “Calculating Consequences.” )

The Common Good Lens

According to the common good approach, life in community is a good in itself and our actions should contribute to that life. This approach suggests that the interlocking relationships of society are the basis of ethical reasoning and that respect and compassion for all others—especially the vulnerable—are requirements of such reasoning. This approach also calls attention to the common conditions that are important to the welfare of everyone—such as clean air and water, a system of laws, effective police and fire departments, health care, a public educational system, or even public recreational areas. Unlike the utilitarian lens, which sums up and aggregates goods for every individual, the common good lens highlights mutual concern for the shared interests of all members of a community.

( For further elaboration on the common good lens, please see our essay, “The Common Good.” )

The Virtue Lens

A very ancient approach to ethics argues that ethical actions ought to be consistent with certain ideal virtues that provide for the full development of our humanity. These virtues are dispositions and habits that enable us to act according to the highest potential of our character and on behalf of values like truth and beauty. Honesty, courage, compassion, generosity, tolerance, love, fidelity, integrity, fairness, self-control, and prudence are all examples of virtues. Virtue ethics asks of any action, “What kind of person will I become if I do this?” or “Is this action consistent with my acting at my best?”

( For further elaboration on the virtue lens, please see our essay, “Ethics and Virtue.” )

The Care Ethics Lens

Care ethics is rooted in relationships and in the need to listen and respond to individuals in their specific circumstances, rather than merely following rules or calculating utility. It privileges the flourishing of embodied individuals in their relationships and values interdependence, not just independence. It relies on empathy to gain a deep appreciation of the interest, feelings, and viewpoints of each stakeholder, employing care, kindness, compassion, generosity, and a concern for others to resolve ethical conflicts. Care ethics holds that options for resolution must account for the relationships, concerns, and feelings of all stakeholders. Focusing on connecting intimate interpersonal duties to societal duties, an ethics of care might counsel, for example, a more holistic approach to public health policy that considers food security, transportation access, fair wages, housing support, and environmental protection alongside physical health.

( For further elaboration on the care ethics lens, please see our essay, “Care Ethics.” )

Using the Lenses

Each of the lenses introduced above helps us determine what standards of behavior and character traits can be considered right and good. There are still problems to be solved, however.

The first problem is that we may not agree on the content of some of these specific lenses. For example, we may not all agree on the same set of human and civil rights. We may not agree on what constitutes the common good. We may not even agree on what is a good and what is a harm.

The second problem is that the different lenses may lead to different answers to the question “What is ethical?” Nonetheless, each one gives us important insights in the process of deciding what is ethical in a particular circumstance.

Making Decisions

Making good ethical decisions requires a trained sensitivity to ethical issues and a practiced method for exploring the ethical aspects of a decision and weighing the considerations that should impact our choice of a course of action. Having a method for ethical decision-making is essential. When practiced regularly, the method becomes so familiar that we work through it automatically without consulting the specific steps.

The more novel and difficult the ethical choice we face, the more we need to rely on discussion and dialogue with others about the dilemma. Only by careful exploration of the problem, aided by the insights and different perspectives of others, can we make good ethical choices in such situations.

The following framework for ethical decision-making is intended to serve as a practical tool for exploring ethical dilemmas and identifying ethical courses of action.

Identify the Ethical Issues

• Could this decision or situation be damaging to someone or to some group, or unevenly beneficial to people? Does this decision involve a choice between a good and bad alternative, or perhaps between two “goods” or between two “bads”?
• Is this issue about more than solely what is legal or what is most efficient? If so, how?

Get the Facts

• What are the relevant facts of the case? What facts are not known? Can I learn more about the situation? Do I know enough to make a decision?
• What individuals and groups have an important stake in the outcome? Are the concerns of some of those individuals or groups more important? Why?
• What are the options for acting? Have all the relevant persons and groups been consulted? Have I identified creative options?

Evaluate Alternative Actions

• Evaluate the options by asking the following questions:
• Which option best respects the rights of all who have a stake? (The Rights Lens)
• Which option treats people fairly, giving them each what they are due? (The Justice Lens)
• Which option will produce the most good and do the least harm for as many stakeholders as possible? (The Utilitarian Lens)
• Which option best serves the community as a whole, not just some members? (The Common Good Lens)
• Which option leads me to act as the sort of person I want to be? (The Virtue Lens)
• Which option appropriately takes into account the relationships, concerns, and feelings of all stakeholders? (The Care Ethics Lens)

Choose an Option for Action and Test It

• After an evaluation using all of these lenses, which option best addresses the situation?
• If I told someone I respect (or a public audience) which option I have chosen, what would they say?
• How can my decision be implemented with the greatest care and attention to the concerns of all stakeholders?

Implement Your Decision and Reflect on the Outcome

• How did my decision turn out, and what have I learned from this specific situation? What (if any) follow-up actions should I take?

This framework for thinking ethically is the product of dialogue and debate at the Markkula Center for Applied Ethics at Santa Clara University. Primary contributors include Manuel Velasquez, Dennis Moberg, Michael J. Meyer, Thomas Shanks, Margaret R. McLean, David DeCosse, Claire André, Kirk O. Hanson, Irina Raicu, and Jonathan Kwan.  It was last revised on November 5, 2021.

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Embodied Ethical Decision-Making: A Clinical Case Study of Respect for Culturally Based Meaning Making in Mental Healthcare

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• Volume 43 , pages 36–63, ( 2021 )

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How does embodied ethical decision-making influence treatment in a clinical setting when cultural differences conflict? Ethical decision-making is usually a disembodied and rationalized procedure based on ethical codes (American Counseling Association, 2014; American Dance Therapy Association, 2015; American Mental Health Counseling Association, 2015) and a collective understanding of right and wrong. However, these codes and collective styles of meaning making were shaped mostly by White theorists and clinicians. These mono-cultural lenses lead to ineffective mental health treatment for persons of color. Hervey’s (2007) EEDM steps encourage therapists to return to their bodies when navigating ethical dilemmas as it is an impetus for bridging cultural differences in healthcare. Hervey’s (2007) nonverbal approach to Welfel’s (2001) ethical decision steps was explored in a unique case that involved the ethical decision-making process of an African-American dance/movement therapy intern, while providing treatment in a westernized hospital setting to a spiritual Mexican–American patient diagnosed with PTSD and generalized anxiety disorder. This patient had formed a relationship with a spirit attached to his body that he could see, feel, and talk to, but refused to share this experience with his White identifying psychiatric nurse due to different cultural beliefs. Information gathered throughout the clinical case study by way of chronological loose and semi-structured journaling, uncovered an ethical dilemma of respect for culturally based meanings in treatment and how we identify pathology in hospital settings. The application of the EEDM steps in this article is focused on race/ethnicity and spiritual associations during mental health treatment at an outpatient hospital setting. Readers are encouraged to explore ways in which this article can influence them to apply EEDM in other forms of cultural considerations (i.e. age) and mental health facilities. The discussion section of this thesis includes a proposed model for progressing towards active multicultural diversity in mental healthcare settings by way of the three M’s from the relational-cultural theory: movement towards mutuality, mutual empathy, and mutual empowerment (Hartling & Miller, 2004).

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Embodied ethical decision-making (EEDM) can effectively influence treatment in a clinical setting when cultural differences conflict. Professional ethics are the standards of care and rules that govern the expectations for professionals, protect patients from harm, and guide ethical decision-making when faced with an ethical dilemma (Welfel, 2016 ). The two determinants of ethical decision-making are biological make-up and cultural norms (Ayala, 2010 ). Biological make-up includes our capacity to 1. Anticipate consequences of actions taken; 2. Make valuable judgments; and 3. Possess the ability to choose between courses of action (Ayala, 2010 ). Cultural norms are learned standards based on our shared experiences with family, friends, school systems, and other social environments (Sieck, 2019 ). Typically cultural norms of dominant cultures and are used to assist therapists with decision-making when faced with ethical dilemmas (Laws & Chilton, 2013 ).

Ethical decision-making is usually a disembodied and rationalized procedure based on ethical codes and a collective understanding of right and wrong. Trahan and Lemberger ( 2014 ) recognized that professional ethics codes are incomplete when considering underrepresented populations. Many studies have provided examples that point to insufficient measures taken in academic settings to address cultural competency, therefore producing counselors, psychologists, doctors, and nurses who are inadequately culturally sensitive and ignore cultural complexities (Alqahtani & Altamimi, 2015 ; Carmichael, 2012 ; Harris, 2016 ; Hebenstreit, 2017 ; Laws & Chilton, 2013 ; McEldowney & Connor, 2011 ; Dominguez, 2017; Wadley, 2016 ). The underlying somatic and intuitive constructs of our cultural norms, morals, and values are what guide our ethical decisions (Robson, Cook, Hunt & Alred, 2000 ). Hervey ( 2007 ) positioned that we can enhance the ethical decision making process by shifting from a rule-based approach to an embodied approach to address dilemmas in a more effective manner.

The purpose of this clinical case study was to explore how Hervey’s ( 2007 ) EEDM steps influenced ethical decision-making when cultural differences conflicted during treatment for a spiritual Mexican–American patient. My intersectional identities as an African-American, non-heterosexual woman have inspired my ambition towards creating change within healthcare systems. Healthcare systems have a long history of creating unsafe environments for people with diverse cultural identities; consequently the construct of cultural safety was established in the 1980′s in an effort to protect people of color from these harmful practices (McEldowney & Connor, 2011 ).

Embodied Ethical Decision-Making

As movers and body-based practitioners, it is difficult to ignore the intelligence held within the body. To explore knowledge surfacing from the body during an ethical dilemma grants vital data and, “using the body as a teacher puts the mover in charge of the process” (Goldman, 2004 , p. 131). It further allows us to use our body for inter-affectivity and empathetic understanding (Schmidsberger & Loffler-Stastka, 2018 ), thereby experiencing and sensing the perspectives of other individuals. Hervey outlined Welfel’s ( 2001 ) nine ethical decision-making steps and paired them with corresponding embodiment suggestions collected from roughly 80 dance/movement therapists and student participants (Table 1 ). These participants attended Hervey’s EEDM workshops, and from there, she analyzed the records of their movement responses and rationales to hypothesized ethical dilemmas (Hervey, 2007 ). I included these movement suggestions from the participants for each step in this article to provide readers with movement stimulating recommendations that may be helpful while engaging in the ethical steps as they were for me. At the time of Hervey’s ( 2007 ) article, Welfel ( 2001 ) identified nine ethical decision-making steps to thoroughly guide counselors in the process of making ethical decisions. In 2012, Welfel added an extra step that includes clarifying socio-cultural contexts of the dilemma. However, since this article is embedded with cultural context, I encourage readers to consider socio-cultural contexts for their patient, the situation, and themselves throughout the entire ethical decision-making process, and how one’s cultural lens can further deepen the movement suggestions presented by Hervey ( 2007 ).

Clinical Case

The case where the ethical dilemma arose involved a Mexican–American male patient, Juan. (Juan is a pseudonym used to protect this patient’s privacy.) Juan hesitantly disclosed having a spirit attached to his right shoulder that he could regularly see, feel, and talk to. Juan was being treated in an urban outpatient hospital facility for generalized anxiety disorder and post-traumatic stress disorder (PTSD), which involved individual therapy and medication management. Neighboring communities that the hospital served were made up of majority Latino and African American identifying populations. As reported by the Chicago Community Trust ( 2018 ), social and economic resources are historically and unjustly distributed in this area, and have resulted in health inequities that nearly three times the well-being concerns of the U.S. on average.

Juan mentioned in the beginning of our work together that he did not trust hospital systems, specifically, employees who identified as White. Therefore, the patient did not disclose important information regarding his mental health to the hospital and me, as his therapist. I reflected on my own mistrust of the medical system and assured Juan that his apprehension was valid and accepted in our therapeutic space. We met once a week for two months to assist Juan with developing coping skills to manage his anxiety and to support his recovery from traumatic experiences. Our sessions included movement experientials that drew from Laban Movement Analysis (LMA) techniques, improvisational movement, and mindfulness-based activities, and were supplemented with verbal processing. Many of our sessions involved evocative verbal exploration into Juan’s interpretation of his life experiences; this helped to strengthen our therapeutic relationship and build trust. During our seventh individual session, one of his deepest secrets was revealed. He stared me in the eyes and stated, “I have a spirit attached to my right shoulder. I can see him and feel him. He’s talking to you. Can you hear him?” I was thunderstruck and became curious about his unexpected disclosure. The spirit had attached to Juan two months prior after he prayed to his God for companionship and guidance. What started out as a positive human-spirit friendship turned into daily negative comments from the spirit, which led the patient to share his experience with me, but not without hesitation.

Juan communicated that he would not return to treatment if the divulgence of his private information had to be revealed as he had his own codes that he lived by. Identified as street codes, or rules regulating interpersonal public behavior (Anderson, 1994 ), these rules evolved from street culture as an adaptation to the lack of faith and trust in America’s oppressive systems. Street codes recognize that toughness is a virtue and that vulnerability equaled death; thus, privacy is a necessary survival skill amongst cultures that are dependent upon street living (Anderson, 1994 ). Additionally, Juan closely identified with being spiritually gifted since childhood. He talked about seeing people’s auras (even mine) and sightings of spiritual entities throughout his upbringing and adulthood. This was the first time Juan had confided in anyone, aside from his mother, about seeing spirits.

Culture Interfaces in Ethical Decision Making

Spirituality, religion, and culture have been omitted from psychology for many decades. Current mental health models are built upon, and view patients through, a mono-cultural lens (Dominguez, 2017) and this miscommunication results in increased and worsened health disparities for populations who identify as non-White. Ethical decisions become harmful when they disempower the cultural identity of a patient and insensitively discount individual and cultural views of treatment (McEldowney & Connor, 2011 ). Although my dance/movement therapy program often brought awareness to culture, I still did not feel prepared or adequately trained to know what to do with Juan’s disclosure.

While the support and involvement of practitioners who identify as persons of color are insufficient, there are new efforts being made to reduce these deficits in mental health programs (Dominguez, 2017; Walker, Burman & Gowrisunkur, 2002 ). For example, Frame and Williams ( 2005 ) introduced an ethical decision-making model from a multicultural perspective that helps therapists view differently the Eurocentric, one-dimensional, and ruled-based way of approaching ethics. The counseling profession has begun to support the idea of spiritual needs in counseling for patients and has shown an increase in therapy effectiveness, both spiritually and psychologically (Giordano & Cashwell, 2014 ).

Theoretical Orientation

Informed by a humanistic/existential paradigm and a relational-cultural theory (RCT) and positive psychology clinical approach, my spirituality, intersectional identities, and familial experiences motivated me to fully engage in this clinical case study and to advocate for increased multicultural competency amongst healthcare practitioners. From a relational-cultural perspective, our goal when Juan and I worked together was to build our relationship, so as to increase the patient’s sense of safety and trust within the treatment facility and me. My positive psychology approach served to foster the patient’s happiness and well-being in addressing his adverse life experiences. Both approaches led to a strong therapeutic relationship between Juan and me, and helped to increase his ability to open up and share with me his circumstance with the spirit.

Exploration of Ethical Decision-Making with Juan

It was clear that further culturally based ethical decisions needed to be made in order to provide ethical, safe and cultural focused care to Juan. This article identifies and evaluates the EEDM process by working through the case using the embodied ethical steps as outlined by Hervey ( 2007 ). Along with the movement recommendations from Hervey ( 2007 ), I also explored my own movement experiences as I embodied each step in response to my ethical dilemma during the process of writing this article.

Step One: Become Familiar

Given how violently ethical conflicts can be experienced in the body, (Hervey, 2007 ), clinicians are drawn away from their embodied experience and shift towards more cognitive approaches to solve ethical dilemmas. Instead of allowing this mind/body disconnect to happen, dance/movement therapists are able to embrace the body using EEDM steps. Hervey ( 2007 ) reminds readers that true ethics started as a body-based experience of wrong and right, and in order to find appropriate solutions for ethical dilemmas, one must return to the body for guidance. Embodiment permits us to move past the rational thinking brain (prefrontal cortex) and enter the body. This allows us to develop ethical sensitivity and recognize that there is an ethical dilemma in existence (Hervey, 2007 ). Step one involves attending to our body’s experience (Csrodas, 1993) by being present and engaged with its perceptual experience. This takes place in the form of movement.

Analytic and somatic movements are two avenues to consider when analyzing bodily movements (Moore, 2014 ). Moore ( 2014 ) introduces analytics as the observation of body movement from an external perspective and somatics as the first-person perspective of internal movement. Csordas ( 1993 ) adds that the somatic dimension of movement not only includes attending to one’s internal bodily experiences but also involves attending to the bodies of others, called the somatic modes of attention. Humans are gifted with the ability to interpersonally connect in a way that allows us to feel what others feel when we exercise our use of mirror neurons. Analytic and somatic movement shifts from one’s self and their environment provide evidence that deepens the collection of information and tell us when we have an ethical dilemma on our hands. Again, in this first step of EEDM, it is suggested to postpone any type of action, only to recognize the existence of an ethical dilemma in order to prevent premature and inappropriate action (Hervey, 2007 ). Instead, Hervey ( 2007 ) positions that “vertical containment” of just attending to the body signals and exploring movement in the horizontal plane is ideal for the initial development of an ethical dilemma.

Embodiment of Step One

In the initial stage of the ethical dilemma presented in this article, my movements became accelerated in the sagittal plane, specifically in my upper limbs, torso, and core. There was a sense of urgency I felt to confide in someone about Juan’s release of private information regarding the spirit attached to his shoulder. I was fascinated by my in-session encounter and wrote in my journals about feelings of excitement and tingling surges running through my body. I also recorded my impression of shaky sensations in my arms, knots in my throat and core, and decreasing pressure in my lower body. Tortora ( 2006 ) explains that weight assumes the physical intention of executing an action; the decreasing pressure I experienced in my legs indicated how careful I was to move forward in the dilemma. The vibratory action in my arms implied feelings of anxiousness, and the knots in my throat and core signified some sort of blockage. In my journal I reported feeling a sense of imprisonment; my body felt the restraint of navigating such a cultural dilemma in a hospital setting embedded with Eurocentric forms of healthcare. Though I was excited to learn more about Juan’s experience with the spirit, my movement observations for my core, arms, and legs suggested and confirmed a hesitancy to approach and navigate the disclosure about the spirit. I was motivated and empowered to advocate for him, but I also felt sad and angered by my thoughts of foreseeable outcomes that would be adverse to our therapeutic relationship. Given the cultural context of the dilemma and its tendency to be overlooked in westernized hospital settings, my thoughts held weight. I avoided making any decisions to address Juan’s case, except to obtain support in supervision.

Step Two: Define the Dilemma

After identifying that an ethical dilemma exists, we are encouraged to define the dilemma and identify potential problem solving opportunities. For this case, the ethical dilemma was respect for culturally based meanings in treatment and how mental health clinicians identify pathology. Juan believed his seeing the spirit was a gift given to him by God; he refused to accept any diagnosis that labeled it otherwise. What Juan described as a spiritual experience is usually understood as a form of psychosis in hospital systems that rely on symptom identification and diagnosis for the treatment of symptoms. Despite encouragement from me, he opposed the idea of talking to his psychiatric nurse about his spiritual experience. I felt stalled between my own spiritual and cultural awareness, Juan’s spirituality, his safety, and having to uphold the policies and procedures of the hospital where I was interning. I understood Juan’s story as a spiritual person, as a clinician, and as a Black woman from the inner city of Chicago; but I wondered if I resonated with his story all too well because we shared the people of color in the American healthcare system narrative. I wanted to make sure he felt heard and included in his treatment. On the other hand, I wanted to avoid compromising his safety in an effort to advocate for him and for increasing cultural awareness at my site. This case with Juan was a culturally embedded ethical dilemma that required my full participation with the embodied ethical steps.

Embodiment of Step Two

My body and my mind felt uneasy about making a decision; there was a fight between my cultural background and my emergence as a clinician. The idea of both weighed heavy on my shoulders and drained my energy. My upper torso gradually sank downward along the vertical dimension and my entire body wanted to enclose itself and curl like a ball. I encountered feelings of isolation as one of few Black clinicians at my internship site as well as in the academic program at my college. I felt lonely in my ethical dilemma. There are very few articles that talk about a Black clinician’s experience of loneliness during a culturally situated ethical dilemma. Smith ( 2012 ), communicated in her thesis about a similar struggle she felt during an ethical dilemma when battling between holding on to her cultural identity as an African American woman versus choosing an identity as a clinician and abiding by ethical codes. I thought with frustration: Why does there have to be a choice? Why cannot my cultural background and my developing identity as a clinician co-exist? Hervey ( 2007 ) acknowledged the need to cope with one’s bodily felt experiences when managing complex cases. She concluded that dance/movement therapist found value in moving out the dilemma with full embodiment to support determining the next direction to take. In my attempt to release my body from the enclosed ball and fully embody the dilemma, I encountered hesitation and emotional discomfort. I felt my anger and frustration expand with my movement in the form of increased pressure and restricted affect. My body was reluctant to engage in an emotionally overwhelming, cultural dilemma, but there was a sense of freedom in knowing that I was not giving up.

Step two further required the embodiment of my patient as well as my supervisors and the treatment team to provide an empathic approach to decision-making and deciding the best course of action. In her workshops, Hervey ( 2007 ) noted that in this step participants commonly collaborated with one another using creative movement to unlock alternatives to ethical dilemmas. I recall deliberating about the advice of my supervisors, unsure if they realized the substance of my patient’s fear and request for confidentiality given that they did not identify as people of color. For them, it appeared simple: make sure he’s not homicidal or suicidal and inform the nurse practitioner. Juan denied suicidal (SI) and homicidal ideation (HI). But again, one of my supervisors informed me that regardless of his denial of SI and HI, it was imperative that I report his spiritual experience to his nurse due to the fact that she prescribed him medication and that operating as a team in our department was a requirement.

Embodying Juan, my supervisors, and others who played part in the dilemma, such as the psychiatric nurse, helped to increase my understanding of their positioning in the case. My movement consisted of taking on each person’s postures and gestures, and verbalizing notable statements from our encounters. My kinesthetic empathy allowed me to view the case from their perspective. I felt each person’s concern for safety: safety for the patient, the hospital, the college, and each person involved in the dilemma, including myself. To consider safety for everyone and everything taking part in the ethical dilemma, it required diverse methods of examination, risk management, and knowledge. My movement responded with openness to the varying perspectives of stakeholders.

Identifying the Options

Lastly in step two, Hervey found it helpful to encourage participants to imagine the most ludicrous option and move it (Hervey, 2007 , p. 103). In this way, options disregarded due to fear and being premeditated as unethical decisions become spontaneous possibilities to solving one’s ethical dilemma (Hervey, 2007 ). Identifying options will help counselors focus their energy during complex ethical dilemmas. In Table 2 , I present options considered for Juan’s case. Ultimately, I wanted to avoid causing harm to him and his beliefs by providing space for autonomy and cultural advocacy. Conversely, I was thoughtful about improperly treating a patient who may in fact benefit from receiving a diagnosis in alignment with his symptoms.

Step Three and Four: Search, Evaluate, and Determine

Hervey ( 2007 ) joins steps three and four of Welfel’s ( 2001 ) ethical decision-making model into one complete phase to evaluate options and to determine the best solution. It requires dance/movement therapists to utilize professional literature, ethical codes and regulations, and agency policies to provide structure for later deliberating processes (Hervey, 2007 ). Referencing codes, regulations and policies, as implied by Constable, Kreider, Smith & Taylor (2011), helps novice therapists navigate the uncertainties associated with ethical decision-making. Even for experienced counselors, this step remains a priority for continued growth and development and enhanced ethical judgment (Oramas, 2017 ). Ethical standards are designed to protect professionals and patients; yet, these standards usually result in more reactive than proactive ethical decision-making (Trahan & Lemberger, 2014 ). So in addition, seeking guidance from ethics scholarship enables counselors to vicariously learn by trial and error from practiced professionals. Aside from providing clarity, focus, and structure, this step also increases confidence through skill building and acquisition of ethical knowledge, and further limits risky decision-making. Once all relevant information has been obtained regarding options identified in step two, dance/movement therapists are to move out those possibilities. It is essential to utilize this step as an explorative measure with movement to create more available options than to rely on rules to quickly resolve the dilemma (Hervey, 2007 ).

Codes and Scholarship

The ethical dilemma of respect for culturally based meanings in treatment and how mental health clinicians identify pathology is related to the American Dance Therapy Association’s (ADTA, 2015) ethical standard of display of integrity within the therapeutic relationship. It states, “Dance/movement therapists encourage the patient’s voice in treatment and respect the patient’s right to make decisions based on personal values” (ADTA, 2015 , p. 3). The ADTA ( 2015 ) Code of Ethics additionally encourages dance/movement therapists to continuously reexamine their own biases and worldviews to avoid imposing them onto patients, and to consider the impact of oppressive systems on individual patient experiences. According to these ethical codes, Juan had every right to name his spiritual experience as he saw most fitting with his beliefs. Providing space for Juan to do that directly aligned with my obligations as an intern dance/movement therapist. However, the hospital did not ascribe to these standards. Though Juan experienced a sense of safety in my office space, we were a part of a larger operating system that he relied on for treatment.

The American Counseling Association’s (ACA, 2014 ) ethical code Avoiding Harm and Imposing Values states that counselors work to avoid harm and minimize potential harm to patients. I perceived there could be potential harm in revealing Juan’s undisclosed information to the treatment team. Counselors are trusted with the safety of each patient as they enter our therapeutic spaces, and as humans who have accepted the responsibilities of a counselor as a life calling, we feel competent enough to complete this task. Avoiding harm requires more than providing evidence-based interventions, private and clean spaces for therapy, judgment-free zones, and upholding ethical standards. It requires constant self-awareness and reflection, and honoring cultural differences.

The ADTA ( 2015 ) Codes of Ethics are informed by and parallel the ACA ( 2014 ) Code of Ethics. It is acknowledged that the ACA Code of Ethics was constructed and shaped by an individualistic, Western society (Birrell & Bruns, 2016 ) and remains firmly established in a modern society that accordingly places emphasis on rules, independence, and power-over rather than relational engagement and power-with patients in treatment. Ergo, complex situations in treatment settings become central when persons in power are compelled to make ethical decisions regarding the well-being of a patient, even when cultural beliefs conflict (Laws & Chilton, 2013 ). The patient in this case had a different cultural meaning of issues regarding his psyche than that of the hospital setting where he received treatment.

The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA) is a manual of classified mental disorders that serves as a guide for interventions and treatment recommendations. In the DSM-5 (APA, 2013 ), a practical diagnosis for Juan’s case would fall under schizophrenia spectrum and psychotic disorders given his presentation of what the mental health field considers visual, auditory, and somatic hallucinations. Overtime, the DSM-5 has integrated cultural factors into disorders in the form of V-codes, described as supplementary conditions influencing a disorder. V-code 62.89, “Religious or Spiritual Problem”, accounts for loss or questioning of religion or spirituality (APA, 2013 , p. 725), however, this code does not encompass religious or spiritual factors as it pertains to this case. The option of diagnosing Juan carried the risk of deterring him from seeking therapy and decreasing his overall well-being. A diagnosis would suggest that his cultural interpretation of his spiritual experience was either false or meaningless. Timimi ( 2014 ) and Allmon ( 2013 ) are clear that these types of interpretations of culturally based beliefs disempower the patient and could increase negative symptoms.

The second professional value listed in the ACA’s ( 2014 ) code of ethics honors and supports, “the worth, dignity, potential, and uniqueness of people within their social and cultural contexts” (p. 3). Since values are the cornerstone of which ethical decisions are carried out, counselors are to refrain from submitting a diagnosis if they know that it will cause harm to the patient in some way (ACA, 2014 ). It is rational to consider how the stigmatization of an oppressive label from the western culture will cause individual, cultural, and societal adverse consequences for some patients (Ratts & Hutchins, 2009 ).

Social consequences for the patient must be taken into consideration when making ethical decisions (Zheng, Gray, Zhu & Jiang, 2014). Usually in the decision-making process, the counselor identifies the ethical dilemma, takes the necessary steps to problem-solve outside of the therapy room, and decides on a resolution to the dilemma absent the patient’s voice (Birrell & Bruns, 2016 ). Yet, the ACA’s ( 2014 ) code of ethics states that counselors work collaboratively with patients to promote growth and development during an ethical decision-making process. Shared decision-making (SDM) is a model that was first developed in the 1980′s to improve the experience of patients in treatment settings by encouraging a collaborative process between the patient and health professional (Bradley & Green, 2018 ). This comes with controversy regarding the risks of granting access to a patient, which allows them to collaborate with doctors regarding their treatment, given their level of competency of medical knowledge may be limited (Christine & Kaldjian, 2013 ; Herlitz, Munthe, Torner & Forsander, 2016). The same is true to consider when patients are invited to autonomously collaborate in counseling settings.

Embodiment of Steps Three and Four

As I embodied the Effort weight, for this ethical dilemma, I found strong feelings surfacing about my cultural identity and the desire to advocate for marginalized groups. There was increasing pressure in my upper body and I associated this with the idea of fighting oppressive systems at my site, as well as healthcare systems in general. I let that increasing pressure sink downward into my lower body and invited decreasing pressure to my upper body. The anger and frustration of having to engage with such a system did not disappear, however, awareness of my embodied experience encouraged me to take a gentler approach to ethical decision-making.

I had a lot mixed feelings that were reflected in my movement while searching the ethics codes and gathering information. I felt confused and surrounded by information as I turned in circles reaching and pulling. The information seemed full of loose ends and, to a great extent, required interpretation. There was increased tension in my shoulders, and I eventually distanced myself from the imaginary visual of the ethics codes and scholarship. I entered into a remote state of increased bound flow and directing as I gazed at the information from a far. I began to move in my preferred style of popping and locking while visualizing the information regarding the clinical case. I was able to bring in my culture when understanding and interpreting the codes. Although complete clarity of the codes was not realized, I experienced increased confidence and intention for working through the dilemma with this new knowledge.

Step Five: Ethical Principles

Step five requires reference to the five ethical principles identified by Kitchener ( 1984 ). They are: autonomy, nonmaleficence, beneficence, justice, and fidelity, along with the added principle: veracity. Ethics involves cultural norms, personal morals, and values during the decision-making process, and these will serve counselors in the self-exploration process of relating to the guiding principles (Evans et al., 2012 ). Ethical principles were conceptualized to provide a foundation of morals to help interpret ethical codes and adjust routine responses to unconventional ethical dilemmas (Chmielewski, 2004 ).

Each ethical principle has been layed out with common movement qualities that were found by dance/movement therapists when they moved out the principles separately (Table 1 ; Hervey, 2007 ). A key part of step five is to be attentive to any embodied responses that are experienced while moving each principle. Principles have the potential to draw out essential details to help us strengthen our understanding of the dilemma and where the conflict is coming from, externally, and internally within ourselves in the form of values (Miller & Davis, 2016 ).

Another key factor is to acknowledge that these principles were created as a guide to culture-specific standards of behavior, and that ethical principles will be prioritized differently within varying cultures (Gauthier, Pettifor, & Ferrero, 2010 ). The new age invites new rules of behaviors, and these rules are changing rapidly (Hoose, 1986 ). It is important to be aware of the cultural body’s response to each principle and how it shapes our experience with them.

Autonomy describes mutual respect in a relationship, where both individuals honor one another’s ability to make autonomous decisions (Kitchener, 1984 ). During complex ethical dilemmas, counselors may feel an urgency to act on impulses, yet feel the tension of respecting the autonomy of the patients, others involved, and that of themselves (Hervey, 2007 ). Indeed, the act of yielding and pushing through movement, which can be realized in dance/movement therapy, informs our boundaries and asserts greater independence (Schwartz, 2018 ).

There was constant pushing in my movement to create boundaries while embodying autonomy. I used my arms to separate and push back on the healthcare system to provide space for Juan and myself. It felt like I was taking on the role of advocate: working to gain autonomy for two people of color in a Eurocentric hospital setting. While moving I wondered how much autonomy could I actually encourage Juan to have given his presentation of symptoms and possible limitations of mental health information. Juan had previously omitted important details regarding his symptoms because he did not feel safe. I cautioned myself against allowing too much space as I thought about what other information might be unknown about him. As I moved and created space for myself, I realized I needed separation from both Juan and my internship site to be free in my own autonomy. In a cultural sense, autonomy for me meant expressing and standing strong with my own beliefs. I had responsibilities as an intern clinician to uphold the policies at the hospital, policies that I understood to be Eurocentric cultural norms and did not fully agree with. However, as a novice clinician, how much autonomy could I possess given my own limitation concerning the knowledge of policies and procedures regarding the clinical case? I engaged in a back and forth movement, suggesting the tug between inviting space for autonomy and enclosing space where autonomy may have been less beneficial to resolving the dilemma.

Nonmaleficence

Nonmaleficence means not causing harm to patients, including intentional actions to harm or carrying out risky actions that have the potential to harm them (Kitchener, 1984 ). This ethical principle corresponded with careful, cautious, and tentative movement responses (Hervey, 2007 ).

I attuned to my visceral experience of decreasing pressure and binding flow, as suggested by Hervey ( 2007 ), as I moved carefully. There were multiple pieces to consider to avoid harm. I wanted to culturally empower Juan and I wanted to keep him safe; however, safety could have looked like many things from the different perspectives of everyone involved in the dilemma. Safety could look like Juan feeling empowered and gaining trust in the healthcare system because he felt heard and believed by his treatment team. Safety could look like diagnosing Juan and giving him medication from the nurse’s perspective. Safety could look like informing Juan’s treatment team and engaging in ongoing investigation of his symptoms from my supervisors’ perspective. Safety could also look like keeping the information to myself and linking Juan to spiritual healers in nearby communities. I engaged in movements that looked like dipping and dodging as I moved, carefully considering all of these pieces that surfaced. I further examined my own safety in relationship to nonmaleficence. A decision to inform Juan’s treatment team would potentially cause harm to my cultural identity; I would feel like I betrayed my values and my community by going against street codes and abiding by rules of a mistrusted healthcare system. On the other hand, a decision to not inform the treatment team would leave me feeling disconnected as a team member at the hospital and also feeling like I am not doing my job correctly as a clinician; both would cause harm to my professional identity.

Beneficence

Beneficence is the act of reducing human suffering by supporting the welfare of others and enhancing their sense of empowerment (Jennings et al, 2005 ). This was a principle that I found myself sitting on during the time of my ethical dilemma. There is a two-sided impression of what doing good actually looks like; it could be the literal act of taking action to do good, or it could involve being good in a time of complexity and chaos (Hervey, 2007 ). Naturally I wanted to advocate for Juan by taking action, and I deemed it necessary for a culturally embedded case. Robson et al., ( 2000 ) argues that beneficence carries the obligation for counselors to seek substantial knowledge and perform in the best interest of the patient’s welfare. On the other hand, I felt that beneficence was just being good for my patient by offering a therapeutic space where his cultural interpretation of his experience was true, regardless whether the site was willing to change its process of labeling pathology. My upper torso instantly advanced forward in the sagittal plane without hesitation, my head shook side to side suggesting the word no, my limbs supported me with increased weight. My body gladly considered no other option but to actively engage in this clinical case by advocating for Juan and other underserved people who could benefit from a change in the healthcare system.

Justice, as an ethical principle, means fairness, treating others as equals, and promoting equality counseling. This ethical principle was most challenging for me to embody. In my body I felt stuck with increased bound flow at thoughts of how inequalities in healthcare systems continue to persist. In my exploration of balancing movements for justice, my body maintained its bound flow in every part except my arms. My bound flow was accompanied by rage and sadness. I attempted to take on the posture of the scales of justice with my hands held outward to the side; they felt empty and light. I brought my hands in front of me, side-by-side, and gazed at the emptiness for a moment. The ethical codes themselves require revamping to address the inequalities that exist within them (Kitchener, 1984 ; Robson, et al., 2000 ; Trahan & Lemberger, 2013). ‘It started to become clear that Juan’s case was a step forward in advocating for others like him who want and deserve fair and culturally sensitive treatment. This clinical case study was a component of seeking justice in itself.

Fidelity is an act of faithfulness; it is about remaining loyal and keeping promises to patients (Kitchener, 1986). This was another challenging principle to embody. The moment a counseling relationship is established, there is an obligation on the part of the therapist to honor commitments and promises, and to fulfill the responsibility of trust and accountability (Wade, 2015 ). While some dance/movement therapists affiliated fidelity with commitment, honesty, and integrity, others associated it with retaining secrets. I considered how this principle could relate to one of my options: doing nothing and disregarding my patient’s spiritual experience in an effort to protect Juan from harm. During my embodied experience, I felt the sensation of being pulled in different directions with an uncomfortable tingling sensation in my stomach. I was confounded, caught in the middle of both my developed and emerging identities. On one end, I felt a pull from my patient to be with him in our marginalized identities. On another end, I felt pulling from my internship site and the counseling field to be an ethical therapist. Lastly, I saw an image of me pulling myself to just be me and to separate from both. I resorted back to autonomy and engaged in boundary setting movements, realizing that being faithful and honest to myself was my first responsibility.

Healthy disconnections are a key factor in the RCT framework. I refused the idea of becoming enmeshed with either the hospital or my patient during process of navigating the dilemma. I desired a healthy balance of connecting and disconnecting, which meant standing in my own identity while engaging with the clinical case. I reflected back to autonomy while moving this dilemma; fidelity helped me see where multiple truths encountered and overlapped one another. The nurse practitioner’s truth may be helping others in an informed way by assigning diagnostic labels in order to effectively treat multiple patients and prescribe medication. The nurse’s truth overlapped Juan’s truth of seeing his mental concerns as something spiritual, but not having many resources to turn to for support. I understood fidelity as a principle to encourage all involved in the case to be true to themselves and not place rules and labels above being human.

Veracity was added to the most recent addition of the ACA’s ( 2014 ) Code of Ethics and is defined as dealing truthfully with individuals during professional interactions. In my embodiment of veracity, I discovered a vertical stance that turned into spiraling movements of my spine with free flow and lightness. I felt authentic and vulnerable in my movement, and I also felt the willingness to share myself and connect with others involved in the ethical dilemma. True veracity requires authenticity to be effective; vulnerability is a bonus. It goes back to fidelity and being aware of placing rules above respect for human differences. The dilemma in this clinical case rose from a lack of acknowledgement of cultural differences and viewing ethical dilemmas through intellectualized codes instead of the truth within the human body.

Step Six: Consult and Share

When does spirituality become pathology? How do we ethically honor a patient’s cultural meaning of spirituality in a westernized medical system? These were the questions that had surfaced for me in supervision. Interestingly, I had three White identifying supervisors, and I was one of very few Black clinicians in training at my academic setting and the only Black supervisee at my site. There is an established power differential that comes with a supervisee-supervisor relationship which was compounded by Black-White dyads that constituted each of my supervisory relationships. Clinicians of color in training commonly experience their voices being silenced in clinical and academic settings, especially when topics of culture and race need to be addressed (Estrada, 2005 ; Hardy, 2015 ; Hernández, 2003 ; Jernigan, Green, Helms, & Perez-Gualdron, 2016 ). This is likely a consequence of practiced cultural conditioning in Western societies as well as a lack of cultural awareness and training that has persisted throughout the counseling field, thus continuing the cycle of supervisors overlooking cultural issues (Estrada, 2005 ; Vereen, Hill, & McNeal, 2008 ; Jernigan, et al., 2016 ; Ivers, Rogers, Borders, & Turner, 2017). As a result of being a therapist in training, a therapist of color, and dealing with an ethical dilemma involving a cultural conflict, I was very hesitant to confide in my supervisors due to our cultural differences.

I struggled with feelings of discomfort when it came time to discuss the dilemma with my supervisors. Supervision felt like an unsafe setting to express my anger and frustrations of being a Black woman working to resolve an ethical situation deeply embedded with cultural conflict. My experience was not normalized. When I brought up the cultural factors of the case, the room seemed to either become silently heavy or the conversation deflected to an idea outside of culture. That only led to more frustration. I wanted to avoid the angry Black woman stereotype that accompanied my skin tone and aesthetic appearance and affected the way others perceived me interpersonally. I knew it would only hurt my professional career if my expressions were perceived outside of professional behavior, whatever professional behavior is according to Eurocentric standards. Consequently, I eventually suppressed my feelings and operated from a place of numbness whenever I had to discuss the clinical case further. I thought it was pointless to continue to take my body through a wave of unheard, misunderstood emotions. Suppressing my feelings and emotions was not the best coping strategy, but it was healthier and less exhausting than continuing to feel shut down or deflected. I objectively shared all the facts about the case with Juan. I did not share my subjective experiences, at least not nearly to the extent of how they lived in my body during supervision.

Embodiment of Step Six

Hervey ( 2007 ) recommends that dance/movement therapists share their ethical dilemma with trusted colleagues or supervisors through authentic movement, verbal communication, or by designing their own way of sharing. Step six aims to increase the mover’s confidence for consultation.

While engaging in this step during my journey of writing this article, I experienced step six to be helpful with extracting the dilemma from my body and putting into movement. I shared the dilemma alone first, and then I shared my movement with a peer. By first moving the dilemma alone, I was able to see what I wanted to share and how I wanted to share it, absent the influence of another body in the room. When I offered my movement to my confidant, I was again nervous, worried about their criticism of my choice of movement, as they were unfamiliar with embodiment practices. The art of moving past internal and external criticism of who I am as a dance/movement therapist allowed me to connect deeper to how the dilemma lived in my body. I could extract it and put it into an art form in which I have always experienced healing. It allowed me to gain control over what was suppressed inside of my Black body.

Step Seven and Eight: Deliberate, Decide, and Rehearse

Steps seven and eight of Welfel’s ( 2001 ) ethical model prompt therapists to deliberate and decide the best plan of action, and Hervey ( 2007 ) puts emphasis on taking responsibility of the final decision. Ethical thinking is a complicated process and we must consider the impact of our decisions on individuals and the institution we serve (Chmielewski, 2004 ). Without careful acknowledgement of the responsibility we hold in these types of situations, counselors run the risk of creating unsafe environments for current and future patients, and further risk producing adverse consequences for institutions. (Chmielewski, 2004 ). This step precedes any action to promote clarifying our intentions while solidifying our final decision.

Decision Made for the Case with Juan

I decided to inform Juan’s nurse practitioner of his spiritual experiences. Ultimately, it felt like I was without much choice as I had already informed my internship site supervisor before I was aware this clinical case was an ethical dilemma, and one that would affect me deeply from a cultural perspective. I abided by the rules of the hospital and complied with directions given to me regarding the next steps to take. Before disclosing Juan’s information, I talked with him in one of our sessions about my obligation as an interning clinician to inform his nurse. Again, I provided the option for him to tell his nurse, alone or accompanied by me; however he refused both. Juan stated he understood and respected my responsibilities, but he would not return to therapy. I informed him of the sadness that his decision brought me and expressed that I also understood his responsibility to protect himself. In the end, Juan ended up coming back to therapy. The relationship we built in our therapeutic space of allowing our cultural identities to exist freely without judgment surmounted the undesired ethical decision that was executed, and led to Juan’s return.

Honestly, if I could go back and engage in this ethical decision-making process and change something, I would not. The process has taught me so much about who I am as a clinician and an advocate of cultural needs in healthcare systems. I also believe that Juan benefitted greatly from our therapeutic relationship that involved increased sensitivity to and active inclusion of cultural differences. Though he felt our trust was broken, we were able to rebuild it in our proceeding sessions by repairing the rupture that had taken place. Repairing our rupture contributed to strengthening our therapeutic alliance even further. From an RCT perspective, the therapeutic relationship was the healing factor to the decision made in this culturally situated ethical dilemma.

Embodiment of Steps Seven and Eight

In order to clarify intentions and solidify a plan, dance/movement therapists are directed to move alone, journal, or do both while deliberating (Hervey, 2007 ). This is a resourceful point in the ethical decision-making process to connect all of the important pieces of the case and evaluate the risks involved for one’s self, the patient, and treatment team. The deliberation process can create feelings of reconnection and groundedness as we reach for clarity. Once deliberation has been finalized and intention clarified, the next measure is to commit to a plan of action (Hervey, 2007 ). It is recommended to rehearse acting out the final decision through movement or imagination to increase one’s confidence before implementing the plan (Hervey, 2007 ). After the decision has been carried out, counselors are to head into the final step of the EEDM process for reflection. In an effort to support a reconnection to my own intentions, it was helpful for me to ask myself questions as a way to facilitate my movement. For instance: What motivated me to engage in this ethical decision-making process? Why and how will this benefit my patient? How will my decision support future patients and therapists who encounter a similar ethical dilemma? It was interesting to notice my arms reaching outward in all directions of the dimensional scale, and then carving their way back to my core, as if they were bringing me something back. I experienced a sense of clarity, and moreover, I experienced a sense of knowing who I am in this dilemma, and on a spiritual plane, what purpose this dilemma has brought to my career as a dance/movement therapist.

Step Nine: Reflect and Evaluate

Though Hervey ( 2007 ) excluded this final step from her workshops, it is important to engage in this reflective step to evaluate how effective the entire EEDM process has been, and doing so in an embodied fashion (Hervey, 2007 ). While understanding what parts of the process were effective, it is also possible to learn what steps can be done differently for future dilemmas (Hervey, 2007 ; Constable et al., 2011 ). Cottone ( 2001 ) agrees that the reflection process is not one of the mind, but an appraisal process of actions and a continued process of seeking alternative perspectives. Cottone ( 2001 ) encourages clinicians to go beyond the perspectives of supervisors, peers, and respected colleagues, and consider the cultural context in which the decision was implemented and how it affects the community at large.

For one, extending an open conversation to the patient in an effort to understand how the final decision affected them can increase feelings of safety and empathy for both the patient and counselor, especially if the ethical decision was contrary to the stated desire of that patient. Furthermore, I also suggest reaching out to community members and persons who identify within that associated culture. Shah (2011), described inviting pushback, where a group of people express resistance or redirection, as a way to show care and feelings of importance to the perspectives of underserved communities that may otherwise go unnoticed. Shah (2011) also brings attention to the fact that mistakes are inevitable during ethical decision-making, and it is essential that counselors prepare themselves for this kind of feedback. If not, the fear of criticism will keep counselors oblivious to the needs of patients, community members, and different cultures, therefore creating greater barriers that could potentially aid in the progression of mental healthcare for those in need.

Embodiment of Step Nine

In my movement reflection, I discovered that I was able to remove the heaviness of my culture from my back and place it in my hands in front of me. I now saw it as a tangible construct, something I could work with and move through. My body felt mobile with free flow as I integrated movements from the previous steps as a way to reflect on my experiences. There was a sense of gained knowledge and tools to assist me with navigating future complex ethical dilemmas in a culturally informed and embodied way.

By engaging in this in-depth exploration with the EEDM steps, I learned how meaningful this case was to me and possibly to underserved populations who engage in healthcare services. As opposed to intellectually escaping my bodily felt responses to the dilemma, these steps encouraged me to listen to and engage with them. Without doing so, I would not have reached the conclusions I have presented in this article. My connection to this clinical case was a deep visceral experience that had been silenced by an oppressive healthcare system and me, but illuminated through an embodied process. Current healthcare practices disempower and affect the long-term health of people of color because they are expected to comply with mono-cultural views of mental health and treatment. I made a decision to share Juan’s spiritual experiences with his nurse against his will. My therapeutic approach of displaying respect and giving prominence to Juan’s culturally based meaning-making of his spiritual experience was what encouraged Juan to return to treatment. Still, it is essential to examine potential harmful outcomes and how they can be prevented or diminished until healthcare systems modify their operations.

Throughout the ethical dilemma, I was the intermediary between my patient, the psychiatric nurse, and my site supervisor. ACA’s ( 2014 ) Code of Ethics assert a collaborative process between counselors and patients, yet, in most ethical dilemmas, the counselor makes decisions in isolation (Birrell & Bruns, 2016 ). Most clinical guidelines similarly recommend involving patients in decisions regarding assessment and treatment thus supporting collaborative and informed goals (Elwyn et al., 2006 ). This type of patient-centered care has been increasingly adopted as interdisciplinary teams realize how valuable shared decision-making (SDM) is for patient success and well-being (Adisso et al., 2018 ; Chewning et al., 2012 ; Elwyn, Edwards, Kinnersley, 1999; Elwyn, Edwards, Kinnersley, Grol, 2000; Légaré et al., 2011 ). Persons directly involved in an ethical dilemma have great potential to effectively influence the decision-making process, and no one voice should be given exclusive privilege over another (Birrell & Bruns, 2016 ). From an RCT perspective, interconnection during ethical decision-making processes can invite real change in a positive direction for not only the patient, but for the counselor and institution as well.

RCT acknowledges that growth-fostering relationships, relationships that include increased understanding and empathy for one another’s thoughts and feelings, display respect for the multitude of sociocultural aspects that each individual brings to the experience (Duffey & Somody, 2011 ). As humans, we are wired to move through and toward connection with others, and it is the connection and relational experience that contributes to healthy functioning and flourishing (McCauley, 2013 ).

What I desired most during my ethical decision-making process was to have all the people involved in the dilemma to be in one room listening to each other with openness, curiosity, and empathy. I was the intermediary of all communication amongst my supervisors, Juan, and the nurse. It was exhausting relaying information, and a lot of the time I was repeating the same information to a different person. So much of my time and energy was expelled in this back and forth communication, only to implement the decision alone. As the intermediary, I additionally witnessed statements from my encounters with each of them that made me feel uncomfortable or suggested a lack of empathy for one another. I wished they were able to learn of one another’s circumstances to create more understanding and empathy within the case. I understood that our workloads prevented a collaborative decision-making meeting that would have included my site supervisor, the nurse, Juan, and myself in one room discussing the details of the case and all the possible solutions to working with Juan’s spiritual experience. I further understood that such a meeting would have been quite frightening for Juan who wanted to keep his experience a secret. I wondered how that might have been different if Juan discovered the hospital altered their policies to accept and consider his meaning making of his spiritual experience? A joint meeting could have saved me much time, energy, and stress over a dilemma that affected others and me deeply.

Based on my experiences with this ethical dilemma, I developed a model for active multicultural diversity (AMD), a term credited to Carmichael ( 2012 ), as a guide for ethical decision-making aimed at increasing effective outcomes for patients by taking culture from a concept that exists in one’s awareness to a concept acted upon (Fig.  1 ). It incorporates the EEDM steps with SDM and the three M’s of RCT: movement to mutuality, mutual empathy, and mutual empowerment. With the embodied ethical decision making steps at the center of decision-making, I encourage the patient, therapist, and treatment team to equally collaborate when making ethical decisions. In this way, the burden of resolving the ethical dilemma is not placed in the hands of one person, but instead, all are responsible for reaching a conclusion, therefore increasing the vitality of each person through involvement and interconnectedness.

Active multicultural diversity in ethical decision-making

Movement Towards Mutuality

Hartling and Miller (2004) describe non-mutual relationships as dominate/subordinate or power-over relationships, which the more powerful or dominant participant in the relationship receives greater benefit. Instead, movement towards mutuality calls for all participants of the relationship to engage in, and take emotional and cognitive action towards change (Hartling & Miller, 2004). This movement towards mutuality benefits people by preventing humiliation while supporting growth, healing, and human rights. All participants in the ethical dilemma must be willing to change where possible and appropriate in order to see each other as equal individuals while collaborating to resolve the ethical dilemma.

Mutual Empathy

Mutual empathy is the ability to be impactful and to be impacted in the relationship through seeing and feeling within the experience (Duffey & Somody, 2011 ). It is through acceptance and validation that an authentic relationship can be built and become a priority (Duffey & Somody, 2011 ; Hartling & Miller, 2004). This is an essential piece to navigating complex ethical dilemmas.

Mutual Empowerment

Empowerment is the feeling of having control and understanding over one’s life (World Health Organization, 2010 ). The World Health Organization ( 2010 ) realizes that institutions have a responsibility of operating in ways that empower the people and communities they serve to encourage vitality, health and well-being. Empowerment in relationships must be mutual so that all parties feel competent, heard, seen and respected as they collectively shape and develop the experience (Hartling & Miller 2004). Decision-making is best done when those engaging in the collaborative process do so feeling confident and empowered.

I envision healthcare facilities employing a designated ethical dilemma consultant, to mediate the collaboration process. Clinicians, nurses, doctors, and even patients could send the consultant a notification that a potential ethical dilemma arose. From there, the consultant would initiate communication for all involved in the dilemma to decide on a date and time to meet and work through the AMD model to resolve the case. The consultation session could be structured according to the persons participating in the meeting. A session may involve a lot of movement or minimal movement with mostly postures and gestures. A simplified version might employ mindfulness techniques to identify body-felt sensations to each embodied step. The three M’s should be illustrated at the beginning of each consultation to help clarify the intent and goal of engaging in the EEDM process. The three M’s, movement to mutuality, mutual empathy, and mutual empowerment, effectively work to create an open and safe atmosphere that encourages full participation in the EEDM steps.

Active Multicultural Diversity for Juan’s Case

In order for AMD to work in this clinical case with Juan, increased funding for mental health programs leading to less overworked professionals is a definite necessity. Professionals at the hospital were consistently double booked with patients for the majority of the workday. The oppressive system in which the hospital was situated, affected patients and employees alike. The hospital consistently treated people of color with limited support service options. It is feasible that if the hospital had sufficient funding for mental health services, increasing staff and office space, the AMD model could have been implemented in this clinical case. Further, to participate in a collaborative process, the patient, nurse, and clinical supervisor would have to be willing to engage with one another with an increased open mind and non-judgmental attitude. This would help cultivate a collaborative process insofar as Juan would have been able to communicate his desires to resolving the dilemma in a way that would also increase his trust for the hospital setting through our relational experience.

Limitations and Possibilities

Active multicultural diversity in ethical decision-making does not come without its challenges and limitations when considering the integral components of how westernized healthcare systems have been operating for decades. For one, SDM requires more time for collective consultations between healthcare professionals and patients (Elwyn et al., 1999 ). Most healthcare professionals are occupied with required treatment planning, writing notes, other consultations, case management, and other daily tasks. Counselors may also experience the obligation to educate patients on mental health to increase competency levels for ethical decision-making, which also requires more time (Elwyn et al., 1999 ). In light of this, patient decision aids, new technologies designed to prepare patients and to increase their knowledge of information related to treatment, are used to assist in making informed choices when collaborating with healthcare providers (Elwyn et al., 2006 ; Adisso et al., 2018 ). In an effort to increase active multicultural diversity in healthcare settings, patient decision aids should be made accessible to all communities, all populations, and in all forms of healthcare. Another limitation of active multicultural diversity is the perceived threat to power in professional-patient relationships (Elwyn et al., 1999 ). This is associated with a lack of cultural competence, caring knowledge, mono-cultural embedded lenses, and power-over preferences from health professionals and institutions. Moreover, just like cultural competency training is deficient in mental health programs, SDM is also deficient in programs and skill building workshops, and is further absent in modeling from older, more experienced clinicians (Elwyn et al., 1999 ). It is possible that with an ethical decision-making consultant on site, regular trainings could be provided to keep professionals and patients informed on ethical decision-making and cultural competency.

Finally, embodiment is a skill that dance/movement therapists and other body-based practitioners are accustomed to, and it could be a challenging to engage non-body-based practitioners and patients in movement during an ethical decision-making process without significant willingness or training. This could reshape healthcare systems requiring leadership figures to provide more resources, education/training, and time to healthcare professionals so they are prepared and available to engage patients and team members in active multicultural diversity for ethical decision-making.

I can embrace the AMD model moving forward by including my patients in the EEDM process as a part of our therapy sessions, if a dilemma happens to emerge during our work together. We could collaborate to identify options to resolve the dilemma. I would then present those options in consultations with the treatment team to include and discuss their viewpoints. Another possibility is having someone from the treatment team join one of the therapy sessions with my patient and have them witness our movement, as identified in step six of sharing the dilemma. After, we might engage in a discussion to decide on an action to take, invite the team member to join the movement, or both. In this manner, there is an inclusion of multiple voices to collectively resolve a dilemma in an embodied way. Inviting a treatment team member into a session also indicates movement towards mutuality as each person shows initiative by taking time out of their day to dedicate to the safety and care of the patient. Mutual empathy happens in the process of moving and witnessing movement; illuminating how the movement affected each person in the room can deepen the process. Mutual empowerment is experienced in the feelings of inclusion, displaying respect and interest in one another’s opinion.

The purpose of this clinical case study was to illustrate how the EEDM steps influenced ethical decision-making when cultural differences conflicted. I found that by engaging in the embodied ethical steps, I was able to deepen the decision-making process by accessing the lived experience of the dilemma in my body. I carried the heaviness of a silenced cultural identity until it was able to speak through movement. The ethical dilemma in this case was respect for culturally based meanings in treatment and how we name pathology. Culture is inadequately considered in healthcare operations, treatment models, and educational programs. We must actively consider how this deficiency affects patient health over time and disempowers underserved populations from engaging in treatment. The EEDM steps provide an effective way for working with diverse populations as we can connect to our bodies to explore new possibilities for complex situations. In this clinical case with Juan, though the decision to inform his nurse practitioner of his spiritual experience was against his will, our relationship encouraged his continued engagement with treatment services. To consider culturally based meanings in treatment, the relational experience is essential in order to receive support from different perspectives. Sharing the embodied decision-making process can be most effective for culturally situated ethical dilemmas. As suggested in the AMD model presented here, engaging in the EEDM steps through a RCT lens benefits silenced and underserved patients, and healthcare professionals with an increased sense of mutuality through a meaningful process.

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Roberts, M. Embodied Ethical Decision-Making: A Clinical Case Study of Respect for Culturally Based Meaning Making in Mental Healthcare. Am J Dance Ther 43 , 36–63 (2021). https://doi.org/10.1007/s10465-020-09338-3

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