The Elements of Ethical Practice

Applied Psychology Ethics in Australia

Nadine Pelling, Lorelle Burton, Nadine J. Pelling, Lorelle J. Burton

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429534997
• Edition: 1
• Topic: Psychology
• Subtopic: Education in Psychology
• Index: Psychology

The Elements of Ethical Dilemmas: Applied Psychology Ethics in Australia is a comprehensive and applied guide to practising psychology in an ethical and professional manner. This book is designed to assist applicants for general registration as a psychologist successfully navigate one of the eight core competencies for general registration set by the Psychology Board of Australia; specifically ethical, legal, and professional matters. The exploration of ethical dilemmas is a core task for the 4+2 pathway to general registration, while related ethical applications require exploration in the 5+1 and higher education pathways to registration as well.

This book will teach readers how to identify, explore, and choose the appropriate professional course of action when confronted by ethical dilemmas in practice. The chapters include personal reflections from expert contributors relating to each of the ethical dilemmas, expertly highlighting clients' and stakeholders' circumstances, ethical codes and guidelines, scholarship and research, as well as other key elements in the ethical decision-making process.

Especially relevant to those applying to become a registered psychologist in Australia, this book offers invaluable guidance on responding to ethical dilemmas as required by the Psychology Board of Australia in various pathways to general registration.

Part B

Ethical dilemmas

I. Practice-focused ethical dilemmas

1 Sleepy drivers die

When a safety slogan is also an ethical concern

Saul Gilbert, Kerry Maxfield, Michael Chia, Jillian Dorrian, Siobhan Banks and Kurt Lushington

Ethical dilemma: reporting obligations regarding fitness-to-drive

A female client is seeking treatment for insomnia. She works full-time as an ambulance driver, typically working 12-hour shifts with one week in four on night shift work. You note when taking her history that she snores loudly at night and this has worsened over the past two years. As well, she has also experienced excessive daytime sleepiness. She reports that several times she has nodded off while waiting at traffic lights and that she almost always falls asleep if alone in the ambulance when parked. A review of the client’s personal situation revealed that she is a sole parent. The general practitioner’s (GP) written mental health care plan asks for a follow-up report after the sixth appointment. As part of the case formulation you note that her symptoms are suggestive of obstructive sleep apnoea syndrome (OSA). OSA is known to impair driving performance, which raises your concern especially regarding her fitness-to-drive and your responsibilities to the client and the broader community in such a situation.

As the treating psychologist, do you encourage the client to take sick leave to seek treatment for their suspected OSA? Do you refer the client back to their GP after the first session rather than waiting until the requested report (after the sixth appointment) based on your clinical concerns? Do you have a duty of care to inform her employer? What actions can you take that are legally and ethically defensible? Do these legal or ethical requirements vary between Australian states? What are the legal requirements on health practitioners regarding fitness-to-drive, and do these legislative requirements also apply to psychologists? What is a psychologist’s duty of care under the Australian Psychology Society’s (APS) Code of Ethics and relevant legislation? These questions will be addressed in the following sections.

Background information

It is reasonable to assume that the client’s daytime sleepiness underlies her propensity to fall asleep while waiting at the traffic lights and when parked (Bioulac et al., 2017). In turn, it is likely that sleep disruption underlies her daytime sleepiness. Several explanations for sleep disruption are evident in this client’s history. A hallmark of modern life is the encroachment of work and social pressures on rest and quality sleep time. Given the client’s work and family responsibilities, then, this could explain the excessive daytime sleepiness and fatigue. Nevertheless, excessive daytime sleepiness is atypical and probably indicates an underlying sleep disorder. A contributing factor could be her insomnia (Hein, Lanquart, Loas, Hubain, & Linkowski, 2017). Alternatively, the symptoms may be secondary to shift work and the resulting circadian disruption to her sleep/wake rhythm. Shift workers are known to sleep less than non-shift workers especially when attempting to sleep during the day when the circadian system is promoting alertness and not sleep (Åkerstedt, 2003). This is also the case with ambulance workers (Sofianopoulos, Williams, & Archer, 2012). A further possible, but less well-appreciated cause could be OSA.

OSA is characterised by repetitive periods of reduced airflow through the upper airways with resultant hypoxia and cyclic arousals from sleep. Clinical features of OSA include habitual snoring, witnessed apnoeic or choking episodes by bed partner, and increased daytime sleepiness. It is now well established that individuals with moderate to severe OSA compared to controls typically have worse cognitive and motor performance (George, 2004). Moreover, individuals with untreated OSA are at 2–7 times greater risk of a motor vehicle accident (MVA) compared to the general population (Howard et al., 2004). In addition, the presence of comorbid sleep disorders is known to exacerbate daytime deficits (Luyster, Buysse, & Strollo, 2010). These factors would place the client at greater risk of a vehicle accident. As well, there is some evidence that people with OSA are also more likely to minimise symptoms including sleepiness, which may place them at great risk for vehicle accidents (Tregear, Reston, Schoelles, & Phillips, 2009). Despite the risk, however, and while the extent of gains is disputed (Vakulin et al., 2011), treatment is reported to reduce the risk of accident in people with OSA (Sassani et al., 2004). Thus, the clinical concern in this case is untreated OSA. This concern is also reflected in the fitness-to-drive legislation where the onus is on reporting untreated but not treated people with OSA.

Fitness-to-drive and the legal obligations of psychologists

In recognition of the impact of untreated OSA on alertness, vigilance, and driving performance, Austroads (2017) require a treating health professional to advise drivers suspected of having OSA or excessive daytime sleepiness to “avoid or limit driving if they are sleepy, and not to drive if they are at high risk, particularly in the case of commercial vehicle drivers.”

Definitions of high-risk drivers include:

• Those who experience moderate to severe excessive daytime sleepiness¹
• Those with a history of frequent self-reported sleepiness while driving
• Those who have had a motor vehicle crash caused by inattention or sleepiness

In this case, the client meets two of the Austroads criteria. Furthermore, as the client is an ambulance driver there is the reasonable expectation that the level of driver performance would be greater than that for a member of the general population. These factors raise the client’s fitness-to-drive to a higher level of concern.

The Austroads guidelines encourage the treating physician not to rely solely on subjective measures or a client’s self-reports to diagnose (or rule out) sleep apnoea. Rather, they suggest that the client should be referred to a sleep physician for overnight polysomnography² and possibly additional tests of sleepiness such as the Maintenance of Wakefulness Test³ (section 8: Austroads, 2017).

In most Australian states and territories, it is left to the discretion of the health professionals to report whether a client may have a diagnosed physical or mental illness, disability or deficiency such that, if the person drove a motor vehicle, they would be likely to endanger the public (ACT Road Transport (General) Act 1999 s. 230 (3) (4), ACT Road Transport (Driver Licencing) Act 1999, s. 28; NSW Road Transport Act 2013. s. 275 (3) & (4), NSW Road Transport (Driver Licencing) Regulation 2008, c. 50; QLD Transport Operations (Road Use Management) Act 1995, s. 142; TAS Vehicle and Traffic Act 1999, ss. 63 (2) & 56, TAS Vehicle and Traffic Act 1999, s. 63 (1); VIC Road Safety Act 1986, s. 27 (4), VIC Road Safety (General) Regulations 2009, r. 68; WA Road Traffic (Administration) Act 2008, s. 136). In contrast, and as based in legislation, health professionals in the Northern Territory (NT) and South Australia (SA) are mandated to report patients at risk (Motor Vehicle Act, 1959 (SA) s.148, Motor Vehicles Act, 1999 NT s.11).⁴, ⁵

The health practitioner is also required by law to notify the person in question that this reporting has occurred as well as the reasons for this report. Notably, SA section 148 in the Motor Vehicles Act (1959) states that mandatory reporting applies to “a legally qualified medical practitioner, a registered optician or a registered physiotherapist.” No reference to psychologists is made in this Act for mandatory reporting. The case is the same for the NT under section 11 of the Motor Vehicles Act (1999).

Notwithstanding that psychologists are not legally mandated to report clients at driving risk, the APS ethical code refers to circumstances under which psychologists are permitted to disclose confidential information. Specifically under section A.5.2 c:

if there is an immediate and specified risk of harm to an identifiable person or persons that can be averted only by disclosing information.

Further to this, the Privacy Act, 1988 (Cth, section 16A, Item 1) states:

that an exception to the Australian Privacy Principles, and allows disclosure of client information if: the entity reasonably believes that the collection, use or disclosure is necessary to lessen or prevent a serious threat to the life, health or safety of any individual, or to public health or safety.

Thus, the psychologist in the instance of reporting an individual at driving risk can be effectively placed under the protection of the discretionary reporting category of both the APS Code of Ethics (section A.5.2.c) and the exclusions under the Privacy Act, 1988 (section 16A item 1). It still remains noteworthy that referral of a patient to a treating medical professional or GP in SA and NT will result in that practitioner being subject to mandatory reporting of the patient if a driving risk is identified (SA Motor Vehicle Act, 1959 s. 148, NT Motor Vehicles Act, 1999 s. 11).⁶

Relevant ethical principles

• Autonomy
• Non-maleficence
• Fidelity

Three ethical principles apply to the management of this fitness-to-drive case. First, autonomy, an individual’s right to self-government and their own decision-making, especially if they are not breaking any law. However, when considering this principle the psychologist must balance the right to autonomy against the risks to others that may arise from impaired driving. There is also the expectation that the individual is making an informed decision. Therefore the onus is on the psychologist to ensure that the client has the capacity to understand the risks and that they are sufficiently educated about the driving risks to make an informed decision.

Second, non-maleficence, to avoid harming the person receiving treatment and more broadly not harming the general community. When considering this principle the psychologist must balance the impact of notification on the client’s wellbeing versus the psychologist’s obligations to other road users and the community.

Third, fidelity, that is, the psychologist must maintain a professional relationship and be loyal and supportive. When considering this principle the psychologist must take into account their duty to be honest with the client about their condition and the risks that their condition has to other road users. This includes balancing the client’s right to confidentiality versus the possible need to disclose information to authorities.

Relevant ethical standards

In reaching a decision the psychologist must take into account and be conversant with the guiding principles in the APS Code of Ethics (2007) and in particular sections A1.3, A.2.2, A5.2, and B1.2. In addition, section 16A item 1 of the Privacy Act (Cth) 1988.

The following ethical decision-making section provides a step-by-step framework for applying the relevant APS ethical principles and standards in such a case.

Ethical decision-making

Kämpf, McSherry, Ogloff, and Rothschild (2009) describe an eight-step model for ethical decision-making. This has been applied to the ethical dilemmas surrounding the client and reporting their fitness-to-drive.

Step 1: Identify individuals and groups potentially affected by the decision

The client is intimately affected by the decision to report their fitness-to-drive. It could result in the loss of employment which as a single parent could be doubly burdensome. The employer may also be affected as they will need to manage the client’s work duties, and, more broadly, it may impact how the organisation manages fitness-to-drive, hours-of-work, shift rosters, and workplace fatigue. The consulting psychologist is also affected as the decision would impact the practitioner-client relationship and, similarly, the GP who is also subject to mandatory reporting requirements. It could also conceivably affect future referral patterns if other clients, or potential clients, hear about the experience of the client in this case and feel uncomfortable discussing sleep disorder symptoms with their health care provider for fear of possible consequences (e.g., reporting and loss of income). Finally, the community is at risk as the client is, firstly, a paramedic with its incumbent clinical demands and, secondly, also an ambulance driver with its incumbent demands for cognitive alertness and a high level of driving skills beyond that of an average driver.

Step 2: Identify the problem, including the relevant ethical and legal issues and clinical practices

The ethical dilemma is whether a client who is not fit-to-drive and therefore a risk to themselves and the community should be reported to the motor licencing authority. Although ther...