A Casebook of Ethical Challenges in Neuropsychology

Shane S. Bush, Shane S. Bush

• Publisher: Taylor & Francis
• Year: 2004
• ISBN:
  9781135330552
• Edition: 1
• Topic: Psicologia
• Subtopic: Storia e teoria della psicologia

The American Psychological Association published a revision of the Ethical Principles of Psychologists and Code of Conduct in 2002.This text, a companion to the 2002 text Ethical Issues in Clinical Neuropsychology by Bush and Drexler, presents the reader with common ethical challenges in neuropsychology. This text examines the differences between the 1992 and 2002 APA Ethics Codes as they relate to neuropsychological activities.
The authors present cases and discuss ethical issues related to neuropsychological practice with a variety of patient populations and in a variety of clinical settings. In addition, ethical issues in neuropsychological research and test development are examined. The text also includes chapters on emerging and particularly challenging aspects of neuropsychological practice, such as the assessment of response validity, and the use of information technology and telecommunications. Through the use of case illustrations, the authors examine ethical issues in neuropsychology and the new Ethics Code, offering a practical approach for understanding and promoting ethical neuropsychological practice.

Section 1
DIFFERENCES BETWEEN THE 1992 AND 2002 APA ETHICS CODES: A BRIEF OVERVIEW

The American Psychological Association Council (APA) of Representatives adopted the newest version of the Ethics Code on August 21, 2002 (APA, 2002), and it went into effect June 1, 2003. As with its predecessor (APA, 1992), the 2002 Ethics Code begins with an Introduction that describes its intent, organization, procedural considerations, and scope of application. The Introduction is followed by a Preamble which offers aspirational suggestions for psychological conduct. The Ethics Code then provides General Principles, which are aspirational in nature, and Ethical Standards, which are enforceable and are used to adjudicate complaints of ethical misconduct. The new code is approximately twenty percent shorter than its predecessor.

Although all of the changes to the Ethics Code have implications for neuropsychology, neuropsychologists are likely to place greatest emphasis on understanding those changes and additions that have the most relevance for their professional activities, such as Standard 9 (Assessment). Readers are referred to other resources for more general commentary on the changes to the Ethics Code (e.g., Fisher, 2003a; Knapp & VandeCreek, 2003) and to the APA Ethics Office website for redline comparisons that detail the changes (http://www.apa.org/ethics/codecompare.html, accessed December 18, 2003). Although casebased discussions of some of the changes to the Ethics Code are offered throughout the text, the following overview examines some of the changes to the Ethics Code that may be most relevant to neuropsychology.

Introduction and Applicability

The Introduction to 2002 APA Ethics Code includes the addition of a paragraph that describes the use of modifiers (e.g., reasonably, appropriate, potentially) in the Code. Modifiers (1) allow professional judgment on the part of psychologists, (2) eliminate injustice or inequality that would occur without the modifier, (3) ensure applicability across the broad range of activities conducted by psychologists, or (4) guard against a set of rigid rules that might be quickly outdated. Although some neuropsychologists may prefer that the Ethics Code provide definitive guidelines for ethical behavior that would apply in all situations, such a task is beyond the scope and purpose of an ethics code. Given the wide range of professional activities that neuropsychologists perform and the unique aspects of situations within each activity, it would be nearly impossible for any set of guidelines to state specifically how a neuropsychologist should resolve every scenario. Instead, the Ethics Code offers overarching ethical principles and a set of standards of varying degrees of specificity that provide the framework by which neuropsychologists can reason through ethical challenges. Other professional publications, such as guidelines from professional organization and peer-reviewed articles, provide further explication specific to neuropsychology, and texts such as this demonstrate how professional guidelines may be applied in actual situations.

Also in this section, a definition of the term reasonable is offered: “As used in the Ethics Code, the term reasonable means the prevailing professional judgment of psychologists engaged in similar activities in similar circumstances, given the knowledge the psychologist had or should have had at the time.” Given the widely disparate views of competent neuropsychologists on a variety of topics (e.g., mild traumatic brain injury, test batteries, symptom validity testing, etc.), it seems that a well reasoned and scientifically defensible position or method of practice would be considered reasonable, whereas extreme positions or behaviors that fall well outside of the usual and customary standards of practice would not be considered reasonable.

General Principles

The revision of the General Principles incorporated widely referenced general biomedical ethical principles: autonomy, beneficence, nonmaleficence, and justice (Beauchamp and Childress, 2001). Incorporation of these commonly used biomedical ethical principles provides neuropsychologists with a useful means of conceptualizing ethical issues and a common language to use when discussing ethics with other medical professionals. In a reduction from six principles to five, the 2002 Ethics Code reflects the deletion of principles entitled Competence and Social Responsibility. Issues of Competence, based on the underlying principle of nonmaleficence, are now emphasized in the Ethical Standards (Standard 2). Content related to Social Responsibility has been incorporated into the Preamble and Introduction. General Principle D (Justice) is a new addition to the Code and emphasizes equality in access to psychological services and in the nature of the services provided. It further emphasizes the need for psychologists to ensure that potential biases and limitations of professional competence do not result in or condone unfair practices.

Ethical Standards

Changes in both the form and content of the Ethical Standards are apparent in the new Ethics Code.

Competence

In the 1992 Code, Competence was listed as a General Principle (Principle A), and was described in various standards (1.04, Boundaries of Competence; 1.05, Maintaining Expertise; 1.06, Basis for Scientific and Professional Judgments; 1.08, Human Differences; 1.22, Delegation to and Supervision of Subordinates; 7.06, Compliance with Laws and Rules). In the 2002 Code, Competence is mentioned in Principle D (Justice) but now also comprises an entire section of the Ethical Standards (Standard 2). Added are sections addressing provision of services to those who might not otherwise be served (2.01d) and provision of services during emergencies (2.02). The increased emphasis and organization in the Standards seems to reflect the importance for psychologists to understand that professional competence is not simply something to which professionals must aspire but is an essential requirement of the successful execution of one’s professional responsibilities.

Informed Consent

For the first time, the Ethics Code directly addresses issues of informed consent in assessments (Standard 9.03). Standard 9.03 outlines the consent process in considerable detail, and it describes exceptions to the need for informed consent. Because many neuropsychologists examine persons who have questionable cognitive capacity to provide informed consent, consent issues become more complicated (American Psychological Association Presidential Task Force on the Assessment of Age-Consistent Memory Decline and Dementia, 1998; Johnson-Greene et al., 1997; Johnson-Greene & National Academy of Neuropsychology, 2003). Ethical Standards 3.10(b) and 9.03(b) provide direction on how to negotiate informed consent issues when patients have or may have diminished decision-making capacity. Standard 3.10(c) is anew subsection that describes consent obligations when services are court-ordered or otherwise mandated.

Despite genuine attempts to comply with ethical standards pertaining to consent, in many situations neuropsychologists are unable provide the examinee with specific information on how test findings will be used or what the implications of the findings will be. Thus, although the consent process in such situations may not always be truly informed, neuropsychologists must nevertheless attempt to explain the potential uses and implications of the examination results to the examinee as early as possible in the examination process.

Multiple Relationships

Standards addressing multiple relationships were clarified (3.05, Multiple Relationships; 3.06, Conflicts of Interest; 10.02, Therapy Involving Couples or Families). Neuropsychologists must refrain from taking on a professional role if it could reasonably be expected to interfere with their objectivity or otherwise negatively affect their ability to perform their duties effectively. The new Code states that multiple relationships that would not be reasonably expected to interfere with one’s professional performance or result in harm would not be unethical (Standard 3.05a).

Multicultural Issues

The APA Ethics Code Task Force (ECTF) reviewed the Ethical Standards with regard to racism and other forms of disempowerment, attempting to view the code from the perspective of such groups (Knapp & VandeCreek, 2003). The results include the following.

The principle of Justice (Principle D) is new in the 2002 Ethics Code and emphasizes that all individuals are entitled to access to and benefit from psychological services of equal quality. Psychologists take steps to ensure that biases and limitations of competence do not interfere with the provision of such services. The 1992 Principle E (Concern for Others’ Welfare) was incorporated into the new Principle A (Beneficence and Nonmaleficence). Both principles emphasize the need to promote the welfare of those with whom neuropsychologists interact professionally.

The 2002 Ethics Code places an increased emphasis on cultural competency in situations in which it has been determined that such competency is essential for delivery of effective services. The Code also stresses increased sensitivity to the difficulties inherent in providing psychological services when language fluency is not shared by the psychologist and the patient. New Standard 2.01(b) requires sensitivity to the impact of culture, disability, and other diversity factors on one’s professional competency. Knapp and VandeCreek (2003) state, “It is not an ethical violation to provide less optimal treatment to members of…any groups; it is only a violation if the knowledge that is lacking is essential for providing services” (p. 303).

New Standard 9.03 (Informed Consent in Assessments) has three subsections that discuss issues related to informed consent in assessments. Section (c) outlines the need for psychologists planning to use the services of an interpreter to obtain informed consent from the patient to do so. To be fully informed, the examinee should be told that the translation may result in a degree of imprecision in the test results, and the degree of imprecision will be greater the farther the interpreter and the examinee are from speaking the same dialect or regional variation of a language. Standard 9.03(c) also outlines the responsibility of psychologists to ensure that their interpreters follow requirements to maintain confidentiality of test results and maintain test security. This addition helps to emphasize the importance of psychologists clarifying with all parties involved in the provision of psychological services the need to be sensitive to the patient’s rights to privacy and confidentiality, as well as to the limits of privacy and confidentiality.

Standard 9.02 (Use of Assessments), subsection (b), is new. This standard requires psychologists to use assessment instruments that have established validity and reliability for use with members of the population that the patient represents. In the absence of such validity or reliability, psychologists must describe the strengths and limitations of the test results and interpretation. Subsection (c) is also new and mandates psychologists to use measures that are appropriate given the patient’s language preference and competence, unless use of an alternative language is relevant to the examination. Throughout the section on Assessment, the Code emphasizes the need to indicate the limitations of one’s interpretations. Standard 9.06 (Interpreting Assessment Results) specifically states that linguistic and cultural differences must be appropriately considered when interpreting assessment results. Also, psychologists are expected to indicate any significant limitations of their interpretations.

Release of Test Data and Materials

During the revision process and following finalization of the 2002 Code, Standard 9.04 (Release of Test Data) received the greatest attention (Fisher, 2003b; Knapp & VandeCreek, 2003). The 2002 Ethics Code distinguishes between test data and test materials. Test data (Standard 9.04a) refers to “raw and scaled scores, client/patient responses to test questions or stimuli, and psychologists’ notes and recordings concerning client/patient statements and behavior during an examination.” With a release from the client/ patient, psychologists are to provide such data to the client/patient or to other persons identified by the client/patient. However, psychologists “may refrain” from releasing such data in order to protect the client/patient or others from substantial harm or in order to avoid misuse or misrepresentation of the data. Without a release from the client/patient, psychologists are to provide others with test data only as required by law or court order. Under the 1992 Code, psychologists were required to refrain from releasing raw data to anyone (other than the patient under certain circumstances) not qualified to interpret or appropriately use the data. Under current guidelines, with a client/patient release, psychologists must provide test data to the patient/client or to anyone identified in the release, unless the psychologist believes that “substantial harm, misuse, or misrepresentation” may result.

In Standard 9.11 (Maintaining Test Security), test materials are defined as “manuals, instruments, protocols, and test questions.” In contrast to test data, psychologists are required to “make reasonable efforts to maintain the integrity and security of test materials…” Because the test data are often written on the test materials, determining how to release test data without releasing test materials becomes problematic. The ability to comply with the requirements of both standards appears further limited when one considers that for some tests, the data and the materials are inseparable (Bush & Macciocchi, 2003). For example, with measures of verbal memory, the stimuli provided by the neuropsychologist and the data produced by the examinee are one and the same. A similar situation is found with graphomotor reproduction tests. Thus, in such situations, it is impossible to meet the APA mandate to release test data but not test materials.

Standard 9.04(a) attempts to provide further guidance in reference to this matter where it states, “Those portions of test materials that include client/patient responses are included in the definition of test data.” That is, the test materials “convert” to test data (Behnke, 2003). Thus, according to the 2002 Ethics Code, test materials, such as protocols, should be safeguarded when they have no answers written on them but no longer need to be safeguarded after answers have been written on them. It appears that this position requires further clarification.

Additionally, Standard 9.04 requires neuropsychologists to r...