Practical Ethics for Effective Treatment of Autism Spectrum Disorder

Matthew T. Brodhead, David J. Cox, Shawn P Quigley

• Publisher: Academic Press
• Year: 2018
• ISBN:
  9780128140994
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Practical Ethics for Effective Treatment of Autism Spectrum Disorder is for behavior analysts working directly with, or supervising those who work with, individuals with autism. The book addresses important topics such as the principles and values that underlie the Behavior Analyst Certification Board's ® Professional and Ethical Compliance Code for Behavior Analysts, and factors that affect ethical decision-making. In addition, the book addresses critical and under-discussed topics of: scope of competence; evidence-based practice in behavior analysis; how to collaborate with professionals within and outside one's discipline; and how to design systems of ethical supervision and training customized to unique treatment settings. Across many of the topics, the authors also discuss errors students and professionals may make during analyses of ethical dilemmas and misapplications of ethical codes within their practice.

• Reviews core ethical principles
• Discusses factors that affect ethical decision-making
• Describes how to create systems for teaching and maintaining ethical behavior
• Discusses how to identify your own scope of competence in autism treatment
• Describes the process of evidence-based practice and how it can be applied to behavior-analytic treatment for autism
• Discusses the importance of interdisciplinary collaboration and how to be a good collaborator
• Reviews common mistakes students and supervisors make when analyzing ethical dilemmas, along with common misapplications of ethical codes

Chapter 1

Introduction to ABA, Ethics, and Core Ethical Principles

Abstract

Clinical ethics have a long and storied past. This chapter briefly covers the historical background of the current dominant ethical theories and principles that are central to modern clinical ethics. The dominant theories reviewed are virtue theory, consequentialism, and deontology. The dominant principles reviewed are beneficence, autonomy, and justice. We then highlight how and why these theories and principles have been combined historically to form Codes of Medical Ethics—which parallel the development of the Behavior Analyst Certification Board’s (BACB) Professional and Ethical Compliance Code. Finally, we discuss the difficulty and contradictions that arise when a code of ethics is dependent on all three ethical theories and all three ethical principles. Board Certified Behavior Analysts (BCBAs) working with individuals with autism should be able to justify their ethical behavior without appealing to “because the code says so.” In so doing, BCBAs as a collective will need to have conversations and make decisions about why and how we believe our ethical behavior is justified.

Keywords

Consequentialism; deontology; virtue theory; beneficence; autonomy; justice

“Every way of seeing is a way of not seeing.”

– Kenneth Burk

What defines the difference between right and wrong; good and evil? Few topics in recorded human history have received as much discussion as what differentiates right from wrong, and good from evil. For thousands of years, humans have killed, imprisoned, sanctioned, and limited access to resources for people who fail to conform to their version of what is right (Harari, 2015). Humans have simultaneously provided various forms of reinforcement (e.g., social attention and material resources) to those who do conform to their version of what is right. These behaviors continue today. The ubiquity of labeling human behavior “right” and “wrong” can be observed through a close look at any group of humans who work together toward a common goal (e.g., members of health professions) or compete for the same resources (e.g., laws regarding theft and market manipulations).

In this chapter, we provide some historical context for different approaches to distinguishing “right” from “wrong” behavior. By the end of the chapter, you should have a better sense of (1) the assumptions that underlie claims of what is “right” conduct for Board Certified Behavior Analysts (BCBAs); (2) theoretical conflicts between different claims to what is “right” conduct for BCBAs; and (3) that applied ethics within Applied Behavior Analysis (ABA) is far from being comprehensive and complete—just like all areas of our science.

The above three points may seem inconsequential to your everyday work as a BCBA. However, this could not be further from the truth. Many BCBAs may not know the philosophical assumptions used to justify the ethical decisions they make. Also, many practitioners may not have realized there often are multiple pathways to what may be called an “ethical decision,” and those pathways are guided by different ethical assumptions. Without a working knowledge of these assumptions, it can be easy for BCBAs to misinterpret and/or misapply the Behavior Analyst Certification Board’s (BACB) Professional and Ethical Compliance Code for Behavior Analysts (hereafter referred to as the BACB Code, 2014).

It is important to describe the historical and philosophical context behind the recommendations that will be provided throughout this book and from which the BACB Code is grounded. From this framework, we can then review practical applications of the BACB Code in autism services. Consider it this way: a behavior analyst is more likely to effectively treat challenging behavior if she understands the context (e.g., environmental variables) in which that behavior was acquired and continues to occur. Likewise, a BCBA is more likely to engage in accurate ethical analysis if she understands the context in which her ethical principles are founded.

Paradigms of Clinical Ethics: Providing the Groundwork

Behavior analysis as a science and practice emphasizes the importance of consequences in affecting behavior (e.g., Catania, 2013; Skinner, 1938). Although the effects of consequences on behavior have been studied scientifically for over 80 years (e.g., Skinner, 1938), the importance of consequences for “right” behavior has been recognized for thousands of years (e.g., Code of Hammurabi; Hammurabi & Johns, 2008). A quick review of any cultural group will yield rules spanning etiquette, ethics, regulation, and law. In addition to conduct, these rules may explicitly state the relevant consequences (e.g., reward or punishment) for following, or not following the laws (Foucault, 1990).

Rules for conduct and the resulting consequences are not the same for all humans. For example, taking another person’s life could result in the death penalty and/or time in prison. However, taking another person’s life could also result in positive social recognition. Both outcomes depend on a host of variables such as the dominant cultural group in the geographical location one resides and the context in which the act occurred (e.g., premeditated mass murder vs. enemy soldier in war). Understanding how the application of consequences is justified based on the larger social context is important for understanding claims of “right” and “wrong.”

Dominant Paradigms in Clinical Ethics

Three paradigms within the realm of clinical ethics are most commonly used to answer why different claims to “right” and “wrong” are justified (Jonsen, 1998). They are virtue ethics, consequentialism, and deontology.

Virtue Ethics

Virtue ethics argues that moral excellence, or virtue, is the proper focus or reflection on ethics and rules for behavior (Hursthouse, 1999; Hursthouse & Pettigrove, 2016). That is, certain behaviors are ethical, “right,” or “good” in and of themselves—regardless of context or outcomes. For example, honesty and patience are often considered virtuous (i.e., “right” or “good”) behaviors regardless of the context and what may happen as a result of being honest and patient. Virtue ethicists label behavior “right” or “wrong” based on what the behavior looks like (i.e., the behavior’s formal properties). For example, honesty is considered good behavior because it has the formal properties of a truthful statement. Famous philosophers, such as Lao Tse, Plato, and Aristotle, are credited for popularizing virtue ethics (Marino, 2010).

From this perspective, one may label an individual as virtuous if two conditions are met. First the virtuous individual tends to emit behavior consistent with the socially agreed-upon virtuous label (e.g., honesty and generosity). For example, when documenting and submitting hours spent on billable services to an insurance company, a virtuous BCBA only reports the true type and amount of services provided. Second the individual’s virtuous response should be fluent in his or her repertoire (Binder, 1996) and maintained by nonsocial reinforcement. A virtuous individual would reliably behave in a manner labeled as “honest,” regardless of any socially mediated consequences that may or may not occur. Given that “virtue” is a social construct, behaviors labeled as virtuous can vary between, and within, different cultures (Skinner, 1957).

Consequentialism

The second dominant paradigm is consequentialism. Consequentialism (also known as utilitarianism) argues the outcomes of a behavior determine whether that behavior is right or wrong (Marino, 2010). Consequentialism arose primarily through the work of philosophers Jeremy Bentham, John Stuart Mill, and Henry Sidgwick. These classical consequentialist philosophers argued for what is today called total hedonistic consequentialism, which is a combination of act consequentialism and hedonism. Therefore we describe consequentialism with these two theoretical components in mind.

Act consequentialism argues that a behavior is deemed “right” or “wrong” if and only if that act maximizes the good.¹ For example, whether it is “right” or “wrong” to lie on my tax returns depends on whether I use the money owed in taxes in a way that benefits more people than would have benefitted from the government using my taxes. Hedonism claims that pleasure is the only “right,” and that pain and aversiveness are the only “wrong.” Using a consequentialist paradigm, a behavior is deemed ethically appropriate if and only if the behavior causes “the greatest happiness for the greatest number.”² Stated differently, we can justify that a behavior is ethical by appealing to what maximizes the good and what minimizes the bad for all relevant parties. For BCBAs, this would be whatever maximizes the overall amount of reinforcers a client contacts in her life relative to the aversive experiences needed to teach her to obtain those reinforcers. Included in the comparison is the amount of reinforcers that would have been contacted without intervention.

Deontology

The final dominant paradigm is deontology. Deontology comes from the Greek word for duty, deon. Deontologists primarily define what is “good” or “right” as a function of behavior and the context in which that behavior occurs. Deontologists establish the central components of this paradigm by highlighting weaknesses in virtue and consequentialist theories.

Deontologists argue that virtue theory is wrong because virtue theory claims specific behaviors are always “right” or “wrong.” As a result, virtue theory cannot account for instances where you should not behave virtuously (e.g., lying to your significant other about where you are going to get them to a surprise party organized for them). Deontologists argue that the context in which behavior occurs is also relevant in determining what is “right” and “wrong.” Behavior should not be labeled “right” or “wrong” based only on what the behavior looks like (i.e., the behavior’s formal properties).

Deontologists argue that consequentialism is wrong for three reasons. First, deontologists believe the consequences of our behaviors are often outside of our control. As a result, consequences are ethically insignificant. For example, it seems unfair to say someone behaved unethically by purchasing coffee that is produced through illegal child labor conditions if they do not know about those labor conditions. Second, deontologists believe that consequentialism places impractical demands on people because you would have to consider all potential consequences for all potential behaviors for all potential people before making a choice (Marino, 2010). Not only would this require a tremendous amount of time and effort, but it also is not clear how all the potential consequences could be included and appropriately compared. Third, deontologists argue that consequentialism fails because it can result in extreme permissiveness. In certain circumstances, consequentialism seems to demand that innocent people be killed, beaten, lied to, or deprived of resources as long as it results in greater benefits for others.

To summarize, deontologists argue that the context within which a behavior occurs has to be considered when determining what is “right” and “wrong.” In addition, deontologists argue that the environmental change resulting from a behavior cannot be used to justify a behavior as ethical or unethical. Rather, a behavior is right or wrong based on conformity to a socially derived norm of behavior (Alexander & Moore, 2016).

Deontology can also be critiqued. One critique of deontology relates to who decides the norms of behavior. Often the people who decide these norms are people who have power of some kind (e.g., religious leaders, governmental officials). However, there is no reason to assume those individuals have any greater ability to decide what is right than other members of society. Second, deontology can potentially lead to posthoc justification for many different behaviors. If what is considered the correct behavior depends solely on the context, then one could argue the reason they behaved in a certain way was based on contextual factors that others did not observe or consider.

Western Clinical Codes of Ethics

The above paradigms used to approach ethical dilemmas can influence how you justify what is “right” or “wrong.” However, these paradigms do not say what is right. Therefore formalized codes of ethics, and principles are necessary to guide what is right. Similar to the development of ethical paradigms, what has come to be considered “right” or “wrong” behavior in healthcare professions has developed over centuries.

Formal Codes of Clinical Ethics

Most modern codes of clinical ethics can be traced back...