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Infertility: Interventions for Shame, Mourning, and Feelings of Inferiority
This outline is not exhaustive. All involve some reference back to the value systems of the writers or the organizations they work for. And they demonstrate the wide variety of values, opinions and ethical stances within our society -- few are deemed 'wrong' unilaterally.
The therapist and the licensed clinic
Few medical settings have quite such a range of issues and rate of change, although I do not want to detract from any other work in medical settings. However I believe that, once in the counseling room, adherence to the Counseling Board's Ethical Framework is the leveling factor in our work with clients. We may take part in the wider debate but it should not affect the client's autonomy.
In some licensed clinics the person delivering the counseling may adhere to a different set of ethical guidelines from those of Counseling Board. The code of practice allows others -- for instance, social workers and psychologists -- to deliver counseling. For them, the primary ethical principle may not be autonomy but may, for example, be beneficence or fidelity. If there are a variety of ethical stances amongst therapists this can lead to sources of stress and the need for respect for the position of others on such matters as disclosure of information and the educative function of the counseling input.
Therapy offered to the clients of licensed clinics can also be offered from a number of different bases. The therapist may be a full member of staff with obligations to their employer and bound by the policies of that clinic. This can throw up ethical dilemmas. They may have practicing privileges for their independent practice at the premises of the clinic but be bound by the additional requirements of the Health Care Commission for such privileges. This too can impinge on the therapist on such matters as note keeping and child protection, and threaten autonomy or confidentiality. The therapist can be a person in a private practice with links to the clinic that can range from loose to close depending on the nature of the contract for service.
So there are many ethical issues a therapist working in this setting has to address. It highlights the enormous importance of good supervision and consultation, along with ethical decision making.
Current ethical issues for counselors
I will briefly consider the child who might be born. We are now at a time when there can be input to the debate from those children born since 1979 and there is information from longitudinal studies on the welfare and progress of these children. It is my view that this may inform those seeking 'implications counseling' (where clients reflect upon and understand the implications for themselves and others of the procedures they propose to undertake, exploring the personal meaning as well as the legal, ethical, social and psychological issues) but that if the counselor interferes with the decision making of the client this is contrary to the principle of autonomy. However, there are counselors who feel that a directive approach is required, for example advising, requiring or educating people on a need to inform children of their genetic origins.
The question has been thrown into relief by the abolition of anonymous gamete donation since April 2005. This was informed by advances in medicine that make DNA testing more accessible, by treatments that work with genetic material, by a culture that is making information and records more available and by those who recognize a benefit from avoiding secrets in people's lives about identity, and the positive gains from knowing and having access to one's complete identity.
Is the client also the clinic and the wider clinical team? This raises a question about how involved the counselor should be in decisions on treatment, entries in patient notes or general feedback. It may be that information comes out about issues in someone's past e.g. about child rearing or illness. Should this be made available to the team or could it be that disclosure is contrary to the principle of fidelity and may also preclude therapeutic work which may bring the person to a place where treatment could be available and thus does not honor the ethical principle of justice. In the light of this, it is my view that the counselor should not be involved in these areas. The BACP Ethical Framework is extremely useful in helping practitioners to manage this and I refer to the section on Working with colleagues. The HFEA code of practice is also clear that counseling is confidential and notes must be kept separately from clinical notes and not be part of assessment.
However, many other people working in clinics have a role where they use counseling skills and have a different contract of confidentiality, for example confidentiality within the clinical team. It is here that I think the clinic and its staff are in some way in the client role. The counselor has a duty to explain difference of role and to ensure that they provide a service that others are confident to make a referral to and to understand when referrals are relevant. Once again, the section in the Ethical Framework on Working with colleagues is invaluable.
* The role in assessment
* The voluntary nature of the contract
* Informed consent
Reflection Exercise #8
Online Continuing Education QUESTION 22
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