Nancy E. Thacker, Jillian M. Blueford
Counselors are becoming more involved with clients pursuing physician-assisted death (PAD) as legislation for legalization increases. PAD may present complex values-based conflicts that can challenge counselors to maintain ethical practice in counseling. When conflicts arise, counselors must engage in ethical decision making that considers systemic influences on personally held beliefs and values. The authors merge ecological systems theory with the counselor values-based conflict model to offer a holistic approach to resolving values-based conflicts surrounding PAD. In this article, the authors review PAD and counselors’ roles in the hastened death process, discuss sources and impacts of personal and professional values through an ecological systems lens, and provide an applied method of managing values-based conflicts with PAD through a case illustration.
Keywords: physician-assisted death, hastened death, values-based conflict, ethical decision making, ecological systems
Individuals with terminal illnesses encounter difficult end-of-life decisions amidst experiencing physical and emotional distress (Daneker, 2006). Currently in six U.S. states and Washington, DC, terminally ill individuals have a legal right to end their lives via physician-assisted death (PAD). As legislation for legalization of PAD increases, more terminally ill patients can consider PAD as an option (Miller, Hedlund, & Soule, 2006). As a result, the need for mental health professionals to assist individuals dealing with these end-of-life decisions is on the rise.
The topic of death presents complex questions about the meaning of life and death and evokes reflections on one’s personal beliefs and values surrounding death and dying (Yalom, 2009). Terminally ill individuals may confront their personal beliefs about a morally just or good death, explore feelings about the process of dying, and consider their levels of personal control or power in their processes of dying (Laakkonen, Pitkala, & Strandberg, 2004; Yalom, 2008). Religion and spirituality often contribute to terminally ill individuals’ beliefs and values surrounding death and dying and can influence end-of-life decisions (Reiner, 2007). Each personal belief and value is influenced by systemic factors, cultural experiences, and cultural customs or expectations that play a role in end-of-life decision making (Laakkonen et al., 2004; Neimeyer, Klass, & Dennis, 2014).
Counselors will confront their beliefs and values about death and dying as terminally ill individuals who are contemplating PAD (PAD clients) seek counseling to explore end-of-life decisions (Werth & Crow, 2009). If counselors’ beliefs and values conflict with PAD clients’ beliefs and values, or PAD itself, then it may present an ethical dilemma that challenges the quality of care counselors provide (Heller Levitt & Hartwig Moorhead, 2013). Although not all counselors may experience a value conflict related to PAD, those who do experience a conflict may look to the American Counseling Association’s (ACA) Code of Ethics (2014) and an ethical decision-making model that accurately addresses the values-based nature of the ethical dilemma at hand.
Multiple scholars have discussed the need to explore values related to personal conflicts to maintain ethical practice in counseling (Cottone & Tarvydas, 2016). However, few sources have yet to provide direction for counselors on how to resolve personal values-based conflicts regarding PAD. There is an added layer of difficulty with PAD clients because of the multifaceted nature of personal and professional values at play. Counselors are grounded on the ethical principles of promoting client autonomy and respecting cultural differences in decisions (ACA, 2014), but hastening death conflicts with the counseling profession’s inherent stance to “first do no harm” and to maintain client safety and preserve life when clients desire to end their lives (Cohen, 2001). Even though hastening death is legal in certain states, values surrounding the decision to end life do not simply cease because there is justified reasoning for a decision. Thus, counselors face a challenging dichotomy between law and values in their practice with PAD clients.
Recent changes in the counseling profession’s ethical code also contribute to the potential challenge of maintaining ethical practice with PAD clients. The ACA Code of Ethics (2005) included codes that addressed counseling practice with clients considering end-of-life options. Section A.9 in the ACA Code of Ethics (2005) provided guidelines about the quality of care counselors should uphold for clients facing the end of their life, including the counselor’s role in assisting clients with end-of-life decisions. Counselors were tasked with the responsibility to reflect upon personal values and morals regarding end-of-life to ensure competent and ethical care. Although the revised ACA Code of Ethics (2014) includes considerations for confidentiality, legal concerns, and client safety during end-of-life care, there is no longer a designated section for the end-of-life care of terminally ill clients, and explicit codes regarding PAD are absent. The ACA Code of Ethics (2014) included guidelines for counselors regarding methods to maintain client autonomy and seek continuing education to address the holistic needs of clients, along with giving clients the tools necessary to make the most appropriate decisions for their care. However, lack of explicit codes about PAD and few guidelines related to end-of-life care might cause ambiguity when values-based ethical dilemmas about PAD arise.
In summary, consideration for counselors’ personal and professional values, along with the ethical and legal implications at hand, creates unique potential for a values-based conflict surrounding PAD unlike other sources of values-based conflicts. Values are influenced by numerous factors in multiple settings and contexts (Heller Levitt & Hartwig Moorhead, 2013). Therefore, resolving value conflicts related to PAD warrants a unique systemic perspective that considers the multiple influential sources that shape values about death and grief in personal and professional realms (Neimeyer et al., 2014).
The authors of this article review PAD, counselors’ roles in the hastened death process, and an applied method of managing values-based conflicts with PAD through a values-based ethical decision-making model and ethical bracketing. The impacts of personal and professional values will be described through an ecological systems lens. It is important for counselors to understand PAD in the context of various systems, as individuals’ decisions concerning PAD are influenced by multiple sources that contribute to their beliefs and values related to death and dying.
PAD is currently legal in six U.S. states: California, Colorado, Montana (by court ruling), Oregon, Vermont, and Washington, as well as Washington, DC (Death with Dignity, 2018). Hawaii will become the seventh state to legalize PAD when their legal statute takes effect in January 2019 (Death with Dignity, 2018). PAD has been a topic of debate throughout American society and health care for decades (Werth & Holdwick, 2000). Many have voiced opposition to PAD as a legalized option (Werth & Holdwick, 2000), and previous “standards of mental health practice [have treated] all suicides as products of mental illness” (Cohen, 2001, p. 279). However, health care advocates of PAD, such as Dr. Jack Kevorkian, have fought for individual rights to choose dignified death when faced with terminal illness (Kevorkian, 1991). As the legalization of PAD emerged in the aforementioned states, the topic of debate shifted from the right to choose hastened death toward the policies that guide health care professionals to assist terminally ill individuals in hastening their deaths (Werth & Holdwick, 2000).
Language within each state statute slightly varies, but requirements to legally hasten death are similar across states. There are no formal requirements for PAD in Montana, because a law permitting PAD does not exist in that state; however, there is a legal precedent that protects physicians from prosecution as long as there is written consent from the patient (Baxter v. Montana, 2009). For all other states, patients must be over the age of 18, permanent residents of the state, have been determined by an attending and consulting physician to be suffering from a terminal illness, and carry a life expectancy of under 6 months to be eligible to legally hasten their deaths. Patients must voluntarily express their wishes to die orally, make a written request for medication to end their lives in a humane and dignified manner, and be deemed mentally competent to make end-of-life decisions by a licensed psychiatrist or psychologist. In addition, there is typically a 15-day waiting period between the initial request and when the physician provides a written prescription for medication to end life (Death with Dignity, 2018).
In the legal requirements of each state and district statute, there is no mandate for counseling services beyond an assessment of competency. However, PAD clients and their families often work with mental health professionals throughout the process of considering hastened death and implementing PAD (Fulmer, 2014). As more states move toward legislation to legalize PAD, counselors are becoming more involved in the interdisciplinary teams of health professionals working to meet the needs of this population. Interdisciplinary teams may be comprised of medical physicians, psychiatrists, psychologists, social workers, palliative care nurses and specialists, occupational therapists, and mental health counselors (O’Connor & Fisher, 2011). Clients pursuing PAD have physical, social, emotional, spiritual, and practical needs as they deal with the process and experience of dying (Daneker, 2006). Helping professionals’ roles can be blurred as the interdisciplinary team works together to meet PAD clients’ needs (O’Connor & Fisher, 2011). Physical needs include keeping clients comfortable in their final months of life when all other treatment options are exhausted. Practical needs include making arrangements for after death and navigating the legal processes to hasten death, including the competency assessment a psychiatrist or psychologist must conduct to ensure that PAD clients are stable and well-informed enough to decide to hasten their death (O’Connor & Fisher, 2011). Clients’ social, emotional, and spiritual needs will vary depending on the nature of the terminal illness, individual contexts, and familial and cultural contexts; counselors are trained to address such biopsychosocial needs within clients’ individual and cultural contexts (Peruzzi, Canapary, & Bongar, 1996; Werth & Crow, 2009).
A counselor’s primary role is to address how clients’ medical diagnoses are impacting their biopsychosocial well-being, including their decision-making processes to hasten death (O’Connor & Fisher, 2011; Peruzzi et al., 1996; Werth & Crow, 2009). Counselors build a unique therapeutic relationship that provides professional emotional support, and they help clients reflect on the factors that have led them to make this life-ending decision. They may explore what hastened death means to clients’ families or communities. Counselors also seek to understand how clients’ spiritual beliefs and emotional needs influence their well-being and decision making. Counselors recognize that spirituality and religious practices can be significant to clients when discussing dying, death, and grief (Altmaier, 2011). Addressing these factors allows counselors to be intentional in creating a safe setting for difficult discussions.
Standards of Counseling Practice With Dying Clients
The ACA Code of Ethics (2014) not only serves as a guide to ethical practice in counseling, but also provides an understanding of the goals and mission of the counseling profession. Counselors are committed to engaging in “a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health [and] wellness” (ACA, 2014, p. 3). In order to engage in such a relationship with ethical integrity, counselors consider the six principles of ethical behavior: autonomy, nonmaleficence, beneficence, justice, fidelity, and veracity (ACA, 2014). These principles are foundational to the ways in which counselors practice ethically across diverse client groups and settings. Counselors working with PAD clients should review relevant ethical codes concerning end-of-life issues, personal value conflicts, and confidentiality concerns pertinent to fulfilling the needs of terminally ill clients. Of these relevant issues, one specific code includes guidance in managing personal values in counseling:
Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors.
Counselors respect the diversity of clients . . . and seek training in areas in which they are at risk
of imposing their values onto clients, especially when the counselor’s values are inconsistent with
the client’s goals or are discriminatory in nature. (ACA, 2014, A.4.b)
As counselors confront the socioemotional and spiritual needs of PAD clients, regulating personal values related to PAD is of utmost importance for the well-being of a dying client (Werth, 1999).
Values and PAD
Personal values exist at individual, professional, and societal levels. Counselors develop and mold their values in multiple contexts and through various experiences in their lifetime. Thus, counselors’ values surrounding death, dying, and PAD are multifaceted and influenced by multiple factors. Counselors’ views and values surrounding death may be impacted by age, race, gender, religion or spiritual beliefs, phase of life, family structure and influence, cultural identity (e.g., individualistic vs. collectivistic), and education (Bevacqua & Kurpius, 2013; Harrawood, Doughty, & Wilde, 2011; Kemmelmeier, Wieczorkowska, Erb, & Burnstein, 2002). How these factors are interwoven into personal views and values depends on counselors’ perceptions of their experiences and influences from their surrounding environments.
Because personal values are constructed and influenced by a multitude of factors and environments (Heller Levitt & Hartwig Moorhead, 2013), a systemic perspective can be used to appropriately explore and understand how personal values may form and influence counselors. Bronfenbrenner (1979) established the ecological model to describe an individual’s development within four ecosystems: the microsystem, mesosystem, exosystem, and macrosystem. In 1994, Bronfenbrenner revised the ecological model to include the chronosystem, which considers the influence of time and history as individuals develop. Each ecosystem interacts with the others and influences how each ecosystem forms and impacts the developing individual. The ecosystems can be understood as “a set of nested structures, each inside the next, like a set of Russian dolls” (Bronfenbrenner, 1979, p. 3). Next to the chronosystem, the outermost system, the macrosystem encompasses one’s culture, societal norms, and traditions. The exosystem lies within the macrosystem and represents the interactions between environments that may or may not directly affect an individual’s daily interactions. An example of this system would be a parent having trouble at work, and that stressor then affecting the relationship with the child. Within the exosystem is the mesosystem. The mesosystem includes the interactions between the individual’s microsystem and has direct effects on the individual. Lastly, the microsystem involves the individual’s immediate settings and relationships. Relationships can include family and caregivers among others in the environment. Each of these ecosystems and the interactions between them impact the developing individual’s behaviors (Bronfenbrenner, 1979).
Within a systemic ecological perspective, beliefs and values can be viewed as forming and ensuing through layers of influence first from the macrosystem and filtered down through the exosystem, mesosystem, and microsystem (Bronfenbrenner, 1979). The chronosystem includes a history of culture that influences development over time, but the cultural expressions of such influence play out in the macrosystem (Bronfenbrenner, 1994). The macrosystem, the most external of systemic influence, can include societal norms of death and dying and a religious or spiritual belief system. These norms and belief systems influence the exosystem, where laws and regulations exist (e.g., the right for individuals to hasten death in legalized states). Events that occur in the exosystem might not directly include counselors, but they impact the ways in which counselors interact with their lower systems (e.g., news reports of terminally ill patients miraculously overcoming illness).
Through the mesosystem structure, counselors directly engage with multiple settings that influence their beliefs surrounding death and dying (e.g., work and family). Counselors’ interactions with two settings, such as workplace and family, will shed light onto how beliefs, values, and behaviors about death and dying are experienced in each setting. Counselors’ values are subsequently influenced by the interactions between the two settings. Finally, direct experiences in counselors’ immediate settings, the microsystem, impact the unique views and values counselors espouse. Although values filter through larger systems with influence from external factors that impact multiple people, counselors will form distinct perceptions of their experiences that inform their intrapersonal reactions to death and dying (Werth & Crow, 2009).
As counselors consider each layer of the surrounding environment that informs their personal values, they face the values of the counseling profession in the mesosystem. The ACA Code of Ethics (2014) highlighted five fundamental professional values:
- enhancing human development throughout the lifespan;
- honoring diversity and embracing a multicultural approach in support of the worth, dignity,
potential, and uniqueness of people within their social and cultural contexts;
- promoting social justice;
- safeguarding the integrity of the counselor–client relationship; and
- practicing in a competent and ethical manner. (p. 3)
These values provide a foundation for counselors’ ethical behaviors and decisions and inform the collective identity of the counseling profession.
Counselors first encounter professional values in their training programs and are continually exposed to new expressions of professional values throughout their careers. Counselors are nurtured throughout their development to integrate their personal attributes with professional factors as they form an identity congruent with the counseling profession (D. M. Gibson, Dollarhide, & Moss, 2010; Post & Wade, 2009). The ways in which counselors integrate professional values and develop their identities depends on the culture of their training programs, professional work settings, experiences in those settings, and individual perceptions that form from those experiences (Francis & Dugger, 2014). As a result, counselors may vary in their level of support for PAD, personal conflicts related to PAD, and general beliefs and values about death and dying. Therefore, counselors must evaluate their values at a personal and professional level as they work through value conflicts and ethical dilemmas with PAD clients (Johnson, Hayes, & Wade, 2007).
Ethical Decision Making and Bracketing
Counselors’ abilities to resolve value conflicts are determined through ethical decision making (Cottone & Tarvydas, 2016; Kocet & Herlihy, 2014). The ACA Code of Ethics (2014) serves as a guide to counselors to uphold equitable standards of care across client populations when ethical dilemmas and value conflicts arise. According to ACA:
When counselors are faced with ethical dilemmas that are difficult to resolve, they are expected to
engage in a carefully considered ethical decision-making process, consulting available resources as
needed. Counselors acknowledge that resolving ethical issues is a process; ethical reasoning
includes consideration of professional values, professional ethical principles, and ethical
standards. (ACA, 2014, p. 3)
Becoming an ethical decision maker is most effectively done through practice in intentional decision-making processes (P. A. Gibson, 2008). There are many ethical decision-making models that are relevant to maintaining ethical integrity during a variety of dilemmas (Cottone & Tarvydas, 2016). Counselors most often use practice-derived models that are produced from counselors’ experiences and are intended to provide a step-by-step guide for practice (Cottone & Tarvydas, 2016). Although each model is distinct in its step-by-step process, there are common elements throughout them that highlight a standard of practice for ethical decision making. Significant commonalities include gathering information; considering the context of the situation; reviewing codes, standards, and laws; evaluating the counselor’s values or biases; consultation; developing a plan; and executing the plan. For counselors working with PAD clients, their decision-making processes will require a more in-depth exploration of the context of the situation, counselors’ values and biases, and the counseling profession’s values (Heller Levitt & Hartwig Moorhead, 2013; Kurt & Piazza, 2012). Thus, a decision-making model that carefully considers values-based conflicts is needed.
Using a practice-derived framework, Kocet and Herlihy (2014) developed the counselor values-based conflict model (CVCM) to specifically address ethical dilemmas stemming from value conflicts. The model includes five steps: (1) determine nature of values-based conflict (personal or professional); (2) explore core issues and potential barriers to providing appropriate standard of care; (3) seek assistance/remediation for providing appropriate standard of care; (4) determine and evaluate possible courses of action; and (5) ensure that proposed actions promote client welfare (Kocet & Herlihy, 2014). Each step includes consideration for potential personal and professional values that may arise for counselors.
A key part of resolving values-based conflicts is avoiding imposing one’s values onto the client. To address this key issue, Kocet and Herlihy (2014) also introduced the term ethical bracketing. Ethical bracketing in qualitative research is “a reflexive process [that] enables [researchers] to bracket or set aside their own experiences and assumptions when they interact with their participants and thus accurately capture their participants’ voices” (Kocet & Herlihy, 2014, p. 182). To apply this concept to counseling, Kocet and Herlihy stated that ethical bracketing
is defined as the intentional separating of a counselor’s personal values from his or her
professional values or the intentional setting aside of the counselor’s personal values in order to
provide ethical and appropriate counseling to all clients, especially those whose worldviews,
values, belief systems, and decisions differ significantly from those of the counselor. (p. 182)
Counselors can engage in ethical bracketing by seeking supervision, consultation, continuing education, and personal counseling (Kocet & Herlihy, 2014). This bracketing technique allows counselors to confront their values and establish awareness of how their values may be impacting their views and interactions with clients. Counselors may more easily recognize the unique worldviews of clients through this process, thereby respecting the diversity of clients in their cultural contexts. Such recognition protects the welfare of clients as counselors strive to work from the client’s worldview rather than their own (ACA, 2014). The CVCM, along with ethical bracketing, can be used as a guiding ethical decision-making framework for counselors to explore the systemic nature of their values and resolve values-based conflicts with PAD.
Values-Based Ethical Decisions and Bracketing With PAD
The CVCM is designed to assist counselors in managing personal conflicts related to values that may arise when working with clients (Kocet & Herlihy, 2014). The model begins with a prompt for counselors to determine if the nature of the conflict is personal or professional and ensues with steps that align with the nature of the conflict. However, considering the systemic makeup of individual values, particularly related to PAD, counselors must be mindful of the influences that stem from the profession’s values in the formation and modification of their personal values. Personal and professional values are interwoven and will consequently impact the ethical decision-making process related to values-based conflicts with PAD (Heller Levitt & Hartwig Moorhead, 2013). As a result, adding a systemic lens to the process of resolving values-based conflicts using the CVCM and ethical bracketing is important to maintaining ethical practice with PAD clients.
The systemic sources of values related to PAD are important to consider in the second step of the CVCM; this step includes a prompt for counselors to “explore core issues and potential barriers to providing appropriate standard[s] of care” (Kocet & Herlihy, 2014, p. 184). Gathering awareness about counselors’ personal views related to death, dying, and PAD is the crux of working through this step in the model. As previously discussed, counselors must engage in reflective practice to examine influential factors throughout each ecosystem. Each system contributes to counselors’ personal views and beliefs, and reflecting will bring awareness to not only the sources of counselors’ values, but also potential barriers to overcoming values-based conflicts (Bronfenbrenner, 1979; Cottone & Tarvydas, 2016; Kocet & Herlihy, 2014).
Beginning with the macrosystem, societal norms and religious and spiritual views of death and dying will influence the exosystem. Legislation that gives clients legal freedom in certain states to decide to end their lives is situated in the exosystem. As the decision to engage in PAD is legalized, it then trickles down into the mesosystem where groups, such as work colleagues and family, hold beliefs and values about PAD. These beliefs and values influence counselors in new ways and impact the intrapersonal reactions counselors have in their microsystem of experience. Counselors must examine the interactions between settings and the messages they receive in those settings. Then, they may more readily discover how their values and beliefs about PAD are formed and either reinforced or undermined. Increased awareness will help counselors identify the ecosystem that is the most salient source of their value conflict with PAD (Bronfenbrenner, 1979). Identifying the salient source may then lead to increased potential for counselors to be more specific in the ways they strategize to bracket their values.
As counselors foster awareness about the sources of their value conflicts, they can move into the third step and engage in ethical bracketing as a strategy to seek necessary assistance to resolve value conflicts. In addition to referring to the ACA Code of Ethics (2014), counselors may consult with other counselors to explore individualized strategies to engage with PAD clients without imposing personal beliefs and value systems. Consultation with other professionals will shed light onto professional standards of care for PAD clients, while also serving as a mirror for further self-exploration about the sources and nature of value conflicts with PAD. It is important to note that counselors should “identify ways to maintain personal/religious/moral beliefs while still providing effective counseling” (Kocet & Herlihy, 2014, p. 184). Ethical bracketing is not designed to push counselors to give up their beliefs or values; rather, counselors simply “set aside their own experiences and assumptions” to effectively step into the client’s worldview (Kocet & Herlihy, 2014, p. 182). Seeking supervision, consultation, and personal counseling can provide guidance for counselors to determine their needs to maintain their personal beliefs and deliver ethical care for PAD clients (Cottone & Tarvydas, 2016; Kocet & Herlihy, 2014).
Next, counselors shift into the fourth step to “determine and evaluate possible courses of action” (Kocet & Herlihy, 2014, p. 184). Using ethical bracketing as a strategy may provide distinct options to consider in this step. Once counselors are aware of the intricacies of their values-based conflict with PAD, they may be more readily able to bracket their values. The guidelines for use of the CVCM in the fourth step note client referral; however, counselors may only refer when they “lack the competence to be of professional assistance to clients,” and their rationale is not the result of personal bias (ACA, 2014, A.11.a.). If counselors lack competence, they may seek appropriate continuing education and supervision to expand their competency in the future. However, in the case of personal value conflicts, referral is not ethical. There is no statement in the ACA Code of Ethics (2014) “that [indicates] referral can be made on the basis of counselor values” (Kaplan, 2014, p. 144). Self-evaluation and consultation is essential to maintain ethical practice surrounding this topic. Once a course of action has been determined as ethical and effective, counselors engage in the fifth step to “ensure that proposed actions promote client welfare” (Kocet & Herlihy, 2014, p. 184). In order to more fully conceptualize resolving values-based conflicts with PAD through this model, a specific example is provided in the following section.
Case Study Application
The following case study explores a counselor’s values-based conflict related to PAD for illustrative purposes. Although many sources may contribute to potential values-based conflicts, personally held religious beliefs are often influential to views and values about PAD (Bevacqua & Kurpius, 2013; Burdette, Hill, & Moulton, 2005; Reiner, 2007). Therefore, personal religious beliefs are explored for the purposes of this case study. Considering a systemic view of counselors’ values, the CVCM and ethical bracketing are used to generate potential conflict resolutions that ensure ethical practice and protect the welfare of the client.
Amy is a licensed professional counselor in the state of Washington. She works for an agency that receives referrals from a local hospital. Amy identifies as a religious person and has connections and support through her religious community. Her personal religious views do not endorse hastening one’s death, even under extreme circumstances like a terminal illness. Amy also has two young children.
Amy has been meeting with Frankie, a 40-year-old woman, for about four months. Frankie was diagnosed with leukemia about six months ago and began treatment shortly thereafter. Frankie recently found out that the leukemia is not responding to treatment and her treatment options are exhausted. Frankie’s oncologist has estimated a five- to six-month life expectancy. Frankie has expressed to Amy that she wants to pursue PAD so that she does not have to be in pain for 6 more months. Frankie has a husband and 6-year-old daughter.
Amy is initially shocked to hear Frankie’s desire to hasten her death. Amy is unsure how to proceed in her work with Frankie because she feels Frankie’s decision conflicts with her religious beliefs. Amy also is wondering if Frankie has considered how her family feels and if they would be okay with Frankie’s decision. Recognizing she needs to process her thoughts and feelings, Amy seeks out a helpful colleague in order to proceed in her work with Frankie.
Beginning with the first step of the CVCM, Amy appears to be dealing with a complex values-based conflict. The nature of Amy’s conflict is primarily personal, but she is faced with some professional conflicts as well. Amy’s religious beliefs and values are personally driven, but the countertransference she is experiencing related to Frankie’s seeming lack of concern for her family can become a professional issue if Amy considers making professional decisions that emphasize family values over Frankie’s requests (Heller Levitt & Hartwig Moorhead, 2013). Furthermore, Amy’s personal religiously driven value conflict intertwines with the counseling profession’s value and ethical standard to respect clients’ worldviews and not impose personal beliefs onto clients (ACA, 2014, A.4.b). Understanding both personal and professional implications allows counselors to move into the second step of the CVCM.
The development and context of Amy’s values may be explored through a systemic ecological lens in the second step. Beginning with the macrosystem, Amy may consider how her religious culture views death and what messages she has internalized to form her understanding of morality and autonomy (Burdette et al., 2005; Johnson et al., 2007). She also could explore how society at large influences her religious beliefs and practices and subsequently how she believes her religion views the practice of hastened death. The interaction between Amy’s religious culture and society is situated in the exosystem. Amy’s interactions with her religious community, which are a part of her mesosystem, also will play a role in her beliefs and actions. She might think about how her immediate community impacts her beliefs and influences her perceptions of hastened death; Amy’s individual perceptions and direct engagement with her religious practices play out in her microsystem. As each ecosystem is explored, Amy can develop a clear understanding of the sources of her value conflict. The same process should be repeated for her values-based conflict about Frankie’s family. Amy may value collective family decisions and could potentially struggle to meet Frankie with acceptance if she believes an isolated decision is improper.
Once Amy has explored the systemic sources of her values, she is ready to seek assistance to ethically move forward with Frankie in the third step of the CVCM. Using ethical bracketing, Amy can reach out to her colleagues to consult about the issues at hand. Exploring her values with a trusted professional may enable her to bracket her values to approach Frankie’s differing beliefs and values. Amy must review the ACA Code of Ethics (2014) before creating a plan of action. Again, Code A.4.b, regarding personal values and biases, is central to an ethical course of action; the profession’s value of client autonomy and Code A.1.a, to protect the welfare of the client, also are important to consider here (ACA, 2014). Attending to legal implications, Amy should keep in mind that Frankie has a legal right in the state of Washington to decide to hasten her death. Lastly, Amy should consider ways she can maintain her own values without compromise while still providing effective care and assistance to Frankie in her decision-making process (Kocet & Herlihy, 2014). Amy may pursue personal counseling or supervision and connect with trusted individuals in her religious community to maintain her personal beliefs and values while providing ethical care (Cottone & Tarvydas, 2016; Johnson et al., 2007).
Moving into the fourth step of the CVCM, referral is an option only if Amy lacks competence to provide Frankie with effective care. According to the CVCM, when a counselor is determining action plans, the choice to refer a client is decided after careful consideration of ethical guidelines, rationale for the referral, and in-depth consultation (Kocet & Herlihy, 2014). Referral based on personal values is not ethical according to the ACA Code of Ethics (2014); therefore, Amy cannot ethically refer Frankie, considering the source of her conflict is related to personal values.
Finally, in the fifth step, Amy can ensure her constructed course of action considers both legal and ethical implications. The rationale for Amy’s action plan should be based on professional competency, not personal bias (ACA, 2014, A.11.a). Amy’s ability to effectively bracket her values will be dependent on her depth of self-exploration, understanding of ethical practice in counseling, willingness to consult and seek appropriate resources, and ability to ensure client welfare as the priority. It is essential for Amy to seek consultation from her professional peers, who can provide insight into maintaining ethical boundaries with clients. Also, Amy can receive permission to speak with Frankie’s lawyer and the primary doctors involved with her decision to hasten her death. By increasing involvement with Frankie’s interdisciplinary team, Amy is ensuring holistic care and attending to the systemic nature of end-of-life decision making surrounding PAD.
Implications for Counseling Practice
The interplay between PAD and the values of counselors and the counseling profession is complex and warrants depth of exploration for counselors to effectively meet the needs of this population. Values-based conflicts do not occur in isolation; instead, multiple systems that impact individuals in varying ways influence the formation and expression of such conflicts (Heller Levitt & Hartwig Moorhead, 2013). No one specific cultural identity, belief, or value can predict a counselor’s conflicts with PAD, but it is crucial to explore values through a systemic lens to successfully manage values-based conflicts with PAD. The CVCM, along with ethical bracketing, can serve as an appropriate framework to confront and resolve values-based conflicts with PAD. Counselors will be better equipped to provide care to PAD clients as they willingly and openly explore their values related to death, dying, and hastening death through an ethical decision-making model (ACA, 2014). Counselors’ effectiveness in self-reflection and ethical practice is reliant in part on counselor education.
As state laws change, counselor educators need to recognize that counselors will play a larger role in caring for potential PAD clients. It can be beneficial to learn about the role of value bracketing in regard to discussing the possibility of a client exploring the option of PAD. It is difficult for counselor educators to prepare counselors-in-training (CITs) for every potential ethical dilemma. However, with a better understanding of PAD, novice counselors can feel more equipped to effectively address concerns their clients may have without interference of their personal beliefs and values. PAD is a topic that will continue to expand. Introducing PAD during training may allow counselors to feel more prepared should a value conflict arise. As counselor educators facilitate conversations with CITs about their personal and professional beliefs toward PAD, CITs can implement their value bracketing skills under the supervision of their faculty. Being in a safe environment can encourage CITs to explore their authentic feelings concerning PAD and evaluate their value bracketing skillset. Addressing concerns and potential red flags during training can prevent harm to future clients and unethical clinical judgment and behaviors.
There is a potential challenge in maintaining consistency in training about end-of-life issues, including PAD, because of the nature of accreditation standards for counseling programs. There is no specific standard of learning in the 2016 Council for Accreditation of Counseling and Related Educational Programs (CACREP) standards regarding end-of-life counseling issues (CACREP, 2016). Counselor educators are tasked to meet learning standards related to human growth and development “across the lifespan,” but they have discretion over what they include and highlight throughout their curriculum (CACREP, 2016, p. 10). Counselor educators should consider the importance and advantages of including specific instruction on end-of-life issues in their curriculum (Servaty-Seib & Tedrick Parikh, 2014).
In addition to educating CITs, more research is needed to further understand counselors’ developing roles with clients pursuing PAD. With more states legalizing this procedure, it is only a matter of time before counselors are face-to-face with a client that needs a counselor’s experience and competency to assist with this life-changing decision. Although data is available concerning grief and loss counseling, literature directly related to counselors’ roles in working with PAD is sparse. Future research should incorporate counselors’ emerging roles with PAD clients and needs for training to prepare CITs. With stronger research in this area, counselor educators may feel more equipped to teach and support CITs
to become aware of and potentially bracket their values about death, dying, and PAD.
Counselors must be knowledgeable about the legal and ethical standards surrounding PAD in order to work effectively and ethically with PAD clients. Counselors also need to be aware of their personal beliefs and values about death and dying and be able to manage values-based conflicts. This article highlighted personal and professional values relevant to counselors working with PAD clients through an ecological systems lens. Considering the values at play, counselors can use the CVCM with ethical bracketing as an integrated method to resolve value conflicts with PAD (Kocet & Herlihy, 2014). Increased knowledge regarding ethical decision making surrounding PAD can encourage counselors to provide care for PAD clients with competence and confidence. Further research on counselors’ roles with PAD clients and needs for training may enhance counselors’ knowledge and competency with this client population.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
Altmaier, E. M. (2011). Best practices in counseling grief and loss: Finding benefit from trauma. Journal of Mental Health Counseling, 33, 33–45. doi:10.17744/mehc.33.1.tu9wx5w3t2145122
American Counseling Association. (2005). 2005 code of ethics. Retrieved from https://www.counseling.org/docs/default-source/library-archives/archived-code-of-ethics/codeethics05.pdf
American Counseling Association. (2014). 2014 code of ethics. Retrieved from https://www.counseling.org/resou rces/aca-code-of-ethics.pdf
Baxter v. Montana, 224 P.3d 1211 (Mont. 2009).
Bevacqua, F., & Kurpius, S. (2013). Counseling students’ personal values and attitudes toward euthanasia. Journal of Mental Health Counseling, 35, 172–188. doi:10.17744/mehc.35.2.101095424625024p
Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press.
Bronfenbrenner, U. (1994). Ecological models of human development. In International Encyclopedia of Education (Vol. 3, 2nd ed.). Oxford, UK: Elsevier.
Burdette, A. M., Hill, T. D., & Moulton, B. E. (2005). Religion and attitudes toward physician-assisted suicide and terminal palliative care. Journal for the Scientific Study of Religion, 44, 79–93.
Cohen, E. D. (2001). Permitted suicide: Model rules for mental health counseling. Journal of Mental Health Counseling, 23, 279–294.
Cottone, R. R., & Tarvydas, V. (2016). Ethics and decision making in counseling and psychotherapy (4th ed.). New York, NY: Springer.
Council for Accreditation of Counseling and Related Educational Programs (2016). 2016 CACREP standards. Retrieved from http://www.cacrep.org/wp-content/uploads/2018/05/2016-Standards-with-Glossary-5.3.2018.pdf
Daneker, D. (2006). Counselors working with the terminally ill. In VISTAS 2006 (pp. 1–13). Retrieved from https://www.counseling.org/Resources/Library/VISTAS/vistas06_online-only/Daneker.pdf
Death with Dignity. (2018). Death with dignity acts. Retrieved from https://www.deathwithdignity.org/learn/death-with-dignity-acts/
Francis, P. C., & Dugger, S. M. (2014). Professionalism, ethics, and value-based conflicts in counseling: An introduction to the special section. Journal of Counseling & Development, 92, 131–134.
Fulmer, R. (2014). Physician-assisted suicide, euthanasia, and counseling ethics. In Ideas and research you can
use: VISTAS 2014. Retrieved from https://www.counseling.org/docs/default-source/vistas/article_53.
Gibson, D. M., Dollarhide, C. T., & Moss, J. M. (2010). Professional identity development: A grounded
theory of transformational tasks of new counselors. Counselor Education and Supervision, 50, 21–37.
Gibson, P. A. (2008). Teaching ethical decision making: Designing a personal value portrait to ignite creativity and promote personal engagement in case method analysis. Ethics & Behavior, 18, 340–352. doi:10.1080/10508420701713022
Harrawood, L. K., Doughty, E. A., & Wilde, B. (2011). Death education and attitudes of counselors-in-training toward death: An exploratory study. Counseling and Values, 56, 83–95.
Heller Levitt, D., & Hartwig Moorhead, H. J. (2013). Values and ethics in counseling: Real-life ethical decision making. New York, NY: Routledge.
Johnson, C. V., Hayes, J. A., & Wade, N. G. (2007). Psychotherapy with troubled spirits: A qualitative investigation. Psychotherapy Research, 17, 450–460. doi:10.1080/10503300600953520
Kaplan, D. M. (2014). Ethical implications of a critical legal case for the counseling profession: Ward v. Wilbanks. Journal of Counseling & Development, 92, 142–146. doi:10.1002/j.1556-6676.2014.00140.x
Kemmelmeier, M., Wieczorkowska, G., Erb, H.-P., & Burnstein, E. (2002). Individualism, authoritarianism, and attitudes toward assisted death: Cross-cultural, cross-regional, and experimental evidence. Journal of Applied Social Psychology, 32, 60–85. doi:10.1111/j.1559-1816.2002.tb01420.x
Kevorkian, J. (1991). Prescription: Medicide, the goodness of planned death. Amherst, NY: Prometheus Books.
Kocet, M. M., & Herlihy, B. J. (2014). Addressing value-based conflicts within the counseling relationship: A decision-making model. Journal of Counseling & Development, 92, 180–186.
Kurt, L. J., & Piazza, N. J. (2012). Ethical guidelines for counselors when working with clients with terminal illness requesting physician aid in dying. Adultspan Journal, 11, 89–96.
Laakkonen, M. L., Pitkala, K. H., & Strandberg, T. E. (2004). Terminally ill elderly patient’s experiences, attitudes, and needs: A qualitative study. Omega: Journal of Death & Dying, 49, 117–129.
Miller, P. J., Hedlund, S. C., & Soule, A. B. (2006). Conversations at the end of life: The challenge to support patients who consider death with dignity in Oregon. Journal of Social Work in End-of-Life & Palliative Care, 2, 25–43. doi:10.1300/J457v02n02_03
Neimeyer, R. A., Klass, D., & Dennis, M. R. (2014). A social constructionist account of grief: Loss and the narration of meaning. Death Studies, 38, 485–498. doi:10.1080/07481187.2014.913454
O’Connor, M., & Fisher, C. (2011). Exploring the dynamics of interdisciplinary palliative care teams in providing psychosocial care: “Everybody thinks that everybody can do it and they can’t.” Journal of Palliative Medicine, 14, 191–196. doi:10.1089/jpm.2010.0229
Peruzzi, N., Canapary, A., & Bongar, B. (1996). Physician-assisted suicide: The role of mental health professionals. Ethics & Behavior, 6, 353–366. doi:10.1207/s15327019eb0604_6
Post, B. C., & Wade, N. G. (2009). Religion and spirituality in psychotherapy: A practice-friendly review of research. Journal of Clinical Psychology, 65, 131–146. doi:10.1002/jclp.20563
Reiner, S. M. (2007). Religious and spiritual beliefs: An avenue to explore end-of-life issues. Adultspan Journal, 6, 111–118. doi:10.1002/j.2161-0029.2007.tb00036.x
Servaty-Seib, H. L., & Tedrick Parikh, S. J. (2014). Using service-learning to integrate death education into counselor preparation. Death Studies, 38, 194–202. doi:10.1080/07481187.2012.738774
Werth, J. L., Jr. (1999). Mental health professionals and assisted death: Perceived ethical obligations and proposed guidelines for practice. Ethics & Behavior, 9, 159–183. doi:10.1207/s15327019eb0902_6
Werth, J. L., Jr., & Crow, L. (2009). End-of-life care: An overview for professional counselors. Journal of Counseling & Development, 87, 194–202. doi:10.1002/j.1556-6678.2009.tb00567.x
Werth, J. L., Jr., & Holdwick, D. J., Jr. (2000). A primer on rational suicide and other forms of hastened death. The Counseling Psychologist, 28, 511–539. doi:10.1177/0011000000284003
Yalom, I. D. (2008). Staring at the sun: Overcoming the terror of death. San Francisco, CA: Jossey-Bass.
Yalom, I. D. (2009). The gift of therapy: An open letter to a new generation of therapists and their patients. New York, NY: HarperCollins.
Nancy E. Thacker, NCC, is a doctoral candidate at the University of Tennessee, Knoxville. Jillian M. Blueford, NCC, is a doctoral candidate at the University of Tennessee, Knoxville. Correspondence can be addressed to Nancy Thacker, 501 BEC, 1122 Volunteer Blvd, Knoxville, TN 37996-3452, firstname.lastname@example.org.