Ethics of Informed Consent Ethical Dilemma: Imagine

Ethics of Informed Consent

Ethical Dilemma: Imagine a psychologist treating a minor child depression minor cutting. Because child's parents divorced, obtained consent treat child father, custodial parent. The mother (noncustodial parent) calls involved son's treatment.

Ethical dilemma: Treating a child of divorced patients

One of the most difficult issues for a therapist regarding the treatment of minors is the question of confidentiality. "An important aspect of treatment is to foster an individual's autonomy, and a great pleasure of treating adolescents is to watch as they come to enjoy their growing independence. One aspect of independence is privacy. As a child grows into adolescence and adulthood, the surrounding zone of privacy should increase, thus making room for a more defined sense of self and a greater sense of autonomy" (Behnke & Warner 2002: 44). In this instance, the custodial parent wants exclusive rights to be involved in the treatment of the minor, while the noncustodial parent also wants to be involved. The father has exclusive custodial rights to a young child of unspecified age who is under treatment for self-harm and depression. The noncustodial parent is the mother who is an alcoholic, not under treatment, who now wants to be involved in the child's care.

First and foremost the obligation of the therapist is to the client, not to either warring side of the participants involved in the divorce. "Standard 4.02, 'Informed Consent to Therapy,' states that when an individual cannot provide informed consent (such as a minor), psychologists 'consider such person's preferences and best interests.' Standard 4.03, 'Couple and Family Relationships,' states that psychologists 'attempt to clarify at the outset (1) which of the individuals are patients or clients and (2) the relationship the psychologist will have to each person'" (Behnke & Warner 2002: 44). The client is not the father or the mother, but rather the child.

Thus, the therapist must evaluate if it is in the client's best interest to have both parents involved in the therapy, and to what degree. Even if both parents are involved, they may not necessarily be involved at the same level. For example, the father may consent to treatment procedures, such as medication, but the mother may be present at specific sessions with the father there or may simply consult with the therapist over the phone. Although the child cannot legally give consent to have the mother involved, depending upon the age and the maturity of the child, the therapist may wish to discuss the possibility of having the mother involved, if the therapist feels it will be productive for the relationship.

While the law views consent in black-and-white terms in terms of age, in the therapeutic relationship the child's personality, mental health status, and developmental stage must be taken into consideration when making decisions. If it is suitable, as in the case of an adolescent, the therapist may wish to discuss the issue of the mother's involvement or noninvolvement at a meeting. If the child is younger or mentally fragile, and the therapist believes that having the mother involved in some aspects of the child's treatment will be helpful, he or she may wish to discuss the issue with the custodial parent in private.

It should be noted, however, that although there is a dividing line between being of age and able to give consent and being regarded as a minor, there are no hard and fast regulations regarding how to treat minor children of divorce. "All states have statutes addressing custody of minor children. Few, however, define the terms used in discussing this issue" (Souders, Strom-Gottfried & DeVito 2009: 1). In most instances, it is suggested although not required by ethical boards that "even though a non-custodial parent's consent is legally immaterial...it may still be ethically and clinically advisable to seek that person's assent (agreement) to treatment" (Souders, Strom-Gottfried & DeVito 2009: 2).

Regardless of what the final decision may be regarding the mother's involvement, a meeting between the father and the therapist -- or, if the child is deemed competent enough, between the child, father and therapist -- seems warranted. Such a meeting should take place ideally even before treatment begins. Typical discussions include the "limits of confidentiality (suspected abuse, danger to self or other) and the clinician's policies on sharing content from counseling sessions with the client's parents" (Souders, Strom-Gottfried & DeVito 2009: 3). This also provides the father with a forum to express in a more detailed and candid way why he believes his spouse's exclusion will benefit his son. The therapist can assess the degree to which personal animosity or the child's welfare is at issue. "Should the clinician decide to render treatment based solely upon one custodial parent's permission, he or she should discuss the possible repercussions of this stance with the parent (and the minor client, if age-appropriate)" (Souders, Strom-Gottfried & DeVito 2009: 3).

Although the therapist is treating the child, not the parents, the therapist can offer advice to assist the parents in improving their relationship in regards to the child's treatment, such as referring the mother to an alcoholic's support group like AA or both parents to another mediating body, such as another therapist or a trained facilitator. "Assisting an estranged couple to effectively communicate and create processes for addressing their children's needs is a worthwhile clinical objective in its own right, not simply an instrumental step to facilitate service to the child" (Souders, Strom-Gottfried & DeVito 2009: 3). If the mother becomes involved, a meeting between the therapist and mother (or all three family members, or the mother and child) should be held to discuss privacy issues as well.