According to Theodore P. Remley, Jr. , and Barbara Herlihy in Ethical, Legal, and Professional Issues in Counseling, once the proper set of codes of ethics has been determined, the counselor must consider how these principles can be applied to the dilemma to express a counselor’s commitment to professional values (2014). Applying codes of ethics often exposes the “gray area” existing in real-life ethical dilemmas, and forces the counselor to consider the implications of an ethical decision from multiple viewpoints.
In the case of Levi and Makena, both of whom function as individuals in private session in addition to their role as a couple within couples counseling sessions, examining the moral dimensions of the dilemma from multiple perspectives is especially paramount. When considering disclosure of Makena’s HIV-positive status, the counselor must consider how Makena’s autonomy is directly affected by the disclosure.
According to Dr. Holly Forester-Miller and Thomas Davis in “A Practitioner’s Guide to Ethical Decision Making,” the counselor can encourage autonomy by guiding an understanding of how decisions and values may be received by others, and how these factors relate to, or potentially infringe upon, the rights of others (1996). Conversely, the counselor must consider how Levi’s autonomy regarding his chosen level of involvement with persons living with HIV appears to be impacted by a failure to disclose this information.
Welfel identifies nonmaleficence as another dimension of ethical decision making within the “Ethical Decision Making Model” (2012). This concept, “above all else, do no harm,” reflects on the counselor’s obligation to not intentionally inflict harm, while also not engaging in or encouraging actions presenting harm to others (Welfel, 2012). The counselor must consider how disclosure interacts with the nonmaleficence principle: if the counselor comes to believe that non-disclosure of Makena’s HIV-positive status could lead to actions directly harming Levi, she must consider disclosing.
If the counselor is able to encourage Makena to self-disclose by encouraging her autonomy over the situation, nonmaleficence may become less of a consideration for immediate action. The counselor must also consider the principle of beneficence in deciding whether or not to disclose Makena’s HIV-positive status to Levi. Beneficence is defined by Forester-Miller and Davis as “to do good, to be proactive and also to prevent harm when possible” (1996).
This principle is directly correlated to the counselor’s respons counselor’s responsibility for the welfare of her client, and as such a full assessment of concerns must be made to make an adequate determination on a course of action (Forester-Miller & Davis, 1996). Does disclosing put Makena at risk of physical violence from her partner? How might disclosing to Levi be used to further stigmatize Makena based on her HIV-positive status (i. e. what if he shares this information with others)? Through the lens of beneficence, disclosing Makena’s status could put her at risk of losing her autonomy over future disclosures, or could act to put her health and safety in jeopardy.
These concerns must be weighted against the welfare of Levi, who is also a client of the counselor. How might not disclosing affect his own welfare? Corey et al. , quoting Kuo (2009), state that withholding secrets of one client to another does not act to move therapy forward, and as such cannot uphold the beneficence principle—something the counselor must consider (2015). The questions presented here are not answerable through the scope of the prompt alone, and as such would require a more thorough assessment of relevant facts. Another principle that must be considered is the justice principle.
Kitchener’s 1984 “Ethical Decision Making Model” makes a distinction between treating all individuals the same and “treating equals equally and unequals unequally but in proportion to their relevant differences” (as cited in ForesterMiller and Davis, 1996). In essence, equity is seen as preferable to equality in this step because it attempts to take into account the sociocultural factors that advantage some and disadvantage others. The counselor must carefully consider this principle in deciding whether or not to disclose Makena’s status to Levi; again, a full assessment is necessary to determine the equity existing between the clients.
The final principle that must be considered, the principle of fidelity, is a critical consideration because it is tied to the foundation of the counselor-client relationship (Forester-Miller and Davis, 1996). In order for clients to maintain trust in the counselor and contribute to the therapeutic relationship’s growth, the counselor must demonstrate loyalty by adhering to obligations to privacy and confidentiality (Forester-Miller and Davis, 1996). In deciding on whether or not to disclose Makena’s status to Levi, the counselor must consider what implications either action could have for her clients.
If she discloses Makena’s status, trust could be broken between Makena and the counselor, potentially resulting in the cessation of the therapeutic relationship. However, the inverse problem seems to apply if the counselor does not disclose: her relationship with Levi, her other client, becomes strained because failure to disclose has resulted in a failure to protect him from potentially contracting HIV. Forester-Miller and Davis note that theoretically all five principles hold equal moral weight, and encourage the counselor to self-determine what principles take precedent when multiple principles seem to be in conflict.
Because this situation involves two individuals to whom the counselor holds ethical obligations, and because these obligations seem to run counter to one another from the start, this becomes complicated. In addressing the hypotheticals of the scenario, the phrase “full assessment” points to the fact that many variables about the situation are unknown. It would seem that the counselor may need to create a more thorough inventory of the specifics of the situation before the impact of disclosing or not disclosing can be more fully realized.
Another consideration, addressed at the beginning of the case study, is the impact geographic positionality has in determining a course of action in HIV/AIDS related cases. Corey et al. encourage the counselor to seek legal counsel in such situation to determine the particular legal implications of disclosure (Corey et al. , 2015). Indeed, according to the Center for HIV Law and Policy, HIV case law currently exists as a patchwork of differing responsibilities that currently must be looked at on a case-by-case, state-by-state basis (“Confidentiality and Disclosure,” 2015).
In Georgia, disclosure is limited to physicians, administrators of the Department of Human Resources, legal entities, and health care providers authorized or order HIV tests under O. C. G. A. $24-9-47, and makes no mention of licensed professional counselors, or any other members of the helping profession. Because there are no available legal statutes to protect the counselor’s disclosure, and because all five principles seem to be in conflict, it seems that the counselor’s best course of action in this instance is to more fully assess the situation, and encourage Makena to self-disclose.
The counselor should offer to let the disclosure take place within the context of the couples counseling session in order to provide appropriate support and mediation, as well as information that the counselor has accrued, that might make both clients more fully informed as to the implications of Makena’s HIV-positive status going forward in their relationship.
If the counselor cannot convince Makena of the importance of self-disclosing her status to Levi, the counselor may have to take action to disclose to Levi—though her ethical obligation and duty to warn Levi may be in conflict with the statutes of her jurisdiction. Going forward, the counselor should consider the terms of her couples counseling sessions. To avoid ethical dilemmas as in the case of Levi and Makena, the counselor should cease offering individual counseling in conjunction with couples counseling to avoid disclosures such as Makena’s.
Corey et al. uggest that private disclosures such as Makena’s work in part to prevent such topics from surfacing in couples’ sessions—effectively rendering the couples counseling sessions benign, as disclosures are no longer being made within the bounds of the session, and encouraging “hidden agendas” of the multiple parties (2015). If no space is allowed for such disclosures to be made privately and the therapeutic relationship is seen as positive, it becomes more possible for Makena to disclose within the couples’ session, and for Levi and Makena to more fully attain established therapeutic goals.
