# Get sued or kill someone: The trolly problems of Psychological practice.

The way I spend most of my day right now is as a student studying neuropsychology. I'm a fourth year, mature age student, and something has come up recently which made me think this community might have something to offer—how do people make choices relating to ethical dilemmas.

I’m doing a course now focused on solving ethical dilemmas within psychological practice. The reason this is heavily taught is that psychologists are often tied up in ethical problems which lead to lawsuits, getting de-registered, or even arrested. The occurrence numbers are quite high for all kinds of weird ethical issues. As you can imagine, there are all instances of boundaries which can be crossed, violated, dual relationships, misrepresenting competences, and sometimes, sadly, people die. So lawsuits and testifying before panels about the care which is given is not uncommon. Ergo, navigating ethical dilemmas can have large consequences.

At the core of many of these dilemmas are tensions between specifics within the code of ethics for psychological practice. I'm sure these codes vary from country to country broadly. But lets say you are not technically competent in working with depressed young girls especially around CBT therapies, but in your town, there are no other psychologists, and remote treatment is not possible—so its you or nothing. Technically, letter of the code, says this falls outside of your competence area, yet also, you have a duty of care to help prevent harm to this girl. So you can either practice outside of your competence, breaking one code, or ignore treatment for the girl entirely, breaking another code. There are probably better examples than this but ultimately, its just always the same thing, a tension between two elements of the code. Often, psychologists are sued because of choosing one path over the other. In the above example, you might treat the young girl, it doesn't pan out, she commits suicide, and the parent sues you. Or, you say its outside your competence, the girl feels helpless, and the same outcome occurs.

As the unit coordinators will say, there are lots of ways to navigate these ethical dilemmas, but something I notice is that the frameworks and formulas showcased are pretty vague*.* They resemble the kind of thing a management consultant might adopt.There doesn’t seem to be a lot of quantitative thinking here, and i’m curious what a rationalist *less wrong *approach might be in navigating dilemmas such as this. Obviously its difficult to answer a general question like this, but I'm imagining myself at the end of this whole learning journey, in practice, and it feels like most of the suggested ways of navigating these dilemmas could be vastly improved.

One method I’ve been given and seen is this Koocher & Keith-Spiegel (2008) eight step problem-solving model which goes something like this.

1.  Describe the parameters of  the situation.
2.  Define the potential ethical‐ legal issues involved.
3.  Consult ethical‐legal guidelines, if any, already available that might apply to the resolution of each  issue.  Consider the broad  ethical principles as well as  specific mandates involved.  Consider cultural characteristics salient to  decision.
4.  Evaluate the rights, responsibilities, and welfare of all affected parties.
5.  Generate a list of alternative  decisions possible for each issue.
6.  Enumerate the consequences of  making each decision.  Consultation with colleagues may be helpful.
7.  Present any evidence that the  various consequences or benefits resulting from each decision will actually occur (i.e., a risk‐benefit  analysis).
8.  Make the decision.  Consistent with  ethical codes, school psychologists  accept responsibility for the decision  made and monitor the  consequences of the course of  action chosen. 

At each one of these steps, I just see countless amounts of room for interpretation and can imagine how psychologists could use something like this and still make suboptimal choices.

I’m just curious how outsiders to psychological practice might consider solving ethical tensions. 

I can’t help but think that there must be a better more rationalist approach to these dilemmas that psychologists might not be considering because they are relying so heavily on supervision. One of the strategies they rely on a lot is to seek input from peers and supervisors who are competent. Yet as you would imagine, people, especially early career psychologists are more likely to seek council from people close to them, or people who *say *they are competent, not from some quantifiable measure of competence. its also unclear if someone new in practice can even evaluate competence. And this more or less is how many of the frameworks for solving ethic dilemmas in psychology seem to be. They seem more grounded in these rules of thumb, without considering if there is any correlation between the frameworks used, and the likelihood of causing less damage.

Anyway, its a bit of a random one, but just curious what members of this community might think about solving ethical dilemmas in psychology. It almost feels like there is some version of *Doing Good Better (The Book)* out there, but instead of it being about donating to charity, its about helping navigate psychological practice Trolly problems. I guess i'm asking, what might that book say? The whole space is very high stakes—lots of law suits, lots of deaths, lots of psychological harm—and it strikes me as odd that the frameworks for resolving the tensions seem very informal, even when presented as formal problem solving methods.