The Challenge of Ethics

By Tim Clark

If you’ve studied entry-level ethics, or even if you haven’t, you might have heard Lawrence Kohlberg’s (1981)¹ story about Heinz and his wife. Heinz had done all he could lawfully to acquire a prohibitively expensive new cancer drug for his dying wife and ultimately decided to steal it from his chemist’s laboratory. Kohlberg asked students to determine if it was right for Heinz to do this.

As with any moral dilemma, there is no ‘correct’ answer, but whatever answer you do reach may reveal something about your ethical maturity (more on this later). Whether you have an answer or not, take a moment to think about how you make ethical decisions.

What processes, if any, do you follow?

Is reason your first port-of-call? Or intuition, emotions, or the advice of others?

What are the unshakeable values that underpin your decisions?

And how do you handle the uncertainty that accompanies moral dilemmas?

Or perhaps you’ve reached a point where you feel you’ve got it all covered, and decision-making is easy and automatic. If that sounds like you, I would argue that the challenge of ethics is not simply to reach a magical endpoint of being an ethical practitioner, but to remain ever-vigilant to how our changing circumstances and unconscious material may influence our behaviour.

Massage training, in colleges and as part of professional development, needs to prepare us to meet this challenge. My experience of ethics training for massage consisted largely of reviewing the codes of the professional bodies and learning what I was and wasn’t supposed to do. I was introduced to notions of boundaries and scope of practice, the imperative of client confidentiality, and the curiously abstract terms ‘transference’ and ‘countertransference’.

For the record, AMT’s Code of Practice is an invaluable resource and should be a cornerstone of massage therapy practice.

Coincidentally, I was completing a degree in counselling and psychotherapy at the same time as my massage diploma. In counselling, ethics is an entire subject in itself, and students must complete it successfully before they can move on to their industry placement. Ethics does not run parallel to the work of the counsellor. In many ways it is the work of the counsellor. Studying the ethics of counselling did not just teach me how to be a good counsellor: it fundamentally affected my character, and now informs decision-making in every sphere of my life.

Why then, I was left to wonder, was the ethics training in my massage course so much less life-changing than in my counselling course? Admittedly, the two qualifications are at different levels of the Australian Qualifications Framework, so expectations are different, but that doesn’t take away from the fact that massage practitioners require a high degree of ethical maturity to cope with the demands of the work.

The ethical decisions we face in clinical practice range from small-but-important to potentially very significant, and sometimes a seemingly innocuous decision can have big consequences:

Have I had enough sleep to be able to treat at full capacity?

Have I given my client enough information to make an informed choice?

Is my need to maintain a business leading me to over-service?

But dilemmas arise where a ‘right’ answer is even less clear. This was evident in a recent discussion in the AMT private Facebook group when AMT member, Clyde Andrews raised a question about a 17-year-old male client, who asked Clyde if it would be okay to be treated without his mother in the room. This is fairly cut-and-dry according to the AMT Code of Practice, which states:

“AMT requires therapists to have a parent, legal guardian or caregiver present at all times during treatment of persons under 18.”

However, the therapist needs to tackle questions like:

What is truly best for this client in these circumstances?

What is likely to cause the least harm, including to the therapeutic relationship?

How can I best support my client’s autonomy?

Which decision am I most comfortable with?

Being ethically mature means we have a clear approach to decision-making in situations like this and can live with the decisions we make, even when doubt lingers.

In Clyde’s case, he discussed with his client and the client’s parents, and ultimately they agreed that the client’s adult brother would sit in on future treatments.

With due credit to the massage educators already teaching these concepts, there are at least three areas in which massage training could use the lessons of counsellor training to help practitioners move toward ethical maturity.

Ethical Decision-making Models

Massage therapists need to be able to justify their decisions on a regular basis, and models of decision-making can be very useful to give structure and clarity to the process. Most ethical decision-making models contain the following steps (Cottone & Claus, 2000):²

1. Clearly and precisely identify the problem.
2. Consult guidelines and colleagues.
3. Identify all possible decisions.
4. Enumerate the possible consequences of each decision.
5. Evaluate each course of action against existing values.
6. Implement a course of action.
7. Reflect on the experience.

Realistically, no practitioner is going to follow such a formula for every decision they have to make, but processes like this, even when used informally, can help us to see that there may be options we hadn’t considered and outcomes we hadn’t anticipated. Reflection on the experience is key to our continued growth as ethical therapists and can help us to recognise gaps between our intentions and our actions. An ethically mature therapist will recognise that good intentions are not enough. We need to be able to implement our decisions.

Stages of Moral Development

The Heinz dilemma was Kohlberg’s tool for figuring out what stage children were up to in their moral development, but it’s useful for us all to consider where we sit on the scale. Kohlberg and Hersh (1977)³ hypothesised three overall stages of moral development:

• At the first ‘pre-conventional’ level, the individual responds to dilemmas by considering the immediate physical consequences of actions. At this level, a response might be: Heinz shouldn’t steal the drugs because he’ll probably go to jail, and his wife will die before he gets out. Also, from this position, deference to power is seen as an absolute good, regardless of the authority’s morality. When massage ethics training is limited to reading relevant codes, it assumes students are capable only of this level of ethical reasoning.
• At the second ‘conventional’ level, the individual seeks to meet the expectations and approval of others and to maintain public order for its own sake. Thinking at this level might lead one to the conclusion that Heinz shouldn’t steal because others will disapprove and the chemist shouldn’t be inconvenienced by someone else’s problem.
• At the final ‘post-conventional’ level, the individual’s own morality and integrity drives decisions. So one could argue that Heinz should steal the drugs, as it is more important to save a life than protect the chemist’s business, but he should hand himself in to authorities to at least partly uphold social order.

What a revelation it was to me, upon first doing this exercise, to consider that there may be situations where stealing could be not only morally defensible but preferable to all other courses of action. In this way, truly ethical behaviour does not shackle us to a set of expectations, but frees us to act according to our own deeply held values, and steels us for the consequences.

Ethical Orientations

Building on Kohlberg’s work, theorists have described a number of overarching schools of thought or ‘orientations’ to describe how people make decisions. ‘Principle ethics’, for example, suggests an approach to decision-making based on an agreed set of rules (“what should I do?”) whereas ‘virtue ethics’ involves the pursuit of being a good person (“who should I be?”).

Similarly, Carol Gilligan (1993)⁴ identified the dichotomy between ‘ethics of justice’ (“what is right and fair?”) and ‘ethics of care’ (“what do others need?”), and even suggested that these orientations are roughly split along gender lines, with men at the post-conventional level typically applying a justice framework and women using care.

Regardless of whether we agree with such delineations or not, an awareness of moral orientations can give us a sense of where our moral judgements typically come from, allowing us to ask if we might need to balance out our approach, or at least consider other ways of approaching problems. If, for example, you’re someone who automatically places the needs of others before your own, it might help to look at situations from a justice perspective and ask, “Well, is it right to give so much?”

And One Last Thing…

My experience of massage ethics training was largely paper-based, whereas my counselling training was very much about interacting with others, including a tutor who was always willing to challenge our preconceptions about what was right and wrong, pushing us to think for ourselves and not just parrot lines from the Code.

Massage training needs to provide students with ethical mentors: human beings who exemplify the struggle to act at the highest level of ethical maturity.

Crucially, these are not ‘perfect people’. On the contrary, they are people who recognise their imperfections and work on them, day in and day out. The massage therapist who thinks they have it all figured out may be the one who most urgently needs to change.

References

1. Kohlberg, L. (1981). Essays on Moral Development, Vol. 1: The Philosophy of Moral Development. San Francisco, CA: Harper & Row
2. Cottone, R. R., & Claus, R. E. (2000). Ethical decision‐making models: A review of the literature. Journal of Counseling & Development, 78(3), 275-283
3. Kohlberg, L., & Hersh, R. H. (1977). Moral development: A review of the theory. Theory Into Practice, 16(2), 53-59
4. Gilligan, C. (1993). In a Different Voice. Harvard University Press

About the Author

Five years ago, if you’d told Tim Clark he would be a massage therapist and psychotherapist in five years’ time he would have laughed in your face. That said, he completed his massage training last year and has just finished the Master of Counselling and Psychotherapy. His Master’s thesis examines the relationship between a massage therapist and her client through the lens of psychotherapy.

Tim is presenting a talk on “The Pleasure-Purpose Principle (or how I learned to stop worrying and enjoy my massage)” and a breakout workshop on “Knowing Thyself: The Role of Self-Awareness in Massage Therapy” on 13 October 2018 at the AMT National Conference. Book your place here.