Understanding Ethics within the context of counselling and psychotherapy

1. The case of Lisa
Ethics and Professional Development in Counselling
Anne Serry Counsellor and Psychotherapist
www.annneserrytherapy.com.au

2. The Vignette
 Lisa is15 years old, recently left school and now works in a factory
packing boxes.
 She lives with her mother, father and three sisters.
 She is of low intellectual function, with delayed emotional maturity.
 Her personality is down to earth, and she is firm and rigid in her
beliefs and attitudes.
 She presents at the local children’s hospital with a referral from her
GP requesting labioplasty.
 From the age of eight, Lisa has expressed concern regarding her
genitalia, specifically her extended labia minora.

3. The Vignette
She states several reasons for wanting labioplasty:
1/ Physical discomfort - Her labia causes pain and discomfort;
rubbing against her underwear and irritating her when exercising.
2/ She has grown up in a family where nudity is common and
accepted. Because of this she was always aware of looking different
from her three sisters.
3/ She just ‘doesn’t like it’.
Lisa’s parents are supportive of her undergoing the procedure. The
hospital surgeon has agreed to the operation on the basis that Lisa’s
labia is of a size that could cause the pain and discomfort she
complains about.

4. Labioplasty Definition
 Labioplasty is a procedure designed to re-shape the
inner lips of the vagina ("labia minora"), or the outer lips
("labia majora").
 The reasons women choose to have this procedure are
most commonly due to:
- Feelings of self-consciousness or embarrassment due to
uneven or protruding labia
- Discomfort caused by protruding labia rubbing on
clothing
- Childbirth distortion
- Painful intercourse

5. The ‘personal dilemma’
You have been asked to sit on the ethics committee at the local
children’s hospital for this case to assess whether Lisa is emotionally and
intellectually capable of understanding the full nature of the
labioplasty procedure in order to provide valid consent.
The weight of your recommendation will be highly regarded by the
committee given your professional experience and work with minors.
However, unknown to the committee members, you feel conflicted
because you have strong views on the over-sexualisation of children
and the prevalence of plastic surgery in society.
You are unsure as to whether your personal bias will affect your ability
to assess Lisa’s case objectively.

6. What do you do in this situation?
A. Decline to sit on the committee, explaining your bias and risk
damage to your personal and professional reputation.
B. Decline to sit on the committee citing other commitments and
not disclose your bias.
C. Accept the role and not disclose your bias as it will be
advantageous for your career.
D. Accept the role disclosing your bias, yet reassure the committee
you are capable of setting aside your personal judgments.
E. Accept the role and not disclose your bias but make a personal
commitment to be fair and objective about this case.

7. Ethical Maturity, Professional
Guidelines & Self-Assessment
Inventory
 Everyone’s ethical compass is set differently.
 In considering how to navigate this part of the
dilemma we present three models for
consideration and assistance in resolving how to
proceed.
1 Ethical Maturity
2 Professional Guidelines
3 Self Assessment Inventory

8. Ethical Maturity
Caroll suggests four features that need to be brought into the process
in order to be capable of making ethical decisions. They are:
1. Reflect - involves the ability to examine and look in some depth
at various aspects of the issue.
2. Rationalise or reason – the ability to work logically and
thoughtfully towards a conclusion. To think critically and examine
in detail using rational approaches.
3. Be in touch with our emotions and feelings about what is
happening – ethical decision making is not just about reason and
rationalizations. Attending to emotions assists us to ask the right
questions to make these reasoned decisions.
4. Note the difference between intention and action – that is to
give others the same credit for their intentions as we would for
ours.

9. Professional Guidelines
 The PACFA Ethical Guidelines and CAPAV Code of
Conduct guidelines may also be reviewed to
understand one’s professional obligations.
 Below are the key points from each code of conduct
that are especially relevant to this case, and would be
useful to be aware of in order to conduct the
assessment in a fair and judicious manner.

10. PACFA
 Counsellors recognise and respect diversity among
people and oppose discrimination and oppressive
behaviour.
 Any publicity material and all written and oral information
should reflect accurately the nature of the service offered
and the training, qualifications and relevant experience
of the Counsellor.
 Counsellors work within the law.
 Counsellors take all reasonable steps to be aware of
current legislation affecting their work.
 Counsellors are committed to protect the public against
incompetent and dishonourable practices and are
prepared to challenge these practices.

11. CAPAV
 2.3 Beneficence: A commitment to promoting the client’s well
being.
 2.4. Non malfeasance: A commitment to avoiding harm to
client.
 2.5. Justice: The fair and impartial treatment of all clients and
the provision of adequate services.
 Integrity: commitment to being just and fair in dealings with
others.
 Personal straightforwardness, honesty and coherence.
 Fairness: the consistent application of appropriate criteria to
inform decisions and action

12. Self-Assessment Inventory
 The third and a more tangible approach involves a self-assessment
inventory as suggested by Corey, Corey and Callanan.
 This examination is a way to ‘survey your basic beliefs, attitudes and values
on specific topics related to the practice of therapy’.
 Here are 5 of the 40 questions from the self-assessment inventory that we
feel are applicable to the case of Lisa.
A. Q5. Being ethical
B. Q14. Objectivity
C. Q17. Role of values
D. Q32 Testing
E. Q40. Role in community

13. What do you do in this situation?
A. Decline to sit on the committee, explaining your bias and risk
damage to your personal and professional reputation.
B. Decline to sit on the committee citing other commitments and
not disclose your bias.
C. Accept the role and not disclose your bias as it will be
advantageous for your career.
D. Accept the role disclosing your bias, yet reassure the committee
you are capable of setting aside your personal judgments.
E. Accept the role and not disclose your bias but make a personal
commitment to be fair and objective about this case.

14. Resolving the dilemma
 Which of the five questions resonated the most in relation to
this dilemma?
 Did the questions help or hinder your decision?
 Did the self-assessment inventory result in you changing your
mind from your original decision and/or assist you to make
your decision?
 How much of the emotional maturity guidelines did you bring
into your decision making process?

15. Resolution
 For the purpose of our case we have selected
Option E.
- Accept the role and not disclose your bias but make a
personal commitment to be fair and objective about this
case.
 Our therapist, Naomi, has chosen to remove her personal
opinions and feelings, and to take an evidence-based
approach to her decision by reviewing the relevant legal
and medical frameworks that relate to Lisa’s situation.

16. Information gathering stage
 Naomi set out an assessment process that took
into account the guiding principles as discussed,
as well as the legal and medical rules around
how to assess Lisa.
 We have assumed Lisa lives in Melbourne and this
case is therefore subject to the statutory
regulations of Victoria only.

17. Legalities
 There is no law in Victoria which fixes the age at which a young
person has legal capacity to either give or withhold consent to
treatment in their own right.
 However, some states have legislation that addresses the issue
of a minor's consent to medical treatment.
 The Consent to Medical Treatment and Palliative Care Act 1995
(SA) prescribes that an individual of 16 years of age or over can
consent to medical and dental treatment 'as validly and
effectively as an adult'. Provided that a medical practitioner,
supported by another medical practitioner, believes that
certain treatment is in the best interests of the child and the
child is 'capable of understanding the nature, consequences
and risks' involved, that child can validly consent to their own
treatment. The SA legislation also provides that medical
treatment can be administered to a child if the child's parent or
guardian consents to it.

18. Legalities
 According to the Minors Act 1970 (NSW), a child aged 14 years or
over may consent to his/her medical treatment. The NSW Act also
allows parents of children under the age of 16 to validly consent to
their child's medical or dental treatment.
 The common law rule that applies in such cases is that the patient
must be old enough to be capable of forming a sound and
reasoned judgment about the matter for which consent is required.
This, of course, depends on the maturity and intelligence of the
patient and the nature and seriousness of the treatment.

19. Medical Perspective
 The Royal Australian and New Zealand College of
Obstetricians and Gynaecologists
 On vaginal procedures:
The risk of potential complications such as scarring,
permanent disfigurement, infection, painful sexual
intercourse, and altered sexual sensations should be
discussed in detail with women seeking such treatments.

20. Medical Perspective
 The Royal Australasian College of Physicians – Paediatrics &
Child Health Division.
 On consent:
 Doctors need to ensure valid consent from a young person
and/or their parent/guardian prior to conducting a genital
examination.
 Valid consent must be voluntary, informed and based on the
capacity of the patient to consent.
 Capacity to consent should be considered on an individual
basis and is not solely related to age.
 Children can consent as long as they have the capacity to
understand the information and the implications of the
procedure to which they are consenting.

21. Medical Perspective
 Special consideration needs to be given to
obtaining consent from patients who are:
- Intellectually impaired
- Mentally ill
- Physically impaired
- Drug or alcohol affected
- Non-English speaking background
- Injured, pain, shock
- Sleep deprived
- Unable to give valid consent

22. How to assess?
 What can be concluded from all sources is that there is much ambiguity in the
parameters around consent and that decisions are made on a case-by-case basis.
 The ethical dilemma here lies in the vagueness surrounding the issue of consent and
Naomi is required to come to her own decision regarding Lisa’s ability to consent.
 Some questions Naomi gave consideration to:
1. Would an adolescent with a sub-standard range of IQ be able to make this
decision?
2. What capacity does Lisa, with her low intellectual function, have to understand
this operation?
3. How can an explanation of the medical procedure and it’s side effects be
tailored to meet Lisa’s intellectual capacity?
4. How to confidently ascertain that Lisa has understood the procedure to
adequate level.
 ://www.youtube.com/watch?v=2DsuasWObWw

23. Professional Assessment
 Naomi developed a series of assessments to ascertain
Lisa’s level of cognitive ability and emotional maturity
which would affect her ability to validly consent.
 DASS Test
 Body Dysmorphic Disorder
 Trauma
 IQ

24. Professional Assessment –
Mental Health
1 DASS/Golderg test—to determine Lisa’s levels of
anxiety and/or depression
 The DASS has been used with adolescents as young as 14
years of age.
 Due to Lisa’s low intellectual function, Naomi adapted the
DASS using The Goldberg Depression Test (aged 10 -17) as
a reference point.

25. Professional Assessment –
Mental Health
2 Body Dysmorphic Disorder (BDD):
 BDD is a preoccupation with a defect in appearance.
- The defect is either imagined, or, if slight physical
anomaly is present, the individual’s concern is markedly
excessive.
- The preoccupation must cause significant distress or
impairment in social, occupational, or other important
areas of functioning.
- The preoccupation must not better be accounted for by
other mental disorders. (from DSM IV)

26. Professional Assessment –
Mental Health
 Professional Opinion (DASS & BDD):
- She does not display significant levels of distress that
affect her ability to function—just a strong desire to have
the procedure.
- Lisa scored in the normal range for depression and
anxiety, and in the mild category for stress.
- Lisa’s protruding labia causing her physical discomfort
meets the requirements for the procedure, therefore it is
reasonable that her concern is appropriate.

27. Professional Assessment -
Trauma
3 Assessing for sexual abuse
 Lisa first became aware of her protruding labia at the age of
eight, which led Naomi to question why a child of this age
would be focusing on her genitalia.
 Steps were taken to ascertain whether her pre-occupation
was the result of sexual abuse by
- taking a detailed FOO history
- interviewing Lisa
- physical examination by a Dr.
- testing for STIs
 Conclusion:
- Through this process it was concluded that it was unlikely
that Lisa had suffered any sexual abuse, and based on this,
Naomi ruled it out.

28. Professional Assessment -
Intellectual
4 Testing Lisa’s intellectual capacity:
 IQ test— The Wechsler Intelligence Scale for Children,
Forth Edition - Australian Standardisation (WISC-IV)
 The assessment of intelligence is across three domains
conceptual, social, and practical.
 Lisa rated 76 from the mean of 100

29. Recommendations
 What were some other ways in which this situation might
have been assessed for greater ethical practice?
 Based on the evidence and assessment we’ve presented,
what would you recommend to the committee and why?
 Do you feel that Naomi has set aside her personal
judgments in making her decision? If so why or why not?
 Class decision regarding Lisa’s ability to validly consent.
 Naomi’s decision regarding Lisa’s ability to validly
consent.

30. Recommendations
 Naomi proceeds to recommend a plan which will help to
ensure that Lisa receives the best level of care and support
should she have the procedure, both before and after.
 A series of three family meetings were called, in which Naomi
could gauge the environment Lisa was living in, and address
any potential concerns within the family relating to Lisa’s
care. These meetings were also designed to ensure that Lisa’s
parents were able to support her adequately in both
explaining any problems she might have and caring for her
after the procedure.
 Limits were placed on any further surgical procedure within
the public system on the sole basis of physical appearance. If
Lisa was dissatisfied with the way the labia looked
aesthetically after the procedure, then she was not able to
undergo any further surgeries and would have to go through
the private system. Of course this excludes any medical
complications which may occur.

31. About Anne Serry
 Anne Serry
 Counsellor and Psychotherapist
 www.anneserrytherapy.com.au
 www.facebook.com/AnneSerryCounselling
 Twiiter @anneserry