Along with the medical field, organized psychology has experienced a paradigm shift in recent years to one in which patients are expected to be active partners in their health care rather than passive recipients. With this new paradigm in mind, we provide an overview of the ethical obligations related to Informed Consent as incorporated into the APA Ethics Code (APA, 2010). We then outline three ethical challenges related to Informed Consent that create opportunities for enhanced clinical relationships and care.
Informed consent in the Ethics Code
References to Informed Consent as an ethical duty can be found throughout the APA ethics code. In the aspirational portion of the code, General Principles C (Integrity) and E (Respect for People’s Rights and Dignity) form the ethical foundation for this duty. The enforceable sections, Sections 10.01 (Informed Consent to Therapy), 3.10 (Human Relations; Informed Consent), 8.02 (Informed Consent to Research), and 9.03 (Informed Consent in Assessments) outline our duties in each of these areas. As the director of the APA ethics office, Stephen Behnke, JD, Ph.D., has pointed out, other sections of the code, including 3.07 (ThirdParty Requests for Services), 3.11 (Psychological Services Delivered to or Through Organizations), and 10.02 (Therapy Involving Couples or Families), do not explicitly include the term Informed Consent in their titles but clearly promote the underlying principles of autonomy and advance notice as ethical duties for psychologists.
Ethical challenges and opportunities
Although not intended to be an exhaustive list, we have identified three interrelated goals for facilitating active patient participation in Informed Consent. We believe that in order to be effective and compassionately enacted, Informed Consent must be:
*Reasonably understandable. *Conceptualized as a process or ongoing interactive conversation that evolves over the course of treatment. *Sensitive to cultural or other contextual factors (such as power differentials) that might reasonably be expected to influence the patient’s sense of autonomy in the relationship.
The term reasonably understandable appears in ethical standard 3.10, which is intended to apply to all areas of psychological work (not just to the provision of psychotherapy). While this may seem like an obvious expectation, several reviews suggest a common failure to meet this standard.
We would strongly encourage all psychologists to adapt their informed consent procedures (including HIPAA Notification of Privacy Practice documents) to the population with whom you commonly work and to specific individuals as needed. As discussed in a recent article, informed consent to psychological treatment has more typically focused on the parameters of the relationship rather than the procedures themselves.
As the use of evidence-based treatments becomes more common, this emphasis may shift. Aspirational practice would lead us to proactively highlight procedural factors that are potentially salient (e.g., providing rationale, discussing typical treatment duration and risks). Developing expertise in offering nontechnical and balanced treatment descriptions (e.g., for exposure response prevention, prolonged exposure, CBT, DBT, ACT) is likely to become an increasingly important ethical competence for psychologists.
Informed Consent becomes an ongoing process and conversation when we revisit it as the circumstances of treatment develop. For example, if a patient is experiencing an increase in suicidal or homicidal ideation, this would be a time to revisit the psychologist’s ethical and legal duty to protect the patient or others (note that this duty varies across states).
If a patient is from a culture that views professionals as authority figures who should not be questioned, it is prudent to more carefully assess the patient’s understanding of what is being consented to. As an example of a contextual factor, a highly distressed patient may want to expedite the informed consent process by signing forms that are not understood. While it is important to validate and be responsive to distress, slowing the process down to ensure adequate understanding may also communicate a sense of calm that is therapeutically beneficial.
In addition to these strategies, it is always useful to consider what we ourselves would want to know before beginning a course of treatment or what it is that we would want to know on behalf of a loved one. This exercise in perspective-taking can ensure that we don’t lose sight of the vulnerability and confusion that our patients may experience as they begin and move through psychological treatment.
April 18, 2020
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