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Guidance or Compliance: What Makes an Ethical Behavior Analyst?

Article · October 2018

DOI: 10.1007/s40617-018-00287-5

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Behavior Analysis in Practice https://doi.org/10.1007/s40617-018-00287-5

DISCUSSION AND REVIEW PAPER

Guidance or Compliance: What Makes an Ethical Behavior Analyst?

Nancy E. Rosenberg1,2 & Ilene S. Schwartz1,2

# Association for Behavior Analysis International 2018

Abstract In 2016, the Behavior Analyst Certification Board (BACB) made effective a new, revised ethical code for behavior analysts, the Professional and Ethical Compliance Code for Behavior Analysts, replacing the code that had been in effect since 2001. In this revised code, the certification board has shifted the language of the code from that of a set of guidelines to that of a set of enforceable rules. This important shift has not been well discussed in the field. This article explores the potential implications and possible consequences of such a shift and describes other ways that ethical behavior has been approached historically. The authors then propose an ethical decision-making process that might provide a better area of focus for the field of behavior analysis in seeking to develop the highest levels of ethical behavior in its professionals and provide a case example using that process to resolve an ethical dilemma.

Keywords Ethics . Behavior analysis . BACB compliance code . Ethical dilemmas . Professionalism

The field of behavior analysis has experienced tremendous growth and change over the past 40 years. In 1977, there were approximately 1,100 members of the Association for Behavior Analysis International (ABAI; Deochand & Fuqua, 2016); in 2017, there were over 7,500 members (Dougher, 2017). In 1977, approximately 1,200 behavior analysts attended ABAI’s annual conference (Kangas & Vaidya, 2007); in 2017, over 5,000 attended the conference (Dougher, 2017). In 1977, there was no formal credentialing or licensing of behavior analysts anywhere in the world (behavior analysts, if licensed at all, had to be licensed under the umbrella of other disciplines, such as psychology); in 2017, there were over 25,000 master’s and doctoral-level behavior analysts credentialed by the inter- national Behavior Analyst Certification Board (BACB; www. bacb.com), and 26 states in the United States have mechanisms to license these professionals (Association of Professional Behavior Analysts, 2017).

* Nancy E. Rosenberg [email protected]

1 Special Education, College of Education, University of Washington, Box 357925, Seattle, WA 98195, USA

2 Haring Center, University of Washington, Box 357925, Seattle, WA 98195, USA

The growth in the field has been fueled primarily by the use of applied behavior analysis (ABA) with individuals with autism and by the concomitant health insurance funding for these services. Stemming largely from the seminal Lovaas (1987) study, which demonstrated a remarkable response to intervention by 9 of the 17 children with autism receiving intensive ABA therapy, and supported by an ever-increasing body of research (e.g., Wong et al., 2015), ABA has become the primary evidence-based treatment for autism. By 2017, 43 states and the national Medicaid program had mandated insur- ance coverage for ABA for children with autism spectrum disorder (Autism Speaks, 2017).

This explosive growth brings a corresponding increase in concerns about the ethical behavior of behavior-analytic prac- titioners, particularly because the growth in the field has pri- marily been in the area of developmental disabilities, involv- ing some of society’s most vulnerable members. There is a long history of mistreatment and abuse of this population, often in the name of therapeutic intervention (Dittrich, 2016; Donvan & Zucker, 2017). Some of this history of misconduct has unfortunately included the work of those claiming to be using behavioral treatments (e.g., Goldiamond, 1974; Kix, 2008; McAllister, 1972). Behavior analysts still combat this association, and it will likely take decades of exemplary eth- ical behavior for the field to break the link. Thus, an ongoing conversation about how to promote top-quality standards of professional and ethical behavior is paramount.

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As the primary accreditation body for behavior analysts, the BACB has taken the lead in articulating what the ethical behavior of a behavior analyst should look like. In 2001, at the advent of certification, the BACB published a code of conduct called Guidelines for Responsible Conduct for Behavior Analysts (BACB, 2001). Fifteen years later, the BACB made effective a revised code, the Professional and Ethical Compliance Code for Behavior Analysts (hereafter referred to as the BACB Code; BACB, 2014a). Any behavior analyst who wishes to obtain certification at any level through the BACB must agree to abide by this code. Hence, because of the number of behavior analysts choosing (or required by licensure or insurance requirements) to become certified, the BACB Code has become the de facto document articulating behavior-analytical ethics and professionalism.

Although the scholarly work offering in-depth discussion and analysis of ethics in behavior analysis is sparse, there have been a number of articles in the past decade that have delved into specific aspects of the BACB ethical code. LeBlanc, Heinicke, and Baker (2012), for example, explored ethical methods for behavior analysts to build boundaries of compe- tence. Several authors (e.g., Brodhead, 2015; Schreck & Miller, 2010) have provided discussion of how behavior ana- lysts can make ethical and professional decisions regarding the use of alternative and nonbehavioral treatments. O’Leary, Miller, Olive, and Kelly (2017) provide an in- depth discussion of social media and the ethical practice of behavior analysts. Several authors (Sellers, Alai-Rosales, & MacDonald, 2016; Turner, Fischer, & Luiselli, 2016) have addressed issues related to ethical supervision.

One aspect of the revised 2016 BACB Code that has not been discussed in the literature is the transition from the char- acterization of the code as a set of guidelines for ethical prac- tice to the characterization of the code as a set of enforceable rules. The original code that guided the ethical behavior of Board Certified Behavior Analysts (BCBAs) from 2001 to 2016 was called the Guidelines for Responsible Conduct for Behavior Analysts. The introduction to that code stated, “The Guidelines are provided for general reference to practitioners, employers, and consumers, of applied behavior analysis ser- vices … these Guidelines … are not separately enforced by the BACB” (BACB, 2001, p. 1; emphasis added). The word “guideline” was used throughout the code to refer to the indi- vidual elements guiding ethical practice.

The new code effective in 2016, on the other hand, is pre- sented as a list of enforceable rules rather than guidelines for behavior. The term “guideline” has been removed from the title, the Professional and Ethical Compliance Code for Behavior Analysts, and has also been completely removed from the document itself. In addition, the BACB has stated that “the Code will be enforceable in its own right and in its entirety” (BACB, 2014b). Thus, the BACB has moved from a stance of providing guidance on how to act ethically to a

stance of seeking compliance with a set of rules for practicing ethically.

This is a significant change. It assumes that there is a set of rules that can define ethical behavior for a behavior analyst in all circumstances and that ethical behavior can best be achieved by policing adherence to that set of rules. The pur- pose of this article is to explore this issue. We identify some of the perhaps unintended consequences of such a directive view of ethics and describe other ways that ethical behavior can be approached. Finally, we suggest an ethical decision-making process that we believe might provide a better area of focus for the field in seeking to develop the highest levels of ethical behavior in its professionals. As we are behavior analysts practicing in the field of developmental disabilities, we focus our examples from our scope of practice but hope that our exploration of the topic encourages behavior analysts from all areas to consider the questions we raise.

Rule-Based Ethics

The idea that there is an absolute set of rules that can govern moral behavior is called deontology, or rule-based ethics (Fisher, 2016, p. 38; Kant, 1785/1959). In deontology, the morality of an action is dictated by its adherence to a rule. Deontology is based on an assumption that it is possible to establish a set of rules or principles that can articulate ethical behavior in all circumstances and across all contexts and that if everyone then adheres to those rules, ethical behavior will be assured. Such an approach has great appeal in that it avoids any suggestion of a subjective approach to ethics: It keeps people from making selfish exceptions for themselves in what constitutes ethical behavior (Shafer-Landau, 2013, p. 442).

However, a rule-based approach can sometimes present problems. We have encountered some of the inherent issues related to this approach in our workwith the BACBCode. The issues that can arise often fall into one of three categories: (a) situations where the context of the ethical dilemma seems to argue against the rules, (b) situations where two or more rules can conflict, or (c) situations where cultural considerations seem to suggest a different course. We consider each of these potential conflicts in turn.

Context Sometimes Matters

Ethicists have argued for centuries about whether there are moral absolutes that apply in every situation. Even with a seemingly straightforward moral admonition such as “Thou shalt not kill,” it is relatively easy to come up with scenarios where adhering to the rule might not be considered the ethical course. Many people who believe generally that killing is a bad thing would agree that to kill a terrorist as he prepares to detonate a bomb designed to kill thousands of innocent people

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would be the right ethical decision. Similarly, the moral state- ment that “one should tell the truth” seems to be a straightfor- ward ethical rule, but again, we can quickly imagine situations where telling the truth may not be the best, or most ethical, course of action. The classic example is that of a German citizen hiding a Jew during the Nazi regime of World War II. Nazis come to the house and demand to know whether any Jews are hidden inside. Most people today would agree that in this situation, lying is the most appropriate ethical behavior. As a guideline or rule of thumb for ethical behavior, “one should tell the truth” works well; however, as an inflexible rule applicable in every circumstance, it runs into problems.

There are a number of scenarios where rules from the BACB Code can be similarly affected by context. Consider code 1.05(d): “In their work-related activities, behavior ana- lysts do not engage in discrimination against individuals or groups based on … socioeconomic status.” As a guideline for behavior, the statement that behavior analysts will not dis- criminate against those without economic means is principled and unarguable. But what it implies, as an enforceable rule, is that a behavior analyst running an agency must take every client coming to his or her door, regardless of the client’s ability to pay either privately or throughmedical insurance; otherwise, a behavior analyst is discriminating based on socioeconomic status. Although most agency representatives would agree that they have some responsibility to provide services regardless of a client’s ability to pay, most would follow this with the state- ment that they would quickly go bankrupt if they took every client who did not have the ability to pay. Agencies grapple every day with the difficult moral dilemmas of how to serve low-income clients and still stay in business (arguably another moral imperative). As a guideline for ethical behavior, this code is strong; as an enforceable rule, true in every situation, the code is problematic and impossible to comply with.

Code 1.06(a) provides another example. The code states, “Due to the potentially harmful effects of multiple relation- ships, behavior analysts avoid multiple relationships.” The potential ethical and professional problems associated with multiple relationships is an important ethical concept for be- havior analysts to understand and, in general, to avoid. But it is also possible to find situations that might argue for an alter- native approach. Consider a behavior analyst named Clarice, living in a university town. Clarice’s 3-year-old daughter is diagnosed with a developmental delay and is exhibiting severe self-injurious behavior. At the local university, there is a be- havior analyst who has significant expertise in self-injurious behavior. Unfortunately, this professor is also Clarice’s former professor and has since become Clarice’s friend and col- league. Clearly, Clarice’s child receiving services from this behavior analyst constitutes a multiple relationship. But this is a complicated situation. Is it right that Clarice should have to forgo the expertise of a clear expert in her child’s presenting problem because this person happens to be a friend and

colleague? Is it possible to carefully set up the situation to avoid potential issues caused by the multiple relationship while still allowing Clarice to get the best for her daughter? The point here is not to say what the right course is in this instance but rather to illustrate that these dilemmas can some- times be difficult and complex situations, not easily addressed by a black-and-white rule.

Two or more Moral Rules can Conflict

In deontological ethics, you can also find situations where two moral rules conflict. This happens frequently in daily life. “Be honest” and “be kind” are two common moral rules. But when presented with a friend’s stunningly bad haircut and asked, “How do you like it?” it may be impossible to be both honest and kind. Similarly, there are situations where two or more rules in the BACB Code come into conflict, making it literally impossible for a behavior analyst to abide by all codes. Take, for example, a situation where a behavior analyst is dealing with a significant personal issue, such as a divorce, which is impacting her work. Code 1.05(f) states that “behavior ana- lysts refrain from providing services when their personal cir- cumstances may compromise delivering services to the best of their abilities.” On the other hand, this behavior analyst has also clearly made commitments to multiple clients to provide service. Code 1.04(c) states, “Behavior analysts follow through on obligations, and contractual and professional com- mitments with high quality work.” Both codes are right, but the behavior analyst cannot simultaneously do both.

In another example, consider the situation where a behavior analyst cannot come to an agreement with an insurance com- pany on what constitutes an appropriate level of service for a client. Code 2.04(d) says,

Behavior analysts put the client’s care above all others and, should the third party make requirements for ser- vices that are contraindicated by the behavior analyst’s recommendations, behavior analysts are obligated to re- solve such conflicts in the best interest of the client. If said conflict cannot be resolved, the behavior analyst’s services may be discontinued following appropriate transition.

This behavior analyst has advocated for the client without success and thus the code suggests she may need to end ser- vices. However, 1.04(c) again states that behavior analysts need to follow through on obligations and professional com- mitments. The family may very much want the behavior ana- lyst to continue, even at a level of service below that which the behavior analyst feels is necessary. Both codes are right, but the behavior analyst cannot simultaneously do both.

True ethical dilemmas are often not those where there is a clear right and a clear wrong. True ethical dilemmas often

Behav Analysis Practice

arise when ethical principles seem to require a person to do two (or more) actions but the person cannot do both (or all) of the actions. Thus, in a world of rules enforceable in their entirety, the person seems condemned to ethical and moral failure no matter what she or he does.

Culture Always Matters

In today’s multicultural world, cultural considerations, wheth- er spoken or unspoken, unequivocally matter in ethical deci- sion making. The need to understand and balance a respect for the different worldviews of clients is paramount in entering into a productive professional relationship with them; clients and behavior analysts may have different values, beliefs, and views of behavior analysis but need to come to a common understanding and place of respect to move the relationship forward. Several authors have highlighted instances where cultural values and beliefs of clients may affect a behavior analyst’s practice (Fong, Catagnus, Brodhead, Quigley, & Field, 2016; Fong & Tanaka, 2013). It is impossible to pro- pose a set of rules that fits every cultural situation. Cultural beliefs and practices vary widely and are influenced by a va- riety of personal, family, and societal issues. Probably one of the most debated codes in the 2016 revised edition of the BACB Code has been code 1.06(d): “Behavior analysts do not accept any gifts from or give any gifts to clients because this constitutes a multiple relationship.” Some behavior ana- lysts have interpreted this as applying to even the smallest gestures by a family, prohibiting behavior analysts from accepting a cup of tea or a token gift (Bailey & Burch, 2016). However, in many cultures, accepting a beverage or food when entering a house is considered a common courtesy and refusing is considered rudeness. In many school environ- ments, accepting a token gift at holiday time is part of school culture and being the one member of a school team to refuse the token gift from parents at the end of the year may be seen as a sign of arrogance or as an implication that other members of the school team are acting unethically. In both situations, refusing the gesture risks damaging relationships. Again, we are not proposing what the right or wrong thing to do is in these situations; rather, we are arguing that these situations are complex, that consequences of either action need to be weighed, and that a consideration deeper than a black-and- white rule is needed.

Reliance on scientific knowledge is a bedrock principle of behavior analysis and is included in several of the BACB Code rules, such as code 1.01, “Behavior analysts rely on professionally derived knowledge based on science,” and code 2.09(a), “Clients have a right to effective treatment (i.e., based on the research literature …). ” However, cultur- ally diverse clients may not have the same faith in scientific evidence that a behavior analyst has. Consider a situation where a behavior analyst is working to build a relationship

with a family who has recently moved to the United States from another country. This family is highly skeptical of be- havior analysis, and the behavior analyst has been working very hard to establish the trust necessary to do her work and help her client. The family wants to try a nonscientifically supported treatment popular in their culture and that has enjoyed favorable reports in the popular press. The behavior analyst believes that this treatment would be harmless and take very little time and that agreeing could greatly improve the relationship with the family. The behavior analyst also fears that without this collegial approach, the family will de- cide to abandon ABA altogether. This behavior analyst could reasonably decide, after a careful weighing of consequences, that in this situation, deciding to include this nonscientific treatment in a robust package of behavioral interventions is the most ethical course. Once again, it is not the final decision we are promoting, but rather the fact that these are complex situations requiring careful analysis rather than black-and- white rules.

It is important to remember that the culture of the behavior analyst also impacts ethical behavior. The belief that a rule- based system, where everybody following the rules produces the greatest good, is a Western-centric belief (Zheng, Gray, Zhu, & Jiang, 2014). Zheng et al. (2014) compare this Western stance with traditional Chinese ethical beliefs, which emphasize the maintenance and propriety of relations as the most important consideration in determining the greatest good. In traditional Chinese thinking, human relationships are considered more important than any other aspect of human life and a rule should not be followed if it promotes disharmo- ny (Zheng et al.). Thus, considering an ethical dilemma, a Chinese behavior analyst is likely to form a very different analysis than a Western-raised behavior analyst would. As behavior analysis spreads throughout the world, it becomes increasingly important that the profession has an approach to ethics that can respect cultural differences.

Other Approaches to Ethical Decision Making

Rule-based decision making, or deontology, is not the only way to approach ethical decisions. Ethicists and philosophers have proposed a number of different methods for ethical de- cision makers over the centuries, including virtue ethics and ends-based ethics.1

Virtue ethics, first expounded by Aristotle (trans. 1999), is very different from rule-based ethics. Virtue ethics involves a commitment to being a good and virtuous person. Ethical decisions are based on what a person decides is most virtuous in a given situation. Virtue ethics specifically says that what a

1 An excellent online resource for a nonspecialist’s introduction to ethics is The Stanford Encyclopedia of Philosophy (https://plato.stanford.edu/).

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person should do in a particular situation cannot be deter- mined beforehand or dictated by

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