November 1983 V/3
COUNSELING AND VALUES
In our pluralistic society, health care professionals are often called upon to counsel or advise people who have a value system different from their own. Patients or clients seek help in making difficult decis.ions with ethical implications: for example, whether to have children, seek a divorce, have potentially debilitating surgery, allow an infant or an aged parent to die, or have an abortion. What is the ethical responsibility of the health care professional when this conflict of value systems occurs? Can the responsible person say, "I leave my values at home when I put on my white coat"? This approach is insufficient because it leads to a form of schizophrenia, forcing a person to stifle conscience when carrying out one's professional responsibilities. Moreover, it implies that there is such a thing as a value-free profession. What then should the ethical health care professional do in the face of value conflict? Declare from the beginning where he or she stands on a particular point and then invite the patient to state his case? Obviously not, because this attitude would hamper the relationship that a counselor must foster in order to help a person make decisions. In order to present a more workable method, we shall review a few principles of counseling.
Principles
Fundamentally, there are two types of counseling: spiritual counseling and ethical counseling. Spiritual counseling is concerned with instilling values, strengthening values, or changing values. A spiritual counselor, sometimes called a spiritual director, is concerned with instructing people in regard to the goals of life and with increasing their affection for these goals. In order to increase commitment to goals, he or she will instruct people but also dispose the person seeking help appreciate and experience the goodness, beauty and effectiveness of the goals in question. In addition, spiritual counseling focuses on the rewards, whether transcendent or temporal, which result from dedication to a particular value system.
Ethical counseling on the other hand is concerned with helping people make informed and free decisions in accord with their own personal value systems. The ethical counselor presupposes that the other person has a valid value system and the counselor's task is to help the person judge and act in accord with that system if at all possible. With this in mind, the ethical counselor has a threefold function:
a. - Offering knowledge necessary for ethical questions (for example, what will a possible surgery involve?);
b. - Helping the counselee understand the options available and the predicted results of these actions (for example, what methods of family limitation are available, what are the physical and psychological results?);
c. - Helping the client make free decisions: that is, decisions which are free of family, peer, or emotional pressure or compulsion (for example, helping a family realize that only unconscious guilt feelings keep them from removing useless life support systems).
This last function is the most important and most difficult of the three: it involves the essence of ethical counseling -- to help free another from emotional conflict, confusion or unconscious fear or guilt that so often accompanies a significant ethical decision. The result of ethical counseling may be a decision accompanied by emotion, but the decision should not be dominated by emotion or unconscious drives.
Discussion
Do health care professionals act as spiritual or ethical counselors? Usually they act as ethical counselors, but a patient will sometimes approach a health care professional asking the type of direction or advice that indicates a desire for spiritual counseling. The health care professional will have to determine which type of counseling is involved by reason of the situation and the type of questions asked. Some may not feel capable of counseling from a spiritual viewpoint; some may not feel capable of counseling from an ethical viewpoint. Personally, I believe that spiritual counseling is easier, comparatively speaking, than ethical counseling, especially if one has internalized a traditional religious value system. Ethical counseling usually requires special training because it involves more unconscious and, at first glance, hidden factors.
In spiritual counseling, if the counselee were to propose an action which violates the common value system, it would be the responsibility of the counselor to call attention to this lack of integrity. One who acts as an ethical counselor, however, does not have this responsibility. Thus the ethical counselor will not try to change a value. Nor will the ethical counselor be called upon to object to the actions of the counselee as long as these actions are in accord with the counselee's value system. Is this a denial of the counselor's integrity? Does this result in a denial of the counselor's own value system? One of the most important values that one should stand for is to respect the conscience of other people. Conscience is the focal point of each person's worth. Religious people believe that conscience is the contact point with God, and because of relationship to God each person has equal value. People who do not consider themselves religious recognize conscience as the source of freedom, and see in the capacity for freedom the characteristic which endows each person with inalienable rights. When we respect another person's conscience then we respond to a value that transcends any one value system and we establish a basis for human community, even in the face of disagreement about other values. We also establish a means of resolving disagreements because of the bond of community.
Though an ethical counselor respects the conscience of the counselee, he or she is not called upon to help the counselee carry out the proposed action. If a person determines that he or she wishes to be allowed to die by having a life-support system disconnected and the attending physician considers this unethical, the physician should withdraw from the case rather than compromise his or her own personal value system. If a third party might be injured as a result of a decision that a patient or client makes in good conscience, the counselor has an ethical responsibility to express disagreement and point out the injustice of the action. Otherwise the counselor's silence might aid and abet the unjust action. In some cases there is not only an ethical but also a legal responsibility to protect a third party. In most states, for example, there are laws against aiding and abetting suicide or other serious crimes.
Conclusion
The relationship between patients and health care professionals goes beyond the bonds of technology, penetrating to the very heart of what makes us human: our conscience. Building relationships that respect the conscience of each person, both patient and professional, is a task that bespeaks the transcendent worth of health care.
Kevin O'Rourke, OP
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