End-of-Life Decision Making: A Slippery Slope

By Caldwell, Charmaine D.; Freeman, Stephen J. | Journal of Professional Counseling, Practice, Theory, & Research, Fall 2009 | Go to article overview

End-of-Life Decision Making: A Slippery Slope


Caldwell, Charmaine D., Freeman, Stephen J., Journal of Professional Counseling, Practice, Theory, & Research


Advances in medical technology have changed how we view and ultimately define death. What it means to be terminally ill, now more than ever, raises difficult moral/ethical questions for all concerned. These changes have created a new role and associated challenges for counselors as active participants in the end-of-life decision making process. This article explores ethical issues and trends in social policies that relate to challenges faced by counselors in negotiating the slippery slope that is end-of-life decision making.

End-of-life decisions are about one's ability to (in-part) control when and how their death occurs, to exercise certain rights regarding their life. In this day of biological revolution and scientific advancement in health care, the possibility of dying a peaceful death with a sense of having some control to stop the anguish resulting from prolonging the inevitable has become a public and legal debate instead of the intimately personal choice of the individual. Types of decisions to be made, the psychological landscape of the terminally ill, some ethical issues to consider, and roles for counselors in end-of-life decision making are presented in the following information.

Decisions about medical treatment that determine the time and nature of a person's death engender strong emotions in health care and other professionals and in families of the terminally ill. These decisions raise difficult moral/ethical questions for all concerned. Can decision to legally end an individual's life, even though he or she has an irreversible diagnosis of eminent death, place society on the slippery slope of no return when these decisions are routinely made or that a reverence for natural death will be jeopardized? Counselors must be aware of the precedence established when decisions of this nature are made, and must, as far as possible, make certain that the decisions made are best for all concerned.

Ethical codes across helping disciplines do not provide consistent and adequate guidelines for mental health counselors, social workers, or psychologists. At times they can be both in conflict as well as in concert with one another often providing confusing guidelines instead of clarifying ways to make difficult decisions such as those encountered when death is inevitable. For instance, the National Association of Social Workers (NASW, n. d.) does not take a position concerning the morality of end-of-life decisions but affirms the right of the individual to determine the level of his or her care. Social workers have the option to participate in or not to participate in diseussions concerning end-of-life decisions, At the same time it is deemed inappropriate for them to participate in the commission of an act of assisted suicide. The Code of Ethics espoused by the American Counseling Association (ACA) is similar to that of the NASW Both codes of ethics can be in conflict as well as in agreement with one another adding to the complexities of use and interpretation,

The ACA's 2005 Code of Ethics for the first time includes a section (A.9.a) that addresses end-of-life care for terminally ill clients. Counselors are to enable clients to obtain high quality care for physical, social, emotional, and spiritual needs; to help clients exercise self-determination given the circumstances; to see that the client has appropriate information so that they can be included in informed decision making regarding their end-of-life care, and to see that the client is assessed by a qualified mental health professional for competency in decision making. Section A.9.b includes the statement that counselors have the option to either work or not work with the terminally ill client who may wish to investigate their end-of-life options, and are to provide appropriate referral information so that the client can receive assistance with these decisions.

There are many new challenges for counselors in light of the 2005 code changes.

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