By Adam Ventura, M.S., BCBA
bSci21 Contributing Writer
My elbow dug deeply into the armrest of my desk chair, acting as a fulcrum to prop up my hand as it supported a troubled brow. I starred endlessly into the depths of my computer screen, my eyes fixed on my bank account balance, waiting for it to change. My company had been providing applied behavior analysis (ABA) services to 40 families covered by a particular insurance company, but for the past six months we had not been remunerated for these services, and payroll was fast approaching. After numerous failed attempts to collect, my savings were depleted, as was my will to continue fighting. It was my first year managing a business independently, and questions about my own competency echoed in my mind. Maybe, I wasn’t ready to do this. “I am letting everyone down,” I thought.
After several hours of self-deprecation, my somber mood was interrupted by a loud ringing noise and a trembling feeling emanating from my desk. As my gaze slowly moved up, I noticed my phone was lit; the vibration was coming from my phone as it inched its way across the desk, getting closer and closer to me as if it were chasing me down. My sleep deprived eyelids were heavy, and my eyelashes were covering half of my field of vision, like blinds blocking light on a sunny day. I had difficulty determining who was calling. As the phone crept closer, I could see the image on the screen, which appeared, at first, to be hieroglyphics. Slowly, the name became clear; it was the parent of one of our clients.
“What does HE want NOW?” I mumbled to myself. I slammed my hand down on the table, like a gavel following a guilty verdict. For a brief moment, I considered my options: accept or decline. After losing a closely fought battle with what only could be described as the conscience dressed in all white perched on my shoulder, I accepted the call. With profound sadness and deep base in my voice, I greeted the parent with a word that could only be phonetically described as “hllow.”
For the first 10 minutes of the conversation, I listened and reflected, parroting back almost every word that he said preceded by the sheepish introduction, “so what your saying is . . .” I had almost no inflection or intonation in my voice. My behavior was robotic, at best, and he quickly noticed, asking the questions that, in retrospect, I think I wanted him to ask: “How are you doing? Is everything OK?”
“Yeah, I’m good,” I replied, “just a little concerned about your son’s insurance.” As the final syllable left my mouth, I knew what I had done, and I was ok with it. I wanted to talk to someone about this, and frankly, I wanted some help.
“What’s wrong with my son’s insurance?” he asked with a quiet but powerful concern in his voice. “They haven’t paid us in six months, and I am not sure how much longer I can afford to continue providing services to your son,” I replied.
Then, after what seemed like the longest 15-second, uncomfortable silence in history, he responded.
“I am going to call you right back in 30 minutes. Please make sure to pick up the phone,” he exclaimed with a confident and chilling undertone that sent shivers down my spine.
After 23 minutes, my phone rang again. This time, I answered with a weird form of excitement and a hint of curiosity in my voice.
“Hello, Adam are you there,” he asked.
“Yes, I am here!” I replied enthusiastically.
He explained that he had the insurance company’s director of claims on the phone.
“She is going to make sure that my son’s claims are paid,” he said.
My ears perked up, and my head rose from the depths of my hands as I responded, “Great! What do you need me to send you?”
Within 3 weeks, a check for a significant portion of the money owed for the affected clients was sent. Over the course of the next few months, I was in regular contact with another individual at the same insurance company, and he routinely communicated that he had a good a relationship with the client whose father I spoke to about the payment issue. Apparently the two had known each other for years and were good friends. That relationship helped broker the payment remedy.
Several months later, the same parent contacted me again. I answered the phone, this time with more verve and energy. The conversation progressed as follows:
Parent: Hi, Adam, I have a little problem I need you to help me with.
Me: I am here for you. What’s the issue?
Parent: Unfortunately, the insurance company has cut my son’s hours by half, and he needs that time!
Me: Don’t worry, I will contact his behavior analyst right away and find out what’s going on!
Parent: Well, I already spoke with his behavior analyst, and she told me that we can’t ethically ask for more hours.
Me: Well, if that is indeed the case, I need to follow the recommendations of my behavior analyst. She is very skilled and has a lot of experience. I trust her judgment.
Parent: Well, Adam, this is just not acceptable to me, and if you cannot get me more hours, then I am afraid I am going to have to stop helping your organization get paid.
As soon as he said it, an angry feeling permeated my body, and I thought to myself, “Did I barter with him already without realizing it?” Then, I thought, “Should I continue to barter with him to save the other families from losing services and ensure my staff gets paid?” I asked myself who and what I was responsible for: the families, my staff, or just following the ethics code exactly? I wondered if there was a code item for this situation. “Am I supposed to create a solution that somehow takes care of all variables at the same time?” I thought.
After a few hours of worry, I was able to get in touch with the client’s behavior analyst, and to my delight, she informed me that the parent had misread the authorization, and his son had indeed received the same number of hours as before. Nothing had changed.
That was four years ago and since then I have put into place MANY different safeguards to ensure that I am never at the mercy of an insurance company like that again. Now, although this situation worked itself out, I learned that ethical decisions are hard to make and not always black and white. Moreover, every decision made as a leader tends to have an ethical component baked into it. This situation prompted me to consider the value of a code of ethics to practitioners in the field trying to do the right thing. So, I sat down to study ethics and morality in greater detail, learning about how and why various ethical systems function.
Decisions, decisions, decisions—how do we make ethical decisions? Ethical decisions can be made in one of two ways:
- Single moral value approach
- Moral Pluralism
In the single moral value approach, ethical decisions come down to determining how to apply a single moral value to all possible situations. Lattal and Clark point out that with moral pluralism, several distinct basic values must be balanced against one another for ethical decisions to made effectively.
Lattal and Clark, 2007 mention four basic values:
- Individual Rights: Or the idea that all people are in a way equally valuable. We should consider everyone on an equal basis.
- Common good: The interests of a few will be subordinated to the interests of the human race as a whole (or a subset of the race in a given setting). “Needs of the many outweigh the needs of the few, or the one” (Mr. Spock, 1982)
- Justice: We selectively help those in most need. Help those who need most help.
- Self-Interest: Sometimes we should put ourselves first and not treat ourselves as just one of the crowd.
In behavior analysis, we use a version of the single moral value approach called deontology. Deontology, the approach used by the Ethical Professional Compliance Code, focuses on the rightness or wrongness of behavior rather than the rightness or wrongness of the consequences of those actions (The Basics of Philosophy, 2008). Using this model of ethical decision making creates a situation described by Robert Nozak as the “paradox of deontology.” It prohibits some acts that maximize welfare overall.
The question emerges: do we want to focus on the wellbeing of our clients, employees, and others, or do we want to follow the code exactly?
Don’t get the wrong idea; I am not suggesting that we get rid of the code. The code is important. As behavior analysts, we believe in science, and science is based on the assumption of determinism. Determinism postulates that the universe is a lawful and orderly place; in other words, there is a reason for everything, and all phenomena occur as a result of other events (Cooper, Heron, and Heward, 2007). This is the old “free will versus determinism” debate we had in graduate school, and most behavior analysts come down on the side of determinism. Having said all of that, research shows that when people believe that they don’t have control over their actions, they are less likely to behave in an ethical manner (There’s no such thing as Free Will, but we’re better off believing in it anyway. The Atlantic, 2016). So not using an ethical code is not an option. Moreover, every respected profession, including medicine and law, has ethical codes to which practitioners must adhere. If we, as behavior analysts, want to be respected within the professional community, I don’t think removing the code would be a good idea.
What I am proposing is adding a training component that discusses not only the behavior that we engage in but also the results of those behaviors and how to balance the four basic values that were discussed above against one another. This would help us to make better decisions in tough situations. For example, what if the situation had NOT worked itself out and I had asked the following questions in relation to that situation I described earlier?
- What was the best thing to do for that individual client if he had really lost his hours?
- Should I continue to barter with the client to ensure that my staff get paid and the clients continue to receive services?
- If I would have never been paid for those services, should I have created a triage model where I decide which clients lose services first based on the severity of their behavior?
- Should I think about myself here and just follow the code to protect my certification, no matter what happens to the clients?
Receiving training how on how to answer those questions is paramount in the maturation of professionals in our field and in doing so, we can ensure that one day, when situations like the one described above occur, we are better prepared to make decisions that can affect the well being of not just one person, but many.
Have you found yourself in similar ethical situations? Let us know in the comments below, and be sure to subscribe to bSci21 via email to receive the latest articles directly to your inbox!
Cave, S. (2016, June 1). There’s No Such Thing as Free Will But we’re better off believing in it anyway. Retrieved May 04, 2016, from http://www.theatlantic.com/magazine/archive/2016/06/theres-no-such-thing-as-free-will/480750/
Deontology – By Branch / Doctrine – The Basics of Philosophy. (2008, January 8). Retrieved May 04, 2016, from http://www.philosophybasics.com/branch_deontology.html
Lattal, A. D., & Clark, R. W. (2007). A good day’s work: Sustaining ethical behavior and business success. New York: McGraw-Hill.
Adam Ventura, M.S., BCBA is a graduate of Florida International University and has been a Board Certified Behavior Analyst (BCBA) since 2008. Adam is the founder and CEO of World Evolve, Inc., a behavioral organization located in south Florida. Adam has been working in the field of applied behavior analysis for over 10 years and has experience working with children and adults with varying disabilities. Adam was a member of the local review committee in Miami, Florida for over three years and is currently a member of the behavior analysis and practice committee (BAPC) for the state of Florida. Adam also currently serves an adjunct professor in the psychology department at Florida International University where he has been teaching undergraduate courses in behavior analysis since 2009. Adam is also the co-founder of two public benefit corporations, namely, The Code Of Ethics for Behavioral Organizations (COEBO) and the Miami Association for Behavior Analysis (MiABA). Adam’s experience has extended beyond the clinical realm and into the business world as he has been responsible for creating several new businesses with and without partners in various industries. Adam’s current focus is on business ethics and technological applications of Behavior Analysis. You can contact him at firstname.lastname@example.org.