A Guide to Establishing Ethics Committees in Behavioral Health Settings

Abstract

Ethical statements typically involve rules. All rules can vary in accuracy and specificity depending on the context to which they are applied. Codes of ethics often involve ethical rules that are written generally to cover the wide-ranging set of possible situations that any one member of the profession may encounter. But, despite being written generally, codes of ethics are applied to specific situations that professional members encounter. The application of general rules to specific contexts can sometimes be challenging and complex. Health care organizations have several options to help their employees behave ethically. One approach is to appoint a single ethics coordinator. In contrast, the dominant approach in most health care organizations is to develop an organizational ethics committee (Moon Pediatrics, 143(5), e20190659, 2019). Despite the popularity of the ethics committee in other professions, the extent to which organizations that provide applied behavior analysis services have established and operate ethics committees is unknown. Ethics coordinator roles and ethics committees both have benefits and drawbacks. This article reviews the benefits and drawbacks of appointing an ethics coordinator and establishing an ethics committee. And, for interested organizations, this article outlines the steps and considerations that organizations can use to guide the creation of an ethics committee.

Ethical statements often involve rules. A rule can be defined as a verbal stimulus that specifies one or more relationships between contexts, responses, and consequences (Barnes-Holmes et al., 2001; Catania, Shimoff, & Matthews, 1989; Schlinger & Blakely, 1987; Skinner, 1969). Rules may be derived in many different ways (Skinner, 1957, 1969). For example, after directly contacting a contingency, an individual may generate a rule about the context-response-consequence relationships he or she experienced (e.g., Baum, 1995; Rosenfarb, Newland, Brannon, & Howey, 1992). The generated rule may then govern the same person’s own behavior in the future (e.g., Rosenfarb et al., 1992) or the behavior of others (e.g., Baum, 1995; Glenn, 1989). And, once the behavior is emitted, others may continue to emit and follow the rule even without contacting the original contingencies responsible for the rule.

Rules have certain characteristics. One characteristic is the degree of rule accuracy. For example, generated rules are unlikely to perfectly specify all characteristics of the original contingencies (Peláez & Moreno, 1998). Rules may also fail to specify how relationships change over time between contexts, responses, and consequences. Relatedly, the contexts, responses, and consequences specified in a rule for a contingency that occurred in one location may not be relevant or occur in a different location. For example, my use of swear words during adolescence looked different depending on if I were on the baseball diamond or at family gatherings. In sum, rules might be less than perfectly accurate because of (a) less than perfect original descriptions; (b) dynamically changing relationships between contexts, responses, and consequences over time; and (c) different context, response, and consequence relationships across different locations. Stated succinctly, all rules will be somewhat inaccurate for someone, somewhere, at some point in time—including ethical rules.

Another characteristic of rules is their degree of specificity. Rules can be specific or general (Peláez & Moreno, 1998). A specific rule precisely identifies the context, response, and consequence contingency. For example, a person might say, “I’m going on vacation in two weeks and will be gone for one month. If you water and mow my lawn each week I am gone, the following month I will pay you $100” (Barnes-Holmes et al., 2001). A general rule ambiguously identifies the context, response, or consequence. For example, a person might say, “I’m going on vacation. If you manage my yard, I’ll make it worth your while.” In the specific example, the speaker precisely identifies the timing and duration of the context under which behavior is reinforced, the specific behaviors that are reinforced, and the reinforcer amount that will be delivered. In the general example, the context, response, and consequence are ambiguous. It is unclear when and for how long the person will be gone (the context), what responses will contact reinforcement, and the amount and type of putative reinforcer the speaker will deliver.

Rules for professional ethics are typically written generally but applied specifically. This can lead to variations in the application of ethical rules across people and contexts. For example, the Behavior Analyst Certification Board’s (BACB) Professional and Ethical Compliance Code for Behavior Analysts (the Code) guideline 1.05 states, “All behavior analysts provide services, teach, and conduct research only within the boundaries of their competence, defined as being commensurate with their education, training, and supervised experience” (BACB, 2014). Each person’s definition and criterion for “competence” are determined by his or her history with contingencies and verbal behavior about the “competence” of his or her, and others’, behavior (Brodhead, Quigley, & Wilczynski, 2018). In total, different learning histories and experiences will likely lead to variation in how each behavior analyst applies the generally written guideline 1.05 to his or her specific repertoire and the specific contexts in which he or she provides services.

Variation in how behavior analysts apply ethical rules is not bad in itself. Variation is simply the result of the behavioral processes involved when applying a general rule to the hundreds of unique situations that behavior analysts find themselves in each day. Additionally, ethical rules that are written too specifically might be unhelpful in some situations and lead to the rules being ignored altogether in favor of behavior determined by the experienced contingencies (e.g., Hackenberg & Joker, 1994). Nevertheless, consistency in how two different behavior analysts apply professional ethical rules would seemingly be expected when two different behavior analysts share similar clientele and experience similar work settings (e.g., two employees who work for the same organization). In turn, organizational leaders may develop formal processes to help each other consistently adapt generally written ethical rules to specific workplace contexts. Two formal processes that can help employees make ethical decisions include establishing an ethics coordinator and creating an ethics committee.

Systems to Aid Ethical Decision Making

Ethics Coordinators

One strategy to help support employees of an organization with ethical decisions is to appoint an ethics coordinator (Brodhead & Higbee, 2012). An ethics coordinator is an individual who functions as the resident expert on ethics and thereby oversees and monitors ethical behavior within an organization (Brodhead & Higbee, 2012). The ethics coordinator is responsible for developing systems for monitoring ethical behavior, creating training materials for the acquisition of ethical behavior, and aiding with the development of ethics-related policy.

There are several benefits to the ethics coordinator role in human health service organizations. The primary benefit is that a single individual is responsible for all ethics-related activities. A lot of time and resources are needed to create the materials, systems, and processes involved with ethics-related activities and oversight. Many agencies that fund health services are unlikely to reimburse for ethics-related activities. As a result, many organizations have to cover the costs associated with ethics-related activities. Having a single individual responsible for ethics-related activities is likely to require fewer resources than supporting multiple employees. Thus, ethics coordinators can be a great starting point when resources limit the ability of organizations to develop full ethics committees. Relatedly, a second benefit to having a single individual responsible for all ethics-related activities is clarity in whom employees can seek out for ethics-related education, consultation, and policy development. In turn, appointing an ethics coordinator may lead to a more efficient implementation of ethics-related processes within larger organizational systems.

The primary drawback of relying on an ethics coordinator is that a single individual is responsible for all ethics-related activities. This drawback can impact ethics-related activities in at least three ways. One drawback of relying on an ethics coordinator involves what it means to be an “ethics expert” and how the ethics coordinator is appointed by an organization. The skill set required to be considered an “ethics expert” has historically been ambiguously defined, and an ongoing debate centers around whether ethics expertise can exist in health care settings (e.g., Brummett & Ostertag, 2018; Ho, 2016; Iltis & Rasmussen, 2016; McClimans & Slowther, 2016; Rasmussen, 2016; Rhodes, 2019). Restated as questions, how do we know someone is qualified to be the ethics coordinator? And what skills and competencies should be demonstrated by someone for him or her to claim expertise in ethics? These questions are far from trivial when a single individual is placed in charge of ethics-related education, consultation, and policy development for an entire organization.

A second drawback of relying on an ethics coordinator involves the potential for biased ethical claims. Here, I am referring to selection bias where a person makes decisions based on a fewer number of observations than all relevant observations that exist (Rothman, Greenland, & Lash, 2008). Different people have different learning histories. The ethics coordinator's unique learning history and current contingencies are likely to differ from the unique learning history and current contingencies for other employees. In turn, ethics-related education, consultation, and policy development might be selectively biased toward the history and contingencies experienced by the ethics coordinator and fail to fully apply to the specific situations that other employees encounter. Restated as questions, how do we know the behaviors claimed as “the right thing to do” by an ethics coordinator are, in fact, the right thing to do? And what data and evidence should ethics coordinators provide to support their claim of “right” or “wrong”?

A final drawback of relying on an ethics coordinator is the possibility of unsustainable or intermittent ethics-related activities. If the organization is not reimbursed for ethics-related work, they have to support ethics-related costs out of pocket or rely on the ethics coordinator to volunteer his or her time. All out-of-pocket costs are considered within the larger financial health of an organization, and out-of-pocket costs might be the first costs cut when an organization enters challenging financial times. Relying on volunteer work also creates challenges for sustained ethics-related activities. Relying on volunteer work puts the maintenance of the ethics coordinator’s behavior at the behest of reinforcement contingencies operating outside of the control of the organization and in competition with the work the ethics coordinator gets paid to perform. Without measuring or controlling these contingencies, the frequency and consistency of ethics-related activities may fluctuate over time relative to competing work and personal contingencies.

Ethics Committees

A second strategy to help support ethical decision making for employees is to create an ethics committee. Though common to many other areas of human service delivery (Moon, 2019), formal ethics committees do not appear to be as common in applied behavior analysis (ABA) organizations. In many health care institutions, ethics committees have become the standard method for several ethics-related activities. These ethics-related activities include educating health care professionals about applied ethics relevant to their workplace settings, drafting and reviewing organizational policy, providing ethics case consultation, providing a forum for employees to voice ethical challenges they face on the job, and reviewing potential research projects within the organization (Moon, 2019).

There are several benefits to creating an institutional ethics committee. First, ethics expertise is not reliant on any single individual. The works of literature on applied, clinical, research, and business ethics are broad and deep. A group of people interested in discussing and applying ethics can contact more of the ethical literature than any person could accomplish individually. Groups of people can also be more likely to effectively problem solve solutions to workplace challenges when the right contingencies exist around cooperative and creative behavior (e.g., Benbunan-Fich & Hiltz, 1999; Heller, Keith, & Anderson, 1992; Mumford, Feldman, Hein, & Nagao, 2001). Contingencies surrounding contact with the literature, collaboration, and creative problem solving with ethics-related activities and decision making may be especially helpful when ethics committee members lack formal training or background in applied ethics (Rasmussen, 2016; Swetz, Hook, Hellyer, & Mueller, 2013).

A second benefit of an institutional ethics committee is that the committee is likely to be less selectively biased in their ethical claims (i.e., more people likely cover more of the total number of possible unique learning histories and current contingencies specific to employees at the organization). There are several ways selective bias can be reduced. Selective bias can be reduced by having all organizational stakeholders be represented and contribute to ethics-related activities. Ethics committees are often composed of one or more members from each department or position within the organization (i.e., stakeholders). For example, an ABA agency providing in-home services for children and adolescents would have organizational stakeholders that implement ABA (e.g., Registered Behavior Technicians [RBTs]), supervise individual cases (e.g., Board Certified Assistant Behavior Analysts [BCaBAs] and Board Certified Behavior Analysts [BCBAs]), oversee operations (e.g., clinical director, chief executive officer), provide administrative support (e.g., Human Resources, billing), receive services (e.g., clients, client caregivers), and fund the services (e.g., state agency, insurance company). As a committee composed of stakeholders, the group has greater access to the rules and contingencies that employees from each position in the company might encounter. Including the perspectives of all stakeholders decreases the likelihood that ethics-related activities are selectively biased toward the learning history and current contingencies of any single individual.

Finally, “many hands make for light work” (Heywood, 1562). For organizations with limited resources and for tasks that can be partitioned, dividing volunteer work among multiple people reduces the time that each person spends on volunteer activities. For example, consider an organization whose ethics-related goals require approximately 4 h per week of volunteer work. Spreading 4 h of volunteer work across eight people leads to 30 min of volunteer work per week per person. This may be easier to accomplish and more sustainable in the long run compared to a single individual asked to volunteer 4 h per week. Additionally, ethics-related activities may stop if outside and competing contingencies no longer support ethics-related volunteer activities for an ethics coordinator. In contrast, losing a single individual from an ethics committee is likely to have less impact on the regular occurrence of ethics-related activities.

There are also several drawbacks to creating ethics committees. First, ethics committees require the coordinated behavior of two or more people. This can add time, complexity, and resources to ethics-related activities. For example, consider an employee who seeks out ethics consultation related to an experience he or she had during an evening ABA session. The ethics coordinator could likely be contacted via a phone call, text, or e-mail and provide guidance or advice before the next ABA session. In contrast, depending on the structure of an ethics committee, the same employee may not receive guidance or advice until a minimum number of committee members convene to discuss the situation. This may take days or weeks and impede practical ethics consultation. This drawback can be mitigated through establishing “ethics hotlines” or other communication methods that signal ethics-related advice is needed quickly.

For efficiency, each committee member might also become the go-to person for advice on specific ethics-related questions. An employee might seek out one member in particular because of that member’s expertise or because the committee member is the employee’s supervisor. Without the right processes and contingencies around process implementation, this may result in the functional equivalent of multiple ethics coordinators operating independently. Whether this is good or bad likely depends on the organization and the function they want the ethics committee to serve. This drawback can likely be mitigated by developing and implementing processes that coordinate committee member behavior (see the section on Structure of Ethics Committees" for more information).

With nonpartitionable tasks, ethics committees require more resources than an ethics coordinator. For example, consider a situation in which an ethics committee is asked to review a proposed policy or research proposal that requires 1 h of time for each person to review. The cumulative amount of time spent with nonpartitioned tasks is at least n times greater, where n is the number of committee members involved. Additionally, the committee would likely want to convene a committee meeting to discuss each person’s review—adding more time. This drawback can be mitigated through proper planning and clarification of the ethics committee’s budget and scope (see the section on "Common Functions of Ethics Committees" for more information.

A second drawback to ethics committees is the increased risk of breaching confidentiality without adequate training and oversight. Ethics committee members may have access to a large amount of client, family, and employee personal information. Confidentiality might be breached during ethics committee meetings in which members use information from related, but separate, cases when discussing a particular topic. Confidentiality might also be breached when members are talking with employees outside of ethics committee meetings when they provide advice on an ethics-related topic. Using examples or strategies from other, similar situations may lead a committee member to accidentally divulge details or information that breaches confidentiality. A breach of confidentiality is certainly a risk with a single ethics coordinator also. However, the risk of breached confidentiality is increased when multiple people are required to maintain confidential information.

Third, bias can also occur when a group makes ethical decisions or provides ethical advice. Groupthink is a phenomenon reported in the social psychology literature that suggests certain situations may lead a group of people to make suboptimal decisions by failing to consider alternative solutions to a problem (for a review, see Turner & Pratkanis, 1998). Translated to operant processes, reduced variability might arise through contingencies of escape/avoidance or differential reinforcement. Escape/avoidance contingencies may lead to groupthink if one or more committee members fail to provide alternative solutions to escape or avoid conflict between committee members during ethics-related discussion. Alternatively, some solutions may contact more reinforcement than other solutions and therefore be offered more frequently in future ethics committee conversations. Bias via groupthink might be considered a case of overgeneralization. Bias from groupthink might be mitigated through contingencies that promote cooperation and variability in solutions, and by regularly changing members of the ethics committee (e.g., Benbunan-Fich & Hiltz, 1999; Heller et al., 1992; Mumford et al., 2001).

Finally, the difficulties involved with financial sustainability for an ethics coordinator role also exist for the ethics committee. Regardless of whether ethics-related activities fall to one person or a group of people, unreimbursed costs are unreimbursed costs. Resource constraints and financial sustainability might be mitigated by using an ethics committee , but they will still exist and may even be exacerbated depending on the structure of the ethics committee (e.g., asking the full committee to provide an ethics consultation compared to asking a single ethics coordinator).

How to Create an Ethics Committee

Several strategies exist for ABA organizations to provide ethics-related activities for their employees. Brodhead and Higbee (2012) provide an overview of how to develop an ethics coordinator position. For individual organizations, groups of organizations, or state ABA chapters that are interested in creating an ethics committee, the remainder of this article outlines the steps to create an ethics committee and some important considerations at each step. The two most important decisions are to determine the function and structure of the ethics committee. After describing each of these areas in more detail, the remaining seven steps to create an ethics committee are outlined and placed in the recommended order of completion (though some steps can be accomplished concurrently).

Common Functions of Ethics Committees

In many health care settings, ethics committees have served one or all of at least five different functions (Moon, 2019; Post & Blustein, 2015). These include (a) ethics education; (b) development, review, and recommendations of institutional policy; (c) case review and consultation; (d) a forum for discussion of ethical issues confronted by stakeholders of the organization; and (e) review of potential research carried out by employees of the organization. Each new ethics committee should determine whether they will serve each of these functions, the relative priority ranking of functions if multiple functions will be targeted, the time that will be devoted to each function, and how they might achieve each function practically and efficiently. The decision to fulfill each function will likely be determined by the collective interest of the committee members, institutional support for the committee, and the overall knowledge and skills of the committee members. Proactively planning the function of an ethics committee will increase the likelihood the ethics committee sustains over time and will help shape data collection systems to measure the effectiveness of the ethics committee in fulfilling its function.

Ethics Education

Several important decisions likely need to be made if a function of the ethics committee is ethics education for employees. The most important decision is arguably the purpose of ethics education in the organization: Why is the organization trying to increase ethics education for employees? Is it a general value the organization holds? Does the organization simply want employees to have a generally higher knowledge of ethics? Are there certain situations that employees commonly face and that the organization would like them to independently manage? Is the organization interested in expanding employees’ knowledge about applied, clinical, research, and business ethics outside of what was covered in their educational training? Is the organization interested in increasing general ethical awareness and sensitivity?

Once the purpose of ethics education is known, a number of additional decisions should likely be made. Some of these decisions include identifying topics for ethics education events, the frequency of ethics education events, the modality for delivering ethics education events, whether contingencies will exist for employee participation, and the goal of each education event. How an organization answers these questions will likely be determined by the purpose of ethics education within the organization and relative to the amount of organizational support available to the ethics committee members.

Policy Development and Review

Several important decisions likely need to be made if a function of an ethics committee is to develop or review institutional policy concerning ethical service delivery. The most important decision is arguably the purpose of having the ethics committee develop or review institutional policy. Is the organization seeking a general, extra set of eyes to review policies where the extra set of eyes comes from employees interested and educated in ethical topics? Or is the organization interested in something more specific? For example, the organization may be interested in improving diversity and equity in hiring practices, improving the social validity and safety of the services delivered by employees, maintaining quality and ethical service delivery while making budget cuts, or developing a new policy to provide guidance for employees facing commonly encountered ethical challenges.

Once the purpose of involving the ethics committee with policy development and review is known, several additional decisions should likely be made. For example, one decision to make is what types of policies the ethics committee will be involved with. Will the ethics committee be involved with all or only a specific set of policy decisions? A second decision is what role the ethics committee will have in developing and reviewing policies. For example, will the ethics committee provide simple recommendations or advice that may or may not be included in policy decisions? Or will the ethics committee be directly involved in composing the policy? A final decision is how frequently the ethics committee will be involved in developing or reviewing policies. Will policy development and review be an ongoing function of the ethics committee, a yearly activity, or on a case-by-case basis? Similar to ethics education, how an organization answers these questions will likely be determined by the purpose of involving the ethics committee with policy development and relative to the amount of organizational support available to the ethics committee members.

Consultation and Case Review

A more common function (along with ethics education) is for ethics committees to provide ethical consultation and case review (Moon, 2019). For this function, several important decisions likely need to be made. Similar to the aforementioned functions, the first decision that likely needs to be made is the purpose of ethics consultation. Ethics consultation may take the form of an “ethics hotline” where the ethics committee (or a few members) provides quick, one-time consultation on an issue that has occurred. Alternatively, ethics consultation could take the form of ongoing participation on a clinical team until the ethics committee is not needed—analogous to bringing in a feeding expert to help on a case until feeding challenges are no longer present. Lastly, ethics consultation could also take the form of case review after decisions have been made to provide feedback and education for employees to shape their behavior moving forward.

Once the purpose of ethics consultation within the organization is decided, several additional decisions should likely be made. For example, one decision involves the kind of events for which employees can request an ethics consultation and who can request an ethics consultation. Questions here may surround whether all employees can request an ethics consultation about any question they have; what experiences and events an ethics consultation can be requested for, whether a team supervisor (e.g., BCBA, BCaBA) needs to be contacted first and give approval that the topic is appropriate for the ethics committee and not a different department (e.g., clinical, Human Resources), who will be involved in the ethics consultation (e.g., clients, caregivers, other team members), and the method by which employees must request an ethics consultation.

The organization will also need to determine what happens with the ethics consultation after it occurs. Questions may involve how the ethics consultation will be documented, if and how the consultation becomes a part of the permanent file for clients or employees, and how privacy concerns will be addressed with ethics consultation activities. Similar to ethics education and policy development, how an organization decides these issues will likely be determined by the purpose of ethics consultation and the amount of organizational support available to the ethics committee members for consultation activities.

Discussion Forum

Several important decisions likely need to be made if a function of the ethics committee is to provide a forum for discussion of ethical issues. The most important decision is, again, deciding the purpose of having an ethics discussion forum. Will the forum allow employees to voice ethical scenarios they contact in their daily work? Will the ethics committee provide scenarios for employees to practice ethical decision making? Will the discussion forum be embedded within other group discussion meetings (e.g., monthly clinical team meetings, administrative meetings) to highlight the ubiquity of ethics within everyday activities? Relatedly, a decision has to be made about what happens with all the information discussed during the ethics forum. Employees may be less likely to attend and continue to participate if no resolution comes from their voicing of ethics-related issues they contact. The ethics committee will have to answer the question: How will we turn ethical discussions into actionable items that might reinforce the continued participation of employees?

Several additional decisions likely need to be made if the function of an ethics committee is to provide a discussion forum for employees. First and foremost is how confidentiality will be maintained. Ethical discussion forums will likely result in a conversation about topics directly related to clients, clients’ caregivers, employees, or people outside the organization and with whom employees work. The privacy of personal, health, and educational information for all people is legally protected (e.g., Family Education Rights and Privacy Act, 1974; Health Insurance Portability and Accountability Act, 1996), and the ethics committee will have to develop and implement policies and procedures to ensure confidentiality within discussions. Relatedly, decisions will have to be made about what topics are and are not appropriate for discussion forums with respect to both privacy and the general relevance of the discussion topics for the determined function of the ethics discussion forum. The ethics committee will also have to decide who will be allowed to participate. Will participation in the ethics committee discussion forums be restricted only to certain employees, only to employees, or to employees and clients/caregivers, or will the discussion forums be open to the public at large? Finally, the ethics committee will have to decide how frequently discussion events will be held. Answers to all of the previous questions will likely be determined by the purpose of formalizing an ethics discussion forum and the amount of organizational support available to the ethics committee for planning and organizing discussion forums and acting on items discussed at the forum.

Research Review

A final function of ethics committees may be to help with reviews of organizational research activities. Here the question becomes: What is the purpose of having the ethics committee involved with research review? Is the purpose to ensure the safety of clients and employees and uphold the principles of the Belmont Report (Office of the Secretary, 1979), which provides guidance on human research protections? Will the ethics committee only review and provide comments on ethical concerns? Or will the ethics committee be embedded within a larger institutional review board (IRB) process? Relatedly, what influence will the ethics committee have with respect to submitted IRB protocols (e.g., recommendations only, full veto power)? Here, it is important to note that the peer-reviewed literature relevant to research ethics is largely distinct, though related, to the literature relevant to clinical ethics (National Academy of Sciences, 2009). This will directly impact the training and education of ethics committee members. Answers to all these questions will, again, likely be determined by the amount of organizational support available to the ethics committee members for their participation in research review activities where such activities might entail ensuring that the rights and welfare of potential research participants are protected through research activities, that the consent process does not contain undue influence toward participation, and that access to research participation is equitable for all clients who meet inclusion criteria.

Structure of Ethics Committees

Ethics committees, by definition of committee, involve more than one person. The number and composition of ethics committee members can be determined in a number of ways (Table 1). However, ethics committees are often minimally composed of an ethics committee chair/coordinator, legal counsel, and a local ethics adviser (American Academy of Pediatrics, 2001; Moon, 2019). The ethics committee chair may be determined by interest, by background education and training, or by some other means. Regardless, the organization will have to determine whether the ethics committee chair will rotate after some fixed period of time (e.g., 1- or 2-year period) or if the position is indefinite. The ethics committee chair is typically responsible for organizing ethics-related activities, managing the ethics committee’s budget, and coordinating the behavior of ethics committee members (if relevant). Legal counsel and ethics advisers may or may not be involved with every activity and meeting of the ethics committee. However, situations may arise during the ongoing activities of an ethics committee that have legal ramifications or involve a tangled web of unfamiliar ethical substance. Proactively identifying who can be contacted for legal and ethical concerns outside the scope of competence of the ethics committee chair can help with ethics committee activities.

Table 1.

Common Structures of Health Care Ethics Committees and Some Benefits and Drawbacks of Using Each Structure

Common Ethics Committee Structures	Benefits	Drawbacks
By interest	1. There are a larger number of members and more employee involvement. 2. Everyone has the opportunity to feel heard and contribute.	1. Membership waxes and wanes. 2. Members are likely required to volunteer their time. 3. It is more difficult to organize activities. 4. The committee’s structure is unlikely to accurately reflect the organizational structure.
By organizational structure	1. It is guaranteed that all positions in the company are represented. 2. Membership is predictable. 3. It is easier to organize and plan ethics committee activities.	1. There is added administrative work involved with selecting and replacing committee members. 2. Some may feel their voices are not heard if they are not selected to be on the committee.

Ethics committees often may also include committee members in addition to the chair, legal counsel, and an ethics adviser (American Academy of Pediatrics, 2001; Moon, 2019). The number and composition of additional ethics committee members can be determined in a number of ways. One approach to determine ethics committee membership is based on interest, in which any employee interested in being involved in the ethics committee can be an active, participating member. Adding committee members by interest has the benefits of allowing more people to potentially be involved and providing every employee with the opportunity to participate. However, this approach may have several drawbacks. Allowing all interested employees to become committee members may lead to waxing and waning membership, making it difficult to organize and conduct activities. Additionally, this approach will likely require that all committee members volunteer, as most organizations likely are unable to afford or proactively budget for a large and varying number of committee members. Finally, this approach may lead to unrepresentative employee membership, as the employees likely to participate will be those who can attend the meetings, are able to volunteer, and have an interest in ethics. In turn, an unrepresentative membership may lead to activities or committee products that are selectively biased toward the employee positions most represented on the committee (e.g., BCBAs, RBTs).

A second approach to including additional members beyond the chair, legal counsel, and an ethics adviser is to have the ethics committee be composed of a fixed number of organizational stakeholders. The specific number of members are decided upon based on institutional representation and/or expertise. With this approach, an ethics committee would be composed of at least one member who represents each department, position, and/or stakeholder within the company. For example, consider a medium-sized ABA agency with 10 BCBAs and 50 RBTs that provides in-home services for children with autism spectrum disorders. In this example, the ethics committee would ideally be composed of at least one BCBA, one RBT, one client or client caregiver, one person from administration/billing, and one person from a funding stream. The idea here is to have the ethics committee be composed of at least one member from each area/department that may be impacted by policy decisions or ethics consultations in ways that may not be considered by people in other departments/areas. A related strategy would have a proportional representation of organizational members on the committee. Using the previous example, this would involve including five RBTs for every one BCBA who is on the committee.

Using a fixed number of organizational stakeholders has the primary benefit of ensuring that all aspects of the organization are represented in the ethics committee’s activities. It is unlikely that any single employee fully appreciates the rules and contingencies that operate on the behavior of all other organizational employees. Including at least one representative from each aspect of the organization increases the likelihood that the impact of committee activities and decisions includes the perspective of at least one individual from each position in the organization. Additionally, using a fixed number and composition for the ethics committee allows the organization to proactively budget for committee members’ time and activities that may lead to more stable ethics committee activities and committee member participation.

The primary drawbacks of using a fixed number of organizational stakeholders are twofold. First, this approach requires the additional administrative work of organizing how committee members will be selected to represent each aspect of the organization (as compared to simply communicating when committee meetings will be held when using the “members by interest” approach). Second, the increased formality of employees being asked to represent their positions on the ethics committee may increase the likelihood of expected compensation for time spent working on committee-related activities and attending meetings. This may increase the financial cost of the ethics committee.

Steps to Develop an Ethics Committee

The most challenging decisions to make when forming an ethics committee are likely what the function and structure of the ethics committee will be. However, these steps are only two of the many steps required to establish and launch an ethics committee. The remainder of this article describes additional steps that likely need to be completed when forming an ethics committee. For convenience, these steps are also outlined in Table 2. Steps 1–3 require the involvement of the executive- and director-level employees of the organization and likely need to occur before the remaining steps. Steps 4-7 are more specific to initial and ongoing ethics committee activities and can likely occur concurrently. Step 8 involves launching and beginning to analyze systems and processes.

Table 2.

Steps to Consider When Developing an Ethics Committee

1. Obtain buy-in from leadership and clarity on available resources.

2. Determine the function and structure of the ethics committee.

3. Educate the staff on the function and structure of the ethics committee.

4. Choose the committee members.

5. Train the committee members on the skills needed to achieve the function of the ethics committee.

6. Identify the guiding principles of the ethics committee.

7. Formally establish the systems, processes, and communication network that allow the committee to fulfill its function.

8. Pilot/run processes, and revise function, structure, principles, and processes of the ethics committee at predetermined intervals.

Note. Steps 1–3 likely need to occur before later steps. Steps 5–8 can likely occur concurrently. Step 9 occurs after the ethics committee has been established.

Step 1: Secure Leadership Buy-In

The first step to establishing an ethics committee is to gain support from organizational leadership to develop and maintain an ethics committee. If organizational leadership is not interested in supporting an ethics committee, then there is little reason to move beyond this step. However, if organizational leadership is interested in supporting an ethics committee, then the ethics committee founders can solicit what resources might be available to support an ethics committee and how the ethics committee might fit within organizational policies and systems. Understanding what resources are available and how the ethics committee’s activities will impact organizational systems helps identify the constraints surrounding what activities are possible. In turn, resource availability and fit within organizational systems will likely impact the function and structure of the ethics committee.

Step 2: Determine the Function and Structure of the Ethics Committee

The second step is for the ethics committee founders to work within the constraints identified in Step 1 to determine the function and structure of the ethics committee. When establishing an ethics committee, this step is likely to require the most time, involves many different questions (outlined in previous sections), and will likely involve many back-and-forth conversations between the committee founders and organizational leadership. The goal of this step is to formally outline what activities the ethics committee will be engaged in, timelines and structures of ethics committee meetings, timelines and evaluation criteria for ethics committee activities, and precisely how ethics committee members will be identified and replaced over time.

Step 3: Educate Staff

The third step is to educate organizational staff about the forthcoming ethics committee. Staff should likely be educated on the purpose of the ethics committee, the activities the ethics committee will and will not be engaged in, how the ethics committee fits within other organizational systems and processes, and how employees can be involved in and take advantage of the ethics committee.

Step 4: Choose Committee Members

The fourth step is to formally identify the ethics committee members using the processes determined and outlined in detail in Step 2. If the “by interest” method is used, then a formal method for signing up would be provided to employees. If the “fixed number” method is used, then a formal process for applying to be members and selecting members would be followed. Relatedly, the ethics committee may want to proactively outline and communicate the specific dates and processes for how ethics committee members will be replaced over time.

Step 5: Train Committee Members

Few organizational employees are likely to have the background and training in all skills needed to fluently implement the ethics committee’s activities. The BACB Code explicitly discusses the importance of practicing within one’s scope of competence (BACB, 2014), and scope of competence is increasingly viewed as an important area of discussion and measurement in the ABA practice literature (e.g., Brodhead, Cox, & Quigley, 2018; Brodhead, Quigley, & Wilczynski, 2018; Teodorescu & Binder, 2004; Turner, Fischer, & Luiselli, 2016). Though typically discussed in terms of ABA service provision, competence also seems relevant to ethics committee activities.

Core competencies for health care ethics consultation already exist (American Society for Bioethics and Humanities, 2011; Courtwright, 2013; Larcher, Slowther, & Watson, 2010). These competencies include factors such as basic concepts of ethical theories and principles; the application and practice of moral reasoning; relevant knowledge of clinical terms and disease/illness/disorder processes; the cultural context of the client and employee populations; knowledge of relevant professional codes of ethics; knowledge of relevant local, state, and federal laws; and knowledge of organizational policies and processes for implementing committee recommendations. It seems likely that most of these competencies are also relevant to ethics committee activities in organizations that provide ABA services. Ethics committees could use these competencies as a starting point for training committee members while the field of ABA continues to discuss additional core competencies specific to the field of ABA and other functions that ethics committees may serve.

Step 6: Identify Guiding Principles

Once core ethics competencies are obtained, committee members can begin to fulfill the ethics committee’s function. Regardless of function, there are likely to be many different tasks and activities that can be accomplished and decisions that require prioritization. With the education function, a decision has to be made about what topics the committee will focus on and the order in which they will be pursued. With the policy function, a decision has to be made about which existing policies will be reviewed or which topics without a current policy will be focused on and the order in which they are pursued. With the ethics consultation function, situations are likely to occur where two different ethical guidelines suggest incompatible behavior (i.e., ethical dilemma) and a recommended course of action will have to be provided. And, with the research function, decisions will have to be made about what types of research projects will be allowed, how resources are allocated among available research projects, and the degree of risk-benefit trade-off that will be allowed.

Decisions that involve prioritization may be aided by developing a set of guiding principles and values that the ethics committee members can use to make decisions as part of fulfilling the committee’s functions (e.g., Craft, 2013). The goal is to develop a set of guiding and ranked principles that will allow the committee to make consistent decisions about prioritization that align with the organization’s values and mission. For example, in the course of the committee providing ethics consultation, a conflict may arise between the ethical principles of primum non nocere (“first, do no harm”) and beneficence (services should work toward maximizing client benefit). How the ethics committee prioritizes and ranks these values will directly influence the recommendations provided during case consultation. Importantly, these guiding values and principles can (and likely should) change over time as the ethics committee gains experience in applying the generally written code of ethics to the specific work settings encountered by employees in the organization.

Step 7: Formalize Committee Processes

By this stage of establishing an ethics committee, the members should have most of the necessary pieces in place to meet the functions of the ethics committee. These include a robust understanding of the resources available to the committee, the function(s) the committee members are expected to fulfill, how committee members will be sustained over time, the content and methods for training members to competency to fulfill their function, and the general ranking of principles that will lead to consistent ethical decisions over time.

Step 7 involves formally outlining all the processes and procedures of the ethics committee as a single, cohesive organizational system. Here, tools from the organizational behavior management literature will likely help with mapping out the ethics committee as an organizational system and how the ethics committee formally fits within the larger organizational system (e.g., behavioral systems analysis: Austin, 2000; Brethower, 1982; Daniels & Daniels, 2004; Rummler, 2004; Rummler & Brache, 1995; communication networks: Houmanfar & Johnson, 2003; Houmanfar, Rodrigues, & Swetz, 2009). Relatedly, perhaps the most important component of Step 7 is to identify the key performance indicators for how well the ethics committee is fulfilling its intended function. That is, the ethics committee should know what data need to be collected to allow the ethics committee to analyze their own behavior.

Step 8: Pilot Processes and Revise Accordingly

The final step in the chain of establishing an ethics committee is to launch and begin piloting the processes devised previously. Entire bodies of literature are devoted to implementation science (for a synthesis of the literature, see Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005). This research is relevant for implementing the processes and procedures outlined previously, as well as for implementing the recommendations the ethics committee provides to employees. Behavioral systems analysis and total performance system diagrams (e.g., Brethower, 1982; Diener, McGee, & Miguel, 2009) can be used with ongoing data collection to analyze the ethics committee’s performance and what happens with provided recommendations. More specifically, the ethics committee will likely want to analyze how well they are fulfilling their intended function, the efficiency of the ethics committee’s processes, and how the processes and value rankings may need to change based on the dynamic situations the employees and organization encounter as they adapt to an ever-changing ABA service delivery marketplace.

Conclusion

Codes of ethics that guide helping professionals have to be written generally to cover the wide-ranging set of possible situations any one member of the profession may encounter. Despite being written generally, ethical guidelines are applied to specific situations that professional members encounter. The application of general rules to specific contexts can sometimes be challenging and complex (e.g., Bailey & Burch, 2011; Sush & Najdowski, 2019). Health care organizations can take several strategies to help their employees behave ethically. One approach is to appoint a single ethics coordinator (Brodhead & Higbee, 2012). In contrast, the dominant approach in most health care organizations is to develop an organizational ethics committee (Moon, 2019). Despite the popularity of the ethics committee in other professions, the extent to which organizations that provide ABA services have established and operate ethics committees is unknown. For organizations interested in establishing an ethics committee, this article provided an overview of the steps that should likely be considered.

Compliance with Ethical Standards

Ethical approval

This article does not contain any studies with human participants or animals performed by the author.