Promoting Ethical Discussions and Decision Making in a Human Service Agency

Abstract

This article describes the development of a system, the Ethics Network, designed to promote discussion of ethical issues in a human services organization. The system includes several core components, including people (e.g., leaders, ambassadors), tools (e.g., hotline, training modules), and resources (e.g., monthly talking points). Data from 6 years of hotline submissions were analyzed to identify the most common concerns, and the data were compared to the pattern of violation notices submitted to the Behavior Analyst Certification Board. Recommendations are provided for creating similar systems in other organizations.

Behavior analysts are held accountable to a code of ethical and professional conduct called the Behavior Analyst Certification Board (BACB®) Professional and Ethical Compliance Code for Behavior Analysts (2014), hereafter referred to as the Code. The 10 different sections of the Code cover topics related to responsibility to clients, responsibility to the field, supervision, and research, among others. This Code guides professional ethics and professional behavior in the practice of behavior analysis, as opposed to personal or everyday behavior (Bailey & Burch, 2016). The Code was developed to assure that the socially important work that behavior analysts do for our clients (e.g., “finding humane and effective solutions, implementing programs that work) occurs while protecting clients’ rights at all times” (Bailey & Burch, 2016, p. 30).

Although the Code is relatively straightforward, the applied context in which one might operate according to the Code is much less straightforward. Behavior analysts are likely to be faced with complex ethical issues regularly, given that they often work with vulnerable and at-risk populations (Brodhead & Higbee, 2012). These issues become more prominent as the profession continues to grow at a very rapid pace (Rosenberg & Schwartz, 2019). Although the Code and published decision-making models exist to guide actions (Bailey & Burch, 2016; Rosenberg & Schwartz, 2019), there is little data from applied behavior analysis (ABA) human service organizations to suggest which ethical conundrums are most likely to occur. The general suspicion is that ethical issues may be common enough in ABA organizations to warrant infrastructure for ethical guidance and oversight (Brodhead & Higbee, 2012).

The BACB (2018) summarized submitted notices of alleged violations against certificants for the years 2016–2017 and indicated that codes 5.0 (supervision) and 10.0 (failure to report to the Board) had the highest number of submitted violations, whereas code 1.0 represented the third highest category. Subcodes from code 2.0 were in the fifth and eighth most commonly submitted categories. In a recent update, Codes 1.0 and 7.0 became the most frequently substantiated violations, with subcodes related to integrity, multiple relationships, and ethical actions frequently cited. Code 10.0 (failure to report to the Board) moved to third place, whereas Code 5.0 (supervision) moved to fourth place. However, these data may represent underreporting and likely do not capture the daily ethical situations that many Registered Behavior Technicians (RBTs), Board Certified Assistant Behavior Analysts, and Board Certified Behavior Analysts (BCBAs) contact that are concerning but might not warrant a report to the certifying body. Many ethical situations can likely be resolved directly through conversation (see Code 7.02c; BACB, 2014), which is in fact the recommended practice for addressing many ethical issues (Bailey & Burch, 2016).

The Trumpet Behavioral Health Ethics Network (hereafter, the Ethics Network) was founded in 2012 by the executive leadership team of a midsize human services agency. The goal was to create a comprehensive ethics network to support team members in being proactive in facilitating open discussion of professional and ethical issues, establishing the highest standards of professional conduct, handling ethical dilemmas swiftly as they arose, and building capacity for ethical conduct at all levels of the organization. The purpose of this article is to describe the Ethics Network for others who might want to replicate the development of the system. In addition, we present data from the first 6 years of the existence of the network to provide a sample of the issues arising in the practice of behavior analysis as a potential guide for other organizations that are developing supports for ethical behavior in human service agencies. Finally, we provide strategies and recommendations for leaders in ABA organizations who might need to modify components of our system to suit the needs of their organizations. This model demonstration represents one option that providers might use as a guide to establish resources for addressing ethics throughout their organization.

Method

Components

The Ethics Team

The Ethics Network team included three groups: (a) the leadership team, (b) the ethics team members, and (c) the clinical and administrative teams throughout the organization. That is, every individual in the organization was considered a member of the Ethics Network, but the leadership team and the ethics team members were most heavily involved in developing and distributing resources and supports (see the section on data-informed resource development). Figure 1 depicts the relation between the positions.

Fig. 1.

Graphic depicting the individuals involved in the Ethics Network

Leadership Team

The highest level of decision making and leadership in the organization (i.e., the executive team) is represented by the director of the Ethics Network. In the 7 years of the Ethics Network’s existence, three people have held the director role, including the first and third authors. They acted as a resource, reviewed data, fueled ideas for resource development, helped facilitate meetings, and received all ethics hotline submissions to determine how, when, and who should respond. The chair and the assistant chair positions were appointed by the executive team and were generally selected from the existing or prior ethics team members. These positions are similar to the ethics coordinator position described by Brodhead and Higbee (2012). A person was appointed to the role of assistant chair for 1 year and then proceeded into the position of chair for a second year (i.e., the assistant chair became the next chair, and a new assistant chair was appointed to support). These two positions were considered leadership and leadership-training positions, and each person in the position received a small stipend for their work at the end of the year and was allotted additional travel support for conferences and professional development activities in ethics.

Ethics Team Members

The ethics team members were volunteers who chose to participate in the regularly occurring meetings and to assist in the development of resources and training materials. These team members could be in almost any clinical or administrative role in the organization, but most often they were in the role of BCBA clinician or were aspiring to that role and actively accruing fieldwork experience hours in preparation for certification. These volunteer positions had no specified length of term, and team members served as long as they had sufficient capacity and interest or until they were appointed to the assistant chair position. Most team members rotated on and off the team within approximately 12–18 months. The Ethics Network leadership team and volunteer team members met approximately one to two times per month for an hour to plan resources and discuss ethical issues and the Code.

The Clinical and Administrative Teams

The clinical and administrative teams were generally the recipients of the efforts of the leadership team and volunteer team. At least annually, the leadership of the organization (i.e., all executive team members, all operational leaders) and the administrative team participated in a discussion about an ethics topic with general administrative applicability (see additional information in the following sections). For example, one discussion focused on the portions of the Code pertinent to human resources and appropriate professional interactions in the workplace. Another discussion focused on ethics issues related to marketing and public statements (e.g., nonsolicitation of testimonials, importance of evidence-based practices). In addition, the clinical teams at all levels (i.e., RBT to BCBA–Doctoral level) participated in one to three additional ethics trainings and discussions each year (see additional information that follows).

The Training Efforts

Establishing Infrastructure and Initial Training

Some of the first goals of the Ethics Network were to establish a foundation for conceptualizing and responding to ethics scenarios using a structured problem-solving approach. The emphasis in this initial training and infrastructure was to teach an overarching problem-solving strategy that was broadly applicable to many different situations, including ethical dilemmas and clinical decision making. To accomplish this objective, two resources were created and incorporated into training materials. The first resource was a multistep, structured problem-solving model commonly used with a broad array of individuals, from children with behavior problems, to executives in multinational corporations, to tackle problems as diverse as aggression and social skills problems to cultural sensitivity (Arya, Margaryan, & Collis, 2003; LeBlanc, Sellers, & Alai, 2020; Smith, Lochman, & Daunic, 2005). Different versions of structured problem-solving models include four, five, six, or seven steps, but all focus on the same basic repertoire (Glago, Mastropieri, & Scruggs, 2009; LeBlanc et al., 2020). We adopted a six-step version of this widely disseminated problem-solving model for all aspects of clinical problem solving, including problem solving for ethical dilemmas. The six steps were (a) recognize the problem, (b) define the problem, (c) generate potential solutions, (d) evaluate the advantages and disadvantages of potential solutions, (e) implement a solution, and (f) evaluate the effects of the solution. Throughout the organization, people were taught to analyze and respond to ethical scenarios based on these six steps as part of their initial (i.e., within the first 2 weeks of hire) training.

The second resource was a conceptualization and depiction of four overarching concepts (selected by the first author) that serve as foundations for ethical and professional behavior in many disciplines, including behavior analysis (Bailey & Burch, 2016; Smith, 2005; Zur, 2007). These four concepts should be adhered to in all professional situations, and failure to do so creates the risk of unethical behavior. Thus, the individual components of the Code and the responses to ethical situations (i.e., the solutions described previously) should all be relevant to one or more of these concepts: do no harm, boundaries, confidentiality, and professionalism. These concepts are similar to the reasons described as underpinning the need for the Code (e.g., humane action, protection of client rights). The graphic used in the initial (i.e., within the first 2 weeks of hire) training materials depicted each concept as a pillar of responsible professional behavior.

Discussion about ethics began early in a staff member’s tenure with the organization, and training was integrated at all levels. As part of their initial training, every employee of the organization completed an online instructional design module that covered various aspects of the Code, the concepts of the pillars of professionalism, and the model for ethical problem solving and decision making. Specific information was included for new therapists and new BCBAs. One version of the module was tailored for the administrative team by focusing on aspects of the Code and ethical problem scenarios that were more likely to be encountered in administrative tasks. Another version of the module focused on aspects of the Code and ethical scenarios that were more likely to be encountered in the delivery of clinical services.

Culture, Contingencies, and Continuous Discussion

The goal of training and ongoing discussion was to create effective and ethical decision makers at all levels of the organization and to facilitate a culture of ethical decision making by identifying and providing contingencies for ethical behavior. In addition, the ethics team regularly invited new volunteer team members from all levels of the organization (e.g., RBTs, aspiring certificants, BCBAs, administrative support professionals). All team members assisted in the development and delivery of trainings and communication resources for the organization and received public acknowledgment as ethics leaders and Ethics Network ambassadors.

After initial training in ethics, there were frequent opportunities for clinical teams to engage in discussion about ethics. The most commonly employed strategies involved the distribution of written material and live dynamic trainings and discussions. The two most frequently used written strategies were monthly talking points and e-mailed information (i.e., ethics “fun facts”). See Table 1 for example topics for each strategy. The monthly talking points were distributed to clinical directors throughout the organization to facilitate discussion about ethics in monthly clinical team meetings. These documents provided a written overview of a common ethical issue (e.g., dual relationships), a detailed review of the relevant codes, and strategies for avoiding or resolving the ethical issue. In addition, the documents often provided scenarios and example scripted responses that could be used in role-plays with team members to help them practice responding to the situation. The ethics fun facts were e-mails distributed organization-wide (i.e., to both administrative and clinical team members of all skill levels). These e-mails were designed to be brief and eye-catching (e.g., infographics, videos) and focused on a single ethics-related topic as a reminder (e.g., the holidays are approaching and we do not accept gifts) or announcements (e.g., there are new ethics codes for RBTs).

Table 1.

Sample Resources Created by the Members of the Ethics Network

Category	Title	Description
Monthly talking point	“Holidays and Potential Ethical Conflicts”	Holidays may present opportunities for ethical dilemmas. Anticipating and planning for these events may reduce the likelihood of conflicts. This talking point provides guidance and sample scripts.
Fun fact	“Supervisory Relationships”	Describes code 5.0 about supervisee–supervisor relationships.
Quarterly clinical team discussions	“Dual Relationships Where You Least Expect Them”	This extended training describes commonly occurring situations that might present dual-relationship conflicts. The training presents strategies for avoiding or resolving these situations by prioritizing professionalism, appropriate boundaries, and doing no harm to the client and family.
Journal club	“Teaching and Maintaining Ethical Behavior in a Professional Organization”	The group read and discussed Brodhead and Higbee (2012).
Semiannual ethics discussion	“Blurred Lines: Ethical Implications of Social Media for Behavior Analysts”	This was a facilitated company-wide discussion about O’Leary, Miller, Olive, and Kelly (2017), with a focus on implications for marketing and outreach activities and personal posts.

The most commonly employed versions of live, dynamic discussions were quarterly clinical team discussions and journal club activities conducted as webinars. See Table 1 for examples of topics. The quarterly clinical team discussions were based on presentations and discussions about advanced ethics and leadership topics (e.g., ethical issues arising when families are separating or divorcing, the importance of operating within your scope of competence). The quarterly discussions were typically created and led by members of the ethics team and were usually created in response to ethical questions that had arisen throughout the year or professional development events from conferences. The journal clubs typically focused on published articles that focused on some aspect of ethical behavior, and the journal clubs were co-led by a member of the ethics team and the author of the article. Finally, each year the ethics leaders conducted a training and discussion with the administrative team about portions of the Code that were particularly pertinent to administrative support activities (e.g., nonsolicitation of testimonials).

The Ethics Hotline

To provide team members with immediate support, an internal ethics hotline was created. The hotline was located on the organization’s intranet and was accessible by any team member. Submissions were anonymous to everyone except the ethics director, who received the submissions via e-mail. Once received, the director removed identifying information. In cases of an emergency, the director contacted the team member within 12 h. In nonemergencies, the director de-identified the submission and reviewed the submission with the chair and assistant chair. These leaders facilitated a discussion about the submission at the next Ethics Network meeting with the volunteers, and one to two team members volunteered to craft a response within 1 week.

The ethics submission form was specifically designed to follow the problem-solving and decision-making steps outlined in the training materials. For example, the form prompts team members to (a) describe their concern (i.e., detect the problem), (b) consider which BACB Code item is relevant to their scenario (i.e., define the problem), (c) nominate possible solutions to their dilemma, and (d) list any pros and cons of the possible solutions. The BACB Code numbers were listed in a drop-down selection menu. See the Appendix.

Data-Informed Resource Development

The ethics leaders and ethics team met regularly (e.g., every 2–4 weeks) to develop and execute the annual resource development and training plan. Sometimes new topics were identified, and sometimes resources that had previously been distributed were redistributed (e.g., information on the ethics of gift giving and receipt from clients was distributed in mid-November each year). The topics were selected based on a review of the recent ethics hotline submissions and direct conversations with individuals in the organization who wanted to offer input (e.g., the managing director suggested a topic on peer interactions in the workplace). Once topics had been suggested, the leaders identified the mechanism that seemed best suited to the topics (e.g., fun fact, monthly talking point, all-staff training). The leaders then recruited members of the ethics team to assist with topics that interested them the most. See Table 1 for a sample of topics covered in each distribution mechanism.

Coding Procedures

We downloaded all ethics hotline submissions submitted by staff members from the conception of the Ethics Network at the end of 2012 through 2019. A total of 137 submissions were reviewed. The submission data were downloaded in a Microsoft Excel® document that included the information completed by each staff member submitter. The fields the submitter completed are included in the Appendix. The names of the submitters were removed before the document was reviewed by the second author.

Data Coding and Analysis

The second author read and coded each submission for the year and month of submission, whether the situation was described as urgent or nonurgent, the position and background of the submitter, and the BACB codes and subcodes identified by the submitter. Next, the coder identified any additional codes or subcodes that were relevant based on the written description of the ethical concern.

The frequency of submissions was calculated for each full year from 2012 to 2019. The percentage of submissions described as urgent by the submitter was calculated by adding the number of submissions marked urgent to the number marked not urgent and dividing by the total number of submissions. The frequency of the positions of submitters was calculated for the following categories and subcategories when applicable: administrative and support services, clinical leadership (i.e., regional director, clinical director), senior clinician, clinician (i.e., clinician, associate clinician), direct care provider (i.e., senior therapist, therapist), and unidentified. The frequency of identification was noted for each of the 10 BACB codes as identified by (a) the submitter and (b) the researchers. Next, the researcher identified the total number of codes and subcodes identified for each submission and calculated an average by dividing the total number of codes and subcodes identified for all submissions by the total number of submissions.

Interobserver Agreement (IOA)

A second independent coder (i.e., the third author) scored 25% of the entries (n = 35) for the pertinent ethical codes for each submission. The second coder downloaded the same spreadsheet along with the BACB Code and scored every third entry to ensure that the entire time span was sampled. She read each selected submission and identified the relevant codes. The primary and secondary coders’ responses were then compared. For an agreement to be scored, the coders had to agree on all relevant codes for that entry (i.e., the submission generated perfect agreement on all codes identified by the reviewers). The overall agreement was calculated by summing the number of agreements by the number of agreements plus disagreements and multiplying by 100 to obtain a percentage. Of the 35 submissions scored for IOA, there were 30 agreements and 5 disagreements, resulting in an overall IOA score of 86%. The most common type of disagreement was for one coder to identify an additional code that the other had not. A second coder also scored the position of the submitter for each submitter (i.e., IOA scored for 100% of submissions). For these measures, IOA was calculated by dividing the smaller number by the larger number and converting to a percentage. The resulting IOA for the submitters’ positions was 100%.

Results

The frequency of submissions for each full year from 2012 to 2019 is depicted in Fig. 2. The partial year of 2012 (November and December) is not graphed but had only a single submission. There was an increasing trend for the first full 3 years, with submissions stabilizing between the years 2015 and 2019 (M = 25.25 for these last four data points). Across all years, the percentage of submissions described as urgent by the submitter was 12%, whereas 88% were described as nonurgent, perhaps suggesting that submitters were using the hotline proactively to initiate discussions about situations that could arise or could become urgent if not addressed.

Fig. 2.

Frequency of ethics hotline submissions per year

The frequency of the position of submitters is depicted in Fig. 3. The category with the lowest number of submissions was “unidentified,” followed by “direct care providers.” The category with the highest number of submissions was “clinician,” which included both BCBAs and those pursuing their credential and serving as a case coordinator under the supervision of a clinical leader. The number of employees of the organization ranged from approximately 600 to 900 during these years, with approximately 75%–80% of employees holding direct service provider positions. Thus, the number of submissions per employee is very low, and clinicians and leadership positions are far overrepresented in reporting compared to direct care providers.

Fig. 3.

When two tiers exist for a position (i.e., clinical leadership, clinician, direct care provider), the more junior tier is represented by the filled bar segment, and the more senior tier is represented by the hashed bar segment

The mean number of relevant BACB codes per submission (i.e., identified by the submitter) was 1.0, with a range of 0 to 4. The majority of submissions with no BACB codes indicated “unsure” as the response. In contrast, the mean number of BACB codes identified from the submissions by the reviewing researcher (i.e., identified by an expert) was higher, at 1.43, with a range of 0 to 5 codes per submission. The distribution of the submissions across the Code areas is depicted in Fig. 4, with the original submitter data represented as a filled bar and the expert reviewer data as a hashed bar. The most frequently identified code area by both submitters and the reviewer was code 2. The second most frequently endorsed area by submitters was “unsure/not applicable,” followed closely by code 1. In contrast, the reviewing researcher identified more items for code 1 and fewer items with no applicable or discernable code. One potential benefit of an ethics network is that people who are unsure about whether a specific code is applicable can seek assistance from a colleague who is more likely to recognize the relevant codes for a situation. A second potential benefit of an ethics network is that behavior analysts who are early in their careers may learn to become better at identifying additional relevant Code violations through their interactions with the ethics hotline team. The reviewing researcher also scored subcodes for the most frequently identified areas (codes 1 and 2) and found that subcodes 1.06 (multiple relationships and conflicts of interest), 2.05 (rights and prerogatives of clients), and 2.06 (maintaining confidentiality). Full data on subcodes for codes 1.0 and 2.0 are available upon request were the most frequently identified.

Fig. 4.

Number of times codes were identified by the hotline submitter and expert coder

A direct comparison with the BACB’s reported data is not possible due to the format of the reporting of the BACB data. That is, the BACB reports combine multiple code sections together by category in their reporting of cases for 2018, whereas we report each code area separately. However, some general observations are possible. The Trumpet hotline data indicate that Codes 1.0 and 2.0 are the most commonly submitted. Similarly, the 2018 data from the BACB reveal that several Code 1.0 elements are represented in notices of alleged violations that resulted in substantiated violations and disciplinary action. Code 2.0 elements, however, are only the fifth, seventh, eighth, and ninth most common groupings in the BACB data, with few substantiated violations per grouping. Finally, the BACB reports (2016–2017; BACB, 2018) both indicate a high proportion of violations related to failure to comply with BACB rules or reporting requirements (i.e., code 10), whereas none of the Trumpet hotline submissions were related to code 10.

Discussion

Brodhead and Higbee (2012) provided recommendations for creating a structure for supporting ethical guidance and training in human service organizations. This article illustrates a system of active supports developed in a large human services agency with the express purpose of fostering open discussion about ethics and systematic problem solving in ethical dilemmas. Many of the components of the system (i.e., the Ethics Network) are similar to the ones described by Brodhead and Higbee (2012), including a team of directors and a focus on training and supervision. Brodhead, Quigley, and Cox (2018) suggest that discerning potential employees should evaluate organizations by examining the “extent to which the organization expects employees to engage in ethical conduct, and actively supports those expectations” (p. 165). One way to actively support those expectations for ethical conduct is to create a system such as the Ethics Network described here.

There are several behavioral explanations for why individuals may behave unethically or fail to report others who behavior unethically. The Ethics Network was designed to address each of these potential behavioral explanations. First, reporting and discussing unethical behavior can be unpleasant, which may lead to avoidance of reports and discussions unless systems are developed that facilitate continuous discussion. Positive reinforcement contingencies for asking for help or offering help were built into the ethics system (e.g., immediate response and support from a leader, status and reinforcement for being involved in the network). Having discussions occur at fixed times rather than in response to crises was designed to eliminate any respondent or operant conditioning process that might occur with contingent (i.e., crisis-triggered) discussions of ethical issues. Second, individuals may have a skill deficit in identifying ethical dilemmas. Without specific training and support for individuals, unethical behavior may occur because of ignorance of the Code and the overarching principles that underly the Code. The training components of the Ethics Network were designed to minimize skill deficits and to focus on a structured problem-solving approach used across contexts and a small number of underlying principles rather than numerical codes. Third, the response effort of obtaining support and resources for ethical decision making may lead to reduced reporting and assistance seeking. Resources that are easy to access and use, such as the hotline, the monthly talking points, and the fun facts distributed via e-mail, were designed to reduce the response effort for ethical support. Each of these possibilities likely exists in the lives of behavior analysts faced with making ethical decisions each day and needs to be considered in the context of creating a culture that promotes ethical decision making.

The analysis of the Ethics Network hotline submissions offers a few points of insight. First, there was an ascending slope in the frequency of submissions throughout the first years of the system. This pattern may suggest that it takes time for the competing positive reinforcement contingencies to overcome the inherent negative reinforcement contingencies. It may also suggest that the ongoing training efforts established important prerequisite skills for submission (e.g., knowledge of the Code, sufficient exemplars to identify dilemmas). Second, the most frequently identified codes were codes 1.0 and 2.0. These areas focus on the responsible conduct of behavior analysts and their responsibility to clients, and the most common subcodes focused on dual relationships or conflicts of interest, rights of clients, and confidentiality.

Another finding worthy of note was the fact that those serving in the role of expert usually identified more codes that were relevant than the original submitter. In addition, the most common source of disagreement between the experts was when one of them identified an additional area that might be relevant. These data speak to the fact that most ethical situations have multiple potential implications and areas of concern. Difficult situations do not readily fall neatly into a single code or subcode without other issues being identified. These findings are also evident in the data reported by the BACB (2018), who found that the majority of violation submissions included multiple violations (i.e., from two to over five). Some of the topics endorsed in hotline submissions differed from the violations reported to the BACB (e.g., no code 10 submissions), but dual relationships and clients’ rights submissions were high for both sources.

Although these data offer some insights into hotline submissions over a span of several years, there was no experimental evaluation of the components of the system as necessary or sufficient to produce robust ethical decision making. The mastery of the instructional design module suggests that certain verbal repertoires were acquired, and the submissions to the ethics hotline suggest that people sought guidance and resources. However, there is no way to know how many actual ethical dilemmas were occurring across the multiyear span as a comparison and means to calculate whether an increasing or substantial percentage of dilemmas was being submitted. Future studies could experimentally evaluate the components included in this ethics network.

The purpose of this article was to provide an example for others who wish to build systems that support ethical behavior and facilitate honest and proactive discussion of difficult situations and potential solutions. In doing so, these types of systems may assist us in our endeavors to do socially important work while protecting clients’ rights at all times (Bailey & Burch, 2016). However, human service organizations may differ substantially in size, resources, and expertise. Trumpet Behavioral Health is a relatively large organization with resources committed to systems development, expertise, and infrastructure to support clinical standards implementation. Other organizations might lack expertise or resources and infrastructure for the multicomponent approach taken at Trumpet.

The following suggestions may assist organizations in modifying the approach to meet their needs. First, there may need to be one single leader of the ethics network in a smaller organization. It is important that the leader have influence throughout the organization so that ethical discussions occur among both clinical teams and administrative support teams. Second, organizations may need to rely on existing resources rather than create their own, as was done at Trumpet. Fortunately, many more published resources on ethics exist now than existed in 2012 when the Ethics Network was started at Trumpet. These published resources can be incorporated into a journal club option even if the other resource categories listed in Table 1 are not possible. Third, now that data exist from this analysis and the BACB, an organization might target ethical discussions and resources at the most commonly reported problems. That is, a focus of discussions on dual relationships, responsibility to clients, and privacy and confidentiality would address many existing and potential ethical problems, though certainly not all of them.

Appendix

Information Completed by Submitters on the Ethics Hotline Submission Form

TBH Ethics Hotline Submission Form Components A. What is your position/role? B. Have you notified your supervisor about this issue? C. Is this urgent? D. Which of the following BACB Guidelines for Responsible Conduct or American Psychological Association Ethics Codes are relevant to your dilemma? E. Tell us about your role, job title, credentials, and any other pertinent information at the time of the dilemma. F. Setting: In which setting did the dilemma occur? If other setting: Please explain, client(s) or others involved. G. Dilemma: Describe what happened or is happening to you that you think is an ethical problem. H. Describe the actions considered and pros/cons of actions, actions taken, and review of outcomes. I. Other: Is there any other information you would like to share about the dilemma?

Funding

No funding was associated with the current study.

Compliance with Ethical Standards

Conflict of Interest

The authors of this manuscript declare no conflict of interest regarding this manuscript.

Ethical Approval

All procedures were performed in accordance with the ethical standards of the institutional review committee and with the 1964 Helsinki declaration and its later amendments.