Modeling Psychologists' Ethical Intention

Article

Modeling Psychologists’ Ethical Intention: Application of an Expanded Theory of Planned Behavior

Psychological Reports 0(0) 1–19 ! The Author(s) 2016 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0033294116647691 prx.sagepub.com

Michal Ferencz-Kaddari Department of Psychology, Bar-Ilan University, Israel

Annie Shifman School of Behavioral Sciences, College of Management Academic Studies, Israel

Meni Koslowsky Department of Psychology, Bar-Ilan University, Israel

Abstract At the core of all therapeutic and medical practice lies ethics. By applying an expanded Ajzen’s Theory of Planned Behavior formulation, the present investigation tested a model for explaining psychologists’ intention to behave ethically. In the pretest, dual relationships and money conflicts were seen as the most prevalent dilemmas. A total of 395 clinical psychologists filled out questionnaires containing either a dual relationship dilemma describing a scenario where a psychologist was asked to treat a son of a colleague or a money-focused dilemma where he or she was asked to treat a patient unable to pay for the service. Results obtained from applying the expanded Ajzen’s model to each dilemma, generally, supported the study hypotheses. In particular, attitudes were seen as the most important predictor in both dilemmas followed by a morality component, defined here as the commitment of the psychologist to the patient included here as an additional predictor in the model. The expanded model provided a better understanding of ethical intention. Practical implications were also discussed. Keywords theory of planned behavior, predicting ethical intention, commitment to patient

Corresponding Author: Michal Ferencz-Kaddari, Department of Psychology, Bar-Ilan University, Kalisher 4, Kfar-Saba 44380, Israel. Email: [email protected]

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Psychological Reports 0(0)

Introduction Ethics is defined as the appropriate behavior adopted by a person or a group (Corey, Corey, & Callahan, 1998). Ethics is a critical issue in medical therapy, and, in particular, within the mental health care professions (Hill, 2004). Because of the inferior position of each patient/client vis-a-vis the therapist, abuse of the relationship is a definite risk to the patient (Gabbard, 1996). In the last few years, research of ethical behavior within treatment modalities has come into focus because of the many social, legal, and economic changes that require the psychologist to adjust to new circumstances (Joscelyne, 2002). The present study applies an expanded version of the theory of planned behavior for explaining psychologists’ ethical intentions. The basic formulation has been successfully used in explaining intentions and behavior (Ajzen, 2001), and the addition here of a morality component was expected to provide further understanding of psychologists’ ethical intentions. Although studies have discussed ethical decision making from a theoretical and rational perspective (Johnson, Barnett, Elman, Forrest, & Kaslow, 2012; Rogerson, Gottlieb, Handelsman, Knapp, & Younggren, 2011) which should allow one to arrive at the “correct” decision in a systematic way, few studies have empirically examined the decision making process by including relevant attitudinal and normative antecedents (Kaiser & Scheuthle, 2003; Norman, Clark, & Walker, 2005). By mapping the therapeutic field and gathering information from therapists describing what actually occurs in their clinics, suitable ethical scenarios were developed (see pretest). The theory of planned behavior, a well-established model with proven predictive efficacy (Ajzen, 2001), which was applied to these issues, required modifying the original scales as to make them appropriate to ethical behavioral intentions. By developing a model of intentions to behave ethically, the present study provided a broad explanation, rather than the more prevalent attempts that offer only a partial explanation, for the phenomenon of behavioral intentions.

The study of ethics in treatment When discussing the ethics of treatment, the authors refer here to applied ethics, which deals with the proper behavior of a psychologist during treatment (Beauchamp & Childress, 2001) or the standard of behavior or actions in one’s relations with others (Levy, 1972). Ethical issues are built into the treatment system and bear little relationship to the treatment approach itself (Koocher & Keith-Spigel, 1998). As these issues are not uncommon (Nigro, 2004), practitioners often cope with them on a daily basis. This is understandable, due to the asymmetry in the psychologist–patient relationship. The psychologist has the responsibility of ensuring the desired conduct within the treatment setting, including applying and maintaining the rules of ethics (Gabbard, 1996; Sylvester, 2002). Coping with arising dilemmas is a dynamic

Ferencz-Kaddari et al.

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and fluctuating process that requires the psychologist to be aware and sensitive to contemporary social values (Callahan, 1995; Pomerantz, 2000). Various types of ethical dilemmas appear in the literature and, over time, new and more complex ones seem to emerge (Allerman, 2001; Gibelman & Mason, 2002; Koocher & Keith-Spigel, 1998; Radden, 2002; Weinstein, 2001). In the field of mental health, the dilemmas of secrecy and dual relationships have appeared to be the most prevalent (Haag, 2006; Lazarus & Sharfstein, 2000; Pope & Vetter, 1992; Radden, 2002). The secrecy dilemma deals with the psychologist transferring information regarding the patient to a third party outside the treatment protocol. The dilemma of dual relationships pertains to interactions beyond the psychologist–patient relationship in which the psychologist may be involved in two roles simultaneously (e.g., psychologist and friend). In addition, issues of money increasingly occupy the psychologists’ time, especially when coupled with managed health care issues. The gap created between technological advancement and the limited resources often available to patients creates various ethical dilemmas that were not known just a few years ago (Johnson, Brems, Warner, & Roberts, 2006). The dilemmas in this case relate to quality of treatment based not only on medical considerations but on financial ones as well, including over-use of treatment for profit and related gains (Eastman, Eastman, & Tolson, 2001; Lazarus & Zur, 2002; Weinstein, 2001). It should be remembered that other taxonomies of medically related ethical dilemmas have been reported in the literature (Gabbard, 1996), including problems of money for treatment; problematic personality-based behavior, such as sexual relations with a patient; problematic profession-based behavior, such as rendering treatment without the suitable skills and qualification; and problems that emerge during university and professional training. The latter may include insufficient training, as well as lack of professional ability (Johnson et al., 2012; Pope & Vetter, 1992; Scaturo & Douglas, 2002). Yet, the dilemmas upon which the present study is based were chosen after a carefully conducted pretest. Based on the pretest, secrecy, dual relationships, and money issues were the two dilemmas that psychologists encounter most frequently.

Ajzen’s theory of planned behavior In trying to understand the process which leads a psychologist to choose a particular behavior when confronting a dilemma, we applied the Theory of Planned Behavior (Ajzen, 1985), a popular conceptual framework for the prediction of intentions and behavior in various areas (Ajzen, 2001). According to the theory, a person intends to act in a rational and active way and considers her intention according to the results of that very action. Furthermore, the person’s intention to act in a specific fashion allows for predicting the behavior even before it has been carried out as intentions expresses readiness to make an effort in implementing that behavior. In other words, the greater the intention,

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the higher the likelihood that the behavior will be carried out. In accordance with this theory, Ajzen (1985) developed a model describing the factors predicting behavior in many disciplines ranging from marijuana smoking (Conner & Mcmillan, 1999) to use of condoms (Reinecke, Schmidt, & Ajzen, 1996). The model has been used in predicting actual behavior as well as intentions with equal success (Armitage & Conner, 2001; Sutton, 1998). The present study employed the Ajzen’s model because of its proven efficacy in the study of behavior in various fields of health research (Masalu & Astrom, 2003). In addition, the model seems appropriate in a study of ethical behavior, as its content is associated with relevant correlates such as beliefs, norms, and attitudes. Indeed, the model has been used to study behavior connected to values, and even ethical behavior in non-medical contexts (Kurland, 1995; Randall & Gibson, 1991). Yet, there is still a need to expand the research of ethics in psychological treatment contexts, particularly, psychologist–patient relations as will be delineated below. As presented in Figure 1, Ajzen’s theory of planned behavior postulates three independent factors as the determinants of behavioral intention: (a) attitudes, which involve the positive or negative evaluation of a particular behavior as determined by how much the behavior is expected to yield positive or negative results (Rhodes & Corneya, 2003). The individual will usually tend toward choosing the behavior he or she evaluates as more positive (Ajzen & Fishbein, 1980; Ajzen & Madden, 1986; Fishbein & Ajzen, 1975); (b) subjective norms, which depict the social pressure felt by the individual to perform (or not) and his belief that important people in the individual’s environment are in favor

Attitude

Subjective Norm

Perceived Behavioral Control

Morality

Figure 1. Theory of Planned Behavior.

Ethical Intention

Ethical Behavior


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(or not) of his performance; and (c) perceived behavioral control, which is the extent to which the individual feels in control of implementing the behavior (Ajzen, 1985; Ajzen & Driver, 1992; Ajzen & Fishbein, 1980; Ajzen & Madden, 1986).

Morality or professional commitment Alongside the traditional predictions afforded by the Theory of Planned Behavior, several investigators have tested new components, relevant to different target behaviors, with the intention of increasing variance explained (Ajzen, Joyce, Sheikh, & Gilbert, 2011; Armitage & Conner, 2001). The present study expanded on Ajzen’s original model by adding a morality component so as to examine whether it can help increase predictive validity for ethical intentions. Morality refers to a normative code of conduct that, given specified conditions, would be put forward by all rational persons (Bernard, 2011). The morality component was introduced in the current study due to its interrelationship as ethical behavior deals with issues of what is good, right, and fair—and morality with values (Sylvester, 2002). In differentiating between the two concepts, ethics can viewed as a code that exists outside the individual and is formed by organizations or society for governing behavior (Trevino, Weaver, & Reynolds, 2006), whereas morality is based on an individual’s internal value system and the moral commitment based on his/her internal world (Kurland, 1995). When treating patients, the two concepts are meant to complement each other (Kitchener, 1984). Moreover, moral principles figure highly in the process of ethical decision-making (Blais & Thompson, 2008). Although morality is central to understanding practical ethical situations, it has been neglected in the education of ethics (Freeman & Peace, 2006) as well as in ethics research (Hill, 2004). This major shortcoming reinforces the importance of the present study, as one of the study’s aims is to examine whether morality affects the ethical behavioral intention of the therapist, beyond what is explained by the theory of planned behavior. There are those who claim that the moral component has already been included in the attitude component or in the subjective norms one utilizes, so there appears to be no need to examine morality separately (Kaiser & Scheuthle, 2003). Others disagree and have added the morality variable to Ajzen’s model, finding an increase in the prediction afforded by its inclusion (Armitage & Conner, 2001; Norman et al., 2005). The latter group of studies included morality in various ways. Some examined the moral commitment to a particular behavior (Randall & Gibson, 1991), while others examined the moral commitment to a particular group of people, such as family (Sparks, Shepherd, Wieringa, & Zimmermans, 1995). The present study examined the moral component as a separate variable, assessing the commitment of the therapist to the patient, using questions collected from the literature (Kaiser & Scheuthle, 2003; Kurland, 1995; Randall & Gibson, 1991).

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For example, Kurland (1995) illustrates the decision that may occur in a specific situation where the psychologist’s behavior is dependent on her commitment either to the patient or the treatment or the family. Several demographics have been examined previously as potential antecedents of ethical behavior. In particular, findings for seniority and gender show mixed results (Gibson & Pope, 1993; Haas, Malouf, & Mayerson, 1988; Webster, 2004; Yarhouse & Devries, 2000). Though included in the data analysis below, no specific hypotheses regarding these variables were proposed. In accordance with the Theory of Planned Behavior, we would expect that as social pressure regarding the treatment of the patient increases (i.e., the greater the subjective norms), the more positively she assesses the implications of treating (i.e., the greater the positive attitudes). Also, as control over the decision whether or not to treat the patient increases (i.e., the greater the perceived behavioral control is), the greater the intention to treat. Furthermore, as the morality component increases (assessed by the degree of commitment the participant feels she has to the patient), the greater the intention to treat the patient. Thus, the following specific hypotheses were tested: Hypothesis 1. Subjective norms concerning treating the patient, attitudes toward treating the patient, and perceived behavioral control over treating the patient will predict intention to treat the patient. Hypothesis 2a. Moral/professional commitment to the patient will predict intention to treat the patient. Hypothesis 2b. Moral/professional commitment to the patient will explain additional variance of intention to treat the patient beyond subjective norms, attitudes, and perceived behavioral control.

Method Pretest: Psychologists’ most prevalent dilemmas There were several stages in developing the scenarios that would be used in the current study. In the first stage, a review of the literature identified six ethical dilemmas commonly confronted by practitioners in the helping professions (Lazarus & Sharfstein, 2000; Pope & Vetter, 1992; Scaturo & Douglas, 2002). Afterwards, a group of 11 professionals including clinical psychologists, psychiatrists, and attorneys, all of whom are involved with ethical boards in their specific disciplines, provided behavioral anchors to each of the dilemmas. For example, a scenario describing a dual relationship where the psychologist is asked to treat a son of a friend was presented to each of these 11 professionals.


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In this case, the anchor for the highest ethical behavior (“7”) is to refuse to treat and for the lowest to accept the individual for treatment without hesitation (“1”). A score of “4” is assigned if the decision is to treat only if there is no choice as the patient would not receive treatment from someone else. Agreement as to the appropriateness of the scale items ranged from approximately 75% to 85%. In the next stage, a sample of 78 clinical psychologists recruited from professional conferences/lectures and over the Internet ranked the dilemmas in order of prevalence, and rated themselves on how they would behave if confronted with scenarios for each of the dilemmas (Secrecy, Dual relationships, Improper professional behavior, Improper personal behavior, Money, Training and academic) with the encores. In order to identify the dilemmas that would yield adequate dispersion and differential responses, dilemmas that yielded high and low mean ratings were chosen. More specifically, an examination of the findings showed that the most prevalent dilemmas related to secrecy, dual relationships, and money (Table 1), similar to findings in other studies (Lazarus & Sharfstein, 2000; Pope & Vetter, 1992; Scaturo & Douglas, 2002). Moreover, from these three dilemmas, the secrecy dilemma was dropped, as its relatively low standard deviation (Table 2) indicated that it would not produce adequate variation in the current study.

Main study: Participants A total of 395 Israeli clinical psychologists took part in the study. As with the pretest, they were recruited from conferences/lectures and over the Internet. Response rate at lectures and conventions was about 37%, similar to other survey studies (Hamilton, 2003). Questionnaires were completed anonymously in about 10 minutes. Two forms were distributed with gender distribution in each group about the same. Of the participants in the dual relationship dilemma,

Table 1. Distribution of most prevalent ethical dilemmas. Psychologists (N ¼ 78)

Secrecy Dual relationships Money Improper professional behavior Training and academic problems Improper personal behavior

N

%

30 25 9 9 2 3

38.5 32.1 11.5 11.5 2.6 3.8

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Psychological Reports 0(0) Table 2. Means and SD’s for ethical behavior in various dilemmas. Experts (N ¼ 11)

Secrecy Dual relationships Money Improper professional behavior Training & academic problems Improper personal behavior

M

SD

6.52 6.43 5.69 5.87 5.38 5.91

0.85 0.95 1.40 1.27 1.21 1.40

81.9% were women and in the money dilemma group, 80.5%. Participants’ age ranged from 22–75 years, M ¼ 42.6 year (SD ¼ 11.3) for the dual relationship dilemma and 43.1 year (SD ¼ 10.8) for the money dilemma. Similarly, in the former group, 67% of participants were women, mean age 42.1 year (SD ¼ 10.2). The samples approximated the age and gender data of psychologists from The Israeli Health Ministry (2010): mean age 42 year (SD ¼ 12.3) and 73% of the psychologists in the directory were women.

Measures Data were collected from 395 psychologists, with 226 responding to the dual relationship dilemma and 169 to the money dilemma questionnaire.

Dilemmas The American Psychological Association has a clear code of ethics that includes dual relationships and money-related issues as potential problems. The scenario chosen here have clear right and wrong ethical answers and were obtained from the respondents in the pretest, who described them as among the most common ethical dilemmas they encounter. The two scenarios each described a specific situation. The dual relations dilemma was presented in the following way: “If you encountered a case whereby the relations veer from a clear and reasonable professional connection—for example, a colleague from work with whom you maintain close ties asks you to treat his/her son.” The money dilemma was presented in the following way: If you encountered one of the two following cases: a patient had undergone private treatment with you for the last half a year and his/her money gave out, or publicly when the insurance policy ceased to finance the treatment, and in either case it is clear to you that he or she needs immediate continuation of the treatment.


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The story was presented without labelling it as either a money or dual relationship dilemma. Based on the pretest findings reported above, in the dual relationships dilemma, cessation of treatment is the ethical behavior alternative, while in the money dilemma, continuation of treatment is the ethical behavior alternative. Theory of planned behavior components. New specific items relevant for these ethical dilemmas were constructed. Reliability measures were determined for each of the modified Azjen scale components. Date showed that coefficient alpha ranged from .64 (subjective norms in the money dilemma) to .95 (attitudes in the dual relationship dilemma). The focus of each of the components was the continuation of treatment by the therapist, even if only for a short while. Following Ajzen’s (1971) approach, the model’s validity is increased when items are formulated in detailed and specific manner and not presented as a general theoretical question (see e.g., Armitage & Conner, 2001; Gollwitzer, 1999; Sutton, 1998). The items in the scale were the same ones that have been used in Hebrew (translated from English to Hebrew and back) in many previous studies. As is usually done with the Ajzen scale, items are modified to reflect the specific area of interest in the research. For example, a recent study in Hebrew (Tabak, Itzhaki, Sharon, & Barnoy, 2013) focused on an area that is quite similar and reported reliabilities ranging from .83 –.93. In addition, the 11 professionals who were involved with ethical committees (as explained above) agreed on the phrasing of items between 80% and 85% of the times. Where there was disagreement, a discussion among some of the professionals resolved the disagreement in all cases. Intention. Two items on a 7-point scale were used here. These items were “I will treat the patient in certain conditions like in an emergency, and only for a short while” ranging from 1 (Very likely) to 7 (Very unlikely); and “Would you treat the patient in certain conditions like in an emergency, and only for a short while?” 1 (Definitely intend) to 7 (Definitely intend not to do). Cronbach’s alpha in the dual relationships dilemma was .90, and in the money dilemma, .70. Attitude. The respondents were presented with the statement “Treating the patient in certain conditions like in an emergency, and only for a short while would be . . .” followed by six bipolar adjective pairs rated on a 7-point scale ranging from 1 to 7: foolish–wise; effective–not effective; advisable–not advisable; good –bad; right–wrong; and positive–negative. Cronbach’s alpha in the dual relationships dilemma was .95, and in the money dilemma, .93. Subjective norm. Two items were used, rated on a 7-point scale from 1 (Always true) to 7 (Never true). These items were, “People who are important in my life

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would tell me to treat the patient, even for only a short while”; and “People who are important to me would tell me to treat the patient, even for only a short while.” Cronbach’s alpha in the dual relationships dilemma was .68, and in the money dilemma .64. Perceived behavioral control. Two items were used, rated on a 7-point scale from 1 (Highly agree) to 7 (Highly disagree). These items were “I feel that all the conditions that allow me to treat the patient, even for only a short while, are under my control; and “For me, it would be easy to treat the patient, even for only a short while.” Cronbach’s alpha in the dual relationships dilemma was .70, and in the money dilemma .83. Moral/professional commitment. As the morality/professional commitment predictor is new to the model, it is described in further detail. The questions were taken from studies that examined similar types of moral behavior (Kaiser & Scheuthle, 2003; Kurland, 1995; Norman et al., 2005; Randall & Gibson, 1991; Sparks et al., 1995). Four items using a 7-point scale ranging from 1 (Highly agree) to 7 (Highly disagree) were used. These items were “I feel a professional commitment to treat him in certain conditions like in emergency, and only for a short while”; “I believe have a moral obligation to treat him in certain conditions like in an emergency, and only for a short while”; “Most of the professionals like me, would decide to treat him in certain conditions like in an emergency, and only for a short while”; and in the dual relationships dilemma “I feel commitment to my friend so I will treat him in certain conditions like in an emergency, and only for a short while” while at the money dilemma “I feel commitment to my patient so I will treat him in certain conditions like in an emergency, and only for a short while.” Cronbach’s alpha in the dual relationships dilemma was .89, and in the money dilemma .88. For an English translation of the questionnaire please contact the senior author.

Procedure The current study received ethics approval from a Bar-Ilan University Ethics committee. Dilemmas were chosen after the pretest described above. Two different groups of participants (clinical psychologists) were asked to respond to one of two dilemmas. The first dilemma focused on a situation where the psychologist was asked to undertake the treatment of a patient who is the son of a friend. The second dilemma dealt with a question of whether the psychologist should continue to treat a patient who no longer had the money required to continue the treatment. The participants were asked to respond to the questionnaire which assessed their intentions, subjective norms, attitudes, perceived


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Table 3. Correlations between attitude, subjective norm and perceived behavioral control, and intention to behave ethically in the dual relationships dilemma (N ¼ 226), and in the money dilemma (N ¼ 169).

Attitude Subjective norm Perceived behavioral control

Intention in the dual relationships dilemma

Intention in the money dilemma

0.84*** 0.51*** 0.49***

0.64*** 0.42*** 0.33***

**p < 0.01, ***p < 0.001.

behavioral control, and morality/professional commitment regarding the treatment of the patient.

Results Overall, the analyses supported the applicability of the Theory of Planned Behavior model to psychologists’ ethical intentions, thus providing support to Hypothesis 1. As Table 3 shows that while all the components’ correlations with intention in both dilemmas were positive and significant, the highest correlation obtained was between attitudes and intention such that as the attitudes toward treating the patient are more positive, the intention to treat the patient also increases. In order to examine the prediction afforded by the model with and without morality, hierarchic regression analyses were conducted separately for each dilemma. Each of the regressions comprised four steps similar to that reported by Podsakoff, LePine, and LePine (2007). The first step included two demographic characteristics—seniority and gender in the second step, subjective norms and attitude were added, in the third step, perceived behavioral control was added, and in the last step, morality was added. As can be seen in Table 4, approximately 72% and 44% of the variance in intention to treat the patient was accounted for by the Theory of Planned Behavior in the dual relationships dilemma and in the money dilemma, respectively. A closer perusal of the table shows some interesting findings—attitude was the most important predictor in both models, similar to what has been reported by others (Armitage & Conner, 2001; Kaiser, Hu¨bner, & Bogner, 2005). Subjective norms were found to be significantly related to intentions only in the money dilemma, whereas perceived behavioral control proved a significant addition only in the dual relationship case. Some of the issues differentiating between the two prediction models will be presented in Discussion section. In order to test the predictive value of the moral/professional commitment component, Pearson correlations between morality and intention were first

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Table 4. Predicting ethical intention using hierarchical regression analyses in the dual relationships dilemma (N ¼ 226), and in the money dilemma (N ¼ 169). Dual relations

Money Step

Predictors

1

2

Seniority .13* .01 Gender .11* .00 Subjective norm .09 Attitude .79** Perceived behavioral control Morality R2 .03** .71** 2 R .03** .68** *p < .05, **p < .01,

***

Step 3

.00 .00 .08 .75** .09* .72** .01*

4

1

2

3

4

.03 .11 .06 .06 .06 .03 .14 .01 .01 .02 .02 .16* .16* .09 .60** .56** .57** .36** .04 .01 .02 *** .29 .35*** ** ** ** .76 .04 .44 .44 .50** ** ** .04 .04 .40 .00 .06**

p < .001.

calculated. Data indicated that correlations were positive and significant for both the dual relationships dilemma, r ¼ .74, p < .001 and for the money dilemma, r ¼ .64, p < .001, such that as the moral/professional commitment to the patient was higher, the intention to treat the patient also increased, providing support for Hypothesis 2a. Moreover, rendering support for Hypothesis 2b, the addition of morality to the hierarchical regression equations in the last step explained an additional 4% (p < .01) in the case of the dual relationships dilemma and 6% (p < .05) in the case of the money dilemma to the variance explained by the theory of planned behavior. Thus, besides attitudes, only morality was significant in both cases.

Discussion The purpose of the present study was to show that an established model in the field of social/cognitive psychology can be applied to predicting ethical behavior in a mental health context. As expected, the theory of planned behavior provided a model for explaining clinical psychologists’ intention to behave ethically. In addition, by including a measure of morality or professional commitment, prediction accuracy afforded by the model increased. A detailed look at the application of the theory of planned behavior to ethical intentions presented here shows that, similar to other studies (Armitage & Conner, 2001; Kaiser et al., 2005), attitude proved to be the best predictor. With the dilemmas analyzed here, attitude seems to have a large effect on intention, as the participant’s perception of the extent to which the behavior is


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positive or desirable, alongside her/his perception of its consequences, can help predict why a person decides to behave ethically. Another central finding revealed that specific model components are sensitive to the target ethical behavior being predicted. Although in both dilemmas, attitudes were found to be the main determinant of ethical intentions such that the practitioner takes into account whether her action will lead to a positive or negative outcome, the dilemmas can still be differentiated by examining the other antecedents. In particular, the importance of subjective norm as an antecedent was seen with the money dilemma and not with the dual relationship dilemma. In comparison to attitude and perceived behavioral control, subjective norm is generally found to be a relatively poor predictor (Armitage & Conner, 2001). Nevertheless, in the money dilemma its contribution was found as significant. A possible explanation for this might lie in the importance of social expectations in the specific dilemma at hand. As compared to other ethical dilemmas tested in the pretest, the appropriate behavior for the money dilemma is simply to continue treating the patient. Thus, subjective norm can be seen as reflecting, to a large extent, the appropriate social dictate as manifested by the therapist’s peers. As for the lack of predictability from perceived behavior control in the money dilemma, it may be possible to explain this finding by the fact that this dilemma does not occur frequently enough to allow perceptions of control to influence intentions. According to the meta-analytic findings reported by Notani (1998), perceived behavioral control is often a poor predictor of intentions when the target behavior is relatively unfamiliar to the respondent. Notani argues that one needs an adequate level of actual experiences in order to truly appreciate the obstacles involved in achieving the target behavior. Thus, the assessment of control may be based on unrealistic assumptions that are not consistently linked to the intention. The inclusion of a morality component to the model increased the variance in intention explained by the theory of planned behavior in both dilemmas. It appears that when confronted with a conflict between two courses of action, moral/professional commitment is found to be an independent factor containing information unavailable in the original theory of planned behavior components. For example, when the psychologist is asked to treat a patient who is unable to pay, it is possible that her attitudes will not be that positive; however, at the same time, it is possible that the sense of obligation to the patient will be seen as affecting the outcome variable (Manstead, 2000; Norman et al., 2005; Raats, Shepherd, & Sparks, 1995; Randall & Gibson, 1991; Sparks & Shepherd, 2002). As several researchers have shown, morality is indeed a significant predictor of ethical behavior, both for the group (Lincoln & Holmes, 2010; Malloy & Agarwal, 2003) and for the individual (Kitchener, 1984; Rest, 1984). In a sense, morality comprises the core of the therapist’s ethics by recognizing the effect the behavior will have on others (Rest, 1984). Accordingly, the importance of morality is more clearly expressed in situations where the psychologist is in

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conflict between the sense of moral obligation to the patient and her own attitudes. Kurland (1995) argues that morality often has an even higher influence on intention than the attitude component. She claims that while the therapist’s perception of the attitude, subjective norms, and perceived behavioral control components rest on society’s imperatives, which are external, morality is derived from her commitment to the patient, and has a more personal, private, and reflective quality, hence is weighted more than the other components. The finding that the addition of the morality component increases the prediction power of the model clarifies Thus, in the case of ethical behavior, the therapist’s moral commitment toward the patient (Randall & Gibson, 1991), her personal moral norms, and the perception regarding her professional and social commitment (Sparks et al., 1995), are all meaningful antecedents, not included in Ajzen’s original model. If this is the case, morality may have an effect on the use of the model in general, outside the ethical field. Further research should be conducted to increase model efficacy.

Limitations and conclusion Several limitations of the current study can be identified. Perhaps, most importantly, this study, as others, focused on examining the intention of the behavior and not the behavior itself. The dependent variable as well as all the independent variables was assessed at the same time. Although the common method problem lends itself to bias, recent research has mitigated this as a major concern (Conway & Lance, 2010). As in other similarly designed studies which were based on Ajzen’s model (see Armitage & Conner, 2001), the predictions afforded here can still be considered reliable and efficient in intention and behavior prediction. Future research may want to examine the variables longitudinally so as to be able to infer causal relationships. Also, the non-random selection of subjects may introduce a bias in the findings. Although demographically, the two samples are quite similar to the population data and to each other, the findings may have led to more definitive implications for understanding intention to behave ethically. In conclusion, by identifying the prevalent dilemmas and relevant correlates one can start planning appropriate training courses and provide guidance for dealing with these issues in a practical setting. Indications of a positive outcome would include the prospect of a change in attitudes, as well as, new attentiveness to the relevant morality concerns involved here. Therapists with improved ethical coping skills would benefit personally and be more likely to provide better treatment to their patients. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


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Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies Michal Ferencz-Kaddari is a clinical psychologist. She received her doctorate from Bar Ilan University, Israel. She is a lecturer and researcher at the Interdisciplinary Center, Herzliya and in Bar-Ilan University. She works in Private practice in psychotherapy with adults, individuals, couples and families, supervisor and consultant in psychotherapy and ethics. She is a member of the Ethics Committees on behalf of the Ministry of Health of Israel in Geha Psychiatric Hospital. Her research interests include ethical behavior, ethical dilemmas in medicine and mental health.


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Annie Shifman is a social organizational psychologist. She is a lecturer and researcher at The College of Management Academic Studies and works as an organizational consultant for number of large companies. She received her doctorate from Bar Ilan University, Israel. Her research interests include withdrawal and misbehavior in organizations and applications of the theories of reasoned action and planned behavior. Meni Koslowsky studied at Columbia where he received his degree in social psychology and measurement theory. His main focus of research includes stress at work, organizational behavior, methods of influence and social power, and impression management. He has written in each of these areas, both books and articles, and has presented papers and chaired sessions at more than 90 professional conferences and meetings over the years. He is a fellow (the highest honorary professional title in the field) of both the American Psychological Association and of the Society of Industrial and Organizational Psychologists and has been a visiting professor at several universities in the United States.