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Ethical Decision-Making and Evidenced-Based Practices

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 Ethical Decision-Making
and Evidenced-Based Practices 4
Videsha G. Marya, Victoria D. Suarez,
and David J. Cox

4.1 Introduction the chain of behaviors that alter the probability of

a terminal response; Skinner, 1953), ethics (i.e.,
To implement an evidence-based practice (EBP), what is the right decision), and choice (i.e., the
behavior analysts practicing within the autism act of selecting the EBP).
intervention field (hereafter referred to as applied There are many ways that researchers attempt
behavior analysts) must first select one EBP from to aggregate empirical findings and theoretical
all available EBPs. Selecting an EBP requires at arguments spanning multiple areas. A common
least three sets of behaviors. One set of behaviors approach to aggregating research findings and
are those that produce information about the cur- theory is to develop models of the phenomenon
rent context and the relevant EBPs. A second set of interest. Many different types and approaches
of behaviors are those related to evaluating the to model building exist; however, models typi-
obtained information to determine what is “best” cally allow the model user to describe, predict,
or “right” for the client in the current context. A and control some phenomenon of interest more
final type of behavior is selecting the EBP to succinctly, efficiently, and parsimoniously than if
implement. Thus, to understand how an applied the model components were considered indepen-
behavior analyst selects the right EBP for a client dently (e.g., Frigg & Hartmann, 2020). Here, we
requires that we understand theoretical and are interested in models related to decision-­
empirical work spanning decision-making (i.e., making, ethics, and choice from available EBPs.
The content of models varies depending on
V. G. Marya the function of the modeler’s behavior (e.g., Cox,
Village Autism Center, Mesa, AZ, USA 2019a). In this chapter, we focus on two types of
Department of Applied Behavior Analysis, Endicott practical models of ethical decision-making with
College, Beverly, MA, USA EBPs: causal models and decision models
V. D. Suarez (Table 4.1). Causal models help the model user to
Department of Applied Behavior Analysis, Endicott describe, predict, and control a phenomenon of
College, Beverly, MA, USA interest. Causal models do this by explicitly
Centria Autism, Mesa, AZ, USA labeling the variables that influence the phenom-
D. J. Cox (*) enon of interest as well as the relationships
Department of Applied Behavior Analysis, Endicott between those variables. Practically, causal mod-
College, Beverly, MA, USA els describe why the phenomenon occurs, the
Behavioral Health Center of Excellence, independent variables that can be manipulated to
Los Angeles, CA, USA influence the dependent variable, and the
e-mail: dcox@[Link]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 47

J. B. Leaf et al. (eds.), Handbook of Applied Behavior Analysis Interventions for Autism, Autism
and Child Psychopathology Series, [Link]
48 V. G. Marya et al.

Table 4.1 Purpose and components of causal and decision models for decision-making
Model
type Purpose Components Use
Causal Identify and outline how and Variables known to influence decision-­ Describe, predict, or
why behavior is evoked, making (e.g., rules, experienced control
maintained, increased, or contingencies, available alternative decision-making
decreased behaviors, effort, delay, and likelihood of
reinforcement/punishment)
Decision Identify and outline what Questions and statements that guide the user Help the user make an
behaviors the user should emit through the chain of behaviors necessary to optimal decision
to answer a question the model make a decision based on available
user is not fluent in answering information

expected direction of change in the dependent causal model would need to be accounted for in
variable when those independent variables are the decision model, otherwise the decision model
manipulated. would likely fail to meet its function – to help the
Decision models help the model user to make decision-maker avoid a suboptimal decision.
a decision. Decision models help the model user The purpose of this chapter is to provide and
to choose between the available alternatives in a describe models of ethical decision-making
situation so that all potentially relevant informa- related to implementing EBPs. To do this, we
tion is considered before making a choice. The start by reviewing a causal model of ethical
findings of researchers in behavioral economics decision-­making. After outlining some of the
over the past several decades suggest that many variables known to influence ethical decision-­
organisms fail to consistently make the optimal making, the chapter reviews decision models as
decision (e.g., Fantino et al., 1997; Pattison & they relate to EBP and the points wherein ethics
Zentall, 2014; Sofis et al., 2015; Zentall, 2016). likely plays a role in shaping decision-making
The purpose of decision models, then, is to help and which EBP is selected. We then combine the
the model user avoid making a suboptimal deci- causal and decision models to create an ethical
sion. Stated differently, accurate decision models decision model for implementing EBPs. The
reduce the probability of bias decisions and chapter closes by demonstrating how the reader
increase our sensitivity to relevant environmental can use the combined causal and decision models
variables that indicate what consequences are to analyze and make ethical decisions related to
likely to result from our decision. EBPs.
Causal models and decision models are inter-
related when ethically making decisions about
EBPs. To accurately predict and control which 4.2  ausal Model of Ethical
C
EBP is selected, the causal modeler likely needs Decision-Making
to know whether the decision-maker has access
to a decision model as well as the decision-­ The goals of scientific research are often descrip-
maker’s learning history with the decision model. tion, prediction, and control. Specifically, scien-
That is, the presence and learned history relative tists seek to: accurately describe the phenomenon
to decision models would be an independent vari- of interest, identify principles and processes that
able in the causal model. Similarly, to reduce the allow for the prediction of the phenomenon of
probability that a suboptimal decision is made, interest, and then use the understanding of the
the decision modeler would need to understand principles and processes to control the phenome-
what current and past contingencies influence non of interest (Cooper et al., 2020). The ideal
decisions with EBPs and what contingencies may outcome of research, then, is to understand the
need to be arranged to avoid a suboptimal deci- cause of a phenomenon so that researchers can
sion. That is, the independent variables from the control the presence, absence, or degree to which
4 Ethical Decision-Making and Evidenced-Based Practices 49

the phenomenon occurs in the future. Researchers making relative to an applied behavior analyst’s
often use causal models to succinctly describe decision about EBPs. One categorization is rela-
the variables that are causally related to the phe- tive to perspective: that of the applied behavior
nomenon of interest. analyst compared to that of the profession-labeled
Causal models are legion in the experimen- applied behavior analysts. Below we discuss how
tal and applied analysis of behavior. For exam- perspective plays a causal role in ethical decision-­
ple, researchers in the experimental analysis of making using the distinction between morality
behavior often use models to describe and pre- and ethics. A second categorization is relative to
dict behavior such as the Rescorla-Wagner the ethical behaviors under consideration: claims
model of respondent conditioning (e.g., about what is right compared to claims about
Rescorla & Wagner, 1972), the generalized why it is right. We discuss these components of
matching equation for response allocation (e.g., ethical decision-making in the second part of this
Baum, 1974; McDowell, 1989), delay or prob- section on descriptive and normative ethical
ability discounting for reinforcer value (e.g., behavior. A final categorization can be made
McKerchar & Renda, 2012; Rachlin et al., regarding the environmental variables and behav-
1991), or the demand equation for the impact of iors involved in decision-making more generally.
effort on reinforcer consumption (Hursh & We discuss these components in the final part of
Silberberg, 2008). this section titled Decision-Making.
The above-referenced causal models of behav-
ior consist of precise mathematical relations
between independent and dependent variables 4.2.1 Morality and Ethics
(e.g., Dallery & Soto, 2013), but not all models in
behavior analysis use math. For example, the Behavior analysts are required to make ongoing
three-term contingency is a model that describes decisions about the treatments they implement
covariance relationships between stimuli and for individuals with autism spectrum disorder
behavior (e.g., Ribes-Inesta, 1997; Skinner, (ASD). The Ethics Code for Behavior Analysts
1953). Thousands of applied behavior analysts (hereafter referred to as the Code; BACB, 2020)
have used this verbal causal model to describe, provides guidance on ethical behavior and the
predict, and control behavior (e.g., Iwata et al., use of effective treatments. However, ambiguity
1982; Paclawskyj et al., 2000). Similarly, the in situations inevitably arises wherein an applied
four-term contingency is a model that allows the behavior analyst still must select between treat-
user to describe, predict, and control behavior ments. Each applied behavior analyst has a
that changes dynamically as a function of context unique learning history that is somewhat similar
and time since contacting various reinforcers and to other applied behavior analysts as well as dif-
punishers (Michael, 1993). This four-term con- ferent from other members of the profession.
tingency has also been used by applied behavior Included in these similar and different learning
analysts to effectively predict and control behav- histories are claims about what is right and wrong
ior (e.g., Endicott & Higbee, 2007; Sundberg professional behavior. For example, the behavior
et al., 2001). In sum, causal models are used of applied behavior analysts is likely to be influ-
extensively in behavior analysis, and, regardless enced by their individual history with rules about
of whether the model uses mathematics or words right or wrong (e.g., from school, local lab or
alone, causal models are instances of human clinic lore, religion, culture, familial) as well as
behavior (Baum, 2018; Marr, 2015). their shared history with other applied behavior
To develop a causal model of ethical decision-­ analysts with rules about right or wrong (i.e., the
making relative to EBPs, we must understand the rules in the Code). Historically, the difference
components that go into the model. There are between right or wrong at the individual level
several ways to categorize and identify the com- versus the professional level has been captured
ponents for a causal model of ethical decision-­ by a distinction between morality and ethics.
50 V. G. Marya et al.

At its root, morality comes from the Latin tacted as “compassion,” “respect,” and “self-­
word moralis which refers to the proper behavior control” (Haidt et al., 2009). In addition, writers
of a person and one’s individual disposition (Cox, often assume that emitting moral and ethical
2020; MacIntyre, 2003). When many people behavior includes the ability to anticipate the
adopt the same pattern of “proper individual consequences of one’s actions (i.e., verbally state
behavior,” moralis takes the plural form and the probability of specific consequences), to
becomes mores – customs and manners of a make value judgments (i.e., accurately tact the
group of people. Thus, in total, morality can be stimulus relations between an event, behavior, or
defined as focusing broadly on what individuals outcome, and defined values), and to choose
should consider to be right and wrong behavior between alternative courses of action based on
and why an individual person should believe that those anticipated consequences and value judg-
is true for them in their daily lives. Note that this ments (Ayala, 1987).
leaves the door open for individuals to develop Morality and ethics also include behaviors
their own unique systems of moral rules that they that are established, maintained, increased, or
live by and of which everyone else may disagree reduced through the same processes as all other
(e.g., Borum, 2010; Harper, 2009; Monestes behaviors (e.g., Baum, 2005; Skinner, 1953,
et al., 2017). 1971). Past writers have typically theoretically
In contrast, ethics comes from the Greek word extended research in the experimental analysis of
ethos which refers to the proper behavior that behavior to argue that morality and ethics are
characterizes a culture, era, community, or pro- broadly maintained by socially mediated conse-
fession (Cox, 2020). Ethics aims to answer the quences delivered based on the similarity of a
question of, as a group of people with some group members’ behavior with the cultural stan-
shared goal or skill set, what are the rules about dards of what is right versus wrong for that group
right and wrong that are relevant to us all? Even of people (Skinner, 1953). More recently,
though ethics is defined as rules relative to what research has begun to emerge that demonstrates
is right or wrong for individuals behaving as these functional relations empirically (Cox,
members of a collective group, this does not 2020).
mean that the group is the ones who decide the More specific functions of moral and ethical
rules. For example, the Pope and the Cardinals of behavior have been discussed in greater detail in
the Catholic church largely decide what is right other areas of the psychology literature. For
or wrong for the group of people known as example, Kohlberg & Kramer (1969) identified
Catholics, the Supreme Court decides the right six potential functions of moral or ethical behav-
way to interpret the law, and small working com- ior which we can translate behaviorally (Skinner,
mittees often determine the rules espoused in 1945). One function might be avoidance. When
professional codes of ethics such as the American young, humans may contact punishment for
Medical Association (AMA) Code of Ethics engaging in immoral or unethical behavior and
(AMA, 2016), the American Psychological thus learn to emit moral or ethical behavior to
Association (APA) Code of Ethics (APA, 2017), avoid punishment. A second function could be
and the BACB Code (BACB, 2020). Stated suc- socially mediated reinforcement wherein one
cinctly, morality is concerned with what is right learns that behaving morally or ethically leads to
or wrong for me as an individual separate from higher rates of reinforcement for the individual
the profession to which I belong, and ethics is and for others (i.e., social reciprocity; Carpenter
concerned with what is right or wrong for all & Matthews, 2004). A third function might be
members of a group or profession. generalized social reinforcement for adhering to
Morality and ethics as behaviors are similar in rules specifying societal norms about what is
many ways. For example, both involve behaviors acceptable versus unacceptable. A fourth func-
labeled as values, emitting behavior relative to tion might be generalized social reinforcement
labels of right and wrong, and emitting behaviors for adhering to rules claimed by perceived author-
4 Ethical Decision-Making and Evidenced-Based Practices 51

ity figures. A fifth function follows recognition only scientifically supported treatments
that groups and authorities often differ on what is (Guideline 2.01, 2.13, 2.14; BACB, 2020). Here,
claimed to be right behavior, and, without an failing to implement a lesson on sexual behavior
objective way to decide between the two, societal may violate their moral rules, whereas imple-
rules and authority claims are viewed relatively. menting a lesson on sexual behavior may violate
Once viewed relatively, Kohlberg (1971) argued their ethical rules given the limited experimental
that personal values and individually derived literature on teaching sexual behavior for indi-
rules play a larger role in what is claimed as right. viduals with ASD (Solomon et al., 2019).
Finally, a sixth function of ethical behavior out- Conflicts between a clinician’s morality and
lined by Kohlberg might be considered as adher- ethics are referred to as conflicts of conscience in
ing to a defined response class tacted as “ethical the bioethics and medical ethics literatures (e.g.,
principles.” That is, for some, ethical principles Adams, 2007; Ford & Austin, 2018). Conflict of
such as justice, honesty, and compassion become consciences are rarely discussed in the applied
the primary method for deriving and ranking behavior analysis (ABA) literature despite the
rules for what is considered right behavior. Each common reported occurrence of conflicts of con-
of these ethical principles, when followed, leads science in other areas of healthcare and education
to consistent patterns of behavior and changes in (e.g., American College of Obstetricians and
the environment. For example, justice leads to the Gynecologists, 2007; Curlin, 2008; Ford &
equitable allocation of opportunity and resources Austin, 2018). Whether the applied behavior ana-
which can be observed and measured, honesty lyst is more justified to follow their moral rules or
can be captured with say-do correspondence, and to follow the ethical rules of the profession to
compassion might be observed and measured as which they belong could be a chapter itself. Here,
behaviors leading to the reduction in behavioral the main takeaway is that morality and ethics can
patterns indicative of pain or suffering in others. be distinguished, the potential for conflict
Despite many similarities, the distinction between morality and ethics exists, and the
between morality and ethics is practically impor- potential for conflict between morality and ethics
tant as one’s personal rules (morality) can con- is an important variable that may influence ethi-
flict with the rules of one’s profession (ethics). cal decision-making with EBPs.
For example, consider an applied behavior ana-
lyst who adheres to personal, moral rules that dis-
courage handling pork. However, this same 4.2.2  escriptive vs. Normative
D
applied behavior analyst works with a client Ethical Behavior
whose most preferred edible reinforcer is bacon.
In this example, handling bacon would violate Historically, philosophers have made a topo-
the applied behavior analyst’s moral rules, but graphical distinction between what is considered
refusing to handle the bacon would violate the to be right behavior (descriptive ethical behavior)
applied behavior analyst’s ethical rules to advo- and why that behavior is considered to be right
cate for the services “designed to maximize behavior (normative ethical behavior). For exam-
desired outcomes” (Guideline 2.01; BACB, ple, one might argue that using Behavior Skills
2020). As another example, consider an applied Training (i.e., BST; Miltenberger, 2012) is the
behavior analyst who has the education and right approach to train Registered Behavior
supervised clinical experiences to teach and pro- Technicians (RBTs). Phrased differently, we can
vide training surrounding sexual behavior. This ask, “What is the right way to train RBTs?”
applied behavior analyst may personally believe Answer: “Using BST.” Note here that our dia-
that their designed interventions are in the best logue with you – the reader – is restricted to
interests of a client and feel morally obligated to words on a page. So, “the right way to train
help their client in this area. However, applied RBTs” is not simply by someone saying, “Use
behavior analysts also have the obligation to use BST.” Rather, “the right way to train RBTs” is by
52 V. G. Marya et al.

actually engaging in the behavioral patterns that that are required by applied behavior analysts,
an observer might tact as, “you are using BST.” generally, as well as specific to EBP. For exam-
Summarizing this example, the descriptive ethi- ple, the Code states that applied behavior ana-
cal behaviors for training RBTs are the behav- lysts should educate clients and stakeholders on
ioral patterns one might tact as “BST.” effective, evidence-based treatments (Guideline
We can also ask the question, “Why is imple- 3.12; BACB, 2020). When applied behavior ana-
menting BST the right thing to do?” The behav- lysts must choose between multiple scientifically
iors involved in answering this question would be supported treatments or teaching procedures, the
historically labeled normative ethical behavior. Code states that other factors should be consid-
Different people may answer this question differ- ered such as client preference and clinician expe-
ently. For some, we should use BST because the rience or training (Guideline 2.14; BACB, 2020).
Code says we should use EBPs, and BST has the As another example of descriptive ethical behav-
most published evidence to support its effective- ior related to EBP, the Code states that applied
ness (Kirkpatrick et al., 2019; Schaefer & Andzik, behavior analysts should provide the appropriate
2020). Others may view a particular author in the amount and level of supervisory hours necessary
behavior analytic literature as an expert in staff to meet treatment goals (Guideline 3.12; BACB,
supervision and training and, if that author says 2020).
BST is the right way to train RBTs, then that is Applied behavior analysts can also learn
the right way to train RBTs. As a final example, descriptive ethical behaviors from other sources
others might argue that BST is the right way to such as mentors, organizational policies, clinical
train RBTs because it leads to the fewest errors settings, and the published literature. For exam-
when the RBT subsequently implements an inter- ple, rules might be passed down from supervisors
vention, and fewer errors are more likely to lead or organizations in the form of policies and pro-
to the best client outcomes. cedures for the right way to conduct assessments
Justifying why someone should implement and implement services. Also, rules about what is
BST to train RBTs is verbal behavior and is topo- right and wrong may not always be formally out-
graphically different from the behaviors of actu- lined or written down. Instead, they might be
ally implementing BST. More generally, passed down via conversations and interactions
descriptive ethical behavior is topographically with colleagues via so-called lab-lore or
distinct from normative ethical behavior. Though clinic-lore.
historically treated topographically in the philo- Formal and informal rules about what is right
sophical literature, recent research suggests that can contribute functionally to what applied
descriptive and normative ethical behaviors are behavior analysts claim as ethical assessment and
also functionally distinct (Cox, 2020). Thus, the implementation of ABA services. For example, a
distinction between descriptive and normative service provision organization may train behav-
ethical behavior is important to consider within a ior analysts to use an interview-informed synthe-
causal model of ethical decision-making related sized contingency analysis (IISCA; Hanley et al.,
to the implementation of EBP as accounting for 2014), while another organization may provide
both is needed. training in functional analyses (FA; Iwata et al.,
1982). Similarly, a behavior analyst may be
[Link] D escriptive Ethical Behavior encouraged by their organization to specifically
and Decision-Making with EBPs conduct indirect functional assessments (e.g.,
If descriptive ethical behavior is what the right Iwata & DeLeon, 1996; Paclawskyj et al., 2000),
thing to do in a given situation, a question that whereas another behavior analyst may be
naturally follows is where the applied behavior encouraged to conduct direct functional assess-
analysts learn descriptive ethical behavior. The ments (e.g., Hanley et al., 2014; Iwata et al., 1982).
most likely influence on descriptive ethical In turn, behavior analysts working at different
behavior is the Code, as it outlines the behaviors organizations and with different educational his-
4 Ethical Decision-Making and Evidenced-Based Practices 53

tories may disagree on what is considered the (IEP) team in a particular school district. Though
right EBP based on their organizational policies, never explicitly stated, the applied behavior ana-
training, and prevailing contingencies (Cox, lyst may derive a rule that it will take more effort,
2020). be a more aversive experience, and hinder the
Conflict between statements about correct implementation of treatment if they recommend
implementation of EBP may occur within the that a direct functional assessment be conducted
same person as well. Behavior analysts who hold before intervention design as opposed to begin-
other professional titles (e.g., licensed psycholo- ning intervention more quickly following an indi-
gist, speech-language pathologists, medical doc- rect functional assessment. Here, the right
tors, teacher certification) have additional approach to recommending which EBP to choose
experience with claims about what is right via might be influenced by an individually derived
those professions’ ethical standards, education rule.
and training, and published literature. All of In sum, descriptive ethical behaviors are the
which may influence descriptive ethical state- patterns of behavior which are considered to be
ments about what might be the right thing to do in right. For applied behavior analysts, descriptions
a given situation. For example, the Association of about what is the right thing to do may come
American Educators (AAE) explicitly recognizes from the Code, mentors, colleagues, textbooks,
the important role of educators in the “moral edu- published research literature, organizational poli-
cation” of students (AAE, 2013). Additionally, cies and procedures, other scientific literatures,
applied behavior analysts are obligated to con- or we may create them ourselves. These descrip-
duct assessments before developing behavior-­ tions about what is the right thing to do can play
change programs (Guideline 2.13; BACB, 2020), a causal role in the behavior we emit. Also, this
involve clients in the planning of the behavior-­ includes the decisions we make about which
change program (Guideline 2.09; BACB, 2020), evidence-­based assessment or intervention we
and practice only within the boundaries of their choose to implement.
competence (Core Principle 4; Guideline 3.03;
BACB, 2020). However, as discussed in more [Link] Normative Ethical Behavior
detail below, interesting questions quickly arise Behavior analytic writings have primarily been
as to how moral behavior will be assessed, whose explicit in what the right thing to do might be.
moral framework should be taught, and what However, historically, why those behaviors are
competence or expertise in moral education looks the right thing to do has been discussed more
like (e.g., Brummett & Ostertag, 2018; Ho, 2016; implicitly. Verbal behavior tacted as “justifying
Iltis & Rasmussen, 2016; McClimans & Slowther, why a specific behavior is right” can be grouped
2016). In these situations, it seems plausible the into theories of normative ethical behavior – pat-
prevailing contingencies will determine which terns of verbal behavior that provide rationale or
code of ethics predominates (Cox, 2019b) – but justification for why something is right. Theories
we can also ask whether this is right. of normative ethics provide benchmarks for mea-
Lastly, behavior analysts have individual and suring whether one’s choices are justified as
personal experiences that contribute to descrip- being right versus wrong. That is, when we agree
tive ethics. Basic research suggests that verbally on why something is right, we can measure
competent humans can derive rules for what to do whether the results of our behavior meet the
in situations and then adhere to those self-derived agreed-upon benchmark.
rules (e.g., Matthews et al., 1985; Ninness & In ABA, there currently is not an agreed-upon
Ninness, 1999; Rosenfarb et al., 1992). There is approach for how applied behavior analysts
no reason to suspect ethical behavior is unique in should justify claims about right or wrong behav-
this regard. For example, an applied behavior ior. However, understanding the normative
analyst may have heard about a colleague’s expe- ethical theory one uses as a benchmark for cor-
rience with an individualized education plan rect ethical decision-making is important for
54 V. G. Marya et al.

resolving ethical dilemmas (Brodhead et al., another example, the principle of justice (i.e.,
2018), making ethical decisions in contexts not treating everyone fairly based on established
covered by existing ethical rules (Brodhead et al., criteria for comparison) is often considered a
2018; Cox, 2020), and because different ethical virtuous behavior (e.g., Huang, 2007). Extended
theories lead to different behaviors labeled as to ABA service delivery, each client a behavior
right (e.g., Brodhead et al., 2018; Cox, 2020). To analyst agrees to provide services for has a cer-
aid applied behavior analysts in identifying an tain number of hours for which the behavior
ethical theory they can use to consistently make analyst receives reimbursement. The principle
ethical decisions, we briefly outline five ethical of justice might require that applied behavior
theories commonly found in modern Western analysts only work the agreed-­upon hours for
medical ethics literature and how they causally that individual so as not to unfairly provide
relate to ethical decision-making for the imple- more time to one client compared to others.
mentation of EBPs. Alternatively, the applied behavior analyst may
One theory of normative ethics is consequen- develop a set of criteria under which they would
tialism (a.k.a. utilitarianism). Consequentialism work more hours than specified in the contract
argues that labels of right or wrong are determined with the understanding that all clients would
by the consequences that follow the ethical deci- have access to that potential for extra attention.
sions, and behaviors that result in the greatest good Contract theory holds that certain behaviors
for the greatest number of people are considered are right or good because they adhere to a social
right (Alexander & Moore, 2016). For example, a contract (Dienstag, 1996). For example, an
person justifying EBP using consequentialism applied behavior analyst may sign a contract with
might argue conducting an indirect functional a client and a third-party payer wherein they
assessment is better than descriptive functional promise to reduce the self-injurious behavior of a
assessments because there is more evidence to client, teach them to communicate their wants
indicate an effective intervention can be imple- and needs in a socially acceptable manner, and
mented more quickly (e.g., Tarbox et al., 2009). accomplish both using 10 hr per week at a reim-
Another theory of normative ethics is deontol- bursement of $85 per hour.1 The behaviors that
ogy. Unlike consequentialism, deontology argues are ethically right in this scenario are the set of
that behaviors cannot be assessed by the conse- behaviors that allow the behavior analyst to effi-
quences that follow from an ethical decision but ciently reduce self-injurious behavior and teach
are determined as right or wrong based on con- functional communication while increasing the
formity to a group’s ethical norm (e.g., a code of probability of generalization and maintenance.
ethics; Alexander & Moore, 2016). For example, Lastly, feminist approaches to normative eth-
a person justifying EBP using deontology might ics argue that determining right or wrong through
justify using edible reinforcers because the Code mathematical adherence to logical principles is
states behavior analysts should use effective misguided. Rather, natural caring relationships
treatments, rather than justifying using edible between humans should provide the basis for
reinforcers because edible reinforcers result in right and wrong behavior (e.g., Gilligan, 1982;
quicker and greater behavior change
(consequentialism).
Virtue theory holds that some behaviors are
1
Note that under this arrangement the client (and their
caregivers) and the third-party payer also have ethical
right or good simply because they are right/ obligations resulting from the agreed-upon contract. The
good by nature, regardless of the consequences client is ethically obligated to show up for the agreed-­
that follow or any rules espoused by authority upon number of hours each week, to participate in their
figures (Annas, 2006). For example, honesty is sessions, and to engage in the behaviors necessary to gen-
eralize the skills to the home environment. The third-party
typically considered a virtuous behavior and payer is ethically obligated to pay the provider at the des-
people should always emit (e.g., Carr, 2014; ignated rate and for a maximum amount of $850 per week
Gachter & Schulz, 2016; Wang et al., 2011). As (10 hr × $85/hr).
4 Ethical Decision-Making and Evidenced-Based Practices 55

Larrabee, 1993; Noddings, 1984). In our context, making with EBPs, we need to understand the
applied behavior analysts have a responsibility to interaction between choice, verbal behavior,
care for the clients or students on their caseload. ethics, and optimality.
Also, through their interactions with clients or
students, applied behavior analysts identify ways [Link] Choice
they can best care for their clients or students in Choice and decision-making have been exten-
the particular social circumstances in which they sively researched within behavior analytic basic
live. EBPs then become a vehicle for which we research (e.g., Fantino, 1997; Herrnstein, 1970;
can demonstrate our care for clients or students. Williams, 1994). Concurrent schedules of rein-
The history of writings on ethics and morality forcement used in basic research have demon-
provides definitions of ethical and moral behav- strated that organisms will allocate more behavior
ior that are useful for claiming what is right to responses that result in increased contact with
behavior and why this may be the case. Moreover, reinforcement and less behavior to the responses
theories of normative behavior are useful for that result in less contact with reinforcement (i.e.,
understanding ways in which behaviors are clas- matching law). For example, when considering
sified as right or wrong to create measures of suc- whether to include a response cost (punishment)
cess. Nevertheless, definitions of ethics and component in a token economy intervention, an
ethical theories are stated at a general and high applied behavior analyst’s decision will be influ-
level. Thus, by themselves, definitions of ethics enced by their past experiences achieving behav-
and ethical theories do not always lead to practi- ior reduction in the presence and absence of
cal solutions when making ethical decisions including response cost.
regarding EBPs. To make ethical decision-­ Choice research has also focused on self-­
making related to EBPs more tractable, it may control (i.e., delay discounting). Self-control is
help to include operant and respondent behav- typically studied by having participants choose
ioral processes and principles that play a causal between a smaller, more immediate reinforcer
role in ethical decision-making. and a larger, more delayed reinforcer (Fisher &
Mazur, 1997; Green & Myerson, 2013). The
general findings are that the relative comparison
4.2.3 Decision-Making between amount and delay to two alternatives
will uniquely determine which response humans
Decision-making involves engaging in behav- make. Translated to our current context, con-
iors to manipulate relevant variables needed to sider a situation where an applied behavior ana-
evoke a decision (Skinner, 1953). As with past lyst must decide whether to use punishment
definitions of ethics, the definition of decision- procedures with a client displaying severe self-­
making provides a general, high-level descrip- injurious behavior (SIB). Using punishment
tion of behavior but does not necessarily allow may decrease the delay to minimal rates of SIB
for the description, prediction, and control of but also includes the use of an aversive stimulus.
decision-­making. A more practical approach is In contrast, refraining from using punishment
to consider the behavioral processes involved. may increase the delay to minimal rates of SIB
Decision-­making appears to involve the inter- but does not include the use of an aversive stim-
action between behavioral processes that con- ulus. Importantly, a robust finding from the self-­
trol choice in addition to verbal behavior. control literature is that individuals are
Further, to evaluate whether people make the differentially influenced by delay (e.g., Green &
right decision, it is necessary to include the Myerson, 2013). Thus, different applied behav-
notion of optimality toward a stated goal. Thus, ior analysts are likely to choose differently in
to understand what causes ethical decision- the above scenario when considering only how
56 V. G. Marya et al.

delay to minimal rates of SIB should determine [Link] C  ausal Model of Ethical
the right EBP. Behavior
In sum, the previous sections have outlined how
[Link] Verbal Behavior causal models can be used to describe and iden-
The relationships between stimuli and verbal tify variables known to control choice and
behavior are important in ethical decision-­ decision-­making in humans. If we assume that
making for several reasons. First, as noted above, ethical behavior is just behavior, then those same
descriptive ethical behavior is often described variables would also apply to ethical behavior
using verbal behavior, and normative ethical and ethical decision-making. Figure 4.1 provides
behavior is verbal behavior. Furthermore, differ- an example visual depiction of a causal model of
ent ethical situations involve the presence and ethical behavior and ethical decision-making.
absence of a variety of stimuli within the
­environment, relations between those stimuli and
behavior, and relations between those stimuli and 4.3 Decision Models
the likelihood of various consequences occur-
ring. Many decision-making models require the In this section we focus on decision models rela-
model user to verbally tact these relations so as to tive to ethical decision-making, clinical decision-­
make the “right” decision based on all available making with EBPs, and how ethical and clinical
information in the decision context (more details decision-making with EBPs can interact.
below). Thus, understanding how verbal stimuli Throughout, we assume that ethical decision-­
interact to control decision-making is important making is behavior and is susceptible to the same
for describing, predicting, and controlling ethical laws and principles that apply to all other behav-
decision-making with EBPs. ior. In particular, we focus on the choice point
faced by applied behavior analysts dozens, or
[Link] Optimality perhaps hundreds, of times every week: Which
The outcomes that result from a decision are intervention is the right choice in this situation
rarely binary (i.e., yes/no). Rather, the outcomes and for this client?
that result from a decision often occur at some Decision-making models are prevalent across
level of a continuous gradient. For example, a wide range of scientific and professional disci-
applied behavior analysts are unlikely to claim an plines. For example, decision models have been
intervention successfully reduced SIB if it published in physics related to quantum rein-
decreased from 100 times per day to 98 times per forcement learning (e.g., Li et al., 2020), biology
day. Technically, it decreased, but a simple “yes” related to decision-making in animals (e.g.,
or “no” as to whether the behavior reduced is McFarland, 1977), political theory related to
likely insufficient for determining whether our public administration (e.g., Simon, 1977), and
decision to use an EBP was the right choice. even in behavior analysis related to risk assess-
Instead, the applied behavior analyst would ment in functional analyses (e.g., Deochand
determine whether their decision was the right et al., 2020). Broadly, decision-making models
choice by measuring how much the SIB reduced are designed to help the model user make the best
(i.e., between 100 and 0 times per day) and how decision in the situation toward meeting a pre-­
quickly the reduction occurred. Measuring and defined goal. Decision-making models accom-
determining the “right” or the “best” ethical deci- plish this by serving as a textual prompt to help
sion with EBPs therefore requires measurement the model user consider the relevant variables
of transitions between stable responding during a and options which may have gone unconsidered
baseline period and during intervention and the without the model prompt. The use of decision-­
analysis of how to most efficiently transition making models results in a chain of behaviors
between the two. that (ideally) leads to an outcome as close to the
pre-defined goal as possible.
4 Ethical Decision-Making and Evidenced-Based Practices 57

Fig. 4.1 Causal model of ethical behavior and ethical an ethical decision with evidence-based practices. Arrows
decision-making related to evidence-based practice. indicate interactions between variables
Underlined text indicates the behavioral chain of making

4.3.1  unction of Ethical Decision

F behavior and ethical decision-making might then
Models be used to identify the intervention that leads to
the best outcomes for the patient (consequential-
Decision models help the model user engage in a ism); fulfills our duties to the client and the field
chain of behaviors that leads to an outcome as of behavior analysis as outlined in the Code
close to the pre-defined goal as possible. For (deontology); is aligned with accepted virtuous
example, Geiger et al. (2010) outlined a decision behaviors (virtue theory); meets the goals of
model to help applied behavior analysts decide behavior change set forth in the contract the cli-
between function-based interventions for chal- ent, the payer, and the behavior analysts agreed to
lenging behavior maintained by escape (Geiger (contract theory); or displays genuine care for the
et al., 2010). The goal of the model user might be client and their situation (feminist ethics). All of
to identify and tailor an intervention that effi- which may center on the behavioral definitions of
ciently and effectively reduces the escape-­ what the client or their caregiver states leads to a
maintained behavior. The function of the decision meaningful life. The function of ethical decision
model is to prompt the model user to consider models, then, is the state of environment-­behavior
variables relevant to current environment-­ relations that meet the predetermined goal
behavior relations that allow the model user to derived from the interaction between client val-
identify an intervention that efficiently and effec- ues and the normative theory an applied behavior
tively reduces the challenging behavior (i.e., to analysts uses to determine their ethical claims.
meet their goal).
But what is the goal of applied behavior ana-
lysts who are using an ethical decision model? 4.3.2 Ethical Decision-Making
Ethical behavior is defined as the set of rules for Models
conduct that all applied behavior analysts should
follow, and ethical decision-making refers to the Hundreds of ethical decision-making models
chain of behaviors that lead the model user to have been published and span dozens of profes-
emit ethical behavior. Thus, the consequences sional disciplines and specific ethical decisions
that maintain ethical decision-making might be (e.g., Ford & Richardson, 1994; Lau, 2003).
attaining the right or desired consequence Outside behavior analysis, scholars and research-
wherein right or desired is defined by the norma- ers have published on ethical decisions in fields
tive theory one uses to justify ethical behavior. such as medicine (e.g., Greipp, 1992; Meyer-­
Specifically for EBPs, the function of ethical Zehnder et al., 2017), education (e.g., Green &
58 V. G. Marya et al.

Walker, 2009; Shapiro & Stefkovich, 2016), psy- action that is “best” and implements it. Finally,
chology (e.g., Cottone & Claus, 2000; Grace some ethical decision-making models recom-
et al., 2020), and even astronomy (e.g., American mend the decision-maker follow-up to evaluate
Astronomical Society, 2017; Hoeppe, 2018). In whether action taken was, in fact, the “best”
behavior analysis, ethical decision-making mod- action or if further action is warranted.
els have been proposed to help the user identify
key stakeholders and Code guidelines relevant to
the ethical decision (Bailey & Burch, 2016), to 4.3.3 Evidence-Based Practice
navigate professional collaboration related to Decision Models
interventions published outside the behavior ana-
lytic literature (Brodhead, 2015), and to Historical accounts of EBP can be traced back to
­incorporate experiences and variables outside the the 1800s and a nurse named Florence Nightingale
Code into the decision-making process who used evidence to promote reform in health-
(Rosenberg & Schwartz, 2019). care (Aravind & Chung, 2010). More recently,
Ethical decision models published within and the concept of EBP was introduced to the field of
outside behavior analysis often have similar com- medicine in the 1990s by Sackett and colleagues.
ponents. Figure 4.2 shows the generally promi- Sackett et al. (1996) proposed a definition of EBP
nent components of ethical decision-making to be practice that integrates “individual clinical
models. The first step to ethical decision-making expertise with the best available external clinical
involves recognition that a situation involves eth- evidence from systematic research” (p. 71). This
ical behavior. Once a situation is identified to definition was later refined to “Evidence-based
involve ethical behavior, the second step is for the practice is the integration of best research evi-
applied behavior analyst to identify the precise dence with clinical expertise and patient values”
ethical problem. Once the specific problem is (Sackett et al., 2000, p. 170). The American
known, ethical decision models often recom- Psychological Association (APA, 2006) adapted
mend the decision-maker gather information the definition proposed by Sackett et al. (2000)
about professional, organizational, or personal and stated that EBP in psychology (EBPP) is the
rules of right conduct that are relevant to the cur- integration of the best available research with
rent situation and what response options are plau- clinical expertise in the context of patient charac-
sible. Next, decision models often recommend teristics, culture, and preferences.
that the decision-maker prioritize and clarify the Several authors within the field of behavior
gathered information and conducts a risk-benefit analysis have also offered definitions of
analysis for the different response options that EBP. Kazdin (2008) describes EBP as clinical
are plausible. Once the information has been syn- practice based on the integration of the best avail-
thesized and the values and potential options able evidence regarding interventions, clinical
ranked, the decision-maker then decides the expertise, and patient values, needs, and prefer-

Fig. 4.2 Decision model for ethical decision-making

4 Ethical Decision-Making and Evidenced-Based Practices 59

ences. Smith (2013) defined EBP as “a service captured in the Code which has several subsec-
that helps solve a consumer’s problem...[that] tions directly related to the three elements of EBP
integrates a package of procedures, operational- such as best available evidence (e.g., Guidelines
ized in a manual, and validated in studies of 2.13, 2.14; BACB, 2020), consideration for client
socially meaningful outcomes” (p. 27). Finally, values and context (e.g., Guideline 2.14; BACB,
Slocum et al. (2014) defined EBP in ABA to be 2020), and clinical expertise (e.g., Core Principle
“a decision-making process that integrates (a) the 4; BACB, 2020). Additionally, the interrelated-
best available evidence with (b) clinical expertise ness of ethics and EBP was implicitly captured
and (c) client values and context” (p. 44). The by Slocum et al. (2014) who referenced the Code
definition presented by Slocum and colleagues to justify their claims.
stresses that EBP is a process of decision-making Descriptive and normative ethical behaviors
that involves the integration of three components are influenced by the process of decision-making
which are also present in the definitions used by with EBPs. For example, consider an applied
other fields like medicine and psychology. Even behavior analyst who is considering verbal
before the concept of EBP was introduced within behavior interventions for a minimally vocal
the field of ABA, the tenets of the field empha- child with autism. To make the “right” decision
sized the importance of relying on interventions on intervention selection (descriptive ethical
based on evidence and creating goals and imple- behavior), the applied behavior analyst would
menting treatments which have high social valid- evaluate the research literature to identify inter-
ity (Baer et al., 1968; Slocum et al., 2014). ventions with the best evidence for individuals
One framework for EBP has been suggested similar to the client and their presenting skills.
by Spencer et al. (2012) in which the authors sug- Additionally, the applied behavior analyst would
gest that in the process of selecting, adapting, and likely consult the family for their preference (i.e.,
implementing interventions, practitioners have to incorporate client values) of alternative and aug-
continually make decisions, and the three compo- mented communication systems (e.g., sign lan-
nents of EBP are influencing the decisions guage or picture based) to ensure the designed
throughout the process. Although the framework intervention will be implemented and lead to
is presented in a linear form, the authors suggest optimal intervention outcomes. Lastly, the
that the process might not always be linear. For a applied behavior analyst would tailor the inter-
full treatment of the history of EBP and EBP vention procedures and behavior change targets
decision models, we refer the reader to Chap. 2 of based on their past history with successful behav-
this book. ior change (i.e., incorporate clinical expertise
within their scope of competence).
The process of decision-making with EBPs is
4.3.4 An Ethical-EBP Decision influenced by descriptive and normative ethical
Model behavior. For example, applied behavior analysts
are currently ethically obligated to implement
Despite different authors treating ethical assessments and interventions with empirical
decision-­making and decisions with EBP sepa- backing (Guidelines 2.01, 2.13, 2.14; BACB,
rately, some authors from medicine have argued 2020). Additionally, applied behavior analysts
that EBPs are integral to clinical ethical decision-­ have an obligation to avoid interventions that
making and vice versa (e.g., Borry et al., 2006; may have empirical backing based on potential
Tyson, 1995). That is, clinical ethical decision-­ short-term or long-term harm to the individuals
making requires careful consideration of current they serve (e.g., Core Principle 1; BACB, 2020).
best-available evidence to make the “right” deci- For a child with life-threatening challenging
sion about how to treat individual clients. In behavior, conducting a gold standard functional
ABA, ethical decision models and EBP decision analysis (best available evidence) may not mini-
models also are interrelated. This is implicitly mize short-term harm to the client. In this situa-
60 V. G. Marya et al.

tion, different descriptive ethical claims suggest terminal environment should be (e.g., to reduce
incompatible behavior with simply “choosing the SIB in the classroom to near zero rates), decision
intervention with the most evidence.” Depending models can help the applied behavior analyst
on the normative ethical theory one prefers, emit a chain of behaviors that will increase the
choosing among available EBPs might mean likelihood of reaching that ideal terminal state.
placing greater weight on the clinical expertise For applied behavior analysts, ethical behavior
component or the client preferences component and the implementation of EBP are intertwined.
of EBP decision models. Also, because ethical behavior, ethical decision-­
In sum, ethical decision-making and decision-­ making, and decision-making relative to EBP are
making with EBPs are necessarily interrelated. all just behaviors, they can be described, pre-
“There is nothing in a methodology which deter- dicted, and controlled by the same laws and prin-
mines the values governing its use” (Skinner, ciples as all other behavior: principles such as
1971, p. 148). Figure 4.3 highlights how ethical those described in the research literature on
decision-making and decision-making with EBPs choice, verbal behavior, and optimality. Thus, in
might interact by combining the common com- total, ethical decision models for implementing
ponents ethical decision-making models with the EBP in ABA should involve prompts regarding
common components of EBP decision models. the variables that should be considered when
The main steps of a clinical decision-making pro- selecting an EBP for a client or student and the
cess are shown in rectangles. Between each step, many ways that our learning history can bias us
we highlight how components of ethical decision-­ into choosing a suboptimal EBP.
making (circles) and components of decision-­ Figure 4.4 shows a decision model for ethi-
making with EBPs (triangles) factor into the cally selecting from multiple EBPs while
clinical decision-making process. accounting for known causes of descriptive and
normative ethical behavior and ethical decision-­
making. For practical use, we have turned the
4.4  pplying Ethical Causal
A decision model into a checklist that applied
and Decision Models to EBP behavior analysts can use to ethically decide
in ABA between two EBPs in situations where multiple
options exist (see Fig. 4.5 for an example of a
To summarize the chapter to this point, ethics for completed worksheet). In the final section below,
applied behavior analysts can be defined as the we discuss how all that we have covered to this
descriptive and normative rules about right and point might practically coalesce into ethical deci-
wrong behavior analytic professional and sions to implement EBP in ABA. As Engels
research practices. Decision-making can be reportedly stated, “an ounce of action is worth a
defined as the chain of behaviors that lead to a ton of theory” (Bohan & Kennedy, 2002). We
defined terminal environmental state. When an have discussed the ton, now we can get to the
applied behavior analyst has a sense of what the ounce.

Fig. 4.3 Decision model showing the interaction between ethical behavior, ethical decision-making, and the imple-
mentation of evidence-based practices in clinical and educational settings
4 Ethical Decision-Making and Evidenced-Based Practices 61

STEPS IN ETHICALLY NAVIGATING EBP DILEMMA

DESIRED OUTCOME Identify goal of behavior-change program
State goal of behavior-change program
Rule out any medical causes
Is the desired behavior amenable to behavioral treatment?

TARGET BEHAVIOR Consider the target outcome, target setting, client/caregiver values

Define target behavior

Conduct assessment to inform behavior-change program
ASSESSMENT (Obtain consent, consider contextual variables)

Identify relevant assessment

Obtain consent to conduct assessment

Implement assessment and synthesize results

Conduct a literature review of interventions and evaluate the results
SEARCH AVAILABLE EVIDENCE using professional judgement

Intervention 1 Intervention 2 Intervention 3 Intervention 4

Is intervention based on science and behavior analysis

Is the intervention commensurate with education, training, or supervised experience
Is the intervention suited for the client based on their values and context? If not, is
there an opportunity to obtain training, supervision, and/or consultation from
someone who is competent?
Long-term and short-term benefits to the clients
Efficiency and cost-effectiveness

Risks and side-effects

Consider any potential biases

Does the intervention include punishment or other restrictive procedures?
Are there any environmental conditions that would prevent implementation of the
intervention

Are there opportunities for collaboration?

Consider client preferences

Is there evidence supporting likelihood of behavior maintenance and generalization?

SELECTED INTERVENTION
The intervention < insert intervention name > was chosen because...
This intervention will best help us meet our intervention goals
JUSTIFICATION STATEMENT because...

ADAPT INTERVENTION
Tailor intervention based on client's unique behavior, environment, and goals

Discuss with client/client's caregivers

IMPLEMENT INTERVENTION

Training for those who will implement intervention

Ongoing monitoring and evaluation

EVALUATE OUTCOME

Fig. 4.4 Worksheet to aid ethical decision-making when selecting among EBP in clinical and educational ABA
settings

4.4.1  iscrete Trial Teaching vs.

D trial teaching (DTT) and natural environment
Natural Environment Training training (NET)? Consider the two cases of Athina
and Gia. Athina and Gia are 4-year-old children
So how does an applied behavior analyst ethi- with an ICD-10 CM diagnosis of F84.0 – autistic
cally choose between the two EBPs of discrete disorder. Both were referred for services due to
62 V. G. Marya et al.

STEPS TO ETHICALLY NAVIGATING EBP DILEMMA

DESIRED OUTCOME Identify goal of behavior-change program
State goal of behavior-change program Teach Athina to follow one-step instructions

Rule out any medical causes Consulted with medical doctor; no biological issues found

Is the desired behavior amenable to behavioral treatment? Yes

TARGET BEHAVIOR Consider the target outcome, target setting, client/caregiver values
Athina will independently and willingly follow 10 varying discriminated instructions. She will initiate following the
Define target behavior presented instruction within 5 seconds of SD presentation.
ASSESSMENT Conduct assessment to inform behavior-change program (Obtain consent, consider contextual variables)
Identify relevant assessment VB–MAPP and parent interview
Obtain consent to conduct assessment Parent consent obtained
Implement assessment and synthesize results VB–MAPP results and parent report showed absence of skill
SEARCH AVAILABLE EVIDENCE Conduct a literature review of interventions and evaluate the results using professional judgement
Intervention 3:Word
Intervention 1: NET Intervention 2: DTT
Retrieval
Yes (Smith, 2001; Tarbox & Najdowski, Not based on behavior
Is intervention based on science and behavior analysis Yes (Sundberg & Partington, 1998; Weiss, 2014). 2008; Lerman et al., 2016), analysis

Is the intervention commensurate with education, No prior experience, but has the opportunity for
supervision and guidance from experienced Yes.
training, or supervised experience Clinical Director.
Is the intervention suited for the client based on their No, discussed intervention with the family.
values and context? If not, is there an opportunity to Intervention is not suitable for the client based Yes, discussed intervention with the
on their values and context (parents report a family. Intervention suitable for the client
obtain training, supervision, and/or consultation from more structured approach is best for Athina’s based on their values and context.
someone who is competent? learning).
Long-term and short-term benefits to the clients Both long-term and short-term benefits Both long-term and short-term benefits
Based on parent report, Athina will not be as Based on parent report, Athina will be
Efficiency and cost-effectiveness efficient with learning via a more naturalistic / more efficient with learning via a more
play-based approach. structured approach.

Given parent report, a naturalistic teaching A more structured approach presentes a

approach poses a risk for not achieving optimal benefit to achieving optimal learning based
Risks and side-effects on parent reports of Athina’s learning
outcomes. style.
Consulted with a colleague about biases and Consulted with a colleague about biases
Consider any potential biases biases have been ruled out. and biases have been ruled out.
Does intervention include punishment/other restrictive No. No.
procedures?
Are there any environmental conditions that would Environmental conditions support intervention. Environmental conditions support
prevent implementation of the intervention intervention.

Are there opportunities for collaboration? Yes. Yes.

Consider client preferences A more structured approach is preferred. A more structured approach is preferred.
Is there evidence supporting the likelihood of behavior Yes, there is literature to support this. Yes, there is literature to support this.
maintenance and generalization?
SELECTED INTERVENTION DTT
The intervention DTT was chosen because it better suits the client’s preferences. Also, the applied behavior analyst has
experience using DTT.
JUSTIFICATION STATEMENT
This intervention will best help us meet our intervention goals because it will suit Athina’s unique learning needs and be
acceptable to caregivers.
ADAPT INTERVENTION
Tailor intervention based on client's unique behavior,
This intervention will be tailored as needed.
environment, & goals
Discuss with client/client's caregivers Client and caregivers consented to intervention

IMPLEMENT INTERVENTION

Training for those who will implement intervention Behavior technicians are trained
Ongoing monitoring and evaluation Continuous assessment will be completed
EVALUATE OUTCOME Data are monitored to evaluate outcome

Fig. 4.5 Example completed worksheet for Athina

concerns regarding their current levels of lan- The first step toward determining which EBP
guage and social skills. Specifically, both did not to choose is for Amir to more specifically define
respond to their names when called, were not the target behavior relative to the desired out-
observed to follow simple instructions, and had come for both Athina and Gia (i.e., target behav-
limited language skills (i.e., defining the desired ior; Fig. 4.4). Once defined, Amir then needs to
outcome; Fig. 4.4). conduct an appropriate assessment to inform
more specifically what responses need to be
4 Ethical Decision-Making and Evidenced-Based Practices 63

taught and what stimuli should be included in using a DTT approach differs from the timing of
training. Based on the information to this point, antecedent and consequence stimulus delivery
Amir chooses to conduct the Verbal Behavior using NET. In NET, learning trials may vary in
Milestones Assessment and Placement Program duration, what defines the beginning and end of a
(VB-MAPP; Sundberg, 2008), and Athina and trial, and may involve one-to-many learning trials
Gia both score in Level 1 for all skills. before moving to something else. Word retrieval
Next, Amir discusses the results of the assess- strategies differ from DTT and NET in the timing
ment with the families and recruits their priorities of antecedent and consequence stimulus delivery.
regarding goals and outcomes for their children. Here, the individual working with the client may
Both families express that they would like for have the participant say or read aloud 5–10 words
their children to respond when called, follow phonologically similar to the tact they want the
instructions (e.g., go get your shoes, sit down, student to emit when finally asked the question,
close the door), and expand their language reper- “What color is this?” (e.g., James & Burke, 2000;
toire. Based on the results of the assessment and Linebaugh et al., 2011).
the parents’ preferences, Amir plans to design DTT, NET, and word retrieval strategies have
acquisition programs to: (a) teach tacts of com- extensive empirical support as a successful
mon items relevant to the children’s daily lives, method for teaching new skills to individuals
(b) respond to their name when emitted by others with ASD and related developmental disabilities.
(e.g., parents, teachers, peers), and (c) follow For example, DTT has been shown to effectively
basic instructions commonly encountered in their teach new forms of behavior and new discrimina-
daily lives (e.g., “come here,” “pick up toy,” and tions and to manage disruptive behavior (e.g.,
“put in box”). Smith, 2001). Similarly, NET has been shown to
The next step is for Amir to search the empiri- effectively teach manding and other motivation-
cal literature to understand what available inter- ally dependent behavior skills (e.g., Sundberg &
ventions have empirical support (i.e., search Partington, 1999; Weiss, 2014). Lastly, word
available evidence; Fig. 4.4). People working retrieval strategies have also been shown to suc-
directly with clients or students can arrange the cessfully result in improved naming performance,
presentation and covariation of environmental generalization to untrained stimuli, and emit
stimuli to teach a new response in many different recall behaviors (e.g., James & Burke, 2000;
ways. After searching the archives of the Journal Linebaugh et al., 2011). Further, in reviewing this
of Applied Behavior Analysis, Behavior Analysis literature, Amir finds that DTT and NET are
in Practice, and Behavioral Interventions, Amir based in science and behavior analysis. However,
finds that DTT (e.g., Lerman et al., 2016; Smith, word retrieval strategies – though scientifically
2001; Tarbox & Najdowski, 2008), NET (e.g., based – are not based on an operant analysis of
Sundberg & Partington, 1998; Weiss, 2014), and verbal behavior. Thus, Amir (via Guideline 2.01;
word retrieval strategies (e.g., McGregor & BACB, 2020) no longer considers this interven-
Leonard, 1989; Wing, 1990) are used in the lit- tion in the selection process.
erature to teach the target behaviors defined for The next step is for Amir to consider whether
Athina and Gia. the identified EBPs are commensurate with
In DTT, the individual working directly with Amir’s education, training, and supervised expe-
the client or student explicitly arranges instruc- rience. Amir remembers reviewing DTT and
tional trials of similar duration and that com- NET in the Intervention Design class from grad-
prises a definite beginning and end (Leaf et al., uate school and fondly remembers the excited
2016). These discrete trials are often delivered group discussion in class on the conditions to
repeatedly in sets of 3 or more trials while focus- choose DTT over NET and vice versa. Amir also
ing on a specific set of responses (Cummings & remembers his supervised practicum training
Carr, 2009; Najdowski et al., 2009). The timing experience binder and the many documented
of antecedent and consequence stimulus delivery instances of implementing and supervising other
64 V. G. Marya et al.

staff-implemented DTT procedures and NET Similarly, Amir learned from the completed lit-
procedures. However, those clients were a bit erature review that NET has the benefits of
older, and, since the practicum finished, the orga- increased engagement with the learning trials and
nization that hired Amir requires new applied greater generalization of learned skills across
behavior analysts to follow a set of programs contexts, but NET also has the drawbacks of
designed by the clinical director. For individuals potentially less efficient rates of acquisition for
aged similar to Athina and Gia, this has involved non-motivationally related targets and special-
only DTT. Nevertheless, Amir also knows that ized training to capture naturally occurring,
the clinical director wrote her dissertation on momentary changes in motivation.
NET, and NET is widely used with other clients At this point, Amir has likely identified what
in the company. So, Amir can get guidance from the ideal EBP would be for Athina and Gia. In
a competent applied behavior analyst, if needed. total, the best EBP for each client was determined
In total, Amir is confident he has the education, based on the desired outcome, the assessment
training, and supervised experience for DTT and results, a review of the empirical literature, client
NET, though less so for NET. values and preferences, Amir’s past experience and
The next step is to determine whether DTT training, and a consequentialist analysis of inter-
and NET are suited for the client based on their vention efficiency and safety. Amir has one final
values and context. Given that Athina’s and Gia’s step to complete before turning the ideal interven-
performance on the VB-MAPP indicated their tion into a practical intervention – self-reflection.
receptive language skills are limited, their par- Ethical decision-making about EBPs is a
ents can help inform Amir of their likely values. chain of behaviors shaped and determined by
In conversations with the parents of Athina, Amir respondent and operant processes. Thus, it is pos-
discovered that they prefer the ABA sessions to sible that the interventions Amir has determined
be heavily structured as Athina would get easily as being ideal for Athina and Gia is the result of
distracted with past RBTs who used more of a Amir’s bias for those approaches. In behavior
play-based approach. In contrast, conversations analysis, bias refers to a pattern of choice that
with the parents of Gia indicated that Gia has cannot be predicted by the schedules of rein-
struggled in the past with RBTs who tried to forcement and punishment specific to the choice
make her sit for long stretches at a time and have context (e.g., Baum, 1974). For ethical decision-­
read stories that too much rote learning trial pre- making between EBPs, we might assume that
sentations can lead to “robot-like behavior” in what ought to reinforce Amir’s choice is what-
children who receive ABA-based interventions. ever leads the client to reach their desired out-
Thus, Gia’s parents would prefer a more natural come. Thus, bias toward one intervention would
and play-based approach to ABA-based be any preference in choice for one EBP that dif-
intervention. fers from the optimal intervention that allows the
The next step in the process for ethically client to reach their desired outcome. To test for
deciding between two EBPs might be considered potential bias, Amir can ask a trusted colleague,
the consequentialist steps. Here, Amir must eval- mentor, or supervisor to play “devil’s advocate”
uate DTT and NET based on their long-term and and review his ethical decision-making process
short-term benefits to the clients, the larger com- and to question all assumptions.
munity, and society as a whole (Guidelines 2.09a After testing for biases, Amir is likely confi-
and 2.09c; Fig. 4.4). From his literature review, dent that he has ethically chosen the ideal EBP
Amir learned that some of the benefits of DTT for Athina and Gia. Now, Amir can shift toward
are efficient rates of response acquisition under practically implementing the EBP. Here, Amir
tight stimulus control (Smith, 2001). However, must determine how environmental conditions
DTT has also been shown to have the drawbacks may hinder implementation of the EBP
of lower generalization across settings and spe- (Guideline 2.16; BACB, 2020). When entering
cialized training to implement (Smith, 2001). this stage of ethical decision-making with EBPs,
4 Ethical Decision-Making and Evidenced-Based Practices 65

Amir should decide how much hindrance would suited for Athina and NET is best suited for Gia,
lead him to either abandon this EBP or switch to Amir then (a) writes adapted EBP programs for
a different EBP or that would potentially require each client, (b) supervises the implementation of
training to those implementing the interventions those behavior change programs, and (c) evalu-
that are not covered by the payer. Stated differ- ates how close the programs are resulting in
ently, there is likely a point wherein the environ- behavior change toward the originally stated
mental conditions are such that the EBP cannot desired outcome.
be implemented effectively as supported by the
empirical literature. Understanding what this
point looks like will help Amir identify when 4.5 Summary
those conditions have been met and a new
approach taken. Before one can implement EBPs, applied behav-
Once the cutoff point for reconsidering the ior analysts must choose among the available
chosen EBP is known, Amir can begin assessing interventions with empirical evidence that are
the environmental conditions that may prevent related to the desired behavior change outcome
implementing the intervention. These conditions for which they have been contracted. Choosing
might be the amount of training and supervision among EBPs necessarily involves ethics – state-
required for the intervention to be implemented ments about the right or wrong way applied
with fidelity (e.g., Smith, 2001), requirements for behavior analysts go about choosing among
collaborating with other professionals based on EBPs. Thus, to ethically make decisions about
the service-delivery context (e.g., Brodhead, EBPs, applied behavior analysts would need to
2015; Cox, 2012, 2019b), the ease with which consider (a) the variables that influence ethical
behavior change can be generalized and main- decision-making (captured by causal models),
tained (e.g., Sundberg & Partington, 1999; Weiss, (b) the information and potential points of error
2014), and what empirical support may exist to that may lead to “wrong” decisions with EBPs
support that any tailoring required for Athina or (captured by decision models), and (c) how
Gia would not mitigate the effectiveness of the causal models and decision models can be practi-
intervention. Succinctly, Amir must determine cally combined for use in the contexts and set-
that the intervention continues to be supported by tings within which applied behavior analysts
evidence once sufficiently tailored to meet the practice.
client’s unique situation. The first section of this chapter discussed
Once the above steps have been completed, causal models of ethical behavior and ethical
Amir can select the EBP ethically justified based decision-making. In the first section, we dis-
on the client’s values, preferences, and desired cussed how morality differs from ethics and how
outcome; the available empirical evidence, con- each may influence ethical decision-making. We
sidering his own clinical expertise, training, and then discussed two types of ethical behavior in
past experiences; and considering the context descriptive ethical behavior (what is the right
within which the intervention must be imple- thing to do) and normative ethical behavior (why
mented. Though not required, it may help with is it the right thing to do). For our conversation,
case-review and record-keeping for Amir to doc- that would be the difference between the behav-
ument the result of the above steps as a justifica- ior of selecting and implementing the right EBP
tion statement. This will allow anyone to quickly (descriptive ethical behavior) and the behaviors
understand why the EBP was chosen and how the of providing evidence and argument to support
EBP aligns with the desired outcome and profes- why that EBP was chosen (normative ethical
sional standards of applied behavior analysts. behavior). Finally, we closed the first section by
Finally, come the multiple steps which applied highlighting some of the many areas of basic
behavior analysts are probably most familiar. behavioral research that are known to influence
Once, Amir has determined that DTT is best decision-making generally and how these com-
66 V. G. Marya et al.

bine into a causal model of ethical decision-­ tool put forth in the current chapter. This does not
making with EBPs. mean that existing tools and decision models
The second section of this chapter discussed should not be used. However, it does suggest that
decision models. Specifically, we discussed how the models might need to be modified and
the function of decision models is typically to improve to avoid model users from making less
help the model user avoid making the wrong than optimal decisions. As a model user, this also
decision. Making the wrong decision means that suggests they should: understand why they are
we have a desired outcome that we are optimiz- using the model, objectively define the client out-
ing for and ethical benchmarks against which we come they are trying to achieve, and consistently
can measure our effectiveness. Many decision collect data and critically examine their decision-­
models have been published specific to ethical making processes to ensure that their clients
decision-making and decision-making with receive the best care possible.
EBPs. In the second section, we reviewed the pri-
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