Running head: APPLIED ETHICS IN CUBA

Applied Ethics in Mental Health in Cuba:

Part II - Power Differentials, Dilemmas, Resources and Limitations

Isaac Prilleltensky

Victoria University, Australia

Laura Sánchez Valdés

Iteso, Mexico

Amy Rossiter

York University, Canada

Richard Walsh-Bowers

Wilfrid Laurier University, Canada

Laura Sánchez Valdés, Department of Psychology; Isaac Prilleltensky, Department of Psychology; Richard Walsh-Bowers, Department of Psychology; Amy Rossiter, Department of Social Work.

This research was supported by the Social Sciences and Humanities Research Council of Canada. We wish to thank the participants for their hospitality, collaboration, time and effort.

Correspondence concerning this article should be sent to Isaac Prilleltensky, Department of Psychology, Victoria University, POBox 14428, Melbourne MC 8001, Australia.

Abstract

This article is the second one in a series dealing with mental health ethics in Cuba. It reports on ethical dilemmas, resources and limitations to their resolution, and recommendations for action. The data, obtained through individual interviews and focus groups with 28 professionals, indicate that Cubans experience dilemmas related to (a) the interests of clients, (b) their personal interests, and (c) the interest of the State. These conflicts are related to power differentials between (a) clients and professionals, (b) professionals from various disciplines, and (c) professionals and organizational authorities. Resources to solve ethical dilemmas include government support, ethics committees, and collegial dialogue. Limitations include minimal training in ethics, lack of safe space to discuss professional disagreements, and little tolerance for criticism. Recommendations to address ethical dilemmas include better training, implementation of a code of ethics, and provision of safe space to discuss ethical dilemmas. The findings are discussed in light of the role of power in applied ethics.

Applied Ethics in Mental Health in Cuba:

Part II -- Power Differentials, Dilemmas, Resources and Limitations

The purpose of this article, second in a two part series, is to report on ethical dilemmas faced by mental health professionals in Cuba. While the first article in this issue of Ethics and Behavior reported on concepts of applied ethics and values, this one delves into the concrete dilemmas experienced by professionals at work. This article complements the first one in that it provides an account of lived experience of ethics. Whereas the first article explored moral conceptions guiding workers' actions, this one investigates the conflicts involved in applying them.

Values and guiding principles provide the theoretical foundation of ethics, but they have to be enlivened with grounded knowledge. In the abstract, the merit of values remains uncertain. For moral propositions to be valid, they have to be useful in the realm of action. The process of enacting moral principles is as important as the principles themselves. Yet, most of the applied ethics literature relates to values and not so much to the process of implementation. By examining the concrete conflicts workers experience in trying to apply these principles, we hope to elucidate the difficulties involved in value-implementation.

We object to the monadic view of the moral agent inherent in dominant models of applied ethics (Rossiter, Prilleltensky, & Walsh-Bowers, in press). Most models assume that given the right developmental and intellectual capacities, individuals should be able to read a conflictive situation "objectively" and neutralize extraneous factors that might interfere with the most ethical reading of the problem. In contrast, we maintain that individuals cannot read ethical dilemmas "objectively" when they are part and parcel of the very dilemma in question. Furthermore, they cannot remain "untouched" by cultural norms that create the very notions of what we regard as ethical and unethical. The worker is constructed by, and at the same time co-constructs, the social context in which he or she operates. Every ethical dilemma presents a unique constellation of factors that redefines the place of the professional within it. The configuration of power relations, for instance, is bound to affect a person's judgment.

Aspirational statements play an important role in applied ethics; they foster normative ethics that can produce guiding principles (Bersoff, 1995). But for these statements to be useful, they have to be tested in professional practice and revised accordingly. While statements of values and principles abound, descriptions of lived experiences of ethics are scarce. Some exceptions include research by Chambliss (1996), Holland and Kilpatrick (1991) and by Reiser, Bursztajn, Appelbaum, and Gutheil (1987). Research identifying ethical concerns faced by psychologists comes closer to our goal of obtaining grounded input (Pope, Tabachnick, & Keith-Spiegel, 1987; Pope & Vetter, 1992), but that line of research does not delve into the subjective experience of the clinicians or into the organizational contexts of the dilemmas. Thus, we lack an understanding of the social processes implicated in professionals' conceptions of ethics. Through the use of qualitative methodology, our research provides a description of specific ethical dilemmas, as perceived and experienced by participants in the helping relationship. By gathering information about ethical dilemmas directly from clinicians, we can increase both the scope and the relevance of theoretical frameworks. This study shows one of our ongoing efforts at theory building through the collection of grounded input.

Traditional renditions of the helping situation do not scrutinize sufficiently the issue of power and the socially constructed nature of ethics (Brown, 1997; Dokecki, 1996; Larsen & Rave, 1995; Prilleltensky, 1997). We propose to study these problems so that we may understand their dynamics. According to critical theory, professionals are viewed as enacting the ideology of instrumental rationality, according to which science, carried out by objective professionals uninfluenced by power dynamics, can solve human predicaments (Dineen, 1996; Herman, 1995; Wilding, 1982). In a culture of professionalism where certified workers are supposed to be objective and depoliticized agents of social improvement, professionals' personal convictions and drive for control tend to be minimized (Herman, 1995; Kultgen, 1988). Instead of being seen as an integral part of human interactions, subjectivity is marginalized and regarded as an undesirable deviation from the course of objectivity.

While dominant models of applied ethics pronounce ideals of power equalization, shared decision-making, and the elimination of harmful behavior, they fall short of their ideals because they presume that professionals can erase years of socialization in inequality by simply reading a code and some vignettes (Dokecki, 1996; Mair, 1992; Pilgrim, 1992; Prilleltensky, 1994). There is the assumption that professionals are able to overcome power differentials and be equal in the microethics of the therapeutic encounter, and that they are able to truly share control of the helping process with clients. As Dokecki (1996) has argued, this is an idealized version of the helping encounter because, in actual fact, clinicians cannot step outside of the tradition that rewards them for thinking they are superior to lay persons.

We are a society that not only tolerates but also invites abuses of power. Professionals are among those who, on behalf of their clients and the good of society, should be leading the effort against the abuse of power. But...they sometimes fall prey to the temptation to use the power inherent in their professional roles primarily for their own good and only incidentally or accidentally for the good of others. (Dokecki, 1996, pp. 3-4)

As feminist theorists have claimed, inequality has to be understood in specific contexts (Bowden, 1997; Lather, 1991; Maynard & Purvis, 1994). While continuous with critical theory in many ways, current feminist theory adds to it a critique of patriarchal domination and an emphasis on local knowledge and context (Bowden, 1997). Contexts vary, and so do the constellations of factors affecting power dynamics and their subjective interpretations. As Bowden (1997) contends, in grand theories of ethics, "attention to the messy contingencies of concrete situations is set aside in favour of the theoretical project of organizing moral knowledge under general principles and rules of conduct that exhibit the exactness and formality of mathematics" (p. 3). In their quest to understand and eradicate the domination and exploitation of women, feminist theorists strive to illuminate the local and unique conditions that perpetuate oppression.

An example of a grounded, contextual and critical interpretation of applied ethics derives from the work of Chambliss (1996). In a research project that spanned nearly fifteen years and included over a hundred interviews and observations in three hospitals, Chambliss (1996) set out to understand what are some of the ethical problems encountered by nurses. What he found supports our contention that ethical actors do not simply engage in cognitive problem-solving. His research flies in the face of much of the applied ethics literature. Whereas the corpus of applied ethics consists mainly of codes of ethics and decision making frameworks to be used by individual agents in moments of ethical despair, Chambliss claims that applied ethics has much more to do with political tension and power struggles than with cognitive problem-solving. In contrast to the principal thrust of applied ethics as an individual's responsibility to identify dilemmas and act according to his or her best judgment, Chambliss situates ethics not in the heads of independent agents, but rather at the center of conflictive social relations. We believe that it is within this intersubjective web that the parameters for ethical discourse and action are set. Ethical knowledge is not abstract but situated knowledge (Haraway, 1989). This is why we need to understand ethics not in the abstract but in specific social contexts (Bowden, 1997).

Research Objectives

Our research in Cuba was intended to contribute to the creation of relevant and useful ethical frameworks. Specifically, the research inquired about clinicians' (a) general concepts of applied ethics, (b) values, (c) ethical dilemmas, (d) ethical resources and impediments, and (e) recommendations for maintaining or improving ethical decision-making processes. This article reports on the last three points. The first article in the series dealt with concepts of applied ethics and values. Methodology

Given that context, research relationship, methodology, and analyses were covered at length in the first article of this series, here we cover just the main methodological points. The reader interested in the details is referred to the previous article. The data were obtained through individual interviews and focus groups with 28 mental health workers in Cuba. The interview guide consisted of open-ended questions addressing concepts of ethics and values, dilemmas, resources, limitations, and recommendations for coping with ethical conflicts. The findings were discussed in-depth with two Cuban research participants who provided important contextual information. Participants in the study were given a summary of the findings in Spanish and had an opportunity to comment on them. The feedback received from participants in Cuba lent support to the interpretation of the data.

Findings

This section is divided into four main parts: ethical dilemmas, resources to resolve dilemmas, limitations in resolution of conflicts, and recommendations to prevent unethical behavior (See Table 1).

1. Ethical Dilemmas

Ethical dilemmas refer to moral problems encountered by interviewees throughout their professional careers. These problems provoke serious internal conflicts, as they involve actions that contradict either their colleagues, their employers, or their own set of values. The dilemmas that were mentioned were grouped in the following categories:

• Conflicts in personal values

• Conflicts with other professionals

• Conflicts with clients

• Conflicts with organizations

  1.1 Conflicts in personal values

  To share or to compete? Dwindling resources and economic hardships have eroded the sense of solidarity among professionals. Some workers in the provinces complain that psychologists in large urban settings do not share with them as many resources as possible or collaborate with them. Psychologists who are at a distance from Havana do not hear as much about conferences and do not have access to literature and other means of information.

  In addition, there is a hidden resentment towards psychologists working in academic settings because they have more access to information and academic exchange. Participants claimed that less resources and opportunities are being shared because there is a need to stand out individually to be recognized. As opportunities to travel abroad and engage in international exchanges are few, there is a sense of competition that was not to there before the economic crisis. Participants felt that the nineties were marked by an erosion in collegiality.

  Some attribute this competitive need to the economic crisis and others to the influx of Western values taking hold in Cuba currently. People need to compete for dwindling resources and want to be seen as leaders in their field, sometimes at the expense of others. Some participants noted with much pain and regret that "Cuba is not the same" since the collapse of the Soviet block and the consequent deterioration in quality of life.

  To be honest or to pretend? Related to the previous dilemma there is a relatively new phenomenon in Cuba called "double morality." Although a certain morality of solidarity and honorable behavior is promoted, due to survival needs people behave with a different morality; that is, there exists "a breakdown between what is said and what is done." This is the case when people buy food illegally through the black market because the prices are lower than the prices in some of the stores. One participant explained that it is difficult to promote certain values in children when what is taught at home is opposed to what is taught in school. Whereas the value of sharing is expounded in school, the opposite is taught at home: not to share their things --pencils, paper, workbooks, etc.-- so that they would last longer. School supplies are very rare and extremely expensive. The following quotes exemplify the personal dilemmas which two of the psychologists faced when experiencing this double morality:

  The double morality phenomenon appears even at a very early age... dishonesty, but there is the need to be clever so that no one takes advantage of you, and so that you can take advantage of others.

  
  
  

  Sometimes you have to project yourself in life with a double morality because of the survival needs, because of the problem of adaptation to reality.

  
  
  

  Although professionals and citizens would like to talk openly about these contradictions, in our view there is a mantle of silence. Some participants were at pain to explain this phenomenon. Mixed emotions and conflicted loyalties were expressed. They understand that in times of crises, such as the current "special period," the population needs to be united to maintain high morale -- criticism of the state may erode public confidence. But on the other hand, citizens wish to be more open about phenomena like competition, hypocrisy, and censorship.

  In part, their agony derives from feeling passionately about civic values and about the revolution. Most of them believe in the mission of the revolution and accept the sacrifices that are expected from the population in times like these. However, they feel somewhat silenced and unable to dialogue openly about these dilemmas and contradictions.

  Although some participants were cautious to comply with the Cuban version of political correctness, most participants felt quite at ease and shared with the interviewers the serious conflicts that beset Cuba. Participants varied in their perception of what is permissible to talk about in Cuba. Whereas some felt no censorship whatsoever, some were guarded.

  1.2 Conflicts with other professionals

  To protest or to acquiesce? Participants experience pressure from other professionals, primarily physicians, with whom they often enter into conflict. Psychologists are opposed to medical doctors stigmatizing patients and grouping them in categories according to pathologies. This conflict was expressed in the following statement:

  I have worked a lot with doctors and sometimes we have a difference of opinion. Some doctors have a very strong biological tendency and they tend to see the problem of men/women as sick men/women, just as a biological problem and they exclude psychological aspects, and this is for me a dilemma as I find myself having to assume the position of defending the human value that is in the psychological aspect of the person, which is ignored.

  
  
  

  Another major dilemma is the fact that psychologists are not allowed to disclose medical diagnoses with terminally ill people, such as cancer patients, because the medical code of ethics forbids it and psychologists do not wish to opposed physicians. Physicians withhold information in order to protect patients from the knowledge that they are about to die. This practice, however, is opposed to the ethical values of the psychologist in his/her search for truth, honesty, and self-determination of clients. According to our participants, hiding the diagnosis hampers therapeutic efforts and the possibility of working through the mourning process with patients and families. This dilemma was expressed by a psychologist saying:

  Here in Cuba, from the medical standpoint, cancer patients don't receive their diagnosis. How can they confront their illness if they don't know what the illness is?

  
  
  

  In these situations the psychologist is faced with the dilemma of either protesting and getting a reputation as a trouble maker, or acquiescing and betraying personal values and commitment to the well-being of clients. As we shall later observe in the discussion section, the amount of power the psychologist wields determines the resolution of the conflict. The greater the amount of power, the higher the likelihood that he or she will challenge deficit-oriented and disempowering practices.

  1.3 Conflicts with clients

  To promote personal responsibility or to absolve clients from duties? A dilemma experienced by psychologists is dealing with patients who refuse to take responsibility for their problems or who use their psychological difficulties to avoid social responsibilities. This dilemma was expressed by a psychologist who talked about adolescents "faking" psychosocial problems in order to avoid duties "such as going to school, or going to fields, which is something

  
  
  

  that is part of our system."

  
  
  

  At play in this dilemma are the competing values of personal and collective well-being. Psychologists who believe in collectivism and the value of working for the State have a dilemma when clients do not want to participate in volunteer or compulsory social contributions. If the psychologist is in agreement with social norms of volunteer work, which can be quite strong in Cuba, then he or she will be inclined to confront the client with his or her lack of social contribution. If, on the other hand, the psychologist is not in favor of pressuring citizens to do volunteer work, he or she may be more amenable to listen to clients' concerns regarding participation in social activities. The solution for this dilemma depends in large degree on the ideological stance of the professional. Whereas many of our participants approved of the State's expectation to volunteer for social causes, some of them objected to the State's pressure on people to do this. Depending on the psychologist's standpoint, this may be either a conflict with the client or with the State.

  To accept or to ignore client's religious beliefs? Certain religious groups are opposed to medical and psychological practice. In some cases religious beliefs put the patient's life at risk. Such is the case when parents refuse to have blood transfusions for their children. In other instances parents or clients object to therapeutic interventions such as hypnosis. In these cases professionals have to confront parents or clients themselves and discuss their disagreements. At play here are the values of clients' self-determination and sensitivity to their cultural beliefs on one hand, and professional knowledge about what might help the client or patient on the other.

  Another aspect of this dilemma is physicians' refusal to allow patients to engage in religious or spiritual practices, such as confession. Although these cultural practices do not put the patients' health in jeopardy, some physicians dismiss them as backward. The psychologist espousing self-determination of clients may again find him or herself advocating for clients against physicians' will.

  1.4 Conflicts with organizations

  To comply or to resist pressure? Some of our participants faced pressure to disclose information about clients and even to interpret test results in favorable light. Unfavorable test results may harm workers in positions of seniority. This is why employers seek positive test results on employees they wish to keep. This dilemma is expressed by one psychologist in the following way:

  I also find myself in situations where I have to make certain evaluations and offer results that are negative for the people, and my superior at that institution applies some pressure on me to change my point of view or to write something else on the document.

  
  
  

  This situation is common among psychologists working in factories and other places of employment where they are expected to serve the State. Psychologists are often consulted on issues of promotion and career counselling, and if their assessment differs from employers' expectations there is conflict.

  Participants also commented that little attention is given to psychologists when institutional changes are planned. This opinion was expressed as follows:

  In institutions where psychologists work, decisions are often made over which the psychologist has no say. One advises, illustrates or instructs about aspects that one considers sufficiently important but decisions are made which we may not consider professionally correct. Many times the interest of an organization, a corporation, a company, or an organism is an interest which is not necessarily the interest of the psychologist towards the individual, but rather the achievement of certain objectives that can be contradictory to some human values.

  
  
  

  2. Resources to Resolve Ethical Dilemmas

  This section refers to the factors that help to solve ethical dilemmas in the professional practice of the psychologist. The resources that were mentioned by the participants can be grouped in the following categories:

• Government support

• Collegial support

  2.1 Government support. Although there are very few material resources, government supports psychologists as a professional group. Government support allows psychologists to experiment with new areas and possibilities. This support is due to the State's concern for individual and public health. Psychologists are seen as contributing to the health of the population, a national priority for Cuba. Although this is not a direct resource to resolve ethical dilemmas, professionals feel that they are held in high regard by the State and that feeling facilitates their work. A participant made this point as follows:

  For ethics to flow there have to be three important components. Political will, in our country the political power is in charge of health, the budget could be bigger but it is a budget that doesn't go down. (2) The other one is group will, that is, the community in itself that is there, (3) and the other one would be scientific-technical professional will. In our country there are all the prerequisites to achieve this. What needs to be sought after is the exchange between these sectors. If you know what the community needs, you can go to the political administration and make a case for a community project that originated in these two components, the group and the scientific one.

  
  
  

  This participant conceptualized ethics in a broad sense. His view was that societal structures have to cooperate for the psychologist to achieve the goals of community mental health. This view is congruent with the conceptualization of ethics offered in the first article of this series. In that article we described Cubans' conceptions of ethics as based on a collectivist understanding of psychological well-being.

  Interviewees told us that recently the government has encouraged discussion of ethical dilemmas in professional circles. Various government ministries have collaborated in organizing symposia and task forces to deal with professional ethics. This is seen as a very positive step forward taken by the government.

  2.2 Collegial support. The interviewees commented that there is appreciable support among psychologists, especially among those living in the provinces. They feel free to go to their colleagues and consult them about ethical dilemmas. For the most part, this support is informal, taking place during breaks and after working hours. Although this is highly appreciated, psychologists would like to have more formal opportunities to discuss ethical dilemmas. As we shall see below, formal ethics committees are rarely used. They are invoked only in extreme cases and are not used as consultative bodies.

  3. Limitations that Impede the Resolution of Ethical Dilemmas

  This section deals with limitations that make it difficult to solve ethical dilemmas. The limitations mentioned by the interviewees can be grouped into two categories: (a) organizational/institutional limitations, which refer to the absence of material resources, academic preparation, and discussion in work settings, and (b) personal limitations of the professional, which refer to the lack of reflection and knowledge in the area of applied ethics.

  3.1 Organizational/institutional limitations.

  Limited discussion of ethical dilemmas. Participants mentioned that in their organizations there is typically an ethics committee, but workers turn to it only in extreme cases. Other than informal conversations, psychologists claim not to have the time or the space to reflect with their colleagues or other professionals about moral dilemmas.

  Another limitation is that psychologists are rarely in administrative positions; their places of employment are typically headed by physicians. Ethics committees are likewise chaired by medical doctors, and psychologists do not have a strong enough voice to make their needs known or to have their point of view respected. Psychologists would like more time to discuss ethical problems, but the occupational climate is dictated by physicians who do not appreciate the ethical dilemmas of psychologists.

  Little formal preparation in ethics. Psychologists complained about little formal preparation in ethics during their training. They mentioned that they had little or no opportunity to reflect on the ethical dilemmas they might encounter in their professional life.

  We were never taught how to relate to our colleagues, how to work in multi-disciplinary groups, how to resolve these ethical problems, what type of ethical problems we could face.

  
  
  

  Lack of attention to the code of ethics. Some psychologists mentioned that they know of the existence of a code of ethics for psychologists in Cuba, but have not seen it. Only two of the participants said that their institutions are in possession of the code of ethics. This seeming neglect might be due to the very high cost of printing and distribution of materials in Cuba.

  Limitation of material resources. A very serious limitation is the lack of material resources. This limitation was mentioned by all participants. The problems include deplorable working conditions, lack of access to technology, minimal access to bibliographies, and the lack of information from outside Cuba and other Cuban provinces. In this respect three psychologists mentioned the following:

  We can't negate the difficult economic situation that our country is experiencing, and as a psychologist and citizen I perceive this. It influences the possibilities that I could have as a psychologist in developing my work. I think that our scientific thinking, our research, progresses despite these circumstances, what keeps us a bit behind is the technology. Not having a tape recorder, better working conditions, which would allow our work to flow better.

  
  
  

  There are difficulties in terms of material resources, not human (resources) because humans exist and in sufficient numbers and they interact a lot, but yes in terms of material resources such as magazines, flyers, bulletins, videos, which could help us to improve the preparation of professionals, resources to deal with ethical problems and dilemmas.

  
  
  

  I have never been able to access the Internet. I can't have access to the Information Highway, so whatever any of us receives we try to get the best use out of it.

  
  
  

  3.2 Personal limitations of the professional.

  Lack of tolerance for critical feedback. Sometimes there is little tolerance for constructive criticism. Some Cubans perceive themselves as easily hurt when they are criticized because they are very careful not to hurt others. Also, there is a fear of being viewed by colleagues as incompetent.

  Lack of professional experience. Some psychologists who just graduated from the university mentioned that their lack of work experience in some cases made it more difficult for them to know how best to solve an ethical dilemma.

  4. Recommendations to Prevent Unethical Behaviors

  The last section of the interview guide focused on recommendations to prevent unethical behaviors. Recommendations were grouped in the following categories:

• Education and training

• Critical posture

• Application of norms and codes of ethics

  4.1 Education and training. This category refers to the need to offer courses and professional development in universities and work settings.

  Discussion and reflection of ethical dilemmas. Participants emphasized that they need to start by recognizing the ethical problems they face. This reflection could be done through discussions, workshops, and symposia with colleagues from Cuba and from abroad. Formalizing group supervision and peer consultation related to ethics was a suggestion made by several participants. A psychologist expressed this idea as follows:

  In the institution where I work there are no official resources to solve ethical dilemmas. There could be a tribunal or a scientific counsel to discuss the problem, but it only exists when there is a serious ethical problem... It would be very good to have work sessions to solve these dilemmas, we could even pose these problems to ourselves.

  
  
  

  Professional development and courses on ethics. We were told that professionals should be required to update their skills and knowledge in the area of ethics. In addition, they should be given more opportunities to consult with psychologists from other countries. The interviewees mentioned the need to review and publish research related to ethical dilemmas of psychologists in Cuba. There needs to be an "actualization and update of ways and methods of teaching ethics."

  4.2 Critical posture. Critical posture refers to the need to scrutinize professional practices from a moral point of view. There is also the need to analyze how the current socio-political and economic climate of Cuba affects professionals' interests and values.

  Review of professional tenets and assumptions. Participants expressed the need to be critical with themselves, about what they do, and about what they believe. This idea was expressed as follows:

  The profession has to look at itself from outside in and see how many things in its own paradigm, in its own structure, already carry the possibility of not respecting human dignity. The paradigms that I carry from science could be upsetting ethical practice.

  Analysis of double morality. Psychologists considered it relevant to their practice to help the population analyze the problem of double morality (a contradiction between what is morally thought correct and what is actually done). This problem occurs in everyday life due to socio-economic and political changes that are currently taking place in Cuba. These transformations, by not being openly addressed by professionals, cause moral conflicts, confusions, and uncertainty for professionals and students alike. "The work of the psychologists consists in helping to interpret reality."

  4.3 Implementation of codes of ethics. This refers to the need to update, revise and implement the Cuban code of ethics for psychologists.

  Revision of Cuban code of ethics. The interviewees considered the implementation of a Cuban code of ethics for psychologists of fundamental importance. One of the psychologists commented that it is indispensable to customize codes to the specific situation of each country. This opinion was expressed in the following way:

  I don't think it is helpful to extrapolate an ethics code from another country to ours. Psychology needs to be particular in terms of how to practice it where you live, according to what surrounds you professionally.

  
  
  

  Revision and evaluation committee. To prevent unethical behavior it was considered very important to have a review and advisory committee that regulates professional practice. evaluates the practice of ethics by professionals. Participants also suggested that psychologists carry out evaluations to assess quality of service and ethical practice. Another recommendation consisted of suspending practitioners' license if the offense was serious. Interviewees suggested that ethical violations of any kind should be reported to ethics committees.

  Discussion

  The purpose of this research was to examine the grounded experience of ethics of mental health professionals in Cuba. Whereas the first article in this series dealt with conceptions of ethics and values, this article addressed the lived experience of ethics in concrete situations. Similar to results of previous research, it was found that ethical dilemmas are experienced primarily in the form of interpersonal conflicts mediated by power (Prilleltensky, Rossiter, & Walsh-Bowers, 1996; Prilleltensky, Walsh-Bowers, & Rossiter, in press; Rossiter, 1998; Rossiter, Walsh-Bowers, & Prilleltensky, 1996; Walsh-Bowers, Rossiter, & Prilleltensky, 1996).

  According to Chambliss (1996), power differentials are ubiquitous and they forever limit workers' ability to act in what they consider to be the most ethical way. Based on this research, we would argue that professionals' conceptions of ethics are framed within an evolving web of social relations, and that dilemmas take place within changing intersubjective and economic spaces. In Cuba, material scarcity has a great deal of impact on the construction and experience of ethics. Ethics is structural and not individual. In a telling paragraph Chambliss notes that

  Ethical problems...reflect divergences of interest among groups. Ethical issues...are not intellectual puzzles to be solved with the aid of clearly elaborated 'principles,' such as respect for autonomy, non-maleficence, beneficence, and justice. They are not abstract issues, solvable by appeals to logic, through academic research, or merely with 'enhanced communication,' although that may help. Ethical issues are not a mere competition of ideas; they are a competition of people, who have their various goals and methods. They represent real problems in organizational action, constrained by legal, economic, social, and personal peculiarities. Education, sensitivity, awareness may marginally affect political alignments, but ethical problems are not solvable by changing people's thought. The problems are not inside people's heads. (italics in original, p. 118).

  The research conducted by Chambliss has to be taken seriously by anyone concerned with promoting the welfare of service recipients in social agencies, treatment centres, and medical settings. His book gives a clean picture of the messy context of ethics, a messiness rarely reflected in the mostly abstract decision-making frameworks (Bursztajn, Gutheil, & Cummins, 1987; Prilleltensky, Rossiter, & Walsh-Bowers, 1996; Rossiter, Prilleltensky, & Walsh-Bowers, in press). Chambliss asserts that different professional groups have competing views of what it means to do the right thing. Physicians want to cure, nurses want to care, administrators want to save money and psychologists want to promote client self-determination. Conflicts among professionals abound, but there are no mechanisms for addressing these disputes. Ethics committees, Chambliss tells us, are not the place to advance workplace democracy. In most cases, these groups are viewed as siding with the powerful players -- read physicians.

  The research reported by Chambliss is congruent with our own findings. We can draw parallels between the hospital settings researched by Chambliss and our own findings in Cuba. In both places people in positions of authority make decisions that are not always deemed the most responsible choice by those who do the front line work. In North American hospitals physicians make decisions without consulting nurses; in Cuban clinics physicians make decisions without consulting psychologists. The less power one has in the system, fewer are the chances to be heard.

  The relative lack of power affects not only the ability of nurses or psychologists to make decisions, but of course the ability of patients as well. Patients are often powerless and helpless in the helping relationship. Therapy clients, welfare recipients, hospital patients, and helpers of all kinds often succumb, in Cuba and North America, to the unquestioned authority of the professional in charge (Dokecki, 1996).

  The fabric of applied ethics is made of interweaving strands of conflict among professional groups on one hand, and between professionals and clients on the other. Each player has a vision of what is the most desirable outcome -- their vision being determined by their respective social location and by their own subjectivity. Based on our own and previous research (Bursztajn, Gutheil, & Cummins, 1987; Chambliss, 1996; Prilleltensky, Rossiter, & Walsh-Bowers, 1996; Prilleltensky, Walsh-Bowers, & Rossiter, in press; Rossiter, 1998; Rossiter, Prilleltensky, & Walsh-Bowers, in press; Walsh-Bowers, Rossiter, & Prilleltensky, 1996), we can identify three powerful determinants in the generation and resolution of ethical conflicts: values, interests, and power (VIP).

  Power interacts with interests and values, and plays a key role in conflicts and resolutions. In the VIP model, power means the ability to (a) advance cogent values, and (b) protect personal interests. A professional's ability to promote a certain value, such as client autonomy, depends on the amount of power and respect commanded by the worker in a particular setting. Similarly, a professional's ability to protect personal interests, such as opportunities for career advancement or the right not to be exploited, depend on his or her status within the organization.

  Values refer to ethical principles that guide behavior. Like power, values also influence the nature of conflict. This is clear in situations in which physicians adopt a paternalistic attitude towards patients and psychologists want to assert patient self-determination and the right to know their diagnosis. Although values also play a role in conflict-resolution, psychologists' ability to promote them is mediated by the power they have in the organization.

  Personal interests also play an obvious role in the creation and resolution of conflict. In the case of personal conflicts with values, a person may wish to denounce hypocrisy or what Cubans call "double morality," but his or her personal interest would be jeopardized by taking such a risk. More than one professional in our research would have liked to be able to call hypocrisy for what it is, but that would have placed them in a very precarious position. Pointing out the contradictions between a written ideology of sharing and an actual practice of competition is a risk that can only be taken if one commands sufficient social and organizational power to voice a dissenting opinion.

  As the research shows, the resolution or outcome of conflict is largely determined by power dynamics. For as long as power differentials predominate, those with most influence will dictate outcomes. This is congruent with our conceptual framework, according to which ethical decisions are not necessarily based on values but on the personal interests of those in control. Integrating our findings with our philosophical orientation, we propose four principles derived from this and past research.

  1. Power equalization: Power equalization among professionals and between helpers and clients is a prerequisite for the creation of safe spaces to debate contradictions and resolve disagreements.

  2. Democratic dialogue: For diverse and dissenting voices to be heard, rules and spaces for democratic communication have to be established. In their absence, the voice of the powerful will continue to dominate. People should be able to express their opinion without fear of negative repercussions or threats to their personal interests.

  3. Reconciliation between personal interests and values: The equalization of power and the creation of safe spaces for dialogue will facilitate reconciliation between personal interests and values. Otherwise, threats to job security (in the case of workers) or to treatment (in the case of clients), will inhibit the enactment of values because of fear.

  4. Critical reflection on ethics: None of the above can occur without critical reflection on one's values, interests, and power. This is perhaps the place to start in efforts to advance ethical decision-making processes. We suggest critical reflection on how personal subjectivity, constructed by the tripartite model of power, values, and interests, inhibits or facilitates ethical decision making and democratic dialogue with colleagues.

  Conclusion

  We have used research derived from qualitative research with Cuban mental health professionals to discuss various influences on ethical dilemmas and conflict resolution. We have argued that fair resolution of conflicts is predicated on power equalization, democratic dialogue, reconciliation of values and personal interests, and critical reflection on ethics. But if power sharing and democratic dialogue are to be more than abstract ideals, if they are "to serve organizational purposes in milieux of increasing complexity and uncertainty, then the subjects' competence to participate in reasonable discussions has to be complemented by forums and procedures that institutionalize them as well as by organizational cultures that nourish them" (McCarthy, 1996, p. 160). We concur with McCarthy's call for forums and procedures to promote conflict resolution in a climate of safety and respect. Ultimately, both in Cuba and in North America, ethical action is the result of the interplay between values, power, and interests. In both geographical locations, power issues suffuse mental health workers' constructions of values and their interpretations of ethical dilemmas. Much is different in the ideology and beliefs of Cubans and North Americans. The role of power in applied ethics, however, remains quite similar. References

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  Table 1

  
  
  

  Overview of Findings

  
  
  

  Main Categories	Themes
  Ethical Dilemmas	Conflicts in personal values To share or to compete? To be honest or to pretend? Conflicts with other professionals To protest or to acquiesce? Conflicts with clients To promote personal responsibility or to absolve clients from duties? To accept or to ignore client's religious beliefs? Conflicts with organizations To comply or to resist pressure?
  Resources to Resolve Ethical Dilemmas	State support Political will, conferences Collegial support Formal and informal consultations
  Limitations in Resolution of Ethical Dilemmas	Organizational/Institutional limitations Limited discussion of ethical dilemmas, little formal preparation in ethics, lack of attention to code of ethics, no material resources Personal limitations Lack of tolerance to negative feedback, lack of professional experience
  Recommendations to Prevent Unethical Behaviors	Education and training University courses and professional development Critical posture Review of professional tenets and assumptions, critique of "double morality" Implementation of code of ethics Review and enforcement body, indigenous code of ethics