Received: 30 September 2022 Accepted: 2 March 2023

DOI: 10.1002/imhj.22055

RESEARCH ARTICLE

The ethics of infant and early childhood mental health

practice
Izaak Lim1,2 Jon Korfmacher3 Alison Steier4 Charles Zeanah5
Paula D. Zeanah6

1 Early
in Life Mental Health Service,
Monash Health, Clayton, Victoria, Abstract
Australia Ethics is concerned with the basis for moral judgments of “right” and “wrong”
2 Department of Psychiatry, School of and is central to the clinical endeavor. Many clinicians integrate ethical estima-
Clinical Sciences, Monash University,
Clayton, Victoria, Australia
tions into their work without much conscious awareness. However, explicit use
3 Chapin Hall, University of Chicago, of ethical principles and frameworks can help navigate clinical decision-making
Chicago, Illinois, USA when there is a sense of moral conflict or ambiguity about the “right” course of
4 SouthwestHuman Development, action. This article aims to highlight the key concepts and principles in clinical
Phoenix, Arizona, USA
ethics as they apply to IECMH practice and stimulate a bigger conversation in
5 Department of Psychiatry and
Behavioural Sciences, Tulane University,
the profession around how to support each other to maintain high ethical stan-
New Orleans, Louisiana, USA dards in working with young children and their families. Specifically, the authors
6 Collegeof Nursing and Health Sciences consider the relevance of Beauchamp and Childress’ four principles framework
and Picard Centre for Child Development,
(respect for autonomy, beneficence, non-maleficence, and justice), and address
University of Louisiana, Lafayette,
Louisiana, USA some of the special ethical challenges in the field, namely, the vulnerability of
the infant, the need for a competent workforce, caring for caregivers, and the
Correspondence
problem of multiple patients. Finally, the role of infant rights is briefly explored,
Izaak Lim, Department of Psychiatry,
School of Clinical Sciences, Monash noting the significant interest and debate that has been generated by the publi-
Medical Centre, Level 3, P Block 246 cation of the World Association of Infant Mental Health’s Position Paper on the
Clayton Road, Clayton, Victoria 3168,
Australia.
Rights of Infants.
Email: [email protected]
KEYWORDS
ethical codes, ethical skills, ethics, infant mental health, infant rights

1 INTRODUCTION cial to IECMH practitioners, who are regularly faced with

ethical challenges of various kinds.
The purpose of this paper is twofold: (1) to establish the We begin by locating ethics in the clinical endeavor
relevance of clinical ethics to the field of infant and early with special attention to how it can and should influ-
childhood mental health (IECMH), and 2) to re-familiarize ence clinical decision-making. We will then explore one
the reader with the concepts that will help them navigate of the most prominent ethical frameworks in use today—
the articles that follow in this special section exploring Beauchamp and Childress’ four principles—in relation to
ethical issues in IECMH. We argue that attending to the IECMH. Finally, we will outline the unique combination
ethical dimension of clinical work is essential to reflective of ethical challenges inherent to the field of IECMH and
and patient-centered care, and that a working knowledge briefly consider the role of infant rights as a significant
of ethical concepts and their application is highly benefi- recent addition to the landscape of clinical ethics.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2023 The Authors. Infant Mental Health Journal published by Wiley Periodicals LLC on behalf of Michigan Association for Infant Mental Health.

Infant Ment Health J. 2023;44:651–662. wileyonlinelibrary.com/journal/imhj 651

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652 LIM et al.

2 ETHICS IN CLINICAL PRACTICE

KEY FINDINGS / STATEMENT OF RELE-
Ethics, as an academic discipline, is the branch of philos- VANCE
ophy concerned with understanding the basis for moral
judgements about what is right and wrong, and hence 1. Infant and early childhood mental health
what constitutes right action. Practical ethics seeks to (IECMH) practice presents special ethical chal-
apply moral concepts of right action to real-life situations. lenges requiring the cultivation of clinical eth-
Clinical ethics refers to practical ethics in the healthcare ical skills, respectful and robust ethical dis-
setting and focusses on how clinicians should be and act cussion, and further development of ethical
in relation to patients and their families. guidance and resources.
Many clinicians integrate ethical estimations into their 2. The principles of respect for autonomy, benef-
everyday practice without thinking about it, for example, icence, non-maleficence and justice are highly
when they behave in a certain way because it feels like the relevant to IECMH practice and can offer help-
right thing to do. When the right thing is obvious, this intu- ful insights into navigating the ethical com-
itive approach may be sufficient. However, when there is a plexity of working with young children and
sense of moral conflict or ambiguity around what a clin- families.
ician should do, a more explicit, analytical approach is 3. An infant rights framework provides one of the
needed. This is where ethical principles and frameworks most definitive forms of ethical guidance avail-
can help navigate clinical decision-making. able to the profession by elevating the moral
Ethics is a normative enterprise, meaning it is concerned status of infants, articulating their basic inter-
with questions of values rather than questions of fact. ests, and creating correlative duties on others
This is a different way of thinking compared to clinical to uphold these interests.
calculations of how to preserve life or relieve symptoms.
Bringing an ethical lens to the clinical encounter involves
asking broader questions about the patient’s experience,
the clinician-patient relationship, and what is most impor-
tant about their care as determined by values and ethical DIVERSITY AND ANTI-RACIST SCHOLAR-
principles. SHIP
Ethical analysis demands the use of reason and justifica- This article aims to reflect an appreciation for
tion in coming to decisions about what to do in situations diversity and an anti-racist approach. It does so by
of moral conflict or ambiguity. This is what distinguishes presenting contrasting perspectives on the West-
this approach from mere intuition or unthinking adher- ern notion of children’s rights, citing the critical
ence to other forms of moral and behavioral guidance, such work of cultural anthropologists. It also makes
as religion, the law, or professional etiquette. Certainly, extensive reference to non-discrimination, anti-
these forms of guidance can help practitioners behave in oppressive practice and the Diversity Informed
a socially desirable way. However, they do not engage the Tenets for Work with Infants, Children and Fami-
practitioner’s moral agency such that action emerges from lies in its discussion of the principle of justice. The
their individual deliberation on what ought to be done. first author comes from a non-Western cultural
In sum, ethics is a way of “understanding and examining background.
moral life to create a coherent sense of what is good and
right in human experience” (Roberts, 2016, p. 3) and, in the
healthcare setting, assists practitioners to make decisions
informed by values over and above what might be clinically optimal decision. Gabbard (2012, p. 30) illustrated the rela-
possible or seemingly preferred. tionship of legally permissible, ethically acceptable, and
clinically optimal decisions in psychiatric patient care as
a series of filters that can be sequentially applied. Of all
2.1 The ethical dimension of clinical possible decisions within a particular social, cultural and
decision-making historical context, practitioners are constrained by what
is legal in their jurisdiction, and therefore this is the first
Attending to the ethical dimension of a clinical scenario and (usually) least ambiguous constraint. Within legally
can help to narrow down the range of acceptable options permissible decisions, practitioners should be further con-
available to the practitioner and thus guide them toward an strained by what is ethically acceptable, as even the best
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LIM et al. 653

clinical decision may not necessarily be ethically sound, if protective behaviors, and build on the therapeutic alliance
for example, it is unacceptable to the patient, or an unfair that will enhance safety into the future. Therefore, the clin-
use of healthcare resources. Therefore, no clinically opti- ically optimal course of action would be to not notify child
mal decisions should fall outside the bounds of ethical protective services at this time.
or legal acceptability. Considered in this hierarchical way,
healthcare professionals need not only well-developed
clinical knowledge and skills, but a sound understanding 2.2 Ethical skills
of legal frameworks and ethical concepts to help guide
their actions. Knowledge of ethical concepts is an important first step,
For example, if a mother brings her 3-month-old infant but this knowledge must then be translated into ethi-
to a child health nurse for help with sleep and settling dif- cal decision-making skills and processes. As mentioned
ficulties and discloses a recent escalation of conflict with above, many practitioners integrate ethical skills into their
the child’s father that “got physical”, the nurse may con- approach to the care of patients without much conscious
sider the need to notify child protective services. According awareness. However, in situations of moral conflict or
to the law in their jurisdiction, the nurse is mandated to ambiguity, we suggest that bringing deliberate attention to
make this notification if they have formed a reasonable the ethical dimension of clinical work is likely to improve
belief that the infant is in immediate need of protection its quality and reduce the likelihood of inadvertent ethical
from physical or sexual abuse. If the nurse’s concerns missteps, minor or major. In their Concise Guide to Ethics
fall below this level of severity and urgency, but they are in Mental Health Care, Roberts and Dyer (2004) outlined
still troubled overall about the safety and wellbeing of the the following essential ethical skills:
infant, they may voluntarily choose to notify child protec-
tive services. In this case, it would be legally permissible for 1. The ability to identify the ethical features of a person’s
the nurse to use their discretion to make the notification care,
or not. 2. The ability to see how one’s own life experiences, atti-
Let us imagine that this mother has strongly negative tudes, and knowledge may influence one’s care of a
views about child protective services based on her own person,
experience of being placed in out-of-home care when she 3. The ability to identify one’s areas of clinical expertise
was an adolescent. When the nurse raises the possibil- (i.e., scope of clinical competence) and to work within
ity of involving child protective services to ensure the those boundaries,
infant is safe from exposure to family violence, the mother 4. The ability to anticipate ethically risky or problematic
becomes distressed and explains that she has already taken situations,
steps to engage a family violence support worker. She also 5. The ability to gather additional information and to seek
tells the nurse that the father has agreed to move out of consultation and additional expertise in order to clarify
the family home and enrol in a men’s behavior change and, ideally, resolve the conflict, and
program. 6. The ability to build additional ethical safeguards into
The nurse has an obligation to consider the prefer- the care situation.
ences of the infant’s mother because the mother bears the
parental responsibility and authority to protect the child’s We believe that these skills are indeed essential to
interests in the way she sees fit. These preferences should reflective and person-centered practice in IECMH and
be weighed and balanced alongside the nurse’s assessment encourage all practitioners working with very young chil-
of the risk of harm to the infant if notification is made or dren and their families to consider their own areas of
not made. In this case, the nurse believes they can miti- strength and development in these domains.
gate the risk of harm to the infant by developing a robust These skills are especially vital for IECMH practitioners
safety plan with the mother, including a follow-up tele- who are working in multidisciplinary teams, where mul-
phone appointment within the next week. Therefore, it tiple perspectives must be heard and weighed. In these
would be ethically acceptable for the nurse to not make a situations, it can be difficult to defend a child-centered
notification. view that challenges persuasive or socially preferred argu-
Finally, the nurse should consider the clinical implica- ments around, for example, parental rights or reproductive
tions of the options before them. By hearing and honoring justice. If the IEMHC practitioner can articulate the ethical
this mother’s preference to not involve child protective concepts and principles that inform their clinical opin-
services, the nurse can show respect for her parental ion, it may help ensure that team decision-making remains
autonomy, support her strengths by helping to consolidate balanced and fair.
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654 LIM et al.

3 ETHICAL PRINCIPLES AND THEIR dren as beings in their own right, who are valued as ends in
APPLICATION TO INFANT AND EARLY themselves, and not just as the property of their parents or
CHILDHOOD MENTAL HEALTH as becoming adults (e.g., Arneil, 2002; Uprichard, 2008). In
this framework, children are seen as having “the capacity
Beauchamp and Childress’ Principles of Biomedical Ethics to act deliberatively, speak for oneself, and reflect on the
has been a touchstone for healthcare professionals since social worlds that shape their lives and the lives of others”
its first edition in the late 1970s. This landmark contribu- (Montreuil & Carnevale, 2016, p510).
tion to clinical ethics identifies and articulates four ethical To respect a child’s agency means to acknowledge their
principles of central importance to healthcare practice, perspective and give it value by eliciting, listening, and pay-
which capture the areas of commonality across compet- ing attention to these perspectives, sometimes referred to
ing normative theories: respect for autonomy, beneficence, as hearing the child’s voice (Hallett & Prout, 2003). Attend-
non-maleficence, and justice (Beauchamp & Childress, ing to the child’s voice is increasingly recognized as an
2013). While these principles do not comprise an eth- important aspect of ethical practice in healthcare settings
ical theory or code per se, they do highlight some of (e.g., Carnevale, 2020; Kars et al., 2015; Singh et al., 2020).
the most important ethical obligations on the part of the Furthermore, while the young child might not have the
healthcare professional when making clinical decisions, capacity to exercise conventional autonomy, they are likely
and they draw on foundational ethical documents in the to become adults who do. Therefore, respect for autonomy
field of biomedicine, such as the Hippocratic Oath and the in the context of IECMH can be thought of as respect for
Nuremberg Code. In the following section, we consider the the autonomy of the future adult. This has been described
application of these principles to IECMH practice. as the child’s right to an open future (Feinberg, 1980),
which obligates the caregivers of children to raise them in
such a way that they have a wide range of options as adults,
3.1 Respect for autonomy and the capacity to choose between these options.
According to this account, the child’s future autonomy
The principle of respect for autonomy pervades much of is held in trust by their parents or guardians until they
the last 100 years of medical ethics discourse. In essence, develop the requisite capacities. Respect for the child’s
autonomy is the ability to make one’s own decisions, autonomy might therefore involve respecting the parent’s
free from controlling influences or limitations that pre- role in making good decisions on the child’s behalf while
vent one from making meaningful choices. To respect a the child’s autonomy remains latent. This can also be con-
person’s autonomy is to respect and support their capac- ceptualized as respect for parental autonomy, that is, the
ity for self-determination (autonomy literally translates to freedom to make decisions about how to raise a child
“self-rule”). In clinical work, this most obviously comes without external interference.
to the fore when thinking about the role a patient should Parental autonomy is, of course, not unlimited. The
take in deciding on their own treatment. However, this harm principle, which has its origins in the work of clas-
principle is also inherent to ethical rules about confi- sical liberal philosopher John Stuart Mill (1982), has been
dentiality, capacity and informed consent, and the use of adapted to the realm of child healthcare ethics by Diekema
coercion. (2004) in a seminal paper on when parents refuse medical
An obvious limitation to this principle’s application to treatment for their children. Diekema argues that “[w]hile
IECMH practice is that young children cannot exercise there are good reasons for granting parents significant free-
autonomy in the conventional sense. Young children do dom in making health care decisions for their children,
not yet have the cognitive abilities required to understand there are certain decisions that are sufficiently harmful
and use relevant information to arrive at decisions in their that they ought not be allowed” (p. 258) and that the risk
own interest, nor do they have the means to influence of serious preventable harm is the threshold at which
their situation independently of the adults around them— parental autonomy should be limited and state interven-
features that have traditionally defined autonomy. This tion invoked. This sets a high threshold at which IECMH
is not to say that young children do not have intentions, practitioners should activate child protective services, for
desires, and preferences of their own. On the contrary, example, as there may be decisions taken by parents that
young children have both meaningful subjectivities and are not in the child’s best interest yet do not cause a risk of
capacities to act purposefully in the world, which has serious harm.
been conceptualized as children’s agency (James & James, The harm principle, while not uncontroversial (e.g.,
2004). Bester, 2018; Birchley, 2018; Wilkinson & Nair, 2016), has
The concept of children’s agency has become a useful become the prevailing standard for overriding parental
(albeit contested) framework to articulate the value of chil- medical decision-making within bioethics and is gaining
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LIM et al. 655

acceptance in the child health and welfare service sys- The mother is convinced that there is something wrong
tems (Birchley, 2016; McDougall & Notini, 2014). However, with the boy and wants the therapist to see him for indi-
the concept of harm itself remains difficult to define pre- vidual sessions to deal with the trauma of witnessing his
cisely, as the meaning often depends on the context and father’s violence against her. The mother is not recep-
has evolved over time (Epstein, 1995). tive to the therapist’s recommendation of dyadic work,
In this paper, we use the word harm to refer to an over- as she does not agree with the therapist’s assessment
all, significant “set-back to interests” (Feinberg, 1987, p. that the boy’s recovery is dependent on his relationship
31), where interests refer to various components of the with her.
child’s well-being (from the basic to the aspirational). A What would it mean for the therapist to show respect
small setback to some interests might not constitute harm, for autonomy in this situation? On the one hand, the
especially if this setback is balanced by the advancement child’s future autonomy is likely to be compromised if his
of other interests. Therefore, determining whether harm social, emotional, and cognitive development continues
has occurred relies on assessing whether the degree of to be derailed by his trauma. The therapist might there-
setback is significant enough (Gillam, 2016). While sev- fore insist on dyadic treatment, noting that any attempt
eral bioethicists (e.g., Diekema, 2004; Ross, 1998) have to provide individual therapy to a child of this age would
offered influential formulations of harm in relation to be developmentally inappropriate and likely ineffective. In
children, there is no definitive consensus in the field on this scenario, the therapist could refuse to continue seeing
how significant is significant enough, and an element of the boy unless the mother agrees to participate in dyadic
interpretation seems inevitable. treatment.
In IECMH practice, there are several complexities On the other hand, the therapist knows that this mother
around how harm is conceptualized and contextualized, must come to her own decision about whether she partici-
and by whom. Naturally, practitioners vary widely in their pates in a dyadic treatment. The therapist has provided her
estimations of the seriousness and likelihood of harm, with all the relevant information to justify the treatment
which is influenced by myriad factors including their pro- recommendation and certainly cannot force her to attend
fessional training, institutional policies and procedures, sessions with the boy. Indeed, compelling the mother to
personal experiences and biases, and the capacity of the attend dyadic treatment sessions when she does not believe
service system to respond to child welfare concerns. To it will help and does not want to participate may render the
offer a definitive account of harm is beyond the scope treatment ineffective. The therapist could consider alter-
of this paper, however, when we refer to serious harm, natives to dyadic treatment, such as working individually
we are alluding to a broad range of threats to a child’s with the mother on parenting skills, noting that this is
interests, including physical, sexual and emotional abuse, unlikely to be as beneficial as dyadic treatment but less
neglect, and the accumulation of less extreme adversities harmful than no treatment at all.
that ultimately derail normal development and jeopardize While the mother’s refusal to accept the recommended
the child’s right to an open future. dyadic treatment might not be in the child’s best interest,
A further complication concerning the application of the disadvantage caused might not be significant enough
the autonomy principle in IECMH practice arises because to activate the harm principle. Only if the therapist is
the mental health treatment of choice for a young child is convinced that the mother’s actions constitute a risk of
dyadic, involving the adult caregiver as a vital participant serious preventable harm to the child does the harm prin-
in the therapy. In this situation, there are two patients— ciple comes into play. Only at this point would the mother
an adult, who does have the capacity to make autonomous have reached the limit of her parental autonomy, and the
decisions on their own behalf, and a child, who does not. state have justification to intervene. Of course, if the state
The healthcare professional has ethical obligations to were to intervene, even by facilitating engagement with
both patients as individuals, not just as a single dyadic family support services, the consequences for the parent-
unit of treatment. Therefore, the healthcare professional child relationship might be complex, and not necessarily
must respect the autonomy of the adult patient (including beneficial. This illustrates the complexities and limitations
their parental autonomy), and the future autonomy of the of relying on the principle of autonomy alone in IECMH
child (as should be held in trust by their parents). When practice.
it is the adult patient who is the agent for both persons, it
may be challenging to determine whose autonomy is being
represented or prioritized at any given time. 3.2 Beneficence
For example, a mother who has strongly ambivalent feel-
ings toward her 2-year-old son may present for IECMH Beneficence refers to the obligation of healthcare profes-
treatment in the context of the child’s aggressive behavior. sionals to act for the benefit of patients. This includes
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656 LIM et al.

relieving harm and suffering, preventing harm and suf- causing risk of harm to the patient and can be thought of as
fering, and promoting the welfare and well-being of the the natural counterpart to beneficence. This principle has a
patient (Beauchamp & Childress, 2013). Beneficence is complicated history in the ethics of end-of-life care and has
at the heart of the healthcare professional’s duty to the been the focus of debates about the differences between
patient—it is indeed the raison d’être for healthcare. To do withholding and withdrawing treatment, intended and
something for the patient’s benefit, one must be guided by foreseeable consequences, and acts of commission and
what is in the patient’s best interest, in other words, what omission (Beauchamp & Childress, 2013).
is good for their well-being. While IECMH practitioners are rarely working in the
Therein lies a tension that has long plagued medical realm of life or death, there are certainly significant harms
decision-making. While the healthcare professional may that can occur to patients caused by the well-intentioned
have a conception of what is in the patient’s best interest, actions of practitioners. Practitioners are morally account-
the patient might not always agree. Historically, the profes- able for foreseeable harms resulting from their actions,
sional’s perspective has often been imposed on the patient, even if these harms are unintended and even unfore-
as if the professional’s understanding of the patient’s best seen (as distinct from unforeseeable). For the practitioner’s
interest was more valid than the patient’s understanding. actions to be ethically justifiable, these foreseeable harms
This dynamic mirrors the relationship between a child must be outweighed by foreseeable benefits and/or respect
and their more powerful and more knowledgeable father, for autonomy.
hence the term, paternalism. Typical examples of such harms include advice or rec-
Paternalism is based on an objective account of best ommendations that lead to the separation of children from
interest, which assumes there are independent criteria by caregivers and families, ongoing or exacerbated symptoms
which to judge a person’s best interest (e.g., Taylor, 2016; because of unskilled or inappropriate therapy, misun-
Wiggins, 1995). In healthcare settings, paternalism implies derstood and/or misapplied parenting advice, and risks
that the clinician knows these independent criteria and is to the safety and well-being of families after disclosing
therefore able to make judgments about the patient’s best confidential information to third parties.
interest regardless of the patient’s perspective. A subjective There is also the matter of harm that can arise from
account of best interest does not assume independent cri- failing to intervene when there is a positive obligation to
teria but instead suggests that what makes a person’s life intervene. This is relevant when it comes to reporting child
go well depends, at least in part, on what matters to them abuse or maltreatment to child protective services. The
(i.e., their personal values). This subjective account of best moral imperative to notify state authorities where there is
interest is similar to the concept of autonomy, but it dif- child abuse or maltreatment can be conceived of as oblig-
fers in that a person’s preference or perspective does not atory beneficence (i.e., a duty to rescue). However, there
rely on having the cognitive capacities to use and weigh is also a strong argument that failing to intervene when
information. harm will predictably come to a person if we do not, consti-
In the IECMH context, the practitioner must be cog- tutes harm in and of itself. This calculation is made more
nizant of the best interests of both the adult patient and the complex by the uncertain but possible harms that may
child patient. Sometimes, the best interests of the adult and come from the intervention itself, which can make weigh-
child will align. For example, the child’s well-being is often ing these possible harms against the intended benefits
dependent on the parent’s well-being, and it is therefore more challenging. An excessively punitive response from
in the child’s interest for their parent to be well cared for. Child Protective Services resulting from a well-intentioned
Similarly, parenting can be made significantly more diffi- call from a worried IECMH practitioner is a typical
cult if the child has emotional difficulties, and therefore it example.
is in the parent’s interest for their child to be well cared There is often no discernible tension between the prin-
for. Sometimes, however, the best interest of the adult and ciples of autonomy, beneficence, and non-maleficence.
child will diverge, which we discuss below. That is, the patient and healthcare professional can be,
and often are, aligned in their assessment of the patient’s
best interest, their perspectives on avoiding harm, and
3.3 Non-maleficence agree on a course of action. Here, the professional’s obli-
gation to act for the good of the patient is supported by
Many are familiar with the maxim “first, do no harm,” the patient’s sense of being informed and able to choose
often incorrectly associated with the Hippocratic tradi- or refuse the recommended treatment, free from coercive
tion (Smith, 2005), which has been highly influential in influences.
Western medical ethics. Non-maleficence is the obligation When the three principles work in synergy like this, the
for the healthcare professional to avoid inflicting harm or sense of well-being that comes from patient empowerment
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LIM et al. 657

and self-determination adds to the benefit of the treatment 2015), which highlights the importance of cultivating self-
and underpins the working alliance. Yet this synergy is awareness when it comes to clinical decision-making. The
more likely to occur for some patient groups than others, IECMH practitioner might ask themselves when working
and it is to this issue of fairness and equity that we now with a family from a minoritized group: What identities
turn our attention. do I share and not share with this family, and how does
this influence my work with them? How does my privi-
lege influence my approach to clinical decision-making?
3.4 Justice If this family were from a dominant group, how would this
change my assessment?
The last of the four principles, and in some respects Non-discrimination, therefore, does not mean being
the most complex, is justice. Justice refers to fair, equi- blind to differences. In fact, the ethical practitioner has an
table, and appropriate treatment in light of what is owed obligation to be aware of differences and provide care in
(Beauchamp & Childress, 2013). In healthcare, this princi- a way that is tailored accordingly, recognizing the unique
ple is often applied to questions of resource distribution, needs and strengths that this difference entails. When
especially when the level of need outweighs the resources working with a family from a minoritized group, this can
available to meet that need, and decisions must be made to mean going beyond the ordinary level of care provided to a
prioritize the allocation of limited resources. family from the dominant group, especially when the sys-
This way of thinking about justice can be referred to tem itself presents barriers to access and quality of care.
as distributive justice, about which there is a rich philo- On an egalitarian account, this represents compensation
sophical literature (e.g., Olsaretti, 2018). One prominent for disadvantage, so that equality of opportunity can be
distributive justice framework is egalitarianism, which achieved.
emphasizes the equal treatment of people, based on their Anti-oppressive practice is another framework for pro-
equal moral status (Arneson, 2013). moting equal regard for human worthwhile recognizing
Influential twentieth century egalitarian philosopher the difference. Emerging from the discipline of social work
John Rawls highlighted fair equality of opportunity, which and informed by critical theory, anti-oppressive practice
implies an obligation to correct or compensate for certain is an approach to challenging unjust power structures in
disadvantages that restrict people’s opportunities to realize the health and social care professions (Burke & Harrison,
basic goals (Rawls, 1971). This kind of reasoning would be 1998). In the field of IECMH, “diversity-informed practice”
familiar to those IECMH practitioners who work in health has emerged as a language that captures this emphasis on
systems that focus on serving those who are most in need, resisting injustice by working in such a way that helps to
where resources are preferentially distributed to the most repair rather than repeat the sociopolitical and historical
disadvantaged members of the community. traumas experienced by infants and their families (Ghosh
While distributive justice may be most obviously appli- Ippen, 2012).
cable to public health and policy, it is also relevant at the Developed and disseminated under the auspices of the
clinical level, in that individual practitioners are obligated Irving Harris Foundation, the Diversity-Informed Tenets
to deliver fair, equitable, and appropriate care to patients. for Work with Infants, Children and Families are a set
For example, patients have a right to non-discrimination, of strategies and tools to integrate principles of diversity,
and practitioners have a correlative duty to uphold this equity, and inclusion into the work of IECMH practition-
right by providing appropriate care regardless of factors ers (St. John et al., 2013). The Tenets are underpinned by
such as age, gender, race, sexual orientation, disability, core concepts of diversity-informed practice, equity, inter-
religious affiliation, or socio-economic status. sectionality, privilege, reflective capacity and social justice
IECMH practitioners, as with other healthcare profes- (Tenets Initiative Irving Harris Foundation, 2018.), and are
sionals, can hold unintentional cognitive (unconscious a valuable guide to the translation of anti-oppressive the-
or implicit) biases that adversely influence the care they ory into practice. The Tenets include injunctions to reflect
provide to patients based on their membership of cer- on their own culture, personal values, and beliefs, to rec-
tain minoritized groups, especially where the practitioner ognize and respect nondominant bodies of knowledge, to
is not a member of the same group(s) (e.g., Chapman honor diverse family structures, and to support families in
et al., 2013; Marcelin et al., 2019; Zestcott et al., 2016). their preferred language.
These biases drive discrimination based on stereotypes, We anticipate that the application of the principle of jus-
and ultimately perpetuate health disparities between tice to clinical practice will continue to grow as an area of
groups. significant interest and debate as the field of IECMH comes
Unconscious bias is a common phenomenon in health- to terms with its role in structures of oppression and in
care professionals (FitzGerald & Hurst, 2017; Hall et al., opportunities for empowerment and emancipation.
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658 LIM et al.

4 THE SPECIAL ETHICAL infant themselves to society in general, as better mental

CHALLENGES OF INFANT AND EARLY health is associated with improved social and economic
CHILDHOOD MENTAL HEALTH participation. This utilitarian calculus adds urgency to
the need for mental health interventions in early child-
In a seminal paper from the WAIMH Task Force on Infant hood, as the earlier the intervention, the greater the
Mental Health, Lyons-Ruth et al. (2017) summarized four benefit.
key reasons to consider infancy as a unique developmen-
tal period that requires separate consideration from older
children and adolescents. In our view, these reasons cor- 4.2 The need for a competent workforce
respond with special ethical challenges that arise in the
course of mental health treatment with young children and Second, the WAIMH task force emphasized developmental
their families, which we have outlined below. differences in the manifestations of psychopathology in the
earliest years, which highlights the need for a specialized
workforce that has a deep understanding of these devel-
4.1 The vulnerability of the infant opmental differences and the competence to integrate this
understanding into their clinical practice. Competence is
First, the task force emphasized that because so much vital to the delivery of safe and effective healthcare and fea-
structural brain development in the earliest years of life is tures in various codes of ethics for healthcare professionals
susceptible to experiences of the infant and young child, (American Psychological Association, 2017).
young children bear unique vulnerability (Lyons-Ruth In the IECMH space, professional competence encom-
et al., 2017). Furthermore, in virtue of their complete and passes the knowledge, skills, behaviors, and values
utter dependence on the care of their caregivers, young required to provide an adequate level of care to young
children are helpless to act on their own behalf if the children and their families, and there are some well-
caregiving environment is failing them in some way. known published frameworks that articulate the standards
The young child’s vulnerability generates special expected of IMH practitioners (e.g., Association for Infant
responsibilities on the part of the caregivers (Lotz, 2013). Mental Health (UK), 2018; Michigan Association for Infant
If caregivers are unable to discharge their responsibilities, Mental Health, 2016).
then it falls to the community, and ultimately the state, to It is an ethical problem when practitioners attempt to
ensure that the infant receives adequate protection and provide treatment beyond their abilities, as a “bad” treat-
the provision of basic needs. IECMH practitioners can ment may cause harm to the patient and it is a betrayal of
form an important part of the network of state agencies the implicit contract between the professional, who claims
that take up the responsibility for infant welfare, and to possess special expertise, and the client, who engages the
provide a unique and valuable resource in relation to professional for the purpose of accessing that special exper-
advising on the infant’s social and emotional well-being tise. In the same way that you would not expect a bowel
and developmental needs. surgeon to agree to performing cardiac bypass surgery on
In their professional role, IECMH practitioners have a person with ischemic heart disease, you would not expect
an obligation to support caregivers in understanding and a mental health practitioner with no expertise in work-
fulfilling their responsibilities to their infant by working ing with young children and their families to agree to
therapeutically with the infant-caregiver relationship. Vul- undertake dyadic psychotherapy with a troubled child and
nerability is a precondition for harm, and by drawing on caregiver.
the principle of beneficence, it is clear that protecting the This comparison is intentionally exaggerated and binary
vulnerable from harm is a high-level obligation held by to highlight the ethical importance of and practicing
healthcare professionals. within one’s scope of competence. In reality, of course,
From a utilitarian perspective, there is a special ethical competency exists on a continuum and there is often
relevance to early intervention in mental health, as invest- no clear line between practitioners who are competent
ing in early childhood has the greatest benefit over the enough and those who are not, nor between basic and more
child’s lifetime (Heckman, 2008). By utilitarian reasoning, advanced skills. For example, when does empathic listen-
one ought to do whatever produces the greatest benefit ing, which most IECMH practitioners should be able to
for the greatest number. Given the convergence of eco- do, move into psychotherapy practice reserved for licensed
nomic, neurobiological and child development research mental health clinicians? Families can benefit from basic
(Knudsen et al., 2006), there is a strong ethical argument therapeutic interventions and might not necessarily pre-
to be made for resource allocation to IECMH services. fer practitioners with extensive training over practitioners
The benefits of early intervention extend beyond the with fewer competencies with whom they have developed
 10970355, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/imhj.22055 by Cochrane Portugal, Wiley Online Library on [21/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
LIM et al. 659

trust and a supportive working alliance (see Author, This possible for the interests of two or more patients to con-
Issue for a detailed case study). flict, and this presents the practitioner with a dilemma, as
Naturally, ethical complexity arises when there is clin- acting in the interest of one patient may be contrary to the
ical need in the absence of a well-trained workforce. For interest of another.
example, in areas of low resourcing, where there is very As mentioned above, in IECMH practice, it is very often
little IECMH expertise available, those in need may have the case that the interests of the caregiver and their infant
no choice but to accept the help of practitioners who have align, as both benefit from dyadic interventions aimed at
received less training and supervision. In this case, some- improving the parent-child relationship, and the practi-
thing may well be better than nothing, and rigid adherence tioner can discharge their obligation of beneficence to both
to scope of practice could be unnecessarily withholding caregiver and infant by providing this intervention. How-
and detrimental to the well-being of young children and ever, there can be malalignment of interests, such as when
their families—the perfect can be the enemy of the good it would be better for the child to remain in the care of their
enough. And yet, from a justice perspective, it is not fair parents, but the parents are unwilling or unable to provide
or equitable that those with fewer resources do not have this care (see Author, This Issue). Conversely, there may be
access to the same level of IECMH care than those with situations where it would be better for the child to spend
more resources. Clearly, if it is possible to refer a family to time with both parents, but each parent feels distressed by
a more competent practitioner, or to seek supervision or contact with the other, and so will not share custody of the
guidance from a more competent practitioner, then this is child.
the ethically preferred course of action. Of course, these examples are simply illustrative, and
it is possible that the care provided by unwilling parents
could be more detrimental to the child than placing the
4.3 Caring for caregivers child in the care of more accepting caregivers, or that the
distress caused to separated parents by a shared custody
Third, they emphasized the relative importance of stres- outweighs the benefit to the child. Yet, the fact that such
sors on caregivers during the developmentally vulnerable dilemmas exist and need working through illustrates the
first 3 years of life. In many respects, the infant’s wellbeing potential for conflicting interests and the inadequacy of
is contingent upon the caregiver’s wellbeing, a principle a “what’s good for the caregiver is good for the infant”
memorably captured by the remark by Winnicott (1960) position.
that “there is no such thing as an infant. . . wherever one That said, inadequate attention paid to the well-being
finds an infant one finds maternal care, and without mater- of caregivers is also detrimental to the well-being of the
nal care there would be no infant” (p. 587). The ethical infant, given the dependence of the infant on the capacity
implications of this interdependence include conceptu- of the caregiver to provide sensitive and responsive care,
alizing the infant in their relational context and being and the interest the infant has in remaining in their family
attentive to the needs of caregivers. For example, as far of origin, embedded in culture and community. A balance
as the IECMH practitioner has obligations of beneficence must be struck between the individual needs of the infant,
and non-maleficence to the infant, these obligations must the individual needs of the caregiver, and the needs of the
extend to the caregiver. This is not to downplay the indi- infant-caregiver relationship.
vidual value of the caregiver as a person in their own right
but to emphasize the clinical reality that if one intends to
help the infant, one must look to help their caregiver. 5 THE ROLE OF INFANT RIGHTS

In 2014, the World Association of Infant Mental Health

4.4 The problem of multiple patients (WAIMH) developed a Position Paper on the Rights of
Infants, which sought to draw attention to the particular
Finally, they emphasized the need for modes of mental needs and rights of the child in the first years of life, in addi-
health intervention that involve both the infant and the tion to those specified by the United Nations’ Convention
caregiver. The problem of multiple patients is perhaps the on the Rights of the Child (CRC) (Keren, 2014).
most vexed issue when it comes to clinical ethics in IECMH The notion of children’s rights has long been contro-
practice. In a typical practitioner-patient relationship, the versial in the philosophical literature (Archard, 2015).
interests of the patient are clearly primary and override the Historically, rights are something that the rightsholder
interests of other people who may be peripherally involved claims against another party when their liberties have been
in treatment, such as family members or other profes- impinged (Griffin, 2008). This negative account of rights
sionals. However, where there are multiple patients, it is has limited application to children, whose liberties are
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660 LIM et al.

frequently and necessarily constrained in the course of diversity-informed practice and decolonizing psychologi-
providing responsible parental care. However, a positive cal discourse more broadly.
account of rights has more relevance to children, who, it Theoretical challenges and controversy notwithstand-
has been argued, are morally entitled to certain protec- ing, the infant rights framework have become another
tions and provisions by virtue of their vulnerability and conceptual tool with which IECMH practitioners can
dependence on others (United Nations General Assembly, navigate ethical conundrums. By elevating the moral sta-
1989). tus of infants and articulating their basic interests, an
Rights come with correlative duties, held by other par- infant rights framework provides one of the most defini-
ties who have a moral responsibility to the rightsholder tive forms of ethical guidance available to the profes-
(Lyons, 1970). For example, the child has a right to safety sion. There remains much debate to be had about the
from danger, and the parent has a duty to protect the child universality of infant needs, development, and behav-
from danger, by virtue of their special moral relationship ior across different cultural contexts, and this will likely
with the child. A rights-based relationship is a serious form influence the acceptability and reach of the infant rights
of moral relationship, where a moral wrong has occurred framework.
if a right has been violated (Feinberg, 1970). For example,
if the child is not kept safe from danger, the parent whose
duty it was to provide protection has committed a moral 6 CONCLUSION
(and now, in many cases, legal) wrong to the child.
The rationale for WAIMH’s Position Paper was four- Ethics is fundamental to good clinical practice in IECMH.
fold: (1) The CRC is not informed by the latest scientific There is a vast literature that can help broaden the ethical
understanding of the impact of early experience on brain awareness of IECMH practitioners and guide the develop-
development; (2) the CRC does not focus on what is unique ment of their essential ethical skills. Of particular note are
about the needs of children in the first years of life, nor the ethical guidelines and codes that have been developed
does it account for the infant’s nonverbal means of com- for healthcare professionals working with young children
munication; (3) the needs and rights of infants are often and their families, which is explored in detail in Author,
overlooked when competing with the needs and rights of this issue). However, this written guidance should always
older children and adults; and (4) many societies pay inad- be combined with honest personal reflection and robust
equate attention to the need of vulnerable infants despite discussions with peers, supervisors, and mentors. Indeed,
the CRC (Keren, 2014). a trusting reflective supervisory relationship is an ideal
The Position Paper has generated significant interest and context in which to explore complex ethical issues with
debate (e.g., Gaskins & Keller, 2019; von Klitzing, 2019a, care and intentionality (Van Horn, 2019). See Author (this
2019b). Rights have been the subject of rigorous cultural issue) for a fuller analysis of the intersection of ethical
critique (e.g., Brown, 1997; Donnelly, 1984), as in many principles, codes of ethics, and reflective supervision.
non-Western cultures, the concept of rights, let alone chil- The struggle of working through ethical challenges
dren’s rights, is a foreign one that has been introduced by together is not something to be avoided, but something
global powers. Indeed, the children’s rights movement has to be embraced. Indeed, the most ethically responsible
been characterized as a manifestation of cultural impe- approach is “to reflect, re-think, acknowledge uncertainty
rialism (Faulkner & Nyamutata, 2020; Hanson & Peleg, and competing values, and sometimes even to agonise and
2020; Reynaert et al., 2009). In this vein, the promulgation struggle” (Gillam, 2015, p. 10). We hope that this article
of infant rights has drawn pointed criticism from cultural has illuminated some of the key concepts and principles
anthropologists who warn that the universal basic needs in clinical ethics as they apply to IECMH practice and will
of infants, which form the basis of arguments for the exis- stimulate a bigger conversation in the profession around
tence of infant rights, are not as universal as they are how to support each other to maintain high ethical stan-
asserted to be. dards in our work with young children and their families.
Gaskins et al. (2017) argue that such normative claims
about childhood and childrearing have been made by AC K N OW L E D G M E N T S
“academic experts. . . [who] have reached ‘scientific’ con- The authors thank Professor Lynn Gillam from the Uni-
clusions about ‘universal’ behavior by studying a narrow versity of Melbourne who provided comments on earlier
range of human behavior that primarily reflects Western drafts of this paper. No funding was received for this
thought and practice, and then overgeneralizing those con- project.
clusions to the rest of the world” (p. 321). The cultural Open access publishing facilitated by Monash Univer-
critique of rights deserves ongoing consideration in the sity, as part of the Wiley - Monash University agreement
field of IECMH, particularly in light of the move toward via the Council of Australian University Librarians.
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LIM et al. 661

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