Abstract

To date, extremely limited research has focused on the ethical aspects of clinical neuropsychology practice in Latin America. The current study aimed to identify the frequency of perceived ethical misconduct in a sample of 465 self-identified neuropsychology professionals from Latin America in order to better guide policies for training and begin to establish standards for practitioners in the region. Frequencies of neuropsychologists who knew another professional engaging in ethical misconduct ranged from 1.1% to 60.4% in the areas of research, clinical care, training, and professional relationships. The most frequently reported perceived misconduct was in the domain of professional training and expertise, with nearly two thirds of participants knowing other professionals who do not possess adequate training to be working as neuropsychologists. The least frequently reported perceived misconduct was in the domain of professional relationships. Nearly one third of participants indicated that they had never received formal training in professional ethics.

Introduction

Neuropsychology is an applied branch of the psychological sciences concerned with the behavioral expression of brain dysfunction (Lezak, Howieson, Loring, Hannay, & Fischer, 2004). Although neuropsychology as a discipline is relatively new, its roots can be traced back a few thousand years (Finger, 2000). Described as having a long history but a short past, neuropsychology extends back to the use of trepanations in South America (Verano, 2003), and the observations made by the ancient Greeks and Romans about anatomic localizations of functions in the brain (Hartlage & Long, 2009). The contributions of European physiologists in the mid-19th century laid the foundation for the development of neuropsychology as a discipline in the first part of the 20th century in Europe, North America, and the Soviet Union (Hallett, 1993; Puente, 1989).

The development of neuropsychology in Latin America dates to the turn of the 20th century, when the first manuscripts and dissertations on the topic of brain–behavior relationships were published in psychiatry and neurology journals in the region. Progress in the development of neuropsychology in Latin America has been substantial in the last 60 years, reflected by the exponential increase of publications and journals related to the topic in the region (Ardila, 1990; Vera-Villarroel, López-López, Lillo, & Silva, 2011).

The seminal contributions to the theoretical argument of neuropsychology as a distinct field of professional activity within psychology in Latin America were pioneered in the first half of the 20th century by scientists from multiple countries. Researchers from Peru, Uruguay, Argentina, Mexico, Chile, Colombia, Brazil, Honduras, Cuba, and Bolivia led the way (Cáceres Velásquez, 2009). Many of these individuals worked within the theoretical paradigms of such established neuropsychologists as A. R. Luria (Soviet Union), H. Hecaen and J. de Ajuriaguerra (France), and A. Benton, H. Goodglass (USA) (Ardila, 1990; Dansilio, 2009; Garcia de la Cadena et al., 2009). The translation and publication of A. R. Luria's neuropsychology texts into Spanish in the late 1970s made many of his classic contributions to the field more accessible and helped to support the study of brain–behavior relationships in Latin America (Galeano Toro, 2009). Around the same time, further collaborative relationships developed between Latin American neuropsychology researchers and their international colleagues (Fernández Garcia et al., 2009), culminating in the pivotal meetings of the Pan-American Congress of Neuropsychology in Bogota, Colombia, in 1981, and the 11th Annual Meeting of the International Neuropsychological Society in Mexico City in 1983 (Ardila, 1990).

Historically, the development of clinical neuropsychology in Latin America has been hindered by a number of factors. Political turmoil and armed conflict, lack of economic and instrumental resources, paucity of educational and clinical training opportunities (resulting in too few qualified professionals), and lack of regional coordination with regard to research and regional standardization of programs for professional training acted as barriers for progress (Cáceres Velásquez, 2009; Garcia de la Cadena et al., 2009; Ocampo Barba, 2009; Rosas Diaz, Tenorio Delgado, & Gárate Maudier, 2009). Nevertheless, the practice of neuropsychology has flourished in the region in recent decades, and professional neuropsychological societies have been created in many Latin American countries (Galeano Toro, 2009; Garcia de la Cadena et al., 2009; Hazin, Bizarro, & de Almeida, 2011; Labos, 2009).

Given lack of standardization of the practice of neuropsychology across Latin American countries (Garcia de la Cadena et al., 2009), neuropsychologists in this region of the world possess a diverse training and educational profile. Traditionally, neuropsychological work was conducted in Latin America by professionals with training in not only psychology, but also medicine (e.g., neurology, neurophysiology, neurosurgery, pediatrics, gerontology, physical medicine and rehabilitation, psychiatry), and other fields such as speech pathology, biology, and education (Fernández Garcia et al., 2009; García de la Cadena et al., 2009; Rosas Diaz et al., 2009). Additionally, the academic level of training among practicing neuropsychology professionals may include those with bachelor's-level degrees. Some Latin American neuropsychologists have master's degrees, but few have doctoral qualifications (Fernández Garcia et al., 2009; García de la Cadena et al., 2009).

Most countries in Latin America have laws which regulate the practice of psychology, and all countries have ethics codes. These codes are documents which were developed via expert consensus by professional psychological organizations, associations, and societies and apply to all practicing psychologists (Consoli, Ardila, & Ferrero, 2012). Such documents state the main ethical principles, outline the main responsibilities of psychologists, as well as establish what actions and behaviors are considered acceptable or unacceptable in the practice of psychology (including those involved in neuropsychology). Given the diverse nature of practice settings (e.g., academic, medical, private, public, etc.) and activities (e.g., assessment, rehabilitation/treatment, research, teaching, etc.) in which neuropsychology professionals may work, ethics codes aim to create some protection for patients and their families and to provide some support for the professionals in their ethical decision-making (Consoli, Ardila, & Ferrero, 2012).

Still, ethical concerns in the practice of clinical neuropsychology are common (Bush & Drexler, 2002), although to date these have only been reported in the literature from Western countries (i.e., the USA, Australia), where neuropsychology is a well-developed field. Binder and Thompson (1995) published one of the first articles to address ethical concerns in neuropsychology, making several recommendations to neuropsychologists for engaging in ethical professional activity. These included practicing, teaching, and researching only within the bounds of one's competence; obtaining appropriate training and certification; avoiding multiple relationships with clients; using only validated measures in testing; not releasing raw test data to individuals lacking the qualification to accurately interpret their meaning (i.e., lawyers in forensic psychology cases); protecting confidentiality of clients; and avoiding harm. More specifically in the context of neuropsychology ethics in rural communities, Allot and Lloyd (2009) offered recommendations for identifying and resolving ethical dilemmas related to competence, multiple relationships, and confidentiality. In a similar vein, Brickman, Cabo, and Manly (2006) discussed ethical questions concerning cross-cultural issues, suggesting that culture must be taken into consideration in neuropsychological testing. They further recommended that race- and ethnicity-specific normative data are needed at times for accurate assessment and that multicultural training be strongly encouraged for all psychologists and required for those who provide supervision. Finally, Bush, Grote, Johnson-Greene, and Macartney-Filgate (2008) presented the views of three neuropsychologists on ethical issues that continue to be a problem, highlighting the continued importance of training and competency.

Despite these studies on the ethical practice of neuropsychology generally, there is extremely scant—if any—published information related to the ethical aspects of neuropsychology in Latin America. An assessment of the current perceptions of various types of ethical misconduct by neuropsychology professionals in Latin America can assist in the formulation of specific guidelines and policies for training in this global region (Sweet & Moberg, 1990). Therefore, the goal of this study is to identify the frequency of perceived ethical misconduct by neuropsychology professionals from Latin America.

Method

Participants

The study was descriptive and utilized a multinational sample of self-identified psychologists who worked in the field of neuropsychology in Latin America. Inclusion criteria included: (1) being over 18 years of age; (2) having at least a Bachelor's degree in psychology; (3) currently residing in Latin America; and (4) either (a) engaging in the specialty practice of neuropsychology (i.e., being involved in neuropsychological assessment/diagnosis, psychotherapy/cognitive rehabilitation, teaching/training [of others] in neuropsychology, or research in neuropsychology) or (b) calling themselves a “neuropsychologist.”

A total of 535 individuals met the inclusion criteria. Of these, 465 participants provided responses to all 20 of the ethics survey questions (completion rate of 86.9%). Chi-squared and t-tests were performed to examine the differences between participants who completed the survey (n = 465) and those who provided incomplete data (n = 70), for gender, age, having completed a Doctorate degree, and number of years in neuropsychology practice. Participants showed no difference in the number of years of experience, t(515) = −1.628, p = .104, gender, χ2(1, n = 535) = 1.145, p = .285, or having a Doctorate degree, χ2(1, n = 535) = 1.522, p = .217, but were significantly different in terms of age, t(533) = −3.590, p < .001, with participants who dropped out of the survey being older (M = 39.99, SE = 1.247) than those who completed the survey (M = 35.59, SE = 0.437). Because these two groups were generally comparable on the majority of demographics, participants with incomplete data were excluded from the current analyses, yielding a complete data set and a final n = 465.

The final sample was 71% female and the mean age was 35.6 years (range 21–73 years). Participants were from Colombia (n = 194; 41.7%), Mexico (n = 114; 24.5%), and Brazil (n = 96; 20.6%), with 13.2% of the sample (n = 61) from other Latin American countries and territories including Argentina, Bolivia, Chile, Cuba, Ecuador, Guatemala, Peru, Puerto Rico, Uruguay, and Venezuela. In terms of setting where these neuropsychology professionals work, 24.3% indicated that majority of their neuropsychological work takes place in a private practice (n = 113), 20.6% at a university (n = 96), 16.3% at a hospital (n = 76), 14.8% at private clinics (n = 69), 5.8% in a school system (primary and secondary; n = 27), and 17.4% in other settings (for profit and non-profit rehabilitation centers, medical centers, and others; n = 81). Participants' average number of years of experience in neuropsychology was 6.7 (range 1–36). One hundred and one participants (21.7%) reported having Doctorate degrees.

Instruments

As the first step in ethics survey development, the researchers conducted a comprehensive literature review on the topic of professional ethics in psychology and identified common ethical misconducts in the field. A brief survey instrument was created, which consisted of questions partly derived from topics posed by Pope and Vetter (1992), which assessed respondents' perception of ethical misconduct by their colleagues in the areas of training, skills, and expertise; clinical care; research/publications; and professional relationships (with patients, students, and colleagues). Subsequently, these survey questions were shown to a panel of experts and professors in neuropsychology from Latin America in order to assess their linguistic, cultural, and professional appropriateness, as well as applicability and value. The corpus of questions was developed in Spanish and was adapted for use in Portuguese and English by bilingual researchers using Chapman and Carter's (1979) methodology, which employed back-translation into Spanish, with any discrepancies resolved mutually. After incorporating the panel's feedback, the final questions were entered into an online survey platform (www.surveymonkey.com). A brief pilot study was carried out to assure accuracy and feasibility of the survey. The survey questions asked the participants to respond yes or no to a series of statements which began as “Other neuropsychologists I know who work in my country …” and presented behaviors which could constitute potential ethical misconduct (Table A1). The purpose of phrasing the survey questions this way was in order to minimize the possible influence of social desirability and to solicit more honest responses, since individuals may be less likely to report their own improprieties or potential ethical misconduct. Participants from Spanish-speaking countries were presented the survey in Spanish (Table A2) and participants from Brazil in Portuguese (Table A3). This project was approved by the Ethics Committee of the University of Deusto.

Procedure

The active study phase, consisting of recruitment and data collection, took place from July to December of 2013. Recruitment was conducted by sending an email inviting participation from neuropsychology professionals in various local, national, and regional psychological and neuropsychological associations prominent across Latin America (e.g., Sociedad Latinoamericana de Neuropsicología, Colegio Colombiano de Psicólogos, Sociedad Mexicana de Psicología, etc.). Additionally, leaders in the area of neuropsychology in Latin America were contacted via email with the study details, the hyperlink to the online survey, and a request for their assistance in recruiting neuropsychology professionals as participants. Use of such sampling method precluded the determination of a response rate. No incentive to participate was offered. Upon the conclusion of the data collection period, participant data were downloaded from the secure server directly into an SPSS file, which prevented data entry errors.

Statistical Analysis

Analyses were conducted using SPSS 22.0 (IBM Corp., Armonk, NY). Responses to the survey questions were expressed as percentages. Chi-squared (χ2) and t-test analyses were used, as appropriate, to identify potential differences in demographic and neuropsychology practice variables between those who completed the survey and those who did not. A significance level of 5% (α < 0.05) was used for the analyses.

Results

Respondents reported knowing others in the field of neuropsychology who engage in ethical misconduct with regard to the following general domains: having proper training and expertise in their work as neuropsychologists, the provision of adequate clinical care, research activities, and relationships with patients, students, and colleagues. Perceptions of ethical misconduct in these areas ranged from 1.1% to 60.4%.

In the domain of professional training, skills, and expertise (Table 1), the overall average percentage of reports of ethical misconduct was 46.7%, making the behaviors of working as and advertising/presenting oneself as a neuropsychologist the most commonly occurring perceived unethical behaviors. Additionally, in this category, 22.8% of respondents indicated that they knew of someone who in the practice of neuropsychology testified in court without the appropriate expertise.

Table 1.

Perceived ethical misconduct regarding training and expertise: percentage of self-identified psychologists who reported knowing others in the field who engage in these acts

Perceptions of ethical misconduct Perentage 
Training/skills/expertise 
 Do not possess adequate training and experience to be working as neuropsychologists 60.4 
 Advertise and present themselves as neuropsychologists but have not actually had the proper training or expertise 56.8 
 Testify in court when they do not have the appropriate expertise to do so 22.8 
 Average 46.7 
Perceptions of ethical misconduct Perentage 
Training/skills/expertise 
 Do not possess adequate training and experience to be working as neuropsychologists 60.4 
 Advertise and present themselves as neuropsychologists but have not actually had the proper training or expertise 56.8 
 Testify in court when they do not have the appropriate expertise to do so 22.8 
 Average 46.7 

The next most frequently reported domain of unethical behaviors dealt with provision of clinical care (overall average 31.3%; Table 2). The most frequently identified unethical behavior in this category was the lack of appropriate training or skills to work with culturally diverse patients. Additionally, over one third of participants indicated that they knew others who withheld or provided substandard services to patients who were unable to pay for them, based diagnostic decisions on inadequate data, as well as provided evaluation results in a manner that was difficult to understand (30.8%, 34.8%, and 37.8%, respectively).

Table 2.

Perceived ethical misconduct regarding clinical care: percentage of self-identified psychologists who reported knowing others in the field who engage in these acts

Perceptions of ethical misconduct Perentage 
Clinical care 
 Do not have the skills or training to work with patients who are culturally different from them 46.5 
 Provide results of neuropsychological evaluations in such a way that patients or other professionals are not likely to understand 37.8 
 Base diagnostic conclusions on inadequate data or ignore important sources of data 34.8 
 Withhold services from or provide substandard services to patients who are unable to pay for services 30.8 
 Discuss information about their patients with people outside of their professional practice who are not involved in treating the patient 27.1 
 Provide interventions with questionable effectiveness or that may even be harmful to patients 26.5 
 Keep silent or not refer appropriately when important medical or psychological issues arise 15.3 
 Average 31.3 
Perceptions of ethical misconduct Perentage 
Clinical care 
 Do not have the skills or training to work with patients who are culturally different from them 46.5 
 Provide results of neuropsychological evaluations in such a way that patients or other professionals are not likely to understand 37.8 
 Base diagnostic conclusions on inadequate data or ignore important sources of data 34.8 
 Withhold services from or provide substandard services to patients who are unable to pay for services 30.8 
 Discuss information about their patients with people outside of their professional practice who are not involved in treating the patient 27.1 
 Provide interventions with questionable effectiveness or that may even be harmful to patients 26.5 
 Keep silent or not refer appropriately when important medical or psychological issues arise 15.3 
 Average 31.3 

The area of research and publishing emerged as the next most frequently reported domain of ethical misconduct (overall average of 25.7%; Table 3). Participants indicated that the most commonly perceived behavior in this category was taking credit for authorship without making a significant contribution to the publication, followed by presenting students' research as one's own. Less frequently endorsed was the perception, indicated by 12% of participants that they knew someone who misrepresented research results or faked data for their professional advancement.

Table 3.

Perceived ethical misconduct regarding research and publications: percentage of self-identified psychologists who reported knowing others in the field who engage in these acts

Perceptions of ethical misconduct Percentage 
Research/publications 
 Appear as authors on publications where they have not made a significant contribution 35.9 
 Present as their own research done by their students 28.8 
 Misrepresent the results of their research or create fake data in order to publish articles or give professional presentations 12.5 
 Average 25.7 
Perceptions of ethical misconduct Percentage 
Research/publications 
 Appear as authors on publications where they have not made a significant contribution 35.9 
 Present as their own research done by their students 28.8 
 Misrepresent the results of their research or create fake data in order to publish articles or give professional presentations 12.5 
 Average 25.7 

Finally, in the area of professional relationships, the average percentage was 14.6% (Table 4). The most commonly reported perception, endorsed by nearly a quarter of participants, was that of negligence or disrespect toward students. This was followed by a slightly lower number of respondents who indicated knowing someone who took deliberate actions to damage their colleagues' reputation. Around one in seven participants indicated knowing others who interact with patients outside of their professional relationship (15.5%) or accept alternative forms of payment (13.5%). In questions that dealt with perception of inappropriate relationships with patients and students, 1% and 8.8% of participants indicated knowing of someone who engaged in sexual relationship with them, respectively.

Table 4.

Perceived ethical misconduct regarding professional relationships: percentage of self-identified psychologists who reported knowing others in the field who engage in these acts

Perceptions of ethical misconduct Percentage 
Professional relationships 
 Are negligent and/or disrespectful to their students 24.9 
 Take deliberate actions to damage the reputation of their colleagues 23.7 
 Know/interact with their patients outside of their professional relationship with the patient 15.5 
 Accept forms of payment other than money for their services from patients 13.5 
 Engage in sexual relationships with their students 8.8 
 Engage in sexual relationships with their patients 1.1 
 Average 14.6 
Perceptions of ethical misconduct Percentage 
Professional relationships 
 Are negligent and/or disrespectful to their students 24.9 
 Take deliberate actions to damage the reputation of their colleagues 23.7 
 Know/interact with their patients outside of their professional relationship with the patient 15.5 
 Accept forms of payment other than money for their services from patients 13.5 
 Engage in sexual relationships with their students 8.8 
 Engage in sexual relationships with their patients 1.1 
 Average 14.6 

In addition to reporting whether participants knew someone who engaged in unethical practices, participants also indicated whether they had received formal ethics training. Three-hundred and one (64.7%) participants indicated that they had received formal training on the topic of professional ethics, whereas 164 (35.3%) responded that they had not received this training (Fig. 1).

Fig. 1.

Percentages of responses to the question “Have you ever received formal training on the topic of professional ethics?”

Fig. 1.

Percentages of responses to the question “Have you ever received formal training on the topic of professional ethics?”

Discussion

To the best of our knowledge, this is the first study to address ethical issues in the practice of neuropsychology in Latin America. The current study aimed to identify the frequency of perceived ethical misconduct by neuropsychology professionals from Latin America in order to better guide policies for training and begin to establish standards for practitioners in the region. Self-identified psychologists engaging in neuropsychological activities in Latin America reported perceptions of ethical misconduct ranging from 1.1% to 60.4% in the areas of providing adequate clinical care, research activities, and relationships with patients, students, and colleagues. The most frequently reported perceived ethical misconduct was in the domain of professional training, skills, and expertise, with nearly two thirds of participants knowing other professionals who do not possess adequate training and experience to be working as neuropsychologists. The least frequently reported perceived ethical misconduct was in the domain of professional relationships. Nearly one third of participants indicated that they had never received formal training on the topic of professional ethics.

The most commonly occurring perceived ethical misconducts were in the domain of professional training, skills, and expertise. Within this domain, lacking training and experience to be working as a neuropsychologist was the most commonly reported behavior. Training and competency have been repeatedly identified as primary ethical challenges facing neuropsychologists (Bush et al., 2008; Grenyer & Lewis, 2012). Bush and colleagues (2008) discussed inconsistencies in training and qualifications for neuropsychologists, highlighting the lack of widely accepted training standards and emphasizing that licensure does not necessarily indicate competence. Grenyer and Lewis (2012) summarized the most frequently reported complaints from the public made to the New South Wales Psychologists Registration Board and found that professional incompetency was the second most frequently reported category of complaint. Indeed, the relative commonness of this ethical misconduct in the current sample seems to be reflected in other global regions as well.

The next most frequently reported domain of perceived unethical behaviors in the present study dealt with provision of clinical care, including lacking the skills or training to work with culturally diverse patients, basing diagnostic decisions on inadequate data, using questionable or harmful interventions, and withholding or providing substandard services to patients who are unable to pay.

The issue of lacking proper training to work with culturally diverse patients was the most common in this domain and has been previously addressed in ethical guidelines from the USA which highlight the obligation for neuropsychologists to seek out cross-cultural training and to consult with cultural experts when necessary (Brickman, Cabo, & Manly, 2006). Like the present study, previous literature has also identified ethical concerns related to problematic assessments, diagnostic conclusions based on inadequate data, and questionable or harmful interventions (Grenyer & Lewis, 2012; Pope & Vetter, 1992). Grenyer and Lewis (2012), for example, found that 3%–4% of ethical complaints addressed inappropriate or insufficient assessment, incorrect diagnoses, and inadequate treatment. Similarly, Pope and Vetter (1992) reported that 3% of ethical concerns in the USA were related to questionable or harmful interventions. However, the lack of normative data for neuropsychological instruments in Latin America has been reported before (Puente & Puente, 2009) and is possibly one of the principal barriers to providing accurate diagnostic information in the region. The global region of Latin America is a large mosaic of nations, with high within-group heterogeneity, which includes a substantial proportion of indigenous populations (Pontón & Ardila, 1999; Puente & Puente, 2009). This consequently requires assessment instruments normed in individual countries in order to improve the clinical impression and diagnostic data, which will in turn inform more effective intervention strategies (assuming that the clinicians have access to and are trained in the use of such instruments and interpretation of obtained results).

Research and publishing emerged as the next most frequently reported domain of perceived ethical misconduct. The more common types of research misconduct in this study involved unjustified authorship on manuscripts and taking credit for a student's work. These forms of ethical misconduct have been identified in previous research (Costa & Gatz, 1992; Goodyear, Crego, & Johnston, 1992). Flanagin and colleagues (1998) reported that 11%–25% of authors in a selection of medical journals were honorary authors (i.e., those individuals who were listed as authors but who have not met authorship criteria), whereas Dotson and Slaughter (2011) found that 14.3% of publications in pharmacy journals in 2009 had honorary authors. The higher education system in Latin America in recent years has been increasingly modeled after that in the USA (Arredondo Vega, 2011; Molina, 2008), with high pressure for professors to increase the quantity of their research output, since their financial future may potentially depend on the number of publications. This in turn may incentivize behaviors which grant authorship on academic papers where no significant contribution has been made. However, it is also possible that the guidelines on authorship, such as those established by the International Committee of Medical Journal Editors (1997), are not clear or known to some neuropsychology professionals in Latin America. This could also give rise to claims of authorship after merely providing mentorship to a student or rudimentary advice or comments on their project. Although knowing someone who misrepresented research results or faked data for their professional advancement was the least common of offenses in the category of research/publications, Leary (2012) has argued that falsification of data is one of the most flagrant forms of research misconduct. For example, fabricating or distorting the results of treatment studies may lead to the clinical use of ineffective treatments.

The final domain assessed in the present study was professional relationships. Fortunately, the most serious offenses in this category—having sexual relations with students or patients—were also the least commonly endorsed. Still, it is troubling that nearly 1 in 10 psychologists in Latin America knows other psychologists who engage in sexual relations with a student. Past studies that have examined the prevalence of this ethical misconduct also report relatively low incidence but warn that it may be difficult to know the true extent to which it occurs, as reports could be biased by selective memory, retrospective studies, unrepresentative studies, and secondary sources (Pope & Vetter, 1992). In most Latin American universities, professors and students do not receive the training on sexual or other types of harassment, and generally there are no mechanisms or procedures in place for students to report such behaviors or be shielded from prosecution for filing a complaint (Association of Canadian College and University Ombudspersons, 2013). Reluctance by students to report misconduct has been reported by other authors (Hrabak et al., 2004). However, if reported, generally there are no protections in place for the student making the report, and the decision-making and investigation (if it ever takes place) likely fall on the department chair. Due to potential conflicts of interest and professional relationships, such complaints are not likely to result in serious disciplinary action (Osorio & Fernández, 2010) and thus may result in a seemingly elevated perception of inappropriate sexual behaviors with students. More effective policies for addressing such misconduct may be needed on an institutional level among neuropsychologists. It has previously been reported that attention drawn to the issue of corruption in medical school administration in Mexico by published survey results helped put into action a plan to curb such damaging practices (Paredes-Solís et al., 2011). One of the goals of the present study is likewise to highlight the perceptions of potentially unethical behaviors in the previously unstudied geographic region with the purpose of beginning a dialogue about the origin of such perceptions as well as possible routes to their remediation.

Implications

The frequency with which participants reported perceived ethical misconduct is a cause for concern. For nearly all of the scenarios presented, at least 1 in 10 respondents knew other neuropsychologists who engaged in the behavior described, often with much higher frequencies. Although the current study provides an idea of the regularity of ethical misconduct, it does not tell us why or how to discourage neuropsychologists from behaving in these ways. Perhaps a contributing factor to the high reports of perceived ethical misconduct is the limited standardization of the field which in turn leads to a lack of formal training in professional ethics in some regions of Latin America.

Although many countries in Latin America have laws and ethics codes which regulate the practice of psychology, the presence of these laws, as well as training and education of neuropsychologists in these countries vary greatly (Garcia de la Cadena et al., 2009). Few practicing neuropsychology professionals in Latin America have doctoral degrees and instead practice with bachelor's or master's degrees (Fernández Garcia et al., 2009; García de la Cadena et al., 2009). In the present study, only about one in five professionals reported having a Doctorate degree. In addition, neuropsychological work has been conducted in Latin America by professionals with training across many fields including psychology, neurology, pediatrics, gerontology, physical medicine, speech pathology, biology, and education (Fernández Garcia et al., 2009; García de la Cadena et al., 2009; Rosas Diaz et al., 2009). Perhaps as a direct result of the lack of standardization in the field in Latin America, a substantial percentage (35.3%) of respondents in the present study indicated that they have not had formal ethics training. Although the professional psychology associations in Latin America have formalized ethics codes to offer protection to patients, their families, and neuropsychology professionals by providing guidance in their ethical decision-making, the mere existence of such codes is not enough—professionals must receive formalized training about such codes in order to know when and how to follow such guidelines. Academic programs in psychology in Latin America generally include ethics coursework as part of the undergraduate curricula, and such training is absent from graduate-level programs. Moreover, in order to engage in professional practice of psychology (including neuropsychology) in most of the countries in Latin America only an undergraduate degree in psychology is required. It may be important to include more specific ethics courses on the graduate level, as well as strengthen or expand the ethics coursework offered on the undergraduate level, which can focus on specific questions that are likely to be encountered during clinical and research practice in the region.

Another potential explanation for the relatively high perception of ethical misconduct in this study is that the ethical standards reflected in this survey may not be fully consistent with the values and practices in Latin America. Many ethical standards in the USA, for example, were developed in response to situations that arose locally, as was the case of creating mandated reporting following the murder of Tatiana Tarasoff (Bersoff, 2014). Therefore, context and issues specific to Latin American cultures should be taken into consideration in discussions of professional ethics for neuropsychologists. However, like the American Psychological Association's [APA] Code of Conduct (APA, 2002), formalized codes of ethics of various countries across Latin America state the importance of general principles as the cornerstone of ethical conduct and include specific standards about competence, professional relations, confidentiality, research, fees, and so on (Ferrero & Andrade, 2008). Despite these similarities of the codes, the role of culture is integral to the understanding of various constructs of ethical behavior (Pipes, Blevins, & Kluck, 2008). More research is clearly needed both to identify causes for objective and perceived ethical misconduct as well as potential remediation in Latin America.

Limitations and Future Directions

The results of the present study must be viewed in light of a number of limitations, some of which may be related to the way the survey instrument was constructed. First, the participants were not asked whether or not they themselves engage in ethical misconduct, but whether they know others in the field of neuropsychology who have engaged in each behavior. This methodology for asking the questions was utilized in an effort to encourage respondents to be more honest and minimize possible social desirability in responses, as they may not want to admit to engaging in behaviors themselves. However, in adopting this method, another type of bias may have been introduced. This conceptual limitation includes the fact that even though a certain percentage of participants indicated knowing someone who engages in a particular ethical misconduct, it does not imply that there is a corresponding percentage of neuropsychologists who engage in such misconduct. In small and tight-knit communities with even a single person engaging in such misconduct to the knowledge of others, all or many of the participants would possibly report knowing that person. Further, some of the behaviors may not be readily observable and may lead to lower percentages of perceived misconduct.

Additionally, this approach of asking yes/no questions does not provide any indication as to the frequency of how often neuropsychologists engage in possible ethical misconduct, as each respondent might know multiple individuals engaging in one type of perceived ethical misconduct and only one individual engaging in another misconduct, yet both scenarios would yield the same frequency. Perhaps future studies could feature both questions asking respondents whether they ever engaged in misconduct, as well as asking the number of other professionals in neuropsychology the participants know who engage in the behaviors. Also, future studies could also employ a more objective analysis of unethical behaviors within neuropsychology, such as the review of complaints brought before respective country's psychology Ethics boards against neuropsychology professionals.

Another set of limitations may stem from the content of the questions. Some questions of this study may have the appearance of not being directly related to the practice of clinical neuropsychology (such as knowing/interacting with patients outside of professional practice) and vary in terms of severity of ethical misconduct (inappropriate sexual relationship with patients being more grave than being disrespectful to students). As such, the survey items did not look at severity of particular ethical issue. However, being disrespectful to students can take different forms, possibly ranging from talking down to someone to engaging in sexual harassment or limiting career options. Similarly, some of the survey questions could be interpreted differently by different participants (such as the meaning of “formal training in professional ethics”) or interpreted as not necessarily constituting ethical misconduct. For example, provision of feedback in a way that patients cannot understand could be arguably understood as poor organizational or professional practice and not automatically implying lack of ethics in professional conduct.

An additional limitation stems from the fact that the study was cross-sectional, and the participants answered a particular set of questions and fulfilled the specific inclusion criteria. This precludes generalization of the findings to psychologists who work in other branches (i.e., industrial-organizational, social) of applied and basic psychology or who have more years of experience in the field. It is possible that some of the practicing neuropsychologists in Latin America were precluded from participation due to lack of access to a computer, the internet, or because of not belonging to an academic or professional network through which the recruitment messages were disseminated. At this time, it is not possible to establish whether professionals who participated in this study mirror the demographics and are representative of all neuropsychology professionals in Latin America. Unfortunately, no studies or research has been conducted to date on the composition and training of neuropsychologists in Latin America, precluding such comparison. However, because the survey was disseminated via principal neuropsychology associations within Latin America, most of the responders are likely representative of those individuals who are more actively involved in their region's professional organizations. Thus, the study likely underrepresents those practitioners who are not engaged with their region's neuropsychology associations.

The ethics questions reported in the current study were the final part of an international questionnaire of professional practices in neuropsychology. Therefore, some participants dropped out of participation in the survey before they arrived at the questions regarding ethics. Additionally, these questions were grouped together, which could have resulted in some participants providing socially desirable responses. Perhaps, the ethics questions should be introduced randomly into the survey to reduce the potential bias inherent in dropout and to solicit more honest responses. Further questions could also focus on other aspects of ethics in neuropsychology, such as plagiarism, appropriation of funds, conflicts of interest, and others.

Another limitation is that questions were partly derived from ethical principles endorsed in the USA by the American Psychological Association and may not reflect ethical guidelines in all of the countries represented in this study. Perhaps, future studies could formulate questions based on the ethics codes specific to the region being studied to ensure that they reflect cultural values and guidelines existing in that country. Overall, these limitations constitute a ripe area for future research and ought to be considered in subsequent investigations on the topic perceptions of ethical misconduct, particularly in global regions where no such data currently exist.

Summary

The current study provides a starting point for additional research on ethical misconduct by neuropsychologists in Latin America. It demonstrates a need for further research to better understand why neuropsychologists may act counter to ethical standards while being aware of traditional cultural practices and attitudes in the region and respective countries. It also suggests a need to investigate ways to encourage ethical behaviors and compliance with ethics codes, as well as more formalized ethical training. Ethics exist in part to provide standardization of care and protect the welfare not only of patients, but also of practitioners, their colleagues and students, and the field as a whole.

Funding

The authors received no financial support for the research, authorship, or publication of this article.

Conflict of Interest

None declared.

Appendix

Table A1.

Neuropsychology ethics survey: English version

Have you ever received formal training on the topic of professional ethics? Yes/No 
Other neuropsychologists I know who work in my country:  
 Discuss information about their patients with people outside of their professional practice who are not involved in treating the patient Yes/No 
 Know/interact with their patients outside of their professional relationship with the patient Yes/No 
 Accept forms of payments for their service from patients other than money Yes/No 
 Testify in court when they do not have the appropriate expertise to do so Yes/No 
 Misrepresent the results of their research or create fake data in order to publish articles or give professional presentations Yes/No 
 Engage in sexual relationships with their patients Yes/No 
 Base diagnostic conclusions on inadequate data or ignore important sources of data Yes/No 
 Do not possess adequate training and experience to be working as neuropsychologists Yes/No 
 Withhold services from or provide substandard services to patients who are unable to pay for services Yes/No 
 Advertise and present themselves as neuropsychologists but have not actually had the proper training or expertise Yes/No 
 Do not have the skills or training to work with patients who are culturally different from them Yes/No 
 Provide interventions with questionable effectiveness or that may even be harmful to patients Yes/No 
 Are negligent and/or disrespectful to their students Yes/No 
 Keep silent or not refer appropriately when important medical or psychological issues arise Yes/No 
 Provide results of neuropsychological evaluations in such a way that patients and other professionals are not likely to understand Yes/No 
 Engage in sexual relationships with their students Yes/No 
 Present as their own research work done by their students Yes/No 
 Appear as authors on publications where they have not made a significant contribution Yes/No 
 Take deliberate actions to damage the reputation of their colleague(s) Yes/No 
Have you ever received formal training on the topic of professional ethics? Yes/No 
Other neuropsychologists I know who work in my country:  
 Discuss information about their patients with people outside of their professional practice who are not involved in treating the patient Yes/No 
 Know/interact with their patients outside of their professional relationship with the patient Yes/No 
 Accept forms of payments for their service from patients other than money Yes/No 
 Testify in court when they do not have the appropriate expertise to do so Yes/No 
 Misrepresent the results of their research or create fake data in order to publish articles or give professional presentations Yes/No 
 Engage in sexual relationships with their patients Yes/No 
 Base diagnostic conclusions on inadequate data or ignore important sources of data Yes/No 
 Do not possess adequate training and experience to be working as neuropsychologists Yes/No 
 Withhold services from or provide substandard services to patients who are unable to pay for services Yes/No 
 Advertise and present themselves as neuropsychologists but have not actually had the proper training or expertise Yes/No 
 Do not have the skills or training to work with patients who are culturally different from them Yes/No 
 Provide interventions with questionable effectiveness or that may even be harmful to patients Yes/No 
 Are negligent and/or disrespectful to their students Yes/No 
 Keep silent or not refer appropriately when important medical or psychological issues arise Yes/No 
 Provide results of neuropsychological evaluations in such a way that patients and other professionals are not likely to understand Yes/No 
 Engage in sexual relationships with their students Yes/No 
 Present as their own research work done by their students Yes/No 
 Appear as authors on publications where they have not made a significant contribution Yes/No 
 Take deliberate actions to damage the reputation of their colleague(s) Yes/No 
Table A2.

Neuropsychology ethics survey: Spanish version

¿Alguna vez ha recibido capacitación formal en ética profesional? Si/No 
Algún(os) neuropsicólogo(s) que conozco y que trabaja(n) en mi país:  
 Habla(n) de la información acerca de sus pacientes con personas que no pertenecen a su práctica profesional y que no están involucrados en la atención de pacientes Si/No 
 Se relaciona(n) con sus pacientes fuera de la consulta Si/No 
 Acepta(n) de sus pacientes dádivas o formas de pagos en especie por los servicios prestados Si/No 
 Testifica(n) en procesos judiciales sin tener la experiencia adecuada para hacerlo Si/No 
 Falsifica(n) resultados en sus investigaciones, con el fin de publicar artículos u ofrecer presentaciones académicas Si/No 
 Mantiene(n) relaciones sexuales con sus pacientes Si/No 
 Basa(n) sus diagnósticos y conclusiones en datos inadecuadamente recogidos o ignoran fuentes importantes de información Si/No 
 No posee(n) entrenamiento y experiencia adecuada para trabajar como neuropsicólogos Si/No 
 Niega(n) servicios o proporcionan servicios de menor calidad a los pacientes que no puedan pagar por ellos Si/No 
 Se promociona(n) y presenta(n) a sí mismos como neuropsicólogo(s) sin tener realmente el entrenamiento y la experiencia apropiada Si/No 
 No tiene(n) las habilidades o entrenamiento para trabajar con pacientes que son culturalmente diferentes a ellos Si/No 
 Proporciona(n) tratamientos de cuestionable efectividad o que pueden ser peligrosos para los pacientes Si/No 
 Son negligentes y/o irrespetuosos con sus estudiantes. Si/No 
 Oculta(n) información o no remiten apropiadamente a los pacientes cuando aparece una condición médica o psicológica importante Si/No 
 Suministra(n) la interpretación de los resultados neuropsicológicos de forma tal, que el paciente o profesionales de otras disciplinas no puedan comprenderlos Si/No 
 Mantiene(n) relaciones sexuales con sus estudiantes Si/No 
 Presenta(n) como propios trabajos de investigación de sus estudiantes Si/No 
 Aparece(n) como autor(es) en publicaciones donde no han tenido una contribución significativa Si/No 
 Realiza(n) deliberadamente acciones encaminadas a dañar la reputación de sus colegas Si/No 
¿Alguna vez ha recibido capacitación formal en ética profesional? Si/No 
Algún(os) neuropsicólogo(s) que conozco y que trabaja(n) en mi país:  
 Habla(n) de la información acerca de sus pacientes con personas que no pertenecen a su práctica profesional y que no están involucrados en la atención de pacientes Si/No 
 Se relaciona(n) con sus pacientes fuera de la consulta Si/No 
 Acepta(n) de sus pacientes dádivas o formas de pagos en especie por los servicios prestados Si/No 
 Testifica(n) en procesos judiciales sin tener la experiencia adecuada para hacerlo Si/No 
 Falsifica(n) resultados en sus investigaciones, con el fin de publicar artículos u ofrecer presentaciones académicas Si/No 
 Mantiene(n) relaciones sexuales con sus pacientes Si/No 
 Basa(n) sus diagnósticos y conclusiones en datos inadecuadamente recogidos o ignoran fuentes importantes de información Si/No 
 No posee(n) entrenamiento y experiencia adecuada para trabajar como neuropsicólogos Si/No 
 Niega(n) servicios o proporcionan servicios de menor calidad a los pacientes que no puedan pagar por ellos Si/No 
 Se promociona(n) y presenta(n) a sí mismos como neuropsicólogo(s) sin tener realmente el entrenamiento y la experiencia apropiada Si/No 
 No tiene(n) las habilidades o entrenamiento para trabajar con pacientes que son culturalmente diferentes a ellos Si/No 
 Proporciona(n) tratamientos de cuestionable efectividad o que pueden ser peligrosos para los pacientes Si/No 
 Son negligentes y/o irrespetuosos con sus estudiantes. Si/No 
 Oculta(n) información o no remiten apropiadamente a los pacientes cuando aparece una condición médica o psicológica importante Si/No 
 Suministra(n) la interpretación de los resultados neuropsicológicos de forma tal, que el paciente o profesionales de otras disciplinas no puedan comprenderlos Si/No 
 Mantiene(n) relaciones sexuales con sus estudiantes Si/No 
 Presenta(n) como propios trabajos de investigación de sus estudiantes Si/No 
 Aparece(n) como autor(es) en publicaciones donde no han tenido una contribución significativa Si/No 
 Realiza(n) deliberadamente acciones encaminadas a dañar la reputación de sus colegas Si/No 
Table A3.

Neuropsychology ethics survey: Portuguese version

Já recebeu algum tipo de formação especializada na área da ética profissional? Sim/Não 
Outros neuropsicólogos que conheça e que trabalhem no meu país:  
 Passam informação acerca dos seus pacientes a pessoas que não pertencem à sua esfera profissional e que não estão directamente envolvidos nos cuidados prestados aos pacientes Sim/Não 
 Relacionam-se com os seus pacientes fora do contexto das consultas Sim/Não 
 Aceitam, dos seus pacientes, formas de pagamento que não em dinheiro pelos serviços prestados Sim/Não 
 Dar pareceres de especialidade em tribunal sem possuir a experiência adequada para o fazer Sim/Não 
 Falsificar resultados de investigações realizadas com o fim de publicar artigos ou apresentar comunicações em contexto académico Sim/Não 
 Manter relações sexuais com os seus pacientes Sim/Não 
 Basear os diagnósticos/conclusões em dados recolhidos de forma inadequada ou ignorar importantes fontes de informação Sim/Não 
 Não possuir experiência ou formação adequada para exercer a actividade de neuropsicólogo Sim/Não 
 Recusar serviços a pessoas em carência económica ou que não têm possibilidade de pagar os serviços Sim/Não 
 Promover-se ou apresentar-se publicamente como neuropsicólogos sem, no entanto, possuir formação e o treino adequados Sim/Não 
 Não possuir preparação e formação adequada para trabalhar com pacientes que são culturalmente diferentes de si (do neuropsicólogo/a) Sim/Não 
 Levar a cabo tratamentos cujo grau de evidência ou eficácia é questionável e que podem oferecer perigo para os pacientes Sim/Não 
 Ser negligente e/ou desrespeituoso para com os seus estudantes Sim/Não 
 Ocultar informação ou não encaminhar de forma adequada os pacientes quando surge uma condição médica ou psicológica importante Sim/Não 
 Reportam a interpretação dos resultados neuropsicológicos de tal forma que o paciente e os profissionais de outras áreas não os conseguem entender Sim/Não 
 Mantêm relações sexuais com os seus estudantes Sim/Não 
 Apresentam como próprios os trabalhos realizados pelos seus estudantes Sim/Não 
 Aparecem como autores de publicações onde não deram uma contribuição significativa Sim/Não 
 Denigrem, de forma deliberada, a reputação dos colegas Sim/Não 
Já recebeu algum tipo de formação especializada na área da ética profissional? Sim/Não 
Outros neuropsicólogos que conheça e que trabalhem no meu país:  
 Passam informação acerca dos seus pacientes a pessoas que não pertencem à sua esfera profissional e que não estão directamente envolvidos nos cuidados prestados aos pacientes Sim/Não 
 Relacionam-se com os seus pacientes fora do contexto das consultas Sim/Não 
 Aceitam, dos seus pacientes, formas de pagamento que não em dinheiro pelos serviços prestados Sim/Não 
 Dar pareceres de especialidade em tribunal sem possuir a experiência adequada para o fazer Sim/Não 
 Falsificar resultados de investigações realizadas com o fim de publicar artigos ou apresentar comunicações em contexto académico Sim/Não 
 Manter relações sexuais com os seus pacientes Sim/Não 
 Basear os diagnósticos/conclusões em dados recolhidos de forma inadequada ou ignorar importantes fontes de informação Sim/Não 
 Não possuir experiência ou formação adequada para exercer a actividade de neuropsicólogo Sim/Não 
 Recusar serviços a pessoas em carência económica ou que não têm possibilidade de pagar os serviços Sim/Não 
 Promover-se ou apresentar-se publicamente como neuropsicólogos sem, no entanto, possuir formação e o treino adequados Sim/Não 
 Não possuir preparação e formação adequada para trabalhar com pacientes que são culturalmente diferentes de si (do neuropsicólogo/a) Sim/Não 
 Levar a cabo tratamentos cujo grau de evidência ou eficácia é questionável e que podem oferecer perigo para os pacientes Sim/Não 
 Ser negligente e/ou desrespeituoso para com os seus estudantes Sim/Não 
 Ocultar informação ou não encaminhar de forma adequada os pacientes quando surge uma condição médica ou psicológica importante Sim/Não 
 Reportam a interpretação dos resultados neuropsicológicos de tal forma que o paciente e os profissionais de outras áreas não os conseguem entender Sim/Não 
 Mantêm relações sexuais com os seus estudantes Sim/Não 
 Apresentam como próprios os trabalhos realizados pelos seus estudantes Sim/Não 
 Aparecem como autores de publicações onde não deram uma contribuição significativa Sim/Não 
 Denigrem, de forma deliberada, a reputação dos colegas Sim/Não 

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