ethics: making critical decisions in treatment patricia sherman, ph.d., lcsw

Ethics: Making Ethics: Making Critical Decisions in Critical Decisions in TreatmentTreatment

Patricia Sherman, Ph.D., LCSWPatricia Sherman, Ph.D., LCSW

An 18-year old adolescent who is 4 months An 18-year old adolescent who is 4 months pregnant has contacted you several times in regard pregnant has contacted you several times in regard to planning for her child. In her last visit, she to planning for her child. In her last visit, she confided to you that she is habituated to heroin. confided to you that she is habituated to heroin. You have expressed your concern that the drug You have expressed your concern that the drug may damage her unborn child, but she does not may damage her unborn child, but she does not seem worried nor does she want to give up use of seem worried nor does she want to give up use of the drug. You also know that she obtains money the drug. You also know that she obtains money for heroin through prostitution and is not attending for heroin through prostitution and is not attending school.school.

You are an agency social worker whose Cuban client You are an agency social worker whose Cuban client has just told you she is HIV positive. She is in a has just told you she is HIV positive. She is in a monogamous relationship and has two young monogamous relationship and has two young children. She does not plan to tell her partner about children. She does not plan to tell her partner about her HIV status, fearing that this knowledge would her HIV status, fearing that this knowledge would cause the relationship to break up. She says she cause the relationship to break up. She says she and her partner do not utilize safer sex practices and and her partner do not utilize safer sex practices and that she could never ask him to use a condom, as that she could never ask him to use a condom, as that would hurt his pride and cause him to become that would hurt his pride and cause him to become suspicious.suspicious.

Purposes of the NASW Code of Ethics ((Stone, 2004Stone, 2004))

Identifies core values on which social work’s Identifies core values on which social work’s mission is basedmission is based

Summarizes broad ethical principles that reflect the Summarizes broad ethical principles that reflect the profession’s core values and establishes ethical profession’s core values and establishes ethical standards to guide social work practicestandards to guide social work practice

Is designed to help social workers identify relevant Is designed to help social workers identify relevant considerations when professional obligations considerations when professional obligations conflict or ethical uncertainties ariseconflict or ethical uncertainties arise

Provides ethical standards to which the general Provides ethical standards to which the general public can hold the social work profession public can hold the social work profession accountableaccountable

Socializes practitioners new to the field to social Socializes practitioners new to the field to social work’s mission, values, ethical principles, and work’s mission, values, ethical principles, and ethical standardsethical standards

Articulates standards that the social work Articulates standards that the social work profession itself can use to assess whether social profession itself can use to assess whether social workers have engaged in unethical conductworkers have engaged in unethical conduct

Provides practitioners with guidance when faced by Provides practitioners with guidance when faced by practice dilemmas that include ethical issuespractice dilemmas that include ethical issues

Protects the public from charlatans and Protects the public from charlatans and incompetent practitionersincompetent practitioners

Protects the profession from governmental control; Protects the profession from governmental control; self-regulation is preferable to state regulationself-regulation is preferable to state regulation

Enables professional colleagues to live in harmony with each other by preventing the self-destruction that results from internal bickering

Protects professionals from litigation; practitioners who follow the Code are offered some protection in suits for malpractice

Social workSocial work Ethical Principles Ethical Principles

Primary goal is to help people in need and to Primary goal is to help people in need and to address social problemsaddress social problems

Challenge social injusticeChallenge social injustice

Respect the inherent dignity and worth of the Respect the inherent dignity and worth of the personperson

Recognize the central importance of human Recognize the central importance of human relationshipsrelationships

Behave in a trustworthy mannerBehave in a trustworthy manner

Practice within areas of competence and develop Practice within areas of competence and develop and enhance professional expertiseand enhance professional expertise

AcceptanceAcceptance

IndividualizationIndividualization

Purposeful expression of feelingsPurposeful expression of feelings

Nonjudgmental attitudesNonjudgmental attitudes

ObjectivityObjectivity

Controlled emotional involvementControlled emotional involvement

Self-determinationSelf-determination

Access to resourcesAccess to resources

Confidentiality and accountabilityConfidentiality and accountability

Begin With Values

Societal Values – Societal Values –

Professional Values – Professional Values –

Client Values – Client Values –

Personal Values – Personal Values –

ValuesValues

VALUEVALUE is the reality in the inner core of a person is the reality in the inner core of a person which:which: shapes one’s ideasshapes one’s ideas conditions one’s feelingsconditions one’s feelings affects one’s behavior (affects one’s behavior (Simon, Simon, Values ClarificationValues Clarification, 1970, , 1970,

p. 25p. 25))

Whether recognized or unrecognized, values are Whether recognized or unrecognized, values are essential to professional action and to any essential to professional action and to any conception of practice theoryconception of practice theory

Are implicit and explicit about what we cherish as Are implicit and explicit about what we cherish as ideal and preferableideal and preferable

Determine which goals and actions we evaluate as Determine which goals and actions we evaluate as “good”“good”

Shape our beliefs and our attitudes and, in turn, our Shape our beliefs and our attitudes and, in turn, our beliefs and attitudes shape our valuesbeliefs and attitudes shape our values

Define norms or guidelines for behaviorDefine norms or guidelines for behavior

Laden with emotionsLaden with emotions

Influence our evaluations of situations and motivate Influence our evaluations of situations and motivate the actions we takethe actions we take

SOCIETAL VALUESSOCIETAL VALUES

•Life and dignity of the human personLife and dignity of the human person

•Call to familyCall to family

•Community and participationCommunity and participation

Social Justice ValuesSocial Justice Values(Catechism of the catholic church, 1994, (Catechism of the catholic church, 1994,

catholic conference of the catholic conference of the united states bishops, 1995, himchak, 2007)united states bishops, 1995, himchak, 2007)

• Rights and responsibilitiesRights and responsibilities

• Option for the poor, the vulnerable, and people at Option for the poor, the vulnerable, and people at riskrisk

• Dignity of work and the rights of workersDignity of work and the rights of workers

• Solidarity and care for God’s creationSolidarity and care for God’s creation

Values shared by all helping Values shared by all helping professionsprofessions

Autonomy Autonomy Nonmaleficence – do no harmNonmaleficence – do no harm Beneficence – promote goodBeneficence – promote good Justice Justice Fidelity – create trusting relationshipFidelity – create trusting relationship Veracity – be truthfulVeracity – be truthful

Common Social Work ValuesCommon Social Work Values

Promotion of the client ‘s well-being and individual Promotion of the client ‘s well-being and individual dignitydignity

Self-determinationSelf-determination

The right to have basic needs metThe right to have basic needs met

The right to actualize one’s full potentialThe right to actualize one’s full potential

Client empowermentClient empowerment

Human diversityHuman diversity

Social and economic justiceSocial and economic justice

Values specific to work areaValues specific to work area

Child welfareChild welfare Protection of childrenProtection of children Preservation of familiesPreservation of families Respect for familiesRespect for families Diligence – “hanging in there” with difficult situationsDiligence – “hanging in there” with difficult situations

culture

When do cultural/religious values of clients create ethical concerns?

When do cultural/religious values of social workers create ethical concerns?

Personal values Personal values exercisesexercises

Scale of social distance

What’s your first response?

On what are you basing your response?

What values does your response reflect?

What feelings do you have about your response?

Cognitive dissonance(Taylor, 2007)

Feeling of discomfort arising from the conflict between professional and/or personal values and job tasks

Social workers have to make decisions that both protect society and maximize the rights of the individual

Strongest when a cognition related to self-concept conflicts with a cognition about behavior

Potential problem areas (IFSW, IASSW)

Social worker’s loyalty often in the middle of conflicting interests

Social workers function as both helpers and controllers

Conflicts between duty to protect clients’ interests and societal demands for efficiency and utility

Limited resources

SOCIAL WORKER’S ETHICAL SOCIAL WORKER’S ETHICAL RESPONSIBILITY TO SOCIETYRESPONSIBILITY TO SOCIETY

The social worker should promote the general welfare of The social worker should promote the general welfare of societysociety

The social worker should act to ensure that all person have The social worker should act to ensure that all person have access to the resources, services, and opportunities which access to the resources, services, and opportunities which they requirethey require

The social worker should advocate changes in policy and The social worker should advocate changes in policy and legislation to improve social conditions and to promote legislation to improve social conditions and to promote social justicesocial justice

Moral questions for Moral questions for the Professionthe Profession

What are the clients’ rights as individuals? What are the clients’ rights as individuals?

What are their obligations to their families? What are their obligations to their families?

Under what circumstances is it permissible to support the Under what circumstances is it permissible to support the breaking up of a family?breaking up of a family?

Under what circumstances is it legitimate to Under what circumstances is it legitimate to override client self-determination (e.g., clients with override client self-determination (e.g., clients with mental illness who will not take medication)?mental illness who will not take medication)?

Is coercion justified in any given case? How far and Is coercion justified in any given case? How far and when is individual dependency a public when is individual dependency a public responsibility; how far and when a private responsibility; how far and when a private responsibility?responsibility?

In what circumstances, if any, should the client’s In what circumstances, if any, should the client’s confidence be violated by the social worker?confidence be violated by the social worker?

Should the social worker ever be responsible for Should the social worker ever be responsible for law enforcement?law enforcement?

ETHICSETHICS

The study of rightness and wrongness The study of rightness and wrongness of human conduct (of human conduct (Varga, 1980, p. ixVarga, 1980, p. ix). ).

It is that part of a moral philosophy that It is that part of a moral philosophy that concerns relationships between people, andconcerns relationships between people, anda set of values, assumptions, beliefs, and a set of values, assumptions, beliefs, and normative rules that identify, support, and normative rules that identify, support, and explain the duties and obligations for good,explain the duties and obligations for good,right conduct right conduct (Siporin, 1982. p. 523).(Siporin, 1982. p. 523).

Relates to what people consider correct or rightRelates to what people consider correct or right

Generates standards that direct conductGenerates standards that direct conduct

Represents “values in action”Represents “values in action”

Social work ethics represents behavioral Social work ethics represents behavioral expectations or preferences that are associated with expectations or preferences that are associated with social work responsibilitysocial work responsibility

Ethics and valuesEthics and values

Ethics are deduced from values and must be in Ethics are deduced from values and must be in consonance with themconsonance with them

The difference between them is that values are The difference between them is that values are concerned with what is good and desirable while concerned with what is good and desirable while ethics deal with what is right and correct. (ethics deal with what is right and correct. (Loewenberg Loewenberg

et al, 2000et al, 2000))

Values deal with what beliefs are appropriateValues deal with what beliefs are appropriate

Ethics address what to do with or how to apply Ethics address what to do with or how to apply those beliefsthose beliefs

Ethical StandardsEthical Standards

Ethical Responsibilities to Clients Ethical Responsibilities to Clients Ethical Responsibilities to ColleaguesEthical Responsibilities to Colleagues Ethical Responsibilities in Practice SettingsEthical Responsibilities in Practice Settings Ethical Responsibilities as ProfessionalsEthical Responsibilities as Professionals Ethical Responsibilities to the ProfessionEthical Responsibilities to the Profession Ethical Responsibilities to Society at LargeEthical Responsibilities to Society at Large

PROFESSIONAL ETHICSPROFESSIONAL ETHICS

Refers to the moral philosophy that is theRefers to the moral philosophy that is theset of values, beliefs, and normative rules set of values, beliefs, and normative rules that prescribes and explains the that prescribes and explains the obligations for good, right conduct on theobligations for good, right conduct on thepart of a profession’s memberspart of a profession’s members

Ethical TheoryEthical Theory

Deontological theoriesDeontological theories – certain actions are – certain actions are inherently right or wrong, or good and bad, without inherently right or wrong, or good and bad, without regard for their consequences. Rules, rights, and regard for their consequences. Rules, rights, and principles are sacred and inviolable. The ends do principles are sacred and inviolable. The ends do not necessarily justify the meansnot necessarily justify the means

Teleological TheoriesTeleological Theories – the rightness of any action – the rightness of any action is determined by the goodness of its consequences is determined by the goodness of its consequences

EgoismEgoism – people should maximize their own – people should maximize their own good and enhance their self-interestgood and enhance their self-interest

UtilitarianismUtilitarianism – an action is right if it promotes the – an action is right if it promotes the maximum goodmaximum good

Act utilitarianismAct utilitarianism – the rightness of an action is – the rightness of an action is determined by the goodness of the consequences determined by the goodness of the consequences produced in that individual case or by that particular produced in that individual case or by that particular actact

Rule utilitarianismRule utilitarianism – takes into account the long- – takes into account the long-term consequences likely to result if one term consequences likely to result if one generalizes from the case at hand or treats it as a generalizes from the case at hand or treats it as a precedentprecedent

Kohlberg moral dilemma Kohlberg moral dilemma exerciseexercise

KANTKANT proposed that an action is good in itself not proposed that an action is good in itself not because of the results it produced, but if it is the because of the results it produced, but if it is the product of good will. Kant’s theory is what is product of good will. Kant’s theory is what is sometimes called a universalistic or conservative sometimes called a universalistic or conservative theory in that there are general rules that are not to theory in that there are general rules that are not to be broken in any situationbe broken in any situation

MORAL POSITIVISMMORAL POSITIVISM states that morality is not states that morality is not determined by the nature of an act but by extrinsic determined by the nature of an act but by extrinsic factors. Morality is made and not discovered. The factors. Morality is made and not discovered. The fact that something is prescribed or forbidden fact that something is prescribed or forbidden makes it good or bad makes it good or bad (Hammurabi Code, Ten (Hammurabi Code, Ten Commandments)Commandments)

THOMISMTHOMISM is an ethical theory that is very influential in is an ethical theory that is very influential in current thinking about ethics in medicine. current thinking about ethics in medicine. According to Aquinas, ”The perfecting of creatures According to Aquinas, ”The perfecting of creatures through the development of their natures through the development of their natures constitutes the highest good for them” constitutes the highest good for them”

The first natural law is that all actions that conserve The first natural law is that all actions that conserve life or avoid death are included in moral lawlife or avoid death are included in moral law

Since all living creatures share a natural inclination Since all living creatures share a natural inclination to propagate the species, a natural law for mankind to propagate the species, a natural law for mankind is that the species should be propagated and is that the species should be propagated and children educatedchildren educated

Human beings are rational beings and should Human beings are rational beings and should therefore seek truth and avoid ignorancetherefore seek truth and avoid ignorance

Aquinas did not believe that actions contrary to Aquinas did not believe that actions contrary to moral law are wrong simply because they are moral law are wrong simply because they are prohibited by God; rather, he believed that they are prohibited by God; rather, he believed that they are prohibited by God because they are wrong prohibited by God because they are wrong

God-given law - Life is sacredGod-given law - Life is sacred

Confidentiality and Confidentiality and Privileged CommunicationPrivileged Communication

Confidential information includes personal details Confidential information includes personal details about the client’s identity, records of verbal about the client’s identity, records of verbal statements made by the client, professional reports statements made by the client, professional reports or professed opinions concerning the client, and or professed opinions concerning the client, and content from other records (Reamer, 1995)content from other records (Reamer, 1995)

Relative Confidentiality is a broad term that exists for Relative Confidentiality is a broad term that exists for the protection of the individual client but may allow the protection of the individual client but may allow a limited amount of disclosure, especially to those a limited amount of disclosure, especially to those co-workers, superiors, and subordinates whose co-workers, superiors, and subordinates whose knowledge of certain communications is required to knowledge of certain communications is required to aid in the therapy or planned change process of the aid in the therapy or planned change process of the clientclient

Privilege refers to legal rights transpired between Privilege refers to legal rights transpired between the worker and client and is protected by law and the worker and client and is protected by law and cannot be revealed without that client’s expressed cannot be revealed without that client’s expressed permission permission (Barker 1999)(Barker 1999)

Relative confidentiality is much more common than Relative confidentiality is much more common than privilegeprivilege

Social Workers may disclose confidential Social Workers may disclose confidential information when appropriate with valid consent information when appropriate with valid consent from a client or a person legally authorized to from a client or a person legally authorized to consent on behalf of a client or when needed to consent on behalf of a client or when needed to defend self defend self (NASW 1996)(NASW 1996)

Should inform the client to extent possible about the Should inform the client to extent possible about the disclosure of confidential information and the disclosure of confidential information and the potential consequences when feasible before the potential consequences when feasible before the disclosure is madedisclosure is made

Self-Determination and Self-Determination and PaternalismPaternalism

Self-determination is an ethical principle that Self-determination is an ethical principle that acknowledges people’s right to make their own acknowledges people’s right to make their own decisions and choices (Barker 1999)decisions and choices (Barker 1999)

Paternalism is action that interferes with a client’s Paternalism is action that interferes with a client’s wishes or freedom for his own good (Reamer 1995)wishes or freedom for his own good (Reamer 1995)

Evaluate client’s decision-making capacity. In the Evaluate client’s decision-making capacity. In the social worker’s professional judgment, clients’ social worker’s professional judgment, clients’ actions or potential actions pose a serious, actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or foreseeable, and imminent risk to themselves or othersothers

It also urges action on behalf of clients and pursuit It also urges action on behalf of clients and pursuit of courses of action that safeguard such clientsof courses of action that safeguard such clients

Dual RelationshipsDual Relationships

Dual Relationships are those where social workers Dual Relationships are those where social workers engage in more than one relationship with a client, engage in more than one relationship with a client, becoming social worker and friend, employer, becoming social worker and friend, employer, teacher, business associate, or sex partner (Kagle teacher, business associate, or sex partner (Kagle 1994)1994)

Social worker assumes more than one role Social worker assumes more than one role concurrently or consecutivelyconcurrently or consecutively

Social Workers should not engage in dual or Social Workers should not engage in dual or multiple relationships with clients or former clients in multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm which there is a risk of exploitation or potential harm to the client to the client (NASW CODE)(NASW CODE)

Involves boundary issuesInvolves boundary issues

Boundaries are invisible barriers that separate Boundaries are invisible barriers that separate various roles and limit the types of interaction various roles and limit the types of interaction expected and considered ethically appropriate for expected and considered ethically appropriate for each roleeach role

Example: Social worker and client attend the Example: Social worker and client attend the same AA meetingsame AA meeting

Think about boundary issues and establish Think about boundary issues and establish professional boundaries from the beginning, taking professional boundaries from the beginning, taking cultural issues into considerationcultural issues into consideration

Consult your supervisor and professional Consult your supervisor and professional colleaguescolleagues

Scrutinize your own motivationsScrutinize your own motivations

Discuss with the clientsDiscuss with the clients

Sexual attraction – refer client to another Sexual attraction – refer client to another professional if this cannot be resolved through professional if this cannot be resolved through supervision; never act on itsupervision; never act on it

Distribute fliers on client rights and professional Distribute fliers on client rights and professional ethicsethics

Whistle-BlowingWhistle-Blowing

Act of informing on another or making public an Act of informing on another or making public an individual’s, group’s or organization’s corrupt, individual’s, group’s or organization’s corrupt, wrong, illegal, wasteful, or dangerous behaviorwrong, illegal, wasteful, or dangerous behavior

How great is the threat to the potential victims?How great is the threat to the potential victims?

What type and quality of proof are available that the What type and quality of proof are available that the wrongdoing has occurred or is going on?wrongdoing has occurred or is going on?

Are there less severe alternative measures you Are there less severe alternative measures you might take to remedy the problem?might take to remedy the problem?

Can you assume the burden of risk? How much do Can you assume the burden of risk? How much do you have to lose?you have to lose?

Guidelines for Ethical Decision Making (Reamer, 1999)(Reamer, 1999)

Rules against basic harms to the necessary Rules against basic harms to the necessary preconditions of human action (such as life itself, preconditions of human action (such as life itself, health, food, shelter, mental equilibrium) take health, food, shelter, mental equilibrium) take precedence over rules against harms such as lying precedence over rules against harms such as lying or revealing confidential information or threats to or revealing confidential information or threats to additive goods such as recreation, education, and additive goods such as recreation, education, and wealthwealth

An individual’s right to basic well-being (including An individual’s right to basic well-being (including goods that are essential for human action) takes goods that are essential for human action) takes precedence over another individual’s right to self-precedence over another individual’s right to self-determinationdetermination

An individual’s right to self-determination takes An individual’s right to self-determination takes precedence over his or her right to basic well-beingprecedence over his or her right to basic well-being

The obligation to obey laws, rules, and regulations The obligation to obey laws, rules, and regulations to which one has voluntarily and freely consented to which one has voluntarily and freely consented ordinarily overrides one’s right to engage voluntarily ordinarily overrides one’s right to engage voluntarily and freely in a manner that conflicts with these and freely in a manner that conflicts with these laws, rules, and regulationslaws, rules, and regulations

Individuals’ rights to well-being may override laws, Individuals’ rights to well-being may override laws, rules, regulations, and arrangements of voluntary rules, regulations, and arrangements of voluntary associations in cases of conflictassociations in cases of conflict

The obligation to prevent basic harms The obligation to prevent basic harms such as starvation and to promote public such as starvation and to promote public goods such as housing, education, and goods such as housing, education, and public assistance overrides the right to public assistance overrides the right to complete control over one’s propertycomplete control over one’s property

Process of Ethical Decision Making

Identify the ethical issues, including the social work Identify the ethical issues, including the social work values and duties that conflictvalues and duties that conflict

Identify the individuals, groups, and organizations Identify the individuals, groups, and organizations likely to be affected by the ethical decisionlikely to be affected by the ethical decision

Determine what additional information you need and how that information might affect your decision

Tentatively identify all viable courses of action and Tentatively identify all viable courses of action and the participants involved in each, along with the the participants involved in each, along with the potential benefits and risks for eachpotential benefits and risks for each

Thoroughly examine the reasons in favor of and Thoroughly examine the reasons in favor of and opposed to each course of action, considering opposed to each course of action, considering relevantrelevant

Ethical theories, principles, and guidelinesEthical theories, principles, and guidelines Codes of ethics and legal principlesCodes of ethics and legal principles Social work practice theory and principlesSocial work practice theory and principles Client’s values (including religious, cultural and ethnic Client’s values (including religious, cultural and ethnic

values, and political ideology), particularly those that values, and political ideology), particularly those that conflict with one’s ownconflict with one’s own

Personal valuesPersonal values

Consult with colleagues and appropriate experts Consult with colleagues and appropriate experts (such as agency staff, supervisors, agency (such as agency staff, supervisors, agency administrators, attorneys, ethics scholars)administrators, attorneys, ethics scholars)

Make the decision and document the decision-Make the decision and document the decision-making processmaking process

Monitor, evaluate, and document the decision’s Monitor, evaluate, and document the decision’s outcomeoutcome

Ethics AuditEthics Audit(Reamer, 2000)(Reamer, 2000)

Client rightsClient rights Confidentiality and privacyConfidentiality and privacy Informed consentInformed consent Service delivery – competenceService delivery – competence Boundary issues and conflicts of interestBoundary issues and conflicts of interest Documentation Documentation Defamation of characterDefamation of character

An ethics audit should assess social An ethics audit should assess social workers’ familiarity with the variety of workers’ familiarity with the variety of ethical dilemmas germane to their ethical dilemmas germane to their practice setting and the procedures practice setting and the procedures they use to make ethical decisions they use to make ethical decisions

Supervision and trainingSupervision and training

ConsultationConsultation

ReferralReferral

FraudFraud

Termination of servicesTermination of services

Practitioner impairmentPractitioner impairment

Discussion ofSpecificEthical Dilemmas