ETHICS AND SOCIAL WORK IN HEALTH

CARE

Chapter 3Handbook of Health Social Work, 2nd Edition

Created by Teri Browne

Ethical dilemma – “When a social worker cannot adhere to professional values or when adhering to one ethic requires behaving counter to another” (Proctor, Morrow-Howell, & Lott, 1993)

Social workers will encounter situations where no completely desirable solutions can be found

Point of discussing these dilemmas is not necessarily to arrive at the “right” answer

COMPLEXITY OF ETHICS

1. Confidentiality & Privileged Communication2. Truthfulness3. Paternalism & Self-Determination4. Laws, Policies, & Regulation5. Whistle-blowing6. Distributing limited resources7. Personal & Professional Values8. Ethical Decision Making (Reamer, 1987)

POINTS TO CONSIDER IN A ETHICAL DILEMMA

Provides direct guidance for practiceProtect the publicProtect the professionPrevent internal strife Protect practitioners against lawsuits

(Lowengerg & Dolgoff, 1996)

PURPOSE OF THE CODE OF ETHICS

Values in relation to human behavior “an enduring belief that a specific mode or end state of existence is personally or socially preferable to an opposite or converse mode or end state” (Rokeach, 1973).

Sometimes used interchangeably with ethics and morals but is different

Values serve as ideals of what is right Values set professions apart from one anotherNeed to examine personal values and as a

practitioner see how it will effect your work when you are interacting with clients who have different values of your own

TERMINOLOGY USED IN ETHICSVALUES

Service Social justice Dignity worth of the person Importance of human relationships Integrity Competence (NASW, 2000)“Social work is among the most value-based

of all professions”- Reamer (1995)

CORE SOCIAL WORK VALUES

“Principals or rules of conduct which define standards for right behavior” – Lowenberg & Dolgoff, 1996)

Not explicitly outlined in the NASW Code of Ethics

Widely excepted notions of right and wrong Shape how values are developed

MORALS

Has had different definitions *Concerned with protection from abuses of power by authorities/individuals *Social control and welfare*Social Justice

Having legislation passed does not change individuals personal beliefs and values

Attending to a law does not mean a social worker is protected from acting in an unethical way.

Social Workers are required to work through the courts to address unjust laws

LAWS

Stage in the formation of values On their own they can serve as “ideals”

Principals inform social work practice Standards – specifically outlines how social workers should conduct themselves

PRINCIPALS AND STANDARDS

Metaethics- the study of methods, language, logical, structure, and reasoning used to arrive at and justify moral decisions (Angeles, 1992)

“What does it really mean to be good or bad?”Normative ethics- identifying morals, values,

principals, or standards that might be relevant in addressing a dilemma (It should be noted that in social work often times in which these conflict making a dilemma that much harder)

Applied Ethics- application of normative ethics. The stage where decisions are made.

ETHICS THREE BRANCHES

Cases of Terri Schiavo, Karen Quinlan, Nancy Cruzan

Social worker must examine their own set of values and how it relates to the patients’ wishes.

When those values and wishes conflict it may be necessary to make a referral

END OF LIFE CARE

Deontological and Teleontological Theories

Utilitarianism

Ethics of Duty (Kantian Ethics)

Ethics of Care Virtue Ethics

BASIC NORMATIVE THEORIES

Deontological - primary emphasis on the ethical value, standard, or principal in determining the correct action without considering the outcome

Teleontological- more concerned with the outcomeExample of these theories and social work ethics

clashing is the 1976 case of Tarasoff v. Board of Regents of the University of California (Kagle & Kopels, 1994).

Thoughts on “duty to protect” vs. “duty to warn”?What would decisions based on the theories

discussed above look like for this court case?

DEONTOLOGICAL AND TELEONTOLOGICAL THEORIES

Principle of utility – belief that a person ought to do that which brings about the greatest happiness to the greatest number of people or community as a whole.

Which of the theories discussed previously would be used in determining decisions this way?

Two main divisions act & rule act- focuses only on outcome rule- defers to established standards

within an ethical framework

UTILITARIANISM

Actions are only right when they are consistent with a particular standard

“Would everyone benefit if everyone participated in a particular act?”

Outcome of an act does not determine whether it is right or wrong

Perfect duties- duties of omission or clear duties of things one should not do

Imperfect duties- not as clearly defined (i.e. Be a good person.)

ETHICS OF DUTYKANTIAN ETHICS

Applications of Care Ethics in heath settings:

1. A shift from principle and institutional rules to an emphasis on a more responsive relationship with the patient

2. An emphasis on self-awareness in order to understand others

3. Placing value on ethical discourse and not focusing only on outcomes

4. A review of gender-based differences in health care5. An emphasis on the nature and dynamics of relationships

and how it may influence ethical decision making 6. Acknowledgment of the reality of moral ambivalence7. Consideration of what traits or virtues one should develop

to further competence in the ethical decision making

ETHICS OF CARE

Refers to the positive attributes of a particular type of personBelieved to help in the development of the professional self

and how it relates to others. May be problematic because what constitutes a “virtuous”

social worker can vary greatly. An agreed upon definition may be hard to develop.

VIRTUE ETHICS

Can be traced back to 477 BCE and the Oath of Hippocrates

Thomas Percival 1803 Code of Ethics *Awareness of larger societal concerns *Explores modern ethical dilemmas *Influenced the American Medical

Association’s (AMA) first code of ethics in 1847.

* Criticized for concentrating on professional etiquette, rather than ethics.

DEVELOPMENT OF MEDICAL ETHICS

Flexner (1915) questioned if social work was a profession, but stated that it might be closer than law or medicine was. He asserted that a profession needed to have values. The field of social work then began its discussion of ethics.

Reamer (1998) identified five periods of development for the social work code of ethics.

1. morality period 2. values period 3. ethical theory & decision making period 4. ethical standards & risk management period

DEVELOPMENT OF SOCIAL WORK ETHICS

Late 19th Century to the 1950s. Clients were seen as “defective” A shift started to address more social justice issues

(external influences). Mary Richmond drafted an early social work code of

ethics in the 1920s. 1923 AAOFSW began work on a code of ethics1947 The American Association of Social Workers

adopted a formal code of ethics. *100 years after the American Medical Association had! 1955 AAOFSW merged with others to form the NASW

MORALITY PERIOD

1950s to 1980

NASW published its first code of ethics in 1960 *consisted of 15 “I” statements

Focus on developing area of practice that would set social work apart.

Continued shift away from clients’ morality to identifying ethical standards

VALUES PERIOD

1980s-1990sLargely influenced by conferences and center and

commission workRecognized need for this in order to resolve health-care and

social justice issues. Malpractice concerns and managed care helped direct ethics

during this time

ETHICAL THEORY & DECISION-MAKING PERIOD

1990s – present Increase in public “scandals” has led social workers to be

more aware of ethical principalsPresently 20 countries have developed social work code of

ethics Social workers need to continue educating themselves and

developing decision making skills to help protect clients against harm and themselves against litigation

1999 NASW Code of Ethics most recent version

What does it mean for a situation to be ethically ambiguous? How would this effect the way in which you make your decisions as a social worker?

ETHICAL STANDARDS & RISK MANAGEMENT PERIOD

In the 1940s-1950s the significant advances in the medical field provided the profession with a false sense of security

1960s these new technologies brought on unexpected difficulties

“Birth” of Bioethics – when a fatal disease became treatable through mechanical means.

What did this mean for the professionals choosing who received treatment? (i.e. dialysis selection committees or donor waiting lists)

These new and confusing dilemmas led to an increase in papers and discussions on ethics in the medical field

DEVELOPMENT OF BIOETHICS

Mondale Hearings of 1968 led to the National Bioethics Commission Commission for the Protection of Human Subjects of Biomedical and

Behavioral Research was established in 1974. *one of the first governmental bodies to consider ethics*created several important documents that set up guidelines for

medical research. (i.e. Belmont Report)What do you think about Albert Jonsen’s later criticism of the report? President’s Commission for the Study of Ethical Problems in

Medicine and Biomedical and Behavioral Research established in 1979 (disbanded in 1983).*Deciding to Forego Life-Sustaining Treatment

*Advised that ethics committees be involved in dilemmas involving life or death care and review concepts of power of attorney.

Human Genome Project developed the world’s largest bioethics program

BIOETHICS

In the past decisions were made “to resolve ethical dilemmas on a case-by-case basis without systematic grounding in ethical principles” (Goldmeier, 1984).

What are some factors to consider when making an informed, ethically sound decision?

Social workers’ input in a health care setting is essential, yet highly impacted by the transdisciplinary team that they are apart of.

DECISION-MAKING MODELS

1. Recognize the problem2. Investigate the variables3. Get feedback from others4. Appraise the values that apply to the dilemma5. Evaluate the dilemma6. Identify and think about possible alternatives7. Weigh the pros and cons of each alternative8. Make your decision (Netting & et al., 1993) Models often share components, but differ in

fundamental areas.

DECISION-MAKING STEPS

What makes completing the last step difficult? When ranking principles an individual should be

able to (Lowenburg & Dolgoff, 1996: Exist with basic needs Receive treatment that is fair and equal Have free choice and freedom Have injury that is minimal or nonexistent Cultivate a good quality of life Secure privacy and confidentiality Understand the truth Receive available information

DECISION MAKING MODELS

What does this term mean to you? What forms can a dual relationships take?

Are dual relationships ever appropriate? Discuss the varying definitions within the field (i.e.

Craig 1991, Hill & Mamalakis 2001) as well as the difference between crossing boundaries and boundary violations.

Most frequent NASW code to be violated

DUAL RELATIONSHIPS

Discuss components of managed care that may increase ethical violations:

*Exaggeration of patient symptoms* Dual Relationships*Informed Consent*Confidentiality

MANAGED CARE

Defined as “the act of notifying authorities of harmful deviation from standards of care or unethical practices within an organization”

Before reporting incident the practitioner should consider: *Severity of harm and misconduct involved

*Quality of evidence of wrongdoing*Effect of the decision on colleagues and agency*Viability of alternative courses of action

What would you do if you witnessed unethical behavior within the agency you were working?

NASW Code of Ethics addresses these issues. It is advised that one always tries to address a co-worker before reporting them.

WHISTLE-BLOWING

IRB (Institutional Review Board) acts as a safeguard against potentially harmful research

What would be some reasons social workers deviate from ethical practice when conducting research?

Key areas to remember in research: *Voluntary participation or consent

*No harm to participants *Deception*Analysis and reporting*Justice and beneficence

Nuremberg Code Tuskegee Study Millgram’s Obedience Study

*Important to remember that the true nature of research is not always apparent.

What could be found out or researched to get a better picture as to why the research is really being conducted?

SOCIAL WORK RESEARCH ETHICS

“Right” answers for ethical dilemmas are not always availableHealth social workers in both the micro and macro settings

must be able to redirect attention to ethical considerations and patient focused care.

What are some things in our current society that can further threatens ethical care?

ETHICAL CHALLENGES IN THE 21ST CENTURY