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This article explores the ethical principles and responsibilities in adult guardianships, including the overlap with the NASW and ND Social Work Codes of Ethics. It discusses ethical decision-making models, presents ethical scenarios, and applies decision-making models to these scenarios.
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Ethics in Adult Guardianships Katie Krukenberg, LCSW University of Mary
Agenda • Guardianship Responsibilities and Ethical Principles and overlap with NASW and ND Social Work Codes of Ethics • Ethical Decision Making Models • Ethical Scenarios and Application of Decision Making Models
Guardianship Ethical PrinciplesNASW Code of EthicsND Social Work Code of Ethics
Purpose of a Code of Ethics (Birkenmaier, et. Al.) • Affirms role as a legitimate profession • Provides guidance for practice circumstances • Sets standards by which public can hold professionals accountable “Hasn’t the public a right to know how the ordinary social worker is likely to act under ordinary circumstances?” The Compass , April 1924
Definitions (Barker, 2003) • Values • Ethics • Code of Ethics • Ethical Dilemma • Ethical Decision Making
National Guardianship Association Ethical Principles (National Guardianship Association) • 1. A guardian treats the person with dignity. • 2. A guardian involves the person to the greatest extent possible in all decision making. • 3. A guardian selects the option that places the least restrictions on the person’s freedom and rights. • 4. A guardian identifies and advocates for the person’s goals, needs, and preferences. • 5. A guardian maximizes the self-reliance and independence of the person. • 6. A guardian keeps confidential the affairs of the person. • 7. A guardian avoids conflicts of interest and self-dealing. • 8. A guardian complies with all laws and court orders. • 9. A guardian manages all financial matters carefully. • 10. A guardian respects that the money and property being managed belong to the person.
Core Values from NASW Code of Ethics • Service • Social Justice • Dignity and Worth of the Person • Importance of Human Relationships • Integrity • Competence
ND Social Work Code of Ethics • Not the same as NASW Code of Ethics • Located in ND Century Code • Social workers licensed in ND sign an agreement to uphold the ND Code of Ethics
Guardianship and Social Work Ethical Guideline Overlap National Guardianship Association Ethical Principles NASW Code of Ethics 6 Core values Client right to self determination Informed consent Competence Conflict of Interest Privacy and Confidentiality Clients lacking decision making capacity • 1. A guardian treats the person with dignity. • 2. A guardian involves the person to the greatest extent possible in all decision making. • 3. A guardian selects the option that places the least restrictions on the person’s freedom and rights. • 4. A guardian identifies and advocates for the person’s goals, needs, and preferences. • 5. A guardian maximizes the self-reliance and independence of the person. • 6. A guardian keeps confidential the affairs of the person. • 7. A guardian avoids conflicts of interest and self-dealing. • 8. A guardian complies with all laws and court orders. • 9. A guardian manages all financial matters carefully. • 10. A guardian respects that the money and property being managed belong to the person.
Does the dilemma meet criteria of a professional dilemma? • The social worker must decide on a course of action • Multiple courses of action exist • Regardless of the course of action, one of the social work ethical principles will be compromised (Allen, 2012, p. 4)
Additional Considerations • Importance of training • Good supervision • Ongoing continuing education • Importance of interdisciplinary teams • Health care, behavioral health, community resource agencies • Idea of “Ethical Humility”
Good decisions are rational, not rationalizations (Hardy) • Rational Decisions are the result of a careful reasoning process evaluating the effectiveness and ethics of options. • Rationalizations are stated reasons developed to justify decisions the decision maker wants to make or has already made.
Resolving Ethical Dilemmas • Codes of ethics provide guidelines, but don’t necessarily tell us what to do. • There is typically no “right” answer, and often no easy answer. • Negotiating ethical dilemmas and decisions in general is a life-long learning process.
Kohlberg’s Moral Development Heinz’s wife was dying from a particular type of cancer. Doctors said a new drug might save her. The drug had been discovered by a local chemist and Heinz tried desperately to buy some, but the chemist was charging ten times the money it cost to make the drug and this was much more than Heinz could afford. Heinz could only raise half the money, even after help from family and friends. He explained to the chemist that his wife was dying and asked if he could have the drug cheaper or pay the rest of the money later. The chemist refused saying that he had discovered the drug and was going to make money from it. The husband was desperate to save his wife, so later that night he broke into the chemist’s and stole the drug.
Reamer’s Steps in Ethical Decision-Making (Birkenmaier, et. Al.) • Identify conflicting ethical issues, values, and duties • Identify those who are likely to be affected by the decision • Identify possible courses of action and their respective risks and benefits • Examine reasons in favor of and opposed to each action • Consult with colleagues and experts • Document decision • Monitor and evaluate decision
Principles of Biomedical Ethics (2009) • Principle 1: Respect for Autonomy • Principle 2: Nonmaleficence • Principle 3: Beneficence • Principle 4: Justice
Right to Client Self Determination • “This principle means that the client is ultimately in charge of making his own decisions and finding solutions to problems, regardless of whether a social worker agrees with his course of action. A social worker may provide guidance and help clients explore their options, but she may not allow her own opinions and personal biases to influence the client. This is a difficult dilemma that is created by the social worker's desire to act in the client's best interest and the need to respect his right to act in a way that he feels is best.” • http://work.chron.com/list-ethical-dilemmas-facing-social-work-21946.html
Best Interest (National Guardianship Association) • to be used in decision-making when the guardian cannot determine the preference of the ward, or when the ward’s preference will cause substantial harm. Choices should reflect the least intrusive, least restrictive options that promote the ward’s wellbeing.
Substituted Judgement (National Guardianship Association) • This decision-making tool promotes the self-determination of the ward in instances where the ward’s preference is known or can be determined. This option is ethically preferred and, when possible, the guardian shall make choices in conformity with the preference of the ward.
Factors to Consider • Applicable laws • Professional Codes of Ethics • Agency Policy • Evidence Based Practice • Best Practice Guidelines • NGA Standards of Practice
How do I handle a situation when the ward’s values differ from my own values, or those of their involved family members?
Relevant Ethical Principles • Client Right to Self Determination (NASW/ND Code of Ethics) • Self Determination comes from the core value of Dignity and Worth of the Person • Acting in Client’s Best Interest (NASW Code of Ethics) • Our need to act in a client’s best interest comes from the core value of Service (Bryan, et. Al.) • National Guardianship Ethical Principles: • A guardian involves the person to the greatest extent possible in all decision making • 4. A guardian identifies and advocates for the person’s goals, needs, and preferences. • Autonomy and Freedom (Ethical Principles Screen)
Decision-making Checklist • Is this decision within the limits of the guardian's authority? • What are the alternatives or options and possible outcomes of each action? • Is the action or treatment congruent with the values and beliefs of the ward? • What are the ward's feelings and wishes about it? • What are the risks and benefits to the ward if the action is taken? • What are the risks and benefits to the ward if no action is taken? • Is it the least restrictive/intrusive action or treatment available? • If the ward’s preference is unknown, is this action in the best interest of the ward?
NASW Directives for Clients Lacking Decision Making Capacity (Bonifas) • When social workers act on behalf of clients who lack the capacity to make informed decisions, social workers should take reasonable steps to safeguard the interests and rights of those clients. • In instances when clients lack the capacity to provide informed consent, social workers should protect clients’ interests by seeking permission from an appropriate third party, informing clients consistent with the clients’ level of understanding. In such instances…seek to ensure that the third party acts in a manner consistent with clients’ wishes and interests…take reasonable steps to enhance such clients’ ability to give informed consent.
Substituted Judgement • Refers to the requirement that the guardian make decisions that reflect what the ward would have decided if he or she were capable of making the decision • If unable to determine what the ward would have decided, required to make decisions based on the best interest of the ward. You are always encouraged to discuss situations with the ward’s caregivers, family, and friends unless doing so would violate the ward’s privacy • When making decisions based on the best interest of the ward, you must select the least intrusive, least restrictive course of action. (New Guardian Guidelines, ND Courts Adult Guardianship)
What guidance is there for decisions pertaining to medication permissions/administration?
Relevant Ethical Principles • NASW/ND Code of Ethics • Informed Consent • Client Right to Self Determination • Acting in Client’s Beset Interest • National Guardianship Association Ethical Principles • 2. A guardian involves the person to the greatest extent possible in all decision making. • 4. A guardian identifies and advocates for the person’s goals, needs, and preferences.
Factors to Consider • In deciding whether or not it is in the ward's best interests, the guardian must consider: • The invasiveness of the medication or treatment. • The likely benefits of the medication or treatment. • The side effects of the medication or treatment (Wisconsin DHS, 2014)
NGA Standards of Practice Checklist NGA Standard 14 – Decision Making About Medical Treatment ___Yes ___No ___N/A Does person have duly executed living will, durable power of attorney or oral declaration of intent? ___Yes ___No ___N/A Have person’s wishes been requested for consideration in decision process? ___Yes ___No ___N/A Does guardian have a clear understanding of the medical issues and discussed the medical condition, proposed treatment options and preferences with the person placed under a guardianship order? ___Yes ___No ___N/A Has guardian received an independent second medical opinion when appropriate and discussed the person’s preference with the physician providing the consultation? ___Yes ___No ___N/A Have legal/ethical considerations been identified and discussed with hospital ethics committee or legal counsel? ___Yes ___No ___N/A Has the guardian only denied medical treatment after doing a thorough review of person’s history and determined what the person’s preference would be if he/she was still competent? ___Yes ___No ___N/A Has the guardian sought court authorization for extraordinary procedures? ___Yes ___No ___N/A Has the guardian done everything he/she could to inform the person and get feedback from the person concerning medical treatment? ___Yes ___No ___N/A Has the guardian discussed palliative care with the person under guardianship order to determine preferences and values and in keeping with those wishes, incorporate palliative care in the health plan?
Rights of wards in long term care centers pertaining to mail and visitors • Any times where limitations needed?
Rights in Long Term Care Facilities From National Long Term Care Ombudsman Resource Center “Nursing Home Resident Rights” • privacy in written communications, including the right to send and receive unopened mail promptly; • A resident shall have the right to receive and send mail or any other correspondence unopened and without interception or interference. • to have private written and verbal communications or visits with anyone of your choice, or to deny or end such communications or visits.
Relevant Ethical Principles • Client Right to Self Determination (NASW/ND Code of Ethics) • Self Determination comes from the core value of Dignity and Worth of the Person • Acting in Client’s Best Interest (NASW Code of Ethics) • Our need to act in a client’s best interest comes from the core value of Service (Bryan, et. Al.) • Privacy and Confidentiality • Duty to Protect • National Guardianship Ethical Principles: • A guardian involves the person to the greatest extent possible in all decision making • 4. A guardian identifies and advocates for the person’s goals, needs, and preferences.
When communicating with client’s with dementia, it is challenging to know if it is best to continue to attempt to relay information to them and solicit their input, if this is creating confusion, agitation, or distress due to features of dementia.
Relevant Ethical Principles • Acting in Client’s Best Interest (NASW Code of Ethics) • Our need to act in a client’s best interest comes from the core value of Service (Bryan, et. Al.) • National Guardianship Ethical Principles: • 1. A guardian treats the person with dignity. • 4. A guardian identifies and advocates for the person’s goals, needs, and preferences.
Katie Krukenberg, MSW, LCSW Asst. Professor of Social Work, Director of Field Education University of Mary 701-355-8087 kbkrukenberg@umary.edu
