Ethics and Social Work in Health Care

1. Chapter 3 Handbook of Health Social Work, 2nd Edition Created by Teri Browne Ethics and Social Work in Health Care

2. Complexity of Ethics • 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

3. Points to Consider in a Ethical Dilemma • Confidentiality & Privileged Communication • Truthfulness • Paternalism & Self-Determination • Laws, Policies, & Regulation • Whistle-blowing • Distributing limited resources • Personal & Professional Values • Ethical Decision Making (Reamer, 1987)

4. Purpose of the Code of Ethics • Provides direct guidance for practice • Protect the public • Protect the profession • Prevent internal strife • Protect practitioners against lawsuits (Lowengerg & Dolgoff, 1996)

5. Terminology Used in EthicsValues • 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 another • Need 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

6. Core Social Work Values • 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)

7. Morals • “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

8. Laws • 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

9. Principals and Standards • 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

10. Ethics Three Branches • 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.

11. End of Life Care • 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

12. Basic Normative Theories • Deontological and Teleontological Theories • Utilitarianism • Ethics of Duty (Kantian Ethics) • Ethics of Care Virtue Ethics

13. Deontological and Teleontological 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 outcome • Example 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?

14. Utilitarianism • 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

15. Ethics of DutyKantian Ethics • 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.)

16. Ethics of Care • Applications of Care Ethics in heath settings: • A shift from principle and institutional rules to an emphasis on a more responsive relationship with the patient • An emphasis on self-awareness in order to understand others • Placing value on ethical discourse and not focusing only on outcomes • A review of gender-based differences in health care • An emphasis on the nature and dynamics of relationships and how it may influence ethical decision making • Acknowledgment of the reality of moral ambivalence • Consideration of what traits or virtues one should develop to further competence in the ethical decision making

17. Virtue Ethics • Refers to the positive attributes of a particular type of person • Believed 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.

18. Development of Medical 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.

19. Development of Social Work 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

20. Morality Period • 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 ethics • 1947 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

21. Values 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

22. Ethical Theory & Decision-Making Period • 1980s-1990s • Largely influenced by conferences and center and commission work • Recognized need for this in order to resolve health-care and social justice issues. • Malpractice concerns and managed care helped direct ethics during this time

23. Ethical Standards & Risk Management Period • 1990s – present • Increase in public “scandals” has led social workers to be more aware of ethical principals • Presently 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?

24. Development of Bioethics • 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

25. 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

26. Decision-Making Models • 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.

27. Decision-Making Steps • Recognize the problem • Investigate the variables • Get feedback from others • Appraise the values that apply to the dilemma • Evaluate the dilemma • Identify and think about possible alternatives • Weigh the pros and cons of each alternative • Make your decision (Netting & et al., 1993) • Models often share components, but differ in fundamental areas.

28. Decision Making Models • 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

29. Dual Relationships • 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

30. Managed Care • Discuss components of managed care that may increase ethical violations: *Exaggeration of patient symptoms * Dual Relationships *Informed Consent *Confidentiality

31. Whistle-Blowing • 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.

32. Social Work Research Ethics • 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?

33. Ethical Challenges in the 21st Century • “Right” answers for ethical dilemmas are not always available • Health 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?