Download Ethics and Social Work in Health Care

ETHICS AND SOCIAL
WORK IN HEALTH CARE
Chapter 3
Handbook of
Health Social
Work, 2 nd
Edition
Created by
Teri Browne
COMPLEXIT Y 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
POINTS TO CONSIDER IN A
ETHICAL DILEMMA
1. Confidentiality & Privileged Communication
2. Truthfulness
3. Paternalism & Self-Determination
4. Laws, Policies, & Regulation
5. Whistle-blowing
6. Distributing limited resources
7. Personal & Professional Values
8. Ethical Decision Making
(Reamer, 1987)
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)
TERMINOLOGY USED IN ETHICS
VALUES
 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
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)
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
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
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
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.
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
BASIC NORMATIVE THEORIES
 Deontological and Teleontological Theories
 Utilitarianism
 Ethics of Duty (Kantian Ethics)
 Ethics of Care Virtue Ethics
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?
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
ETHICS OF DUTY
KANTIAN 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.)
ETHICS OF CARE
Applications of Care Ethics in heath settings:

1.
2.
3.
4.
5.
6.
7.
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
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.
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.
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
MORALIT Y PERIOD
 Late 19 th 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
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
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
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 ef fect the way in which you make your decisions
as a social worker?
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
dif ficulties
 “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
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 fir st governmental bodies to consider ethics
*created several impor tant documents that set up guidelines for
medical research. (i.e. Belmont Repor t)
What do you think about Alber t Jonsen’s later criticism of the repor t?
 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
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.
DECISION-MAKING STEPS
1.
2.
3.
4.
5.
6.
7.
8.

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.
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
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
MANAGED CARE
Discuss components of managed care
that may increase ethical violations:
*Exaggeration of patient symptoms
* Dual Relationships
*Informed Consent
*Confidentiality
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
*Ef fect 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.
SOCIAL WORK RESEARCH ETHICS
 IRB (Instituti onal Review Board) acts as a safeguard against potentially
harmful research
 What would be some reasons social worker s deviate from ethical practice
when conducting research?
 Key areas to remember in research:
*Voluntar y par ticipation or consent
*No harm to par ticipants
*Deception
*Analysis and repor ting
*Justice and beneficence
 Nuremberg Code
 Tuskegee Study
 Millgram’s Obedience Study
*Impor tant 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?
ETHICAL CHALLENGES IN THE
21 ST 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?