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Ethics: Making Critical Decisions in Treatment Patricia Sherman, Ph. D

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1 Ethics: Making Critical Decisions in Treatment Patricia Sherman, Ph. D
Ethics: Making Critical Decisions in Treatment Patricia Sherman, Ph.D., LCSW

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

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

4 Purposes of the NASW Code of Ethics (Stone, 2004)
Identifies core values on which social work’s mission is based Summarizes broad ethical principles that reflect the profession’s core values and establishes ethical standards to guide social work practice

5 Is designed to help social workers identify relevant considerations when professional obligations conflict or ethical uncertainties arise Provides ethical standards to which the general public can hold the social work profession accountable

6 Socializes practitioners new to the field to social work’s mission, values, ethical principles, and ethical standards Articulates standards that the social work profession itself can use to assess whether social workers have engaged in unethical conduct

7 Provides practitioners with guidance when faced by practice dilemmas that include ethical issues
Protects the public from charlatans and incompetent practitioners Protects the profession from governmental control; self-regulation is preferable to state regulation

8 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

9 Social work Ethical Principles
Primary goal is to help people in need and to address social problems Challenge social injustice Respect the inherent dignity and worth of the person

10 Recognize the central importance of human relationships
Behave in a trustworthy manner Practice within areas of competence and develop and enhance professional expertise

11 Acceptance Individualization Purposeful expression of feelings Nonjudgmental attitudes

12 Objectivity Controlled emotional involvement Self-determination Access to resources Confidentiality and accountability

13 Begin With Values Societal Values – Professional Values –
Client Values – Personal Values –

14 Values VALUE is the reality in the inner core of a person which:
shapes one’s ideas conditions one’s feelings affects one’s behavior (Simon, Values Clarification, 1970, p. 25) Whether recognized or unrecognized, values are essential to professional action and to any conception of practice theory

15 Are implicit and explicit about what we cherish as ideal and preferable
Determine which goals and actions we evaluate as “good” Shape our beliefs and our attitudes and, in turn, our beliefs and attitudes shape our values

16 Define norms or guidelines for behavior
Laden with emotions Influence our evaluations of situations and motivate the actions we take


18 Social Justice Values (Catechism of the catholic church, 1994, catholic conference of the united states bishops, 1995, himchak, 2007) Life and dignity of the human person Call to family Community and participation

19 Rights and responsibilities
Option for the poor, the vulnerable, and people at risk Dignity of work and the rights of workers Solidarity and care for God’s creation

20 Values shared by all helping professions
Autonomy Nonmaleficence – do no harm Beneficence – promote good Justice Fidelity – create trusting relationship Veracity – be truthful

21 Common Social Work Values
Promotion of the client ‘s well-being and individual dignity Self-determination The right to have basic needs met

22 The right to actualize one’s full potential
Client empowerment Human diversity Social and economic justice

23 Values specific to work area
Child welfare Protection of children Preservation of families Respect for families Diligence – “hanging in there” with difficult situations

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

25 Personal values exercises

26 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?

27 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

28 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

The social worker should promote the general welfare of society The social worker should act to ensure that all person have access to the resources, services, and opportunities which they require The social worker should advocate changes in policy and legislation to improve social conditions and to promote social justice

30 Moral questions for the Profession
What are the clients’ rights as individuals? What are their obligations to their families? Under what circumstances is it permissible to support the breaking up of a family?

31 Under what circumstances is it legitimate to override client self-determination (e.g., clients with mental illness who will not take medication)? Is coercion justified in any given case? How far and when is individual dependency a public responsibility; how far and when a private responsibility?

32 In what circumstances, if any, should the client’s confidence be violated by the social worker?
Should the social worker ever be responsible for law enforcement?

33 ETHICS The study of rightness and wrongness
of human conduct (Varga, 1980, p. ix). It is that part of a moral philosophy that concerns relationships between people, and a set of values, assumptions, beliefs, and normative rules that identify, support, and explain the duties and obligations for good, right conduct (Siporin, p. 523).

34 Relates to what people consider correct or right
Generates standards that direct conduct Represents “values in action” Social work ethics represents behavioral expectations or preferences that are associated with social work responsibility

35 Ethics and values Ethics are deduced from values and must be in consonance with them The difference between them is that values are concerned with what is good and desirable while ethics deal with what is right and correct. (Loewenberg et al, 2000)

36 Values deal with what beliefs are appropriate
Ethics address what to do with or how to apply those beliefs

37 Ethical Standards Ethical Responsibilities to Clients
Ethical Responsibilities to Colleagues Ethical Responsibilities in Practice Settings Ethical Responsibilities as Professionals Ethical Responsibilities to the Profession Ethical Responsibilities to Society at Large

38 PROFESSIONAL ETHICS Refers to the moral philosophy that is the
set of values, beliefs, and normative rules that prescribes and explains the obligations for good, right conduct on the part of a profession’s members

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

40 Teleological Theories – the rightness of any action is determined by the goodness of its consequences Egoism – people should maximize their own good and enhance their self-interest Utilitarianism – an action is right if it promotes the maximum good

41 Act utilitarianism – the rightness of an action is determined by the goodness of the consequences produced in that individual case or by that particular act Rule utilitarianism – takes into account the long-term consequences likely to result if one generalizes from the case at hand or treats it as a precedent

42 Kohlberg moral dilemma exercise

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

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

45 THOMISM is an ethical theory that is very influential in current thinking about ethics in medicine. According to Aquinas, ”The perfecting of creatures through the development of their natures constitutes the highest good for them” The first natural law is that all actions that conserve life or avoid death are included in moral law

46 Since all living creatures share a natural inclination to propagate the species, a natural law for mankind is that the species should be propagated and children educated Human beings are rational beings and should therefore seek truth and avoid ignorance

47 Aquinas did not believe that actions contrary to moral law are wrong simply because they are prohibited by God; rather, he believed that they are prohibited by God because they are wrong God-given law - Life is sacred

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

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

50 Privilege refers to legal rights transpired between the worker and client and is protected by law and cannot be revealed without that client’s expressed permission (Barker 1999) Relative confidentiality is much more common than privilege

51 Social Workers may disclose confidential information when appropriate with valid consent from a client or a person legally authorized to consent on behalf of a client or when needed to defend self (NASW 1996) Should inform the client to extent possible about the disclosure of confidential information and the potential consequences when feasible before the disclosure is made

52 Self-Determination and Paternalism
Self-determination is an ethical principle that acknowledges people’s right to make their own decisions and choices (Barker 1999) Paternalism is action that interferes with a client’s wishes or freedom for his own good (Reamer 1995)

53 Evaluate client’s decision-making capacity
Evaluate client’s decision-making capacity. In the social worker’s professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others It also urges action on behalf of clients and pursuit of courses of action that safeguard such clients

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

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

56 Involves boundary issues
Boundaries are invisible barriers that separate various roles and limit the types of interaction expected and considered ethically appropriate for each role Example: Social worker and client attend the same AA meeting

57 Think about boundary issues and establish professional boundaries from the beginning, taking cultural issues into consideration Consult your supervisor and professional colleagues Scrutinize your own motivations

58 Discuss with the clients
Sexual attraction – refer client to another professional if this cannot be resolved through supervision; never act on it Distribute fliers on client rights and professional ethics

59 Whistle-Blowing Act of informing on another or making public an individual’s, group’s or organization’s corrupt, wrong, illegal, wasteful, or dangerous behavior How great is the threat to the potential victims?

60 What type and quality of proof are available that the wrongdoing has occurred or is going on?
Are there less severe alternative measures you might take to remedy the problem? Can you assume the burden of risk? How much do you have to lose?

61 Guidelines for Ethical Decision Making (Reamer, 1999)
Rules against basic harms to the necessary preconditions of human action (such as life itself, health, food, shelter, mental equilibrium) take precedence over rules against harms such as lying or revealing confidential information or threats to additive goods such as recreation, education, and wealth

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

63 The obligation to obey laws, rules, and regulations to which one has voluntarily and freely consented ordinarily overrides one’s right to engage voluntarily and freely in a manner that conflicts with these laws, rules, and regulations Individuals’ rights to well-being may override laws, rules, regulations, and arrangements of voluntary associations in cases of conflict

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

65 Process of Ethical Decision Making
Identify the ethical issues, including the social work values and duties that conflict Identify the individuals, groups, and organizations likely to be affected by the ethical decision

66 Determine what additional information you need and how that information might affect your decision
Tentatively identify all viable courses of action and the participants involved in each, along with the potential benefits and risks for each

67 Thoroughly examine the reasons in favor of and opposed to each course of action, considering relevant Ethical theories, principles, and guidelines Codes of ethics and legal principles Social work practice theory and principles Client’s values (including religious, cultural and ethnic values, and political ideology), particularly those that conflict with one’s own Personal values

68 Consult with colleagues and appropriate experts (such as agency staff, supervisors, agency administrators, attorneys, ethics scholars) Make the decision and document the decision-making process Monitor, evaluate, and document the decision’s outcome

69 Ethics Audit (Reamer, 2000) Client rights Confidentiality and privacy
Informed consent Service delivery – competence Boundary issues and conflicts of interest Documentation Defamation of character

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

71 Supervision and training
Consultation Referral Fraud Termination of services Practitioner impairment

72 Discussion of Specific Ethical Dilemmas

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