Introduction: Ethical decision-making is crucial in the field of human services. It should be noted that deciding not to make a decision is also considered a choice (Keith-Spiegel & Koocher, 2010). The purpose of this paper is to explore applied ethics and decision-making, utilizing a framework that integrates moral theories (Reamer, 1993).
The approach to managing this situation relies on the interpretation of personal beliefs regarding ‘right’ and ‘wrong’, as well as considering important factors. Initially, this paper introduces the ethical dilemma and explores the principles and ethics that are endangered. It further provides an explanation of various ethical theories applicable in recognizing decision-making influences. Subsequently, a framework for ethical decision-making (McDonald, 2001) is introduced, involving discussions and reasoning while considering emotions, personal vulnerabilities, personality traits, professional values, legislations, and situational context.
In order to handle the ethical dilemmas that may emerge, I took proactive steps to address them positively while demonstrating empathy and considering the welfare of all individuals affected by this circumstance. The ethical dilemma arises from multiple sources, encompassing both the patient’s expectations and the expectations imposed by authoritative bodies like hospitals and government regulations. Additionally, my own set of values, including moral principles, societal obligations, and professional duties, also contribute to this complex situation.
The predicament I am encountering has three components: patient confidentiality, child care, and my stance on complying with the patient’s desires. The issue of patient confidentiality arises as I contemplate whether or not I am violating this ethical rule by disclosing the patient’s intentions to the appropriate authorities or discussing them. Additionally, there is the matter of arranging child care for Mrs. Sara’s 10-year-old son, which her mother does not seem particularly enthusiastic about taking on herself.
The legal aspect presents strong barriers to meeting the desires of patients. These barriers include Mrs. Sara’s mother acting as power of attorney, laws, and my own legal problems, such as being sued for breaching confidentiality. In order to manage these risks, it is crucial to adhere strictly to the principles outlined in relevant laws, policies, professional standards, and ethics codes provided by AASW. Risk management plays a vital role in mitigating the various risks that arise in this scenario.
Another central point I consider is the importance of self-protection against the hazards of modern-day professional services (Bennett, Bryant, VandenBos, & Greenwood, 1990; VandeCreek & Knapp, 2000; Walker, 1999), also known as defensive ethics. In relation to this, I advocate for vigilant ethics, which emphasizes that the main reason for being ethically aware and sensitive as a clinical social worker is not solely for self-protection. By maintaining high standards, I can act with benevolence and courage instead of relying on protective armor.
The strategies I have chosen to manage these risks involve utilizing elements of good practice such as keeping thorough records, reviewing client files, documenting reasons for decisions, and seeking consultation with colleagues or other appropriate individuals regarding the patient’s situation (while maintaining her confidentiality and adhering to ethical guidelines). It is important to carefully document these meetings (Kennedy, Vandehey, Norman, & Diekhoff, 2003). In dealing with this dilemma, I believe that ethical theories are crucial tools for practitioners.
They offer resources to professionally address human concerns in order to enable people to progress and lead fulfilling lives. In this case, my main concerns are the well-being and confidentiality of the patient, Mrs. Sara (AASW, 2010, p. 27-29). ‘Social workers, regardless of their location in the service continuum, may engage in individual and collective debates regarding the core values of advancing social justice, empowering client autonomy, and enhancing social well-being’ (Connolly & Harms, 2009). The pure theoretical approach refers to strictly adhering to a specific theory, which can be challenging, while eclectic practice involves employing theories flexibly based on their usefulness in a given situation. Therefore, a comprehensive understanding of ethical theories is necessary for this purpose.
The utilization of various approaches without deeper understanding could compromise effective practice, while a purist approach provides a straightforward guideline, though it can be challenging to navigate during implementation (Connolly & Harms, 2012). I chose an eclectic approach to theory because I lean towards a structured approach, and I agree that a more structured theoretical approach can offer a comprehensive understanding from explanation to technique. This situation incorporates components from all major ethical theories. The theories that influence my decision-making process include:
In my pursuit to benefit the patient (consequentialism), I believe in utilizing teleology. I strive for the patient to receive the care and treatment that any human may hope for, which aligns with virtue-based ethics. Additionally, I aim to be truthful and good as a person and professional and cause happiness for the patient, which falls under value-based ethics. Furthermore, I consider the Ethics of care due to our relationship and my concern for the patient’s care. Despite these various ethical considerations, I believe that my dilemma and its resolution can be best explained by the theory of deontology.
Deontologism is focused on the action itself and its process, as well as the moral rules and principles associated with the act. It emphasizes the importance of acting in accordance with ethical principles, including respect for autonomy, non-malfeasance, beneficence, justice, fidelity, veracity, and avoiding killing (Kornblau & Starling, 1999). In the context of an ethical decision-making framework, questions arise about whether to base ethics on reason or sympathy and whether professional duties conflict with personal religious beliefs about doing good to others.
If I discharge my client from my services, will it violate my social contract as a clinical social worker? There is a concern that this action may result in legal problems due to breaching confidentiality (Veatch, 2000). The decision-making process regarding ethical or unethical actions is influenced by various individual factors such as knowledge, values, attitude, and intentions. These factors interact with organizational and governmental factors, including significant others and legislations. McDonald’s (2001) ethical decision-making framework reveals that multiple factors play a role in determining the likelihood of ethical actions taken by individual decision makers.
The AASW Codes of Ethics (2010, p. 14) offers codes without a comprehensive framework. One essential aspect is the possession of professional and personal skills required to work within these frameworks. This can include skills such as ethical assessment, which encompasses bioethics, agency policies, professional codes, religious and cultural values. Additionally, process skills such as effective interaction with key decision-makers, and interpersonal skills like the ability to listen and communicate respectfully, supportively, and empathetically with all stakeholders may be necessary.
Below is the structured process as per framework.
1. Information collection and problem identification
1.1. Alert at morally charged situations
The basic ethical codes in black and white available as ready reference to me are Australian Association of Social Workers (AASW) Code of Ethics (2010). My personal moral values are against suicide or assisting in one. My professional training and ethics prohibits it and breaching of confidentiality on moral grounds and legislations (AASW, 2010, p. 27-29).
1.2. Identification of what I know
In order to maintain patient and institutional confidentiality (AASW, 2010, p. 27-29), I considered the viewpoints of the patient, their family, the physician, and the administrator. I conducted numerous visits and meetings to collect precise and thorough information. However, it is important to acknowledge that there might be a balance between acquiring more information and potentially compromising morally significant decisions. Consequently, in certain instances, I had to make choices without fully comprehending the complete situation.
The Appendix provides a summary of the case, including information about the patient’s condition. The ethical dilemma and its resolutions have already been addressed. It is important to note that the patient’s mother holds power of attorney, and it should be highlighted that Australian law strictly forbids euthanasia and any form of assistance in such situations. These various factors and organizations, including AASW, play significant roles in the decision-making process. Fortunately, there are no conflicts of interest for myself or other involved parties. All these elements contribute to understanding the context within which decisions are made (1.4).
The timing of evaluating Mrs. Sara’s reasoning for termination is crucial to determine the correctness of her decision. To better understand the situation, it is necessary to gather clinical information regarding her medical history, diagnosis, and prognosis. Although she is facing severe cancer, it is still reversible and the treatment she is undergoing has positive results in achieving intended goals. While contingency plans have been prepared in case of treatment failure, they are unlikely to be needed. Ultimately, following the outlined rules will benefit Mrs. Sara by reducing her suffering and preventing further harm.
The patient’s preferences are being respected as she has communicated her lack of desire for the treatment, stating that enduring it would not be worth it if it leads to a shorter lifespan. The patient has been fully informed about the treatment’s benefits, risks, and potential impact on her son’s life, including effects on his confidence, personality, and relationships. Furthermore, consideration is being given to the patient’s mental well-being (Appendix). It is important to note that the patient’s mother is legally authorized to make decisions on her behalf. In conclusion, ethical principles and legal regulations ensure that the patient’s right to make choices is honored.
The gathered information indicates that there are no cultural, religious, or family issues that would affect her treatment, as she is a native Australian. There are also no legal ramifications regarding the treatment itself. However, it is necessary to adhere to Australian legislation regarding the care of Mrs. Sara’s son, and Centrelink provides thorough guidelines and procedures for this. As the ethical decision maker, I have the option to prioritize Mrs. Sara’s wishes.
Sara is experiencing extreme suffering from her current treatment and has a valid reason to believe that she may not survive much longer even with continued treatment. I am unable to personally assist her due to legal restrictions, but I can offer guidance on options such as seeking medical referral in a country where euthanasia is legal. However, this decision would greatly impact her remaining family, as Mrs. Sara serves as the linchpin of three generations. It is important to consider the potential implications on future overseas referrals and establish appropriate policies for similar situations. An alternative course of action for me would be to dismiss the case entirely and withdraw my involvement.
However, going against my personal ethics and prioritizing my own self and career over a life is not something I am willing to do. Additionally, I could face legal trouble due to breach of confidentiality if the patient decides to sue me. On the other hand, if I do not inform the administration or relevant personnel about her intentions, it can be dangerous. 3. Morally significant factors 3. 1. Principles Other principles that are taken into consideration include autonomy, where no promises are made to the patient and she is not exploited in any way.
The principle of non-maleficence, or avoiding harm, is upheld to ensure the well-being and safety of the patient and the wider community. Similarly, the principle of beneficence involves prioritizing the welfare of both the patient and her family. Furthermore, fair treatment for all individuals involved, including the patient and her family, is required by the principle of justice. It is important to note that none of their moral rights and entitlements are disregarded in this process. As a professional, it is my duty to remain loyal to my profession and institution by refraining from actions that violate fidelity.
Additionally, I have access to reliable sources such as the AASW Codes of Ethics and literature which provide ethical and legal guidance. These sources offer universally accepted principles that align with our communities’ and organizations’ moral values. They also provide professional guidelines for effectively navigating these situations compared to other sources. Legal precedents have clearly established that there are currently no provisions for assisting anyone if it would cause harm to their life or others.
When considering my personal ethics and values, which are influenced by my religious and cultural traditions, I came to the same conclusion. I believe that the patient is a mentally strong woman, and this judgment is shared by others including physicians, colleagues, and supervisors. To help resolve ethical dilemmas, the Ethics Consultation Service by AASW (AASW, 2010, p. 14) is a valuable resource. Conducting formal case conferences with involved personnel and ethics consultants has proven to be effective. Regarding possible resolutions, following my choice would result in the best consequences. Although breaching confidentiality may lead to legal problems, it may also be justified by saving the patient’s life. This decision would eliminate the dilemma of child care and avoid challenging the patient’s mother’s authority. However, not following my choice to breach confidentiality and assisting the patient in her wishes could potentially harm herself and create complications in her son’s life such as being placed with an unknown family. In such a scenario, I may face legal actions from the patient’s mother and the state.
The theoretical approach implies that the worker is favoring one side. In this situation, I may appear to be taking Mrs. Sara’s mother’s side if I choose not to help her fulfill her wish or support it, or if I prioritize her son’s future and child care. On the other hand, if I support Mrs. Sara’s wish, her mother may accuse me of taking sides in a wrongdoing. 5. The Decision Considering these ethical factors, my critical analysis leads me to only one option with minimal risks and more benefits.
Considering the impact of my decision on the ethical performance of others is crucial. This consideration makes it easier for them to make the right choice. Additionally, the available literature supports this course of action in similar situations. The majority of advice leans towards doing more good in these dilemmas. However, the long-term challenge lies in maintaining trust with others. To ensure trust, it is essential to continue deserving it especially when others are under my care or dependent on me.
After considering the entire process, it is evident that in order to prioritize the greater benefit for the patient and her family, I must, to some extent, breach her confidentiality and communicate with the appropriate administration and personnel. It is not justifiable to comply with the patient’s desire to solely focus on the positive aspects of her situation. The legal and ethical principles prohibit me from abiding by her request to cease treatment, as this may require a certain amount of time but will yield the most favorable outcomes through appropriate actions. In conclusion, adherence to ethical principles prompted me to reflect on determining what consequences are beneficial or valuable.
By considering ethical resources such as theories, codes, and legislations in the decision-making process, I acknowledge the responsibility for my choice. This also involves recognizing the potential for being incorrect or making a suboptimal decision. The goal is to make the best possible choice with the information and resources at hand, rather than striving for perfection. As a social worker, like professionals in any field, it is important to learn from both failures and successes. References
AASW, (2010). Code of Ethics. Australian Association of Social Workers, 2010, 14, 27-29. Australian Association of Social Workers, (2010). Code of Ethics. Retrieved from: www.aasw.asn.au/document/item/740
Bennett, B. E., Bryant, B. K., VandenBos, G. R., & Greenwood, A. (1990). Professional liability and risk management. Washington, DC: American Psychological Association.
Conolly, M. & Harms, L. (2009). Social Work: Context and Practice. 2nd ed. Melbourne: Oxford University Press.
Conolly, M. & Harms, L. (2012). Social Work: From theory to practice. 1st ed. Melbourne: Cambridge University Press.
Keith-Spiegel, P. & Koocher, G. P. (2010). Responding to research wrongdoing: A user-friendly guide.
Kennedy, P. F., Vandehey, M., Norman, W. B., & Diekhoff, G. M. (2003). Recommendations for risk-management practices. Professional Psychology, 34, 309-311.
Kornblau, B. L. & Starling, S. P. (1999). Ethics in rehabilitation: a clinical perspective. Thorafare (NJ): Slack Inc. 1999, 53-54.
McDonald, M. (2001). A Framework for Ethical Decision-Making: Version 6.0. Ethics Shareware (Jan, ’01).
Reamer, F. G. 1993). The philosophical foundations of social work.New York: Columbia University Press.
Rogerson, M. D., Gottlieb, M. C., Handelsman, M., Knapp, S., Younggren, J. (2011). Nonrational processes in ethical decision-making. American Psychologist, 66, 614-623.
Tjeltveit, A. C. & Gottelieb, M. C. (2010). Avoiding the road to ethical disaster: Overcoming vulnerabilities and developing resilience.Psychotherapy Theory, Research, Practice, Training’s (2000) article titled “Risk management and life-threatening patient behaviors” by VandeCreek and Knapp examines the connection between risk management and patients displaying life-threatening behaviors.
Journal of Clinical Psychology, 56, 1335-1351. Veatch, R. M. The basics of bioethics. 2nd ed. Upper Saddle River (NJ): Prentice Hall. Walker, R. (1999). Heading off boundary problems: clinical supervision as risk management. Psychiatric Services, 50, 1435-1439. Appendix Scenario This scenario illustrates an ethical dilemma faced at a local hospital by a Clinical Social Worker. For the purpose of clear ethical decision-making process demonstration, I will be presenting the role of the Clinical Social Worker in this particular scenario.
As part of my caseload, I work with numerous patients battling terminal illnesses. Recently, a young woman (referred to as Mrs. Sara to protect her privacy) was admitted to the hospital for metastatic prostate cancer, and I visited her. During our first meeting, 33-year-old Mrs. Sara expressed her desire to discontinue her challenging cancer treatment and embrace death. Despite her situation, she maintained a neat appearance while lying in bed and interacted with me appropriately, maintaining eye contact.
Despite her restless legs, Mrs. Sara’s speech appeared normal in tone, volume, rate, quality, and fluency. Subjectively, she reported feeling fine and euthymic. Following our conversation, I consulted with her physician and mother to better understand the reason behind her emotional state. It was revealed that Mrs. Sara has been diagnosed with depression and has been consuming excessive pain medication. She confided in her doctor about her intention to end her life after being discharged. Additionally, she experiences progressive weakness in her legs, rendering her unable to walk.
Her physician has advised that if she can control her drug addiction and continue treatment, there is a high possibility of her cancer going into remission. However, this outcome is dependent on her adherence to these guidelines. The patient is scheduled for a debulking operation, and the chemotherapy is displaying signs of progress. Additionally, the patient’s mother has revealed that she has a ten-year-old son who relies on her presence in his life. The mother strongly opposes her daughter’s wish to die, believing it to be an act of suicide and considering her too young to succumb to such thoughts.
As the medical decision maker, she, who is also her daughter’s Advance Directive, refuses to discontinue treatment despite her daughter’s wishes and statements. This decision is made under her authority as power of attorney. It is expected that there may be some physical challenges post-treatment and surgery, such as difficulties in fast walking or running and hair loss. However, there are no reports of any mental problems. These physical challenges may lead to minor social impairments, but overall, the patient will still be able to lead a normal life. There are no predictions of severe future conditions that would make life undesirable for her.
According to the physician, the patient will receive nursing services at home for her palliative care under Medicare. The physician’s clear observations have had a positive impact on the treatment decision. However, breaching confidentiality to some extent is necessary to discuss the patient’s wishes and case with colleagues, administration, and supervisors. Fortunately, there are no issues with the allocation of resources, whether human or non-human.
