Introduction There are some times when there is no choice but to make decisions with possible ethical consequences at some point in any human services career when an ethical dilemma is faced. If one chooses not to make a decision, it is a decision itself (Keith-Spiegel & Koocher , 2010). In this paper, I am concerned with applied ethics and decision making using framework for a positive decision in presented scenario (Appendix) which guide the conduct for decisions based on theories about what is morally right or wrong (Reamer, 1993).
How this situation dealt with relies on how I make sense of what I believe about ‘right’ and ‘wrong’ and what factors I believe are worthy of consideration. In this paper, first the ethical dilemma presented. Then principles and ethics at risk are discussed. Different ethical theories applicable to scenario for acknowledging the influences on decision making are illustrated. After that a framework for ethical decision-making (McDonald, 2001) is presented where discussion and reasoning are made while considering the factors such as emotions, personal vulnerabilities, personality, professional values, legislations and context of situation.
I tried here to recognize, approach constructively, and reconcile potential ethical predicaments, while at the same time remaining compassionate and attuned to the well-being of all the parties involved in this scenario. The Ethical Dilemma The ethical dilemma is caused due to several factors such as the expectations of the patient, organizational expectations (hospital, governmental regulations and AASW code of ethics) and my personal values (like moral philosophies, the perceived social responsibilities and sense of professional duty) and how they all interact with each other.
The dilemma I face here has three parts: the patient confidentiality, the child care and my position as to go with the patient’s wishes. The confidentiality of patient plays part as if I am breaching this ethical rule or not by informing relevant authorities or by discussing her intention. The child care for the 10 years old son of Mrs. Sara creates another situation which is not possible for Mrs. Sara’s mother in her statement and her mother not seems to be too much interested in the job on her own.
The legal aspect strongly stand in between the patients desires to be met. These include Mrs. Sara’s mother as power of attorney, the laws, and my own self facing legal problems like sued for breach of confidentiality. The Risks There are a number of risks which pop up in this scenario, which are to be mitigated by the risk management. The key to the effective risk management here is to scrupulously uphold the tenets of relevant laws, policies, professional standards, and ethics codes provided by AASW.
Another central point considered by me is on self-protection against the hazards of modern-day professional services (Bennett, Bryant, VandenBos, & Greenwood, 1990; VandeCreek & Knapp, 2000; Walker, 1999) as the defensive ethics. For this point, I take position for vigilant ethics that the primary rationale for being an ethically aware and sensitive clinical social worker is not for self-protection. Maintaining high standards will allow me to act with benevolence and courage rather than donning protective armor.
The strategies opted by me to manage these risks include the elements of good practice, keeping careful notes, reviewing client file, recording reasons, and consulting with colleagues or appropriate others about the patient (while protecting her identity and not breaching confidentiality) and carefully documenting such meetings (Kennedy, Vandehey, Norman, & Diekhoff, 2003). Ethical Theories Applicable to Dilemma I consider theories to be indispensable tools for practitioners.
They provide resources that help professionally address human concerns so that people can move forward and live rewarding lives. Here the well being and confidentiality of the patient, Mrs. Sara, are major apprehensions for me (AASW, 2010, p. 27-29). ‘Social workers may debate, both individually and collectively, aspects of the core values of securing social justice, supporting client autonomy, and promoting social well-being, no matter where we may work across the service continuum. (Connolly & Harms, 2009) The purist theoretical approach refers to following a particular theory to its word, is quite difficult, while eclectic practice refers to an approach that does not specifically favor one theory but uses theory flexibly as it is considered useful in any given situation. For this purpose, the complete knowledge of ethical theories is required.
Superficial use of a variety of approaches could undermine good practice whereas purist approach offers a relatively clear blueprint, but easy to get lost along the practice route (Connolly & Harms, 2012). I took the eclectic approach to theory is as I am inclined towards a structured approach, and I agree that a more structured theoretical approach can provide a complete picture from explanation to technique. This scenario has elements of all major ethical theories. The theories influencing my decision process are:
Teleology, in my pursuit to benefit the patient (consequentialism); Virtue-based ethics to strive for the patient to receive the care and treatment that any human may hope for; Value-based ethics to be truthful and good as a person and professional and cause happiness for the patient, and Ethics of care due to the our relationship and my concern for patient’s care. However, I believe that my dilemma and its resolution were derived from and best explained by the theory of deontology.
Deontologism focuses on the very action and its process, and the moral rules and principles involved with the act versus the consequences of the action itself. It emphasizes that one must act in accordance with rules and principles of ethics such as respect for autonomy, non-malfeasance, beneficence, justice, fidelity, veracity and avoidance of killing (Kornblau & Starling, 1999). Ethical Decision-Making Framework Some questions that arose as part of the dilemma were; do I resolve my ethics based on reason or do I base it on sympathy? Do my professional duties conflict with my personal religious beliefs to do well unto others?
Will my social contract as a clinical social worker be broken if I discharged my client from my services since I may face legal problems for breaching confidentiality (Veatch, 2000). Individual factors (including knowledge, values, attitude, and intentions) are posited as interacting with organizational / governmental factors (including significant others and legislations) to influence individuals involved in ethical / unethical decision-making dilemma. The ethical decision-making framework presented by McDonald (2001) demonstrates that multifaceted factors affect the likelihood of the ethical actions by individual decision makers.
AASW Codes of Ethics provides codes but no proper framework (AASW, 2010, p. 14). One important thing is professional and personal skills set needed for working as per frameworks. These may be but are not limited to ones I presumed for myself in the given scenario like ethical assessment skills including bioethics, agency policies, professional codes, religious and cultural values; or process skills like effective interaction with key decision-makers; and interpersonal skills like ability to listen and communicate with respect, support and empathy for all.
Given 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
I tried to be within bounds of patient and institutional confidentiality (AASW, 2010, p. 27-29), and made sure that I have the perspectives of patient and family as well as physician and administrator. By multiple visits and meetings, I made sure that information is accurate and thorough. But it should be noted that I already knew that there can a trade-off between gathering more information and letting morally significant options disappear, so I may have to make some decisions before the knowledge of full story. 1. 3. Brief case, facts and circumstances
The case is presented at Appendix with the facts about the condition of patient. I have part decisions to make for this dilemma already mentioned under The Ethical Dilemma. The mother of the patient is power of attorney in this case. Then there is legislation of Australia that does not allow the euthanasia in any form and prohibits the assistance in same. These factors and entities (AASW inclusive) are also playing important roles in decision making. One thing positive in this scenario is that there is no conflict of interest for me also elaborated by all involved entities. 1. 4. Context of decision-making
The timing is essential here because we ought to get Mrs. Sara to see to it that her reasoning for letting go is right or wrong and depending on the outputs as well. The context is made clearer by gathering the clinical information, about Mrs. Sara’s medical history / diagnosis / prognosis. The cancer is critical but reversible. As goals, the treatment is showing positive responses. The contingent plans in case of treatment failures were prepared but will never required. The abiding rules presented in scenario will benefit the patient lessening her suffering in time and the harm be avoided.
Considering the preferences, patient does not prefer the treatment, not considering it worth of suffering if she has less time to live after treatment. For that reason, she has been informed about the benefits and risks involved including her son’s life which may not be the same after her. His confidence, personality and relations will all be affected. The mental health of the patient is also taken into account (Appendix). Her mother is legally competent. In sum, the patient’s right to choose is being respected to the extent possible in ethics and law.
The information gathered as the contextual features briefed that there are no cultural, religious or family issues as she is Australian by birth and no such factors are there to influence her treatment. There are no legal implications of the treatment itself. But the child care of Mrs. Sara’s son has to be undertaken as per law, which are quite clear in Australian legislations and Centrelink provides the detailed prospect and procedures. 2. The feasible alternatives As ethical decision maker, I have a choice to go with the wishes of Mrs.
Sara to stop treatment as she is suffering too much having quite a good reason that she may not live long even after the treatment. I may not be able to so due to legal bounds but I can guide her about the options like going to a country on medical reference where euthanasia is permissible, the consequences of which; the remaining family shatters as Mrs. Sara is the bonding glue among three generations. The consultation will affect as for future abroad referrals and policies may be needed for this type of scenarios. Another alternative with me is to drop this case and withdrew.
But that again is against my personal ethics that I have the least priority (but there is) to protect my own self and career rather than a life. Then there is breach of confidentiality, which can put me in legal trouble if patient decides to sue me. Otherwise if I am not informing administration or relevant personnel about her intentions, it can be hazardous. 3. Morally significant factors 3. 1. Principles Some other principles considered are; autonomy, where no promises are made to the patient or she is not exploited in any means.
Non-maleficence, where no harm is sought for the patient or in larger perspective for the public or community as whole. The beneficence; by taking decisions for the good to patient and her family. By treating the patient, her family and others involved in the case and just under justice. It may be noted here that none of the morally significant right and entitlement of patient, family or any other person involved has been disrespected. It is quite obvious for me to be faithful to my profession and institution and I am sure not to go against fidelity. . 2. Ethically and legally informed sources The other resource available with me is the AASW Codes of Ethics and literature which provides me the principles that are widely accepted in one form or another in the common moralities of our communities and organizations and provide me with the professional norm to cope with such scenario in better ways than other sources. The legal precedents made it clear that currently there is no provision for assisting anyone, specially my patient in such action which will end in harm to her life or others.
The same is the answer when I went through my wisdom from my religious and cultural tradition which in turn make up a lot of my personal ethics and values. 3. 3. Personal judgments My personal judgment about the patient is that she is a mentally strong woman. The judgment of others including physician, my colleagues and supervisor are also invaluable. 3. 4. Organized procedures for ethical consultation The Ethics Consultation Service by AASW (AASW, 2010, p. 14) is a help in this regard which can advice about the dilemma resolution. The formal case conferences with personnel involved and ethics consultant provides good results. . Possible resolutions If I go with my choice it will produce the best possible consequences. The breach result in legal problem, but there is a big chance where the life of patient is justified for it. The child care dilemma automatically vanishes and the patient’s mother’s authority is not challenged. If I don’t go with my choice of breaching, and assisting the patient with her wishes the patient can harm herself, in turn producing a very big twist in her son’s life, facing another problem his fostering with unknown new family risks and myself facing legal actions by the mother of the patient and state.
The theoretical approach leaves an impression that the worker is taking sides. This is the very stance in this scenario, where I seem to be taking the side of Mrs. Sara’s mother if I am going with decision of not assisting her to fulfill her wish or advocate it, or protecting her son’s future considering the child care. On the other hand, if I advocate Mrs. Sara’s wish, I may be blamed by her mother taking Mrs. Sara’s side in a wrong deed. 5. The Decision If I consider these ethically pivotal factors, my critical analysis direct me to only one option with few risks and good for more.
I have to consider the impact of this decision on the ethical performance of the others as well, which in my case, makes it easy for others to do the right thing. Another thing is the literature available for the cases like these. With such dilemma; majority has the decisions or advice to the direction of more good. The only problem in long term will be the trust relationship with others, and it is important that if others are in my care, or dependent on me, I continue to deserve their trust.
After going through the whole process, it is clear to me that for larger good to patient and her family, I have to breach somewhat her confidentiality, and discuss it with concerned administration and personnel, and not to go with the wish of the patient and make her look at the bright side with reasons. The legal and ethical values do not allow me to go along her wish to stop her treatment, which may take some time but will get the best results with best actions. Conclusion The ethical principles caused me to introspect on what kinds of consequences are good or valuable.
By going through the process of considering the ethical resources like theories, codes and legislations to the decision making process, which overlap with each other on different aspects, I accepted the responsibility for my choice. It also means accepting the possibility that I might be wrong or that I will make a less than optimal decision. The object is to make a best choice with the information and resources available, not to make a perfect choice. As a social worker, like any other career, I have to learn from my 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. st 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, 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, 47, 98-110. VandeCreek, L. & Knapp, S. (2000). Risk management and life-threatening patient 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 many patients fighting against terminal illness. Recently a young woman (Mrs. Sara, aliased for reference so that identity of the patient is not discernible) has been admitted in hospital for metastatic prostate cancer, and I went to meet her. During my initial visit, Mrs. Sara age 33, explained to me that she wants to stop her difficult cancer treatment and wants to die. Her appearance was kempt and lying in bed. She had an appropriate eye contact and behavior with me.
Her legs were restless but her speech was normal in tone, volume, rate, quality and fluency. Her mood was subjectively fine and subjectively euthymic. After leaving her, I sought her physician and mother for further consultation, to gain the sight of why she feels like the way she does. I learned that Mrs. Sara suffers from depression and has been taking extra pain killers. She confided in her physician that she would take her own life when discharged. She has progressive weakness in legs and is unable to walk.
Her physician also informed that if she could contain her drug addiction and continues treatment then there is a good chance that her caner could go in remission, if she could abide by those rules. She will be having the debulking operation and chemotherapy is showing effects. Also the mother of patient informed that the patient has ten years old son, who needs her in his life and she will not accept her daughter’s desire to die. Her mother says that she is too young to die and considers her wish to be a suicide.
She was named her daughter’s Advance Directive (medical decision maker) and refuses her daughter to stop the treatment despite her daughter’s statements and wishes, as power of attorney. There may be some physical problems she has to face after treatment and surgery, like a bit difficulty in fast walking or running, hair loss etc. but no mental problems as such are mentioned in reports. The physical problem may result in minor social deficits but on the whole, the normal life is all that will be in hand of patient. There is no severe condition predicted for the future for her that will make the life undesirable for her.
It was also informed by the physician that under Medicare, she will be provided with the nursing services at home for her palliative care. The physician in this case is very determined and clear in his observations and has influenced in very positive way to treatment decision. The only problem I face is that I have to breach the confidentiality to a limited extent, as one point of view, for discussion her wishes and case to other colleagues, administration and supervisor. There are no problems regarding the resources and their allocation, in both human and non-human form.
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Ethical Decision Making. (2016, Sep 18). Retrieved from https://graduateway.com/ethical-decision-making/