Eye on Ethics: Managing Ethics Emergencies — Pulling the Andon Cord
By Frederic G. Reamer, PhD
Social Work Today
Vol. 18 No. 3 P. 6

Years ago I worked on a locked unit of a psychiatric hospital. This high-security facility served patients who had committed very serious crimes (such as murder, arson that resulted in deaths, rape, child molestation, armed robbery, and assault with a deadly weapon) and been found not guilty in criminal court because of their severe psychiatric disabilities. The unit also served people who had been charged with crimes but determined to be not competent to stand trial. Others had been transferred to the unit from the state prison, where they were serving lengthy sentences, due to their severe psychiatric symptoms.

One morning I happened to witness a staffer behaving very inappropriately during his group meeting with a number of patients. By coincidence, I was in an adjacent room speaking with a patient and heard the staffer abusing several patients verbally and using graphic sexualized language. I was stunned.

I chose not to intervene in the moment; my colleague's group was wrapping up its discussion for the day and I decided that barging in right then would be disruptive and confusing for the unit's patients. Instead, I took some time to collect my thoughts about the best way to handle this uncomfortable, distressing situation. I felt like I was in the midst of an ethics emergency.

Shortly thereafter I decided that I was obligated to share my concerns and observations with the unit's director. I went to her office and told her I had something important to discuss. She invited me in and closed the door. I told her that I wanted to describe some troubling behaviors I had observed on the unit that morning and talk about how to handle the predicament. Initially I did not share the staffer's name; I wanted to limit the disclosure of identifying information, at least at that point in the process. I recognized that later I might need to share more details.

After I described what I had observed, the unit director asked me whether the staffer I observed was so-and-so (my colleague's name). I nodded yes and asked how she knew. She told me that she had heard rumors that several patients had commented on the staffer's inappropriate behavior and that I was the first staff person to have witnessed it. Sadly, the unit director said, the patients' expressions of concern had been viewed somewhat skeptically, given the patients' serious psychiatric conditions.

The unit director encouraged me to prepare a written statement. I gulped, knowing that this sort of disclosure was likely to lead to a complex investigation, turmoil for all involved, and serious discipline. I thought long and hard and, with some trepidation, concluded that I had an ethical obligation to disclose what I had witnessed.

Within one week, the staffer whose behavior I observed was fired and faced legal consequences. The quick, but thorough, investigation into his behavior, which included extensive interviews with patients, uncovered other egregious violations, including inappropriate sexual contact with two patients.

Over the years I have consulted on a number of cases where conscientious social workers had to make difficult decisions about whether to intercede when they encountered what appeared to be unethical conduct.

• A social worker employed at a hospice program learned that a coworker had begun socializing with a deceased client's partner shortly after the client's death. About two months after the client's death, the social worker's coworker and the deceased client's partner moved in together. The social worker had to decide whether to report the coworker to the agency's director.

• A social worker at a family service agency worked in a state-funded program that serves children with developmental disabilities. One of the children died, which led to a fatality investigation by the county child welfare agency. The social worker, who had not been involved in the child's care, was asked by the agency director to review the clinical record and prepare a written summary. The social worker discovered that several of the clinical notes written by another social worker who was involved in the case were falsified. The social worker who conducted the record review figured out that several notes were written on days when the writer was on sick leave. The social worker wrestled with her duty to disclose the fraud. The social worker was concerned that disclosure of this fact would jeopardize the agency's funding from the state, ultimately limiting its ability to serve vulnerable clients.

• A social worker who was an assistant director at an addictions treatment program interviewed several social workers who applied for a case-management position. The social worker hired one of the applicants. Two weeks later another employee informed the social worker that the woman who was just hired had been a classmate when both were undergraduate students and had lied to the social work administrator about having graduated from college; it turned out that the new employee had been expelled from her college in her final semester when her field instructor learned that she had become sexually involved with a client at her field placement.

Most, if not all, social workers encounter unethical conduct during the course of their careers. Fortunately, these are relatively rare instances. However, when such misconduct occurs, social workers must decide whether or not to speak up.

Of course, at times this is easier said than done. Social workers who blow the ethics whistle may be concerned about being labeled a "snitch" and about possible repercussions for their own careers. In the end, however, social workers cannot tolerate and ignore blatantly unethical conduct.

Pulling the Andon Cord
In the manufacturing industry, there is a well-known phenomenon known as "pulling the Andon cord." The term "andon" comes from an old Japanese word for paper lantern. This traditional Japanese lantern was very popular during the Edo period, from the 17th to the 19th centuries.

An Andon system is one of the principal elements of the Jidoka quality-control method pioneered by the Toyota Corporation. It gives automobile manufacturing workers the ability, permission, and encouragement to stop production when a defect is found, and immediately call for assistance. Common reasons for manual activation of the Andon are a part shortage, a manufacturing defect, tool malfunction, or the existence of a safety problem. Work is stopped until a solution has been found.

Social workers who encounter ethical misconduct must decide whether to pull the Andon cord, so to speak. The NASW Code of Ethics includes several standards that guide practitioners:

Social workers should take adequate measures to discourage, prevent, expose, and correct the unethical conduct of colleagues (standard 2.10[a]).

Social workers should be knowledgeable about established policies and procedures for handling concerns about colleagues' unethical behavior. Social workers should be familiar with national, state, and local procedures for handling ethics complaints. These include policies and procedures created by NASW, licensing and regulatory bodies, employers, agencies, and other professional organizations (standard 2.10[b]).

Social workers who believe that a colleague has acted unethically should seek resolution by discussing their concerns with the colleague when feasible and when such discussion is likely to be productive (standard 2.10[c]).

When necessary, social workers who believe that a colleague has acted unethically should take action through appropriate formal channels (standard 2.10[d]).

Disclosing ethical misconduct is rarely easy. Social workers should think through these decisions carefully, not impulsively. Ideally, social workers who face such decisions will consult the NASW Code of Ethics and seek consultation with thoughtful, principled, and knowledgeable colleagues. Further, social workers should consider their motives, the quality of their evidence, and the likelihood that disclosure will lead to productive intervention.

Sometimes, social workers must pull the Andon cord.

— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work at Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, health care, criminal justice, and professional ethics.