Eye on Ethics

The Concept of Standard of Care
By Frederic G. Reamer, PhD
May 2014

What do social work and architecture have in common?

You may think this is the opening line of a bad joke, but it's not. In fact, social work and architecture have a great deal in common, mostly because of a critically important Maine Supreme Court case decided in 1896, shortly before the formal inauguration of the social work profession.

This landmark court case concerned a protracted dispute between an architect, George Coombs, and his client, Clarence Beede, who retained Coombs to prepare architectural plans for a house in the city of Lewiston. Beede claimed that Coombs' plans were not consistent with Beede's explicit instructions and, as a result, he did not pay Coombs' invoice for services rendered. Coombs, in contrast, claimed he fulfilled his professional duty to Beede.

In its fine-grained analysis, the Maine Supreme Court explored the essential elements of professional duty when a practitioner enters into a relationship with a client. In its formally published and oft-cited opinion, the court wrote:

In an examination of the merits of the controversy between these parties, we must bear in mind that the plaintiff [architect Coombs] was not a contractor who had entered into an agreement to construct a house for the defendant [owner Beede], but was merely an agent of the defendant to assist him in building one. The responsibility resting on an architect is essentially the same as that which rests upon the lawyer to his client, or upon the physician to his patient, or which rests on anyone to another where such person pretends to possess some skill and ability in some special employment, and offers his services to the public on account of his fitness to act in the line of business for which he may be employed. The undertaking of an architect implies that he possesses skill and ability, including taste, sufficient to enable him to perform the required services at least ordinarily and reasonably well; and that he will exercise and apply in the given case his skill and ability, his judgment and taste, reasonably and without neglect (Coombs v. Beede 36A 104 [1896] Supreme Court, Maine).

Ordinary, Reasonable, and Prudent Practice
The prescient words of the Maine Supreme Court have echoed far and wide since the late 19th century in litigation cases involving a wide range of professionals, such as dentists, physicians, nurses, engineers, accountants, psychologists, and social workers. In typical cases, disgruntled patients and clients sue practitioners alleging that the practitioners somehow were negligent and failed to fulfill their professional duty. Plaintiffs, the parties bringing the suit, usually claim that the practitioner owed them a duty, breached the duty, and caused harm to the plaintiff as a result of the breach or dereliction of duty. Common cases involve allegations of, for example, medical error, faulty engineering design, and incompetent counseling services.

Under the common law doctrine of standard of care that is rooted in Coombs v. Beede, courts usually seek to determine what a typical, reasonable, and prudent (careful) practitioner with the same or similar education and training would have done under the same or similar conditions. In many instances, establishing the standard of care is easy. Ordinary, reasonable, and prudent surgeons do not operate on the wrong body part. Ordinary, reasonable, and prudent accountants do not knowing violate Internal Revenue Service regulations when preparing a client's tax return. Ordinary, reasonable, and prudent social workers do not forge clients' signatures on releases or develop intimate relationships with them.

But in other instances, it is not easy to establish what constitutes ordinary, reasonable, and prudent practice. Well-educated, skilled, thoughtful, and careful practitioners in every profession may disagree with colleagues about the best course of action in complex circumstances, perhaps because of their different schools of thought, training, and experience. For example, extraordinarily talented oncologists, civil engineers, and clinical social workers may reach different conclusions in complicated cases. Differences of opinion do not necessarily mean one or more of them is wrong; rather, in complex cases, ordinary, reasonable, and prudent minds may reach different conclusions.

Relevance to Social Work Ethics
I find it helpful to draw on the concept of standard of care when I think about social work ethics. Certainly, the standard of care in some ethics cases is crystal clear. Ordinary, reasonable, and prudent social workers do not sexually exploit clients, falsify documents, or bill for services that never were provided.

But in the most difficult ethics cases, where social workers' duties and obligations clash and where there does not appear to be any simple solution, practitioners may be hard pressed to agree to a single, clear standard of care. Take, for instance, social workers who live and work in small or rural communities (e.g., the military). In my experience, a representative sample of social workers in these settings likely will disagree about how best to manage inevitable boundary crossings and dual relationships, particularly when it is impossible to avoid all social encounters with clients.

Similarly, over the years, I have found that remarkably thoughtful and principled clinical social workers disagree about whether, under what circumstances, and to what degree it is appropriate to disclose personal information to clients for therapeutic purposes. I also have noticed that astute, thoughtful social workers in administrative and policy positions disagree about the fairest way to allocate scarce and limited resources (such as agency funds and resources), whether it is ever acceptable to knowingly violate a law or regulation (especially when doing so may benefit one's agency), and whether to blow the whistle on a colleague's unethical conduct.

Procedural Standard of Care
What I have come to believe is that while social workers cannot always agree on a singular standard of care in complex ethics cases, we can agree on the process or procedurethat ordinary, reasonable, and prudent social workers should follow when they must make difficult ethical decisions, even when, in the end, we may not reach consensus. In my experience, the most helpful steps include the following:

• Identify the social work values, duties, and obligations that conflict.

• Tentatively identify all viable courses of action and the participants involved in each, along with the potential benefits and risks for each.

• Thoroughly examine the reasons in favor of and opposed to each course of action considering relevant personal and professional values, codes of ethics and ethical standards, ethical theories, and legal principles.

• Consult with thoughtful colleagues, supervisors, and ethics experts.

• Make the decision and document the decision-making process.

I imagine that architect Coombs never anticipated that his judgment about managing his relationship with Beede would have such profound reverberations. In fact, the way contemporary social workers think about their professional relationships and ethical decisions is linked inextricably to this small-town dispute in the 19th century.

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