Eye on Ethics

Making Difficult Decisions
By Frederic G. Reamer, PhD
Social Work Today
October 14, 2002

Recently, I received a phone call from a seasoned social worker seeking consultation. The social worker is employed by a community mental health center where she provides clinical services to people with chronic mental illness. Two days earlier, one of her clients, Alice M., committed suicide. According to the social worker, Alice struggled for many years with depression and cocaine addiction.

Immediately following the suicide, Alice’s parents—who had participated in her treatment at various times in the context of family counseling—contacted the social worker to discuss this tragic turn of events. The social worker met with her parents, with whom she had considerable rapport, and they talked about Alice’s lifelong triumphs and challenges. Alice’s parents spoke at length about how much they appreciated the social worker’s earnest efforts to help their daughter. The parents also talked about how difficult it would be for them to bury their daughter the following day.

Toward the end of the conversation, Alice’s parents told the social worker that they wanted to ask a special favor. They explained that the social worker was an important person in their family’s life and that it would mean a lot to them if the social worker would deliver a eulogy at their daughter’s funeral.

The social worker was touched by the parents’ sentiments and their poignant request. She felt close to the family and wanted to be supportive. At the same time, however, the social worker quickly recognized the ethical dilemma facing her. She was especially concerned about violating Alice’s privacy and confidentiality. The social worker was also concerned about managing the boundaries in her relationship with the family; she wanted to avoid entering into an inappropriate “dual relationship.” The social worker was deeply ambivalent and unsure about how to resolve this ethical dilemma—a situation in which professional values, duties, and obligations clash.

In recent years, social workers have refined their approach to ethical decision making. Although many practitioners completed their formal education at a time when content on ethical dilemmas and ethical decision making was not a prominent component in the social work education curriculum, continuing education on the subject is now common. Today’s social workers and social work students are being introduced to state-of-the-art frameworks to help them identify ethical dilemmas and make difficult decisions.

Ethical dilemmas come in all shapes and sizes. Many involve social workers’ delivery of services to individuals, families, couples, and small groups. Typical examples involve disclosing confidential information without a client’s consent (for example, when a client threatens to harm himself, herself, or someone else); limiting a client’s right to self-determination against his or her wishes (for example, when a social worker pursues involuntary psychiatric hospitalization of a troubled client); or social contact with a former client.

Other ethical dilemmas pertain to agency administration, community work, social policy, and research. Examples include administrators’ decisions about the allocation of scarce or limited agency resources (what moral philosophers refer to as distributive justice issues), conflicts of interest among staff, and the use of ethically questionable marketing strategies to solicit clients. Still other ethical dilemmas involve relationships among professional colleagues. Common examples involve a social worker’s response to a colleague who has behaved unethically or who is impaired or incompetent (the ethics of “whistle-blowing”).

The literature in most professions now contains thoughtful discussions of conceptually based frameworks designed to guide practitioners’ ethical decisions. These frameworks do not guarantee easy solutions to hard ethical choices, of course; rather, they provide useful guideposts to help professionals who face daunting ethical circumstances. Although the frameworks vary, they tend to contain common elements.

1. Identify the ethical issues, including the social work values and ethics that conflict.

In the case involving the social worker who faced a decision about delivering a eulogy at the funeral of her client who committed suicide, the practitioner would focus primarily on conflicting values and duties related to the deceased client’s privacy and dignity, the parents’ right to self-determination, the social worker’s commitment to client well-being, and ethical standards related to informed consent and dual relationships.

2. Identify the individuals, groups, and organizations that are likely to be affected by the ethical decision.

In this case, those most likely to be immediately affected include the deceased client (with respect to her dignity and right to privacy and confidentiality), the deceased client’s parents, and the social worker. In addition, the social worker’s colleagues at the community mental health center where she is employed and the social work profession itself could be affected. That is, the social worker’s actions might be viewed by the public as an extension of the agency or the social work profession and their respective policies and standards.

3. Tentatively identify all possible courses of action and the participants involved in each, along with possible benefits and risks for each.

Put simply, the social worker can agree to deliver the eulogy or reject the parents’ request. Between these stark options are more subtle possibilities that include attending but not speaking at the funeral and speaking at the funeral without disclosing to attendees any information concerning the nature of the social worker’s relationship with the deceased client.

If the social worker delivers the eulogy, she may provide comfort to the deceased client’s parents and others who attend the funeral. The social worker, too, may gain some solace in the process.

On the other hand, delivering the eulogy may compromise the deceased client’s privacy and confidentiality. Further, those who attend the funeral may feel uncomfortable hearing the social worker’s comments, particularly if the social worker discloses the nature of her relationship with the deceased. Also, the social worker’s reputation may be harmed—along with that of her agency and the social work profession—if those in attendance are critical of the social worker’s decision to deliver the eulogy.

If the social worker declines, the deceased client’s parents may be angry and hurt and may suffer emotionally. Also, the social worker may feel some misgivings as a result, especially if the social worker’s relationship with the parents becomes strained.

4. Thoroughly examine the reasons in favor of and opposed to each possible course of action, considering relevant (a) ethical theories, principles, and guidelines; (b) codes of ethics and legal principles; (c) social work practice theory and principles; and (d) personal values (including religious, cultural, and ethnic values and political ideology).

In recent years, social work students and practitioners have been introduced to the rudiments of ethical theory—grounded in moral philosophy—as a tool in the analysis of ethical dilemmas. Briefly, classic ethical theory involves various schools of thought concerning what constitutes morally right and wrong action in the face of ethical dilemmas.

For example, according to the deontological perspective—often associated with 18th-century German philosopher Immanuel Kant—certain actions are inherently right or wrong, or good or bad. Deontological statements include the following: Always tell the truth, always obey the law, and never kill an innocent person. Thus, a deontologist might argue that the deceased client has a fundamental right to privacy and that it would be unethical for the social worker to speak at the funeral about any aspect of the client’s life or the parties’ therapeutic relationship.

In contrast, a teleological perspective in moral philosophy asserts that one’s ethical obligation is determined by the goodness of the consequences that are likely to result. That is, the decision maker’s emphasis should be on likely outcomes rather than on conclusions about what is the morally right or wrong action.

From this vantage point, the social worker should conduct a utilitarian calculus (a phenomenon introduced more than a century ago by philosophers Jeremy Bentham and John Stuart Mill), weighing the potential benefits and costs of each possible course of action. Although there are several versions of utilitarianism—also known as consequentialism—the most common states that when faced with an ethical dilemma, one should act in a manner that produces the greatest balance of good over bad consequences. Thus, if the social worker concludes that more harm than good would result if she delivers the eulogy, she would not honor the parents’ request.

In addition to considering pertinent ethical theories and their respective strengths and limitations, the social worker should also consult relevant codes of ethics and legal principles. The National Association of Social Workers’ (NASW) Code of Ethics, for example, contains a number of explicit standards related to client self-determination (standard 1.02), informed consent (standards 1.03 [a][c]), conflict of interest (standards 1.06 [a][c]), and privacy and confidentiality, including the rights of deceased clients (standards 1.07 [a][b][g][r]). In addition, the code makes specific reference to a social worker’s obligation to consult with colleagues when necessary to make sound decisions in complex circumstances (standards 2.05 [a-c]).

The social worker in this case must also be cognizant of legal issues. State laws and licensure regulations often address clients’ privacy and confidentiality rights, informed consent requirements, and dual relationship issues. In addition, the social worker should be aware of the possibility, albeit perhaps a remote one, that disgruntled parties who are upset with the social worker’s handling of this circumstance could file an ethics complaint (for example, with the state licensing board or NASW) or lawsuit alleging unethical conduct or malpractice.

Of course, the social worker should also draw on his or her knowledge of pertinent ethical theory and principles, especially concerning key ethics concepts and clinical phenomena related to grief and loss. Also relevant are the social worker’s own values, in this case related perhaps to personal loyalty and respecting individuals’ dignity.

5. Consult with colleagues and appropriate experts (such as agency staff, supervisors, agency administrators, attorneys, ethics scholars, and ethics committees).

Any social worker who faces difficult, complex ethical decisions should make a concerted effort to consult with knowledgeable colleagues and ethics experts. Some human services agencies now sponsor ethics committees—formally known as institutional ethics committees—whose members have training in ethics-related matters and provide collegial consultation. In addition to offering consultation, many ethics committees sponsor in-service training and facilitate the development of agencies’ ethics-related guidelines and policies. In some settings—usually healthcare agencies such as teaching hospitals and rehabilitation facilities—professional ethicists may be available for consultation. Typically, ethics consultants are human services professionals who have received advanced training in ethics or moral philosophers who have become knowledgeable about professional practice. Finally, when ethical dilemmas pose legal questions—for example, related to interpretation of state laws or regulations, or potential lawsuits—social workers would be wise to consult with an attorney who specializes in professional malpractice and risk management.

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

Once the decision is made, social workers should document the process carefully. Not only is this act consistent with sound social work practice and documentation standards, but also careful documentation can protect social workers in the unlikely event that ethics complaints or lawsuits are filed against them. Thorough notes describing the social worker’s decision-making steps and rationale provide compelling evidence of the practitioner’s prudence and professionalism.

7. Monitor, evaluate, and document the decision.

What may appear to be a final decision is not the end of the ethical decision-making process. Once the decision is made, the social worker should keep track of both immediate and more distant consequences and respond to them conscientiously. For example, if the social worker in this case decides to attend but not speak at the client’s funeral, the social worker should monitor the parents’ reactions to ensure that there are no untoward or harmful clinical repercussions.

Ethical decision making is a complex process. Today’s social workers are learning much about the nature of ethical dilemmas and sound decision-making procedures. There is no guarantee, of course, that even the clearest set of decision-making guidelines will yield simple solutions to complex ethical problems. No set of guidelines can produce such outcomes. In the final analysis, even the most thoughtful and reasonable practitioners may disagree about the most ethical course of action. In this respect, ethical decisions are no different from complex clinical or other social work decisions. Conceptual frameworks are useful and help to guide practitioners’ decisions; however, they do not guarantee clearcut solutions or collegial consensus. What they do ensure is systematic, thorough analysis and reflection—essential elements of competent practice.

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