How The Pandemic has Changed our View of Ethic and what Social Workers Need to Know

UNIVERSITY OF CALGARY SOCIAL WORK GROUND ROUNDS KERRY BOWMAN PHD

Our goals for today

1. Learn foundational information about what ethics is and how it works.

2. Understand how applying ethics to all elements of our work improves our practice and deepens our thinking.

3. Consider how the pandemic has significantly changed our view of ethics - pushing us further from individual free choice toward more collective decisions

Why are ethics important?

u Ethics corresponds to basic human needs and social well-being

u Ethical values create credibility

u Ethical values help decision making

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What is Ethics….

Ethics u Moral principles to live

by

u A moral inquiry; an exploration

Philosophyu Study of the

fundamental nature knowledge and existence

u An academic discipline

Canadian ValuesAn evolving perspective

uFree will. Health care strongly grounded in the principle of autonomy.

uPluralism/diversity Democracy

uLiving peacefully and safety

uJustice and equity

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The untrained approach to an ethical dilemma…

approached as an opinion to be rationalized

Dilemma= position=analysis=justification

A trained approach

approached as a subject of inquiry

Dilemma=analysis=justification = position

Ethicsu A branch of philosophy that involves

identifying, defending and recommending concepts of right (good) and wrong (bad) conduct.

u Exploration into why we ought to behave in a certain way why that is justified and what those behaviours ought to be.

u Philosophies differ in regard to what principles/foundations are used to justify certain behaviours.

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Eastern World View u Harmony between

opposites

u The unity of all things

u Acceptance of “not knowing “

u To understand universal connections ;to be liberated from the “self”.

Western World View u Focus on analysis

u Endeavours to understand the nature of Reality

u Application of logic

u Western ethics to achieve self direction and to understand oneself

Ethical dilemma

u Questions where multiple values conflict; no clear consensus as to the “right” thing to do.

u A conflict between moral obligations that are difficult to reconcile and require moral reasoning

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Ethics is about values, what ought to be rather than codes of conduct.

Ethics is often confused with the following:q Etiquette

q Social morality

q Professional codes of ethics

q Moral theology

Ethics is NOT…

u Determined by strict rules or rigid guidelines…

u Laws set forth by federal, municipal or provincial governments…

u Policies or guidelines…

u The application of logic…

Ethics and Law

q Law and Ethics are often confused, but they are not the same since an action can be legal without being ethical, and vice versa

q Laws do reflect morals, and are therefore thought to be ‘morally codified’

Why Ethics?

! Ethics asks us to think carefully about feelings that are strong. If we follow our instincts and reactions alone we may be following belief systems that are based on unjust reasoning.

! The constant focus on ethics in our work encourages us to see complexity and avoid simplistic assumptions.

! Change in our working systems is occurring at an unprecedented rate, ethics helps us consider the human side of these changes.

What is an Ethical Dilemma? (1) ! An ethical dilemma occurs when there is tension

between loyalties, rights, duties or values all of which are good in themselves, but not all of which can be satisfied in a particular outcome.

What is an Ethical Dilemma? (2)! What is so often declared an ethical dilemma is

in fact a problem of communication, careful assessment is of the utmost importance.

Another Definition…

q An ethical dilemma arises when equally compelling ethical arguments both for and against a course of action are recognized and a decision must be made.

Adapted from the CNA

Two components of a health care dilemma

q What can we do is the technical question.

q What ought we do is the ethical question.

Peter Singer

Anticipate conflict, it is inevitable

Why is it inevitable?

q Many people from various backgrounds.

q Working with the public under conditions of intense stress.

q Health care decisions evoke strong feelings.

Thinking About Ethics

q It is often in our nature to want to feel that things are clear cut even when they may not be…

q … Sometimes the best thing to do is live with a situation for a bit before deciding what to do on the basis of our feelings.

Thinking About Ethics

q Careful, gradual, consideration takes strength.

q Understanding the roots of our values is the first step in this careful, gradual consideration.

Thinking About Ethics

q It is important to realize that our feelings are easily manipulated (e.g. by the media).

q In the helping professions it is best to consider ethics by looking at our own behaviour rather than the ethical practices of others.

Definitions…Ethics: The exploration of what is right and wrong.

Morals: An evaluation of actions in relations to a larger cultural or religious context.

Values: What is good and desirable.

Values Formation-1Personal Experience-Life History

! Many of our values are shaped by unique life experiences.

Values Formation-2Cultural/Religion Background

! Most things we assume to be “just common sense” to all people are, in fact, culturally formulated.

! Moral reasoning is primarily based in our cultural/religious background.

Values Formation-3Professional Values, Training and Experience

! The dominant value in North American helping professions is autonomy. This is evidenced in the focus we place on personal choice, self-determination, and informed consent.

Values Formation-3 Cont.Professional Values, Training and Experience

! All professions hold covert values, practices, and standards not written or articulated.

! We are highly influenced by the values ascribed to by our peers in our working environment.

Values Formation-3 Cont.Professional Values, Training and Experience

! A deep commitment to a single clinical framework can limit our moral consciousness.

! Contrast creates changes in our consciousness.

Ethical TheoriesTheory Historical

AdvocatesArticulation

Principlism Tom Beauchamp and James Childress

Ethics consists of 4 main principles: Autonomy, Beneficence, Non-maleficence, and Justice

Utilitarianism Jeremy Bentham/ John Stuart Mill

Right actions are those which, on balance, bring about the best consequences. (Greatest good for the greatest number)

Ethical TheoriesTheory Historical

AdvocatesArticulation

Deontology Immanuel Kant

Following duty is the overriding basis of morality, regardless of the consequences. Duties are usually conceived of as absolute moral rules

Virtue Ethics Aristotle Right actions are those which promote the functioning excellence of human beings

Cultural/ Ethical Relativism

Gilbert Harman, Edward Westermarck

The view that moral standards are relative to particular times, people and places; there is no universal morality

Social Work and ethics

Social Work and Ethics

u Social work is “moral terrain” we are dealing with struggling, vulnerable people.

u The roots of Social Work is truly values based.

u Social justice is central to Social Work practice.

Social Work…. ethical history

u Ethical standards in social work have changed dramatically during the profession’s history.

u During the late 19th and early 20th centuries, social work’s ethical standards were sparse and generally vague.

Social Work…. ethical history

u Ethical standards in social work have changed dramatically during the profession’s history.

u During the late 19th and early 20th centuries, social work’s ethical standards were sparse and generally vague.

Social Work and Ethics

u Yet in relation to other professions Social Work has been relatively slow to identify ethical standards and practice.

u Ethics has so far been mostly “implied”.

u Ethics and the “culture of Social Work” have not been well examined.

The expansion of Social Worku Into virtually all aspects of western society

and employment.

u Global initiatives expanding.

u Environmental ethics?

Early history of social work and social activism…..

u Social Work often swung between radical social activism and conservatism.

u Prior to the 1930's, the need for quick reform drew social work in an "activist mode”. During this period social workers took considerable risks.

u Government monitoring, maintained a more conservative approach in the decades following the 1930's.

History continued….u In the 1960's, the increasing

recognition of class, racial, and social justice in relation to civil rights generated more radical activism.

u This was soon followed by the women's movement and the gay/lesbian movement.

u In the 1980's, a relatively non-activist professionalism emerged in response to growing political conservatism and reduction in social service expenditures.

Present day..u An era of flux and polarity…

u Today, we find ourselves in a highly mixed era that is both trying to empower movements that have not been adequately addressed in previous times.

u Fostering greater understanding of the range of human diversity and how embracing it has a positive effects on a society.

Present Day

u Black lives Matter

u Society and the police force

u Examination of Systemic injustice has never been greater

u Extinction Rebellion

Present day…..

u …Yet also establish social work as a competent, refined clinical discipline that will fit into the medical and child welfare world and many aspects of public service delivery.

Can we good clinicians and strong social advocates at the same time?

u Are these spheres mutually exclusive?

u Can social work clinicians take positions on socially contentious issues?

Has Social Work become primarily procedural?

The great dilemma…..u As social workers, we strive to build and

maintain professional stature and accountability. This is warranted as many of us spend a great deal of time and energy in university programs and field work/practice.

u Yet, along with the benefits that come with professionalism (recognition, opportunity), do restrictions to many social interventions emerge.

The great dilemma…

u To what extent ought we engage in matters of social justice and reform?

u Are Social work efforts toward significant social reforms being limited our need for professional acceptance?

Is social activism productive?

u Many argue that working within existing power structures is the most efficient means of social reform. Is it?

u Are there not equal opportunities to counter this and explore serious change in social activism.

u Perhaps a continuum and “culture” of activism can fit within Social Work's balance between responsiveness to oppression and commitment to professional standards.

What now ?

u Views of individual autonomy and choice are being redefined by the pandemic

u We are in an era where there are increasing voices from people who need assistance on many levels.

u If not us then who?

Ethical challenge 1

The strengths and limits of our clinical approach….

“Clinical” approaches…

u Clinical methods often ignore the qualities of ethical, spiritual, imaginative, creative, and other subjective experiences or reduce them to quantifiable variables.

u Many clinical approaches create the impression of the of mind as an information-processing device that solves problems in rational, logical, and linear ways.

u Yet an ethical dilemma is a truly a dilemma because rationality and logic

The down side of the movement toward clinical efficiency ….u Contemporary Social Work increasingly focuses

on getting to "the problem" quickly and efficiently and getting it ”resolved."

u Short term, strategic, and systems approaches to practice emphasize control, efficiency, and expediency.

u In many instances, such approaches are appropriate but these methods tends to blur our focus on ethics and values.

Clinical vs. ethical

u Psychology wants to know what a man's problems are;

u Virtue, ethics and values has to do with how he surmounts them.

u A significant part of the human spirit is the triumph of character over psychology.

The limits of theory, clinical knowledge and codes….

u Wisdom helps us recognizes that theory, clinical knowledge and codes have significant limits.

u We learn that there is paradox and ambiguity when dealing with the complexities of the human condition.

Ethical challenge -2

Taking ethics beyond codes.

Limitations of ethical codes….

u Social works codes of ethics set the desired norms for professional behaviours as well as creates a useful blueprint for value based ethical practice.

u More difficult is the ethical enigmas that emerge in practice, for these, there are few, if any, prescriptions for action.

Limitations of ethical codes….

! Laws, rules and professional codes tend to be reactive, having often been set from what has occurred rather than considering what may occur.

! Codes are meant to be guidelines not to remove all aspects of judgement and consideration.

Limitations of ethical codes….

! Acting ethically is something that best comes form within rather than acceptance of rules.

! Professional codes often don’t tell you what to do in complex situations.

Clinical, procedural and ethical mindset …. u The clinical mindset asks why is this happening?"

u A procedural (codes) mindset asks what should we do?

u An ethical mindset asks what ought we do?

Ethical challenge -3

Respecting diversity while respecting autonomous choices…

Autonomy; the foundational ethical principle of Social Work

u How do we balance autonomy with the views of many cultures which value independence over interdependence?

Ethical challenge-4

THE ENVIRONMENTAL THREAT IS OUR GREATEST CHALLENGE

WHERE DO WE STAND?

LINKING HUMAN WELL BEING WITH ENVIRONMENTAL HEALTH

u What is social work’s position on the protection of non-human life?

u Obligations of justice to future generations.

u New terrain for most of us; great need for conciousness raising.

The Pandemic has brought massive change

The greatest changes

u Strong concept of Utilitarianism (Greatest good) has superseded concepts of autonomy.

u We have been given permission to be intolerant.

u Our leaders have cultivated an us and them mentality.

u We may have lost considerable ground on acceptance of differing opinions

The Good News

u Social determinants of health is no longer considered a marginal unsubstantiated concept.

u Pandemic has given us strong examples of systemic inequalities and discrimination.

u Medical cultures have been forced to think more broadly

The Greatest Failure

u Tremendous lack of will to deal with this crisis globally.

u Contributed to much suffering and death

u Very worrisome in relation to the environmental crisis

The impossible Risk/Benefit equation

The neglected ethics of prevention

The Precautionary Principle

WHERE THERE IS REASONABLE EVIDENCE OF AN

IMPENDING THREAT TO PUBLIC HEALTH, IT IS

INAPPROPRIATE TO REQUIRE PROOF OF CAUSATION

BEYOND A REASONABLE DOUBT BEFORE TAKING STEPS TO

AVERT THE THREAT…..

Vaccine priority Ethics

Vulnerability

THE PANDEMIC HAS MADE IT CLEAR THAT QUESTIONS OF

JUSTICE AND EQUALITY ARE SEVERELY AMPLIFIED BY THE

PROFOUND STRUCTURAL INEQUALITIES WITHIN SOCIETY. THIS

PUBLIC HEALTH CRISIS HAS ILLUMINATED - FOR ALL TO SEE - THE

DEGREE TO WHICH THE DISPARITIES THAT APPEAR IN HEALTH

OUTCOMES ARE GROUNDED IN PRE-EXISTING, SYSTEMATIC

DISADVANTAGES, AND HOW OUR SO FAR HOBBLED ATTEMPTS

AT SOCIAL JUSTICE DEMAND GREATER ATTENTION AND ACTION.

• Protocols are designed to standardize triage decision-making in the context of profoundly difficult choices. Those who are most likely to recover quickly will receive preferential treatment.

• In the event of an equal emergency. it will no longer be a matter of treating the person who is the least well, but rather the one who is the healthiest.

CRITICAL CARE TRIAGE PROTOCOLS

In maximizing the use of resources at the expense of individual patients’ rights, these protocols would represent a fundamental reversal of the universal and egalitarian approach that currently prevails in our health care system.

The individual’s right to receive medically necessary care would be subordinated to the "common good."

u Critical Care Triage protocols -2

Discrimination against people in vulnerable situations: though it is mentioned in these protocols that they should not be applied in a discriminatory manner, this will nevertheless be the case. In fact, those excluded from care (as a result of a determination that they won’t be able to recover as quickly as others) will, for the most part, be individuals in vulnerable conditions due to their age, their disability, their chronic illness, or their lack of home support or financial means. In this respect,

it should be remembered that because a norm is based on scientific criteria doesn’t mean it isn’t discriminatory.

u The reality of discrimination

Discrimination against people in vulnerable situations: though it is

mentioned in these protocols that they should not be applied in a

discriminatory manner, this will nevertheless be the case. In fact, those

excluded from care (as a result of a determination that they won’t be able to

recover as quickly as others) will, for the most part, be individuals in

vulnerable conditions due to their age, their disability, their chronic illness, or

their lack of home support or financial means.

It should be remembered that it isn’t because a norm or rule is based on

scientific criteria that it isn’t discriminatory.

u Societal implications

Vaccine passports?

GOOD SCIENCE?

GOOD ETHICS?

Pandemic Surveillance

Lock down Ethics

Medical Assistance in Dying in Canada, Where are We Going?

Summary of Canada’s Public Health Ethics Framework:

Ethical values and principles

Trust (foremost)

Justice (foremost)

Respect for persons, communities and human rights

Promoting well-being

Minimising harm

In application-1……EFFECTIVENESS: THERE SHOULD BE A REASONABLE LIKELIHOOD THAT THE PROPOSED DECISION OR ACTION WILL ACHIEVE ITS GOALS, AND THAT ITS IMPLEMENTATION IS FEASIBLE. IF SCIENTIFIC EVIDENCE IS AVAILABLE, THE PROPOSED ACTION OR DECISION SHOULD BE SUPPORTED BY THE EVIDENCE;

PROPORTIONALITY: POTENTIAL BENEFITS SHOULD BE BALANCED AGAINST RISKS OF HARM. MEASURES SHOULD BE PROPORTIONATE TO THE RELEVANT THREAT AND RISKS, AND THE BENEFITS THAT CAN BE GAINED. IF A LIMITATION OF RIGHTS, LIBERTIES OR FREEDOMS IS DEEMED ESSENTIAL TO ACHIEVE AN INTENDED GOAL, THE LEAST RESTRICTIVE MEASURES POSSIBLE SHOULD BE SELECTED, AND IMPOSED ONLY TO THE EXTENT NECESSARY TO PREVENT FORESEEABLE HARM;

In application-2 RECIPROCITY: THOSE WHO ARE ASKED TO TAKE INCREASED RISKS OR FACE GREATER OR DISPROPORTIONATE BURDENS IN ORDER TO PROTECT THE PUBLIC GOOD SHOULD BE SUPPORTED BY SOCIETY IN DOING SO, AND THE BURDENS THEY FACE SHOULD BE MINIMISED TO THE GREATEST EXTENT POSSIBLE;

PRECAUTION: SCIENTIFIC UNCERTAINTY SHOULD NOT PREVENT DECISION MAKERS FROM TAKING ACTION TO REDUCE RISKS ASSOCIATED WITH COVID-19. THE CONTINUED SEARCH FOR SCIENTIFIC EVIDENCE SHOULD NONETHELESS BE A GOAL.

The precautionary principle should prevail in response to pandemic threats.

Civil liberties must be balanced with collective altruism in a pandemic; the reciprocal ethical obligation for those in leadership is reasonable, accountable, and transparent governance is.

Trust is the most powerful force for leadership to earn in a pandemic and will greatly influence outcomes and recovery.Transparency builds trust; the people must know not just what decisions were made but how those decisions were made.

The COVID-19 pandemic has shone a spotlight on many dimensions of social inequality, injustice and vulnerability. F social vulnerability is not just an ethical concern but also a clear public health threat. .

u Some Conclusions

Yemen