Wisconsin Public Psychiatry Network Teleconference (WPPNT)

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Understanding Ethics & Boundaries to Resolve Ethical Dilemmas

March, 2012

Peggy Sleeper, MSSW, LCSW Clinical Associate Professor, UW Madison School of Social Work Email: msleeper@wisc.edu

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Agenda

• What makes an “ethical dilemma?”• Myths we comfort ourselves with• A bit about boundaries• A bit about values• A tool that might come in handy when

working through ethical dilemmas• Example using the tool• Discussion

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Ethical Dilemmas

applicable, & sometimes conflicting, values (including those in

professional codes) & moral principles

applicable,& sometimes conflicting, statutes,

policies & procedures

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The BIG Myth

• Learning ethical standards, principles and guidelines, along with examples of how they have been applied, translates into ethical practice as long as we (1) follow our professional codes of conduct and (2)understand their relationship to the pertinent legal statutes [Pope, Sonne & Greene, 2006, p.16]

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Strategies used to justify behavior as ethical (whether it is or not) Pope, Sonne & Greene, 2006

• It’s ethical if our agencies or insurance companies require it

• It’s ethical if other people are doing it• It’s ethical as long as it is legal• It’s ethical as long as our professional

association’s code of conduct allows it• It’s ethical as long as we meant well

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Strategies (cont.)

• It’s ethical as long as no one complains about it

• It’s ethical if we find a consultant who says it’s OK

• It’s ethical as along as we can say– “anyone else” would have done the same thing– it came from the heart (or gut)– I just knew that’s what the client needed

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Professional Boundaries(what are they good for)

• Boundaries protect• The client from intrusion & exploitation• The worker from impossible expectations &

burnout, and intrusion• The relationship, so that helping can take place

• Establishing & maintaining professional boundaries is the responsibility of the professional potential ethical dilemma in a system of care that values collaboration and client choice (autonomy)?

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Wearing multiple hats simultaneously: Boundary “crossings” & “violations” Reamer, 2003

• CROSSING - Dual relationship is not intentional or coercive. It may be helpful, hurtful, or neutral. Examples: joint affiliations and memberships, mutual acquaintances & friends

• VIOLATION - Dual relationship involves exploitation, manipulation, deceit, coercion. It is always hurtful. Examples: sexual relationships, using client information for personal gain/benefit, intentional conflicts of interest where client is at risk for exploitation

• What about apparently unavoidable “multiple hats?” Example: You are the team leader of a rural CSP. You find out in August that your daughter’s fifth grade teacher will be a person who is the father of a long-time client of your program & who is heavily involved in his son’s services, & often critical of the CSP.

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Another area involving boundaries where ethical dilemmas may be present: The “zone of helpfulness”

Under-Over-

Involvement Involvement

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Example from “real life:” a social worker who worked both “on” & “off” the clock with clients

being discharged from the hospital

She drove patients to their new residence in the community and then spent countless hours and days providing them with "hands on" support and assistance to help them live in the community. [She] helped clients move in and get sheets on the bed and a telephone installed; she taught clients how to use the local laundromat by doing laundry with them again and again. She instructed them how to ride the bus to the mental health center to get medications by going side by side with them as many times as was needed. She worked next to her clients at the sheltered workshop until they felt comfortable. [She] telephoned clients often to problem solve and provide emotional support; she gave clients and their family and/or landperson her home telephone number to call evenings or weekends if a crisis arose. If there was an emergency, she drove out and intervened.

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Absolute Values That Guide Ethical Decision-Making

• Autonomy – Freedom of choice & action• Nonmaleficence – “Do no harm,” including both

intentional harm & engaging in behaviors/actions that risk harm to others

• Beneficence – Do what is best; do good, prevent harm where possible

• Justice – Fairness. “Unequal” treatment must be rationalized & justified by “unequal context”

• Fidelity – Loyalty, faithfulness, honoring commitments

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Other values that may be important

• Integrity – acting on convictions, leadership by example• Obedience – obey legal & ethical directives• Conscientious refusal – disobey illegal or unethical directives• Competence – be knowledgeable & skilled• Stewardship – use resources wisely• Diligence – work hard• Restitution – make amends to persons injured• Self-interest – protect yourself• Compassion – empathy for & action to relieve suffering• Honesty – tell the truth• Respect – for the dignity & worth of self and others• Accountability - responsibility

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Making an ethical decision involves

• Weighing absolute values – those “categorical imperatives” that impose an absolute duty on a person

• Evaluating the likely consequences of the behavior, and weighing the good it may cause against the harm it may cause ... sometimes simplified to “the greatest good for the greatest number”

• Evaluating the impact the decision will have on the people involved – stakeholders. A decision which does not take into account the way in which it may affect others is not ethical regardless of its actual consequences (Wm. White)

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Strategy for Ethical Decision-Making

• Define the problem carefully & gather all the necessary facts

• List the stakeholders who may be affected, and consider both their interests & vulnerability, & any obligations to these parties

• Determine who should be involved in the decision-making & who could consult

• What are the applicable legal & professional codes, relevant agency policies?

• List the values involved in the decision – “absolute” values, personal & work-related

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Strategy (cont.)

• Generate a list of possible alternative actions, and the consequences of the actions

• Of all the stakeholders, whose interest is most important & why?

• What is the highest value in this situation?• Which of the alternatives will cause the greatest good,

and least harm?• Make the decision & act on it• Evaluate the process, the decision & the outcome – and

document this

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Test Drive

Scenario: You are the team leader of a rural CSP. A few weeks before school starts, you find out that your daughter’s fifth grade teacher will be a person who is the father of a long-time client of your program. The father is heavily involved in his son’s services, & is often critical of the CSP, as well as your oversight of the CSP team. Your daughter has a learning disability and requires accommodation in the classroom to learn effectively. Getting her needs met has required vigorous advocacy on your part with School teachers and the principal.

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References

• Pope, K.S., Sonne, J. L. & Greene, B. (2006) What Therapists Don’t Talk About and Why. Understanding taboos that hurt us and our clients. Washington, D.C.: American Psychological Association

• Reamer, F. (2003) Boundary Issues In Social Work: Managing dual relationships. Social Work 48 (1): 121-131

• The Center for Ethical Practice (2010) http://www.centerforethicalpractice.org

• The Origins of PACT As Told By Mary Ann Test. Retrieved from http://www.actassociation.org/origins/

• White, W. L. & Popovits, R.M. (2001) Critical Incidents. Ethical issues in the prevention and treatment of addiction. Bloomington, IL: Lighthouse Institute