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ETHICAL DILEMMA IN THE CLINICAL SETTING: A MEDICAL SOCIAL WORKERS PERSPECTIVE. Part 1

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ETHICAL DILEMMA IN THE CLINICAL SETTING: A MEDICAL SOCIAL WORKERS PERSPECTIVE. Part 1

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In the clinical settings we often encounter sensitive issues such as informed consent, truth telling, confidentiality, end of life care and patients right. As medical social workers, we have received referrals of patients seeking to be discharged against medical advice, patients refusing blood transfusion, patients refusing amputation of malignant limbs, relations refusing post mortem of coroner cases. Religion and socio-cultural factors cannot be over looked because they are significant in the clinical ethics.Clinical ethics is a practical discipline that provides a structured approach to assist physicians, nurses, physiotherapist, medical social workers and other clinicians in identifying, analysing and resolving ethical issues in clinical practice. Hence, the paper explored the ethical dilemma in the clinical settings, the perspective of the professional friend of the patients, the counsellor, the clarifier, the educator, the comforter, the advocate, the silent achiever.The following operational definition of terms will be used:

  1. Ethics: this is a set of values, principles and beliefs that guides the behaviour of a specified group engineers, doctors, lawyers, journalist, medical social workers. They can be termed as ‘standard of conduct’
  2. Dilemma: according to Groiler (1971) dilemma means a situation requiring a choice between equally objectionable alternatives.
  3. Clinical setting: A health facility where medical attention is given to patients. Medical Social Workers are guided by the ethical priniciples of social work
  4. Medical Social Worker: A trained health professional who assists patients(Clients) with their psychosocial problems
  5. Clinical ethics: The branch of bio-ethics that addresses ethical conflicts that arise in daily clinical practice in health care institutions through the establishment of hospital ethics committee and ethics consultation services.

It must be noted that, Medical Social Workers must be represented in any Hospital Ethics Committee of International Standard. We are clinical ethicist.The Greek physician’s Hippocratic oath is the most famous ethical work. Hippocrates made the following statement on medical ethics. As to diseases, make a habit 2thing -          To help and not to harm:As medical social workers in various clinical settings we have been involved in various ethical dilemmas. But for the purpose of this paper, we will explore the ethical responsibilities of social workers according to the International Federation of Social Workers.

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Ethical Responsibilities of Social WorkersEthics evolved from the Greek words, ‘ethikos’, ethos, which means, ‘Customs, habbit’. Ethics therefore, refers to well-founded standard of rights and wrong that prescribe what human ought to do, usually in terms of rights, obligations, benefits to society, fairness or specific virtues.

  • It is also conceived as a social religions or civil code of behaviour considered correct, especially that of a particular group, professional individuals.
  • Ethics is a moral principle that governs a persons behaviour or the conducting of an activity
  • It is the branch of knowledge that deals with moral principles
  • A set of moral principles, especially ones relating or affirming a specified group, field or term of conduct.
  • Ethics is a set of concepts and principles that guide us in determining what behaviour helps or harms sentiment creation- Richard & Linda, (2014)
  • Ethics are standards of conduct (or social norms) that prescribe behaviour Fayomiwo, (2013)

Purpose of Ethics in Social Work

  1. It identifies core values in which social work mission is built or based
  2. It summarises the broad ethical principles that reflect the professional core values and establishes a set of ethical standards that should guide social work practice.
  3. It is designed to help social workers to identify relevant considerations when professional obligations conflict or ethical constraints arises
  4. It provides ethical standards to which the general public can hold the social work profession accountable
  5. It socializes the practitioners who are new to the field of social work’s mission, values, ethical principles and ethical standard.
  6. The code articulates the standards that the social work profession itself can use to access whether social workers have engaged in unethical conduct or behaviour.

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Ethical Responsibilities of Social WorkersEthics evolved from the Greek words, ‘ethikos’, ethos, which means, ‘Customs, habbit’. Ethics therefore, refers to well-founded standard of rights and wrong that prescribe what human ought to do, usually in terms of rights, obligations, benefits to society, fairness or specific virtues.

  • It is also conceived as a social religions or civil code of behaviour considered correct, especially that of a particular group, professional individuals.
  • Ethics is a moral principle that governs a persons behaviour or the conducting of an activity
  • It is the branch of knowledge that deals with moral principles
  • A set of moral principles, especially ones relating or affirming a specified group, field or term of conduct.
  • Ethics is a set of concepts and principles that guide us in determining what behaviour helps or harms sentiment creation- Richard & Linda, (2014)
  • Ethics are standards of conduct (or social norms) that prescribe behaviour Fayomiwo, (2013)

Purpose of Ethics in Social Work

  1. It identifies core values in which social work mission is built or based
  2. It summarises the broad ethical principles that reflect the professional core values and establishes a set of ethical standards that should guide social work practice.
  3. It is designed to help social workers to identify relevant considerations when professional obligations conflict or ethical constraints arises
  4. It provides ethical standards to which the general public can hold the social work profession accountable
  5. It socializes the practitioners who are new to the field of social work’s mission, values, ethical principles and ethical standard.
  6. The code articulates the standards that the social work profession itself can use to access whether social workers have engaged in unethical conduct or behaviour.

 

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ETHICAL DILEMMA IN THE CLINICAL SETTING: A MEDICAL SOCIAL WORKERS PERSPECTIVE PART 2Ethical considerations in social work Different social work association in different countries have come up with different ethical standards that their members must subscribe to. Example of these, include, British Association of Social Worker (BASW), Canadian Association of Social Worker (CASW), National Association of Social Workers (USA), (NASW), International Federation of Social Workers (IFSW) of all the afore stated, the National Association of Social Workers (NASW) shall be our guide. National of Association Social Worker (USA) was founded in 1955 it is formation was the fusion of seven association in Social Work fields. These are American Association of Social Worker, American Association of Psychiatric Social Worker, American Association of Group Workers, Association for the Study of Community organisation, American Association of Medical Social Workers, National Association of School Social Worker and Social Work Research Group. As at March, 2011, the association had 145,000 members.Ethical considerations as documented in the National Association of Social Worker, USA’s ethical codes is divided into six areas. These are; ethical considerations to the clients, colleagues, employer or agency, social workers comportment to the professional body and to the society.

  1. Ethical Consideration as a professional social worker
  • Maintenance of high standard of personal conduct is a must for the social workers
  • He/she must avoid dishonesty fraud and deception
  • Avoid discrimination
  • Private conduct must be worthy of emulation
  • Accept employment on the basis of competence and qualification
  • Espoused and maintain integrity
  • Impairment- recognise your impairment and make effort to compensate for it.
  • Scholarship and research: Applies all the rules that guide conduct of researchers studies.
  • Avoid misrepresentation: Differentiate actions and statement on behalf of employing agency.
  • Solicitations: Do not solicit for favour or gratifications during or after professional relationship
  • Acknowledgement of credit: Do not take credit for work you did not do.

Acknowledge the work and contribution of other:

  • Service: regard as primary the service obligation of the social work profession

Ethical consideration to the clients:

  • Primary of client interests: Commitment to the client is utmost responsibility of the social worker

However, this can be limited by law child abuse or threat to commit or harm self or others.

  • Self-determination: However, this can be limited by social work by it poses threat or foreseeable and imminent risk to themselves or others – (To be discussed later fully inder ethical dilemma)
  • Informed consent
  • Competence
  • Cultural competence and social diversity.

Conflict of interest

  • Do not take advantage of client
  • Do not engage in dual or multiple relationship

Privacy and Confidentiality

  • Access to records
  • Sexual relationship: No sexual relationships with both current and relationship or anybody related to the clients.
  • Physical contact
  • Sexual harassment e.g. sexual advance, sexual solicitations, request for sexual favour and other physical conduct of a sexual nature.
  • Derogatory language: Social Worker should always use accurate and respectful language in all communications with the clients.

Payment for services:

  • Set a fair ties
  • Do not accept goods as replacement fees
  • Do not solicit for payment if your agency pays for the services used by clients.
  • Minor or invalid clients : Safeguard the interest of clients who cannot make decisions by themselves.
  • Interruption of services: Ensure that services continues despite disruption by illness, relocation, transfer, disability, death, etc

Termination of services:

  • Terminate service if it does not serve the interest of the client again.
  • If the goal of the relationship has been achieved
  • Do not terminate service in pursuit of other interest- sexual, financial or other social relationship with the clients.
  • Terminate service mutually if client is owing service fees.
  •  Notify clients of imminent disruption, interruption or termination- transfer, withdrawal, sack, etc

Ethical responsibility to the colleagues:

  • Respect: Be objective in your criticism of your colleague
  • Confidentiality: Disclose as little information to your colleague as it is suffice for the case under discussion
  • Interdisciplinary collaboration
  • Dispute involving colleagues: Do not exploit disputes with colleagues to advance personal gains or advance owes position.

Consultation:-          Seek professional advice of colleague to better the lot of clients.-          Keep abreast of colleagues’ area of expertise and competence and seek consultation from colleague who has demonstrated competence in the area needed for consultation-          Disclose least information in consultation

  • Referral for services: Refer clients to other professional if such will serve the best interest of the clients.
  • Sexual relationships: Do not engage in sexual relationship with your colleagues especially supervisor- supervisees.
  • Sexual harassment: Do not harass supervisee, interns or students on placement.
  • Impairment of colleagues: Do not revel in the impairment of your colleagues, rather seek a one-to-one discussion with him to find an antidote to it
  • Incompetence of colleagues: offer helps to amend it and improve his or her practice
  • Unethical conduct of colleagues: Help him to drop unethical conduct.
  • Defend him/her if charged for unethical conduct.

Ethical Responsibility to the Employers and employing organisations:

  • Supervision and consultation: Supervisors should be competent and knowledgeable.
  • Education and training:

-          Provide instructions to students, supervisors and trainees within their (supervisors) competence -          Assess or evaluate students fairly-          Interim clients when services are being provided by students -          Do not engage in dual relationship with the students.

  • Performance evaluation: Fulfil it in a fair and considerate manner within the ambit of the set criteria.
  • Client Records:

-          Must be accurate and reflect services rendered-          Documentations must be detailed and timely.-          Information contained must relate to the delivery of services.-          Store the records, even after termination of relationships for future purposes.

  • Billing: Establish billing practice that accurately reflect the nature and extent of services provided and that identify who provided the service in the practice setting (agency)
  • Client transfer:

-          If dual or multiple relationships are imminent. -          If client feels he/she can not cope with the attitude of the social worker.-          If relationship becomes unhealthily conflictual

  • Administration

-          Advocate for adequate resources to meet client’s needs-          Advocate for resources in an open manner (integrity)

  • Continuing Education and Staff Development: Administration and supervisors should take steps in this direction e.g regular seminars, workshops, conferences, in-service training e.t.c
  • Commitment to employers
  • Labour management disputes: Social workers should take into account the values, standards and ethical principles before embarking on industrial strike

Ethical Consideration or Responsibility to the Social Work profession: Maintain the integrity of the profession-          Maintain, prevent and enhance the dignity and integrity of the profession.-          Should take action appropriately against unethical conduct by any other member of the profession. -          Should act to prevent the unauthorized and unqualified practice of social work-          Social worker should make no misrepresentation in qualification competence, service or results to be achieved.

  • Community Service: Assist the profession to make social services available to the general public:

-          Provide time and expertise for utilization of social work skills and expertise-          Social worker should support the formulation, development, enactment and implementation of social policies.

  • Development of knowledge:

-          Should base practice upon recognised knowledge relevant to social work-          Should be current in the practice of social work-          Should contribute to knowledge base of social work through research and knowledge and wisdom sharing with colleagues. Ethical responsibility to the Society:

  • Promote the general social welfare of the society:

-          Ensure fairness in practice-          Ensure everybody (clients have equal access to public social resources.-          Provide appropriate professional services in public emergencies -          Should and advocate changes in policy and legislation to improve social conditions and to promote social justice-          Encourage people to participate in actions that foster better living.  The Y’s of Ethical Dilemma in Social Work An ethical dilemma is a predicament where a person (Social Work) must decide between two viable solutions that seven to have similar ethical value.Ethical dilemma exists in social base on the following premises:-          The fact that the loyalty of social workers is often in the middle of inflicting interests-          The fact that social workers function as both helpers and controllers-          The conflicts between the duty of social workers to protect the interest of the people with whom they work and societal demands for efficiency and utility. Ethical Principle for decision making

  1. Autonomy: The right to make critical decisions about one’s own destiny. This is in line with our principle of self determination. The principle of self of determination is so dear to people that even after death, they want their wish to be respected. Hence people have ‘living will’ a legal document in which they express what they wish to be done for them even when they are in a state of unconsciousness. In ‘living will’ some people state that they must not be resuscitate when they are unconscious. Some even wear DNR bands(Do Not Resuscitate). Some indicate in their living will that their corpses should be donated to the hospital for research.
  2. Beneficence: it highlights the benefits of the option or procedure. The desire to do good
  3. Non-maleficence: This is consideration for prevention of harm. It is unfortunate that sometimes the aftermath of some procedures do more harm than the initial medical problem.
  4. Justice: This is the principle highlighting equity and fairness

The 4-Step Model of clinical ethics In a collaborative effort, 3 clinical ethicist, a philosopher Jonsen, a physician, Siegler and a lawyer, Winslade have developed a method which to work through difficult cases. The process can also be termed ‘ethics work up’Four (4) topics that are basic and intrinsic to every clinical encounter are:

  1. Medical indications
  2. Patient preferences
  3. Quality of Life
  4. Contextual features

Medical Indications: All clinical encounters include a review of diagnosis and treatment optionsPatient preferences: the patient’s values wishes and choices are integral to the encounter. This is in line with the principle of self-determination in social workQuality of Life: The objective of all clinical encounters is to improve or at least address, quality of life for the patient.Contextual features: All clinical encounter occur in a wider context beyond physician and patient to include family, the law, hospital policy, insurance companies and so forth.Ethics and Clinical Research In the clinical setting and most especially in the tropics, ‘informed consent’ has now become everyday concept and it might be taken for granted. In clinical research involving human subject ‘genuine consent’ must be sought. The information provided to the participant must be relevant accurate, understandable and sufficient to enable a genuine choice to be made. The procedure involved and the potential risk and benefits must be clearly stated. Some ethical dilemma in the clinical setting The following are example of ethical dilemma medical social workers often experience in the clinical settings in the sub-Sahara African countries. -          Informed consent not taken before an HIV screening and the result comes out +ve. How will the post-test counselling be handled? -          A patients dies at Emergency Department 6hours after admission. It is coroner’s case requiring post mortem but relations are insisting on taking the corpse away for burial on religious ground.-          Parents of paediatric patients are insisting on discharging their child against medical advice. All counselling did not work. Patient also had hospital bill of over N500,000 and parents are economically challenged.-          A patient with a malignant leg is refusing to have an amputation. He believes in reincarnation and does not want reincarnate as a one legged man.-          The wife of comatose patient on ventilator wants the ventilator switched off. The sister of the patient wants the ventilator on. The patient’s next of kin who is his brother is deceased. Whose will, will be done?-          An accident victim was brought in an unconscious state into emergency department of the hospital by a good Samaritan. His PCV was 10%. He was transfused immediately. On regaining consciousness, he claims to be a Jehovah Witness and vows not sue the hospital. -          Should HIV positive medical social worker, doctor disclose his own sero status to his patients?-          A patient with burns is in severe pains and requesting for very potent but dangerous analgesics which might damage the kidneys. Is it a road to physician assisted suicide?-          A psychiatric patient is refusing to take his drugs. Can the nurse cleverly hide it in his food?-          A surgeon made a serious mistake during surgery. The patient does not know, if he knows, he might sue the hospital. What is the way out?-          An HIV positive patient does not want his wife told and he claims ‘she will leave me and if she leaves me, I will commit suicide’. How does the medical social worker handle this?-          A psychiatric patient needs a medical report for his employer. He might be sacked on health grounds if they know his mental state. What does the psychiatrist do?Should we continue to have paradox of poverty in the midst of poverty?Some Nigerians are overeating, becoming obese and developing medical problems while other Nigerians are dying of hunger. The clinical ethics is very sensitive, hence the issue should be carefully identified, analysed and resolved. We must always remember our ethical responsibilities to our God, our clients, our profession, our employer, and our society at large. Another ethical guide is the Rotarian Four-way Test which was created in 1932 by Rotarian Herbert J Taylor. 4 way test of what we think, say or do;

  1. Is it the truth?
  2. Is it fair to all concerned?
  3. Will it build goodwill and better friendship?
  4. Will it be beneficial to all concerned?   

 References Andre, (2002) Bioethics as practice, The University of North Carolina Press.Biestek F.P. (1961), The casework relationship Allenand Unwin.Cambell, A.V, (1971), Establishing Ethical Priorities in Medicine, British Medical Journal, 818-821.Dana, B. (1977), The social components of Health Care System, Encyclopedia of Social Work, New York NASW Inc.Fuchs, V.R. (1974). Who Shall live, Health Economics and Social Choice.Groiler, W. (1971). The New International Dictionary of the English Language. Groiler Inc. New York.Ogundiran, T.O (2004). Enhancing the African Bio-ethics Initiative. BMC Medical Education. World Medical Association (2005) Medical Ethics Manual.