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 2 things: 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.
Ethical Responsibilities of Social Workers
Ethics 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.
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.
Acknowledge the work and contribution of other:
Ethical consideration to the clients:
However, this can be limited by law child abuse or threat to commit or harm self or others.
Conflict of interest
Privacy and Confidentiality
Payment for services:
Termination of services:
Ethical responsibility to the colleagues:
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
Ethical Responsibility to the Employers and employing organisations:
- 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.
- 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.
- 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
- Advocate for adequate resources to meet client’s needs- Advocate for resources in an open manner (integrity)
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.
- 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.
- 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:
- 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
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:
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;
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