3/4/2014 1 The purpose of this training program is to assist social workers in dealing with ethical dilemmas encountered in social work practice. This session will describe at least three NASW ethical principles which apply to Ethical Social Work practice, identify the difference between ethical dilemmas and legal issues, and formulate an ethical question to facilitate an ethical consultation. Objectives Describe at least three NASW ethical principles which apply to Ethical Social Work practice. Identify the difference between ethical dilemmas and legal issues. Formulate an ethical question to facilitate an ethical consultation. • An ethical dilemma can be described as the competing values of more than one right way to handle an issue “Ethics is the discipline that considers what is right or what should be done in the face of uncertainty or conflict about values. Ethics involves making reflective judgments about the optimal decision or action among ethically justifiable options.” (VA, 2009) Definitions Right Way
Transcript
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The purpose of this training program is to assist social workers in dealing with ethical dilemmas encountered in social work practice. This session will describe at least three NASW ethical principles which apply to Ethical Social Work practice, identify the difference between ethical dilemmas and legal issues, and formulate an ethical question to facilitate an ethical consultation.
Objectives
Describe at least three NASW ethical principles which apply to Ethical Social Work practice.
Identify the difference between ethical dilemmas and legal issues.
Formulate an ethical question to facilitate an ethical consultation.
• An ethical dilemma can be described as the competing values of more than one right way to handle an issue “Ethics is the discipline that considers what is right or what should be done in the face of uncertainty or conflict about values. Ethics involves making reflective judgments about the optimal decision or action among ethically justifiable options.” (VA, 2009)
Definitions
Right Way
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General Ethical Dilemmas, Examples
Right Way
Ethics Quality
Ethics quality refers to practices throughout the organization that are consistent with widely-accepted ethics standards, norms, or expectations for a health care organization and its staff. Ethics quality encompasses individual and organizational practices at the level of decisions and actions, systems and processes, and environment and culture. (VA, 2009)
VA Mandate
Each facility and VISN must develop and maintain an active IE (Integrated Ethics) Program that is organized and managed according to the provisions of this handbook. (http://vaww.ethics.va.gov/docs/policy/VHA_Handbook_1004-06_IntegratedEthics_20090616.pdf)
Is there a mandate at your facilities?
More Definitions
Ethics are based on a profession’s core values
Social work has a set of core values that are held by most social workers
Many years ago VA Social Work adopted the NASW Code of Ethics as its ethical framework
Ethical versus Legal Legal is essentially what has been codified into law by elected
representatives
Ethical is what a group of people set down as values that are held
Most if not all professions have a code of ethics, some aspects of which are codified in law
NASW Code of Ethics
The mission of the social work profession is rooted in a set of core values. These core values, embraced by social workers throughout the profession’s history, are the foundation of social work’s unique purpose and perspective: service
social justice
dignity and worth of the person
importance of human relationships
integrity
competence (NASW, 2008)
NASW Code of Ethics
The six core values of the social work profession are accompanied by an ethical principle
Social
Justice Competence
Dignity &
Worth of The Person
Importance
of Human Relationships
Integrity
Service
Core Values and Ethical Principles
1. Value: Service Ethical Principle: Social workers’ primary goal is to help people
in need and to address social problems.
2. Value: Social Justice Ethical Principle: Social workers challenge social injustice.
3. Value: Dignity and Worth of the Person Ethical Principle: Social workers respect the inherent dignity and
worth of the person. (NASW, 2008)
Social Justice
Service
Dignity & Worth of
the Person
Social Justice
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Core Values and Ethical Principles
4. Value: Importance of Human Relationships Ethical Principle: Social workers recognize the central importance of
human relationships.
5. Value: Integrity Ethical Principle: Social workers behave in a trustworthy manner.
6. Value: Competence Ethical Principle: Social workers practice within their areas of
competence and develop and enhance their professional expertise. (NASW, 2008)
Importance of Human
Relationships Integrity Competence
VHA Integrated Ethics (IE) Program
Integrated Ethics is a national education and organizational change initiative that provides VA facilities with the tools they need to transform their traditional ethics committees into integrated ethics programs that better match their needs. http://vaww.ethics.va.gov/IntegratedEthics/
The goal of IE is to support, maintain, and improve ethics quality. While IE recognizes that employees must comply with laws, regulations, and institutional policies, IE also emphasizes a values-oriented approach to ethics that looks beyond rules to inspire excellence. (VA, 2009)
What is the Ethics program where you practice?
IE Areas of Practice/VA
Ethics Consultation. The consultation service at each facility must respond to both requests for consultation about ethical questions pertaining to an active clinical case and requests for general information, policy clarification, document review, discussion of hypothetical or historical cases, and ethical analysis of organizational ethics questions.
IE Areas of Practice/VA
Preventive Ethics (PE). The PE team at each facility must use a systematic approach for proactively identifying, prioritizing, and addressing ethics quality gaps on a systems level. The goal of the preventive ethics function is to reduce disparities between actual practices and best or preferred practices by implementing systems-level changes.
Ethical Leadership. The ethical leadership function requires that leaders make clear through their words and actions that ethics is a priority; and communicate clear expectations for ethical practice, practice ethical decision making, and support of their organization’s ethics program.
Rules-Based/Values-Based Ethics
Rules-Based – prevent, detect and punish violations of the law
Values-Based – More than compliance with the law Make well-considered judgments that translates organizational
values into practice (NASW code of Ethics)
Need to create an ethical environment and culture
Ethics Consultation
We look at rules, but most of our time is examining values conflicts between stakeholders
Having an Advanced Directive (AD) makes this process much easier if even needed
Ethics Consultation
The ethics consultation service assists individuals and groups in resolving uncertainty or conflict about values. Issues involving allegations of misconduct, violations of rules, or intentional unsafe acts should be referred to other appropriate VHA or VA programs or offices
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Ethics Consultation
According to the IE booklet, each Ethics Consultation Service is to: o 1) Promote practices consistent with high ethical standards,
o 2) Resolve conflicts in a respectful manner,
o 3) Honor participants’ authority and values in decision
making, and effectively educate participants to handle
current and future ethical concerns.
Ethics Consultation
Ethics Consultation Service at Indianapolis VA Team of Professionals meet weekly
Social Workers
Nurses
Doctors
Administrators
Physical Therapy
Patient Advocates (Customer Service)
Ethics Consultation
Ethics Consultation Service at Indianapolis VA Ethics Consults are addressed by one of three rotating teams
Team lead
Three or four other members
Ethics Case Study
A consult is requested on a 42 year-old male veteran with no discernable brain activity. The medical team wants to know if they can take out his ventilator and let him proceed to a natural death. He was not responsive when he was found at the mission and was resuscitated. He has been coded twice since admission. No Advanced Directive on file and social worker has not been able to find any family members. What are the values issues and/or dilemmas? What is the ethical question?
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CASES Approach to Ethics Consultation
Clarify the consultation request – Characterize the type of consultation request, obtain preliminary information and formulate the ethics question in the following format: Given(uncertainty or conflict about values), What decisions or
actions are ethically justifiable?
Given (uncertainty or conflict about values), is it ethically justifiable to (decision or action)?
CASES Approach to Ethics Consultation
Assemble the relevant information - Consider the types of information needed. Identify the appropriate sources of information and gather information systematically from each source. Summarize the consultation and the ethics question.
Synthesize the information - Determine whether a formal meeting is needed. Engage in ethical analysis. Identify the ethically appropriate decision maker. Facilitate moral deliberation among ethically justifiable options.
CASES Approach to Ethics Consultation
Explain the synthesis - Communicate the synthesis to key participants. Provide additional resources. Document the consultation in the health record. Document the consultation in consultation service records
Support the consultation process - Follow up with participants. Evaluate the consultation. Adjust the consultation process. Identify underlying systems issues.
CASES Approach (Values Dilemmas/Definitions)
Authenticity The quality or condition of being trustworthy or genuine
Allegiance Loyalty or the obligation of loyalty
Autonomy The condition or quality of being independent
Benevolence An inclination to perform kind, charitable acts
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Ethical Question
Given the competing values of compassion (Deep awareness of the suffering of others coupled with the wish to relieve it) and empathy (Identification with and understanding of another's situation, feelings, and motives.), What decisions or actions are ethically justifiable?
Given the competing values of compassion (Deep awareness of the suffering of others coupled with the wish to relieve it) and empathy (Identification with and understanding of another's situation, feelings, and motives.)is it ethically justifiable to stop all but comfort care?
CASES Approach (Values Dilemmas/Definitions)
Caring Feeling and exhibiting concern and empathy for others
Compassion Deep awareness of the suffering of others coupled with the wish to relieve it
Competence The state or quality of being adequately or well qualified
Competitive To strive to do something better than someone else
CASES Approach (Values Dilemmas/Definitions)
Concern Regard for or interest in someone or something, medical do-no-harm
Determination Firmness of will, strength, purpose of character
Empathy Identification with and understanding of another's situation, feelings, and motives.
Fairness Consistent with rules, logic, or ethics
CASES Approach (Values Dilemmas/Definitions)
Honesty Fairness and straightforwardness of conduct
Hope The feeling that something desired can be had or will happen
Humility Feeling that you have no special importance that makes you better than others
Integrity Strict adherence to moral values and principles
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CASES Approach (Values Dilemmas/Definitions)
Loyalty A feeling or attitude of devotion, attachment and affection.
Optimism A bright, hopeful view and expectation of the best possible outcome
Patience The ability to accept delay, suffering, or annoyance without complaint or anger
Promise-keeping Keeping your word that you will certainly do something
CASES Approach (Values Dilemmas/Definitions)
Responsibility That for which someone is responsible or answerable
Safety
In this context the medical belief of doing no harm
Sensitivity Awareness of the needs and emotions of others
Tolerance Recognizing and respecting the beliefs or practices of others
CASES Approach (Values Dilemmas/Definitions)
Trustworthiness The trait of deserving confidence
Understanding Knowing how something works or a positive, truthful relationship between people
Decision Algorithm
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Request
Question 1: Does the requester want help
resolving an ethics concern?
Request is not appropriate for
ethics consultation.
Refer requester to another office
Question 2: Does the request pertain to an active
clinical case?
Request is appropriate
for ethics consult.
Tailor the approach
depending on the request. NON-CASE. Request is appropriate.
Use CASES or similar systematic approach
Yes
Yes
No
No
Case Study
Mr. Smith is a 75 year-old veteran with numerous chronic medical problems including cirrhosis of the liver, diabetes, COPD, CHF and he is on dialysis. He is in the inpatient medical unit due to severe breathing difficulties. The medical team has stated that none of his illnesses are apparently and immediately life threatening. He has had numerous inpatient stays in psychiatry, but has not been adjudicated incompetent to make medical decisions. He is currently refusing all treatment, including his psychiatry medications. There is an Advanced Directive, but it is 10-years old. An ethics consult has been requested, What are the values issues and/or dilemmas? What is the ethical question?
Ethical Question
Given the competing values of autonomy (The condition or quality of being independent) and (Regard for or interest in someone or something, medical do-no-harm), What decisions or actions are ethically justifiable?
Given the competing values of autonomy (The condition or quality of being independent) and (Regard for or interest in someone or something, medical do-no-harm), is it ethically justifiable to force medical care on this patient?
Always remember that the role of the ethics consultation service is to help patients, providers, and other parties in a health care setting resolve concerns stemming from uncertainties or conflicts about values. In this context, values are strongly held beliefs, ideals, principles, or standards that inform ethics decisions or actions.
