77233 • Ethics for Social Work

Table of Contents

77233 • Ethics for Social Work

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Behavioral Health Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. HISTORICAL CONTEXT OF SOCIAL WORK ETHICS

PHILOSOPHICAL HISTORY OF ETHICS

HISTORICAL EVOLUTION OF ETHICS IN SOCIAL WORK

DEVELOPMENT OF THE CODES OF ETHICS IN SOCIAL WORK

3. COMMON TERMS USED IN THE DISCUSSION OF ETHICS

VALUES

ETHICS

4. NASW CODE OF ETHICS

ILLUSTRATIVE EXAMPLE

5. ETHICAL THEORIES

DEONTOLOGIC ETHICAL THEORIES

TELEOLOGIC ETHICAL THEORIES

VIRTUE ETHICS

RELATIONAL ETHICS

6. PRACTICAL APPLICATION OF ETHICAL THEORY

RELATIONSHIP BETWEEN ETHICAL THEORIES AND THE NASW CODE OF ETHICS

RELATIONSHIP BETWEEN ETHICAL THEORIES AND PROFESSIONAL PRACTICE

7. ETHICAL DECISION-MAKING FRAMEWORKS

DECISION-MAKING MODELS FOR ETHICAL DILEMMAS

LIMITATIONS OF ETHICAL DECISION-MAKING FRAMEWORKS

8. ETHICAL SELF-REFLECTION

PSYCHOLOGICAL CONTEXT OF MORAL DECISION MAKING

9. MANAGED CARE AND ETHICS

10. DIVERSITY AND MULTICULTURALISM: ETHICAL ISSUES

DEBATES WITHIN MULTICULTURALISM/DIVERSITY AND ETHICS

INFUSING DIVERSITY INTO THE ETHICAL DECISION-MAKING MODELS

SELF-CARE AND THE NASW CODE OF ETHICS

MULTICULTURALISM/DIVERSITY AND THE NASW CODE OF ETHICS

TECHNOLOGY AND THE NASW CODE OF ETHICS

INTERPROFESSIONAL COLLABORATION AND ETHICS

11. CONCLUSION

12. RESOURCES

Works Cited

77233 • Ethics for Social Work

Alice Yick Flanagan, PhD, MSW

Michele Nichols, RN, BSN, MA

www.netce.com

Copyright © 2022 NetCE, All rights reserved.

Ethical issues do not exist within a vacuum; rather, they emerge, evolve, and adapt within the sociocultural context of a particular society. In past decades, the field of professional ethics has received increased attention. Much of the discussion began in the 1960s in the medical field, where the blending of ethics, legalities, and medicine has become known as bioethics. Its emergence into history occurred because there was a need to talk about how research and healthcare decisions and regulations could be made, who could make them, and what their long-term implications would be. In the late 1960s, philosophers, theologians, physicians, lawyers, policy makers, and legislators began to write about these questions, hold conferences, establish institutes, and publish journals for the study of bioethics. Around the same time, many existing professional organizations and agencies, such as those for counseling, social work, and law enforcement, began implementing their own ethical codes. When an institution is young, the creation of a formal code of ethics is standard practice to inform prospective members; unify, advise, and protect existing members; help resolve ethics issues; protect those which the profession serves; and help establish and distinguish an organization, agency, and its members.

77233 • Ethics for Social Work

Education Category. Ethics - Human Rights

Release Date. 04/01/2022

Review Date. 04/30/2024

Expiration Date. 06/30/2026

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/2341 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

Ethical issues do not exist within a vacuum; rather, they emerge, evolve, and adapt within the sociocultural context of a particular society. In past decades, the field of professional ethics has received increased attention. Much of the discussion began in the 1960s in the medical field, where the blending of ethics, legalities, and medicine has become known as bioethics. Its emergence into history occurred because there was a need to talk about how research and healthcare decisions and regulations could be made, who could make them, and what their long-term implications would be. In the late 1960s, philosophers, theologians, physicians, lawyers, policy makers, and legislators began to write about these questions, hold conferences, establish institutes, and publish journals for the study of bioethics. Around the same time, many existing professional organizations and agencies, such as those for counseling, social work, and law enforcement, began implementing their own ethical codes. When an institution is young, the creation of a formal code of ethics is standard practice to inform prospective members; unify, advise, and protect existing members; help resolve ethics issues; protect those which the profession serves; and help establish and distinguish an organization, agency, and its members.

Audience

This intermediate to advanced course is designed for social workers and related professionals required to complete ethics continuing education.

Accreditations & Approvals

As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. This course, Ethics for Social Work, Approval #07012022-26, provided by NetCE is approved for continuing education by the New Jersey Social Work Continuing Education Approval Collaborative, which is administered by NASW-NJ. CE Approval Collaborative Approval Period: Tuesday, July 12, 2022 through August 31, 2024. New Jersey social workers will receive 6 Clinical or Ethics CE credits for participating in this course. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

Social workers participating in this intermediate to advanced course will receive 6 Ethics continuing education clock hours. This course meets the qualifications for 6 hours of continuing education credit for ASWs and LCSWs in the area of Law and Ethics as required by the California Board of Behavioral Sciences. NetCE is authorized by IACET to offer 0.6 CEU(s) for this program.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Special Approvals

This course fulfills the Florida requirement for 3 hours of Professional Ethics and Boundaries education.

Course Objective

The purpose of this course is to increase the social work professional's knowledge base about ethical theories, principles, and the application of these principles to social work practice. A historical context of ethics in social work and in the larger context of the helping professions, such as nursing and other human service areas, will be explored. The course will also examine the specific components of the National Association of Social Workers (NASW) Code of Ethics, ethical theories, ethical decision-making processes, the psychological context of moral development, and multiculturalism and ethics.

Learning Objectives

Upon completion of this course, you should be able to:

1. Discuss the historical context of ethics in social work and the emergence of the National Association of Social Workers (NASW) Code of Ethics.

2. Define common terms such as ethics, morality, ethical dilemmas, and ethical principles.

3. Identify the purpose and functions of the NASW Code of Ethics.

4. Differentiate between deontologic, teleologic, motivist, natural law, transcultural ethical, and ethical relativism theories.

5. Discuss the relationship between ethical theories and the NASW Code of Ethics.

6. Identify the different ethical decision-making models.

7. Discuss the psychologic context of ethical decision making by applying Lawrence Kohlberg's theory of moral development.

8. Discuss ethical issues that emerge with social work practice under managed care systems.

Faculty

Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.

Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.

Michele Nichols, RN, BSN, MA, received her Associates Degree in Nursing in 1977, her Bachelor of Science Degree in Nursing in 1981 and obtained her Master of Arts Degree in Ethics and Policy Studies in 1990 through the University of Nevada, Las Vegas. She was Chief Nurse Executive at Valley Hospital Medical Center in Las Vegas, Nevada, and retired as the System Director for the Valley Health System University, a five hospital system in Las Vegas, Nevada. She is currently a volunteer nurse for Volunteers in Medicine of Southern Nevada.

Faculty Disclosure

Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Contributing faculty, Michele Nichols, RN, BSN, MA, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Ethical issues do not exist within a vacuum; rather, they emerge, evolve, and adapt within the sociocultural context of a particular society. In past decades, the field of professional ethics has received increased attention. Much of the discussion began in the 1960s in the medical field, where the blending of ethics, legalities, and medicine has become known as bioethics. Its emergence occurred because there was a need to talk about how research and healthcare decisions and regulations could be made, who could make them, and what their long-term implications would be. In the late 1960s, philosophers, theologians, physicians, lawyers, policy makers, and legislators began to write about these questions, hold conferences, establish institutes, and publish journals for the study of bioethics. Around the same time, many existing professional organizations and agencies, such as those for counseling, social work, and law enforcement, began implementing their own ethical codes. When an institution is young, the creation of a formal code of ethics is standard practice to inform prospective members; unify, advise, and protect existing members; help resolve ethics issues; protect those that the profession serves; and help establish and distinguish an organization, agency, and its members.

2. HISTORICAL CONTEXT OF SOCIAL WORK ETHICS

Two events in the 20th century served as catalysts to facilitate the codifying principles and behaviors that protected the rights of research participants. This set the context for establishing codes of ethics in human service arenas, including social work. One event was the atrocities exposed during the Nuremberg trials in Germany in 1945 and 1946. Another significant event occurred in the United States when, in 1932, the Public Health Service initiated a syphilis study on 399 African American men from Tuskegee, Alabama. The goal of the study was to observe the men over a period of time to examine how the disease progressed in African Americans. When the study began, there was no cure; however, 15 years into the study, penicillin was discovered to be a cure for syphilis. The research participants were never informed, and treatment was withheld in spite of the fact that by the end of the experiment in 1972, 128 men had died either from the disease or related complications [1].

These two events triggered the realization that an organized standard of ethics was needed. Values of self-determination, voluntary consent, and informed consent needed to be upheld. In 1966, the Public Health Services established ethical regulations for medical research. In 1974, the National Commission for the Protection of Human Subjects was created by public law. Finally, in 1979, the commission published The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research. The commission recommended that all institutions receiving federal research funding establish institutional review boards. Today, these boards, made up of researchers and lay people, review social science research proposals to ensure that they meet ethical standards for protecting the rights of the potential subjects. In 1991, the "Common Rule" or the federal policy about protecting human research participants was published [72]. In 2011, revisions to the Common Rule were introduced to provide additional protections for human research participants and lesson researcher burden [73].

In 1973, the first edition of the Hastings Center Studies pointed out the problems and the needs that would become paramount in developing healthcare research projects. Remarkable advances were projected in the areas of organ transplantation, human experimentation, prenatal diagnosis of genetic disease, the prolongation of life, and control of human behavior. All of these had the potential to produce difficult problems, thus requiring scientific knowledge to be matched by ethical insight. This report laid the foundation for other disciplines to develop their own ethics guidelines.

The federal government, private philanthropists and foundations, universities, professional schools, and committed professionals moved quickly to address these questions. A plethora of codes of ethical behaviors and guidelines have been set forth by many human service disciplines. The specific code of ethics developed for each profession is guided by the overall value system of that profession. Codes of ethics serve to bring about greater public confidence to the profession, and it helps the practitioner and the profession resist environmental pressures [20].

Table 1 provides a summary of codes of ethics commonly utilized by mental health professionals, counselors, marriage and family therapists, social workers, and other helping practitioners [2].

Table 1: CODE OF ETHICAL BEHAVIORS UTILIZED IN HUMAN SERVICE DISCIPLINES

Name of Association

Code

National Association of Social Workers

NASW Code of Ethics

National Board for Certified Counselors

NBCC Code of Ethics

American Association for Marriage and Family Therapy

AAMFT Code of Ethics

American Mental Health Counselors Association

Code of Ethics for Mental Health Counselors

Association for Specialists in Group Work

Ethical Guidelines for Group Counselors

American Psychological Association

Ethical Principles of Psychologists and Code of Conduct

American Counseling Association

Code of Ethics and Standards of Practice

American School Counselors Association

Ethical Standards for School Counselors

International Association of Marriage and Family Counselors

Ethical Code of the International Association for Marriage and Family Counselors

Association for Counselor Education and Supervision

Ethical Guidelines for Counseling Supervisors

National Association of Alcoholism and Drug Abuse Counselors

NAADAC Code of Ethics

National Organization for Human Services Council for Standards in Human Service Education

Ethics of Human Services

National Rehabilitation Counseling Association

Rehabilitation Counseling Code of Ethics

International Society for Mental Health Online

Suggested Principles for the Online Provision of Mental Health Services

Source: [2]

PHILOSOPHICAL HISTORY OF ETHICS

It is important to understand historical philosophical underpinnings in order to understand the evolution of the definition of ethics and how ethical principles emerged [3]. Historically, ethics is viewed as developing within two major eras in society: modernism and postmodernism.

Modernism

The term modernism refers to an era during which scholars were encouraged to shift from a basis of metaphysics to rationalism in analyzing the world and reality [3]. In a modernist world, it is believed that human reason can determine truth on all subjects [3,74]. Practitioners who are rational and autonomous take personal responsibility to behave in an ethical manner [74]. Just as science evolved from being religion- or faith-based, modernists sought to understand social phenomena by explicating universal ethical laws [3].

Modernist philosophy argues that all individuals are similar and individual rights are supreme [4,74]. This philosophy has permeated much of biomedical ethics, and as such, each of the four ethical principles that form the backbone of ethical codes—autonomy, beneficence, nonmaleficence, and justice—should be universally adhered to and applied [5]. Utilitarian ethical principles, rationalism, and evidence-based scientific applications are at the heart of modernism [94].

One of the main criticisms of modernism as applied to ethics is that moral uncertainty exists when it comes to making ethical decisions, and ethical decision-making cannot always be laid out in a rational and linear manner [45]. Furthermore, the modernist perspective reinforces hierarchy, with the practitioner designated the expert and the client designated novice or student, which can diminish client self-determination [45].

Postmodernism

Postmodernism is a reaction to the belief that there is "rational scientific control over the natural and social worlds" [3]. Postmodernism is characterized by diversity, pluralism, and questioning the belief that there are objective laws or principles guiding behavior [3,95]. This perspective recognizes that knowledge is not error free and the world is characterized by fluidity [45]. Postmodernists argue that ethical principles should take into account historical and social contexts to understand individuals' behaviors [4]. According to this view, the concepts of "right" and "good" are seen as social constructs influenced by historical and current social forces [45]. This philosophical climate emphasizes situational ethics in which there are no black and white rules about principles of good and bad. Ultimately, a set of universal ethical principles cannot be easily applied [3].

Since 2015, there has been increasing discussion regarding the apparent shift to postmodernism in the ethical landscape [94,95]. In part spurred by the political environment in the United States during this period, the concept of a universal set of ethical principles appeared to be challenged; instead, ethical relativism appeared to move to the forefront. The growing use of social media and the Internet helped to present a highly individualized set of "truths" (or "alternative facts") [94].

Today, ethical codes and practices are also influenced by critical theory. Critical theorists focus on eliminating inequities and marginalization [74]. Ethics from this perspective explores the role of power and power inequalities, exploring who or what defines truth and whose voices are represented [74]. Reality is a socially and culturally shared experience and is shaped and navigated by both the practitioner and client [96]. Therefore, ethics is not a top-down experience, whereby ethical rules are unilaterally imposed. Rather, handling and negotiation of ethical challenges should be a collaboration [96].

HISTORICAL EVOLUTION OF ETHICS IN SOCIAL WORK

Reamer provides an excellent synopsis of the historical climate in social work that set the stage for the evolution of ethical norms, principles, and standards [6]. He identifies four stages in the profession's history: the morality period, the values period, the ethical theory and decision-making period, and the ethical standards and risk management period. He argues that from the early conception of the field, social work focused primarily on the client's values and eventually matured and shifted to wrestling with complex ethical dilemmas. The culmination of this maturation is reflected in the field's third code of ethics, ratified by the National Association for Social Work (NASW) in 1996. The following is a brief overview of each historical period in social work [6].

Morality Period

In the late 1800s, social work was concerned primarily with the morality of the poor [6]. Organized relief focused on pauperism and efforts to lift the poor out of their "shiftless" and "wayward" behaviors and habits. Poverty was attributed to internal personality traits. By the early 1900s, with the settlement house movement, social work ideology was moving away from attributing social problems to the individual and focused instead on causative environmental factors. However, an emphasis remained on the morality of social change and reform as focus shifted from the personal to the social [6,97]. Consequently, a social worker's ethical obligation was to promote social justice and reform.

Values Period

Although social work is a value-based profession, it was not until the 1920s that there was some inclination to explore the role of values and ethics, but the majority of the work did not appear until the 1950s. After the Flexner Report (published in 1915) stated that social work could not be considered a profession until it had a code of ethics, Mary Richmond began developing the first experimental code of ethics for caseworkers in 1920 [7]. However, it was not until 1947, after many years of discussion and debate, that the Delegate Conference of the American Association of Social Workers adopted a code of ethics. Finally, in 1966, the NASW released a comprehensive ethical code [98]. In addition, several social work journals published articles on ethics and the core values of respect of persons, valuing individuals' capacity for change, client self-determination, client empowerment, individual worth and dignity, commitment to social change, and social justice. Unlike previously, this period was marked by exploration of the field's values and practitioners' personal values rather than an emphasis on client morality [6].

To this day, many argue that social work as a profession is "among the most value based of all professions" [46]. The core values laid out by the NASW Code of Ethics lay the foundation of the mission of social work [46].

Period of Ethical Theory and Decision Making

In the 1970s, a new field of applied and professional ethics emerged, which had a dominant role in medical ethics. This new field emerged during a social and political climate that begged for answers to philosophical questions. For example, there were debates about welfare rights, prisoners' rights, and healthcare issues such as organ transplants, abortion, and end-of-life decisions. In addition, the public wrestled with the scandal of Watergate. Amidst the social climate of the 1970s, social work paid more attention to the topic of ethics as there were an increasing number of allegations of professionals' unethical behavior and malpractice litigations [46].

In the 1980s, social workers continued to further explore the profession's values. Drawing on ideas from philosophy and the newer field of applied ethics, social work literature focused on ethical theories, ethical decision making, and ethical challenges confronted in direct practice such as client self-determination, informed consent, and the relationships among practitioners [6].

Ethical Standards and Risk Management Period

In 1996, the NASW revised its Code of Ethics for Social Workers to include a section on core values and ethical standards. The revised Code offered new guidelines to improve service and enhance social workers' self-protection in an increasingly diverse and litigious society.

Digital Period

In the 2010s, a fifth period—the digital period—was introduced. This period is characterized by an increasing reliance on technology in social work and the related impact on the ethical landscape [75]. Social workers today should consider the impact of the Internet, social media, and smartphones on the micro, mezzo, and macro levels [75].

Contemporary Issues

To meet the needs of the changing multicultural landscape, in 2008, the NASW Delegate Assembly revised the Code of Ethics to include cultural competency and social diversity [47]. Social work professionals should maintain professional knowledge regarding diversity, oppression, and marginalization as they relate to the different dimensions of diversity (e.g., race, culture, ethnicity, age, religion, ability, immigration status, gender/sexual identity, political affiliations) [47].

In view of the growing role of technology in clients' lives and on the provision of social work services, the 2017 revision of the NASW Code of Ethics made the inclusion of guidelines for the ethical use of technology its major focus [8]. Social work professionals should consider the role of technology in ensuring informed consent, competence, conflicts of interest, privacy/confidentiality, and professional relationships and boundaries. In addition, in 2017 the NASW, in conjunction with the Association of Social Work Boards, the Council on Social Work Education, and the Clinical Social Work Association, published specific guidance in its publication Standards on Technology and Social Work Practice[71]. In 2021, the NASW Delegate Assembly approved revisions to the NASW Code of Ethics, adding self-care as one of the purposes of the code and revising language and expanding the scope of the discussion of cultural competence [8]. A review of these most recent changes is available at https://www.socialworkers.org/LinkClick.aspx?fileticket=UyXb_VQ35QA%3D&portalid=0.

DEVELOPMENT OF THE CODES OF ETHICS IN SOCIAL WORK

As noted, the first informal code of ethics targeted to caseworkers was developed by Mary Richmond in 1920 [7]. In 1955, the American Association of Group Workers, American Association of Psychiatric Social Workers, American Association of Social Workers, Association of the Study of Community Organization, National Association of School Social Workers, and the Social Work Research Group consolidated to form the NASW. In 1960, the NASW formulated and approved their first Code of Ethics [75].

It consisted of 14 general and idealistic statements that described social workers' responsibilities and obligations to the field [7]. In 1979, this Code of Ethics was revised, and the second iteration consisted of a ten-page document that described social workers' conduct and their responsibility to their clients, colleagues, professional field, and society. It was the first time that it was explicitly stated that social workers needed to abide by any disciplinary rulings based on the code. In 1990, another revision was made. This third iteration eliminated the prohibition against soliciting colleagues' clients and added a statement that prevented social work professionals from exploiting relationships with clients for personal advantage or accepting anything for making a referral. In 1993, the fourth iteration included two additional amendments—social workers' responsibility to impaired clients and the prohibition against dual relationships [7].

There were many criticisms of these different iterations. Some argued that the previous codes applied to direct service professionals and less so to supervisors, administrators, or educators. Others argued that the previous codes focused on work with individual clients and did not deal with groups and/or families. Finally, issues that were becoming increasingly relevant such as confidentiality, technology, sexual harassment, managed care, cultural sensitivity and competence were not at all addressed in the previous code [7]. Consequently, the NASW set out to again revise the Code of Ethics, and in 1994, formed a committee of social work leaders, educators, professionals, and experts in ethics to develop a new code. It was finally approved by the Delegate Assembly in 1996 and went into effect on January 1, 1997 [7]. In 2008, the code was amended to include additional contemporary issues, specifically gender identity or expression and immigration status. In 2017, the code was revised substantially, with a focus on issues related to the use of technology [8,76]. An additional revision was completed in 2021 (as discussed). The current Code of Ethics is considered to be one of the most comprehensive ethical standards in NASW history. It will be examined in greater detail in various sections throughout the course.

3. COMMON TERMS USED IN THE DISCUSSION OF ETHICS

VALUES

Frequently, the terms values and ethics are employed interchangeably; however, the terms are not synonymous. Values are beliefs, attitudes, or preferred conceptions about what is good or desirable that provide direction for daily living. They stem from our personal, societal, and agency values. Rokeach has argued that values may be organized into two categories: terminal values and instrumental values [9]. Terminal values describe the desired end-goal for a person's life; they are identified as: happiness, inner harmony, wisdom, salvation, equality, freedom, pleasure, true friendship, mature love, self-respect, social recognition, family security, national security, a sense of accomplishment, a world of beauty, a world at peace, a comfortable life, and an exciting life. Instrumental values are those that help a person to achieve their desired terminal values, such as love, cheerfulness, politeness, responsibility, honesty, self-control, independence, intellect, broad-mindedness, obedience, capability, courage, imagination, logic, ambition, cleanliness, helpfulness, and forgiveness. Ultimately, all of these types of values influence how a person will behave. Not all individuals will identify with all of these values; most will have a few terminal values that are important to them. When there is conflict or tension between values, such as politeness and honesty, individuals will begin to prioritize [9,69].

It is important for social workers to have a high level of self-awareness, understand the nature and origins of value conflicts, and understand the impact of values on their decisions. Values include our life experiences, worldview, cultural outlook, professional values (e.g., training), societal values (e.g., in the United States: achievement, equality, freedom, justice, self-actualization), and religious beliefs. Values are also based on knowledge, aesthetics, and morals [10].

Values in the NASW Code of Ethics

The NASW Code of Ethics identifies six core values (Table 2) [8].

Table 2: CORE VALUES EMBODIED IN THE NASW CODE OF ETHICS

Values

Definitions of Values

Service

Provision of assistance, resources, benefits, and service in order for individuals to achieve their potential

Social justice

The ideal in which every individual in society has equal access to rights, opportunities, social benefits, and protection

Dignity and worth of the person

Placing the individual in high esteem and valuing individual differences

Importance of human relationships

Valuing and appreciating the interaction, connections, and exchange that exists in the social worker and client relationship, which creates a positive working relationship

Integrity

Trustworthiness and adherence to moral principles

Competence

Having the skills and abilities to work with clients effectively

Source: [8]

The value of service has been the core of the social work field throughout history. At the heart of this value is giving—the giving of oneself to others to contribute to society [77]. The primary goals of the social worker are to help people in need, to advocate, and to link clients to services [7]. However, a social worker's commitment to this value is tested when presented with a client who may not be able to afford services. The code encourages pro bono work.

The value of social justice is integral to the field. The American settlement house movement started in the United States in the late 1800s, a time when there was a large influx of immigrants arriving. Settlement houses sought to improve urban conditions and promote social and economic reform [12]. Social justice, therefore, emphasizes social work's commitment to eradicating oppression and discrimination and promoting cultural diversity and sensitivity [7,41]. Social workers are dedicated to advocating for equity for all people [77].

The value of dignity and worth of the person aims to promote a client's self-determination and autonomy. Respecting and valuing of all people is at the crux of this value [77]. However, social workers can face conflict with this value when, for example, a client is repeatedly abused by her spouse yet returns to him after each incident. Often, promoting self-determination and client autonomy may not be consistent with the professional's view of what is perceived as the best option.

The value of importance of human relationships spans across all different types of situations in social work. It involves not only the client's individual relationships with his/her family or other individuals, but also the social worker's interactions with communities, organizations, and other helping professionals to strengthen connections as well [7]. For this to occur, social workers should emphasize clear communication and working through differences [77].

The value of integrity is essential to building relationships with clients and other professionals. The social work professional must be truthful to the client and colleagues in what he/she can provide or what he/she will or will not disclose [7].

Finally, the value of competence reinforces the belief that social workers should only practice in areas in which they have the requisite knowledge and abilities. Professionals can only help if they have the proper tools and skills to utilize them effectively. Social workers must also improve their knowledge and abilities so they can further assist clients and contribute to the advancement of their profession [7,8,11]. Growth and continual learning are lifelong endeavors for social workers and ensure they can most effectively serve clients and communities [77].

ETHICS

Ethics are the beliefs an individual or group maintains about what constitutes correct or proper behavior [13]. To put it simply, ethics are the standards of conduct an individual uses to make decisions. The term morality is often confused with ethics; however, morality involves the judgment or evaluation of an ethical system, decision, or action based on social, cultural, or religious norms [13,14]. The term morals is derived from the Latin word mores, which translates into customs or values.

An ethical dilemma presents itself when a social worker must make a choice between two mutually exclusive courses of action. The action may involve the choice of two positives or the choice of avoiding two harms. If one side of the dilemma is more valuable or positive than the other side, then there is no dilemma because the choice will lean toward the side that is more desirable [15]. The process of making the choice is the ethical decision-making process.

Ethical decision making is influenced by the ethical principles to which individuals adhere. Ethical principles are expressions that reflect humans' obligations or duties [10]. These principles of correct conduct in a given situation originated from debates and discussions in ancient times and became the theoretical framework upon which we base our actions as individuals and societies. Most prominently, it was the Bible and Greek philosophers, such as Plato and Aristotle, who created most of the familiar ethics and morals in use today.

The following are general ethical principles that social work professionals recognize [10]:

- Autonomy: The duty to maximize the individual's rights to make his/her own decisions

- Beneficence: The duty to do good

- Confidentiality: The duty to respect privacy and trust and to protect information

- Fidelity: The duty to keep one's promise or word

- Gratitude: The duty to make up for (or repay) a good

- Justice: The duty to treat all fairly, distributing risks and benefits equitably

- Nonmaleficence: The duty to cause no harm

- Ordering: The duty to rank the ethical principles that one follows in order of priority and to follow that ranking in resolving ethical issues

- Publicity: The duty to take actions based on ethical standards that must be known and recognized by all who are involved

- Reparation: The duty to make up for a wrong

- Respect for persons: The duty to honor others, their rights, and their responsibilities

- Universality: The duty to take actions that hold for everyone, regardless of time, place, or people involved

- Utility: The duty to provide the greatest good or least harm for the greatest number of people

- Veracity: The duty to tell the truth

Based on these ethical principles, professions develop ethical codes that embody the values of the profession and guide behaviors of members. Of course, codes of ethics do not guarantee ethical practice [99]. They do not always provide clear direction, and in some cases, the tenets of the codes are in direct conflict with each other.

It is also important to note that codes of ethics should be dynamic, reflecting the changing social and cultural climate. If the codes are not revised periodically, they can become obsolete [99].

4. NASW CODE OF ETHICS

The NASW Code of Ethics is the ethical code most widely used by social workers in the United States. It is divided into four sections [8]:

I. Preamble – Summarizes the mission of social work and the six core values of the profession. The mission of social work is "to enhance human well-being and help meet the basic needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty" [8]. The six core values are:

- Service

- Social justice

- Dignity and worth of the person

- Importance of human relationships

- Integrity

- Competence

II. Purpose of the NASW Code of Ethics – Provides an overview of the purpose and functions of the Code. This section identifies the Code's six major aims [8]:

1. Identifies core values on which social work's mission is based

2. Summarizes broad ethical principles that reflect the profession's core values and establishes a set of specific ethical standards that should be used to guide social work practice

3. Helps social workers identify relevant considerations when professional obligations conflict or ethical uncertainties arise

4. Provides ethical standards to which the general public can hold the social work profession accountable

5. Socializes practitioners new to the field to social work's mission, values, ethical principles, and ethical standards

6. Articulates standards that the social work profession itself can use to assess whether social workers have engaged in unethical conduct

III. Ethical Principles – Presents six broad principles that can be drawn from the six core values stated in the preamble [8]:

1. Social workers' primary goal is to help people in need and to address social problems (drawn from core value of service).

2. Social workers challenge social injustice (drawn from core value of social justice).

3. Social workers respect the inherent dignity and worth of the person (drawn from the core value of dignity and worth of the person).

4. Social workers recognize the central importance of human relationships (drawn from the core value of importance of human relationships).

5. Social workers behave in a trustworthy manner (drawn from the core value of integrity).

6. Social workers practice within their areas of competence and develop and enhance their professional expertise (drawn from core value of competence).

IV. Ethical Standards – This section includes specific principles clustered around six major categories, which include the following [8]:

1. Ethical responsibilities to clients

2. Ethical responsibilities to colleagues

3. Ethical responsibilities to practice settings

4. Ethical responsibilities as professionals

5. Ethical responsibilities to the social work profession

6. Ethical responsibilities to the broader society

The Code of Ethics are aspirational in that the values, principles, and standards reflect the ideals that social workers should strive toward [100]. For each of these six professional arenas, ethical principles are highlighted. To view the full code, visit https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English.

ILLUSTRATIVE EXAMPLE

Client A, a Chinese immigrant man 85 years of age, is brought to the hospital's emergency department by ambulance after his wife found him lying on the floor after a fall. Because Client A and his wife speak limited English, Chinese-speaking hospital staff is located to help with interpreting.

After testing is complete, the emergency room physician diagnoses Client A with aortic dissection. The client must make a decision of whether to proceed with surgery, which has significant risks. He is informed that he has only a slight chance of recovery given his age. He is also informed he must make a decision immediately. Client A and his wife say they cannot make a decision without consulting with their children, who are in transit to the hospital but still a few hours away. The treating physicians are pressuring the client to make a decision, as the window for success is short. A white social worker visits the couple. She knows that Asian culture is very family oriented and highly collectivistic. She indicates to the physicians that, in this case, decision-making will not necessarily revolve around self-autonomy.

In this case, the social worker is operating under the value of promoting the dignity and worth of the person, which is at the heart of social work. This value is reflected in NASW Ethical Standard: 1.02: Self-Determination. Another important ethical consideration stems from the Standard: 1.05: Cultural Awareness and Social Diversity. Western values emphasizing autonomy are not necessarily paramount for all clients. In Client A's case, given his collectivistic cultural orientation, family decision-making is vital. Before making any decisions or recommendations, the social worker also addresses her own level of competence, which reflects Standard 1.04: Competence.

5. ETHICAL THEORIES

Ethical theories provide a framework that can be used to determine the principles that might decide whether an action is ethical. Ethical theories do not solve ethical dilemmas; instead, they are a lens through which to analyze them [78].These ethical systems are each made up of principles, precepts, and rules that form a specific theoretical framework, providing general strategies for defining the ethical actions to be taken in any given situation.

In its most general and rudimentary categorization, ethics can be classified into three different headings: deontologic (i.e., mandatory) ethics, teleologic (i.e., aspirational or consequential) ethics, or virtue ethics [16]. When a social worker wears a mandatory ethics lens, he/she views the world in terms of polar opposites, in which one must make a choice between two behaviors. On the other hand, those who adopt aspirational ethics assume that there are a host of variables that play a role in benefiting the client's welfare [16]. Those who adhere to virtue ethics assume that the moral character of the social worker or even the social service agency will drive ethical behavior and decisions [48]. For all ethical decision-making models, there is an underlying ethical theory that drives the model. Therefore, it is important to understand the various ethical theories.

DEONTOLOGIC ETHICAL THEORIES

Deontologic theories concentrate on considering absolutes, definitives, and imperatives [7,79]. Deontologic theories may also be referred to as fundamentalism or ethical rationalism [17]. According to this perspective, ethical behavior is based on objective rules an individual follows in order to fulfill his/her obligation to society, the profession, the community, clients, and/or employers [48,80,101]. Persons adhering to this perspective ask: What rules apply? What are the duties or obligations that provide the framework for ethical behavior [102,103,104]? The deontologic theorist would argue that values such as self-determination and confidentiality are absolute and definitive, and they must prevail whatever the circumstances (i.e., universally applicable) [17]. Other underlying principles include beneficence, non-maleficence, and justice [103]. An action is deemed right or wrong according to whether it follows pre-established criteria known as imperatives. An imperative in our language is viewed as a "must do," a rule, an absolute, or a black-and-white issue. This is an ethic based upon duty, linked to absolute truths set down by specific philosophical schools of thought. As long as the principles dictated by these imperatives are met with dutiful compliance, one is said to be acting ethically.

The precepts in the deontologic system of ethical decision making stand on moral rules and unwavering principles. No matter what situation presents itself, the purest deontologic decision maker would stand fast by a hierarchy of maxims. These are as follows [18,103]:

- People should always be treated as ends and never as means.

- Human life has value.

- Always tell the truth.

- Above all in practice, do no harm.

- All people are of equal value.

Social work professionals making ethical decisions under the deontologic ethical system see all situations within a similar context regardless of time, location, or people. It does not take into account the context of specific cultures and societies [17,78]. The terminology used in this system of beliefs is similar to that found in the legal justice system.

One of the most significant features of deontologic ethics is found in John Rawls' Theory of Justice, which states that every person of equal ability has a right to equal use and application of liberty. However, certain liberties may be at competition with one another. There are also some principles within the same ethical theoretical system that can conflict with one another. An example of this conflict might involve a decision over allocation of scarce resources. Under the principle of justice, all people should receive equal resources (benefits), but allocation can easily become an ethical dilemma when those resources are scarce.

A framework of legislated supportive precepts, such as the NASW Code of Ethics, serves social work professionals by protecting them in their ethical practice. However, even these systems of thought will not clearly define the right answer in every situation. Most professionals will not apply the concept of the means justifies the end if the end outcome is harmful to the patient, client, or others in their social group. When duties and obligations conflict, few will follow a pure deontologic pathway because most people do consider the consequences of their actions in the decision-making process.

Theologic Ethical Theory

A well-known deontologic ethical theory is based upon religious beliefs and is known as the theologic ethical theory. The principles of this theory promote a summum bonum, or highest good, derived from divine inspiration. A very familiar principle is to do unto others as you would have them do unto you, which guides this system of beliefs.

Categorical Imperative

Another deontologic ethical principle is Immanuel Kant's categorical imperative. Kant believed that rather than divine inspiration, individuals possess a special, inborn sense that reveals ethical truth to them and causes persons to act in the proper manner. Some of the enduring ethical principles originating from Kant will become more familiar as the principles associated with bioethics are discussed. These include individual rights, self-determination, keeping promises, privacy, personal responsibility, dignity, and sanctity of life.

TELEOLOGIC ETHICAL THEORIES

Telos is a Greek word meaning end, and the teleologic ethical theories (or consequential ethics) are outcome-based theories [105]. It is not the motive or intention that causes one to act ethically, but the underlying goal and consequences of the act [7,79]. If the action causes a positive effect, it is said to be ethical. So here, the end justifies the means. From this perspective, the question is: What are the possible good and bad outcomes? What would be the most or least harmful [101,102,104,105]? Teleological theories focus more on societal effects of actions, while deontological theories emphasize effects on the individual [103]. Therefore, deontological theories may be more patient-centered.

The founder of modern utilitarian ethics, Jeremy Bentham, introduced in An Introduction to the Principles of Morals and Legislation the principle of utility for the evaluation of appropriate actions [12,13]. The rightness or wrongness of a selected action is decided according to whether the action would maximize a positive outcome, that is, whether the action would bring less pain and more pleasure to the most people. Bentham quantifies the amount of pain and pleasure created from actions in a moral utilitarian calculus that examines the rightness or wrongness of the selected actions in terms of seven factors: intensity, duration, certainty, propinquity or remoteness, fecundity, purity, and extent [12,13,14].

Utilitarianism

Utilitarianism is the most well-known teleologic ethical theory. This is the principle that follows the outcome-based belief of actions that provide the greatest good for the greatest number of people [49,80,106]. In other words, the rights of individuals may be relegated in order to benefit the greatest number of people. Social laws in the United States are based upon this principle. The individual interests are secondary to the interest of the group at large. There are two types of utilitarianism: act utilitarianism and rule utilitarianism [106]. In act utilitarianism, a person's situation determines whether an act is right or wrong. In rule utilitarianism, a person's past experiences influence one to greatest good. There are no rules to the game; each situation presents a different set of circumstances. This is currently referred to as situational ethics. This situational ethics precept would say that if the act or decision results in happiness or goodness for the person or persons affected, it would be ethically right.

Individuals may choose the utilitarian system of ethics over another because it fulfills their own need for happiness, in which they have a personal interest. It avoids the many rules and regulations that may cause a person to feel lack of control. In Western society, the rule of utility is whatever leads to an end of happiness fits the situation.

One of the limitations of utilitarianism is its application to decision making in social work. In developing social policies for a nation of people based upon the principle of doing the greatest good for the greatest number, several questions arise. Who decides what is good or best for the greatest number: society, government, or the individual? For the rest of the people, are they to receive some of the benefits, or is it an all or nothing concept? How does "good" become quantified in social work?

Existentialism

One modern teleologic ethical theory is existentialism. In its pure form, no one is bound by external standards, codes of ethics, laws, or traditions. Individual free will, personal responsibility, and human experience are paramount. This perspective assumes that a person is highly aware and sensitive and has the capacity to reflect on his or her personal responsibility, freedom, pressures experienced by others, and practical constraints of a situation [50]. Existentialism lends itself to social work because one of the tenets is that every person should be allowed to experience all the world has to offer. A critique of the existential ethical theory is that because it is so intensely personal, it can be difficult for others to follow the reasoning of a social worker, making proof of the ethical decision-making process a concern.

Pragmatism

Another modern teleologic ethical theory is pragmatism. To the pragmatist, whatever is practical and useful is considered best for both the people who are problem solving and those who are being assisted. This ethical model is mainly concerned with outcomes, and what is considered practical for one situation may not be for another. Pragmatists reject the idea that there can be a universal ethical theory; therefore, their decision-making process may seem inconsistent to those who follow traditional ethical models.

VIRTUE ETHICS

Virtue ethics is based on the belief that moral character is the foundation for ethical decision making. Virtues, such as integrity, wisdom, compassion, courage, truthfulness, and modesty, will guide ethical behavior [48,51,67,79,101]. According to Aristotle, there are two categories of virtues: intellectual and moral. Intellectual virtues include wisdom, understanding, and prudence; moral virtues encompass liberality and temperance [107].

This perspective does not emphasize rules or the motivations or outcomes of an action. Instead, it focuses on the individual's personality traits or character. Professionals with this perspective ask themselves what a good practitioner would do in light of an ethical dilemma [104]? Virtues relevant to the practice of social work include openness, care, compassion, honesty, empathy, patience, gratitude, humility, hopefulness, courage, fair mindedness, and diligence [52]. Virtue ethics theorists argue that primary and continuing social work education should focus on character formation in addition to social work competencies and skills in order for practitioners to develop crucial virtues to become a good person [51,53]. In reality, social workers simultaneously employ multiple ethical theories. In doing so, they mitigate the limitations inherent in using only one primary ethical theory. Ethical dilemmas may be analyzed using all three major ethical theories [54]. The deontologic framework assists social workers to consider their absolute principles and obligations, for example, through the use of the NASW Code of Ethics. The utilitarian framework offers a cost and benefit analysis of certain actions taken, and virtue ethics provides an opportunity for the social worker to reflect on his/her character, motives, and the type of social worker he/she wants to be [54].

RELATIONAL ETHICS

A relational model of ethics focuses on the network of relationships and social connections rather than universal absolutes, as humans are embedded in a social web [81; 82; 108]. Cooperation and care are key in relational ethics. Gilligan's ethics of care is an example of relational ethics. At the heart of relational or care ethics is consideration of the care responsibilities of a practitioner [104].

In summary, ethical dilemmas may be analyzed using all three major ethical theories [54]. The deontologic framework assists social workers to consider their absolute principles and obligations, for example, through the use of the NASW Code of Ethics. The utilitarian framework offers a cost and benefit analysis of certain actions taken, and virtue ethics provides an opportunity for the social worker to reflect on his/her character, motives, and the type of social worker he/she wants to be [54]. Traditionally, social work has focused mainly on deontological and utilitarianism as the dominant ethical paradigms [109].

6. PRACTICAL APPLICATION OF ETHICAL THEORY

It is important to remember that ethical theories are just that—theories. They do not provide absolute solutions to ethical dilemmas nor do they guarantee moral actions in a given situation. They do provide a framework for ethical behavior and decision making when adjoined to professional codes of ethics and to the critical information we obtain from the clients and families. In other words, theories serve as lenses to how we approach ethical dilemmas, solve problems, create assessments, and evaluate interventions.

RELATIONSHIP BETWEEN ETHICAL THEORIES AND THE NASW CODE OF ETHICS

The 1990 NASW Code of Ethics was classified as deontologic because it contained three ethics statements that were more rule-based [21]. The most recent NASW Code of Ethics also has a deontologic style because it also includes the responsibility of the social work professional to understand the ethical statements instead of merely inscribing the ethical statements as a prescriptive rule [21]. It has been noted that the values set forth in the NASW Code of Ethics are deontologic in nature, but frequently, social workers will use teleologic reasoning to make their decisions when confronted with ethical dilemmas [7].

RELATIONSHIP BETWEEN ETHICAL THEORIES AND PROFESSIONAL PRACTICE

As discussed, professional ethical codes define a particular organization's values and create boundaries that members must abide. In practice, most social work professionals adopt a combination of ethics that agree with personal and client values and prioritize these values based on the situation or application, while at the same time adhering to professional codes of ethics. This often occurs naturally, without giving much thought to the theories that the various values are derived from. One study found that social work professionals tend to adhere to deontologic ethical principles; however, in their day-to-day practice, they utilize a utilitarian approach [55].

Ethics inform all aspects of practice, not just the resolution of dilemmas. It is important to remember that ethical obligations and repercussions differ somewhat between applications. Ethics used in research are abstract and do not necessarily take into account a unique client situation; however, when performing an assessment to guide a real-world intervention, values must be evaluated and prioritized to help clients achieve specific goals [43]. Most practitioners would agree that personal value systems must be flexible in order to accommodate the needs of the individual client-system (e.g., clients from differing cultures, elderly clients, clients with substance abuse disorders, groups). Of course, certain values, such as respect, should always be a high priority. It has been shown that respect is a fundamental value in social work and that demonstrating respect toward clients (in a variety of ways) can lead to better outcomes [44].

It is also important to understand that each objective's or each intervention's outcomes can be evaluated using different theoretical lenses or outlooks. A social worker can compare the outcomes of similar cases against the intervention being evaluated, but practitioners may judge the outcome differently based on their personal values and ethics. Bloom argues that deontologic (i.e., absolutist) ethics are "fairytale-like and unsuited to the real world" because they promote an all or nothing attitude during evaluation and an unrealistic expectation of perfection [43]. On the other hand, teleologic (i.e., consequential) ethics allow for acceptance of varying degrees of success and for outcomes to be gauged by a variety of measures. If the goals of an agreed upon intervention plan are not 100% achieved, the absolutist social worker will deem the intervention a failure, but the practitioner using consequential ethics will view the achieved positives and eliminated problems of an intervention, individually, as successes.

Although the all or nothing approach may have some merit and may work for a given objective (i.e., target) or intervention, there are instances where even a fraction of improvement is very desirable. Bloom gives the example of an elderly man that is extremely angry and resentful at being moved into a nursing home due to lack of social contacts/support [43]. Ensuring anger reduction is important, but because it may be unlikely that his anger will ever dissipate completely, clinicians should identify another acceptable outcome. By comparing his case to other similar cases or research studies, a social worker can identify an average and the range of decrease in anger and resentment among many individuals and use that to set an intervention goal, which can either be a percentage of improvement or a reduction on a 10-point scale [43]. The goal may be a 30% reduction in anger or going from a 9 to a 6 on a 10-point scale.

If there is only a 10% reduction in anger during the intervention period, and the goal was not reached, the evaluation can reach several conclusions. Practitioners with an absolutist ideology might contend that the intervention failed because the goal was not realized. This presents a separate ethical issue: whether to continue the intervention despite a lack of documented improvement with an extremely difficult client (and at the potential expense of helping another client). However, during the course of the intervention, a social worker with a consequentialist ideology may decide that 10% is all that is realistically achievable for the client; additionally, they can note other specific positives and eliminated negatives achieved as individual successes, even if the overall goal was not reached. This social worker may decide it best to terminate the intervention, having the belief that the client has stabilized to an appropriate level for the given situation (i.e., the client's anger level is within the normal range, or the improvement is outside the range but further anger reduction is unlikely). This allows the social worker to produce the greatest good for a greater number (e.g., to help another recent nursing home resident with anger and resentment issues).

Ethics also play a large role in the ongoing and dynamic client assessment process. Bloom outlines six particular ethical considerations for social work [43]:

- "Demonstrable help" must be provided to the client in the context of the social setting.

- There is a burden on the practitioner to prove that no harm was done to the client-system. If either the client or the social context is significantly harmed as a result of the intervention, the intervention is unethical.

- If harm is caused, the social worker has an ethical obligation to reevaluate the intervention plan; this includes physical, psychologic, and/or social harm. Deterioration detection is a vital component of the dynamic, multidimensional assessment. Clients that are "acting out" or that are not following the agreed upon objectives are providing the practitioner additional information that can be used to modify the assessment (e.g., if self-reflection causes client distress, gather progress information from other sources).

- The client must be directly involved in the assessment process. Objectives/targets and the intervention goal(s) must be agreed upon so they can proceed unimpeded. Practitioners should restate the clients' goals so there is clear understanding by both parties.

- Confidentiality is paramount. Informed consent should be used to gather information useful to all parties while harming none.

- Culture-, income-, education-, sexual orientation-, and gender-specific assessment are vital to predict how the client will perform their objectives, reduce the dropout rate, and increase cost-effectiveness.

These same ethical considerations, with minor alterations, can and should be applied to research settings [43]. They can also be used to solve ethical dilemmas.

Case Study

Now let us see how a social worker might take one of these theories and translate it to a reasoning process in the ethical dilemma presented [15].

Child A, diagnosed with attachment disorder, has been seeing a caseworker twice weekly since entering the agency program eight months ago. The program works with emotionally disturbed children 6 to 12 years of age. She lives in a group home with her sister, Child B, who is 3 years of age, and three other children. The sisters have been in the group home for two years, and parental rights are in the process of being terminated. Each child has her own worker.

Both Child A's and Child B's caseworkers have been asked to make independent recommendations regarding whether the sisters should be placed together or whether each sibling should be placed separately. Both workers are aware that a recommendation to keep the siblings together will reduce their chances for adoption, particularly for Child B. In other words, Child B is the more desirable candidate for adoption if she is alone [22].

Child A's caseworker's primary responsibility is to Child A, but also has a responsibility to avoid harm to the third party, Child B. What should Child A's caseworker do?

Child A's caseworker used a teleologic approach, weighing the goods and harms of two decision options. After applying the teleologic approach, the caseworker sees that the cumulative good of keeping the siblings together surpasses the cumulative good of separating them. Similarly, the total harm of separating them outweighs the harm of keeping them together. The caseworker decides to keep the siblings together until a single adoptive home is available for both sisters.

Discussion

Practitioners should employ ethical theories to reflect upon the ethical decisions they make [79]. In the case of Child A, because the case worker used a teleologic approach, he/she might assess the consequences of the decision and if the decision adheres to the values of social justice and well-being [79]. If the social worker had based the decision on virtue ethics, he/she might assess if the decision reflects the values and attributes he/she strives to embody as a social worker. If the social worker had based the decision on relational ethics, specifically an ethics of care perspective, he/she might explore whether the decision promoted the importance of social relationships, receptiveness, and responsibility [79].

7. ETHICAL DECISION-MAKING FRAMEWORKS

Whenever the social worker-client relationship is established, a moral relationship exists. Moral reasoning is required to reach ethically sound decisions. This is a skill, not an inherent gift, and moral reasoning must be practiced so that it becomes a natural part of any social work professional's life.

The decision-making frameworks presented in this section are decision analyses. A decision analysis is a step-by-step procedure breaking down the decision into manageable components so one can trace the sequence of events that might be the consequence of selecting one course of action over another [23]. All ethical decision-making models include the steps of identifying the problem, identifying alternatives, consulting with others, and implementing and evaluating the decision [99]. Decision analysis frameworks provide an objective analysis in order to help practitioners make the best possible decision in a given situation, build logic and rationality into a decision-making process that is primarily intuitive, and lay the potential outcomes for various decision paths [23]. These frameworks are helpful when rules are not clearly defined or if there are multiple sets of competing rules [83]. They are also attempts to shift the process of moral decision making from the arena of the personal and subjective to the arena of an intellectual process, characterized by rigor and systematization [24]. Ethical decision-making models are helpful tools to stimulate discussion but do not guarantee with absolute certainty that the decisions are infallible [78]. They can be particularly helpful for novice practitioners to organize the information that surfaces when an ethical dilemma emerges [110]. The models assist in providing a linear series of steps to make an informed decision in order to reduce the likelihood of making a truncated decision [110].

Osmo and Landau note that there are two types of argumentation: explicit and implicit [25]. Implicit argumentation involves an internal dialogue, whereby the practitioner talks and listens to him/herself. This internal dialogue involves interpreting events, monitoring one's behavior, and making predictions and generalizations. It is more intuitive and automatic, and this type of dialoguing to oneself has tremendous value because it can increase the practitioner's level of self-awareness. However, Osmo and Landau also argue for the importance of social workers' use of explicit argumentation [25]. Research indicates that just because a professional code of ethics exists, it does not automatically guarantee ethical practice. Explicit argumentation involves a clear and explicit argumentation process that leads to the ethical decision. In other words, the social worker must provide specific and explicit justification of factors for a particular course of conduct regarding an ethical dilemma [25]. Explicit argumentation is like an internal and external documentation of one's course of action. One can explain very clearly to oneself and others why one made the choices.

Osmo and Landau employ Toulmin's theory of argumentation [25,26]. Toulmin defines an argument as an assertion followed by a justification. According to Toulmin, an argument consists of six components: (1) the claim, (2) data, evidence, or grounds for the claim, (3) a warrant, which is the link between the claim and the data (may include empirical evidence, common knowledge, or practice theory), (4) qualification of the claim by expressing the degree of confidence or likelihood, (5) rebuttal of the claim by stating conditions that it does not hold, and (6) further justification using substantiation. In essence, decision-making frameworks are an attempt of explicit argumentation.

In general, decision analyses typically include the following: acknowledging the decision, listing the advantages or disadvantages (pros or cons), creating the pathways of the decision, estimating the probabilities and values, and calculating the expected value [23].

It is important to remember that following an ethical decision making framework step-by-step does not mean that the final decision is the only or best option. Instead it represents a "good enough" choice, given the reality of the situation [83]. A "good enough" perspective does not connote mediocrity; rather, it represents a rational choice, with the ultimate goal of striving for excellence [84].

DECISION-MAKING MODELS FOR ETHICAL DILEMMAS

Congress ETHIC Model

The ETHIC model framework was developed by E.P. Congress to take into consideration social work values, the NASW Code of Ethics, and social work professional contexts (Table 3) [7]. The first step in the ETHIC model is to examine relevant personal, societal, agency and professional values [7]. Social work professionals should identify all the different values that impinge on their worldviews—their own personal values, the agency in which they operate, the client's values and belief systems, and the discipline's values. Secondly, they should think about what ethical standard of the NASW Code applies to the situation, as well as the relevant laws and case decisions.

Table 3: CONGRESS'S ETHIC MODEL

Examine

Think

Hypothesize

Identify

Consult

Source: [7]

Next, social work professionals should hypothesize about the possible consequences of different decisions. They may use the teleologic approach, listing the pros and cons for different scenarios. By doing this, they can identify who will benefit and who will be harmed in view of the most vulnerable clients. The final step is to consult with supervisors and colleagues about the most ethical choice.

Kenyon's Ethical Decision-Making Model

Kenyon has adapted an ethical decision-making model from Corey, Corey, and Callanan and from Loewenberg and Dolgoff (Table 4) [10]. The first step in Kenyon's decision-making model is to describe the issue [10]. Social work professionals should be able to describe the ethical issue or dilemma, specifically, by identifying who is involved and what their involvement is, what the relevant situational features are, and what type of issue it is. Next, they should consider all available ethical guidelines; professional standards, laws, and regulations; relevant societal and community values; and personal values relevant to the issue.

Table 4: KENYON'S ETHICAL DECISION-MAKING MODEL

1. Describe the issue.

2. Consider the ethical guidelines.

3. Examine the conflicts.

4. Resolve the conflicts.

5. Generate all possible courses of action.

6. Examine and evaluate the action alternatives.

7. Select and evaluate the preferred action.

8. Plan the action.

9. Evaluate the outcome.

10. Examine the implications.

Source: [10]

Any conflicts should be examined. Social work professionals should describe all conflicts being experienced, both internal and external, and then decide if any can be minimized or resolved. If necessary, they may seek assistance with the decision by consulting with colleagues, faculty, or supervisors, by reviewing relevant professional literature, and by seeking consultation from professional organizations or available ethics committees.

After all conflicts are resolved, social work professionals can generate all possible courses of action. Each action alternative should be examined and evaluated. The client's and all other participants' preferences, based on a full understanding of their values and ethical beliefs, must be considered. Alternatives that are inconsistent with other relevant guidelines, inconsistent with the client's and participants' values, and for which there are no resources or support should be eliminated. The remaining action alternatives that do not pass tests based on ethical principles of universality, publicity, and justice should be discarded. Social worker professionals may now predict the possible consequences of the remaining acceptable action alternatives and prioritize them by rank. The preferred action is selected and evaluated, an action plan is developed, and the action is implemented.

Finally, social work professionals may evaluate the outcome of the action and examine its implications. These implications may be applicable to future decision making.

In both Kenyon's and Congress's ethical decision-making frameworks, there are five fundamental components to this cognitive process. They encompass naming the dilemma, sorting the issues, solving the problem, and evaluating and reflecting [8,10].

Naming the dilemma involves identifying the values in conflict. If they are not ethical values or principles, it is not truly an ethical dilemma. It may be a communication problem or an administrative or legal uncertainty. The values, rights, duties, or ethical principles in conflict should be evident, and the dilemma should be named (e.g., this is a case of conflict between client autonomy and doing good for the client). This might happen when a client refuses an intervention or treatment that the social worker thinks would benefit the client. When principles conflict, such as those in the example statement above, a choice must be made about which principle should be honored.

Sort the issues by differentiating the facts from values and policy issues. Although these three matters often become confused, they need to be identified, particularly when the decision is an ethical one. So, ask the following questions: what are the facts, values, and policy concerns, and what appropriate ethical principles are involved for society, for you, and for the involved parties in the ethical dilemma?

Solve the problem by creating several choices of action. This is vital to the decision-making process and to the client's sense of controlling his or her life. When faced with a difficult dilemma, individuals often see only two courses of action that can be explored. These may relate to choosing an intervention, dealing with family and friends, or exploring available resources. It is good to brainstorm about all the possible actions that could be taken (even if some have been informally excluded). This process gives everyone a chance to think through the possibilities and to make clear arguments for and against the various alternatives. It also helps to discourage any possible polarization of the parties involved. Ethical decision making is not easy, but many problems can be solved with creativity and thought. This involves the following:

- Gather as many creative solutions as possible by brainstorming before evaluating suggestions (your own or others).

- Evaluate the suggested solutions until you come up with the most usable ones. Identify the ethical and political consequences of these solutions. Remember that you cannot turn your ethical decision into action if you are not realistic regarding the constraints of institutions and political systems.

- Identify the best solution. Whenever possible, arrive at your decision by consensus so others will support the action. If there are no workable solutions, be prepared to say so and explain why. If ethics cannot be implemented because of politics, this should be discussed. If there are no answers because the ethical dilemma is unsolvable, the appropriate people also must be informed. Finally, the client and/or family should be involved in making the decision, and it is imperative to implement their choice.

Ethics without action is just talk. In order to act, make sure that you communicate what must be done. Share your individual or group decision with the appropriate parties and seek their cooperation. Implement the decision.

As perfect ethical decisions are seldom possible, it is important to evaluate and reflect. Social work professionals can learn from past decisions and try to make them better in the future, particularly when they lead to policy making. To do this:

- Review the ramifications of the decision.

- Review the process of making the decision. For example, ask yourself if you would do it in the same way the next time and if the appropriate people were involved.

- Ask whether the decision should become policy or if more cases and data are needed before that step should occur.

- Learn from successes and errors.

- Be prepared to review the decision at a later time if the facts or issues change.

It is important to remember that Kenyon's and Congress's ethical decision-making frameworks are based on a rational model for ethical decision making. One of the criticisms of rational decision-making models is that they do not take into account diversity issues [27].

Ethical Principles Screen

Loewenberg and Dolgoff's Ethical Principles Screen is an ethical decision-making framework that differs slightly from the Kenyon and Congress models [28]. This method focuses on a hierarchy of ethical principles to evaluate the potential course of action for ethical dilemmas. The hierarchy rank prioritizes ethical principles; in other words, it identifies which principle should be adhered to first. The first ethical principle is more important than the second to the seventh [11]. Social work professionals should strive for the first ethical principle before any of the following ethical principles. In a situation where an ethical dilemma involves life or death, then this ethical principle should be adhered to first before principle 6, which is adhering to confidentiality. When reading Loewenberg and Dolgoff's hierarchy, the social worker can see that only conditions to maintain the client's right to survival (ethical principle 1) or his/her right to fair treatment (ethical principle 2) take precedence to ethical principle 3, which is free choice and freedom or self-determination.

Collaborative Model for Ethical Decision Making

The Collaborative Model for Ethical Decision Making is relationally oriented and is based on values emphasizing inclusion and cooperation [27,29]. Essentially, it entails four steps [27]:

- Identify the parties involved in the ethical dilemma.

- Define the viewpoints and worldviews of the parties involved.

- Use group work and formulate a solution in which all parties are satisfied.

- Identify and implement each individual's proposed recommendations for a solution.

I CARE Acronym

The I CARE Model was formulated on the NASW Code of Ethics along with several other decision-making models specifically for work with transgender clients [111]. It consists of [111]:

- Identification: Identify the ethical values and principles that emerge given the dilemma.

- Consultation: Seek information from literature and other professionals to become familiar with the issues at hand, the psychosocial needs of the client population, and one's own implicit biases.

- Action: Formulate action steps and evaluate the benefits and limitations of the action steps (and benefits and consequences of not taking certain action steps).

- Rebuttal: Identify counterpoints to the arguments.

- Evaluation: Evaluate or assess the outcomes of decision while documenting rationale.

LIMITATIONS OF ETHICAL DECISION-MAKING FRAMEWORKS

One of the criticisms of ethical decision-making frameworks is that they portray decision making in a linear progression, and in real life, such prescriptive models do not capture what professionals do [30]. In essence, these frameworks stem from a positivist approach. Positivism values objectivity and rationality. In subjectivity, one's values, feelings, and emotions are detached from scientific inquiry. Research has indicated that practitioners having these linear ethical decision frameworks in their knowledge base do not necessarily translate them into ethical practice. Consequently, Betan argues for a hermeneutic approach to ethical decision making. The person making the decision is not a detached observer; rather, the individual is inextricably part of the process. Betan maintains that this is vital because "ethics is rooted in regards to human life, and when confronting an ethical circumstance, one calls into service a personal sense of what it is to be human. Thus, one cannot intervene in human affairs without being an active participant in defining dimensions of human conduct and human worth" [30]. In one qualitative study, counselors were asked to walk through their ethical decision-making processes [85]. The researchers found that the counselors did not necessarily follow the steps outlined in various decision-making models. Instead, they tended to make a quick and automatic decision based on their experiences, their personal values and worldviews, and their professional responsibilities. This does not necessarily mean that professionals should discard the linear approaches to ethical decision making. Rather, professionals should work toward understanding how the principles fit within the therapeutic context as well as the larger cultural context. Furthermore, some maintain that even if practitioners follow a decision-making model, they are often prone to rationalizing their decisions despite ethical violations [110]. Another criticism is that ethical decision-making models are difficult to implement. When an ethical issue arises, decisions are often made rapidly, and as such, going through numerous steps may seem burdensome and inefficient [56]. Many ethical decision-making models also fail to take into account diversity and culture [112].

8. ETHICAL SELF-REFLECTION

Mattison challenges social work professionals to not only use decision-making models to infuse logic and rationality to the decision-making process, but to also incorporate a more reflexive phase [24]. Practitioners frequently overestimate their own levels of competence, which places them at risk in making errors. Self-reflection is vital to combat this tendency. This involves objective and direct observation and evaluation of one's own thought processes [86]. In many ways, Mattison's assertion is similar to Betan's call for integrating a hermeneutic perspective to ethical decision making. This is referred to as ethical self-reflection. The process is to learn more about oneself as a decision maker or to better understand the lens one wears to make decisions [24]. It is impossible to remove one's character, conscience, personal philosophy, attitudes, and biases from the decision-making process [31]. Just as social work emphasizes the person-in-situation perspective in working and advocating for clients, so too should the person-in-situation perspective be employed in increasing self-awareness as a decision maker in ethical situations [24]. The person-in-environment perspective argues that to understand human behavior, one must understand the context of the environment that colors, shapes, and influences behavior. Therefore, the social worker must engage in an active process by considering how their individual level (e.g., prior socialization, cultural values and orientations, personal philosophy, worldview), the client's domain (e.g., values, world views, beliefs), organizational context (i.e., organizational or agency culture, policies), professional context (i.e., values of the social work profession), and societal context (i.e., societal norms) all play a role in influencing moral decision making [24].

Chechak offers an alternative view regarding the role of personal values in self-reflection and evaluation [63]. He asserts that because social workers chose the profession, their personal values and worldviews should conform to the Code of Ethics and its underlying values—the standards should not be reinterpreted to align with separate personal values.

A qualitative study with social work students found they tended to place higher importance on the principle of self-determination over beneficence when confronted with an ethical dilemma, resulting in tension and conflict [57]. The researchers argue that students tend to be more familiar with the principle of self-determination, and as a result, they automatically resort to it. To combat this reflex, reflectivity to identify biases and values and how they influence ethical action is key. Social work agencies should ensure that reflection is incorporated into professional development on ethics to provide social workers an opportunity to apply ethical decision making to real-life case scenarios [57]. Supervision is also key in facilitating self-awareness and reflection when making ethical decisions [113].

PSYCHOLOGICAL CONTEXT OF MORAL DECISION MAKING

As discussed, ethical decision making does not operate within a vacuum. As Mattison acknowledges, there is an array of factors that influence the ethical decision-making process [24]. Consequently, it is impossible to talk about ethical decision making without looking at the psychology of moral development. Psychologists have looked at many of the same questions that philosophers have pondered but from their own professional perspective. Their theories of moral development permit us to learn something else about how moral disagreements develop and even how we may untangle them. Lawrence Kohlberg, a former professor at Harvard University, was a preeminent moral-development theorist. His thinking grew out of Jean Piaget's writings on children's intellectual development. Kohlberg's theories are based on descriptive norms (i.e., typical patterns of behavior) rather than on proven facts. Others in this field have taken issue with his categories, saying they are based too exclusively on rights-oriented ethical approaches, particularly those based on responsibility for others.

Kohlberg presumes that there are six stages of moral development that people go through in much the same way that infants learn first to roll over, to sit up, to crawl, to stand, and finally to walk [32]. The following section is from Lawrence Kohlberg's theory on moral development. There are two important correlates of Kohlberg's system:

- Everyone goes through each stage in the same order, but not everyone goes through all the stages.

- A person at one stage can understand the reasoning of any stage below him or her but cannot understand more than one stage above.

These correlates, especially the latter one, are important when it comes to assessing the nature of disagreements about ethical judgments. Kohlberg has characterized these stages in a number of ways, but perhaps the easiest way to remember them is by the differing kinds of justification employed in each stage. Regarding any decision, the following replies demonstrate the rationale for any decision made within each stage level.

Stage 1: When a person making a stage 1 decision is asked why the decision made is the right one, he or she would reply, "Because if I do not make that decision, I will be punished."

Stage 2: When a person making a stage 2 decision is asked why the decision made is the right one, he or she would reply, "Because if I make that decision, I will be rewarded and other people will help me."

Stage 3: A stage 3 decision maker would reply, "Others whom I care about will be pleased if I do this because they have taught me that this is what a good person does."

Stage 4: At this stage, the decision maker offers explanations that demonstrate his or her role in society and how decisions further the social order (for example, obeying the law makes life more orderly).

Stage 5: Here, the decision maker justifies decisions by explaining that acts will contribute to social well-being and that each member of society has an obligation to every other member.

Stage 6: At this final stage, decisions are justified by appeals to personal conscience and universal ethical principles.

It is important to understand that Kohlberg's stages do not help to find the right answers, as do ethical theories. Instead, recognizing these stages helps social work professionals to know how people get to their answers. As a result, if you asked the same question of someone at each of the six levels, the answer might be the same in all cases, but the rationale for the decision may be different. For example, let us suppose that a social worker is becoming more involved in the life of his female client. He drives her home after Alcoholics Anonymous meetings and is talking with her on the weekends. Here are examples of the rationale for the social work professional's decision and reply, in each stage, to the question of whether this relationship is appropriate.

Stage 1: "No, because I could lose my license if anyone found out that I overstepped the appropriate boundaries."

Stage 2: "No, because if I became known as a social worker who did that kind of thing, my colleagues might not refer clients to me."

Stage 3: "No, because that is against the law and professionals should obey the law," or, "No, because my colleagues would no longer respect me if they knew I had done that."

Stage 4: "No, because if everyone did that, social workers would no longer be trusted and respected."

Stage 5: "No, the client might benefit from our relationship, but it is wrong. I need to merely validate her as a human being."

Stage 6: "No, because I personally believe that this is not right and will compromise standards of good practice, so I cannot be a party to such an action."

These stages can give the social work professional another viewpoint as to how ethical decisions can get bogged down. A person who is capable of stage four reasoning may be reasoning at any level below that, but he/she will be stymied by someone who is trying to use a stage six argument. Ideally then, if discussion is to be effective or result in consensus or agreement, the participants in that discussion should be talking on the same level of ethical discourse.

Whenever individuals gather to address a particular client's case, the members of the team must be sure that they are clear about what values they hold, both individually and as a group, and where the conflict lies. Is it between the values, principles, or rules that lie within a single ethical system? Is it between values, principles, or rules that belong to different ethical systems? When consensus has been reached, the members should be aware of the stage level of the decision.

Since Kohlberg formulated his theory, several theorists have revised or reinvented it. James Rest used Kohlberg's theory as a basis for his Schema Theory [58]. Schema Theory consists of three domains: personal interest schema, maintaining norms schema, and postconventional schema [59]. The personal interest schema focuses on the individual experiencing the moral dilemma and how he/she should evaluate the personal gain or loss. During this period, there is almost no thought about the ultimate ethical decision or how it will impact society [59]. The maintaining norms schema is based on law and order. In this phase, a person will make an ethical decision based on laws and recognizing that disruption and disorder will occur if laws are not adhered to [59]. The post conventional schema is the most advanced type of moral reasoning in Schema Theory. It stresses shared ideals that are open to the evaluation by the community. Consensus building, due process, and safeguarding rights of all members in society are emphasized [59].

Kohlberg's theory of moral development and followers of Kohlberg's theory have been criticized for being androcentric. In other words, his moral dilemmas capture male moral development and not necessarily female moral development. Gilligan, backed by her research, argues that men and women have different ways of conceptualizing morality, and therefore, the decisions made will be different [33]. This does not necessarily mean that one conceptualization is better than the other. Brown and Gilligan maintain that men have a morality of justice while women have a morality of care [34]. This is particularly relevant in social work because the field has a predominance of female social workers. This longing for relatedness and connectedness results in a "feminine" ethic of care, and it is this that guides female professionals' ethical decision making [35]. In other words, the decision-making process includes both a rational-cognitive component as well as a personal-emotive one. The social worker's "feminine" ethic of care involves a dynamic process of balancing objectivity, systematization, and rationality to reflect upon the moral dilemma, without forsaking the affective component [35]. Since Gilligan's work, scholars have discussed care ethics and mature care, which encompasses a relational care but also reflective examination of the self. In other words, ethics of care involves the care of others as well as self [60]. From this perspective, an ethical professional is one who cares for the needs of others, but also recognizes his/her own needs. Furthermore, ethics of care is not restricted to women; rather, some argue care is essential to morality [61]. Ultimately, the goal is not to elevate one form of moral development as the scientific standard; rather, it is crucial to view female ethics of care as complementing the standard theories of moral development.

9. MANAGED CARE AND ETHICS

Managed care has changed the climate in the provision of health and mental health services, and a range of practitioners have been affected, including social workers. In part due to negative public perception, there has been a shift away from the term "managed care" and toward terms such as "behavioral health," "integrated behavioral health," and "behavioral mental health" to refer to managed mental health care [87]. This shift acknowledges that mental health issues are complex and involve physical, psychologic, and emotional components [88]. So, more coordinated and integrated services should ultimately benefit the consumer [87,88]. This section is not meant to be an exhaustive discussion of how managed care or integrated behavioral health has impacted ethical practice, but it is meant to provide an overview of the ethical issues raised in a managed care climate that are complex and multifaceted.

Managed care is a system designed by healthcare insurance companies to curb the increasing costs of health care [62,89]. A third party (utilization reviewer) reviews treatment plans and progress and has the authority to approve further treatment or to terminate treatment [16,89]. In addition, certain types of interventions are reimbursable while other types of care are not [36]. Furthermore, professionals have to learn new ways to decrease costs and improving the efficacy of manpower and these skills may include learning to use computer technology for documentation, empirical validation of interventions, and business strategies to increase profit margins [62].

The ethical concerns in managed care revolve around the issue of whether a social worker or practitioner should continue to provide services outside the parameter of the managed care contract [16]. Is early termination of services deemed on a probability that payment will not be obtained? In a cost-benefit analysis, what is the role of the client? How does the ethical principle of beneficence come into play? Certain diagnoses will be deemed reimbursable by the managed care organization. Is it beneficial for the client if a different diagnosis is given in order for services to continue [114]?

At the core, it is the ethical conflict of distributive justice versus injustice [37]. Distributive justice stresses the role of fairness in the distribution of services and states that, at minimum, a basic level of care should be provided. However, the principle of distributive justice may be compromised when services are allocated based on fixed criteria and not on individuals' needs [37]. Situations will then emerge in which the utilization reviewer indicates that the client is not approved for more services, and the social worker may find him or herself unable to provide services that are still necessary. In this case, it is suggested that social workers utilize their roles as advocates to encourage and coach their clients to go through grievance procedures for more services from their managed care provider [37]. One of the consequences of ethical conflict between a client's need for services and the environmental pressure of financial constraints is moral distress [63]. Moral distress is the psychologic tension produced when practitioners know the right thing to do but cannot behave accordingly given environmental and organization constraints [64]. A survey of 591 social workers found that those who perceived they had higher levels of competence with managed care experienced lower levels of emotional exhaustion [62].

Another ethical issue emerging within social work practice in a managed care environment is that of the social worker's fiduciary relationship with the agency versus a fiduciary relationship with the client [37,70]. Each relationship has competing sets of loyalties and responsibilities. First, the social worker has a fiduciary relationship to the managed care company. The responsibility to the agency is to keep expenditures within budget. Yet, there is also the social worker's obligation to the client's best interests and needs [37]. Galambos argues that while the NASW Code of Ethics emphasizes both the importance of the social worker's obligation to their agency and the ethical principle of respect for the inherent dignity and worth of the person, the client's welfare is paramount. One way of managing this conflict is for social workers to be involved in the advocacy and development of policies that allow some leeway for clients who may require additional services.

Confidentiality, which is founded on respect and dignity, is of paramount importance to the therapeutic relationship. However, managed care systems also present challenges to the ethical issue of client confidentiality, as they often request that clients' records be submitted for review and approval of services [38,114]. Accessible electronic health records further complicate this issue [88]. Consequently, social workers and other practitioners should explain up front and provide disclosure statements that establish the limits to confidentiality, what types of information must be shared, how this information is communicated, treatment options, billing arrangements, and other information [38,39]. Knowing that other staff members may obtain sensitive information can influence the extent to which sensitive information is included in notes [88].

Regardless of what social workers might think of managed care, the social worker bears the responsibility of upholding his/her respective professional ethical principles. In order to assist social workers and practitioners in developing their own ethical standards, the following self-reflective considerations for those working in a managed care environment should be considered [16]:

- Reflect on one's therapeutic and theoretical orientation and its compatibility with the philosophies of managed care. Depending on the assessment, social workers may have to reassess their practices or obtain additional training to acquire the necessary competencies to work in a managed care environment.

- Reflect on one's biases and values regarding managed care and how these attitudes influence one's practice.

- Develop a network of colleagues to act as peer reviewers, as they may evaluate one's ethical practice within the managed care climate.

10. DIVERSITY AND MULTICULTURALISM: ETHICAL ISSUES

It has been argued that ethical principles may not be easily applied to different cultural contexts. The majority of established ethical principles and codes have been formulated within a Western context; therefore, these ethical principles may have been formulated without consideration for linguistic, cultural, and socioeconomic differences. Harper argues that a cultural context must be taken into account because many of these groups constitute vulnerable populations and may be at risk of exploitation [17]. In this course, an inclusive definition of diversity is utilized, encompassing age, race, ethnicity, culture, immigration status, ability, educational level, religion, gender, sexual orientation, gender identity or expression, and socioeconomic status, to match the increasing diversity of contemporary American society [40,68].

DEBATES WITHIN MULTICULTURALISM/DIVERSITY AND ETHICS

Much of the traditional ethical systems and philosophies that have influenced the United States stems from Christian-based and scientific empiricism [42]. Positivism assumes there is one universal that can be counted or measured. In addition, it postulates that reality is objective and value-free [42]. This positivistic approach to ethics was challenged by Joseph Fletcher in 1966 when he published Situation Ethics. He challenged the assumption made by many scholars in the 20th century that one resolved ethical dilemmas by turning to universally accepted principles. His work caused a paradigm shift from a universal approach to ethics to deconstructing it and developing a constructivist, contextual approach [42]. In situation ethics, one takes the context (including culture and diversity) into account.

Others argue that a postmodernist perspective is beneficial when working with clients from diverse cultures [65]. This approach argues for cultural relativism, maintaining that there is no reference point to which to compare cultural norms [65].

In our multicultural society, definitions of "good" or "bad" will inevitably vary from group to group. One of the struggles when dealing with multiculturalism and diversity issues while developing ethical guidelines is the question of how to develop one ethical guideline that can fully apply to the many diverse groups in our society. Strictly speaking, multiculturalism promotes the idea that all cultural groups be treated with respect and equality [19,68]. The complexity of defining multiculturalism and diversity is influenced by the tremendous differences within a group in addition to the differences between groups. Certainly religion, nationality, socioeconomic status, education, acculturation, and different political affiliations all contribute to this within-group diversity. To make matters even more complex, multiculturalism and diversity within a society are dynamic rather than static, as are the words used to describe problems [44]. For example, the term "vulnerable populations" has long been used in social work research and practice. However, in the past few years experts have begun to argue that the term undermines the social work value "respecting the dignity and worth of the person," as it may convey a lack of ability to make decisions [90].

Consequently, the questions that arise in this debate are: Should ethical guidelines be based on the uniqueness of groups, taking into account distinct values, norms, and belief systems? Or should ethical guidelines be developed based on the assumption that all human beings are alike [44]? Some experts have argued that the underlying values of many of the professional codes of ethics in the United States mirror "Americanness," essentially overemphasizing autonomy and individualism [66]. If clients ultimately want to be treated with dignity and respect, then honoring dignity may be more important than honoring autonomy [66].

INFUSING DIVERSITY INTO THE ETHICAL DECISION-MAKING MODELS

Several ethical decision-making models have been reviewed in this course. The major criticism of these models is that they do not take into account issues of diversity. Garcia, Cartwright, Winston, and Borzuchowska developed the Transcultural Integrative Model for Decision Making, which includes a self-reflective activity [27]. This allows practitioners to recognize how cultural, societal, and institutional factors impact their values, skills, and biases. Furthermore, the model stresses the role of collaboration and tolerance, encouraging all parties to be involved in the evaluation of ethical issues and promoting acceptance of diverse worldviews [27].

The authors of this model maintain that its strength lies in the fact that it is based on several underlying frameworks: rational, collaborative, and social constructivist. It employs a rational model in providing a sequential series of procedures. The collaboration model is used because it acknowledges the importance of working with all stakeholders involved, employing a variety of techniques to achieve consensus. Finally, the Transcultural Integrative Model employs social constructivist principles by acknowledging that meanings of situations are socially constructed [27]. No single theoretical framework can provide solutions to complex and multifaceted ethical solutions; therefore, an array of strengths from various frameworks is harnessed. The Transcultural Integrative Model consists of four major steps, with sub-tasks within each step [27].

Step 1: Interpreting the Situation through Awareness

First, the social worker or counselor examines his/her own competence, values, attitudes, and knowledge regarding a cultural group. The social worker or counselor then identifies the dilemma not only from his/her own perspective, but also from the client's perspective. Relevant stakeholders, or meaningful parties relevant to the client's cultural context and value systems, are identified. Finally, cultural information is garnered (e.g., value systems, immigration history, experiences with discrimination, prejudice).

Step 2: Formulating an Ethical Decision

In the second step, the dilemma is further reviewed within its cultural context. It is important to examine the professional ethical code for specific references to diversity. A list of possible culturally sensitive and appropriate actions is formulated by collaborating with all parties involved. Each action is then evaluated from a cultural perspective, examining the respective positive and negative consequences. Again, feedback from all parties is solicited. Consultation with individuals with multicultural expertise is sought to obtain an outsider perspective. Finally, a course of action is agreed upon that is congruent with the cultural values and is acceptable to all parties involved.

Step 3: Weighing Competing, Nonmoral Values

Social workers and counselors should reflect and identify personal blind spots that may reflect values different from that of the cultural values of the client. Larger professional, institutional, societal, and cultural values should also be examined.

Step 4: Implementing Action Plan

In the final step, cultural resources are identified to help implement the plan. Cultural barriers that might impede execution of the plan, such as biases, stereotypes, or discrimination, are identified. After the action is implemented, it should be evaluated for accuracy and effectiveness. Such an evaluation plan should include gathering feedback from multicultural experts and culturally specific and relevant variables.

SELF-CARE AND THE NASW CODE OF ETHICS

Self-care is at the heart of social work practice [115]. If social workers do not prioritize their own wellness, compassion fatigue, burnout, and secondary traumatization can result, which leads to higher attrition rates and can harm clients.

Before the 2021 revisions to the NASW Code of Ethics, there was only implicit reference to self-care [116]. In an effort to clarify the importance of this issue, new language about self-care was added to the Purpose and Ethical Principle sections of the Code of Ethics [116]. The Purpose section now includes the following language [8]:

Professional self-care is paramount for competent and ethical social work practice. Professional demands, challenging workplace climates, and exposure to trauma warrant that social workers maintain personal and professional health, safety, and integrity. Social work organizations, agencies, and educational institutions are encouraged to promote organizational policies, practices, and materials to support social workers' self-care.

MULTICULTURALISM/DIVERSITY AND THE NASW CODE OF ETHICS

In the 2017 NASW Code of Ethics, references to cultural competence were changed to cultural awareness [8,91]. However, the 2021 update reverts back to the language of cultural competence, as it connotes the inclusion of culturally informed practice and cultural awareness. The concept of cultural humility has also been added to the standard [116].

Standard 1.05, which is titled "Cultural Competence" reads [8]:

(a) Social workers should demonstrate understanding of culture and its function in human behavior and society, recognizing the strengths that exist in all cultures.

(b) Social workers should demonstrate knowledge that guides practice with clients of various cultures and be able to demonstrate skills in the provision of culturally informed services that empower marginalized individuals and groups. Social workers must take action against oppression, racism, discrimination, and inequities, and acknowledge personal privilege.

(c) Social workers should demonstrate awareness and cultural humility by engaging in critical self-reflection (understanding their own bias and engaging in self-correction), recognizing clients as experts of their own culture, committing to lifelong learning, and holding institutions accountable for advancing cultural humility.

(d) Social workers should obtain education about and demonstrate understanding of the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical ability.

(e) Social workers who provide electronic social work services should be aware of cultural and socioeconomic differences among clients' use of and access to electronic technology and seek to prevent such potential barriers. Social workers should assess cultural, environmental, economic, mental or physical ability, linguistic, and other issues that may affect the delivery or use of these services.

The 2021 Code of Ethics, with its emphasis on cultural competence, calls for understanding and demonstration through knowledge.

TECHNOLOGY AND THE NASW CODE OF ETHICS

Today, social workers use a variety of technologies in their daily practice with clients, families, stakeholders, and colleagues. These technologies include e-mail, social networks, videoconferencing, smartphones, blogs, and electronic records [92,93]. The 2017 revision of the NASW Code of Ethics included many changes and new standards that reflect the role of technology in social work; these remain in place with the 2021 revision. However, it is important to note that all of the ethical standards outlined in the NASW Code of Ethics apply to social workers who use technology with clients. Social work professionals should consider how the ethical principles and standards apply to technologic tools and interactions. For example, the NASW Code of Ethics includes five ethical standards regarding technology and informed consent [8]:

1.03 Informed Consent

(e) Social workers should discuss with clients the social workers' policies concerning the use of technology in the provision of professional services.

(f) Social workers who use technology to provide social work services should obtain informed consent from the individuals using these services during the initial screening or interview and prior to initiating services. Social workers should assess clients' capacity to provide informed consent and, when using technology to communicate, verify the identity and location of clients.

(g) Social workers who use technology to provide social work services should assess the clients' suitability and capacity for electronic and remote services. Social workers should consider the clients' intellectual, emotional, and physical ability to use technology to receive services and the clients' ability to understand the potential benefits, risks, and limitations of such services. If clients do not wish to use services provided through technology, social workers should help them identify alternate methods of service.

(h) Social workers should obtain clients' informed consent before making audio or video recordings of clients or permitting observation of service provision by a third party.

(i) Social workers should obtain client consent before conducting an electronic search on the client. Exceptions may arise when the search is for purposes of protecting the client or other people from serious, foreseeable, and imminent harm, or for other compelling professional reasons.

The 2021 updates include expanded language on the use of technology in social work practice. Standard 1.05: Cultural Competence requires social workers to have a commitment to prevent barriers to effective technology use [117].

INTERPROFESSIONAL COLLABORATION AND ETHICS

Interprofessional collaboration is defined as a partnership or network of providers who work in a concerted and coordinated effort on a common goal for clients and their families to improve health, mental health, and social and/or family outcomes [118]. It involves the interaction of two or more disciplines or professions who work collaboratively with the client on an identified issue [119]. Providers come together to discuss and address the same client problem from different lenses, which can ultimately produce more inventive and effective solutions [120]. The client/patient is not excluded from the process; rather, shared decision making by all team members advances the goal of improving client/patient outcome(s) [118].

Interprofessional collaborations have been touted for multiple reasons. Positive outcomes have been demonstrated on individual and organizational levels. For example, on the client level, reduced mortality, increased safety and satisfaction, and improved health outcomes and quality of life have been demonstrated [121,122,123]. Practitioners also experience benefits, including increased job satisfaction, staff retention, improved working relationships, and more innovative solutions to problems [121,123,124].

There is a difference between the traditional model of professional ethics and interprofessional ethics [125]. The traditional model revolves around a single profession's unique code of ethics, which addresses the specific profession's roles, expertise, core values, and ethical behaviors. Each professional's code of ethics demands the practitioner's loyalty and commitment to the values, specialty, and expertise [125]. On the other hand, interprofessional ethics emphasizes the relationship and interactions of practitioners from different professions and the unique ethical issues that emerge from working with a diverse team (e.g., interpersonal conflict, misuse of power, respect) [125]. Practitioners in an interprofessional setting should engage in collective interprofessional ethics work, which is defined as "the effort cooperating professionals put into collectively developing themselves as good practitioners, collectively seeing ethical aspects of situations, collectively working out the right course of action, and collectively justifying who they are and what they do" [126].

Standard 2.03 in the NASW Code of Ethics states [8]:

(a) Social workers who are members of an interdisciplinary team should participate in and contribute to decisions that affect the well-being of clients by drawing on the perspectives, values, and experiences of the social work profession. Professional and ethical obligations of the interdisciplinary team as a whole and of its individual members should be clearly established.

(b) Social workers for whom a team decision raises ethical concerns should attempt to resolve the disagreement through appropriate channels. If the disagreement cannot be resolved, social workers should pursue other avenues to address their concerns consistent with client well-being.

Because interprofessional team members come from different disciplines, there may be divergent views on how to handle ethical dilemmas. This is a challenge and can result in friction among the team. Practitioners should communicate openly about each members' roles, expertise, and responsibilities in client care and decision-making processes [99]. It is also important to delineate who will be involved in the informed consent process, documentation, and record keeping. Most importantly, practitioners should not act outside the scope of their practice and licensing and regulatory requirements.

11. CONCLUSION

The application of ethical theories and ethical decision making is challenging. Without a background of knowledge and understanding, social work professionals will be unable to make sound decisions about ethical problems and be unable to help clients and families in their decision making. Although every situation differs, decision making based upon ethical theories can provide a useful means for solving problems related to client situations. Hopefully, as a result of this course, you feel more prepared and confident in facing future ethical decision making situations.

California LCSWs

An excerpt from the California Board of Behavioral Sciences Statutes and Regulations Relating to the Practice of Clinical Social Work is available by clicking here.

12. RESOURCES

Social workers play an important role in advocacy and education. To be more effective, social work professionals may need additional resources. The following are some resources, including organizations and articles about ethics in general and specifically in social work.

APA Ethics Office

https://www.apa.org/ethics

Center for the Study of Ethics in the Professions

This center was established in 1976 for the purpose of promoting education and scholarship relating to the professions.

http://ethics.iit.edu

Ethics Updates

Ethics Updates is designed primarily to be used by ethics instructors and their students. It is intended to provide updates on current literature, both popular and professional, that relates to ethics.

http://ethicsupdates.net

National Association of Social Workers

https://www.socialworkers.org

https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

https://www.socialworkers.org/About/Ethics/Ethics-Education-and-Resources/Ethics-Consultations

Social Work Today

https://www.socialworktoday.com/eye_on_ethics_index.shtml

The New Social Worker

https://www.socialworker.com/feature-articles/ethics-articles

Standards on Technology and Social Work Practice

https://www.socialworkers.org/includes/newIncludes/homepage/PRA-BRO-33617.TechStandards_FINAL_POSTING.pdf

W. Maurice Young Centre for Applied Ethics

https://ethics.ubc.ca

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