Ethics Anxiety

This case report, drawn from an American hospital, explores a phenomenon best described as ethics anxiety, a feeling of uncertainty as to what is ethically required or permitted, leading to clinical delay and confused decisions. In the specific clinical situation presented, the clinicians find themselves confronting, under severe time constraints, a complex, multidimensional problem with ethical and legal implications. The situation deteriorates as the clinicians find themselves unable to find what they perceive as the expert advice, either clinical or ethical, that would enable them to resolve the problem presented. In the discussion section of the case report, some attention is given to the role that the bioethics movement itself has had in creating these situations and undermining clinical decision‐making.     

When Freedom is Not an Endless Meeting: A New Look at Efficiency in Consensus‐Based Decision Making

It is axiomatic among scholars of participatory democracy that consensus‐based decision making is inefficient, yet no study has systematically assessed that claim. This article examines the efficiency of consensus decision making in 12 social movement groups from the German autonomous and nonviolence movements. Data were analyzed from 62 semistructured interviews regarding how long it took each group to make a typical decision and what types of decisions were the easiest and most difficult to make. A measure of inclusiveness was included to determine whether efficiency was attained by silencing dissent. Most decisions were made in less than two hours. Factors were identified that distinguished more and less efficient groups.     

A Bioethics Approach to Social Work Practice With Transgender Clients

Increased advocacy for the informed consent model of transgender health care specifies that patients should be in control of access to receiving medical interventions such as hormone therapy or surgery. However, in practice, mental health clinicians, including clinical social workers, are increasingly called upon by medical providers to serve as gatekeepers for these processes. It is frequently the role of social workers to assess transgender clients’ baseline mental health and their understanding of the consequences of treatment, and to forward recommendations to medical providers regarding the readiness of patients to transition. Therefore, social workers assisting transgender clients must be aware of the ethical standards that are particularly pertinent to their work with this marginalized and oppressed population. They must also be prepared to address unique ethical dilemmas that may be especially challenging to resolve. In this article we apply the most commonly utilized bioethical framework known as Principlism to describe the ethical standards and values that are particularly important to consider when working with transgender clients, namely autonomy; beneficence; nonmaleficence; and social justice. Because clinical social workers are frequently in the position of balancing client self-determination with their role as gatekeepers, a framework for resolving resulting ethical dilemmas is described (I CARE) and applied to three case examples.     

Health Care and Female Survivors of Childhood Sexual Abuse: Health Professionals' Perspectives

The present study explored health professionals' experiences with adult survivors of child sexual abuse in New Zealand. Face-to-face, semistructured interviews of up to an hour took place with 13 health professionals. The participants were asked about training, screening practices, their response to disclosures, and advice to other health professionals. A model—transition to ethical practice—emerged from the data, where delivering more sensitive health care to child sexual abuse survivors sits on a continuum from lack of awareness of child sexual abuse to delivery of care where all patients are comfortable. We recommend making sensitive care for all as the standard care of practice and providing training for health professionals on how to deal with disclosures.     

Decision‐Making Fairness and Consensus Building in Multisector Community Health Alliances: A Mixed‐Methods Analysis

Given their inherently diverse composition and potentially competing interests, a foundational activity of community health alliances is establishing consensus on the vision and strategies for achieving its goals. Using an organizational justice framework, we examined whether member perceptions of fairness in alliances' decision‐making processes are associated with the perceived level of consensus among members regarding the alliance vision and strategies. We used a mixed‐methods design to examine the relationship between perceptions of fairness and consensus within fourteen multisector community health alliances. Quantitative analysis found the perceived level of consensus to be positively associated with decision‐making transparency (procedural fairness), inclusiveness (procedural fairness), and benefits relative to costs (distributive fairness). Qualitative analysis indicated that the consensus‐building process is facilitated by using formal decision‐making frameworks and engaging alliance members in decision‐making processes early. Alliance leaders may be more successful at building consensus when they recognize the need to appeal to a member's sense of procedural and distributive fairness, and, perhaps equally important, recognize when one rather than the other is called for and draw upon decision‐making processes that most clearly evoke that sense of fairness. Our findings reinforce the importance of fairness in building and sustaining capacity for improving community health.     

Patient Rights: An Advocate's Perspective

Abstract

The current growing concern about patients' rights and the delivery of student health care precipitates an environment of fear, distrust, and uneasiness within university health services. This paper addresses several selected clinical, ethical, and legal issues which have come into conflict during recent years. Our examination surveys ethical and legal principles of confidentiality, defines areas in which breaches are most likely to occur, and suggests ways of preventing breaches of confidence between students and health services.

While the fundamental ethical principle underlying confidentiality is the individual's right of privacy, many issues of confidentiality are extremely difficult to resolve. University health services have expanded the concept of health care to encompass all the conditions — medical, emotional, social, economic and environmental — which affect the health of students. As a result, health service administrators should be fully aware of the laws and associated legal complexities in their own state which affect confidentiality. Furthermore, student health physicians, and particularly mental health therapists must be sensitive to needs for protecting the privacy of students.

Legal principles of confidentiality discussed in this paper with respect to specific problem situations which might arise in a student health center include: 1) right to privacy; 2) privileged communications; 3) releasing information from the medical record; 4) releasing information to the student; and 5) treating minors without parental consent. Finally, in addition to the responsibilities which must be assumed by the health professional, certain student responsibilities in the selection and utilization of health professionals are recommended.     

The role of narrative in public relations ethics pedagogy

Competence in ethical decision making is one of the most important issues in the industry and practice of public relations, yet professionals entering the discipline overestimate their knowledge and skills related to ethical principles. This article features a pedagogical approach to strengthen ethics education in public relations through the use of collaborative student-professional ethics narratives. This technique attempts to move beyond a traditional case study approach and transcend traditional classroom boundaries through the development of narratives featuring real ethics situations experienced by public relations professionals. The project involved the development, implementation and assessment of the pedagogical approach that required students to interview local communication professionals (mostly in public relations) and to craft narratives that explore ethical dilemmas these professionals faced. Pre- and post-test surveys and group feedback helped explore the impact of narrative inquiry in helping students internalize ethical lessons.     

Professional Decision Making on Elder Abuse: Systematic Narrative Review

Social work and health care professionals internationally are recognizing the need to understand and respond to the abuse of older people. Policy and guidance have identified processes but definitions of key concepts remain problematic, and the literature suggests that practitioners and agencies have little insight or guidance for decision making. Nine bibliographic databases were searched for studies on professional decision making regarding abuse of older people. Relevant studies retrieved were appraised for quality using explicit criteria. The findings of the 19 articles meeting the inclusion criteria were synthesised using a structured narrative approach. Common themes identified were abuse factors, situational factors, and broader contextual factors. Abuse factors relating to risk levels and client vulnerability were central; age, gender, and health status were considered as key indicators of vulnerability. The opinion of adult protection workers about the potential effectiveness of their intervention was a factor in deciding about responding to alleged or suspected abuse. Professionals struggled with complex ethical dilemmas created by elder abuse, particularly when the victim did not want an investigation. Making objective judgements was difficult when faced with complex family and contextual factors. A structured approach to narrative synthesis of a diverse range of studies retrieved through an explicit search and inclusion process provided a useful summary of key issues for practice and identified gaps in the research literature.     

Physical health decision making and decision aid preferences of individuals with severe mental illness

Individuals with severe mental illness (SMI) often suffer from comorbid physical health conditions that reduce quality of life and longevity. The integrated care movement has improved access to primary care services, but system change does not necessarily impact health behaviors. In an effort to better understand health behaviors of persons with SMI in integrated care, we explored physical health decision making and decision aid preferences. We conducted three focus groups, including two consumer groups and one mental health staff group. Data were analyzed using a grounded theory approach, employing independent coding, thematic analysis, and meaning-making processes. Data suggest that overall, the consumer groups preferred a shared decision making process, with the doctor making the final treatment decision. Staff indicated that decision making depended on a consumer’s functioning level. Consumers liked the idea of using a decision aid, and reported preferring the computerized aid. Staff felt that decision aids were dependent on consumer level of functioning. Consumers generally view primary care doctors as experts, but like the idea of using decision aids to assist in making medical decisions. Staff feel that consumers may need help in both decision making and decision aid use in primary care.     

A Practical Model for Ethical Decision Making in Issues Management and Public Relations

The deontological philosophy of Immanuel Kant (1724–1804) provides a powerful framework for the analysis of ethical dilemmas. Kant's philosophy is discussed and applied to what this research poses as the "practical model for ethical decision making" (see Figure 1). This Kantian model establishes an ethical consideration triangle and incorporates symmetrical communication. The issues management of 2 global organizations was used as an empirical test of the model and to refine it for practical implementation. I argue that rigorous analysis of ethical decisions and symmetrical communication result in ethical issues management.     

EMERGENCY PSYCHIATRY AND THE FAMILY: THE DECISION TO ADMIT

The author's work with families presenting to a psychiatric emergency service points to the prominence of families' wishes that one family member be hospitalized. The pressure on the cliniciancan be extreme. A number of studies in the literature on the decision to admit contain similar observations emerging from varied methodologies and vantages. The author draws from clinical practiceand the literature to focus on an interpersonal dimension to emergency interventions. Awareness ofinterpersonal forces upon mental health clinicians is crucial to allow mature balancing of the many factors involved in the decision making process. An integration of family and systems thinking into the practice of emergency psychiatry can enhance comfort and effectiveness in many difficult crisis situations.     

Ethical assessment and moral reasoning in child therapy

Social workers find it hard to operationalize the profession's Code of Ethics, and few professionals even rely on the Code, as a point of reference in making judgments when faced with ethical dilemmas. Children and adolescents hold a special position in clinical practice. Issues requiring ethical judgments are more complex, because any intervention involves people other than the child. How the professional meets the interests of the parents and those of the child, is frequently a cause for conflict. This article presents philosophical models of moral reasoning, and ethical assessment, to assist clinicians in identifying and resolving frequently faced practice dilemmas, with the goal of improving the quality of patient care, in terms of both the process and the outcome. Emphasis is not only on the ethics of the actual decision but also on the ethics of the decision-making process itself.This article is based on the author's unpublished dissertation, seminars, and grand rounds presentations on applied ethics in clinical social work. Additionally, this author has had consultative and collaborative contact with the Hastings Center, Institute of Society, Ethics and Life Science.     

Constructing the ‘ideal’ family for family‐centred practice: challenges for delivery

Family‐centred practice positions families as the key decision‐makers, central to and experts in the wants and needs of their child. This paper discusses how families interviewed for a Western Australian study describe their relationships with a range of allied health professionals in the paediatric disability sector. The allied health professionals, in turn, describe how they characterize the role of families caring for children with disabilities. We argue that the successful implementation of family‐ centred principles in service delivery need to move beyond the individualizing of responsibility and acknowledge the structural and systemic limits to family‐centred practice, as well as the social complexity within which diverse families live.     

Organizational ethics, decision making, undecidability

In this paper we develop a conceptualisation of organizational decision‐making as a practice that is, necessarily, ethical. The paper starts with a discussion of the notion of decision‐making as it relates to organizational rationality and the relationship between management and control. Drawing on Derrida's discussions of undecidability and responsibility, we suggest that as well as being able to consider organizational decision‐making as an instance of (albeit bounded) rationality or calculability, it can also be regarded as a process of choice amongst heterogenous possibilities. On that basis, we follow Derrida in arguing that for a decision to be considered an instance of responsible action it must be made with neither recourse to knowledge of its outcome nor to the application of pre‐ordained rules. Illustrating our argument with a discussion of Eichmann's ‘I was just following orders’ defence, we suggest that rules for ethical decision making, rather than ensuring ethical outcomes, can work to insulate organizations from moral responsibility. We conclude with a discussion of ethics and democracy in relation to responsible decision making in organizations.     

The Ethical Practitioner in Formation: Issues of Courage,Competence and Commitment

This article reports on a small study exploring students' accounts of ethically difficult situations. Participating students were studying professional qualifying programmes in social education and social work at three higher education institutions in Finland, France and the UK. Variations in how students describe ethically difficult situations are noted—including whether they feature the student as an active moral agent facing a difficult ethical decision and the extent to which they utilise recognisably ‘ethical’ language and concepts. The types of situations reported as ethically difficult are identified as focusing on: the difficulties of challenging service users and colleagues; the power and responsibility of the worker; and defining the boundaries of the professional relationship. Similar types of situations were raised by students in the different countries, although there is some variation in how they describe their ethical difficulties and the specific concerns they raise. Implications for teaching include the need to develop skills and qualities in students that enable them to recognise the ethical dimensions of difficult situations and to develop the courage to act on their decisions.     

Animating community supported agriculture in North East England: Striving for a ‘caring practice’

This paper draws on a case study of a new Community Supported Agriculture (CSA) scheme in the north of England to draw attention to some of the ethical issues encountered when using a participatory action research approach to animating CSA. Both CSA and participatory action research have been associated with the concept of ‘caring practice’ and an ‘ethic of care’. CSAs can be conceptualised as attempts to engage with ethical issues in the food system. Action research is also a value laden approach. The case study illustrates how the complexities of conducting this type of research leads to many instances of having to make ethical choices and claims that these decisions are helpfully framed by Warren’s (1999) claim that these choices should aim to result in ‘care practices’. Similar dilemmas and choices will arise in other contexts and require situated negotiation and decision making. Focussing on caring practice may help to construct a rationale for consistent choices.     

Towards Customized Deliberations

ABSTRACT

The profession of social work has important contributions to make in the rapidly developing dialog about medical care decision making and to the evolution of hospitals as systems that engage with people as patients, for whom illnesses create increased vulnerability (Gruber, 1998). Professional ethics clearly states that the individual professional social worker has a responsibility to influence processes involving vulnerable populations. Articulating social work's responsibility and potential contributions in the area of medical care decision making begins with an application of social work's mission and values, and then continues with consideration of the profession's evolving role in hospitals. Pertinent aspects of the health care industry, including current models for continuum of care and for provider-patient relationships, are discussed in terms of opportunities to modify the models used to guide interactions with patients. Finally, the impact of a growing number of distinct treatment options is also considered. The objective of the article is to offer social workers in health care settings a conceptual framework for considering professional ethical obligations and for participating in the contemporary dialog regarding medical care decision-making.     

Being central to decision making means I am still here!: The essence of decision making for people with dementia

The ability to make choices and decisions, and to have those decisions upheld, is central to self-determination. For people living with a diagnosis of dementia, however, it can be difficult to remain involved in decision making. While many studies show that people with mild or moderate dementia have the ability to participate in decision making, there are also indications that the attitudes of those around them, including health professionals and family carers, can sometimes be a barrier, and there is generally little understanding about the nature of decision making for this population. This small pilot study draws on van Manen's approach to phenomenology to explore the essence of decision making for people living with dementia. The findings highlight the importance of remaining central to decision making, and the key role that subtle support from carers plays in enabling this.     

DO SUNK COSTS MATTER?

That sunk costs are not relevant to rational decision making is often presented as one of the basic principles of economics. When people are influenced by sunk costs in their decision making, they are said to be committing the “sunk cost fallacy.” Contrary to conventional wisdom, we argue that in a broad range of situations, it is rational for people to condition behavior on sunk costs because of informational content, reputational concerns, or financial and time constraints. Once all the elements of the decision‐making environment are taken into account, reacting to sunk costs can often be understood as rational behavior. (JEL D0, D01, D8, D81, D83, D9, D90)     

The assessment of values in medical decision making

Individuals, families, and health care providers consider medical treatment decisions in light of their respective values about life iin varying states of health. The clarification of health care values is important not only in the context of everyday clinical decision making, but also for advance care planning and the resolution of ethical dilemmas. This article argues that objective assessment tools may facilitate the process of clarifying and communicating health care values in these contexts. The article reviews arguments for the importance of values assessment in health care planning, methods used to date for health care values assessment, conceptual and methodological challenges for the measurement of health care values, and lessons learned through the process of developing and piloting a Health Care Values Survey. Objective values assessment tools appear useful for eliciting health care values, although multiple challenges for reliable, valid, and clinically useful measurement of values are identified.