Social Work Research Paper

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Abstract

Social workers are critical participants in bioethics discussions, debates, and activities. Social workers serve as case managers, clinicians, agency managers and administrators, community organizers, policy analysts, advocates, and researchers. They address a wide range of ethical issues, such as end-of-life decisions, reproductive rights, management of confidential information shared by patients and family members, informed consent, minors’ rights to confidentiality and treatment, patients’ right to refuse treatment, paternalism, conscience clauses, and allocation of limited resources. This entry provides an overview of the social work profession, social workers’ role in health-care settings, the evolution of ethical standards in social work, ethical challenges facing social workers in health-care settings, and relevant ethics concepts.

Introduction

Social workers throughout the world address issues of health care, poverty, mental illness, substance abuse, homelessness and affordable housing, eldercare, child welfare (protective services, adoption, foster care), disabilities, crime and delinquency, domestic and family conflict, trauma, and discrimination and oppression. Social workers serve as case managers, clinicians, agency managers and administrators, community organizers, policy analysts, advocates, and researchers. The roles social workers assume in various nations vary considerably. In some nations – particularly Western nations – significant numbers of social workers provide psychotherapeutic and other counseling services; in many nations, social workers serve primarily as case managers, advocates, and administrators.

The social work profession was inaugurated formally in the late nineteenth century, primarily in Europe and North America. Social work’s earliest practitioners provided services in settlement houses, hospitals, psychiatric clinics, schools, and juvenile courts. Since then, the social work profession has broadened its reach to include a much wider range of settings and client populations.

Social Work In Health Care

Many social workers provide services in healthcare settings, such as medical and psychiatric hospitals, outpatient medical facilities, hospice programs, rehabilitation facilities, physician group practices, skilled nursing facilities, nursing homes, home health agencies, and addiction facilities. Social workers in health-care settings provide services to patients, families, and groups to enhance their physical and emotional well-being. Social workers explain health-care resources and policies to patients, family members, and professional staff; help plan for post-hospital patient needs by arranging for services at another facility or in the home; explain to patients the causes of diseases, including environmental risk factors; help patients and families receive needed follow-up care by referral to health-care resources; understand and address social, cultural, and religious factors that contribute to patients’ responses to illness and their use of health-care resources; provide advocacy through appropriate government and private-sector organizations; and help patients with advance directives and other long-term care issues.

Social workers have played a vital role in health-care settings since the early twentieth century. Social work was formally introduced to medical settings in the USA by Dr. Richard C. Cabot in 1905. Cabot, a professor of both clinical medicine and social ethics at Harvard University, was instrumental in adding social workers to his clinic staff at Massachusetts General Hospital in Boston. Under the direction of their first department head, Ida Cannon, these social workers helped patients and their families cope with illness, disease, disability, and hospitalization by focusing particularly on their psychosocial needs, including their emotional reaction and adaptation (Kerson et al. 2010).

Over time, social work’s function and influence in health-care settings have expanded significantly (Gehlert and Browne 2012), thus increasing the range of ethical issues they encounter. In addition to assisting hospitalized patients and their families, contemporary social workers provide genetic counseling, hospice services, psychotherapy and counseling in mental health agencies and outpatient health clinics that serve adults and children, and treatment of people with HIV-AIDS, eating disorders, and various addictions. These services sometimes involve complex ethical issues such as patient privacy and confidentiality, professional boundaries, informed consent, paternalism, truth-telling, and conflicts of interest. For example, a patient may disclose sensitive confidential information to a social worker concerning a mental health or addiction issue and ask the social worker not to share this information with family members or home health-care providers. Conversely, family members may share sensitive information with a social worker about the patient’s complex personal history and ask the social worker not to share the information with the patient. Or, a terminally ill patient may want to talk to a social worker confidentially about her suicidal thoughts and end-of-life preferences . Such situations require complex management of sensitive ethical issues.

Social workers are also skilled in organizing and facilitating support groups for various populations, such as cancer patients, molestation and sexual assault victims, and parents of seriously impaired infants. They work to enhance the availability of community-based resources (e.g., support groups, health-care clinics in low-income neighborhoods, residential services), advocate on behalf of individual patients who are in need of services, and advocate to ensure that important public policy issues related to health care are addressed (e.g., health-care subsidies for low-income patients and family members who provide them with home-based care, coverage for mental health and addiction services). These roles also lead to challenging ethical issues. For example, social workers who facilitate support groups must be familiar with unique ethical standards pertaining to the confidentiality rights and obligations of group participants. Social workers who participate in the development of guidelines concerning involuntary psychiatric commitment must be familiar with ethical standards concerning informed consent and patients’ right to refuse treatment. Social workers who seek to establish residential addiction facilities or HIV-AIDS programs may find themselves caught between the competing rights of clients and neighborhood residents who oppose locating such programs in their community.

In addition to ethical issues social workers encounter when they provide clinical and advocacy services, health-care social workers also face ethical challenges in their roles as program administrators, policy professionals, and members of institutional ethics committees and institutional review boards. Social work education’s broad focus on clinical, administrative, advocacy, and policy knowledge and skills is particularly useful when practitioners encounter ethical issues in health-care settings.

Social workers’ efforts to develop conceptual frameworks to address ethical issues began especially in the 1970s, as the broader field of applied, professional, and practical ethics developed.

These efforts were particularly prominent with respect to social work in health-care settings, due largely to the emergence of bioethics as a specialized area of knowledge and professional practice. However, ever since social work’s emergence in the late nineteenth century, practitioners have focused on a variety of ethical and moral issues.

The Evolution Of Social Work Ethics

Social workers’ exploration of ethical issues, including those related to health care, has evolved over time and includes several conceptually distinct, albeit sometimes overlapping, periods. These include the morality period, values period, ethical dilemmas and decision-making period, risk management period, and digital period.

Social work’s historical literature suggests that for many years, especially during the late nineteenth and early twentieth centuries, the profession was focused much more on the morality of clients (often known as paupers) than practitioners. In many scholarly discussions, one finds Bibliography : to concern about the moral fiber, or the alleged lack thereof, of clients who struggled with issues such as poverty, unemployment, alcohol use, mental illness, or poor health. The phrase “professional ethics” did not exist during this period. Some of the discussions of clients’ morality had a rather paternalistic tone.

As social work matured as a profession, a handful of scholars and practitioners began exploring and writing rich commentaries about the profession’s core values, such as client dignity, self-worth, self-determination, and confidentiality. These important discussions and analyses sought to explore the implications of social work’s central values, especially when there were conflicts among the profession’s values, the broader society’s values, and social workers’ personal values. Especially during the turbulent 1960s and early 1970s, several social work authors wrote about the complex connections between social work values and contemporary controversies surrounding civil rights, women’s rights, welfare rights, prisoners’ rights, discrimination, and abortion (Banks 2012; Dolgoff et al. 2012; Hugman 2013; Reamer 2012). These discussions and debates were especially prominent in health-care settings with respect to clients’ right to refuse treatment, informed consent related to medical treatment, and women’s reproductive rights.

In the late 1970s, a relatively small group of social work scholars and practitioners began to pay close attention to the nature of ethical dilemmas in the profession. This development was an outgrowth of the dramatic emergence and maturation of the broader field of applied and professional ethics, especially bioethics. During this period, increasing numbers of scholars and practitioners in a wide range of professions (e.g., medicine, nursing, psychology, social work, journalism, business, law enforcement, engineering) focused explicitly for the first time in their respective histories on the nature of challenging ethical dilemmas facing practitioners. Discussions frequently focused on conflicts among professionals’ duties and obligations. Prominent examples in social work included conflicts between clients’ confidentiality rights and social workers’ duty to disclose confidential information without client consent to protect third parties; management of complex dual relationships and conflicts of interest; and imposing limits on clients’ right to self-determination and autonomy. In health-care settings, social workers focused especially on ethical dilemmas related to end-of-life decisions, reproductive rights, management of confidential information shared by patients and family members, informed consent, minors’ rights to confidentiality and treatment, patients’ right to refuse treatment, paternalism, conscience clauses, and allocation of limited resources (such as healthcare funds and scarce organs).

During this period, scholarship burgeoned on the subjects of ethical dilemmas in practice and ethical decision-making protocols. The richest discussions identified links between ethical theory, drawn from the discipline of moral philosophy, and real-life challenges faced by professionals, particularly those involving conflicts among professional duties and obligations.

For the first time in social work’s history, textbooks included in-depth overviews of ethical dilemmas and conceptual frameworks practitioners could use to address them. In social work, common topics concerned professional paternalism, the limits of clients’ confidentiality rights, managing informed consent challenges, complicated boundary issues, dual relationships, conflicts of interest, allocation of limited resources, whistle-blowing, and compliance with allegedly unjust laws. Over time, social work education programs developed curricula to teach students about ethical dilemmas and decision making.

In the early 1990s, yet another trend emerged, especially in the USA, which, compared with many other nations, is generally known as a relatively litigious society. This trend continues today. Although many social workers have sustained their interest in ethical dilemmas and decision making, new concerns emerged regarding ethics-related risk management. Data began to circulate concerning increases in lawsuits and licensing board complaints that raise ethical issues. Until this period, social workers rarely discussed such risks. Increased publicity have alerted social workers to relatively new information about the ways in which their ethical judgments could lead to litigation and licensing board complaints. Social workers have discovered how disgruntled clients and others could file formal complaints alleging, for example, mismanagement of clients’ confidential and privileged information, boundary and dual relationship violations, conflicts of interest, negligent service delivery, fraud, and inappropriate termination of services.

For the first time in social work’s history, literature has emerged about the links between social workers’ ethical judgment and potential malpractice, negligence, and professional discipline (Reamer 2014). Licensing boards in some nations, especially the USA and Canada, have developed websites listing social workers who were sanctioned because, for example, they committed fraud, had sex with clients, and disclosed sensitive confidential information without proper authorization.

Professional ethics no longer is limited to questions such as, “What’s the right thing to do in this complicated situation?” For many social workers, ethics now includes questions such as “Can I be sued or have a licensing board complaint filed against me if I.. .?” Ethics-related risk management has become a relatively new component of social work education and training. In health-care settings, social workers have been concerned about making ethical judgments in ways that protect clients and prevent lawsuits and ethics.

Today’s social workers in health-care settings can provide clinical services online or via video counseling or telephone to clients they never meet in person. They may receive Facebook friend requests from clients or former clients that lead to boundary challenges. In this digital era, social workers can use e-mail and text messages as therapeutic tools and provide clients with specialized smartphones that enable them to record and transmit summaries of their deeply personal health symptoms and moods to their clinicians and caseworkers, receive therapeutic messages and alerts, and communicate with other people in their digital network who face similar health challenges (a virtual support group).

The advent of this technology in health care has introduced unprecedented and controversial ethical challenges for social workers related to informed consent, privacy and confidentiality, boundaries, documentation, client abandonment, and the delivery of services across jurisdictional borders. Licensing boards and regulatory bodies in a number of nations are actively engaged in earnest efforts to develop constructive guidelines to govern entirely new forms of social work practice.

The Social Work Role In Bioethics

Social workers offer a unique perspective on bioethical challenges in health-care settings because of the profession’s broad-based and explicit focus on clinical, administrative, policy, social justice, cultural diversity, and ethical issues (Banks 2012; Dolgoff et al. 2012; Hugman 2013; Reamer 2012, 2013). As clinicians, social workers can help clients and family members cope with difficult moral judgments related, for example, to end-of-life care, genetic screening, pregnancy management, consent to treatment, and termination of services.

As administrators, social workers can participate in difficult ethical judgments about the allocation of limited and scarce health-care resources (known in moral philosophy as issues of distributive justice), implementation of controversial health-care laws and regulations, management of ethics crises and unethical practices, and the implementation of patients’ rights policies. As community organizers and advocates, social workers can help stakeholders navigate orchestrated challenges to controversial health-care policies and laws and manage complex conflicts concerning health-care financing. As policy professionals, social workers can contribute to discussions and debates about the ethical implications of health-care reforms, especially regarding access to health care for vulnerable and oppressed populations. That is, social workers are trained to examine ethical issues through multiple lenses, focusing simultaneously on pertinent clinical, policy, administrative, social justice, and cultural diversity issues.

Social workers in health-care settings typically function as part of an interdisciplinary team, which may include physicians, nurses, occupational and physical therapists, nutritionists, rehabilitation staff, clergy, and health-care administrators. On occasion, social workers facilitate the process through which health-care professionals negotiate differences of opinion or conflict among themselves concerning specific ethical issues. In this respect, social work’s unique mission, perspectives, and methods can be especially useful when health-care professionals encounter ethical challenges. Social workers are trained to mediate conflict and understand that clinical ethics (e.g., decisions about access to services, end-of-life care, reproductive rights, organ donation, and patient privacy) is linked inextricably with challenging policy and social justice issues. Hence, the social work perspective – which calls for simultaneous examination of relevant clinical, administrative, policy, cultural diversity, religious, social justice, and ethical issues – is particularly valuable in interdisciplinary health-care settings where colleagues (especially physicians, nurses, and other allied health professionals) may be inclined to focus primarily on clinical issues.

Using their clinical skills, social workers can be particularly helpful when there is complicated intersection between ethical issues and patients’ mental health challenges and family dynamics. For example, social workers’ skilled use of mediation techniques can help to resolve disagreements that sometimes arise in health-care settings between patients and family members. Often, what appear to be intense ethics-related disagreements among family members – for example, decisions about honoring a patient’s wishes regarding end-of-life care or telling a relative the truth about a grim prognosis – may reflect long-standing family conflicts; skilled clinical social workers who are sensitive to ethical issues can help family members and health-care professionals resolve complex ethical challenges by identifying and addressing relevant family issues. Social workers use their unique training and clinical skills to help patients, family members, and colleagues understand how some ethical issues intersect with mental health issues and family dynamics. Further, social workers understand the ways in which patients’ mental health challenges (e.g., chronic and debilitating depression or anxiety) may influence the patients’ management of ethical choices pertaining to end-of-life care, disclosure of confidential information, refusal of treatment, and informed consent.

In the policy arena, social workers are critically important participants in discussions of healthcare reform. Debate among politicians, healthcare advocates, citizens, insurance industry executives, and health-care administrators about health-care benefits and coverage, eligibility criteria, and access to services ultimately has moral implications. Social workers’ participation in these conversations can increase the likelihood that participants will appreciate and address the ethical implications of their policy decisions for patients, families, communities, and the broader society (Holtz 2008).

Social work’s traditional focus on cultural and religious diversity is especially relevant when ethical issues arise in health-care settings around the globe. Social workers’ sensitivity to ethnic, cultural, and religious issues can be particularly helpful when there is a clash between the patients’ and families’ values and prevailing ethical norms, health-care policies, and practices (e.g., concerning the acceptability of certain lifesaving interventions, organ donation and transplantation, mood-altering medication, autopsy, or blood transfusion). Social workers are trained to understand that key bioethics concepts such as informed consent, privacy, confidentiality, boundaries, paternalism, truth-telling, and autonomy are interpreted very differently in diverse international communities and across ethnic, cultural, social, and religious groups. For example, some cultures value autonomy and patient self-determination, whereas others are more likely to defer to health-care professionals’ authority and judgment. Some cultures insist on strict boundaries between the practitioners’ and clients’ lives, while others are much more flexible and appreciate well-meaning dual relationships. In the USA and Canada, for example, both laws and ethical norms emphasize the clients’ right to control disclosure of confidential information. In contrast, in some Asian nations, ethical norms permit and encourage social workers to share sensitive information with the clients’ family members even though clients have not provided formal consent for the release of this information (Marsiglia and Kulis 2009; Reamer 2012).

Some of the bioethical issues that social workers encounter require specialized knowledge pertaining to specific medical conditions (Kerson et al. 2010). Examples include ethical dilemmas related to a family’s decision about withdrawal of a cancer patient’s life support, abortion following a rape, organ transplantation, the use of restraints with a noncompliant psychiatric patient, or a patient’s decision to refuse neuroleptic medication. When such issues arise, social workers often serve as important intermediaries in relationships among patients, their families, and health-care professionals. In these instances, social workers help patients and their families make difficult personal decisions, facilitate communication among members of the health-care team, advocate on a patient’s or family’s behalf, or raise policy issues that need to be addressed by a hospital, nursing home, home health agency, or rehabilitation facility.

Other bioethical issues concern the nature of relationships and transactions between social workers and patients or their families. For example, social workers in health-care settings must be familiar with privacy, confidentiality, informed consent, and boundary-related norms that govern relationships with patients and families. They must also be sensitive to complex ethical issues involving patients’ right to self-determination, truth-telling, professional paternalism, and whistle-blowing).

In particular, social workers can clarify differences among the different, sometimes conflicting, ethical obligations that guide various health-scare professions. For example, social workers in a health-care setting can help clarify the ethical responsibilities of various professionals when minors request health-care services without notification of their parents or when staff suspect child abuse or that a patient with AIDS poses a threat to a sexual partner. Laws in different jurisdictions vary, for instance, regarding minors’ right to health care and regarding which health-care professionals are permitted to disclose confidential information, without patients’ consent, to protect third parties who are at risk of exposure to HIV or AIDS (Slater and Finck 2012). These laws differ among nations and among jurisdictions within nations.

In addition to their clinical role, social workers may be members of institutional ethics committees (IECs) that discuss ethically complex cases and health-care policies (Hester and Schonfeld 2012; Post et al. 2007). They may offer a particularly valuable perspective because of their extensive contact with patients and their families and can, therefore, contribute to discussions about, for example, resuscitation guidelines, patients’ right to refuse treatment, advance directives, organ transplantation, treatment of severely impaired infants, patients’ privacy rights, and patients’ participation in high-risk research protocols. Because of their broad-based education, social workers who serve on ethics committees can offer both clinical and policy-related expertise, particularly when issues arise concerning the implications of cultural diversity (including ethnicity, race, disability, gender identity and expression, sexual orientation, and religion) for ethical judgments and policies.

The concept of ethics committees (also known as institutional ethics committees) first emerged in 1976, when the New Jersey Supreme Court in the USA ruled that Karen Ann Quinlan’s family and physicians should consult an ethics committee to help them decide whether to remove Quinlan from life-support technology. Ethics committees, which have been most prominent in health-care settings (especially hospitals, nursing homes, rehabilitation facilities, hospice, and home health-care programs), typically include representatives from various disciplines and positions, such as nursing, medicine, social work, the clergy, and agency administration. (There is some debate about whether an agency’s attorney should be on an ethics committee because of lawyers’ unique fiduciary duty to protect their clients’ interests first and foremost.)

Some ethics committees include an ethicist – either an agency employee (for instance, in large teaching hospitals) or an outside consultant – who has formal training in applied and professional ethics, moral philosophy, and ethics consultation. Some ethicists are trained philosophers or theologians with a special interest in professional ethics and bioethics, and some are members of a human services profession (such as nursing, social work, or medicine) who have supplemental education related to ethics.

Many ethics committees provide agency staff with case-related consultation services and nonbinding advice, particularly when staff members or clients want assistance in thinking through difficult ethical decisions. For example, in hospital settings, ethics committees may offer consultation and nonbinding advice on issues related to termination of life-support technology, the use of aggressive care with terminally ill patients, patients’ right to refuse treatment, and patients’ eligibility for organ transplantation. Although ethics committees are not always able to provide definitive advice or guidance about complex ethical issues, they can offer colleagues and clients with a forum for organized, focused, explicit, and principled exploration of ethical dilemmas. This can provide participants with a greater understanding of the issues and options they face and enhance the quality of their decision making.

Many ethics committees also serve other functions. Some are responsible for reviewing existing ethics-related policies in health-care settings and suggesting revisions, sometimes in response to controversial case-related issues that arise in the agency. Ethics committees also draft new ethics related policies and procedures for more formal review and approval by agency administrators and boards of directors.

Some social workers are active participants on institutional review boards (IRBs) in health-care settings that examine a variety of ethical issues in research involving human participants. Ethical standards in social work pertaining to research include extensive guidelines concerning evidence-based practice, informed consent, privacy and confidentiality, protection from harm, and conflicts of interest.

In addition, social workers may be involved in workplace discussions and legislative advocacy about the ethical aspects of health-care financing mechanisms and cost-containment measures. They may also propose ways to advocate on patients’ behalf or to advocate for policy reform in the public and private sectors that may provide a more just allocation of scarce health-care resources at the local, national, or international level. An example is social workers’ participation on a task force whose mission is to enhance low-income people’s access to basic health care or on a hospital committee concerned about pressure to limit care provided to, and hasten discharge of, psychiatric patients covered under managed care programs operated by private, for-profit insurers. In these instances, social workers may help identify the psychosocial consequences of various strategies to allocate limited health-care resources.

Enhancing Social Work’s Contribution To Bioethics

To participate fully in discussions of bioethical issues and dilemmas, social workers need specialized knowledge and training. First, they need to be familiar with the history, language, concepts, and theories of bioethics as they pertain to practical ethics challenges, particularly as they have evolved since the early 1970s, when the professional ethics field began in earnest (Copp 2007). Second, social workers should be knowledgeable about formal mechanisms that can help healthcare professionals monitor and address bioethical issues. These include phenomena such as institutional ethics committees, institutional review boards, utilization review and quality assurance committees, informed consent procedures, and advance directives. Social workers should understand the nature of ethics consultation in healthcare settings and the ways in which ethicists can serve as useful resources. In addition, social workers should participate in policy-making efforts in health-care settings concerning such issues as conscience clauses, advance directives, organ donation and transplantation, patients’ rights, do-not-resuscitate orders, withholding or withdrawing life-sustaining treatment, refusal of blood transfusion, stem cell research, and research involving human participants.

It is also useful for social workers to be acquainted with relevant codes of ethics and legal considerations (statutes, regulations, case law) related to patients’ rights and health-care professionals’ obligations. In many nations, codes of ethics in social work and allied health professions have become increasingly sophisticated with regard to issues such as informed consent, confidentiality, privacy, privileged communication, conflicts of interest, dual relationships, client abandonment, allocation of limited resources, compliance with unethical policies and orders, dishonesty and fraud, and impaired professionals (Reamer 2006).

The breadth and depth of social work codes of ethics around the world vary considerably. Social work codes of ethics exist in three different contexts. First, internationally, many professional social work associations have developed codes of ethics. These are voluntary associations of social workers. Thus, these codes typically carry no legal or formal regulatory authority, although the associations may insist on compliance with the code as a condition of membership. The International Federation of Social Workers publicizes ethics codes from Australia, Canada, Denmark, Finland, France, Germany, Ireland, Israel, Italy, Japan, Luxembourg, Norway, Portugal, Russia, Singapore, Spain, Sweden, Switzerland, Turkey, the USA, and the UK.

Secondly, in some nations, social work ethics codes have been developed or adopted by governmental licensing boards or regulatory bodies that authorize social work practice. Some governmental licensing boards and regulatory bodies develop their own ethical standards, some formally adopt portions of codes developed by prominent voluntary social work associations, and some formally adopt entire codes developed by prominent voluntary social work associations. These ethical standards become legally enforceable once they are incorporated into licensing statutes or regulations.

Thirdly, many private-sector human and social service agencies have adopted codes of ethics or ethical standards to which employees are bound. Here too, some of these organizations develop their own unique ethical standards and some draw on codes of ethics developed by prominent voluntary professional associations. In some instances – especially when the agency hires employees educated in different professions – agencies will draw on ethical standards from diverse professions, choosing those standards that are most relevant to their mission, client population, programs, services, and local cultural norms.

Social work codes of ethics are remarkably diverse in their purpose, content, and format. Several prominent examples illustrate this diversity. For example, in the UK, the British Association of Social Workers (BASW), a voluntary association, offers a code of relatively modest length that defines social work and provides an overview of core values and principles and guidelines for ethical practice focusing on “service users,” the social work profession, the workplace, and social workers’ responsibilities in particular roles (management, education, training, supervision and evaluation, independent practice, and research). Since membership in the BASW is voluntary, this code is not used for regulatory purposes.

In England, a mandatory code of conduct for social workers has been adopted by the General Social Care Council (the body appointed by the UK government to regulate professional social work and professional social work education). As a result, the term “social worker” became a protected title. Social workers are required to accept a code of conduct and could be disciplined if their actions are deemed to have breached the code. Prior to implementation of this code of conduct, any person in the caring professions could use the term social worker irrespective of role or qualification. The English code includes three broad sections: an introduction that describes the function of the guidelines, a code of practice for employers, and a code of practice for social care workers.

Similar to the BASW, the Canadian Association of Social Workers (CASW) offers a widely disseminated code of ethics to which members are held. In contrast to the English approach, which enforces ethical standards through a national code of practice that applies to a diverse group of “social care workers,” the individual Canadian provinces have the authority to develop and adopt legally enforceable codes of ethics that pertain exclusively to social workers. The CASW Code of Ethics is a relatively short document; it includes a brief preamble and a summary of core social work values and principles related to respect for inherent dignity and worth of persons, pursuit of social justice, service to humanity, professional integrity, confidentiality, and competence. The CASW also publishes a companion document, Guidelines for Ethical Practice, which offers detailed guidelines regarding a wide range of ethical issues and challenges.

In Canada, enforceable ethical standards exist at the provincial level. Thus, the Alberta College of Social Workers, the Ontario College of Social Workers and Social Service Workers, and the Newfoundland and Labrador Association of Social Workers, among other regional groups, have the authority to develop their own standards of practice.

In yet another arrangement, the principal set of ethical standards in Australia is promulgated by the Australian Association of Social Workers (AASW), a voluntary professional association. In Australia, the AASW code is the national lodestar, even though the organization does not have the legal authority to regulate social work. Some social workers choose not to join AASW and, therefore, fall outside the AASW’s purview. The AASW code includes a summary of core values, ethical standards, and a brief guide to ethical decision making. The AASW also publishes extensive practice standards with which members are expected to adhere in conjunction with the code of ethics.

In contrast, the Singapore Association of Social Workers Code of Ethics includes a mix of general principles and narrowly focused ethical standards concerning social workers’ ethical responsibilities to clients and colleagues, in practice settings, to the social work profession, and to the broader society. This is an example of a code adopted by a voluntary professional association that incorporates abstract principles concerning social work’s mission and narrowly worded standards concerning such topics as audio recording of clients, sexual misconduct, and informed consent by minors.

The National Association of Social Workers (USA) Code of Ethics has served as an influential model and resource for many codes of ethics around the world. This detailed code includes a preamble and mission statement for the social work profession, a summary of core values and broad ethical principles, and a comprehensive list of specific ethical standards. A number of social work associations, licensing boards, regulatory bodies, and private social and human service agencies have drawn on the NASW code. Within the USA, the NASW Code of Ethics is the best known and most influential set of ethical standards applying to social workers. Ethics codes have also been developed by other social work organizations in the USA, such as the National Association of Black Social Workers and the Clinical Social Work Association.

In the USA, codes of ethics are used by several bodies that govern social workers. The NASW, the nation’s largest professional social work association, uses the NASW Code of Ethics to review and adjudicate ethics complaints filed against NASW members. Further, many of the individual state licensing boards in the USA have formally adopted the NASW Code of Ethics, or portions of the code, and use it to review and adjudicate ethics complaints filed against licensed social workers. Finally, many public and private social service agencies have adopted the NASW Code of Ethics or portions of the code, as formal agency policy, and use the code’s standards to guide and assess employees’ conduct.

In addition to the codes of ethics promulgated by voluntary social work associations, licensing and regulatory bodies, and private agencies in many nations, the code developed by the International Federation of Social Workers (IFSW) and International Association of Schools of Social Work (IASSW), Ethics in Social Work: Statement of Principles, provides an overarching, truly international code of ethics. The IFSW represents social work organizations in some 90 nations and places special emphasis on human rights, human dignity, social justice, and professional conduct. The IASSW includes members from educational institutions throughout the world. This code was written deliberately at a fairly high level of abstraction. The IFSWIASSW code makes explicit reference to relevant international human rights declarations and conventions, including the Universal Declaration of Human Rights and the International Covenant on Civil and Political Rights.

It is essential for social workers to appreciate the ways in which their involvement in, and view of, ethical issues vary in different nations and cultures. Concepts such as informed consent, privacy, confidentiality, and professional-client boundaries have very different meanings in different cultural contexts. Issues pertaining to the allocation of health-care resources are profoundly different in countries with nationalized health care and countries where health-care services are provided by for-profit and nonprofit private-sector hospitals and outpatient clinics. In nationalized health-care systems, resource allocation decisions are not based on implications for investors or shareholders; however, decisions in for-profit health-care settings are likely to be guided by such considerations.

Finally, social workers should be familiar with the various schools of thought and bioethics concepts that pertain to ethical decision making and ethical theory (including relevant theories of normative ethics, such as deontology, utilitarianism, virtue ethics, and care ethics). This can be particularly useful when social workers are involved in discussions of cases with professional ethicists, for example, when a decision must be made about when and how to tell a fragile, terminally ill patient the truth about his or her diagnosis or to disclose confidential information, against a patient’s wishes, in order to protect a third party. This training may be offered as part of agency-based in-service education, professional conferences, or undergraduate and graduate social work education.

Conclusion

Especially since the 1970s, social workers throughout the world have been aware of the diverse and complex bioethical issues involved in health care, whether they involve acute or chronic, inpatient or outpatient, or medical, rehabilitative, nursing, or psychiatric care. Social workers’ growing awareness of, and enhanced expertise in addressing, global bioethical issues helps to ensure the protection of patients’ and families’ rights and the soundness of ethical decisions made in health-care settings.

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  19. Zastrow, C. (2014). Introduction to social work and social welfare (11th ed.). Belmont: Brooks/Cole.

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