Ethical Dilemmas: a continuing education course for CE, CEU, MFT, LCSWs, MFCCs

"What is usually the right thing to do?" Consider the following four opinions.

"We cannot afford that much help."............"The more we give, the more we get"

"People should forgive people" ............................................... "We can never forgive the Nazis"

To deal with ethical dilemmas, you need to find the answers to these questions:

1. How do you define a dilemma?
2. What values are at stake in the dilemma?
3. What principles are at stake in the dilemma?
4. What personal issues are at stake in the dilemma?
5. How will you solve the given 10 dilemmas?

Since a dilemma deals with two possible rights, these two right choices must be clearly stated. Then the dilemma can move to a solution, where one of the rights is preferred over the other one.

Determine the two sides of the dilemma. (__v. __) Write the dilemma as "a. one view" versus "b. another view."

Analyzing dilemmas: Ethical dilemmas are termed in the form of _____v. ______, such as Equality of workers v. Integrity of organization. Many dilemmas are also written as dealing with :

1.1 Primacy of the interests of one party over the other (client or group)
1.2 Distribution in one way or other (merit or equal share)
1.3 Obligation of one to another (duty, custom, legal obligation)
1.4 Responsibility to client, colleague, profession, employer, society etc.

Some cases may be also deal with
* Permanency v. physical safety
* Best interest of client v. obligation to do no harm, etc (or v. rights of others, benefits)
* Quality of life v. prolonging of life
* Client self-determination v. obligation to prevent harm
* Right to confidentiality v. autonomy
* Effectiveness of service v. client privacy

Explore the relevant values in the authorities literature of the case. Individuals may validate their basic ethical values from such sources as laws, social science research, and the Bible.

Some of the issues concerning values are:
2.1 The right or wrong of an action.
2.2 The acceptance, reputation or embarrassment of an action.
2.3 Qualification and disqualification of a person, with reasons.
2.4 Virtues such as integrity, love, forgiveness, respect, purity, trust, sanctity of life.

Select the relevant principles that apply to the case and explain the reasoning process that you used to arrive at a tentative solution. Some of the terms presented in the dilemma definitions in Section 1. also suggest principles that may be at stake.

Some relevant principle may be:
3.1 Protection of life etc.
3.2 Conflict avoidance
3.3 Greatest good of group, etc.
3.4 Truth telling
3.5 Acceptance of Biblical command
3.6 Accountability

Consider what personal issues of people or populations may effect the outcome of the case to such an extend that a particular ethical position is required. Reconsider your tentative solution in light of the personal issues involved and suggest a final solution.

In some cases, the loyalty for one group takes precedence over the loyalty to another group. Some groups include the:
4.1 victim
4.2 family
4.3 employer
4.4 profession
4.5 community

Use each of the above four steps to analyze the following cases, describe your reasoning, and reach a solution. For an example of using a case worksheet, see www.learnwell.org/reality.htm.

2. Values for a_________________________________ b____________________________

3. Principles for a______________________________ b____________________________

4. Personal issues for a________________________ b_____________________________

5. Reasoning and solution:____________________________________________ circle a b

4.0 Two orphans: Two sisters, Ann (age 6) and Bev (14), who live in foster care must leave the place. They have very different problems, Ann is physically handicapped, Bev is mentally handicapped. Should the sisters be placed together or separately? (Case 1.2)

4.1 Wanting to die: Mrs. Klimov (age 33) wants to stop her difficult cancer treatment and wants to die. She has a ten-year old son, who can be taken care of by her mother. Her mother says she is too young to die and considers it suicide. She was named her daughter's Advance Directive (medical decision maker) and refuses to let her daughter stop the treatment. (Case 1.3)

4.2 Adoption: Mary (age 15) was adapted 12 years ago and now wants to know who her birth-parents are. The records are sealed. Her adopted parents do not want her to meet her extremely poor birth-parents for they feel that it will upset her too much and that she may want to leave them. (Case 1.7)

4.3 Computer Records: To be more efficient, Pastor Jones places his confidential home visitation records on his officer computer. That will make record-keeping easier and he could visit more homes. While at present he is the only one with access to that computer, it would be easy for anyone to access the information when he is not in the office, that is usually unlocked. It could compromise the records. (Case 3.2)

4.4 Cultural Differences: Mr. Kim has immigrated from Korea some 3 years ago and joins the Washington Writer's Society. He speaks and writes very good English but has many problems adopting to the rules of the Society, which seem very strange to him. All his practices are acceptable in Korea, but not in Washington. The Society is considering if it can keep Mr. Kim as member because his presence disrupts the Society. (Case 3.3)

4.5 Organizational Mission: Joe, age 25, comes to a social worker at JKM, an organization that serves and supports homosexuals. He requests help in becoming heterosexual. JKM does not have a program for that and does not advocate sexual-orientation changes. (Case 3.4)

4.6 Suicide: Bill, age 45, has been abused as a child and has recently lost his wife. He is very depressed and visits his only friend, a male nurse. He threatens suicide. His friend things that he will get over it and tries to motivate him to living. He could also commit him to a clinic for treatment. Next day Bill commits suicide. (Case 4.1)

4.7 Family: Henry, age 95, is keen of mind but feeble, lives alone and wants to stay living alone. He sometimes falls, but has not injured himself seriously. His daughter is concerned and wants him to come live with her. He refuses to move. (Case 4.4)

4.8 Rape Report: Jane, age 16, was raped by a neighbor and comes to tell her teacher she trusts. She asks the teacher not to tell anyone about that. The teacher feels that reporting it to the police and the investigation may be worse than the rape itself. Reporting may also place Jane's life in danger. (Case 4.9)

4.9 Tasha's Baby: Tasha, age 23, is single and 3 month pregnant. She uses drugs that endanger her fetus. Her mother tries to persuade her to give up drugs. She refuses. She also refuses to go see a doctor for she feels that the doctor will make her feel bad about her drug-use. (Case 5.3)

The above cases were adapted from Juliet Cassuto Rothman's From the Front Lines: Case Studies in Social Work Ethics, Allyn and Bacon, 1997.

Study Start Date:

August 2002

Description:

Ethics support services are being developed in many European countries, but the evidence base concerning the types of ethical dilemmas faced by physicians in these countries is small. The ways in which physicians respond to ethically difficult situations and the types of ethical support they would consider useful in such cases are also largely unexplored. In this study, we aim to explore the experience of physicians regarding ethical issues at the bedside in Italy, Norway, Switzerland, the UK, and the US. These are countries with very different cultural contexts, where ethics support services are in various stages of development. A better understanding of the ethical difficulties encountered by physicians in these different settings and the ways in which they respond to them would be useful locally to assist the development of support services. It would also permit intercultural comparison of the practical answers given to difficult questions for which there cannot be said that there is one right answer.

One of the ethical dilemmas faced by physicians at the bedside is the allocation of scarce resources. This is of particular interest, as it has implications that go beyond the physician-patient encounter. The choices made by physicians in situations of scarce resources not only reflect their values, but also the constraints they must work with. Knowing more about the role of those factors could be an important contribution to an evidence base for health policy.

This is an exploratory cross-sectional self-administered mailed survey of physicians in primary care in Italy, Switzerland, and the UK. The part of the survey instrument exploring physicians' experience and attitudes regarding resource allocation at the bedside will also be conducted in the U.S. The questionnaire will address the type and frequency of ethical dilemmas faced by physicians, how they approach such dilemmas, the type of ethical support they would find useful in such situations, as well as their attitudes and practices in situations of scarce resources. Data will be analyzed using descriptive statistics, factorial analysis of variance to determine factors associated with the type and frequency of ethical difficulties encountered, and logistic regression to determine factors associated with reported rationing behavior and with perception of the equity of the health care system. Independent variables used in the analysis of the last two points will also include health care systems' characteristics collected from the literature. Participants will be selected on the basis of national listings. To ensure sufficient exposure to direct clinical practice, inclusion criteria will include direct patient care for at least a year and at least 20% of the participants' time.

http://clinicaltrials.gov/ct2/show/NCT00352573

Living with conflicts-ethical dilemmas and moral distress in the health care system.

Department of Public Health and Caring Sciences, Uppsala University, Uppsala Science Park, S-751 85, Uppsala, Sweden. sofia.kalvemark@apoteket.se

Abstract

During the last decade, the Swedish health care system has undergone fundamental changes. The changes have made health care more complex and ethics has increasingly become a required component of clinical practice. Considering this, it is not surprising that many health care professionals suffer from stress-related disorders. Stress due to ethical dilemmas is usually referred to as "moral distress". The present article derives from Andrew Jameton's development of the concept of moral distress and presents the results of a study that, using focus group method, identifies situations of ethical dilemmas and moral distress among health care providers of different categories. The study includes both hospital clinics and pharmacies. The results show that all categories of staff interviewed express experiences of moral distress; prior research has mostly focused on moral distress experienced by nurses. Second, it was made clear that moral distress does not occur only as a consequence of institutional constraints preventing the health care giver from acting on his/her moral considerations, which is the traditional definition of moral distress. There are situations when the staff members do follow their moral decisions, but in doing so they clash with, e.g. legal regulations. In these cases too, moral distress occurs. Hitherto research on moral distress has focused on the individual health care provider and her subjective moral convictions. Our results show that the study of moral distress must focus more on the context of the ethical dilemmas. Finally, the conclusion of the study is that the work organization must provide better support resources and structures to decrease moral distress. The results point to the need for further education in ethics and a forum for discussing ethically troubling situations experienced in the daily care practice for both hospital and pharmacy staff.

ERIC_NO: ED413544, A Practitioner's Guide to Ethical Decision Making. by Forester-Miller, Holly; Davis, Thomas E., 1995
ABSTRACT: Counselors must make sound ethical decisions but, often, determining the appropriate course to take when confronted with a difficult ethical dilemma can be a challenge. This guide assists counselors in ethical decision making; it is presented as a supplement, and is to be used in conjunction with, the American Counseling Association (ACA) Code of Ethics and Standards of Practice. This practitioner's guide addresses principles that are globally valuable in ethical decision making and provides a model for professionals to utilize in their practice. It opens with a review of the five moral principles that are viewed by many as the cornerstone of ethical guidelines: autonomy, nonmaleficence, beneficence, justice, and fidelity. These principles provide an absolute against which counselors can explore an ethical dilemma, thereby gaining a better understanding of conflicting issues. A sequential, seven-step, ethical, decision-making model is presented next and comprises the following: (1) identify the problem; (2) apply the ACA Code of Ethics; (3) determine the nature and dimensions of the dilemma; (4) generate potential courses of action; (5) consider the potential consequences of all options and then determine a course of action; (6) evaluate the selected course of action; (7) implement this action. www.eric.ed.gov

ERIC_NO: ED334468, Resolving Ethical Dilemmas in the Workplace: A New Focus for Career Development. ERIC Digest No. 112., by Lankard, Bettina A., 1991
ABSTRACT: The diverse, multicultural population that constitutes today's work force faces ethical dilemmas on the job that bring pressures to protect their own or their company's interests, at the risk of losing their personal integrity. Employers and vocational and career development personnel are recognizing the need for decision-making and problem-solving skills that will facilitate negotiation and conflict resolution in the workplace. Conflicts arise between two or more personally held values, between personal values and those of another person or the organization, between principles and the need to achieve a desired outcome, and between two or more persons or groups to whom one has an obligation. The resolution of conflicts requires interpersonal and negotiation skills; the application of "employability skills" such as honesty, cooperation, and integrity; and the participation of all stakeholders in a situation. Ethics training should help employees (1) recognize which decisions involve ethics; (2) understand the values of all stakeholders; and (3) weigh the potential impact of various options on those values. As part of a career development curriculum, discussions and analyses of case studies, use of ethics committees and resource people, and training in critical thinking, conflict resolution, communication, group processes, and mediation skills can prepare students for the ethical dilemmas they may face in the workplace. www.cdc.gov/od/ethics .

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