Ethical Decision-Making

Ethical dilemmas arise frequently in social work practice when two or more ethical principles, values, or obligations conflict. Unlike ethical violations (where there is a clear right and wrong), ethical dilemmas involve situations where the social worker must choose between competing "goods" or determine the least harmful course of action.

Ethical Decision-Making Models

Several ethical decision-making models provide structured approaches for analyzing dilemmas:

ETHIC Model (Congress, 2000):

1. Examine — Examine relevant personal, societal, agency, client, and professional values
2. Think — Think about what ethical standards apply (NASW Code of Ethics)
3. Hypothesize — Hypothesize about possible courses of action and their consequences
4. Identify — Identify who will benefit and who will be harmed by each option
5. Consult — Consult with supervisor, colleagues, or ethics committee

Reamer's Ethical Decision-Making Framework:

1. Identify the ethical issues, including competing values and principles
2. Identify all individuals, groups, and organizations affected
3. Identify all possible courses of action and the participants in each
4. Examine the reasons in favor of and opposed to each option
5. Consult with colleagues and experts
6. Make the decision and document the decision-making process
7. Monitor and evaluate the outcome

Hierarchy of Ethical Obligations

When ethical principles conflict, some obligations generally take priority. A commonly used hierarchy (adapted from Loewenberg, Dolgoff, and Harrington) ranks ethical principles:

1. Protection of life — highest priority (e.g., breaking confidentiality to prevent suicide)
2. Equality and inequality — fair and equal treatment
3. Autonomy and freedom — self-determination
4. Least harm — choosing the option that causes the least damage
5. Quality of life — promoting well-being
6. Privacy and confidentiality — protecting client information
7. Truthfulness and full disclosure — being honest with clients

Key point: Protection of life always takes priority over confidentiality. This is why mandated reporting and duty to warn override the obligation to keep client information confidential.

Dual Relationships (Multiple Relationships)

Dual relationships occur when a social worker has a professional relationship and simultaneously or sequentially has another type of relationship with the same person (personal, financial, social, business, etc.).

Types of Dual Relationships:

• Social: Socializing with a client outside of sessions
• Business: Entering into a business arrangement with a client
• Romantic/Sexual: Having a romantic or sexual relationship with a client (always prohibited with current clients)
• Familial: Providing services to a friend's family member
• Digital: Accepting a client's social media connection request

NASW Guidelines on Dual Relationships:

• Social workers should avoid dual relationships when possible
• When dual relationships are unavoidable (especially in rural or small communities), the social worker must take steps to protect the client and maintain clear boundaries
• The social worker bears the responsibility for setting and maintaining appropriate boundaries
• Document any unavoidable dual relationships and the steps taken to manage them
• Consult with a supervisor or colleague when dual relationship concerns arise

Confidentiality

Confidentiality is a fundamental ethical obligation in social work. It means that information shared by a client within the professional relationship is protected from disclosure without the client's consent, with specific exceptions.

Legal Exceptions to Confidentiality:

• Duty to warn/protect (Tarasoff): When a client poses a serious, credible threat to an identifiable third party
• Mandated reporting: When there is reasonable suspicion of child abuse/neglect, elder abuse, or dependent adult abuse
• Court orders and subpoenas: When a court orders disclosure (a subpoena alone does not compel disclosure without a court order)
• Client danger to self: When a client is at imminent risk of suicide
• Consultation: Sharing minimal necessary information with other professionals for treatment purposes (with appropriate consent)
• Insurance/billing: Sharing diagnostic and treatment information required for reimbursement (with client's consent)

Key Distinctions:

• Confidentiality vs. Privileged Communication: Confidentiality is an ethical obligation; privileged communication is a legal right that protects certain communications from being disclosed in court. The privilege belongs to the client, not the social worker.
• Subpoena vs. Court Order: A subpoena requests information; a court order compels disclosure. A social worker who receives a subpoena should consult with an attorney and their licensing board before releasing information.

Informed Consent

Informed consent is the process of ensuring that clients understand and agree to the services being provided. It is both an ethical obligation and a legal requirement.

Elements of Informed Consent:

• Nature of services: What type of treatment or services will be provided
• Purpose: Why the services are being recommended
• Risks and benefits: Potential positive outcomes and possible risks
• Alternatives: Other treatment options available
• Right to refuse: The client's right to refuse or withdraw from services at any time
• Confidentiality and its limits: What information is protected and when exceptions apply
• Fees and billing: Costs, payment expectations, and insurance billing
• Emergency procedures: What to do in case of crisis outside of scheduled sessions

Special Considerations:

• Minors: Generally, consent is obtained from parents/guardians, but assent (agreement to participate) should also be sought from the minor
• Clients with diminished capacity: When a client cannot provide informed consent, the social worker should seek consent from a legally authorized representative while still explaining services to the client in understandable terms
• Involuntary clients: Even mandated clients have the right to understand what services involve and what information will be shared with the referring entity

Self-Determination

Self-determination is the ethical principle that clients have the right to make their own decisions about their lives, even when the social worker disagrees with those decisions. This principle is central to social work values and practice.

Limits on Self-Determination:

• When the client's actions pose a serious, foreseeable, and imminent risk to self or others
• When the client lacks capacity to make informed decisions (due to cognitive impairment, intoxication, psychosis, etc.)
• When the client is a minor and parental/guardian involvement is legally required

Key Exam Concept: On the ASWB exam, self-determination is almost always the correct answer when a question asks about respecting client choices, unless there is a clear and imminent safety risk.