2.3 Identifying and Resolving Ethical Dilemmas

ASWB Clinical exam items in this area typically present a scenario and ask what the social worker should do first or next. The trick is recognizing when a situation is a true ethical dilemma — a conflict between competing values — versus a legal question with a clear answer or a clinical problem that calls for a treatment adjustment.

Distinguishing Ethical Dilemmas From Other Problems

The exam rewards the candidate who says "this is a legal issue, so follow the law" when it is legal, and "this is an ethical dilemma, so apply a decision-making model" when it is not. Misclassifying is the most common error.

The NASW Code of Ethics as the Primary Framework

The NASW Code is the primary ethical framework for U.S. social workers. The 2021 revision (still current in 2026) is organized into four parts:

1. Preamble — the mission and core values of the profession.
2. Purpose of the NASW Code of Ethics — articulates the Code's six major functions.
3. Ethical Principles — six broad principles based on the core values.
4. Ethical Standards — six sections of enforceable rules:
   1. Social workers' ethical responsibilities to clients (standards 1.01–1.17)
   2. Social workers' ethical responsibilities to colleagues (2.01–2.10)
   3. Social workers' ethical responsibilities in practice settings (3.01–3.10)
   4. Social workers' ethical responsibilities as professionals (4.01–4.08)
   5. Social workers' ethical responsibilities to the social work profession (5.01–5.02)
   6. Social workers' ethical responsibilities to the broader society (6.01–6.04)

The Code is hierarchical in spirit: a standard can be overridden only by another standard or an overriding legal duty. When two standards conflict, the social worker ranks them by the situation — this is exactly what a decision-making model helps with.

Ethical Principles Screen (EPS)

The Ethical Principles Screen (EPS), developed by Elaine Congress, is a tool for ranking ethical principles in a dilemma. It lists seven principles in priority order:

1. Protection of life
2. Equality and inequality
3. Autonomy and freedom
4. Harm minimization (least harm)
5. Quality of life
6. Privacy and confidentiality
7. Truthfulness and full disclosure

The EPS is hierarchical: when principles conflict, the higher-ranked principle generally prevails. Protection of life sits at the top — which is why a credible suicidal threat can override confidentiality. The EPS is a screening tool, not a substitute for the NASW Code, but the exam tests the ranking.

Reamer's Seven-Step Ethical Decision-Making Model

Frederic Reamer's seven-step model is the most widely taught and most commonly tested decision-making framework. The steps:

1. Identify the ethical issue(s) and the applicable NASW standards, laws, regulations, and agency policies.
2. Identify the individuals, groups, and organizations likely to be affected by the decision.
3. Brainstorm possible courses of action and evaluate the consequences of each for the parties identified in step 2.
4. Consult with relevant colleagues, supervisors, ethics committees, and legal counsel.
5. Make the decision and document the reasoning, the consultation, and the steps taken.
6. Implement the decision.
7. Monitor, evaluate, and document the outcomes; adjust as needed.

The exam most often tests steps 1, 4, and 5 — identify the issue, consult, and document. When an item asks what the social worker should do first in a dilemma, the answer is almost always to identify the issue and relevant standards/laws or to seek consultation, depending on urgency.

Principle-Based Ethics: The Core Principles

The bioethical principles that ground most ethical reasoning in clinical practice:

• Autonomy — the client's right to self-determination (NASW 1.02).
• Beneficence — acting in the client's best interest.
• Nonmaleficence — avoiding harm ("first, do no harm").
• Justice — fair, equitable treatment; allocation of resources.
• Fidelity — keeping promises and trust.
• Veracity — truthfulness.

In a dilemma, two or more of these principles will pull in different directions. The clinician's job is to name them, weigh them in the specific situation, and document the reasoning.

Common Clinical Dilemmas

Confidentiality vs. Duty to Protect

A client with command hallucinations names a specific coworker as a target. Confidentiality (NASW 1.07) says protect the disclosure; duty to protect (state Tarasoff-style law, reinforced by EPS principle 1 — protection of life) says warn the identifiable victim and notify law enforcement. The decision: protection of life prevails, the social worker takes reasonable steps to protect the victim, and discloses only the minimum necessary.

Self-Determination vs. Safety

A client with a serious mental illness wants to stop taking medication and leave a supportive residence. Self-determination (NASW 1.02) says respect the client's choice; beneficence and nonmaleficence say the client may decompensate. The decision depends on whether the client meets civil-commitment criteria (imminent danger to self or others, or grave disability). If they do not, the social worker respects the choice while continuing to engage and offer services. If they do, the social worker pursues involuntary evaluation per state law.

Dual Relationships in Rural, Military, and Religious Communities

In small or closed communities, dual relationships are sometimes unavoidable. A rural clinician may have a client who is also the only mechanic in town; a military social worker may treat a fellow service member's family; a clinician in a faith community may have a client who is a fellow congregant. NASW 1.06 requires social workers to avoid conflicts of interest and dual relationships that could impair professional judgment or risk harm to clients — but acknowledges that some dual relationships are unavoidable. When unavoidable, the social worker must set clear boundaries, document the dual relationship, obtain informed consent about its limits, and seek consultation to verify that the relationship is not exploitative.

Vignette: The Small-Town Dual Relationship

A clinical social worker in a rural town accepts a new client for therapy. The client is the spouse of the social worker's child's school principal, and they regularly attend the same small church. What should the social worker do?

Best practice: (1) Assess whether the dual relationship could impair clinical judgment or risk harm; (2) Discuss the dual relationship openly with the client as part of informed consent, including what the social worker will do if a social encounter occurs; (3) Document the dual relationship and the steps taken; (4) Seek consultation or supervision to verify that the arrangement is not exploitative; (5) Refer out if the dual relationship cannot be managed safely.

Resource Allocation

A community mental health agency has a waiting list of three months. A social worker must decide how to allocate scarce slots among clients with comparable need. The principle of justice applies: allocation should be fair, transparent, and based on clinically relevant criteria (urgency, fit, capacity to benefit), not on personal preference or favoritism. NASW 3.09 (commitments to employers) and the broader-society standards (6.01–6.06) bear here.

Documenting the Decision-Making Process

NASW 3.04 requires social workers to document professional and ethical decisions accurately and in a timely manner. A defensible note for an ethical decision includes:

• The dilemma identified and the competing values or standards
• The relevant NASW standards, laws, and agency policies considered
• The consultation sought (supervisor, ethics committee, legal counsel) and the date
• The reasoning that produced the decision
• The action taken and the follow-up plan

Documentation is not a chore after the decision; it is part of the decision. An undocumented decision is, in a malpractice review, a decision that may as well not have been made.

Consultation and Supervision

NASW 2.05 (consultation) requires social workers to seek advice and counsel from colleagues, supervisors, or experts when it serves the client's interests. In ethical dilemmas, consultation is both an ethical expectation and a clinical protection. The exam rewards answers that include "consult with supervisor or ethics committee" — particularly when the situation is novel, high-stakes, or legally complex.

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The unifying exam rule: when two values conflict, do not rush to action. Name the dilemma, identify the relevant standards and laws, consult, decide, and document.