Three Dimensions of Ethics

DR. RICHARD BAUMGARTNER

Dr. Richard E. Baumgartner is Professor and Chair, Department of Human Resources, East Central University, Ada, Oklahoma. He has over twenty three years of teaching experience in rehabilitation at both the undergraduate and graduate level. His teaching expertise is in the areas of Case Management and Administration.

Abstract: Major ethical concerns faced by the work adjustment specialist are presented. The complexity of decision making is considered in light of today’s rehabilitation environment. This article presents a three dimensional model for use in ethical decision making. The model uses the traditional ethics principles of beneficence, nonmaleficence, autonomy, justice, and fidelity as a basis for consideration of choices as perceived from the perspective of the organization, the client, and the work adjustment specialist.

Ethics is discussed much more in the aftermath of a negative event than in proactive preparation for the challenges which rehabilitation practitioners face. Individuals working in the rehabilitation profession are expected to act and react ina responsible and ethically correct manner. In fact, ethics is not that simple. A decision that turns out to be less than effective or results in perceived damage will cause us to renew our concern with “The Code of Ethics”. Typically we must deal with the ripple effects for extended periods. The purpose of this article is to facilitate proactive responses incorporating ethical decision making. If we are successful, the incidents of crisis and negative occurrences are reduced.

A definition of ethics is provided to remind the reader of its meaning. According to Black’s Law Dictionary (1983), ethics is defined as, “...of or relating to moral action, conduct, motive or character; as, ethical emotion. Also, treating of moral feelings, duties or conduct; containing precepts of morality; moral. Professionally right or befitting; conforming to professional standards of conduct: (p. 286). Brady (1990) adds a more real world or day-to-day explanation by stating that, “Ethics is a matter of both the heart and the head, and people can do right or wrong things for either reason” (p. 11). When the wrong action is taken we are shocked and outraged. When, in hind sight, the correct action is taken, we take little notice. The problem with expecting individuals to do the right thing is that each individual and each situation is different. Expected outcomes are not clear cut and appropriate action is often only visible after the test of time. Ethical decision making models are of great help. Feuer (1990) sums up the importance of ethical practice with the statement that, “Ethics is more than a set of guidelines. It is a way of life. It begins with personal conduct and reaches out to the areas of patient care, professional relationships, and how we deal with community resources and services” (p. 6). One excellent model for ethical practice, discussed frequently in the literature, is particularly relevant. This model has its roots in medical ethics. Beauchamp and Childress (1983) use the interaction and opposition of a set of principles when considering the resolution of an ethical dilemma. The principles are beneficence, nonmaleficence, autonomy, justice, and fidelity. In this application, beneficence is acting or reacting in a manner which is helpful and growth producing. The principle of nonmaleficence indicates that the professional should not be a party to causing harm. In autonomy, the client’s right for independent decision making is to be protected. The principle of fidelity seek to remind us that promises made should be kept. The final principle of justice addresses the need to treat an individual fairly. This model has been applied to a wide variety of settings and client situations. This is exemplified by the fact that the same principles are used by Roessler and Rubin (1992) to provide a case management decision making model. Daniluk and Haverkamp (1993) have found this model to be equally effective in intervention and treatment of adult survivors of incest. Using this model, decisions are made after consideration of how alternative solutions either support or oppose one or more of the relevant principles. This model is extremely helpful in justification of the alternative ultimately chosen.

Another model developed by Rumsey and Christie (1996) took a more pragmatic approach to the ethical decision making process. It uses a broader perspective for the decision maker to consider. In addition, this model factors in all the organizations and systems that will in some way shape the decision being made. The six basic areas or questions to be addressed by this model are:

Ø What is the potential ethical issues in the situation?

Ø Who are the stakeholders (individuals or groups impacted by the decision – e.g., the client family members, other individuals, employers, society, yourself?)

Ø Describe the environment in which this issue takes place (i.e., oppressive, supportive, etc.).

Ø List all possible choices of action.

Ø Which choice is the most ethically defensible?

Ø Make the decision (p.6).

This model provides structure for the decision maker. Documentation of the issues, raised by the model, help to show exactly how the decision can best be made.

A new approach suggested here by the writer utilizes three variables for consideration in decision making. This approach, with a working title of “Three-Dimensional Ethical Decision Making Model” considers the organizational needs and demands, the professional’s unique perspective, and the client’s viewpoint. All three dimensions contribute to problem solving from a distinct perspective. All three are active participants in the decision making process. The Three-Dimensional model includes the key elements of both models discussed above. The values and beliefs of the organization, professional, and client are always present to a greater or lesser degree in each and every decision made at the service provision level. These factors are especially salient when an ethical dilemma exists. First, the organization is likely to have a formally stated policy for responding to and/or solving certain types of problems. It may also have a history of either acting inconsistently or counter to that policy, or it may respond in a predictable manner. This variable will certainly contribute to successful forecasting of future decisions. The predictability, or lack of such, will influence the options perceived to be available by the professional and the client. Second, the professional representing the organization in the in the decision making situation also brings a set of personal, professional, and cultural values and beliefs into contention. This person’s history in the organization, as well as prior experiences with the client, may also serve to define the decision making environment. The totality of these experiences on the part of the work adjustment professional help to determine the agenda brought to the decision making table. The third dimension in the process, the client, also has had experiences with the organization and the professional. Like the professional, the client possesses a set of personal, professional, and cultural values and beliefs. In addition the client brings specific needs and problems to the forefront.

Once the problem has been defined and alternatives developed from the three dimensions, choices must be narrowed by

measuring the impact of the alternatives through utilization of the principles of beneficence, nonmaleficence, autonomy, justice, and fidelity. These principles are also useful in the determination of possible courses of action at each of the individual dimensional levels. A flow chart of the model is presented below.

The Three-Dimensional Model encourages a careful examination of the problem, potential solutions, and the interaction of the three viewpoints. Examination of a problem from this perspective must surely provide opportunity for a higher quality decision to be made.

Even the use of one of the models discussed above, to determine which course of action will be chosen, there is no guarantee that the alternative chosen will prove to be the best decision possible. Each situation requires recognition of its uniqueness.

One way for increasing the possibility for making informed decisions is through the practice of day-to-day behavior which stands the test of ethical analysis. The remainder of this discussion will consider the conduct or standards of individuals and groups who are charge with decision making with, or on behalf of, work adjustment clients. As stated above in the Three-Dimensional Model, three of the major variable which determine both attitudes and practice of appropriate ethical behavior are the “organizational environment”, the “individual practitioner”, and the “client”. Each is important in determining outcome. The magnitude of importance may change concerning one of the dimensions as the interaction of the variables and situations change. The interaction of the dimensions is discussed below in terms of specific expectations and situations which occur in the field or rehabilitation.

The Organization

An organizational system, either officially or by practice, tends to adopt an overall framework for dealing with situations thought to require consideration of ethical courses of action. In general these are policies and/or rules which attempt to define appropriate and inappropriate conduct or behavior. Personnel matters such as hiring, discipline, and termination are profiled as areas of concern because an inappropriate action often has long-term effects of lost time, energy and money. Three common positions exercised by organizations are:

§ utilitarian;

§ rights;

§ justice (Cavanagh, Moberg, & Valasquex, 1981)

A summary of these three approaches help to clarify how the organizational philosophy contributes to actions of individuals in the organization.

An organization which follows the “utilitarian” view of ethics will make its decisions and complete its plans on the premise that the best response is based on a desired outcome. This approach primarily considers end result. Action is usually based on what is best for the largest number of individuals. The major problem in use of this model is that an individual, though right and able to justify an action, is in the minority. The end result may be that an appropriate action may still be punished in some way. The “rights” approach to organizational ethics concerns itself with the protection of the basic rights of individuals. The human and civil rights of the members of the organization are held to be the prime consideration in decision making and activity planning. On the surface this approach appears to be highly desirable. On closer inspection, we often find that the organization is almost rendered unable to act due to the possibility of breach of individual rights. The third view of ethics is the “justice” approach. This approach provides close attention to treating each member of the organization in the same manner. The major concern is to enforce rules in a fair and impartial manner. While this seems faultless on first examination, think about some of the possibilities. Individuals in the organization may perceive the fairness motive as an opportunity to demand equal treatment whether or not it has been earned. This approach has many negative implications for the work adjustment professional. In reality, organizations may actually apply their ethics in a way that utilizes two or all three of the above positions. It may also address some issues from one philosophical basis and resolve others by using another. The question may then become, which response is the organization likely to reward? In many situations individuals in an organization are likely to be confused, not only about actions for specific situation, but about the attitude of an organization as it applies to unique situations which arise.

The Professional and the Client

As stated above, the other two dimensions in the decision making process are the rehabilitation professional and the client. In the rehabilitation professional and the client. In the rehabilitation profession, the decision making equation must include a shared responsibility for decisions and for resolving ethical dilemmas as they arise. In reality, most if not all issues will only be resolved by a significant contribution from each of these individuals. The relationship between the professional and client is critical because it sometimes places the professional into a position of power and influence. One description of the situation is that a fiduciary relationship has been established. This relationship was described by Kutchins (1991) as:

§ “special duties arise because of the trust or confidence reposed in the fiduciary;

§ the fiduciary has special powers to dominate and influence the client because of the nature of the relationship; and,

§ as a consequence, the fiduciary must act in the best interest of the client and cannot take advantage of the client to promote the fiduciary’s own interests” (p. 107).

Clients come to the relationship with a wide variety of trust, mistrust, and other experiences. A large percentage grow to trust the profession as time facilitates a healthy nurturing relationship. The possibility of a fiduciary relationship and its potential for abuse become real factors. In any case, the nature of the relationship is cause for caution. In the fulfillment of the process of making decisions we must be sure they are ethically appropriate. This is especially of concern in the use of the “three-dimensional model” discussed above.

Mehr (1988) identifies seven “human rights issues” relevant to the client-professional relationship discussion. Included in his discussion are voluntary versus involuntary services, due process, the right to services, the right to refuse services, least drastic or restrictive environment, confidential communication, and the duty to warm. While all of these are certainly important to the practice of the work adjustment profession, discussion here will be limited to issues most likely relevant to decision making between the client and the professional. Discussion includes voluntary versus involuntary services, the right to receive and to refuse services, and treatment in the least drastic or restrictive way.

Some clients are not willing applicants for services yet are required to participate. Those who are required may fall into two categories. First, the client’s participation may be required in order to receive another service or maintain eligibility for financial assistance. Clients may also be pressured to participate by parents, a spouse, or school officials. Mehr (1998) discusses this concept as “voluntary versus involuntary services” (p. 309). This discussion identifies the differences in processing and treatment of these two client groups. In summary, the voluntary client is a partner in the relationship, sharing in making decisions and the determination for when and how services are rendered. On the other hand, the involuntary client is dependent on to others to make decisions, required to participate in treatment, and may lack motivation for participation. The client in the involuntary treatment category has little power for self determination and is certainly more dependent on the professional. Ethical decision making is typically much easier when both the professional and client are actively participating. When one person is more involved or has more power in the relationship the potential for ethical problems are multiplied. In fact, as a general statement, it is easy to act in a professional manner when the relationship is positive and moving in a positive manner. It is much more difficult when problems are intensified with the nature of a relationship influenced by reluctance, lack of motivation, and goals that are divergent from requirements and expectations of the program. It is this situation that calls on the professional to be diligent in treating clients in a fair and appropriate manner.

Another of the issues identified by Mehr (1988), concerns the client’s right to have access to services, or be able to refuse services. These issues are particularly relevant institutions which clients are either confined or guardianship has been granted to an institution or individual professional. At issue here is the notion clients have the right to make decisions for themselves when possible. The professional must be careful not to make decision without consulting the client. A related issue, informed consent, should be added to this discussion of client’s right to require or refuse participation in a service. Informed consent figures prominently into the process of decision making. It is impossible for one to make a good decision without knowing both the positive and negative aspects of the available choices. Somerville (1978) identifies three concerns for meeting the requirements of informed consent. These requirements are paraphrased here as they relate to this topic. The rehabilitation professional should take steps to assure the client’s competence to understand the issues concerning the problem. Care should be taken to make sure the client is allowed to decide without being pressured by the professional. In addition, the client should be informed of the negative aspects as well as the positive outcomes which may result from the upcoming decision. In the practice of the rehabilitation professional it is simply not enough to ask a client to sign a consent form. Work adjustment specialist must be sure the individual has the capacity and the necessary information to elect to participate or decide not to participate. In like manner, the client must have all necessary information when asked to be a participant in the resolution of an ethical dilemma.

Another human rights issue identified by Mehr (1988) is treatment of a client in the least drastic or restrictive environment. In discussion of this issue, it is important to remember each client has the right to be treated in an environment which affords him r her the right to determine their own level of participation. Self direction is encouraged to the degree of their ability to function. To facilitate this process, the concept of substituted judgment or guardianship may become an issue. It is important to remember the professional, in a substituted judgment situation, is responsible for representing the client in any and all decision. Substituted judgment is never the same as the client’s own decision making process. Care must be taken due to the overwhelming responsibility of making a decision that would be consistent with one the client would make if he or she were capable. Stebnicki (9\1994) has discussed five basic issues common to the literature concerning guardianship. These issues apply to a variety of circumstances. Each assumption is certainly relevant to the process of making decisions using models suggested by this discussion. A summary of these assumptions follows:

§ persons with disability can benefit from a legally appointed substitute decision-maker to make appropriate choices for them;

§ a responsible guardian will make decisions which are consistent with the principles of autonomy, beneficence, and nonmaleficence;

§ parents and family members who are guardians should be held to the same standards as members of the rehabilitation profession. This is, in many cases, not always true

§ codes of ethics will be used to help resolve ethical dilemmas as they arise;

§ guardianship is fairly non restrictive concerning such things as power of attorney and control of financial resources.

In this process the professional is charged with two of the three dimensions discussed in the decision making model. The professional must represent, not only his or her own position, but must represent the client.

Summary

As discussed above, decision making and action of the client and the professional tends to be filtered through the organization’s influence. Each organization has a separate and unique culture and interpretation of how to make decisions. Each defines exactly how it will function in terms of ethical behavior. Each individual’s value systems, a basic ingredient in the decision making process, is also different from others. Interpretation of societal rules, customs and expectations is processed in a highly individualized manner. Professional boundaries, personalities and environments are also pertinent to deciding a course of action. Any of these variables may influence one individual to act differently than another, given the same situation. In reality, all the above mentioned variables, as well as others not identified, are factored into the day-to-day practice of the work adjustment professional. The current economic and political reality adds to the complexity. It has become increasingly difficult to make decisions that will not be questioned in terms of their ethical appropriateness. When a situation arises which causes us to be torn between two or more actions or decisions, an ethical dilemma exists. Work adjustment professionals must move forward with their best effort to serve the client in an effective way. Certainly, successful accomplishment of effectiveness will be enhanced by remembering that the best decisions make use of all three dimensions, the client, the professional, and the organizational perspective.

Ethical Decision Making Model

Ethical Dilemma

1) A choice must be made between two actions.

2) There are significant consequences for either action.

3) Both actions can be supported by ethical principles.

4) Choosing either action will compromise ethical principles that support the other course.

FIVE ETHICAL PRINCIPLES

BENEFICENCE: Acting in a manner that promotes the growth and well being of the client.

AUTONOMY: Acting in a manner that respects the client’s freedom of choice.

NONMALEFICENCE: Acting in a manner that does not cause harm to clients or prevents harm to clients.

JUSTICE: Treating clients fairly.

FIDELITY: Keeping promises or commitments to clients, colleagues, and agencies, both stated and implied.

Six Steps of the Ethical Decision Making Model

1. Review the case situation and determine the two courses of action from which you must choose.

2. List the factually based reasons supporting eachcourse of action. These reasons will often be important consequences.

3. Given the reasons supporting each course of action, identify the ethical principles that support each action.

4. List the factually based reasons for not supporting each course of action. These reasons will often be important consequences.

5. Given the reasons for not supporting each course of action, identify the ethical principles that would be compromised if each action were taken.

6. Formulate a justification for the superiority of one of the two courses actions by processing all information from the previous five steps. This means that an effective justification provides an analysis of the dilemma that includes:

a. Factually based reason(s) supporting each of the actions. These reasons will often be important consequences.

b. The ethical principle(s) supporting each of the actions, given the reasons in a.

c. The selected course of action and the reasons, why precedence should be given, in that situation, to the ethical principles supporting the selected course of action.

ETHICS

LEGISLATION

Freedom of Information Act 1966 defined as government records or public records unless fall into 9 exempt categories such as personnel issues, psychiatric records, grades, transcripts, etc. If about you, then it is yours.

Privacy Act 1974 companion legislation to freedom act granting the individual access tohis or her records and providing a mechanism for correction of that record. If about you, you need a way to get it and given a way to fix it. (Credit reports)

Two restrictions of the privacy act.

1. Privacy Act applies only to systems of records.

2. If the information is restricted under Freedom of Information they won’t be released under Privacy Act.

Sunshine Law 1976 Response to Privacy Act. Also known as Open Meeting Law. It is regular

scheduled government meetings. Meetings are opened and closed. Exception to open meeting

involves personnel issues. These are executive sessions and are closed as involve personnel

issues.

Confidentiality The individuals right to privacy expressed or implied with both legal and ethical implications. Disclosure to be made under circumstances required to protect client and community. Confidentiality is an ethical issue with legal tendencies.

Expressed is when client is asked to read confidentiality and sign as understanding.

Implied No application or document is signed but occurs in situations when around clients. Individuals right to privacy is implied.

Privileged Communication There are 2 types.

1. Absolute – Priest, physician, and lawyer. Anyone that is protected by privilege cannot tell

anyone or disclose. The client has privilege and can wave the privilege at any time. If have privilege and break it then commit a felony. Absolute is federal law.

2. Qualified Privilege – State determined who has privilege such as a licensed professional. Privilege is a Legal status. It starts with the clients absolute right to privacy.

Three Reasons for Privilege

1. Protects individual from self incrimination (priest)

2. Protects systems e.g. injury

3. Provides a mechanism for full disclosure on behalf of the client

Potential Problem Areas for Case Management

1. Record Padding – selective recording, creative writing

2. Legal document – it is a working document

3. Labeling – “The uncooperative client”

4. Confidentiality a Mask – Hiding behind

5. Consumer as Co-Manager – Client has input on decisions

Organizational Models of Ethical Practice

1. Utilitarian Model – Decisions are made solely on the basis of outcome or consequences. The goal is to provide the greatest good for the greatest number. This is typical in private business and is consistent with efficiency, productivity and profits. Problem – Can ignore individual rights.

2. Rights Model – Calls for decisions to be made that are consistent with fundamental liberties and privileges as set forth in documents like Bill of Rights. Concerned with protecting basic rights of individuals, such as the right to privacy, free speech, and due process. (Protects whistle blowers) Problem – Can produce an overly legalistic environment with limited productivity. Can get bogged down with red tape in hiring, firing and discipline.

3. Justice Model – Calls for enforcement of rules fairly and impartially so there is an equitable distribution of benefits and cost. (Example – Union pay scale) Problem – Can produce a sense of entitlement that reduces risk taking, innovation and productivity.

Types of Potential Lawsuits

1. Malpractice – Hard to prove. Conditions that must be proven in order to file a malpractice suit:

a. There has to be a standard. Can’t file suit unless there is a standard of operation (CRC). A standard is a recognized standard of performance that must exist for that job. If the profession has an entry level test such as license and or job description then that becomes part of the standard. If don’t have CRC then evaluations become very import. If have CRC then supervisor is in line of fire.

b. Have to show that a violation of that standard has occurred. The individual clearly operated outside the limits of the standard.

c. You can have the standard and show it was violated but must show that damages have occurred. Harder to prove psychological than medical.

2. Liable (written) / Slander (spoken) – Results from saying or writing something that can be heard or read by a third party that is not true. It must be shown that information is not true. Concern is case record. Can avoid in case record by stating “in my professional opinion, or it seems, it appears or the evidence suggests”.

3. Civil Rights Lawsuit – is basically treating one individual or group differently than other individual or group. There are three categories:

a. discrimination – you cannot discriminate on the basis of race, religion, color or philosophy. Race and religion are most common issues for lawsuit.

b. improper record keeping – case recording that is inaccurate or failing to write down. Failure to take appropriate security precautions with record keeping. (Locking up)

c. treatment or processing groups or individuals differently than others. (Immigratin, disability, special ed)

Civil Rights Issues

1. Voluntary v. Involuntary – Court ordered versus voluntary admittance to treatment. If voluntary client set own goals, make own decisions and can check out any time. Client is in control. If involuntary client can’t leave is not in control and has very little input.

2. Due Process – the means that are laid out proactively for solving disputes. E.g. Fair hearing. It has time limits.

3. Right to Treatment – Clients right to file an application. Institutional setting, medical.

4. Right to Refuse Treatment – Mentally ill most likely to refuse treatment. How do you support someone that refuses treatment.

5. Treatment in the least drastic or restrictive environment.

6. Confidentiality

Special Ethical/Legal Issues

1. Duty to warn and protect

2. Informed Consent

3. The Fiduciary Relationship

4. Substituted Judgment

Duty to Warn

1. Action Model – Waldo and Malley. Due to the special relationship to the dangerous person the case manager will recognize threat and danger. He or she will also be able to identify potential victims. With knowledge reasonable decisions can be made to take actions below:

a. notify parent or significant other

b. notify probation officer, police

c. designate someone to inform the intended victim

d. warn the potential victim

e. detain the client

f. seek voluntary or involuntary confinement

g. document what and why

2. Confidentiality v. Protection Model Making a determination of action to take in the delicate balance between confidentiality and the duty to warn others on a case by case basis. The case manager is vulnerable to lawsuits when confidentiality is breached as well as when confidentiality was protected and incident causes harm.

a. be able to recognize warning signs of suicide, homicide, etc.

b. have a crisis plan in place with referral sources

c. develop interventions skills and knowledge

d. take action if there is a risk

e. consider least intrusive action first

f. consult with colleagues and supervisor

g. inform others who may be at risk

h. if others are reluctant the case manager has an ethical responsibility to prevent harm.

Informed Consent – Three aspects to consider.

1. The individual making the decision must be competent to understand and process the necessary information

2 The decision must be made voluntarily and not as a result of coercion.

3. The client must know all the necessary facts, choices and risks.

The Fiduciary Relationship – Confidence is reposed on one side and domination and influence result on the other, such a relationship exists when there is reposing of faith, confidence and trust and the placing of reliance upon the judgment and advice of the other.

a. special duties arise because of the trust or confidence reposed in the counselor

b. the counselor has special powers to dominate and influence the client because of the nature of the relationship

c. as a result of the above, the counselor must act in the best interest of the client and cannot take advantage of the client to promote own interests.

Substituted Judgment – Guardianship relinquish most if not all of an individual’s autonomy.

a. a substituted decision making can serve to protect the individual

b. a responsible guardian will act in ways to promote the individual’s welfare

c. parents and family members who become guardians should be held to the same standards as non family members

d. guardians should use ethical principles to resolve problems as they arise

e. guardianship should be non restrictive and should include such things as power of attorney

Goal – is broad based stating the final outcome

Objective - narrows down the goal. It is specific and measurable. It has time frames and is

tied back to the goal.

Baumgartner, Richard (1997) Vocational Education and Work Adjustment Bulletin, (Winter), 39, 94-98.