Eye on Ethics
The Emergence of Agency Ethics Committees in Social Work
Carla L., MSW, was a social worker in an outpatient mental health clinic affiliated with a large private psychiatric hospital. She provided counseling to individual clients, couples, and families.
One of Carla L.’s clients was a 23-year-old woman, Alma B. Carla L. provided counseling to Alma B. for nearly two years, after Alma B. was diagnosed with bipolar disorder. For a period of time, Alma B. functioned well while receiving weekly counseling from Carla L. and taking psychotropic medication prescribed by the clinic’s psychiatrist. Occasionally, Carla L. met with Alma B. and her parents to help them address a number of compelling family issues.
One afternoon, Carla L. received a call from Alma B.’s mother, who told Carla L. that the night before Alma B. had committed suicide by overdosing on prescription medication. Alma B.’s parents and Carla L. were devastated, of course. Alma B.’s parents asked Carla L. whether they could make an appointment to talk about their daughter’s death and the circumstances surrounding it. Alma B.’s parents also had a unique request. They told Carla L. how much they appreciated all she had done to help their daughter and asked Carla L. to attend Alma B.’s funeral and deliver a eulogy.
Carla L. was uncertain about whether it was appropriate for her to attend a deceased client’s funeral or deliver a eulogy because of the confidentiality, privacy, and boundary issues. Neither the outpatient clinic nor the psychiatric hospital had any policies governing the issue. Carla L.’s supervisor suggested they ask for an emergency consultation with the agency’s ethics committee.
Social workers who are unsure about how to handle an ethical issue can seek consultation from various sources, including the NASW (National Association of Social Workers) Code of Ethics (and related codes); colleagues; supervisors; pertinent literature, regulations, laws, and agency policies; and ethics committees. Many agencies have developed ethics committees to help professional staff make difficult ethical decisions. The concept of ethics committees (often known as institutional ethics committees) first emerged in 1976, when the New Jersey Supreme Court 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 healthcare settings (hospitals, nursing homes, rehabilitation facilities, hospice, and home healthcare 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 obligation 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 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 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. In a community mental health setting, ethics committees may offer consultation and advice related to staff members’ ethical decisions about boundary issues and dual relationships, conflicts of interest, confidentiality, privacy, informed consent, termination of services to noncompliant clients, and impaired colleagues.
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 and suggesting revisions, sometimes in response to controversial case-related issues that arise in the agency. For example, an ethics committee in a family service agency may review agency policies and guidelines related to complicated confidentiality issues (such as disclosure of confidential information to the parents of clients who are minors, disclosure of information about deceased clients, and disclosure of information in response to subpoenas or informal requests from law enforcement officials). An ethics committee in a community mental health center may review and suggest revisions of the agency’s policies concerning the termination of services to clients who do not comply with treatment recommendations.
Ethics committees also draft new ethics-related policies and procedures for more formal review and approval by agency administrators and boards of directors. For example, in a program that serves clients who have serious drug and alcohol problems, the ethics committee may draft new guidelines concerning the hiring of former clients as staff members. An ethics committee in a nursing home may draft new guidelines concerning consensual sexual relationships among residents, and an ethics committee in a residential treatment program for children with serious physical and mental disabilities may draft new guidelines concerning the handling of gifts given to staff by the children’s parents.
Ethics committees also sponsor ethics-related training and education for agency staff. This may include continuing education seminars for licensed practitioners and various types of in-service training on a range of ethics-related topics. Ethics committees may help develop the training and education curriculum, develop teaching material, and recruit presenters.
Agency ethics committees provide social workers and their colleagues with a valuable resource when they encounter complex ethical issues. Social workers should not assume, however, that ethics committees function as final arbiters or judges of what is ethically right or wrong. Although ethics committees are sometimes approached about relatively simple ethical matters, more typically they are asked to consult on remarkably difficult and controversial issues that resisted easy resolution by line staff and their supervisors before reaching the ethics committees. In such instances, as one may expect, ethics committee members themselves may disagree about what is ethically appropriate.
This is not a design flaw in ethics committees or even a serious limitation. Rather, we should expect constructive differences of opinion on committees that, by design, are expected to examine and facilitate discussion of truly complex and controversial issues. What ethics committees offer is a rich and disciplined opportunity for social workers and others to wrestle with hard moral choices and challenges that sometimes emerge in professional life.
— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work, Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, healthcare, criminal justice, and professional ethics.