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Eye on Ethics: The Importance of Motives in Ethical Decisions
By Frederic G. Reamer, PhD
Social Work Today
Vol. 21 No. 2 P. 8

Learn how the doctrine of double effect comes into play.

Recently, several colleagues and I provided outreach to people who struggle with homelessness in our community. In conjunction with a local agency that offers supportive services to this population, we set out at 6:30 in the morning to locate people who might need assistance.

Along with skilled agency staffers who had developed longstanding relationships with people living on the street, we quietly and respectfully engaged people we encountered who had slept the previous night in tents, behind bushes, and in alleyways. We checked in with these individuals briefly and inquired about their well-being. Colleagues who knew these individuals well provided them with information about pending benefits applications, offered to arrange medical and psychiatric appointments, and explored housing options.

It was clear that some of the individuals we encountered were responsive and appreciative. Others were relatively passive and, apparently, not interested in engaging with us.

One man we encountered appeared to be experiencing delusions. Standing near a bus stop, he told me about the voices in his head that tell him to prepare for an invasion of extraterrestrial beings. The man asked me my name and offered to help me defend against the invasion. At the conclusion of our encounter, an agency staffer explained to me that this man has a history of severe and persistent mental illness, has been hospitalized psychiatrically on occasion, and recently has been refusing to take the antipsychotic medication that he had been prescribed.

My colleague joined our discussion and asked the man whether he felt like he needed to return to the psychiatric hospital. “No,” he said emphatically. “I hate that place. Just let me be.”

Standing on the street corner, my colleague and I chatted about the age-old challenge in social work: choosing between respecting clients’ right to engage in what appears to be self-harming behavior and interfering with them against their wishes, allegedly for their own good. Seasoned social workers recognize this as the tension between clients’ right to self-determination and professional paternalism.

For nearly a century, social work’s literature has been filled with commentary about challenging ethical decisions about the limits of clients’ right to self-determination. On the one hand, social workers deeply respect clients’ right to chart their paths. In general, clients have a right to refuse treatment and services, even when social workers think it would be in the client’s best interest to accept them.

Interfering with clients for their own good—to protect them against the consequences of self-injuring behavior—can lead to harm, even if not intended. Individuals who receive services against their wishes may come to resent the social workers in their lives. Unwanted paternalism—for example, seeking involuntary hospitalization of a person who appears to be delusional—can erode trust between social workers and clients. And, clients who are recipients of services they do not want may feel coerced and suffer emotionally.

 On the other hand, social workers recognize that there are limits to clients’ right to self-determination in extraordinary circumstances. According to the NASW Code of Ethics, “Social workers may limit clients' right to self-determination when, in the social workers' professional judgment, clients' actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.” That is, at times social workers must make judgment calls about interfering with clients’ wishes in order to protect them or others from harm.

The Doctrine of Double Effect
Over the years, theologians and moral philosophers have examined this dilemma through another conceptual lens: the doctrine of double effect, which entails a set of ethical criteria that a number of scholars have embraced to evaluate the permissibility of intervening when one's otherwise legitimate act (for example, addressing the needs of people who struggle with homelessness) may also cause an effect one would otherwise be morally obliged to avoid (engaging in conduct with clients who feel coerced and emotionally distraught as a result).

The first known example of double-effect reasoning is Thomas Aquinas' 13th-century discussion of homicidal self-defense in his work Summa Theologica.

According to classic arguments on the doctrine of double effect, an action that has foreseeable harmful effects is permissible when the following three conditions prevail:

• The nature of the act is itself good, or at least morally neutral. Of course, one must define “good.” Clearly, offering assistance to a vulnerable person is good, taken by itself. However, social workers may disagree in other instances. For example, some may argue that social workers who engage in civil disobedience to protest allegedly unjust laws are engaging in “good” and defensible conduct. Others may argue that deliberate violation of the law is not “good.” From their perspective, social workers have a moral duty to obey the law, and deliberate violation of it, no matter how noble one’s aims, is not permissible.

• The agent intends the good effect and does not intend the bad effect, either as a means to the good or as an end in itself. This criterion suggests that motive matters. That is, social workers who contemplate interventions that may have undesirable outcomes must have noble aims. Their actions must be motivated by altruistic purposes such as efforts to provide safety and shelter to a person who struggles with homelessness and who may have difficulty caring for himself because of his mental illness.

In contrast, forcing the man to enter a psychiatric hospital against his wishes primarily to remove him from the streets because some people find his behavior annoying may not be defensible, particularly if the man does not pose a serious and imminent threat to others.

• The good effect outweighs the bad effect in circumstances sufficiently grave to justify causing the bad effect and the agent exercises due diligence to minimize the harm. Some philosophers argue that people who contemplate engaging in “good” actions that may result in “bad” outcomes (such as violating a law or forcing someone to receive services against his or her wishes) should engage in what, in effect, is a utilitarian calculus, a sort of cost-benefit analysis (in the moral sense of the term).

Utilitarianism was first championed more than a century ago by philosophers Jeremy Bentham and John Stuart Mill. Put simply, utilitarianism entails weighing the potential benefits and costs of each possible course of action. Although there are several versions of utilitarianism—also known as consequentialism—the most common states that when faced with an ethical dilemma, one should act in a manner that produces the greatest balance of good over bad consequences.

Although social workers might not routinely use the formal language of the doctrine of double effect in their day-to-day practice, the core elements of this perspective frequently find their way into practitioners’ thinking and conduct. Consider, for example, social workers who work in child protective services. Often these practitioners are called on to investigate reports of abuse or neglect of children, older adults, and people with disabilities. Once they have investigated the allegations and considered all relevant facts, these social workers have to make daunting decisions about whether to remove the alleged victim from their homes and find alternative housing arrangements (for example, foster care).

Social workers who make these judgments know full well that decisions to remove the alleged victims are nearly always traumatic. Harm results even though social workers do not seek that outcome. However, sometimes such actions are necessary—in accord with the doctrine of double effect—because, at least in principle, (a) the nature of the act is good (protecting vulnerable people from harm), (b) the social worker intends the good effect and does not intend the bad effect either as a means to the good or as an end in itself, and (c) the good effect outweighs the bad effect in circumstances sufficiently grave to justify causing the bad effect and the agent exercises due diligence to minimize the harm.

Social work is filled with comparably disconcerting moral challenges. The doctrine of double effect can help us think them through.

Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work at Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, health care, criminal justice, and professional ethics.