Eye on Ethics
The Challenge of Paternalism in Social Work
Andrew D., BSW, was a social worker on the community intervention team of a local shelter for the homeless. The team offered social services (eg, housing, healthcare, crisis intervention, mental health assistance) to people living on the streets. On a daily basis, Andrew D. and his colleagues monitored various locations in the city where homeless people typically congregate.
One evening, Andrew D. introduced himself to Michelle K., a middle-aged woman who had been sleeping for more than a week in an alleyway adjacent to an abandoned tenement. Michelle K. told Andrew D. she had been living on the streets for nearly three months.
“I had nowhere to go when I got kicked out of my apartment,” she said. “The rent went up and I just couldn’t afford to stay there with the amount I get from my monthly disability check. I haven’t been able to work or nothin’ ever since my leg was amputated ‘cause of my diabetes. I’m still looking for another place to stay, so this will have to do for now.”
Andrew D. told Michelle K. that he could provide her with temporary housing in his agency’s shelter. The temperature was expected to drop to 5˚ below zero that night and he wanted to get her out of the freezing cold. Michelle K. told Andrew D. that she hated “those shelters—I just don’t feel safe there and I can’t stand all the rules. I’ll be OK here. Look over there—I’ve collected a pile of blankets.”
Andrew D. asked his supervisor whether they should try to pressure Michelle K. to go to a shelter in light of her health risks and the ominous weather forecast.
Social workers are drawn to the profession because of their deep-seated wish to help vulnerable people. They are trained to identify problems, assess people’s needs, and design and implement interventions. Social workers can find it hard to stand on the sidelines when individuals reject practitioners’ offers of assistance.
Yet, social workers are trained to respect clients’ fundamental right to self-determination, even if that means rejecting social workers’ offers of assistance. The concept of client self-determination has been a hallmark in the profession ever since its formal inauguration in the late 19th century. As the current National Association of Social Workers (NASW) Code of Ethics states, “Social workers respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals” (standard 1.02).
Over time, social workers have enhanced their understanding of the complex concept of client self-determination. Although the concept has great intuitive appeal and is certainly consistent with social workers’ instinct to help people pursue the goals they have selected for themselves, client self-determination poses special challenges for social workers when clients’ decisions appear to pose a threat to themselves.
To what extent do clients have the right to engage in seemingly self-destructive courses of action? How should social workers respond when a battered woman decides to return to her abuser’s home to “give him one more chance?” To the psychiatric client who decides to stop taking his psychotropic medication despite the recommendations of mental health professionals? To the distraught client who wants to commit suicide after losing her entire family in a house fire? To the homeless individual who prefers sleeping in subfreezing temperatures to temporary housing in a shelter?
Such circumstances force social workers to balance their commitment to clients’ right to self-determination and their instinct to protect clients from themselves, or what moral philosophers refer to as paternalism. Paternalism occurs when social workers interfere with individuals’ right to self-determination to protect them from self-harm. The concept of paternalism has been debated at least since Aristotle’s time. Perhaps the best-known statement on paternalism appears in John Stuart Mill’s 1859 essay “On Liberty,” where he argued that individuals have the right to assert sovereignty over their own lives so long as they do not pose a threat to others.
In social work, paternalism tends to take three forms. The first occurs when social workers believe they should withhold information from clients “for their own good.” Examples include withholding information from a hospital or rehabilitation patient about his or her poor prognosis or from a child about a parent’s serious legal problems, based on the belief that the clients cannot handle the truth.
The second form of paternalism involves actually lying to clients for their own good in contrast to merely withholding information. This occurs when social workers deliberately give clients inaccurate information about some important aspect of their lives. Examples include lying to an older woman about her supposedly “temporary” stay in a nursing home or misleading a client with a severe drug addiction about the amount of money remaining in his trust fund.
The third form involves physical interference with clients against their wishes—again for their own good. Forcing Michelle K. to go to a shelter against her wishes is a prototypical example.
Contemporary debate about the nature and limits of paternalism began in earnest in the 1960s, largely because of that era’s intense focus on civil rights and civil liberties issues. Professionals, policymakers, and general citizens engaged in vigorous debate about the appropriateness of paternalistic treatment of people with mental illness and physical disabilities, prison inmates, welfare recipients, older adults, and children.
Social workers understand that while they should generally respect clients’ right to self-determination, extreme circumstances—where there is compelling evidence of serious risk—may require paternalistic intervention, at least temporarily, to protect clients from serious harm. In fact, this reality is acknowledged in 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…” (standard 1.02; emphasis added). For paternalistic interference to be justifiable, social workers must demonstrate that clients would otherwise face dire, perhaps irreversible, consequences.
Paternalism is a serious problem, however, when interference with clients goes beyond what is absolutely necessary to protect clients from harm. In some instances, professionals use the language of paternalism to interfere with clients for self-serving purposes, not primarily to protect clients from self-harm. Examples include social workers who pressure homeless people to go to shelters primarily because it is so difficult for the social workers to arrange alternative community-based services, and social workers who withhold information from clients or lie to them because they do not want to “deal with” clients who may have difficulty handling the truth. Using the language of paternalism for self-serving purposes and to justify lying to, deceiving, and interfering with clients is what I call pseudopaternalism.
Reasonable, thoughtful social workers can disagree about when paternalism is justifiable. What practitioners can agree on is the fact that one of the enduring challenges in social work is balancing the profession’s simultaneous commitment to client self-determination and protection of clients from harm.
— 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.