Eye on Ethics
Eye on Ethics: Omission and Commission in Social Work Ethics
By Frederic G. Reamer, PhD
Last month I received a telephone call from a clinical social worker who sought ethics consultation. The caller, Maria D., is a seasoned clinician who spent many years counseling clients in a large community mental health center before starting her own independent practice. Maria has considerable experience counseling parents whose children struggle with significant behavioral issues.
Maria provided counseling services to a single mother, Angela R., and her 9-year-old son Daren. Daren had been diagnosed with ADHD; a developmental pediatrician prescribed psychostimulant medication for Daren and referred both him and Angela to Maria for counseling. According to Angela, Daren is "really impulsive and has lots of difficulty controlling his anger. His school has suspended him many times and the school's principal and social worker have told me to consider placing Daren in a special school for kids with behavior problems. I really don't want to do that, but I may not have a choice. I've already been to court once because of all these problems. The judge questions my ability to parent Daren."
Maria spent considerable time in clinical sessions acquainting Angela with a variety of parenting and behavior management skills that might be useful with Daren. Maria also helped Daren develop ways to cope with stressful circumstances and use impulse control strategies and self-soothing techniques.
One afternoon Angela arrived for her counseling appointment in great distress. She told Maria that the previous evening, Daren was "completely out of control. He got upset with me when I told him he had to go to his room when he hit me during dinner. He started cursing at me and actually picked up a kitchen knife and threatened to hurt me. I just lost it and started screaming at him. I grabbed the knife out of Daren's hand and threatened him right back; I actually held it against his chest. I never would have used the knife; I just wanted to scare him. I know I shouldn't have done that. I can't believe things have gotten this bad." Angela sobbed heavily when she shared these details with Maria. "I'm so afraid the judge is going to take Daren away from me," Angela said to Maria.
Maria empathized with Angela and talked with her about how Angela might have handled the situation using the parenting skills they had worked on together. According to Maria, Angela demonstrated considerable insight:
"We had a great conversation, during which we replayed what happened and what steps Angela might have taken to prevent things from spinning out of control. We talked about how Angela could have used some of the parenting skills she has learned. She knows she panicked.
"But here's the problem: Because Angela told me she threatened Daren with a knife, I told her I might have to report this to child protective services. When Angela heard that she freaked out. She begged me not to call; she worried that the state agency or the judge would take Daren from her, which happened once before. I've been going back and forth in my mind about whether I should call protective services. I know I'm supposed to under my state's mandatory reporting law, but I also know Angela has been doing really well overall and has made lots of progress. I'm worried that getting the state involved will make matters worse. And I think there's a real chance that Angela would feel so betrayed if I called the state that she would flee treatment. I don't think she would trust me."
Omission and Commission in Social Work Ethics
Social workers who face ethical choices often think in terms of taking proactive steps, otherwise known as acts of commission. Acts of commission occur when individuals initiate some course of action. In contrast, in some instances social workers decide to not take proactive steps to resolve an ethical dilemma—acts of omission. Here are several examples that illustrate this contrast:
• A social worker who provides assistance to the homeless encountered a man who was sleeping outside in freezing weather. The man seemed disoriented, as evidenced by his inability to answer the social worker's questions during a basic mental status exam conducted by the social worker. The social worker was concerned about the man's basic safety and, at the same time, was concerned about interfering with the man's right to self-determination, a core social work value. The social worker would engage in an act of commission if, against the man's wishes, he arranged for the man to be escorted to an emergency shelter. However, the social worker would engage in an act of omission if he decided to respect the man's right to self-determination and, as a result, did not arrange for the man to be transported to an emergency shelter, despite the risks he faced.
• A school social worker provided counseling to a 16-year-old student who struggled with symptoms of clinical depression. During their work together the teen disclosed to the social worker that he thinks he is gay and that he is profoundly worried about his parents' reactions, given their strict religious beliefs. The teen told the social worker that because of his distress he has been self-medicating with drugs and has cut his wrists on several occasions. The teen begged the social worker to not share any of this information with his parents. If the social worker decided to respect his client's privacy and confidentiality and not share any of the information with the teen's parents, he would engage in an act of omission. However, if the social worker shared any of the information with the teen's parents, even if the disclosure was limited to the information about the teen's drug use and substance abuse, the social worker would engage in an act of commission.
• A social work administrator, the associate director of a prominent family service agency, discovered during a financial audit of the agency that the executive director had been engaging in fraudulent activity. The audit indicated that the executive director diverted more than $75,000 in federal funds to the executive director's discretionary account, which he then used to pay for personal travel and entertainment expenses. The agency had been awarded these federal funds to provide state-of-the-art services to people struggling with major mental illness and addiction. The social worker learned that the executive director has a serious gambling problem, which appeared to explain his diversion of agency funds. The social worker had to decide whether to disclose the fraudulent activity to the federal agency that awarded the grant and to law enforcement officials. If the social worker disclosed this information, he would engage in an act of commission. If he chose to not disclose in order to protect the executive director and the agency, he would engage in an act of omission.
Often, social workers believe that addressing ethical challenges requires explicit action. In fact, ethical judgments in complex cases often call for distinguishing between acts of commission and acts of omission, in whole or in part. Some ethical judgments require acts of commission, some require acts of omission, and some require elements of both; social workers can be held accountable for acts of commission and omission. Appreciating these nuances is part of the art of ethical decision making.
— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work at Rhode Island College. He's the author of many books and articles, and his research has addressed mental health, health care, criminal justice, and professional ethics.