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Eye on Ethics

Viewing Social Work Ethics Through an International Lens
By Frederic G. Reamer, PhD
March 27, 2012

I recently returned from a trip to Taiwan where I had been invited—and was privileged—to deliver a series of lectures on social work ethics. My task was to identify compelling ethical issues and explore their implications for professional education and regulation in Taiwan.

This was a daunting task. On the one hand, based on my pretravel communications with Taiwanese social workers, I sensed that some of the ethical issues that practitioners encounter in the United States are comparable to those faced by social workers in that nation. After all, sexual misconduct with clients and documenting services that were never provided seem to be unethical acts in any nation. Similarly, social workers everywhere must decide how to respond to clients’ gifts and requests for personal information about their practitioners’ lives. Indeed, I discovered that Taiwanese social workers are as concerned about boundary issues involving their use of Facebook as are their American counterparts. Although the cultural norms concerning the management of these issues may vary from nation to nation, the broad challenges seem to be universal.

But my conversations with social workers in Taiwan confirmed what I have long suspected based on my travels over the years to several European and other Asian countries to discuss social work ethics: It is vitally important for social workers to view ethical issues through a sharply focused international lens. What constitutes an ethical challenge for social workers in one nation may not loom large elsewhere or may be managed very differently because of profoundly unique cultural norms and contexts. Here are several examples:

• In the United States, social workers employed in healthcare settings (e.g., hospitals, nursing homes, rehabilitation facilities) are accustomed to discussing with patients advance directives, living wills, and durable powers of attorney. The subject of death and severe disability, while difficult at times to broach, is commonplace in social work conversations with clients. In contrast, many healthcare social workers in Taiwan told me that discussions of death are not routine, that the subject is still considered largely taboo in many healthcare settings.

• Especially with the advent of HIPAA and other strict confidentiality statutes and regulations, social workers in the United States are preoccupied with protecting client confidentiality. With rare exceptions (e.g., emergencies involving imminent risk), social workers cannot share confidential information about clients with their family members without client consent.

However, in some other cultures, the family unit is considered primary, so much so that social workers are expected to share information about the client with the family, even in the absence of the client’s informed consent; individual clients’ privacy interests are secondary. Indeed, in some cultures, the concept of informed consent is not widely recognized. Further, in some cultures, family members are inclined to share confidential information about the client with the social worker, fully expecting that the social worker will not share this information with the client (e.g., concerning the client’s poor health prognosis or the family’s plan to place the client in a nursing home).

• In the United States, a social worker’s primary duty is to assist clients in their efforts to cope with their life challenges. An agency-based social worker would not be expected to carry out the duties of the business office, such as monitoring the client’s bill payment and seeking the collection of overdue payments—a potential conflict of interest. In contrast, several social workers in other nations have told me that their employers fully expect that, as part of their duties, they will track down clients who have not paid their bills and insist on payment. In some cultures, apparently, this dual role is not viewed as a conflict of interest.

• During my recent visit to Taiwan, I talked with several social workers about their view of clients’ right to self-determination, especially in relation to the treatment of mental illness. These social workers told me they have an ethical duty to respect the wishes of families of clients with serious and persistent mental illness (for example, schizophrenia) who wish to seek help from a Buddhist monk or priest rather than mental health professionals, particularly if family members view the mental illness as the by-product of demon possession or an evil spirit that lurks because of a client’s alleged ethical misdeeds in this or a past life. The client and family may believe that the illness can be cured through the power of faith and ritual. Many individuals go to temples to chant and receive counseling from their spiritual leaders.

Social workers who are trained in the West or who are inclined to adopt Western-oriented interventions for mental illness must reconcile their beliefs in clients’ fundamental right to self-determination with their beliefs about what interventions are in clients’ best interest as reflected in the evidence-based professional literature summarizing “best practices.” This challenge entails complex questions concerning professional paternalism, that is, circumstances where social workers contemplate interfering with clients’ right to self-determination for clients’ own good.

The complex challenge for all social workers, it seems, is to recognize that while some ethical issues are truly international and cross-cultural, others are unique to diverse nations and cultures. The concepts of confidentiality, privacy, boundaries, and self-determination are relevant for social workers everywhere, but their particular meaning and application vary considerably. Social workers who firmly embrace ethical standards and concepts in their own nation, language, and cultural context must be careful to avoid assuming that these standards and concepts translate well in other nations, languages, and cultural contexts. Ethical hubris—where social workers assume that their view of ethical issues fits squarely everywhere in the world—is dangerous.

In this respect, social workers can learn much from widely accepted principles in cultural anthropology. For decades, cultural anthropologists have reminded us how important it is to enter another culture sensitively and empathically. Skilled ethnographers rely on participant observation and efforts to learn from key informants in a way that is deeply respectful of the informants’ worldview. Social workers who seek to understand and appreciate the ways in which different nations and cultures interpret and apply key ethics concepts would do well to draw on these time-honored principles and methods.

An enduring question for social workers is whether, in fact, there are any universal “truths” in social work ethics. Are social work values and ethical standards always dependent on local view and custom, or are some applicable across all cultures? To what extent is it appropriate to say that social workers everywhere, without exception, should be truthful with their clients and not lie to them, avoid dual relationships, and respect clients’ right to self-determination? To what degree are these vitally important social work values culture bound? At the very least, social workers should be mindful of the exhortation in the NASW Code of Ethics concerning practitioners’ duty to learn about, and be sensitive to, clients’ cultures: “Social workers should have a knowledge base of their clients’ cultures and be able to demonstrate competence in the provision of services that are sensitive to clients’ cultures and to differences among people and cultural groups” (standard 1.05[b]).

— 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.