Eye on Ethics

The Challenge of Modern Technology
By Frederic G. Reamer, PhD
Social Work Today
October 1, 2001

Recently I visited a large teaching hospital for a meeting. As I walked through the halls, I tried to imagine what hospital-based social work was like when Ida Cannon was pioneering this specialty at Massachusetts General Hospital in the early 20th century. I pictured Cannon strolling the halls with pen and paper to record important facts about her patients and their families and using the still-novel telephone to communicate with doctors, family members, and colleagues involved in her patients’ lives—patients whose healthcare depended on technology that was primitive by contemporary standards.

Compare that scenario to the professional environment in which today’s social workers function. Today’s Ida Cannons perform their duties with pagers clipped to their belts, cellular telephones that provide access to the Internet in addition to wireless conversations, fax machines, e-mail, and computer-based records that require electronic passwords. Their patients’ lives may be sustained with transplanted or artificial organs and their x-rays and lab reports can be reviewed electronically or via satellite transmission by “vacationing” consulting physicians on remote islands. Once discharged to their homes, patients can wear monitors that feed important data wirelessly to healthcare professionals, and patients who find themselves in dire circumstances can summon emergency help by pushing a button that hangs around their necks. Times have changed and at an exponential pace that many of us find difficult to grasp.

Today’s social workers are surrounded by technology that has changed the way they practice. Most of us can hardly imagine returning to the days before this technology existed, although we sometimes complain about the resulting demands on our lives.

Along with the spectacular and life-altering changes that have occurred with the advent of modern technology are a number of unique and unprecedented ethical challenges for social workers. The most glaring ethical implications concern issues of communication, service delivery, and healthcare. 

Communication
Perhaps the most obvious ethical issues involve confidentiality and privacy. Ever since the profession’s inception, social workers have embraced strict standards designed to protect clients. Practitioners have long understood how privacy and confidentiality are essential ingredients in trusting relationships between social workers and clients.

Several technological innovations used widely by social workers pose unique threats to client privacy and confidentiality. Most social service agencies and independent practitioners now maintain computer-based client records for clinical or billing purposes. Although firewalls and passwords provide considerable protection, these mechanisms are not infallible.

Social workers in nearly every setting now use fax machines routinely in their communication with clients and other professionals. How many social workers routinely explain to clients the potential risk involving faxed confidential documents and obtain clients’ informed consent before pushing the “send” button? How many social workers contact the receiving party to ensure that incoming faxes will be retrieved immediately and will not be available to unauthorized parties? (I often remind audiences that sending a confidential document via fax is akin to sending a love letter on a postcard: Any curious individual who handles the missive can read its contents.) What steps do social workers take to ensure that sensitive documents are not faxed to the wrong party (for example, as a result of a misdialed fax number)?

Similar breaches can occur with wireless telephones. Some cellular telephones are susceptible to eavesdropping on inexpensive scanners. Also, the telephone’s portability sometimes means that social workers carry on conversations within earshot of people who should not hear the identifying information mentioned by the social worker during the call (for example, conversations conducted at restaurant tables, conferences, athletic events, on buses or trains, and in hallways). In one notorious case in which I consulted, a social worker’s client was shopping in an electronics store and overheard on one of the store’s sample scanners a wireless telephone conversation that the client’s social worker was having concerning another client.

Social workers’ use of electronic mail also has some risk.  In one case a social worker intended to send a confidential message to a colleague about a mutual client. When the social worker scrolled through her electronic address book to find her colleague’s e-mail address, she inadvertently clicked on, and sent the message to, a friend’s address that was adjacent to the colleague’s name (bad cursor aim), thereby disclosing intimate details concerning her client’s life.

Service Delivery       
With the advent of Internet communications has come a wide array of Web-based social services. Among them are clinical services offered by social workers (and other mental health professionals) who provide psychotherapy exclusively via e-mail communication. Under this arrangement, the provider and client do not meet in person. Rather, the social worker uses Internet communication to conduct an assessment and to provide clinical services. Pertinent ethical issues concern the adequacy of such computer-based services (i.e., the extent to which clients’ mental health needs can be met adequately through this counseling medium) and the challenge of informed consent. Key questions include the following: Do clients fully understand the nature of the clinical services they will be provided via the Internet, including their advantages (e.g., convenience, anonymity) and limitations (e.g., the absence of nonverbal cues which may be clinically significant)? Do clients understand what other options may be available to them (e.g., individual, family, couples, or group counseling in person)? Do clients understand possible privacy and confidentiality risks? Have social workers taken reasonable steps to encrypt their communications and to ensure secure storage of electronic records? Have social workers put in place adequate measures to ensure quality and respond to clinical emergencies?

Noncomputer technologies also pose ethical challenges in the delivery of social services. For example, many social workers employed as parole officers are attaching electronic bracelets to clients to monitor their whereabouts in the community. Social workers employed in programs for clients with severe behavioral problems may use electronic technology to control clients’ behavior (e.g., helmets that provide aversive stimuli when clients engage in inappropriate behavior). Social workers in psychiatric facilities may use strategically placed cameras and one-way mirrors to monitor patients’ movement, therapy, and recreational activities. And for many years now, social workers have participated in programs that make extensive use of pharmacological technology (i.e., neuroleptic and psychotropic medications) to treat emotional and behavioral symptoms. Clearly, these and other forms of technology can be helpful and constructive; at the same time, their use forces us to think seriously about potential ethical trade-offs related primarily to privacy, exploitation, coercion, and civil liberties.

HealthCare
Social workers in healthcare settings—hospitals, rehabilitation facilities, home healthcare programs, and nursing homes—have long understood the ethical implications of technology, mainly because the healthcare field has pioneered so many of the technological innovations that are part of professional practice. For decades now, social workers involved in genetic counseling and reproductive health have faced difficult ethical issues concerning the use of technology for genetic selection and engineering, in vitro fertilization, surrogate motherhood, and abortion. Social workers in neonatal intensive care units have understood for years the ethical implications of decisions to use technology to sustain the lives of remarkably premature, low-birth weight, or otherwise impaired infants. Most recently, a handful of social workers associated with healthcare programs involved in cloning and stem cell research have had to wrestle with a host of widely publicized and daunting bioethical issues. In addition, social workers involved in organ transplantation programs at major medical centers participate in ethical decisions and debate concerning the allocation of scarce hearts, kidneys, and livers, as well as the selection of candidates for artificial organs. Oncology social workers, along with other social workers involved with terminally ill patients, participate in ethical decisions concerning the termination of life support, the limits of aggressive medical treatment, and other end-of-life decisions involving technology.

Social workers’ use of technology has increased dramatically in recent years. Our collective understanding of pertinent ethical issues also has grown. Fortunately, the profession has begun to develop relevant ethical guidelines. The current NASW Code of Ethics, for example, contains a number of new standards specifically related to electronic communications, such as e-mail, fax machines, computers, and electronic records.

Social workers should not be complacent about these issues. We are just beginning to identify and clarify the ethical dimensions of newer forms of technology, and, considering recent history, we can anticipate rapid development of novel technological innovations that, today, are hard to imagine. As recently as 10 years ago, what social worker could have forecasted the technological innovations that today’s practitioners find commonplace? Imagine the look on Ida Cannon’s face if a colleague had tried to convince her exactly a century ago that early 21st century social workers would use wireless telephones, computer-based and satellite communication, facsimile machines, and voice mail to provide social work services. Who knows, then, what technological innovations await us and how they will affect social work practice in the near and distant future?

— 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.