Eye on Ethics
Pattern Recognition Theory and Social Work Ethics
Social workers have come to understand that professional work often produces exceedingly complex moral and ethical challenges that demand keen insight, astute analysis, and skilled management. In some instances, social workers reach quick consensus about the most appropriate course of action. In the most challenging cases, however, thoughtful, principled, and earnest social workers who have a firm grasp of the pertinent facts may disagree about what is ethical. That is, reasonable minds may differ.
When I sort through complex ethical issues, often I find myself identifying key dilemmas, principles, and standards that were relevant in other cases I have encountered. One major advantage of experience in any line of work is that one can draw on lessons learned from accumulated precedents, other scenarios that required somewhat similar analysis. Although the fact pattern in other cases may differ somewhat, sometimes key elements resemble pertinent facts in a new situation. Researchers refer to this as pattern recognition.
Perhaps the clearest example of pattern recognition involves medical diagnoses. When we visit our physicians when we are not feeling well or are in pain, doctors typically sort through a myriad of symptoms, test results, and patients’ self-reports looking for a familiar pattern that may lead to a clear diagnosis. Clinical social workers do much the same when they gather comprehensive data from and about clients in an effort to assist them. Social workers who are community activists or policy planners identify and draw on patterns they have observed in their work addressing homelessness and poverty. Social work researchers look for patterns in the data they collect in conjunction with needs assessments and program evaluations. I think the same applies to social work ethics.
Consider this recent case. I received an urgent call from a social worker who directs a prominent substance use disorder treatment program. The agency receives funding from a variety of sources, including federal and state agencies and private insurance companies. The social worker who called me explained that one of the agency’s clients is a licensed nurse who sought treatment because of her struggle with substances (including opioids). The caller told me that the nurse is employed at a local hospital and works in the facility’s cardiac care unit. The social worker explained to me that the agency’s medical director, who supervises the nurse’s medication-assisted treatment, told the social worker that she, as a licensed physician, feels obligated to notify the nurse’s licensing board about the nurse’s impairment, as a matter of public safety. The physician reported that she had consulted with the administrator of the licensing board for physicians and was told that, indeed, under state licensing regulations the physician had a duty to report her concerns about the nurse, despite the nurse’s objections. Understandably, the nurse was concerned about the impact that such a report might have on her career. The nurse reportedly argued that she was actively engaged in treatment and, therefore, there was no imminent risk to any of her patients.
Patterns in Social Work Ethics
First, the social worker and I talked about whether the nurse might voluntarily report herself to the nursing licensing board, perhaps with the assistance of a trusted staffer at the substance use treatment program. I know from experience that licensing boards sometimes cooperate and support a practitioner who is struggling, seeks treatment, and is engaged in a conscientious effort to address her or his challenges. This nonpunitive approach sometimes enables impaired practitioners to avoid onerous disciplinary proceedings and the most serious sanctions, such as license suspension or revocation.
Second, I explained to the social worker that, in my opinion, the agency is obligated to comply with a very strict federal law governing disclosure of confidentiality information related to substance use disorder diagnosis, treatment, and referral. This prominent federal law—42 CFR Part 2: Confidentiality of Substance Use Disorder Patient Records—generally prohibits disclosure without client consent. The rationale is that these strict protections are necessary to encourage people who struggle with substance use to seek treatment with assurance that their privacy and confidentiality will not be compromised. Under several very narrow exceptions, disclosure without client consent may be permitted, but usually only with authorization by a court of law (for example, when disclosure is warranted in conjunction with law enforcement officials’ investigation or prosecution of an extremely serious crime allegedly committed by a client). I also explained that we needed to review the language in HIPAA with regard to disclosure without a client’s consent.
Third, I pointed to several state laws governing disclosure of confidential health information. These included a statute pertaining to all health care providers and, as well, provisions in the state’s social work licensing law.
Fourth, we examined relevant standards in the NASW Code of Ethics, particularly with respect to disclosure of clients’ confidential information, without their consent, to protect third parties from harm (see section 1.07).
Toward the end of our lengthy conversation, I recommended to the social worker that she consult with a local attorney who specializes in health care law. I reiterated that as a social worker, I am not able to provide legal advice. Moreover, I explained, consulting a lawyer would add a layer of protection in the event that the nurse filed a complaint against the agency and social worker in conjunction with its management of this complex situation.
The social worker heeded my advice and consulted with two attorneys. Both attorneys reviewed pertinent laws and agreed that disclosure by the agency’s physician to the nurse’s licensing board without the nurse’s consent would violate her confidentiality rights and expose the agency to considerable legal risk (especially with regard to violation of 42 CFR Part 2, which imposes significant civil and criminal penalties for unauthorized disclosures).
In the end, all of us agreed that the medical director at the treatment program had not received sound advice about her duty to disclose and that the agency, the nurse, and the public would be served best by facilitating the nurse’s rehabilitation efforts (recognizing that significant noncompliance by the nurse may warrant disclosure, in accord with the law, court authorization, and Code of Ethics standards). Unauthorized disclosure could have led to significant harm to the agency-client relationship, the nurse’s career, and the agency itself. Ultimately, what saved the day, I think, was pattern recognition.
— 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.