CASE STUDY : WHO DECIDES? THE RIGHT OF SELF-DETERMINATION
In your Becoming an Ethical Helping Professional text, the authors discuss the essential responsibility of a professional to ensure that a client has exercised informed consent, allowing for agreement as well as refusal. Self-determination is a principle that underlies the practice of obtaining informed consent permissions from clients. In instances where mental health clients may or may not have an advanced directive and decide to leave a facility because they feel, “I am perfectly alright,” consider who should decide. The question is, can a client be said to have an absolute right to self-determination, or are there circumstances when that principle may not be applicable? What is the supervisor’s response to an employee’s rejection of a client’s invocation of the right of self-determination, when the exercise of that right can harm the client or harm others?
Drawing on your readings, consider this dilemma and offer your decision with an explanation to the employee faced with this circumstance.
2.
RESOLVING ETHICAL DILEMMAS
Human interactions in personal, professional, and community settings can be demanding when questions of ethical expression are required. What do we mean by ethical expression? We mean conscious and unconscious verbal, physical, and emotional responses to social, cultural, intellectual, and physical behaviors that are vocalized, demonstrated physically, and even evidenced by an emotional response.
When there are several ethical or moral choices that are to be made involving persons from rural or urban settings or from different cultural groups, the human services professional is often required to make a decision about how to express an ethical response. Whether the requirement is of a supervisor guiding a subordinate or a service provider engaged in a relationship with a client, a decision must be made.
The decision that a professional weighs requires understanding one’s personal ethics and boundaries, community ethics, cultural ethics, and other diverse conditions that may be defined by the workplace (whether a government agency, for-profit, or nonprofit organization) or by government-established laws and regulations.
The human services professional may need to rely on colleagues with whom to consult, a supervisor or organizational authority, and sometimes the legal and regulatory rules established by the town, city, county, state, and central government.
Based on your readings, discuss the approach you would take to decide whom you would seek to consult to resolve the question of the appropriate ethical expression when considering how you most appropriately direct or inform a subordinate service provider. Suppose the service provider wishes to act more independently with her clients and to set aside the organizational code of ethics, and even city and state laws, since, as she will say, “I know my clients, and they require different needs that are not considered by the organization or the government.” Justify your approach as a supervisor.
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2/4/2020
Ethics in Social Services: How to Think About Them and How to Handle Them Transcript
Print
ETHICS IN SOCIAL SERVICES: HOW TO THINK ABOUT THEM
AND HOW TO HANDLE THEM
BECKET GREMMELS
An 82 year old guy comes into the hospital with very low blood sugar. He has diabetes. He lives at home with his
wife. He has two kids. He took his insulin and he didn’t eat anything, so naturally he’s going to have low blood sugar.
It makes sense. This time it was very low. I don’t know, but for those of you that know numbers, it was about 28,
which is ridiculously low. That’s so low we’re bordering on brain damage because the brain doesn’t have enough
sugar. This was not the first time he’d come in with low blood sugar because he took insulin and didn’t eat anything.
He does this about once or twice a year. This is the worst it’s been so far, but this seems to be a pattern he’s getting
into of showing his inability to manage his medication and his disease well on his own.
His children, very concerned, very appropriate children, having his best interest in mind, I think that was clear from
the outset, they want him to go into some type of assisted living that’s going to help him manage his medicine, do his
laundry, that kind of stuff. The doctor says, “This is clearly a pattern of an inability to manage your medication at
home. Yeah, you need to do this, sir.” He said, “Absolutely not. I’ve lived in this home for 35 years. I built it myself, I
don’t want to live anywhere else, and nobody’s going to tell me what to do.” And of course he jumps straight to,
“They just want my house so they can sell it for the money. That’s all my kids want. That’s all they care about.”
I never saw his house. I don’t know how much it is. Regardless of the fact, that’s where they jumped to. He could not
see that they simply had his best interest in mind. Maybe they did want the money. I don’t know. Regardless of the
case, you can see that there’s some good intentions on the part of the children. Naturally, he didn’t end up going
home. Ultimately the question hinged on the decision-making process we were talking about.
We live in a liberal society. I use the liberal there, this is the fostering. It’s not in terms of liberal versus conservative,
you know President Bush versus President Obama. That’s not what we’re talking about. We’re talking about liberal in
that we value liberty. That’s where the word liberal comes from, again etymologically. In other words, in our country,
in our society, liberty is almost always the primary value that we uphold. That’s what we were founded on as
Americans. You know, don’t tread on me, liberty or death. So we place freedom, my freedom comes before a lot of
other values, where a lot of other countries, a lot of other societies don’t place that value on freedom so much. They
balance it with other things. Other things take precedence.
For the most part, in our country, you can do what you want as long as you don’t hurt someone else. For the most
part. There are lots of exceptions, naturally. But for the most part, that’s how we think about things. How many times
a day do you hear, “Well, it’s still a free country, isn’t it?” That’s how we think about things as a society. There are
some limits to liberty, and one of those classic ones is you can’t act so that you’re impinging on another person’s
liberty. Your freedom can’t impose on another person’s freedom. But ultimately, I think this comes from a respect for
autonomy.
Autonomy is, literally, it comes from Greek, and it means self-law. That you are the law unto yourself. You are your
own king, you are your ruler, you are your own determiner. You determine yourself, your life, your body, what you do
with how you live. Some other kind of definitions of what it means with respect for autonomy, again more
philosophical, but all people have an obligation to forbear from unconsented-to force against other people. In other
words, you have a duty, an obligation, a requirement not to force people to do things against their will. That’s one
here. Another is recognizing everybody has the right to have these values and beliefs that we talked about and the
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2/4/2020
Ethics in Social Services: How to Think About Them and How to Handle Them Transcript
right to act on those beliefs and their values and make choices on them and live their life in accordance with those
beliefs and values. Therefore, we have an obligation to kind of quasi let them do that, act how they see fit.
Some other definitions. This is one of the older ones, “Treat human beings as an end in themselves and never
merely as a means to an end.” That’s from Immanuel Kant, a famous philosopher. This is one of my favorite ones,
as far as being fluffy and flowery and all that, “The right to define one’s own concept of existence, of meaning, of the
universe, and of the mystery of human life.” That’s from the Supreme Court. So enough on that.
Contrast this, kind of it’s like about 50-60 years ago, again using medicine, here, we doctors made decisions. We
didn’t necessarily ask the patient if they wanted chemotherapy, you just ordered it and did it. You didn’t necessarily
tell a patient they were dying of cancer, because that was thought to be too difficult for them to deal with, so you
talked to the family members. And they may or may not have told the patient. That was how medicine went 60-70
years ago. That was the norm. And that’s been really kind of denigrated. Paternalism is the term that we use for it in
medicine. You know, the doctor knows what’s best, kind of in the way that Daddy knew what’s best, that kind of stuff,
so the doctors wanted to tell you what it is that we’re going to do.
Ultimately, if you think about it, it’s beneficence. Doing good for people is the most important value that we’ve talked
about. If that’s the primary value, then we should do what’s best for patients regardless of what they want. Think
about that case I talked about, the 82 year old guy. It’s pretty clear that he can’t manage his medicine by himself,
and that he is a danger to himself doing that. It’s best for him to have help with that, therefore we’re not going to ask
what he wants, we’re going to tell him what we’re going to do about what’s happening.
Anybody who’s ever had children know that simply because you want something doesn’t mean it’s best for you.
That’s what we’re talking about here. Again, over the past 50 years or so, we’ve had a switch between beneficence
as the primary principle and respect for autonomy as the primary principle. Again, this is in the hospital world. That’s
a response to a number of things, but one of them is, “How do you define what’s best?” How do you define that for
other people? We can disagree on that. What’s good for this guy, he thinks it’s going home. He thinks living in his
house outweighs any risk whatsoever of brain damage from low blood sugar. But more importantly, who are you to
tell me what’s best for me? I know my life. I know what I want.
Anybody have teenagers in here? You know exactly what I’m talking about. I have a two year old right now, and this
is exactly, we had this fight yesterday about what’s best for him. Who are you to say what’s best for him? If it’s a two
year old, that’s one thing, but if it’s two adults in a situation, it’s tough to argue to say that I know what’s best for you
so much so that I’m going to force you to do it. And that, ultimately, is I think why we’ve had this pendulum swing
over to respect for autonomy over the past 50, 60, 70 years or so.
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12:42
courseroomc.capella.edu
Readings
Use your Becoming an Ethical Helping
Professional text to read the following:
…I LTE
• Chapter 6, “Confidentiality and
Trust,” pages 135-157.
Chapter 7, “Boundaries, Roles and
Limits,” pages 160-183.
Use the Capella library to read the
following:
• Tefre, Ø. S. (2015). The
justifications for terminating
parental rights and adoption in the
United States. Children and Youth
Services Review, 48, 87-97.
Use the Internet to view a video
regarding autonomy versus self-
determination:
Gremmels, B. (n.d.). Ethics in social
services: How to think about them
and how to handle them [Video] |
Transcript. Retrieved
from https://www.youtube.com/wa
tch?v=D_iRQ3N8pLY.
o Becket Gremmels, Director of
Ethics at Saint Thomas Health
in Nashville, delivers an
excellent presentation in
social services ethics from the
100th Tennessee Conference
on Social Welfare (TCSW) in
Nashville, Tennessee. This
video (runtime: 0:06 minutes)
