Social workers are routinely confronted with ethical dilemmas and conflicts in practice. A situation in which a difficult choice has to be made between two courses of action, either of which entails transgressing a moral principle (Oxford Living Dictionaries, accessed 28/01/2018). In determining what constitutes an ethical dilemma, it is necessary to make a distinction between ethics, values, morals, and laws and policies. Ethics are prepositional statements (standards) that are used by members of a profession or group to determine what the right course of action in a situation is. Ethics rely on logical and rational criteria to reach a decision, an essentially cognitive process (Congress, 1999; Dolgoff, Loewenberg, & Harrington, 2009; Reamer, 1995; Robison & Reeser, 2002). Values, on the other hand, describe ideas that we value or prize (Allen & Friedman, 2010). Morals describe a behavioral code of conduct to which an individual ascribes. (Dolgoff, Loewenberg, & Harrington, 2009). Ethical conflict is an action is against your values. There is no doubt in your mind. e.g. Honesty is one of your values. Accepting bribe would be an ethical conflict. (Ref: Amit Anand, Student of Ethics, Oct 29, 2016, online accessed 28/01/2018)
When ethical dilemmas and conflicts can arise – there are two conditions that must be present for a situation to be considered and ethical dilemma and conflicts while providing care, support, and protection to service users. The first one has limitation or not fully explained the communication of intent, and the second, is tension between the concept of protection and the concept of safeguarding. In practice the two concepts sometimes can be confusing, but they are distinct, and this can be a cause of conflict when one concept is incorrectly applied. Therefore, it is useful to remind us of the major difference between the two concepts, Calpin et al (2012) argue that ‘… protection implies a domination over others to make decisions for an individual rather than with them, safeguarding accepts that individuals have the right to take risks so long as they have the capacity and understand the implications or consequences of any choices’ (Calpin et al, 2012:159). Once the difference has been established it is possible to explain the ethical dilemmas and conflicts arising when providing care, support and protection to service users.
Now I am bringing a simple example here to make this explained taking 2 service users, who are head injury survivors with their mental capacity intact. However, one service user, Mr P, was left with a minor form of paralysis in the left leg, which causes him to stumble and he is not steady walking even with a Zimmer frame. He should really use wheelchair. The other service user, Mr R, has minimal use of his right hand, which was his dominant hand and is quite mobile. Mr P and Mr R would like to attend a stage drama in the local park. In terms of mobility Mr R is quite capable of attending without help; his ability to be mobile and make trips outside the home unattended by staff, but with a community family friend, has been documented in his care plan properly. A dilemma, however arises, with Mr P who has not come to terms with his limited lack of mobility, as a ‘fiercely independent’ (his own phrase in describing himself) individual prior to his head injury, Mr P wants to attended the stage drama but does not want to look like a kid with a member of staff attending him. While Mr R’s situation is a safeguarding issue, Mr P’s situation is a protection issue. Here arises the dilemma of balancing the rights of Mr P to independence and choice against our duty of care as his care provider at Sathi Care Home.
Mr P is clearly a vulnerable person as defined by the Department of Health (2000) since he is a person who ‘is or may be in need of community care services by reason of mental or other disability, age or illness; and who is or may be unable to take care of him or himself …’ (:8). In a situation such as this our judgement is that Mr P can attend the stage drama but in a wheelchair as at least one of the paths in the park is uneven, and even if all the paths are ‘smooth’ there is no telling when Mr P’s leg can cause him to stumble and possible damage his left knee as he tries to steady himself on the Zimmer frame. Mr P is very image conscious and it was clear that our ‘reasonable’ argument was becoming very unproductive, with us maintaining our stance of duty of care towards him, recognising to do otherwise would be going against his agreed care plan completed with his and his son before he arrived at the home. Mr P is now asserting that he feels much better now, then when he first arrived at Sathi Care, however, we have observed differently. A potentially explosive situation on the part of Mr P’s growing agitation of being treated like a kid, as he did not want to be accompanied by a member of staff was defused by a suggestion which was amicable agreed by both the parties.
A member of staff volunteered to go in her lunch break and borrow an electronic hand-controlled chair for the disabled and bring it back to the home. Mr P, who used to drive, would be shown how to use the chair and be able to attend the stage drama, with a carer in close proximity but not close enough to appear if Mr P was ‘not in control’ of his life. This is an example where team work pays off for a positive outcome in a potentially conflicting situation of service users’ rights in tension with our duty of care towards the service user. The member of staff did not have to volunteer, or even make the suggestion, but having done so an amicable solution was reached; this intervention was noted in the staff member’s file for future consideration in her annual review.
Notably, mobility is just one of a number of issues which often give rise to conflicts amounting to an ethical dilemma of when to ‘give in’ and allow a service user to assert his or her rights, or to hold firm to our undertaking to provide a duty of care. Most assuredly it can never be acceptable to stand by and allow a service user to exercise his or her rights to his or her detriment or that of another service user or member of care. Hence, in staff training sessions the difference between safe guarding issues and protection issues are reiterated quite often. Junior staff know when the intervention of a member senior care team is required if a service user refuses to comply with an agreed protection arrangement, as per his/her care plan, or in the face of an immediate unplanned for protection issue. Such an issue may be one that requires the use of restraints which is painstakingly documented in our protocol file. Even when a restraint is the last agreed resort in an agreed care plan it is still an issue if it has to be implemented, and even more so if it has not been agreed with the service user, the service user’s family or representative, or the management team as a specific case. As with all our protocols, our restraint policy is in line with national guidelines as provided by The Mental Capacity Act (2005) which provides clear guidelines on which we have based and developed our local policy and procedure on the use of restraints at Sathi Care Home.
Another situation which can arise from time to time is associated with service users’ ‘pocket change’. Many of our service users’ finance are handled by the office staff; an arrangement put in place when the service user arrives at Sathi Care Home (SCH). When, by prior arrangement, clients attend a day centre each client is allocated £3 to access the services provided by the centre. In a number of cases this situation has not had a positive outcome. For example, Mr D would keep the £3 and when he returned he would give the money to a domestic to place a bet on a dog. This unfortunate situation could have continued had not the centre contacted us to inform us that Mr D had not paid the weekly contribution. To compound the situation, Mr D first blamed the Health Care Workers (HCW) and maintained this position, until an investigation discovered his betting habit. After consulting his family, Mr D, who liked to attend the day centre agreed to allow SCH to make the contributions directly to the day centre. The domestic was given an informal warning and agreed to attend a refresher safe guarding course. This action was taken because Mr D, as agreed by his family, had not been financially abused by the domestic and was not classed as financially vulnerable. Thus, we implanted our safeguarding policy to protect Mr D and our staff who were being accused of stealing.
The final example of a dilemma may not appear at first consideration to be a dilemma but since it impacts on our service users’ right to independence and choice it will be considered here. In the communal TV room there have been issues with the TV remote control. Mrs L, who does not have any mental health issues, feels that she has the right to control what is watched in the TV room and once she has the TV remote control she will not relinquish it. Mrs L has a TV in her room which the staff encourages her to watch to follow her own programmes which are not favourites with the majority of service users in the TV room. This was found to be amicable arrangement with Mrs L joining the other service users to watch agreed programmes such as Downtown Abbey.
Dilemmas arises in so many different situations but the best approach is to follow the code of conduct as established by SCH, based on national policies, and seek advice from senior management when events fall outside the breadth of the code of conduct.
Calpin, P. J., Langridge, E., Morgan, B., Platts, R., Rowe, J. and Scragg, T. (2012) Diploma in Leadership for Health and Social Care Oxford: Oxford University Press
Department of Health and Home Office (2000) No Secrets: Guidance on Developing and Implementing Multi-Agency Policies and Procedures to Protect Vulnerable Adults from abuse London: DOH and Home Office