Outline the general ethical responsibilities on helping relationships and discuss them with examples from a variety of caring roles.
Outline the general ethical responsibilities on helping relationships and discuss them with examples from a variety of caring roles.
The responsibilities on helping relationships are to maintain the general trusts of their clients and patients, not only through care, but also through observing certain codes of practice to preserve their rights.
These codes are referred to as ethical codes and they act as guidelines to shape and uphold the general principles regarding staff and patients relationships.
This essay would attempt to outline the general codes of ethics, and discuss the moral principles underpinning ethical responsibilities within helping relationships, with particular examples from health and social care and counselling roles. Ethical conflicts will also be identified within these roles making particular reference to policies that work in conjunction with these codes.
Within caring or helping professions, the counsellor or carer needs to be aware that the client is in their care, because they feel they can help their present situation. Any mistrust or doubt created by these professionals could result in the betrayal of the client's trust. It is therefore important that codes of guidance are enforced in order to ensure good practice within these roles.
What are Ethics?
Ethical issues are the science of morals, that branch of philosophy, which is concerned with human character and conduct; a system of morals or rules of behaviour, the treatise on morals. (Chambers dictionary p.554)
Professor David Raphael, cited by Gillon 1992, defined philosophy as the critical evaluation of assumptions and arguments, and moral philosophy as the philosophical inquiry about norms, values, right and wrong and what ought and ought not to be done.
Arguably, ethical issues involve a choice or decision about what one should do rather than what one would do.
There are general moral obligations instilled in individuals to achieve the highest possible results in whatever they undertake. This obligation is stressed in ones cultural, religious and professional practices, to name but a few.
Jeremy Bentham (1789), a British philosopher adopted this view, and subsequent thinkers have developed his approach, known as Utilitarianism, because it claims that the moral value of actions consists in their 'utility' or 'usefulness' in bringing about valuable results. According to this concept, human actions are not fundamentally good or bad. They are only considered to be one or the other, when they act as means to an end (Tschudin, 1993). For example, issues of being truthful and honest are not valuable in themselves unless these issues are likely to lead to states of affairs that one might consider to be valuable. Similarly the codes of ethics are ineffective when viewed independently, without the reinforcement of moral principles.
Caring and helping professions such as social work, medicine, counselling, and psychotherapy, are all involved in catering for and assisting the wellbeing of individuals with needs ranging from social, physical and psychological issues. Likewise, these individuals are from different ethnic, cultural and religious backgrounds, which according to Hugman and Smith 1995, are each in different ways, moral concerns, embedded in the mores of society, and so are laden with social values (Timms 1983; Horne 1987).
Although the professions i.e. (medicine, social work and counselling) around which this study will be based are different in some aspects of their professional practices, they are however guided by similar codes of ethical principles and morals of practice. Each institution has governing bodies, which ensures their smooth running. In counselling organisations, the British Association of Counsellors (BAC) has the responsibility to ensure that counsellors abide by and practice the codes of ethics. Within medicine, this responsibility lies with the General Medical Council (GMC) and social workers have the British Association of Social Workers (BASW).
The general codes of ethics are:
* Responsibility - safety of clients or patients rests with the professional whilst in their care. However, according to Jones et al 2000, counselling may tend to be concerned with the principles of autonomy, and therefore do not often take responsibility for their clients, but are arguably responsible for the work undertaken with the client.
* Confidentiality - respect and protect the client's or patients details to preserve trust.
* Boundaries - the awareness of any overlapping of pre-existing relationships
* Competence - the need for continuous development of skills through training and to recognise the limits of professional competence.
* Anti discriminatory practice - personal beliefs should not pose a threat to the quality of care administered to the patient or client
* Contracts - This mainly applies to counselling were the counsellor or therapist needs to set terms and conditions on which counselling is offered, and ...
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* Confidentiality - respect and protect the client's or patients details to preserve trust.
* Boundaries - the awareness of any overlapping of pre-existing relationships
* Competence - the need for continuous development of skills through training and to recognise the limits of professional competence.
* Anti discriminatory practice - personal beliefs should not pose a threat to the quality of care administered to the patient or client
* Contracts - This mainly applies to counselling were the counsellor or therapist needs to set terms and conditions on which counselling is offered, and this should be made clear to clients before the counselling sessions commences.
One could possibly argue that these codes are not entirely observed without moral dilemmas.
The issues of being ethically bound by confidentiality for professionals within health and social care could often present them with ethical conflicts. These conflicts could also arise when other ethical issues clashes with certain laws and policies. Informed consent for example, means that confidentiality is not absolute. Within the legal and ethical structure of counselling, confidentiality can be broken if the client poses danger to themselves and others, or for legal reasons the client requests that there records be released to themselves or a third party, or if the court orders the counsellor to make records available.
In cases dilemma or conflict, universal moral principles are implemented to help caring professionals and helpers deal with the problems presented. It is also important to note that ethical codes and the law are liable to changes and it is the duty of professionals to update themselves on these changes. Nevertheless, the morals still remain the same regardless of these changes.
Within medicine, however, these moral principles are often referred to as moral philosophical codes of ethics, which are similarly, additional and complementary to the traditional medical codes of ethics and ultimately can be expected to reinforce them. Hence its intentions are embedded in the Socratic tradition which emphasises that, "the unexamined life is no life for a human being"(Gillon 1992p.2). Thus moral ethics explains or present thoughtful arguments of justifications to ethical dilemmas.
These moral principles according to Jones et al 2000, are:
* Beneficence - achieving the greatest good
* Non-maleficence - causing least harm
* Justice - what is fairest
* Respect autonomy - maximising opportunity for all to implement their choices
* Law - what is legal
Added to these moral principles, is the concept of fidelity. The general nature of caring and helping relationships is based on trust as stated earlier in this study, therefore fidelity should be maintained as far as it could legally be stretched.
Within social work, these approaches to ethical dilemmas could be slightly different from other caring professions. This is due to the fact that their roles according to Hugman and Smith 1995, involves the care of people who have a variety of needs with family relationships, with social responses to offending and needs arising from structural causes such as poverty. Likewise their codes of practice are concerned with non-judgemental approach to clients, outlined by Biestek 1961, which to certain extent could identify with the code of anti-discriminatory practices. Although the practice of ethical principles has underlying morals, there is a general concern as how far one could distinguish ethics and morals.
The British medical journal (BMJ), states that the primary goal of medical treatment is to benefit the patient by restoring and maintaining the patients' health as far as possible, maximising benefit and minimising harm. In addition to this and the general code of ethics, doctors are required to
* Make the care of their patients their first concern
* Respect patients' dignity and privacy
* Respect the rights of patients to be fully involved in decisions about their care
Their values are minimising the effect of disease, reduction in mortality and enabling patients physically, intellectually and emotionally.
Doctors are faced with the dilemma of deciding on what to do with a patient who wishes to end her life. The patient Mrs Pretty, who's case was turned down by the high courts after requesting for her husband to assist her in committing suicide, is suffering from a life threatening disease. This disease has left her physically paralysed and is pleading to be given the right to die with dignity.
The medical code requires doctors' respect for their patients' right to be fully involved in decisions about their care. The moral principle in this case first and foremost is autonomy. The patient has made a choice and the requirement is for the doctor to respect that choice. At the same time, within the law, the Human Rights Acts reinforces the right to life and the issues that underpin this right are abortion, availability of life-saving treatments, euthanasia and deaths in custody. In this case therefore, the least harm would be to reduce suffering, and respect the patient's dignity and choice. However, law supersedes these moral obligations.
Similar dilemmas occur within helping professions such as counselling and psychotherapy. The values of a counsellor are integrity, impartiality and respect, but these values arguably, could often be put to the test. According to the registered charity for Prevention of Professional Abuse Network (POPAN), the abuse of patients and clients by those professionals responsible for their care is an issue that should concern everyone working in the health and social care services. However, most professionals do not abuse their clients or patients, and many of those who do, usually do not intentionally set out to do so. An example of such issue would be the case of a client who may develop a sexual attraction to their therapist and become overtly and persistently seductive towards the therapist in a way he or she finds difficult to resist. In such cases, the moral and ethical decision would be to inform the supervisor, in order to prevent harm, betray trust, observe boundaries and to do good. If this therapeutic relationship is to come to an end, this end has to be handled respectfully and effectively. Should the client object to this, it is in the best interest of the counsellor to explain that any further contact would pose a threat of jeopardising any good that was established at the start of the session.
Likewise, the code of confidentiality could also be broken if a client confesses to be a terrorist. Under the law of terrorism, there is a responsibility for the counsellor to hand the client over to the authorities.
In social work practice, would the desire of an offender be granted because they choose to do so?
Choice or autonomy in this case is unacceptable and unwarranted.
Part 2
Using one of the examples provided, write about your understanding of the ethical issues involved and indicate how you would seek to resolve them, drawing on appropriate theoretical material
According to the case study, the patient Mark, confides in the nurse by indicating that he is HIV positive. However, his partner Jill, whom the nurse met in the ante-natal clinic, accompanied by Mark, revealed when asked, that there is no infection in herself or her partner. This automatically states that she is unaware of her partners infection and the dilemma is how could one proceed to deal with this situation.
Tschudin 1993, citing Thiroux 1980, outlined five ethical principles for nursing. These are:
* The value of life
* Goodness or rightness
* Justice or fairness
* Truthtelling or honesty
* Individual freedom
Within the confidentiality codes of conduct, the International Council of Nurses (ICN) Code for Nurses (1973) states,
* the nurse must hold in confidence personal information and use judgement in sharing this information.
The American Nurses Association (ANA) code for nurses (1976), states,
* the nurse safeguards the client's right to privacy by judiciously protecting information of a confidential nature.
The United Kingdom Central Council (UKCC), published a third edition of the Code of Professional Conduct for the Nurse, Midwife, and Health Visitor 1992. This states that:
As a registered nurse, midwife or health visitor, you are personally accountable for your practice, and in the exercise of your professional accountability, must:
* Protect all confidential information concerning patients and clients obtained in the course of practice, and make disclosure only when consent, where required by the order of a court or where you can justify disclosure in a wider public interest. (Tschudin, 1993, p. 4 &5)
Confidentiality is paramount to all nursing codes, and in all cases the focal word is trust.
One has a moral duty to uphold this trust and try to do good by the client. Confidentiality according to Tschudin 1993, is a person's right, and therefore keeping confidentiality is 'doing good'.
Taking the 'value of life' into consideration, the moral issue is to decide how to minimise the risk of harming those, whose lives are at stake. The are several ethical conflicts involved in this case. Before any action could be taken, one has to think about the consequences these actions would have on both parties involved.
Diseases like HIV are not widely accepted by society and sufferers face different types of prejudices. The utilitarian method, if applied to this issue, would therefore explore various consequences resulting from whatever choice of action one adopts. It may upset Mark should one try to reason with him to tell Jill, and there is no guarantee about the way Jill would react to this dilemma. There is also an unborn baby involved, what repercussions is this going to have on the pregnancy or the baby? The fact that Mark has confided in someone else outside his relationship could mean that he probably cannot find the courage to bring himself to tell his girlfriend. Hence the most ethical thing to do in this situation, would be to discuss this issue in private with Mark and try to convince him to tell his partner or give one an informed consent to do so. This will be accepted within the principles of utilitarianism that although, initially Mark would likely be upset, morally, the end result would be aimed at prolonging the lives of others involved. It should be made clear to him that the sooner the issue is disclosed the better the chances for prolonging the lives of those involved. Information about on going research and new medical interventions relating to his illness could prove useful as well. The principles of 'goodness and rightness' are concerned with beneficence and non-maleficence. In order to do the least harm, it will be seen as justifiable to do good by maintaining confidentiality and respecting the clients' autonomy by giving him the chance to decide on an appropriate choice of action.
Another possible way to get Mark to agree to disclose this issue to Jill would be to bring to his awareness the amount of help available. Perhaps suggest that if he is in doubt, then he could call charities or help-lines established for helping people with HIV and AIDS. Give him a brief description of what type of help he can get or perhaps recommend that he speak to someone of similar experience of dealing with patients with HIV within the hospital. It is within ones power to inform the patient about the number of choices available to him. Awaken his awareness by letting him know he is not alone in this situation and that a number of patients, have benefited from most of these options.
Also make it known to him that from November this year, all pregnant women would be offered HIV test, which they cannot be forced to take, but if in the case of Jill she agrees to do so, then she would be bound to find out in the end.
The worst case scenario in this dilemma would be Mark's total refusal to co-operate with any of the options given. In this case, the option will be to inform someone in higher authority without obviously disclosing the name or identity of the client. What ever decision is derived from this discussion would be used as a method of convincing Mark. Where this also fails, then there is no other option, but for one to uphold justice and observe the principles of fairness. Justice would be carried out if the case is referred to the UKCC. As far as the Human Rights Act is concerned there is a right to life for every individual. Therefore in the case of those whose lives are being jeopardised, one would have to be fair and be just in order to give them a chance of prolonging their lives.
The final analysis would be, that perhaps the case would be sent to court for a supreme judgement. An example of such instances occurring was in the case of the Siamese twins, who would have both died if they had not been separated. Separation was against the patients' belief, but the doctors involved had a moral obligation to save life, reduce mortality, do the most good, to prevent harm. The same method would perhaps be applied to this case to maximise the lives of others involved.
The expected outcome of this case would have been to use every method of persuasion to get the patient to disclose this conflict to his partner, in his own way, or by giving informed consent to the nurse to do so.
Ultimately, it is difficult to distinguish ethics and morals in problem solving and further to this confusion is the evidence that laws are not made explicit enough to enable professionals to fully observe these codes of practice.
A recommendation would be to implement codes, which would interact with moral principles of ethics rather than pose a conflict. The general principles and morals which require doing good and causing little or no harm could often unintentionally set out in dilemmas like these, to contradict the very meanings they represent.
REFERENCES
Blunden, F. and Nash, J.: The Prevention of Client Abuse in Psychotherapy, 2001, www. bac.co.uk / POPAN
Bond, T.: Standards and Ethics for Counselling in Action, 1997, Sage Publications Ltd, London
Corey, G. et al: Issues and Ethics in the Helping Professions, 1993, Brooks / Cole USA
Gillon, R.: Philosophical Medical Ethics,1992, Antony Rowe Ltd., London
Hugman, R. and Smith, D.: Ethical Issues in Social Work, 1995, Routledge, London
Jones, C. et al: Questions of Ethics in Counselling and Therapy, 2000, Open University Press, Buckingham
Pence, G.E.: Classic Cases In Medical Ethics, 1990, McGraw-Hill, Inc. USA
Singer, P.: Practical Ethics, 1993, Cambridge University Press, UK
Tschudin, V.: Ethics; Nurses and Patients. 1993, Sctari Press, England
Code of Ethics for Counsellors, www. bac.co.uk
Conflicting Duties: The Journal for Members of The Medical Protection Society, Casebook 17. Summer 2001.
Good Medical Practice, 2001, www. gmc-uk.org/standards
BIBLIOGRAPHY
Blunden, F. and Nash, J.: The Prevention of Client Abuse in Psychotherapy, 2001, www. bac.co.uk / POPAN
Bond, T.: Standards and Ethics for Counselling in Action, 1997, Sage Publications Ltd, London
Corey, G. et al: Issues and Ethics in the Helping Professions, 1993, Brooks / Cole USA
Gillon, R.: Philosophical Medical Ethics,1992, Antony Rowe Ltd., London
Hugman, R. and Smith, D.: Ethical Issues in Social Work, 1995, Routledge, London
Jones, C. et al: Questions of Ethics in Counselling and Therapy, 2000, Open University Press, Buckingham
Pence, G.E.: Classic Cases In Medical Ethics, 1990, McGraw-Hill, Inc. USA
Singer, P.: Practical Ethics, 1993, Cambridge University Press, UK
Tschudin, V.: Ethics; Nurses and Patients. 1993, Sctari Press, England
JOURNALS
British association for Counselling, August 1997, Volume 8 No3
Code of Ethics for Counsellors, www. bac.co.uk
Conflicting Duties: The Journal for Members of The Medical Protection Society, Casebook 17. Summer 2001.
Good Medical Practice, 2001, www. gmc-uk.org/standards
ETHICS ASSIGNMENT
PARTS 1 AND 2
